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BACKGROUND Historically, hemorrhage has been attributed as the leading cause (40%) of early death. However, a rigorous, real-time classification of the cause of death (COD) has not been performed. This study sought to prospectively adjudicate and classify COD to determine the epidemiology of trauma mortality. METHODS Eighteen trauma centers prospectively enrolled all adult trauma patients at the time of death during December 2015 to August 2017. Immediately following death, attending providers adjudicated the primary and contributing secondary COD using standardized definitions. Data were confirmed by autopsies, if performed. RESULTS One thousand five hundred thirty-six patients were enrolled with a median age of 55 years (interquartile range, 32-75 years), 74.5% were male. Penetrating mechanism (n = 412) patients were younger (32 vs. 64, p < 0.0001) and more likely to be male (86.7% vs. 69.9%, p < 0.0001). Falls were the most common mechanism of injury (26.6%), with gunshot wounds second (24.3%). The most common overall primary COD was traumatic brain injury (TBI) (45%), followed by exsanguination (23%). Traumatic brain injury was nonsurvivable in 82.2% of cases. Blunt patients were more likely to have TBI (47.8% vs. 37.4%, p < 0.0001) and penetrating patients exsanguination (51.7% vs. 12.5%, p < 0.0001) as the primary COD. Exsanguination was the predominant prehospital (44.7%) and early COD (39.1%) with TBI as the most common later. Penetrating mechanism patients died earlier with 80.1% on day 0 (vs. 38.5%, p < 0.0001). Most deaths were deemed disease-related (69.3%), rather than by limitation of further aggressive care (30.7%). Hemorrhage was a contributing cause to 38.8% of deaths that occurred due to withdrawal of care. CONCLUSION Exsanguination remains the predominant early primary COD with TBI accounting for most deaths at later time points. Timing and primary COD vary significantly by mechanism. Contemporaneous adjudication of COD is essential to elucidate the true understanding of patient outcome, center performance, and future research. LEVEL OF EVIDENCE Epidemiologic, level II.

Introduction Computed tomography scans often are repeated on trauma patient transfers, leading to increased radiation exposure, resource utilization, and costs. This study examined the incidence of repeated computed tomography scans (RCT) in trauma patient transfers before and after software upgrades, physician education, and encouragement to reduce RCT. Methods The number of RCTs at an American College of Surgeons Committee on Trauma verified level 1 trauma center was measured. The trauma team was educated and encouraged to use the computed tomography scans received with transfer trauma patients as per study protocol. All available images were reviewed and reasons for a RCT when ordered were recorded and categorized. Impact of system improvements and education on subsequent RCT were evaluated. Results A RCT was done on 47.2% (n = 76) of patients throughout the study period. Unacceptable image quality and possible missed diagnoses were the most commonly reported reasons for a RCT. Preventable reasons for a RCT (attending refusal to read outside films, incompatible software, and physician preference) decreased from 25.8 to 14.3% over the study periods. Conclusions The volume of unnecessary RCT can be reduced primarily through software updates and physician education, thereby decreasing radiation exposure, patient cost, and inefficiencies in hospital resource usage.

Background This study’s purpose was to determine if age, fall height, fall mechanism, landing surface, and landing position are associated with injury severity and hospital outcomes among pediatric fall patients. Methods A retrospective review was conducted of patients aged ≤18 years who sustained fall-related injuries admitted to an American College of Surgeons verified Level 1 trauma center from January 1, 2006 through December 31, 2015. Results Patient age, fall mechanism, landing position, and landing surface were associated with the need for surgery. Patient age, fall mechanism, and landing position were also associated with intensive care unit admissions. Fall mechanism was the only variable associated with injury severity. No variables were associated with the need for mechanical ventilation or mortality. Conclusions Patient age, fall mechanism, landing surface, and landing position need to be considered with regard to injury severity and patient outcomes among pediatric fall patients.

Introduction Laparotomy, embolization, and observation are described for blunt splenic injury management. This study evaluated outcomes of blunt splenic injury management based on baseline factors, splenic injury severity, and associated injuries. Methods A nine-year retrospective review was conducted of adult patients with blunt splenic injury. Collected data included demographics, injury characteristics, treatment modality, complications, and outcomes (mechanical ventilation, days on mechanical ventilation, intensive care unit [ICU] admission and length of stay, hospital length of stay, and in-hospital mortality). Categorical and continuous variables were analyzed using χ2 analysis and one-way analysis of variance for normally distributed variables and a non-parametric test of medians for variables that did not meet the assumption of normality, respectively. Results Splenic injury grade was similar between operative and embolization groups, but severe hemoperitoneum was more common in the operative group. Complications and mortality were highest in the operative group (50.7% and 26.3%, respectively) and lowest in the embolization group (5.3% and 2.6%, respectively). Operative patients required more advanced interventions (ICU admission, mechanical ventilation). There were no differences between those treated with proximal versus distal embolization. Observation carried a failure rate of 11.2%, with no failures of embolization. Conclusions Embolization patients had the lowest rates of complications and mortality, with comparable splenic injury grades to those treated operatively. Further prospective research is warranted to identify patients that may benefit from early embolization and avoidance of major abdominal surgery.

BACKGROUND There are no clear guidelines for the best test or combination of tests to identify traumatic rectal injuries. We hypothesize that computed tomography (CT) and rigid proctoscopy (RP) will identify all injuries. METHODS American Association for the Surgery of Trauma multi-institutional retrospective study (2004-2015) of patients who sustained a traumatic rectal injury. Patients with known rectal injuries who underwent both CT and RP as part of their diagnostic workup were included. Only patients with full thickness injuries (American Association for the Surgery of Trauma grade II-V) were included. Computed tomography findings of rectal injury, perirectal stranding, or rectal wall thickening and RP findings of blood, mucosal abnormalities, or laceration were considered positive. RESULTS One hundred six patients were identified. Mean age was 32 years, 85(79%) were male, and 67(63%) involved penetrating mechanisms. A total of 36 (34%) and 100 (94%) patients had positive CT and RP findings, respectively. Only 3 (3%) patients had both a negative CT and negative RP. On further review, each of these three patients had intraperitoneal injuries and had indirect evidence of rectal injury on CT scan including pneumoperitoneum or sacral fracture. CONCLUSION As stand-alone tests, neither CT nor RP can adequately identify traumatic rectal injuries. However, the combination of both test demonstrates a sensitivity of 97%. Intraperitoneal injuries may be missed by both CT and RP, so patients with a high index of suspicion and/or indirect evidence of rectal injury on CT scan may necessitate laparotomy for definitive diagnosis. LEVEL OF EVIDENCE Diagnostic, level IV.

Background This study aimed to determine the incidence of intra-abdominal injuries in elderly patients after a ground-level fall. Methods A 6-year retrospective review was conducted on patients 65 years of age or older involved in a fall from standing and evaluated at a level 1 trauma center. Each patient presented with a pelvic, thoracolumbar, and/or lower rib fracture. Data collection included demographics, injury characteristics, FAST exam results, CT imaging results, and hospitalization outcomes. Results A total of 324 patients met study inclusion criteria. The majority of patients were white (95.1%) females (65.4%) with an average age of 82.0 ± 7.3 years. Only 22 patients (6.8%) reported abdominal pain, although an abdominal CT was performed in 91 patients (28.1%). Only 1 patient (0.3%) was found to have an intra-abdominal injury when no abdominal pain was reported and the FAST exam was negative. This injury was not clinically significant enough to warrant surgical intervention. Conclusion Elderly patients who suffer a ground-level fall do not benefit from PAN-SCAN, even when presenting with rib, thoracolumbar, and/or pelvic fractures.

