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The ACS Committee on Trauma specifies prehospital criteria that trigger trauma team activation (TTA). The study aims to define the relationship between TTA and time of day, mechanism of injury, and need for operative intervention. All trauma patients presenting to LAC1USC (January 2008–July 2018) after triggering TTA were screened. Patients were excluded if time of ED arrival was undocumented. Demographics, injury data, and outcomes were analyzed. After exclusions (

After traumatic injury, primary anastomosis after colon resection has overtaken ostomy diversion. Improved technology facilitating primary anastomosis speed and integrity may have driven this change. Trends in ostomy versus anastomosis have yet to be quantified, and recent literature comparing outcomes is incomplete.The National Trauma Databank (2007-2014) was queried for all blunt colon injuries requiring resection. Patients were dichotomized into study groups based on whether they underwent ostomy creation. Ostomy creation frequency was compared over time. After subgrouping patients by colon injury location, multivariate regression adjusted for baseline characteristics and evaluated the impact of ostomy on clinical outcomes.A total of 13,949 colon injuries requiring colectomy were identified. Ostomy frequency did not vary by study year (P = 0.536). Univariate analysis showed that patients undergoing ostomy were older (median, 40 versus 32; P 0.001) and more often had comorbidities (65% versus 56%; P 0.001). Multivariate analysis showed that ostomy creation was significantly associated with lower mortality after sigmoid colon injury (odds ratio, 0.512; P = 0.011) and higher rates of unplanned reoperation after transverse colon injury (odds ratio, 3.135; P = 0.048). Across all colon injuries, ostomies were significantly associated with longer hospital length of stay, intensive care unit length of stay, and ventilator days.Ostomy creation for colonic injury has reached an equilibrium trough. The impact of ostomy creation varies by not only clinical outcome but also injury location. Further study is needed to define the optimal surgical management for blunt colon injuries requiring resection.

Shotgun wounds pose diagnostic challenges due to variable fragment penetration and degradation of CT images. This study compared epidemiology and outcomes between shotgun wounds and gunshot wounds (GSWs), and defined the diagnostic capabilities of CT scan after shotgun wounds. All patients presenting to our Level I trauma center after ballistic injury (01/2008–03/2017) were included. Study groups were defined by shotgun vs GSW. Demographics, clinical data, and outcomes were compared using univariate analysis. The diagnostic yield of CT scan after shotgun wounds was calculated. Of 3177 patients, 3126 (98%) were injured by GSWs and 51 (2%) by shotguns. Of the shotgun-injured patients, 5 (10%) had superficial wounds, 8 (16%) underwent emergency surgery, and 38 (74%) underwent CT scan [10 (26%) were then brought to OR and 28 (74%) were managed nonoperatively]. The sensitivity, specificity, PPV, and NPV of CT scan after shotgun wounds were 0.93, 0.96, 0.93, and 0.97. There was one false-negative CT scan, which missed a hollow viscus injury. There was one false-positive CT scan, which suggested a hollow viscus injury, although none was found on exploratory laparotomy. Patients injured by shotgun required fewer cavitary explorations (25% vs 59%, p = 0.006) but more soft tissue (21% vs 8%, p = 0.013) and extremity vascular surgeries (86% vs 9%, p

Intraoperative consultations are an important component of acute care surgery (ACS). The nature of these consultations is incompletely characterized by the existing literature. The study objective was to define the characteristics of intraoperative consults managed by a mature ACS program at a Level I trauma center. All intraoperative consultations requested from the ACS service at LAC1USC Medical Center (January 2011–July 2016) were identified. Demographics, date/time of consultation, referring service, procedure data, and outcomes were abstracted. Sixty-four intra-operative consultations were identified. Patients had a mean age of 45 (range 21–64) and 84 per cent (n = 54) were female. Gynecology was the most frequent consulting service (n = 42, 66%), followed by urology (n = 12, 19%). Surgical intervention was required in 61 per cent (n = 39) and verbal advice with clinical follow-up was required in 39 per cent (n = 25). The most common procedures were repair of an injury (n = 19, 49%), usually to the small bowel or colon; resection of an incidental finding (n = 13, 33%), typically the appendix or a Meckel's diverticulum; and lysis of adhesions (n = 7, 18%). In conclusion, intraoperative consultation is provided by ACS to a wide range of consultants, especially gynecology and urology. These consults are most frequently requested for concern for iatrogenic injury. Both surgical and verbal interventions are used.