Introduction Recent studies have provided guidelines on the use of head computed tomography (CT) scans in pediatric trauma patients. The purpose of this study was to identify the prevalence of these guidelines among concussed pediatric patients. Methods A retrospective review was conducted of patients four years or younger with a concussion from blunt trauma. Demographics, head injury characteristics, clinical indicators for head CT scan (severe mechanism, physical exam findings of basilar skull fracture, non-frontal scalp hematoma, Glasgow Coma Scale score, loss of consciousness, neurologic deficit, altered mental status, vomiting, headache, amnesia, irritability, behavioral changes, seizures, lethargy), CT results, and hospital course were collected. Results One-hundred thirty-three patients (78.2%) received a head CT scan, 7 (5.3%) of which demonstrated fractures and/or bleeds. All patients with skull fractures and/or bleeds had at least one clinical indicator present on arrival. Clinical indicators that were observed more commonly in patients with positive CT findings than in those with negative CT findings included severe mechanism (100% vs. 54.8%, respectively, p = 0.020) and signs of a basilar skull fracture (28.6% vs. 0.8%, respectively, p = 0.007). Severe mechanism alone was found to be sensitive, but not specific, whereas signs of a basilar skull fracture, headache, behavioral changes, and vomiting were specific, but not sensitive. No neurosurgical procedures were necessary, and there were no deaths. Conclusion Clinical indicators were present in patients with positive and negative CT findings. However, severe mechanism of injury and signs of basilar skull fracture were more common for patients with positive CT findings.

Introduction This study compared outcomes between patients injured at a motorbike track, which requires riders to follow safety equipment guidelines, and those involved in recreational riding where safety equipment usage is voluntary. Methods A retrospective review was conducted of all patients presenting with motorbike-related injuries at an American College of Surgeons verified level-I trauma center between January 1, 2009 and December 31, 2013. Data collected included demographics, injury details, safety equipment use, hospitalization details, and discharge disposition. Comparisons were made regarding protective equipment usage. Results Among the 115 patients admitted, more than half (54.8%, n = 63) were injured on a motorbike track, and 45.2% (n = 52) were injured in a recreational setting. The majority of patients were male (93.9%), Caucasian (97.4%), and between the ages of 18 to 54 (64.4%). Helmet usage was higher among track riders (95.2%, n = 60) than recreational riders (46.2%, n = 24, p < 0.0001). Comparisons of injury severity and outcomes between those who wore protective equipment and those who did not were not significant. Conclusion Even though track riders wore protective equipment more than recreational riders, there was no difference between the groups regarding injury severity or hospital outcomes. These results suggested that motocross riders should not rely on protective equipment as the only measure of injury prevention.

Agricultural work results in numerous injuries and deaths. Efficacy of farm equipment safety interventions remains unclear. This study evaluated agricultural mortality pre- and postimplementation of safety initiatives. A 31-year retrospective review of mortality data from agriculture-related injuries was conducted. Demographics and injury patterns were evaluated by mechanism of injury. There were 660 deaths (mean age 48.6 years). Female deaths increased from 5.2 to 11.7 per cent (P = 0.032). Mortality associated with tractors decreased (75.6% vs 53.9%; P0.001) and with all-terrain vehicles increased (3.5% vs 22.0%; P0.001) from Period I to III. However, tractors remain the primary cause of mortality. For mechanical equipment-associated mortality, there was a decrease (83.3% vs 50.0%) in "caught in equipment," and an increase (6.7% vs 38.9%) in those killed by "crush injury" from Period I to III. Application of safety devices to enclose and stabilize machinery has led to an overall decrease in mortality associated with tractors and "caught in equipment." Expanded rural education, as well as further development and use of safety devices, is warranted to curtail farm-related injuries and deaths.

Most emergency medical service personnel rely on one of two techniques to extricate motor vehicle crash victims; the Rapid Extrication Maneuver (REM) or the Kendrick Extrication Device (KED). The purpose of this study was to compare pre- and postextrication neurological outcomes between these two techniques. A retrospective review was conducted of all adult patients with a vertebral column injury resulting from motor vehicle collision and admitted to a Level I trauma center between January 1, 2003 and December 31, 2010. Standardized pre- and postextrication neurological examinations were reviewed for all patients. More than half of patients (N = 81) were extricated using the KED (53.1%, n = 43) and 46.9 per cent (n = 38) were extricated with the REM. Except for the thoracic Abbreviated Injury Score, no differences between groups emerged related to the Glasgow Coma Scale score, Injury Severity Score or Abbreviated Injury Score. There were no pre- and postextrication changes for motor to all extremities and sensation to all extremities using either method. The results of this study suggest that the REM and the KED are equivalent in protecting the patient from neurologic injury after motor vehicle collision.

The effects of methamphetamines (MAs) on trauma patient outcomes have been evaluated, but with discordant results. The purpose of this study was to identify hospital outcomes associated with MA use after traumatic injury. Retrospective review of adult trauma patients admitted to an American College of Surgeons verified-Level I trauma center who received a urine drug screen (UDS) between January 1, 2004 and December 31, 2013. Logistic regression analysis was used to identify factors associated with mortality. Patients with a negative UDS were used as controls. Among the 2321 patients included, 75.1 per cent were male, 81.9 per cent were white, and the average age was 39. Patients were grouped by UDS results (negative, MA only, other drug plus MA, or other drug without MA). A positive drug screen result of other drug without MA demonstrated a significantly lower risk for mortality, but longer intensive care unit and hospital length of stay, as well as increased ventilator days than negative results. Results of MA only did not alter the risk of mortality. These findings suggest that patients who test positive for MAs are not at an increased risk of in-hospital mortality when compared with patients having a negative drug screen.

Background Agriculture is an industry where family members often live and work on the same premises. This study evaluated injury patterns and outcomes in children from farm-related accidents. Methods A 10-year retrospective review of farm-accident related injuries was conducted of patients 17 years and younger. Data collected included demographics, injury mechanism, accident details, injury severity and patterns, treatments required, hospitalization details, and discharge disposition. Results Sixty-five patients were included; 58.5% were male and the mean age was 9.7 years. Median Injury Severity Score and Glasgow Coma Scale were 5 and 15, respectively. Accident mechanisms included animal-related (43.1%), fall (21.5%), and motor vehicle (21.5%). Soft tissue injuries, concussions and upper extremity fractures were the most common injuries observed (58.5%, 29.2%, and 26.2%, respectively). Twenty-six patients (40%) required surgical intervention. Mean hospital length of stay was 3.4 ± 4.7 days. The majority of patients were discharged to home (n = 62, 95.4%) and two patients suffered permanent disability. Conclusions Overall, outcomes for this population were favorable, but additional measures to increase safety, such as fall prevention, animal handling, and driver safety training should be advocated.

Background Currently, no national standard exists for educating medical students regarding radiography or formal research indicating the level of improvement regarding computed tomography (CT) interpretation of medical students during clinical rotations. Methods Students were evaluated based on their response to twenty-two open-ended questions regarding diagnosis and treatment of eleven de-identified CT images of life-threatening injuries. The number of incorrect answers was compared with correct or partially correct answers between students starting third-year clinical rotations and those starting their fourth year. Results Survey results were collected from 65 of 65 (100%) beginning third-year students and 9 of 60 (15%) beginning fourth-year students. Students in their fourth-year had less incorrect answers compared to third-year students, with five questions reflecting a statistically significant reduction in incorrect responses. The image with the least incorrect for both groups was epidural hemorrhage, 33.9% and 18.5% incorrect for third-year students for diagnosis and treatment, respectively, and 11.1% and 0% incorrect for fourth-year students. Outside of this image, the range of incorrect answers for third-year students was 75.4% to 100% and 44.4% to 100% for fourth-year students. Conclusion Baseline CT knowledge of medical students, regardless of clinical experience, indicated a strong deficit, as more students were incorrect than correct for the majority of CT images.

BACKGROUND: A shortage of pediatric surgeons exists. The purpose of this study was to evaluate pediatric outcomes using pediatric surgeons vs adult trauma surgeons. METHODS: A review was conducted at 2 level II pediatric trauma centers. Center I provides 24-hour in-house trauma surgeons for resuscitations, with patient hand-off to a pediatric surgery service. Center II provides 24-hour in-house senior surgical resident coverage with an on-call trauma surgeon. Data on demographics, resource utilization, and outcomes were collected. RESULTS: Center I patients were more severely injured (injury severity score = 8.3 vs 6.2; Glasgow coma scale score = 13.7 vs 14.3). Center I patients were more often admitted to the intensive care unit (52.2% vs 33.5%) and more often mechanically ventilated (12.9% vs 7.7%), with longer hospital length of stay (2.8 vs 2.3 days). However, mortality was not different between Center I and II (3.1% vs 2.4%). By logistic regression analyses, the only variables predictive of mortality were injury severity score and Glasgow coma scale score. CONCLUSION: As it appears that trauma surgeons' outcomes compare favorably with those of pediatric surgeons, utilizing adult trauma surgeons may help alleviate shortages in pediatric surgeon coverage. Language: en

The absence of a comprehensive database of grain elevator-associated injuries hinders accurate evaluation of injury prevalence and may lead to discordant information about injury frequencies. The main purpose of this study was to identify the most common mechanisms of injury related to grain elevator events. Comparisons of hospital outcomes between patients who sustained traumatic injuries associated with grain elevators at Occupational Safety and Health Administration (OSHA)-regulated industrial sites versus those on OSHA-exempt farming operations were also made.A retrospective review was conducted of all patients' presenting with grain elevator-related injuries at a level-1 trauma center between January 1, 2003, and December 31, 2013. Data collected included demographics, mechanism of injury, injury severity, hospitalization details, and discharge disposition. Data were summarized, and comparisons were made between the groups.All patients (N = 18) in the study were male, with a mean age of 37 years. Falls and being caught in equipment each accounted for 27.8% of injuries. Among the 18 patients, there were a total of 37 injuries. The majority of injuries were either lower extremity (29.7%) or chest injuries (21.6%). The average hospital length of stay was 4 ± 4.5 days, and one patient required mechanical ventilation. There were no reported deaths.The literature reports entrapments as the leading cause of grain elevator-related injuries; however, this study found that falls and being caught in equipment were the most common mechanisms of injury. This suggests that a greater emphasis should be placed on fall prevention and equipment safety.

Background Children with confirmed brain injury usually undergo follow-up computed tomography (CT) scan of the head within 24 hours of admission. To date, no evidence exists to validate the diagnostic or therapeutic value of these repeat CTs. The purpose of this study was to (1) evaluate progression of traumatic brain injuries, (2) determine if routine repeat imaging changes management, and (3) compare the efficacy of recognizing worsening hemorrhage with serial neurological examination versus repeat imaging. Methods A 5-year retrospective review was conducted of all patients aged under 18 years with blunt traumatic head injury (n = 95). Data included demographics, type and size of intracranial hemorrhage, exam findings, diagnostic and management changes, and hospital outcomes. Results Most patients (68.4%) had at least one repeat CT; of these, 67.7% (n = 44) showed no change or reduced hemorrhage. In only one patient did a repeat CT scan result in a surgical procedure; however, that CT scan was prompted by a change in neurological status. Among patients with more than two repeat head CTs, 42.9% led to a change in management, most frequently an additional CT scan. Presence of neurological symptoms was associated with having repeat CT scans (p = 0.025). Changes in Glasgow Coma Scale score were associated with increased hemorrhage (p = 0.012) but not repeat scans (p = 0.496). In the majority of cases, increased hemorrhage only resulted in an additional head CT and prolonged intensive care unit stay. Excluding patients who arrived with brain death, there was no difference in mortality between patients with and without repeat imaging. Conclusion Findings from this study support a selective approach for repeating head CTs with emphasis on changes in neurological symptoms and Glasgow Coma Scale score. Prospective studies on timing and indications for repeat CT scans are needed to support development of clinical guidelines. Level of evidence Therapeutic study, level III.

Background When retained hemothorax occurs, video-assisted thoracoscopy or thoracotomy is performed, but recently, tissue plasminogen activator (tPA) has been used. This study evaluated intrapleural tPA use for retained traumatic hemothoraces. Methods A retrospective review was conducted of trauma patients treated with intrapleural tPA for retained hemothorax. Data included demographics, past medical and surgical histories, injury details, treatment details, and outcomes. Results Seven patients (median age=47 years, male=6, blunt trauma=6) met study criteria. All patients received a chest tube. Six patients later received computed tomography-guided drains for tPA infusion. Number of tPA treatments per patient varied from 1 to 5. Median total tPA dosage was 24 mg. Median time from injury to chest tube placement was 11 days and from chest tube placement to first tPA treatment was 4 days. No patients required a video-assisted thoracoscopy; however, 1 patient required thoracotomy. There were no deaths or bleeding complications attributed to intrapleural tPA. Conclusion Although future studies are needed to identify optimum treatment guidelines, intrapleural tPA appears to be a safe and efficacious treatment option.

Introduction Innominate artery injury occurs, although rare. The innominate artery is the second most common aortic vessel injured as a result of blunt trauma. A blunt mechanism has been associated with up to 35% of innominate artery injuries. Associated innominate artery injuries include aortic or aortic branch injury, pneumothorax, rib fracture, head trauma, and long bone extremity fracture. Traditionally, surgical correction has been the preferred management option. Surgical options include the use of a graft verses primary repair, a bypass exclusion technique, cardiopulmonary bypass, and profound hypothermia or shunts, especially to maintain or protect cerebral perfusion. Stenting is another treatment option. The use and timing of these interventions depends on the characteristics of the innominate artery injury, associated concomitant injuries, resources of the facility, and comfort level of the surgeon. The branching pattern of the human aortic arch is varied. These variations should be kept in mind when dealing with great vessel injuries. The term “bovine arch” will not be used to describe the aortic arch branching pattern anomaly found in the current case as a true bovine arch involves a large brachiocephalic trunk that gives rise to both subclavian arteries and a bicarotid trunk. Two forms of human anomalous arch anatomy have been described as a bovine arch. The first arch variant is characterized as having a common origin of the innominate artery and the left common carotid artery. In a report by Layton and colleagues, they indicated that this variant occurred in approximately 13% of patients. He also reported that the second variant, in which the origin of the left common carotid artery arises from the innominate artery, occurs in less than 10% of the general population. The presence of these anomalies may contribute to the location of a great vessel injury as well as influence the management of the resulting injury in regards to maintaining cerebral perfusion. We report the case of an innominate artery injury in a man with anomalous arch circulation and our management of the injury.