The objective of this study was to determine the survival outcome associated with large-volume blood transfusion after trauma. This was a retrospective study at a Level I trauma center from January 2000 to December 2014 that included trauma patients who received ≥25 units packed red blood cell (pRBC) within the first 24 hours of hospital admission. Univariate and multivariable logistic regressions identified risk factors for mortality. Receiver operating characteristic curve analysis evaluated the ability of pRBC volume to predict mortality. Among 74,065 adults (‡18 years old), 178 patients (0.24%) received ≥25 units of pRBC in the first 24 hours, of which 142 (79.8%) received 25 to 49 units, 28 (15.7%) received 50 to 74 units, and 8 (4.5%) received ≥75 units. Overall, 92.2 per cent were male, mean age 33.9 (614.0), mean Injury Severity Score 28.9 (614.3), and median Glasgow Coma Scale score 12 (3–15). The overall mortality was 65.2 per cent and 64.1 per cent for those receiving 25 to 49 units, 64.3 per cent for 50 to 74 units, and 87.5 per cent for ≥75 units. In univariate analysis, female gender was associated with lower mortality [odds ratio (OR) 0.24, P = 0.025]. Decreasing Glasgow Coma Scale (OR 0.82, P < 0.001), increasing Injury Severity Score (OR 1.07, P < 0.001), and thoracotomy (OR 3.91, P < 0.001) were associated with higher mortality. There was no transfusion cutoff that was significantly associated with higher mortality.

Research is lacking around how best to approach trauma care in resource poor settings, particularly in remote areas such as the islands of the South Pacific. Without examples of successful treatment of high-risk cases in these settings, countries are unable to move forward with developing policies and standardized procedures for emergency care.The Republic of Kiribati is a Pacific Island nation composed of 33 islands spanning over 2,000 miles in the central Pacific Ocean. With the only hospital located on Kiritimati Island and inadequate boat transportation, the government recently committed to providing an aircraft for patients to receive appropriate medical care. In 2016, a 20-year-old female, primigravida, on a neighboring island, failed to progress in labor for 24 hours and needed an emergency cesarean section. A radio call was made to Kiritimati, and a team consisting of a general surgeon, nurse, and a laboratory technician was dispatched. The patient was brought to the local clinic and flown to Kiritimati where a team was prepared to perform the cesarean section.The successful patient evacuation emphasizes the importance of a dedicated health care team, government commitment, and the constant quality communication when approaching feasibility of trauma and emergency care. (Disaster Med Public Health Preparedness. 2019;13:774–776).

BACKGROUND Patients who sustain pelvic gunshot wounds (GSWs) are at significant risk for injury owing to the density of pelvic structures. Currently, the optimal workup for pelvic GSWs is unclear. The aims of this study were to determine the diagnostic yield of tests commonly used in the investigation of pelvic GSWs and to develop a diagnostic algorithm. METHODS All patients 15 years or older presenting to the Los Angeles County + University of Southern California Medical Center (January 2008 to February 2015) who sustained one or more pelvic GSWs were retrospectively identified. Patients' demographics, clinical assessment, investigations, procedures, and outcomes were abstracted. The diagnostic yield of computed tomographic (CT) scan, cystogram, gross inspection of the urine, urinalysis, endoscopy, and digital rectal examination (DRE) in the detection of clinically significant injuries to the pelvis were calculated. RESULTS Three hundred seventy patients were included. Patients with peritonitis, hemodynamic instability, an unevaluable abdomen, or evisceration were taken to the operating room for immediate laparotomy (n = 138 [37.3%]). All others (n = 232 [62.7%]) underwent CT scan and further investigations as indicated. The sensitivity, specificity, positive predictive value, and negative predictive value of the investigations were CT scan: 1.00, 0.98, 0.74, and 1.00; cystogram: 1.00 for all parameters; gross inspection of the urine: 1.00 for all parameters; urinalysis: 1.00, 0.71, 0.17, and 1.00; endoscopy: 1.00, 0.82, 0.75, and 1.00; and DRE: 0.77, 0.99, 0.77, and 0.99. CONCLUSION In the workup of pelvic GSWs, patients with hemodynamic instability, peritonitis, evisceration, or an unevaluable abdomen should undergo immediate laparotomy, while all others should undergo CT scan. Computed tomography-positive patients should be managed for their injuries. If the CT is negative, the likelihood of a clinically significant injury is very low. If the CT is equivocal for rectal or bladder injury, endoscopy or cystogram should be used to guide definitive management. There is no role for routine urinalysis or DRE. Further prospective validation of these findings is warranted. LEVEL OF EVIDENCE Diagnostic study, level III; therapeutic study, level IV.