Introduction. Increasing use of main coil angioembolization for splenic injury has raised concerns of increased complication rates and resource utilization compared to splenectomy. This study examined complication rates for severely injured patients undergoing splenectomy versus main coil angioembolization. Methods. Demographic data (age, sex, and race), Injury Severity Score (ISS), and splenic injury grade were collected prospectively on all patients admitted to the intensive care unit with blunt splenic injury treated with splenectomy or main coil angioembolization. Outcome measures (transfusion requirements, mechanical ventilation use and duration, mortality, intensive care unit and hospital length of stay, infection rate, and systemic inflammatory response syndrome or SIRS score) were reviewed daily. Results. Of 116 patients reviewed, 65 underwent splenectomy and 51 underwent main coil angioembolization. Groups were comparable for age, sex, race, and mechanism of injury. Splenectomized patients had a higher ISS (41 vs 31) and splenic injury grade (3.7 vs 3.2). The main coil angioembolization group had a lower transfusion requirement, hospital length of stay, incidence of mechanical ventilation, nosocomial infection rate, and SIRS score. Overall, mortality and ventilator days were lower but not statistically significant. Conclusions. Severely injured patients treated with splenectomy had significantly higher infection rates and resource utilization compared to those treated with main coil angioembolization.

Blunt injury of the abdominal aorta is highly fatal. We present an unusual case of an osteophyte impaling the abdominal aorta treated by endovascular repair. A 77-year-old man sustained a thoracolumbar fracture-dislocation with posterior aortic rupture between his celiac and superior mesenteric artery origins. His aortic injury was treated with a stent graft, excluding the celiac origin. He was dismissed on postoperative day 6. At 6 months, he had returned to most preinjury activities, and at 2-year follow-up, he continues to have good functional outcome. Endovascular repair may be successfully employed in select aortic injuries in hemodynamically stable patients.

Gunshot wounds and blast injuries to the face (GSWBIFs) produce complex wounds requiring management by multiple surgical specialties. Previous work is limited to single institution reports with little information on processes of care or outcome. We sought to determine those factors associated with hospital complications and mortality.We performed an 11-year multicenter retrospective cohort analysis of patients sustaining GSWBIF. The face, defined as the area anterior to the external auditory meatuses from the top of the forehead to the chin, was categorized into three zones: I, the chin to the base of the nose; II, the base of the nose to the eyebrows; III, above the brows. We analyzed the effect of multiple factors on outcome.From January 1, 2000, to December 31, 2010, we treated 720 patients with GSWBIF (539 males, 75%), with a median age of 29 years. The wounding agent was handgun in 41%, explosive (shotgun and blast) in 20%, rifle in 6%, and unknown in 33%. Prehospital or resuscitative phase airway was required in 236 patients (33%). Definitive care was rendered by multiple specialties in 271 patients (38%). Overall, 185 patients died (26%), 146 (79%) within 48 hours. Of the 481 patients hospitalized greater than 48 hours, 184 had at least one complication (38%). Factors significantly associated with any of a total of 207 complications were total number of operations (p0.001), Revised Trauma Score (RTS, p0.001), and head Abbreviated Injury Scale (AIS) score (p0.05). Factors significantly associated with mortality were RTS (p0.001), head AIS score (p0.001), total number of operations (p0.001), and age (p0.05). An injury located in Zone III was independently associated with mortality (p0.001).GSWBIFs have high mortality and are associated with significant morbidity. The multispecialty involvement required for definitive care necessitates triage to a trauma center and underscores the need for an organized approach and the development of effective guidelines.Therapeutic/care management, level III.

BACKGROUND Respiratory failure after acute spinal cord injury (SCI) is well recognized, but data defining which patients need long-term ventilator support and criteria for weaning and extubation are lacking. We hypothesized that many patients with SCI, even those with cervical SCI, can be successfully managed without long-term mechanical ventilation and its associated morbidity. METHODS Under the auspices of the Western Trauma Association Multi-Center Trials Group, a retrospective study of patients with SCI at 14 major trauma centers was conducted. Comprehensive injury, demographic, and outcome data on patients with acute SCI were compiled. The primary outcome variable was the need for mechanical ventilation at discharge. Secondary outcomes included the use of tracheostomy and development of acute lung injury and ventilator-associated pneumonia. RESULTS A total of 360 patients had SCI requiring mechanical ventilation. Sixteen patients were excluded for death within the first 2 days of hospitalization. Of the 344 patients included, 222 (64.5%) had cervical SCI. Notably, 62.6% of the patients with cervical SCI were ventilator free by discharge. One hundred forty-nine patients (43.3%) underwent tracheostomy, and 53.7% of them were successfully weaned from the ventilator, compared with an 85.6% success rate among those with no tracheostomy (p < 0.05). Patients who underwent tracheostomy had significantly higher rates of ventilator-associated pneumonia (61.1% vs. 20.5%, p < 0.05) and acute lung injury (12.8% vs. 3.6%, p < 0.05) and fewer ventilator-free days (1 vs. 24 p < 0.05). When controlled for injury severity, thoracic injury, and respiratory comorbidities, tracheostomy after cervical SCI was an independent predictor of ventilator dependence with an associated 14-fold higher likelihood of prolonged mechanical ventilation (odds ratio, 14.1; 95% confidence interval, 2.78-71.67; p < 0.05). CONCLUSION While many patients with SCI require short-term mechanical ventilation, the majority can be successfully weaned before discharge. In patients with SCI, tracheostomy is associated with major morbidity, and its use, especially among patients with cervical SCI, deserves further study. LEVEL OF EVIDENCE Prognostic study, level III.

Traumatic soft tissue, or "degloving" injuries from trauma are common. These injuries are a result of shearing and disrupt tissue planes, such as the junction between muscle and bone. Traditional repair involves debridement followed by skin grafting or flap reconstruction. Many degloving injuries, however, extend to bone or tendon and the decreased vascularity of the wound bed can compromise the success of traditional repairs. Additionally, medical comorbidities make some patients poor candidates for flap reconstruction. The purpose of this study was to evaluate the success of a dermal regeneration template in the treatment of complex traumatic degloving injuries at an American College of Surgeons verified Level 1 Trauma Center. A retrospective review was conducted on all patients sustaining traumatic degloving injuries from January 2009 to July 2010, who were treated with Integra Dermal Regeneration Template followed by split-thickness autografting. Medical records were reviewed and patient demographics, injury characteristics, comorbidities, hospital course, and outcomes were summarized. Ten patients were studied. All had traumatic degloving injuries of an extremity ranging from 50 to 1000 cm. Nine had injuries extending to bone and/or tendon. After debridement, patients underwent placement of Integra followed by a split-thickness skin graft. Of the 10 patients nine had complete take of their grafts with excellent cosmetic and functional results. Degloving injuries are common in trauma. These injuries often extend to tendon and bone, which poses challenges to repair because of decreased vascularity. Placement of a dermal regeneration template followed by a split-thickness autograft is a viable alternative to traditional methods of repair.

First popularized in Japan, hydrogen sulfide (H2S) gas suicide is an underreported form of suicide with known risk for secondary disaster. Mortality rate commonly exceeds 90% because of the gas's lethal, noncontained nature. Instances in the United States are increasing, up from 2 cases in 2008 to 18 in 2010. Because H2S poisonings remain rare, there exists a lack of knowledge regarding the residual effects of gas venting after victim extrication. Identifying instances of the efficacious use of personal protection equipment (PPE) is critical in the effort to alleviate risks faced by hospital and rescue personnel. The current case demonstrates the effective use of PPEs after prolonged H2S exposure. In 2011, a 20-year-old man threatened suicide using H2S gas inside a vehicle on a remote rural highway. First responders identified a "rotten egg smell" and subsequently experienced low poisoning symptoms. After prolonged Hazmat-assisted extrication (4 hours) the patient was unconscious and experiencing seizures. He was decontaminated on-scene (20 minutes) and transported to the closest hospital (22 minutes). Ambulance personnel who wore PPE and used the ambulance's reverse ventilation system (RVS)reported no adverse effects. The patient was transferred to the authors' burn facility by helicopter (38 minutes). Life-flight personnel, who did not wear PPE (no ventilatory system available), complained of watery eyes, headache, and dizziness. Hospital personnel, who did not use PPE (or RVS), complained of watery eyes or headache. Exposed personnel demonstrated no deficits or residual effects. In spite of spontaneous movement, the patient began to seize and died. This case is unique given the multiple primary and secondary H2S gas exposures involved. Exposed personnel without RVS and not using PPE demonstrated moderate H2S symptoms. PPE (self-contained breathing apparatuses) and RVS were shown to be effective during an H2S emergency; however, there are currently limited data supporting their appropriate use. Until data demonstrating duration of H2S venting for small enclosed spaces are made available, PPEs should be required.

Background This study analyzed outcomes and cost of splenic embolization compared with surgery for the management of blunt splenic injury. Methods We performed a retrospective chart review of all patients admitted with isolated, blunt splenic injury. An intent-to-treat analysis was initially conducted. Outcomes and cost/charges were compared in patients treated with embolization and surgical treatment. Results Of 236 patients admitted with isolated, blunt splenic injury, 190 patients were ultimately managed by observation, 31 by splenic embolization, and 15 by surgical management. Comparing outcomes and cost data for splenic embolization versus surgical management, there was no significant difference in intensive care unit use, hospital stay, complications, or re-admission. Surgical management patients required more blood transfusions and incurred higher procedure charges. Conversely, splenic embolization patients underwent more radiologic evaluations and charges. Total procedure-related charges were higher for surgical management when compared with splenic embolization ($28,709 vs $19,062; P = .016), but total hospital cost and total hospital charges were not significantly different. Conclusions Nonsurgical treatment of blunt splenic injury is safe and cost effective. Angioembolization was statistically similar to surgical therapy regarding cost.

Use of damage control surgery techniques has reduced mortality in critically injured patients but at the cost of the open abdomen. With the option of delayed definitive management of enteric injuries, the question of intestinal repair/anastomosis or definitive stoma creation has been posed with no clear consensus. The purpose of this study was to determine outcomes on the basis of management of enteric injuries in patients relegated to the postinjury open abdomen.Patients requiring an open abdomen after trauma from January 1, 2002 to December 31, 2007 were reviewed. Type of bowel repair was categorized as immediate repair, immediate anastomosis, delayed anastomosis, stoma and a combination. Logistic regression was used to determine independent effect of risk factors on leak development.During the 6-year study period, 204 patients suffered enteric injuries and were managed with an open abdomen. The majority was men (77%) sustaining blunt trauma (66%) with a mean age of 37.1 years±1.2 years and median Injury Severity Score of 27 (interquartile range=20-41). Injury patterns included 81 (40%) small bowel, 37 (18%) colonic, and 86 (42%) combined injuries. Enteric injuries were managed with immediate repair (58), immediate anastomosis (15), delayed anastomosis (96), stoma (10), and a combination (22); three patients died before definitive repair. Sixty-one patients suffered intra-abdominal complications: 35 (17%) abscesses, 15 (7%) leaks, and 11 (5%) enterocutaneous fistulas. The majority of patients with leaks had a delayed anastomosis; one patient had a right colon repair. Leak rate increased as one progresses toward the left colon (small bowel anastomoses, 3% leak rate; right colon, 3%; transverse colon, 20%; left colon, 45%). There were no differences in emergency department physiology, injury severity, transfusions, crystalloids, or demographic characteristics between patients with and without leak. Leak cases had higher 12-hour heart rate (148 vs. 125, p=0.02) and higher 12-hour base deficit (13.7 vs. 9.7, p=0.04), suggesting persistent shock and consequent hypoperfusion were related to leak development. There was a significant trend toward higher incidence of leak with closure day (χ for trend, p=0.01), with closure after day 5 having a four times higher likelihood of developing leak (3% vs. 12%, p=0.02).Repair or anastomosis of intestinal injuries should be considered in all patients. However, leak rate increases with fascial closure beyond day 5 and with left-sided colonic anastomoses. Investigating the physiologic basis for intestinal vulnerability of the left colon and in the open abdomen is warranted.

The use of computed tomography (CT) to identify injury after penetrating torso trauma has become routine in the hemodynamically stable patient. The diaphragm has been a historically difficult structure to evaluate, however, and missed injuries to the diaphragm may result in significant morbidity. With the increasing use of multidetector row CT (MDCT), we hypothesized that CT would be an accurate detection modality to identify patients with diaphragm injuries.We retrospectively reviewed the admission CT of consecutive patients admitted for penetrating injury to the torso during a 4-year period. The CT scans were reviewed and classified into three categories: positive (P), negative (N), or equivocal (Eq). Data from the medical records of these patients were abstracted to identify demographics, injury-specific data, length of stay, length of follow-up (LOFU), and operative findings.There were 803 patients who met inclusion criteria. Mechanism of injury was gunshot wound in 36% and stab wound in 64%. Mean length of stay was 4 days (+/-6.6) and mean length of follow-up was 43 days (+/-184). CT was read as P in 57, N in 710, and Eq in 36 patients. Diaphragm injury was detected in 67 patients overall and was excluded in 736. For the entire study population, sensitivity and specificity were calculated as 94.0% (95% CI = 88.4-99.7) and 95.9% (94.5-97.4) with an overall accuracy of 95.8% (94.4-97.2) if the CT scan was used to exclude diaphragm injury ([P and Eq] vs. N). Sensitivity and specificity were 82.1% (72.9-91.3) and 99.7% (99.4-100) if CT was used to detect diaphragm injury (P vs. [N and Eq]). One hundred and forty-eight patients underwent operative procedures in which the diaphragm was evaluated. Diaphragm injury was identified in 50 (38 P, 4 N, 8 Eq) and was surgically excluded in 104 patients (2 P, 93 N, 9 Eq). Three hundred and eighty-four patients were lost to follow-up; including 348 who had negative finding on CT. There were no known missed diaphragm injuries during the study period or in follow-up.Injuries to the diaphragm occur commonly after penetrating torso trauma. MDCT scan is an accurate test to detect diaphragm injury. When MDCT is equivocal, further investigation is required to evaluate the diaphragm.