Traumatic coagulopathy (TC) occurs in 24% to 38% of adults and is associated with up to a six-fold increase in mortality. This study's purpose was to determine the incidence of pediatric TC and its impact on mortality.A retrospective review (2004-2009) of all trauma patients from our Level I trauma center was performed. Coagulopathy was defined as an international normalized ratio of 1.5 or higher or activated partial thromboplastin time of more than 36 seconds or platelets less than 100,000/mm. Clinical outcomes were compared between pediatric (younger than 16 years) and adult patients (≥16 years or older).A total of 20,126 patients were identified (7.6% pediatric, 92.4% adult). Mean ± SD age was 8.7 ± 4.8 years for pediatric patients and 37.6 ± 16.7 years for adults. The incidence of admission coagulopathy was lower in children (5.8% vs. 8.4%; p0.001). Pediatric patients were less likely to develop coagulopathy (8.4% vs. 12.4%; p0.001) and developed coagulopathy later than adults (102.3 ± 123.2 hours vs. 59.2 ± 1,823.9 hours; p0.001). Traumatic brain injury (TBI) and non-TBI-related coagulopathy increased in stepwise fashion with age (up to 19.5% in elderly). Adult and pediatric TC was associated with increased mortality (pediatric: 14.4% vs. 0.5%; p = 0.02; adult: 18.3% vs. 1.8%; p0.001).Pediatric trauma patients are less likely to present with coagulopathy, are less likely to develop coagulopathy during their admission, and tend to develop coagulopathy later than adults. If they develop coagulopathy, however, mortality increases in a stepwise fashion with age and is associated with a two- to four-fold increased risk of death.Epidemiologic study, level III.

Purpose It remains unknown whether critically ill trauma patients can be successfully managed by advanced practitioners (APs). The purpose of this study was to examine the impact of night coverage by APs in a high-volume trauma intensive care unit (ICU) on patient outcomes and care processes. Materials and methods During the study period, our ICU was staffed by APs during the night shift (7 pm -7 am ) from Sunday to Wednesday and by resident physicians (RPs) from Thursday to Saturday. On-call trauma fellows and attending surgeons in house supervised both APs and RPs. Patient outcomes and care processes by APs was compared with those admitted by RPs. Results A total of 289 patients were identified between July 2013 and February 2014. Median lactate clearance rate within 24 hours of admission was similar between study groups (10.0% vs 9.1%; P = .39). Advanced practitioners and RPs transfused patients requiring massive transfusion with a similar blood product ratio (packed red blood cell:fresh frozen plasma) (2.1:1 vs 1.7:1; P = .32). In a multiple logistic regression analysis, AP coverage was not associated with any clinical outcome differences. Conclusions Our data suggest that, with adequate supervision, a high-volume trauma ICU can be safely staffed by APs overnight.

Penetrating abdominal vascular injuries result in significant mortality. In the pre-hospital phase of care, “scoop and run” is the optimal strategy while on-scene interventions are restricted only to basic airway maneuvers. Early in-hospital diagnosis and operative interventions are prerequisites for survival in vascular trauma. Hypotension and peritonitis following penetrating abdominal trauma mandate immediate access to the operating room with vascular surgery capabilities. Patients presenting in extremis should be managed with a resuscitative thoracotomy in the emergency department. The majority of abdominal vascular injuries surviving to the operating room are subjected to damage control intervention. In hemodynamically stable patients, diagnostic modality of choice is computed tomography angiography and endovascular interventions are evolving.