This article reports on a study of injuries associated with personal watercraft (PWC). The authors conducted a retrospective review of the trauma registry at a Level I trauma center, covering data between 2000 and 2008, and including all patients (n = 24) injured as a result of PWC use in either Kansas or Oklahoma. The data included patient demographics, location of accident (lake or river), mechanism of accident, type and use of safety equipment, mechanism of injury, indication of intoxication, neurologic status, radiological studies, need for surgery, intensive care unit (ICU) admission and length of stay, need for mechanical ventilation, ventilator days, hospital length of stay (LOS), and discharge status (home, rehabilitation, or death). Average patient age was 29.8 years (plus or minus 14.2 years) and patients were predominantly male (66.7%). The majority of patients were not wearing safety equipment (62.5%) and no patients were known to be wearing protective head gear. Traumatic brain injury (TBI) was the most common injury (n = 9; 37.5%). Bony skeletal injury to the extremity or pelvis was the next most common injury (n = 7; 29.2%). All patients survived with 87.5% discharged to home. There were two delayed diagnoses (8.3%) and five unexpected readmissions (20.8%). The authors stress that, with appropriate education and increased emphasis on safety mechanisms and equipment, many PWC accidents can be prevented. They call for legislative efforts to require mandatory safety measures and impose uniform age restrictions. In addition, both drivers and passengers are cautioned to wear protective head gear.

Injury from personal watercraft has continued to increase. Prior attempts to delineate patterns of injury and relative frequencies have yielded varied results. We retrospectively reviewed Trauma Registry data and charts of all patients who suffered personal watercraft injury treated at the R. Adams Cowley Shock Trauma Center between August 1996 and January 2001. Patient demographics included mechanism of injury, injuries sustained, and outcomes. Attempts were made to correlate events around the injury and injury pattern. During the study period 24 patients were treated. Mechanisms consisted of direct collision, fails from the watercraft, handlebar straddle injuries, axial loading, and hydrostatic jet injury. Traumatic brain injury was most common occurring in 54 per cent of patients. Spinal injury was also common occurring in 29 per cent of patients. Axial loading from falls while wave jumping seemed to correlate with skeletal injury. Thoracolumbar spine injury were often skeletally unstable requiring either brace or operative fixation. Inexperience and reckless behavior were found to be the greatest contributing factors. Substance abuse did not influence injury.

Background Head injuries are common in the pediatric population, but when an isolated skull fracture is found, there are no guidelines for repeat imaging. This study evaluated the need for repeat head computed tomography (CT) for isolated skull fracture. Methods A 10-year retrospective review was conducted of patients 17 years and younger with isolated skull fractures. Data included demographics, injury severity score (ISS), fracture location, clinical indicators of head trauma, intracranial hemorrhage, and mortality. Results Of the 65 patients in this study, mean age was 4.2 years, ISS was 7.2, and head/neck abbreviated injury score was 2.3. Most injuries were from falls (69.2%) and motor vehicle collisions (23.1%). The most common clinical indicators associated with skull fractures were nonfrontal scalp hematoma (40.0%), severe mechanism (30.8%), and loss of consciousness (30.8%). One patient who developed intracranial hemorrhage after the initial head CT showed no bleed. There were no deaths. Conclusion Isolated skull fractures in the pediatric population do not necessitate a repeat head CT as long as they do not develop worsening clinical indicators of head injury.

Significant resources are expended on the assessment of trauma patients who arrive at the trauma center based solely on mechanism of injury. We hypothesized that rollover motor vehicle crashes (ROMVC) are not an independent predictor for trauma center care. All patients seen between January 1, 2001, and December 31, 2005, involved in a ROMVC, were reviewed. Patients with any confounding factors were removed, leaving those transported to the trauma center based on mechanism only. Five hundred sixty-nine patients were transported to our center for the mechanism of ROMVC. Of the 569 patients, 369 (65%) were evaluated and discharged with minimal Injury Severity Score and regional Abbreviated Injury Scale scores. Of the remaining 200 (35%) patients admitted, 130 required surgery, predominantly for closed extremity and facial fractures. Six patients required immediate surgery for life-threatening injuries: 3 splenectomies, 1 subdural evacuation, and 2 vascular repairs (1.1%). Of the remaining 123 (4.2%) patients requiring surgery, 24 required urgent surgery (2 craniotomies, 9 laparotomies, and 13 spinal fixations). None of the patients with spinal injury had neurologic deficit. Eight patients were admitted to the intensive care unit for neurologic monitoring (1.4%). Only 6.7 per cent benefited from initial Trauma Triage Criteria. Therefore, ROMVC is not an independent predictor of the need for trauma center evaluation or admission. The majority of these patients could be safely evaluated and treated at nontrauma centers or transferred later.

The objective of this study was to evaluate incidence of chylous injury in blunt trauma using a retrospective chart review. We present two patients who sustained chyle duct injury after blunt trauma. The first patient is a pedestrian struck by car. Abdominal CT scan revealed duodenal thickening and a moderate amount of paraduodenal fluid, which prompted surgical exploration. At laparotomy, the patient was found to have a disruption of his lymphatics at the level of the inferior vena cava (IVC) without duodenal injury treated with hemoclips, fibrin sealant and elemental gastrojejunal feeds. The second patient was involved in a high speed motor vehicle collision (MVC) resulting in transection of the mesentery of the transverse colon. Disrupted lacteals were treated intra-operatively with hemoclips and fibrin sealant decreasing the lymph leak. In both cases, the leak completely resolved with use of tube feedings with medium chain triglycerides. On literature review, six prior patients with spontaneous chylous retroperitoneum were described undergoing similar operative management. Chylous leakage due to blunt trauma is a rare finding. Mechanism of injury includes hyperextension or flexion resulting in stretching and shearing of the tethered lymphatics. Open ligation or clipping of the injured ducts seems effective. Tube feeds with medium chain triglycerides may enhance efficacy of operative treatment.

BACKGROUND: Motor vehicle collisions (MVCs) are the second leading cause of injury among octogenarians. Physicians and families lack outcomes-based data to assist in the decision-making process concerning injury treatment in this population. The purpose of this study was to evaluate 1-year postdischarge mortality in octogenarian MVC patients, cause of death, and patterns predictive of mortality. METHODS: A 10-year retrospective review was conducted of trauma patients 80 years and older who were involved in an MVC and were subsequently discharged alive. Data collected included demographics, injury severity and patterns, hospitalization details, and outcomes. State death database and hospital records were queried to determine cause of death for patients who died within 12 months of hospital discharge. Analyses were conducted to explore if a relationship existed between severity of injury and injury patterns to 12-month postdischarge mortality. RESULTS: Among the 199 patients included in this study, mean (SD) age and Injury Severity Score (ISS) was 84.2 (3.3) years and 9.3 (8.2), respectively. Twenty-two patients (11.1%) died within 12 months. Among these patients, cause of death was directly related to trauma in nine (40.9%), likely related to trauma in seven (31.8%), and unrelated to trauma in six (27.3%). More severely injured patients (ISS >15, p = 0.0041) and those admitted to the intensive care unit (ICU) (p = 0.0051) were more likely to die within 12 months of discharge. Results indicated a trend toward higher mortality in patients with pneumonia. Rib, hip, and pelvic fractures; spinal injuries; intubation upon hospital arrival; and need for mechanical ventilation were not associated with higher postdischarge mortality rates. CONCLUSION: The commonly held belief that the majority of octogenarians with MVC-related trauma die within 1 year of hospital discharge is refuted by this study. Only injury severity, ICU admission, and ICU duration were predictive of mortality within 12 months following discharge. LEVEL OF EVIDENCE: Prognostic study, level III. Language: en

Background While percutaneous tracheostomy (PT) is becoming the procedure of choice for elective tracheostomy, there is little late complication data. This study compared incidence of, and factors contributing to, tracheal stenosis following PT or open tracheostomy (OT). Methods A 10-year review was conducted of trauma patients undergoing tracheostomy. Data on demographics, injury severity, tracheostomy type, complications, and outcomes were compared between patients receiving PT or OT and for those with or without tracheal stenosis. Results Of 616 patients, 265 underwent OT and 351 underwent PT. Median injury severity score was higher for PT (26 vs 24, P = .010). Overall complication rate was not different (PT = 2.3% vs OT = 2.6%, P = .773). There were 9 tracheal stenosis, 4 (1.1%) from the PT group and 5 (1.9%) from the OT group ( P = .509). Mortality was higher in OT patients (15.5% vs 9.7%, P = .030). Patients developing tracheal stenosis were younger (29.8 vs 45.2 years, P = .021) and had a longer intensive care unit length of stay (28.3 vs 18.9 days, P = .036). Conclusion Risk of tracheal stenosis should not impact the decision to perform an OT or PT.

The study first assessed comfort levels of physical and occupational therapists who provide burn care prior to a hands-on intervention, then assessed therapists' confidence levels following an educational intervention. Physical and occupational therapists who previously treated burn survivors were invited to complete a preworkshop confidence level survey. From this information, four burn rehabilitation interventional categories were identified: positioning and exercise, compression, wound healing, and burn resources. A one-day workshop was held targeting these categories. Surveys were offered at the conclusion of the workshop as well as at 6-month follow-up. Initial survey results (n = 31) indicated that more than 75% of therapists felt unconfident or strongly unconfident in providing burn rehabilitation to patients. The postworkshop survey demonstrated significant improvements in all interventional categories. Further analysis revealed that baseline confidence levels for positioning and exercise were significantly higher than the other categories (P < .03). Six-month follow-up results (n = 20) confirmed that confidence gained from the workshop remained significantly higher than preworkshop confidence levels. Baseline therapists' confidence levels in treating burn survivors were low, but improved following a one-day educational workshop. Providing hands-on burn education improved the confidence of therapists who treat burn survivors. Future efforts to improve therapist confidence and patient outcomes need to be explored.

Traumatic brain injury remains one of the most prevalent and costly injuries encountered within the discipline of trauma and represents a leading cause of morbidity and mortality within our society. The purpose of this study was to compare the safety of intracranial pressure (ICP) monitor placement by general surgery residents and neurosurgeons.A retrospective chart review of all trauma patients requiring ICP monitor placement at an American College of Surgeons-verified Level 1 trauma center during a 10-year period was performed. Comparison of demographic variables, injury severity, intracranial injuries, incidence of ICP monitor-related complications, and outcomes were made between general surgery residents, trauma surgeons, and neurosurgeons.There were 546 patients included in the study. The average age of the cohort was 37.6 years, with an average hospital length of stay being 16.0 days and an Injury Severity Score of 27.7. Mechanisms of injury varied, but 58.8% was a result of motor vehicle and motorcycle collisions, and an additional 19.2% was a result of falls. No significant difference was found in terms of procedure-related complications between subgroups, including intracranial hemorrhage, infection, malfunctions, dislodgment, or death.Our results demonstrate that the placement of ICP monitors may be performed safely by both neurosurgeons and non-neurosurgeons. This procedure should thus be considered a core skill for trauma surgeons and surgical residents alike, thereby allowing initiation of prompt medical treatment in both rural areas and trauma centers with inadequate neurosurgeon or fellow coverage.Therapeutic study, level IV.

The open abdomen is a requisite component of a damage control operation and treatment of abdominal compartment syndrome.Enteral nutrition (EN) has proven beneficial for patients with critical injury, but its application in those with an open abdomen has not been defined. The purpose of this study was to analyze the use of EN for patients with an open abdomen after trauma and the effect of EN on fascial closure rates and nosocomial infections.We reviewed patients with an open abdomen after injury from January 2002 to January 2009 from 11 trauma centers.During the 7-year study period, 597 patients required an open abdomen after trauma. Most were men (77%) sustaining blunt trauma (72%), with a mean (SD) age of 38 (0.7) years, an Injury Severity Score of 31 (0.6), an abdominal injury score of 3.8(0.1), and an Abdominal Trauma Index score of 26.8 (0.6). Of the patients, 548 (92%) had an open abdomen after a damage control operation, whereas the remainder experienced an abdominal compartment syndrome. Of the 597 patients, 230 (39%)received EN initiated before the closure of the abdomen at mean (SD) day 3.6 (1.2) after injury. EN was started with an open abdomen in one quarter of the 290 patients with bowel injuries. For the 307 patients without a bowel injury, logistic regression indicated that EN is associated with higher fascial closure rates (odds ratio [OR], 5.3; p G 0.01), decreased complication rates(OR, 0.46; p = 0.02), and decreased mortality (OR, 0.30; p = 0.01). For the 290 patients who experienced a bowel injury,regression analysis showed no significant association between EN and fascial closure rate (OR, 0.6; p = 0.2), complication rate (OR, 1.7; p = 0.19), or mortality (OR, 0.79; p = 0.69).EN in the open abdomen after injury is feasible. For patients without a bowel injury, EN in the open abdomen is associated with increased fascial closure rates, decreased complication rates, and decreased mortality. EN should be initiated in these patients once resuscitation is completed. Although EN for patients with bowel injuries did not seem to affect the outcome in this study,prospective randomized controlled trials would further clarify the role of EN in this subgroup.

An occult pneumothorax (OPTX) is found incidentally in 2% to 10% of all blunt trauma patients. Indications for intervention remain controversial. We sought to determine which factors predicted failed observation in blunt trauma patients.A prospective, observational, multicenter study was undertaken to identify patients with OPTX. Successfully observed patients and patients who failed observation were compared. Multivariate logistic regression was used to identify predictors of failure of observation. OPTX size was calculated by measuring the largest air collection along a line perpendicular from the chest wall to the lung or mediastinum.Sixteen trauma centers identified 588 OPTXs in 569 blunt trauma patients. One hundred twenty-one patients (21%) underwent immediate tube thoracostomy and 448 (79%) were observed. Twenty-seven patients (6%) failed observation and required tube thoracostomy for OPTX progression, respiratory distress, or subsequent hemothorax. Fourteen percent (10 of 73) failed observation during positive pressure ventilation. Hospital and intensive care unit lengths of stay, and ventilator days were longer in the failed observation group. OPTX progression and respiratory distress were significant predictors of failed observation. Most patient deaths were from traumatic brain injury. Fifteen percentage of patients in the failed observation group developed complications. No patient who failed observation developed a tension PTX, or experienced adverse events by delaying tube thoracostomy.Most blunt trauma patients with OPTX can be carefully monitored without tube thoracostomy; however, OPTX progression and respiratory distress are independently associated with observation failure.