Despite significant progress in surgery, controversy persists about timing of appendectomy. Objective of this prospective observational study was to determine associations between time interval from onset of symptoms in appendicitis to appendectomy and postoperative complications. After institutional review board approval, all adult consecutive patients subjected to emergency appendectomy between 1/9/2013 and 1/12/2014 were prospectively enrolled. Data collection included demographics, open vs. laparoscopic appendectomy, comprehensive complication index (CCI), and 30-day follow-up. To determine time-dependent associations between delay of surgery and complications all patients were stratified into subgroups based on 12-h time intervals from onset of abdominal pain to surgery. Primary outcome was complications per CCI in correlation to delay from symptoms to appendectomy. Secondary outcomes included duration of surgery, hospital length of stay (HLOS), and incidence of complication within 30-day follow-up. A total of 266 patients with a mean age of 35.4 ± 14.8 years met inclusion criteria. Overall, 83.1 % of patients were subjected to laparoscopic appendectomy. Delay to surgery in 12-h increments showed stepwise-adjusted increase in complications per CCI (adj. P = 0.037). Also, delay to appendectomy increased significantly duration of surgery and HLOS, respectively (adj. P

Background Hemorrhage remains the leading cause of preventable death after trauma. The XSTAT expandable minisponge hemostatic device was developed for the control of severe, life-threatening bleeding from junctional wounds not amenable to tourniquet application. This is an initial report of the clinical use of this novel method of hemorrhage control for civilian penetrating injury. Methods A review of trauma admissions at a high-volume Level I trauma center was performed from July 2016 to November 2017. All patients sustaining penetrating trauma with active hemorrhage were evaluated for XSTAT use. Ten device deployments occurred during this time. Each deployment was reviewed in detail, capturing patient and injury data, efficacy of hemorrhage control, and evaluation of any potential device or treatment related complications. Results Six thousand three hundred sixty-three trauma admissions were reviewed with 22.1% sustaining a penetrating mechanism of injury. XSTAT was deployed in 10 (0.7%) penetrating trauma admissions with a mean age of 38.3 (range, 16-59) years, systolic blood pressure (SBP) of 126.7 (range, 74-194) mm Hg, Glasgow Coma Scale (GCS) score of 14.5 (range, 13-15), and New Injury Severity Score (NISS) of 9.5 (range, 1-27). Eight patients had an identifiable arterial injury; the remainder had vein or soft tissue bleeding. Overall, half were junctional injuries. XSTAT was able to stop bleeding in nine of ten patients on the first deployment, with the remaining patient requiring one repeat injection. Dwell times ranged from 1 hour to 40 hours (median, 15 hours). There were no technical device failures or embolic complications. Retained sponges were identified in two patients on initial postremoval x-rays following wound exploration for definitive hemorrhage control and sponge removal. No patient died during the study period. Conclusion XSTAT use appears safe. It is rapid, reliable, and provides a high degree of hemorrhage control on first deployment. Sponge removal should always be followed by radiographic clearance. For patients with hemorrhage from cavitary wounds not amenable to tourniquet placement, this device was effective. Further study is warranted as XSTAT use becomes more widespread. Level of evidence Therapeutic study, level V.

Background When ground-level falls occur in the bathroom, there is particular potential for morbidity and mortality given the high density of hard surfaces. Risk factors are not clearly defined by the existing literature. The objective of this study was to define the epidemiology, injury patterns, and outcomes after falls in the bathroom. Materials and methods All patients presenting to LAC+USC Medical Center (01/2008-05/2015) after a fall in the bathroom (ICD-9 code E884.6) were included. Demographics, injury data, investigations, procedures, and outcomes were collected. Results Fifty-seven patients were included, with mean age 45 y (range 0-92). All ages were affected, with ages 41-60 y at highest risk. Common comorbidities included cardiovascular disease (n = 23, 40%), neuromuscular disorders (n = 13, 23%), and diabetes (n = 9, 16%). Ten patients (18%) were intoxicated. Home medications included antihypertensives (n = 18, 32%), antipsychotics (n = 9, 16%), and anticoagulants (n = 8, 14%). Common investigations included X-rays (n = 41, 72%) and CT scans of the head (n = 20, 35%). The most frequent injuries were contusion/laceration (n = 45, 79%), fracture (n = 12, 21%), and traumatic brain injury (n = 7, 12%). Most patients did not require hospital admission (n = 46, 81%), although 4 (7%) needed intensive care unit care and operative intervention (ORIF [n = 2, 4%] or craniectomy [n = 2, 4%]). Mortality was low (n = 1, 2%). Most patients were discharged home (n = 40, 70%). Conclusions All ages, especially 41-60 y, are susceptible to falls in the bathroom. Despite the potential for serious injury, most do not require hospital admission. Risk factors include drugs/alcohol, cardiovascular disease, neuromuscular disorders, and diabetes. Efforts to minimize fall risk should be directed toward these individuals.

Severe bleeding due to pelvic fractures may require damage control procedures, such as preperitoneal packing. In many cases, preperitoneal packing is performed without full abdominal exploration. There are concerns that such an approach may miss major iliac vascular injuries or other intraabdominal injuries. This analysis assessed the incidence of iliac vascular and intraabdominal injuries in patients with pelvic fractures. The National Trauma Data Bank was queried for blunt trauma patients. Patients with severe pelvic fractures were observed. Common or external iliac vascular lacerations (CEIVL) and associated intraabdominal injuries were recorded. The study comprised 42,122 patients with pelvic fractures, of which 3,221 (7.6%) were severe pelvic fractures. The incidence of CEIVL in patients with severe pelvic fractures was 10.7 per cent. Patient age greater than or equal to 65 years was an independent predictor of CEIVL. A total of 34.3 per cent of severe pelvic fracture patients had severe associated intraabdominal injuries, including injuries to the bladder (26.5%) and bowel (16.7%). Severe pelvic fractures are associated with a high incidence of iliac vascular and intraabdominal injuries. Preperitoneal pelvic packing without abdominal exploration may miss these injuries.

Diagnostic peritoneal aspiration (DPA) refers to the insertion of a catheter in the peritoneal cavity and aspiration of any fluid. Diagnostic peritoneal lavage (DPL) involves infusion of normal saline, lavage of the cavity, and macroscopic and microscopic evaluation of the returned fluid. DPA and DPL have largely been replaced by CT scan and abdominal ultrasound. However, in select cases it can provide quick information about intraperitoneal bleeding or infection. The most common trauma indication for DPA/DPL is suspicion of intraperitoneal bleeding in a hemodynamically unstable patient with a negative or equivocal ultrasound, who cannot undergo CT scan evaluation. DPA/DPL might be useful in selected unstable ICU patients with suspected peritonitis or who otherwise cannot be safely transferred for CT scan evaluation. There is evidence that the DPA is as sensitive as DPL in identifying clinically significant intraperitoneal bleeding. DPA/DPL does not identify retroperitoneal bleeding.

It remains unclear whether the timing of neurosurgical intervention impacts the outcome of patients with isolated severe traumatic brain injury (TBI). We hypothesized that a shorter time between emergency department (ED) admission to neurosurgical intervention would be associated with a significantly higher rate of patient survival.Our institutional trauma registry was queried for patients (2003-2013) who required an emergent neurosurgical intervention (craniotomy, craniectomy) for TBI within 300 minutes after the ED admission. We included patients with altered mental status upon presentation in the ED (Glasgow Coma Scale [GCS] score9). Patients with associated severe injuries (Abbreviated Injury Scale [AIS] score ≥ 2) in other body regions were excluded. In-hospital mortality of patients who underwent surgery in less than 200 minutes (early group) was compared with those who underwent surgery in 200 minutes or longer (late group) using univariate and multivariate analyses.A total of 161 patients were identified during the study time frame. Head computed tomographic scan demonstrated subdural hematoma in 85.8%, subarachnoid hemorrhage in 55.5%, and equal numbers of epidural hematoma and intraparenchymal hemorrhage in 22.6%. Median time between ED admission and neurosurgical intervention was 133 minutes. In univariate analysis, a significantly lower in-hospital mortality rate was identified in the early group (34.5% vs. 59.1%, p = 0.03). After adjusting for clinically important covariates in a logistic regression model, early neurosurgical intervention was significantly associated with a higher odds of patient survival (odds ratio, 7.41; 95% confidence interval, 1.66-32.98; p = 0.009).Our data suggest that the survival rate of isolated severe TBI patients who required an emergent neurosurgical intervention could be time dependent. These patients might benefit from expedited process (computed tomographic scan, neurosurgical consultation, etc.) to shorten the time to surgical intervention.Prognostic study, level IV.

In surgery patients, low preoperative serum transthyretin (TTR) level is associated with greater rates of infection and mortality. However, the predictive value of TTR on surgical outcomes after major trauma has not yet been studied.Critically ill trauma patients who underwent surgery for trauma and had TTR preoperatively measured after admission to the surgical intensive care unit (ICU) at the LAC+USC Medical Center (01/2008-05/2014) were identified retrospectively. Univariable and multivariable regression analyses determined the significance of TTR on outcomes.We identified 348 patients. Univariable analysis indicated that patients with lower TTR had more infections (P.001), higher mortality (P = .007), longer hospital stay (P.001), longer ICU stay (P.001), and increased ventilator days (P.001). Even after adjusting for differences in patient characteristics, lower TTR level was associated with greater infectious complication rates (P = .001), greater mortality (P = .005), longer hospital stay (P = .013), longer ICU stay (P = .030), and increased ventilator days (P = .044).In critically ill trauma patients, low serum TTR level is associated with poorer clinical outcomes, and its prognostic utility warrants further study.