Occult pneumothorax (OPTX) represents air within the pleural space not visible on conventional chest radiographs. Increased use of computed tomography has led to a rise in the detection of OPTX. Optimal management remains undefined.A pediatric subgroup analysis (age18 years) from a multicenter, observational study evaluating OPTX management. Data analyzed were pneumothorax size, management outcome, and associated risk factors to characterize those that may be safely observed.Fifty-two OPTX (7.3 ± 6.2 mm) in 51 patients were identified. None were greater than 27 mm; all those under 16.5 mm (n = 48) were successfully managed without intervention. Two patients underwent initial tube thoracostomy (one [21 mm] and the other with bilateral OPTX [24 mm, 27 mm]). Among patients under observation (n = 49), OPTX size progressed in 2; one (6.4mm) required no treatment, while one (16.5 mm) received elective intervention. Respiratory distress occurred in one patient (10.7 mm) who did not require tube thoracostomy. Nine received positive pressure ventilation; 8 did not have a tube thoracostomy. Twenty-four patients (51%) had one or more rib fractures; 3 required tube thoracostomy.No pediatric OPTX initially observed developed a tension pneumothorax or adverse event related to observation. Pediatric patients with OPTX less than 16 mm may be safely observed. Neither the presence of rib fractures nor need for PPV alone necessitates intervention.

Background: Splenic artery embolization (SAE) improves non-operative splenic salvage rates in adults, but its utility and safety in the pediatric population is less well defined. Objective: Because adolescent trauma patients are often triaged to adult trauma centers, we were interested in evaluating SAE in this particular population. We hypothesize that angiography and embolization is a safe and effective adjunct to non-operative management in the adolescent population. Methods: A retrospective review of all patients aged 13–17 years admitted to our Level I Trauma Center with blunt splenic injury from 1997–2005 was performed. We reviewed patient demographics, operative reports, admission, and follow-up abdominal computed tomography (ACT) results, angiographic reports, and patient outcomes. Results: A total of 97 patients were reviewed. Eighteen patients underwent immediate surgery, and 79 of the remaining patients had planned non-operative management. Of those participating in non-operative management, 35/79 (44%) were initially observed and 44/79 (56%) underwent initial angiography, 23/44 having embolization. Patients in the embolization group had an overall high grade of injury (American Association for the Surgery of Trauma mean grade 3.3, SD 0.6). The overall splenic salvage rate was 96% (76/79) in the non-operative management group; 100% splenic salvage was seen in the observational group; 100% salvage was also seen in patients with negative angiography, and 87% salvage (20/23) in the splenic artery embolization group. Conclusion: Splenic artery embolization may be a valuable adjunct in adolescent blunt splenic injury, especially in higher grade injuries or with evidence of splenic vascular injury on ACT.

To determine the need for further therapy in patients with persistent or new pseudoaneurysms (PSAs) after splenic main coil embolization.The institutional review board approved the study. The study group consisted of 400 hemodynamically stable patients (261 men, 139 women; mean age, 38.5 years) with blunt splenic injury. Abdominal computed tomography (ACT) images were assessed for grade of splenic injury, volume of hemoperitoneum, and evidence of splenic vascular injury including splenic vascular lesions and active bleeding. Splenic arteriography was performed for high-grade splenic injury and for ACT evidence of vascular injury. Follow-up ACT was reviewed for evidence of new or persistent PSAs after main coil embolization of the splenic artery. Medical records were reviewed to determine final outcome and any additional therapies used.Thirty-two patients had persistent (27) or new PSAs (5) after main coil embolization. Of these patients, two required splenectomy and one splenorrhaphy. The nonoperative salvage rate was 91% and the splenic salvage rate was 94%; this was comparable to the overall salvage rate of 95%.Splenic embolization remains a valuable adjunct in splenic salvage. Patients with persistent or new splenic PSAs after main coil embolization have similar splenic salvage rates to the overall cohort without additional therapies.

Daily multidisciplinary discharge rounds have been shown to decrease length of stay (LOS), increase patient volumes, and virtually eliminates "bypass" (inability to accept admissions). Originally, these were attended by senior house staff from each trauma team. Implementation of the 80-hour workweek precluded house staff participation, raising concerns that these rounds would loss their benefits. Certified nurse practitioners (CRNPs) were added to the trauma teams to assist in patient care and represent the team on discharge rounds, replacing the fellows. We hypothesized that this would offset any potential negative effects.A senior trauma physician leads discharge rounds, focusing on each patient's plan of care. Rounds cover 90 inpatient beds and last approximately 60 minutes. CRNPs from each trauma team, orthopedics, and neurosurgery as well as the teams' discharge planner, hospital bed manager, unit nursing staff, and physical, occupational, and speech therapists participate in discharge rounds.The results are stratified by time period: June 1998 to May 1999 is before discharge rounds, June 1999 to May 2001 is during the house staff period, and June 2001 to May 2004 is when CRNPs replaced fellows and residents. During the 5-year period, 1999 to 2004, daily discharge rounds maintained their efficacy. We have increased admissions, whereas LOS has remained the same. Admissions of greater than 24 hours have increased, whereas average injury severity score has statistically remained the same. Bypass has virtually been eliminated.Adding CRNPs to discharge rounds has allowed us to have the continued benefits of decreased LOS and increased patient volume. Bypass remains rare. CRNPs can effectively replace some house staff functions.

BACKGROUND: To determine the accuracy of contrast-enhanced multidetector CT (MDCT) in demonstrating splenic vascular injury based on results of splenic angiography and operation. STUDY DESIGN: This institutional review board-approved study included 392 hemodynamically stable blunt trauma patients whose admission MDCTs demonstrated splenic injury. Images were assessed for parenchymal injury grade, hemoperitoneum volume, and evidence of bleeding and nonbleeding splenic vascular injury. Splenic arteriography was performed for high splenic injury grade and splenic vascular injury. Medical records were reviewed to determine arteriographic interpretation, surgery indications and findings, outcomes, and demographics. Sensitivity, specificity, predictive values, and accuracy of MDCT in detecting vascular injury were calculated based on results of arteriography and operation. RESULTS: Splenic vascular injury was seen in 22% of patients (86 of 392) on MDCT. Presence of a vascular injury correlated with the CT-based parenchymal splenic injury grade (p < 0.0001). Active splenic bleeding was associated with subsequent clinical deterioration (p < 0.0001). Overall, MDCT had a sensitivity of 76% (76 of 100); specificity of 90% (95 of 106); negative and positive predictive values of 80% (95 of 119) and 87% (76 of 87), respectively; and accuracy of 83% (171 of 206) in detecting vascular injury compared with reference standards. The success rate of nonoperative management was 96%. CONCLUSIONS: MDCT provides valuable information to direct initial clinical management of patients with blunt splenic trauma by demonstrating both active bleeding and nonbleeding vascular injuries. Not all vascular injuries are detected on MDCT, and splenic angiography is still indicated for high-grade parenchymal injury.