Incidental pneumomediastinum is a common radiologic finding following blunt thoracic injury; however, the clinical significance of pneumomediastinum on screening imaging is poorly defined (Curr Probl Surg. 2004;41(3):211-380; Injury. 2010;41(1):40-43). The purpose of this study was to define the incidence of aerodigestive injuries in patients with pneumomediastinum after blunt thoracic and neck injury.After institutional review board approval was obtained, a retrospective review was performed of all patients admitted to Los Angeles County + University of Southern California Medical Center with blunt neck and/or thoracic injuries between January 2007 and December 2012. All patients with pneumomediastinum on radiologic investigation were included. Data accrued included demographics, admission clinical data, injury severity patterns, incidence of aerodigestive injuries, operative findings, morbidity, mortality, as well as intensive care unit and hospital lengths of stay.A total of 9,946 patients were included in the study. The predominant mechanism was motor vehicle collision (49%), disproportionately male (76%). Overall, 258 patients (2.6%) had a pneumomediastinum: 65 (25%) and 193 (75%) were diagnosed on a chest x-ray or on a computed tomography (CT) scan, respectively. A total of 21 patients (8.1%) had an aerodigestive workup with bronchoscopy, esophagram, and/or esophagoscopy. Overall, four aerodigestive lesions (1.6%) were diagnosed. Three tracheobronchial injuries were identified on CT scan, and one esophageal injury was diagnosed on an esophagram. Two tracheobronchial injuries required surgery, while the remaining cases were managed nonoperatively. The overall mortality in this cohort was 10.9%.Isolated findings of pneumomediastinum on screening chest x-ray or CT following blunt trauma is a poor predictor of an aerodigestive injury. Highly selective workup in this clinical setting is warranted.Prognostic/epidemiologic study, level III; therapeutic study, level IV.

The optimal timing of same-admission laparoscopic cholecystectomy (LC) for acute cholecystitis (AC) in elderly patients, especially those with significant comorbidities, is not clear.This is a National Surgical Quality Improvement Program study, which included patients older than 65 years undergoing LC for AC. Patients with choledocholithiasis were excluded. Patients were divided into two subgroups as follows: no significant comorbidities (American Society of Anesthesiologists [ASA] score ≤ 2) and significant comorbidities (ASA score2). Patients undergoing LC within 24 hours of admission (early LC) were compared with patients undergoing LC later than 24 hours after admission (delayed LC), using univariable and multivariable regression analyses.A total of 4,011 patients were included in the study. Early LC was performed in 38.0% and delayed LC in 62.0% of the patients. Regression analysis identified early LC as an independent predictor for shorter anesthesia time and postoperative length of stay, overall and in the subgroup with an ASA score greater than 2.Early, within 24 hours of admission, LC for AC in patients older than 65 years with significant comorbidities is associated with shorter postoperative stay and no increase in postoperative complications or conversion to open cholecystectomy.Therapeutic study, level IV.

Background Computed tomography of the abdomen and pelvis (CTAP) is highly specific for injury identification and commonly used in the evaluation of blunt trauma patients. Despite this, there is no consensus on the required clinical observation period after negative imaging, often impacting patient flow and hospital cost. The purpose of this study was to evaluate the use of CTAP after blunt trauma and the need for observation after negative imaging. Methods A prospective analysis at a large Level I trauma center was conducted from November 2014 to May 2015. All blunt trauma patients, older than 14 years with CTAP on admission were included. Symptomatic patients were defined as having abdominal pain or external signs of trauma on admission. The main outcome was missed injury. Results Over the study period, there were 1,468 blunt trauma admissions, of which 1,193 patients underwent CTAP. Eight hundred six (67.6%) patients were evaluable on admission (Glasgow Coma Scale score, 15), and of these, 327 (40.6%) were symptomatic, 479 (59.4%) asymptomatic. Among the evaluable asymptomatic patients, there were 65 (13.6%) positive computed tomography scans including 11 patients with grade III, IV, or V solid organ injury and three that required operation. In the 414 evaluable asymptomatic patients with negative imaging, median length of stay was 3 days, and there were zero missed injuries. All images were reviewed by an attending radiologist. Conclusion Abdominal imaging after trauma is justified in the appropriate clinical setting to evaluate for significant abdominal injury regardless of symptomatology. In asymptomatic, evaluable patients with a negative CTAP, clinically significant abdominal injury is unlikely, and these patients may be considered for early discharge or disposition to another treatment service. Level of evidence Diagnostic, level III; Therapy, level IV.

Background Major trauma leads to increased nutritional requirements. However, little is known about the actual amount of calories and protein administered and the factors affecting the intake over time in critically ill trauma patients. Methods Prospective study including 100 trauma patients admitted to the Los Angeles County + University of Southern California Medical Center intensive care unit between March 2014 and October 2014. Inclusion criteria were age > 16 y, surgery at admission, and no oral nutrition. The caloric and protein intake was recorded, and requirements were calculated daily for 28 d. The nutritional intake and the impact of clinical factors on the intake over time were assessed using mixed model analysis. Results The caloric and protein intake significantly increased over time, but the median intake did not meet the median calculated requirements at any time. Multivariable analysis revealed a smaller increase of the nutritional intake over time in patients with an injury severity score > 45, whereas penetrating injury and laparotomy were associated with a higher increase of the intake. Body mass index scores ≥ 30 kg/m2, traumatic brain injury, and gastrointestinal tract injuries were associated with a smaller increase of the caloric intake over time. Conclusions The median nutritional intake did not meet the median calculated requirements over time. A smaller increase of the nutritional intake over time was found in patients with a higher injury burden, whereas penetrating injury and laparotomy were associated with a higher increase of the intake. Higher body mass index scores, traumatic brain injury, and gastrointestinal tract injuries were associated with a smaller increase of the caloric intake over time. These clinical factors can help to adjust the nutritional support in critically ill trauma patients.

Patients with psychiatric illness have been shown to experience higher rates of traumatic injury. Injury patterns, treatment decisions, and outcomes have not been well characterized in patients with psychiatric illness after injury, in particular those who undergo acute surgical intervention. The purpose of this analysis was to determine mortality, complications, and surgical intervention rates in patients with psychiatric illness after traumatic injury.This is a retrospective study of trauma patients ≥18 years old admitted to LAC + USC Medical Center between January 2008 and March 2015. Patients with psychiatric diagnoses were identified using ICD-9 diagnosis codes. Multivariate logistic regression analyses taking into account demographic and injury characteristics were used to identify associations between psychiatric comorbidity, injury mechanism, surgical interventions, and outcomes in patients after injury.A total of 26,502 patients were analyzed. Of these, 3,040 (11.5%) had a documented psychiatric comorbidity (2.0% depressive disorder, 0.8% bipolar disorder, 1.3% schizophrenia, 0.5% anxiety disorder, 3.2% substance use disorder). Patients with psychiatric illness were significantly older (49.6 years vs. 42.0 years, p0.001), had a lower proportion of penetrating injuries (13.8% vs. 18.1%, p0.001), and had a higher incidence of self-inflicted injuries (11.6% vs. 0.72%, p0.001). No difference in gender distribution was observed (74.2% men vs. 74.4% men, p = 0.80). Overall mortality was similar in both groups (adjusted odds ratio [aOR], 0.73; p = 0.07). Patients with psychiatric illness were significantly less likely to undergo acute surgical intervention within 6 hours of emergency department admission (aOR, 0.64; p0.001). Time from ED arrival to consent for acute surgical intervention was similar in both groups (94.8 min vs. 93.0 min, p = 0.84). No significant difference in mortality after acute surgical intervention was observed (aOR, 0.26; p = 0.10). Psychiatric illness was associated with a significantly higher likelihood of developing complications (aOR, 1.90; p0.001) and longer hospital lengths of stay (10.6 days vs. 6.2 days, p0.001).Trauma patients with comorbid psychiatric illness were observed to have lower rates of acute surgical interventions, higher complication rates, and longer hospital lengths of stay. Further studies are needed to better characterize the causative factors underlying these associations.Epidemiological, level III.

Background Traumatic, non-iatrogenic esophageal injuries, despite their rarity, are associated with significant morbidity and mortality. The optimal management of these esophageal perforations remains largely debated. To date, only a few small case series are available with contrasting results. The purpose of this study was to examine a large contemporary experience with traumatic esophageal injury management and to analyze risk factors associated with mortality. Methods This National Trauma Data Bank (NTDB) database study included patients with non-iatrogenic esophageal injuries. Variables abstracted were demographics, comorbidities, mechanism of injury, Abbreviated Injury Scale (AIS), esophageal Organ Injury Scale (OIS), Injury Severity Score (ISS), level of injury, vital signs, and treatment. Multivariate analysis was used to identify independent predictors for mortality and overall complications. Results A total of 944 patients with non-iatrogenic esophageal injury were included in the final analysis. The cervical segment of the esophagus was injured in 331 (35%) patients. The unadjusted 24-h mortality (8.2 vs. 14%, p = 0.008), 30-day mortality (4.2 vs. 9.3%, p = 0.005), and overall mortality (7.9 vs. 13.5%, p = 0.009) were significantly lower in the group of patients with a cervical injury. The overall complication rate was also lower in the cervical group (19.8 vs. 27.1%, p = 0.024). Multilogistic regression analysis identified age >50, thoracic injury, high-grade esophageal injury (OIS IV–V), hypotension on admission, and GCS

BACKGROUND Early pancreatic dysfunction after resection in trauma has not been well characterized. The objective of this study was to examine the incidence and clinical impact of new-onset endocrine and exocrine dysfunction after pancreatic resection for trauma. METHODS All patients sustaining a pancreatic injury from 1996 to 2013 were identified. Patients with preinjury diabetes were excluded. Survivors were divided into three groups according to the extent of anatomic resection-distal, proximal, or total pancreatectomy. Clinical demographics and outcome data were abstracted. Blood glucose levels, hemoglobin A1c, and insulin requirements were used to assess endocrine pancreatic function. Reported steatorrhea, diarrhea, or supplemental pancreatic enzyme requirements were used to assess exocrine pancreatic function. RESULTS During the study period, 331 pancreatic injuries were identified, of which 109 (33%) required resection and 84 survived to hospital discharge. Four were excluded. Of 80 cases analyzed, 73 (91%) underwent distal pancreatectomy, 7 (9%) proximal pancreatectomy, and none a total pancreatectomy. The distal resection group was predominantly male (88%), median age 24 years, and mean BMI 27 (kg/m). Thirty-eight (52%) required insulin postoperatively, with the greatest proportion (47%) requiring insulin for ≤1 day; no patients were discharged on insulin. The proximal resection group was predominantly male (86%), median age 31 years, and mean BMI 32 (kg/m). Six of seven required insulin postoperatively and two of seven were insulin dependent at time of hospital discharge. For both distal and proximal resections, none had evidence of exocrine dysfunction or received pancreatic enzyme supplementation at discharge. CONCLUSION Exocrine dysfunction after distal or proximal pancreatectomy for trauma is rare. The incidence of early onset endocrine dysfunction after traumatic distal pancreatectomy is also rare; however, it can be seen after proximal resection. LEVEL OF EVIDENCE Therapeutic study, level IV.

Brain Trauma Foundation (BTF) guidelines recommend intracranial pressure (ICP) monitoring in patients who sustained severe traumatic brain injury (TBI). Compliance to BTF guidelines is variable, and the effect of ICP monitoring on outcomes remains a controversial issue. The purpose of this study was to assess guidelines compliance in patients who sustain a severe TBI and to analyze the effect of ICP monitoring on outcomes. Trauma Quality Improvement Program database study, which included patients with isolated severe blunt head trauma (head Abbreviated Injury Scale ≥3 with Glasgow Coma Scale

The traditional classification of neck injuries uses an anatomic description of Zones I through III. The objective of this article was to characterize the association between external wounds and the corresponding internal injuries after penetrating neck trauma to identify the clinical use of the anatomic zones of the neck. Patients who sustained penetrating neck trauma from December 2008 to March 2011 were analyzed. All patients underwent structured clinical examination documenting the external zone where the wound(s) were located. All internal injuries were then correlated with the external wounds. An internal injury was defined as “unexpected” if it was located outside the borders of the neck zone corresponding to the external wound. In total, 146 patients sustaining a penetrating neck injury were analyzed; 126 (86%) male. The mechanism of injury was stab wounds in 74 (51%) and gunshot wounds in 69 (47%). Mean age was 31 years (range, nine to 62 years). Thirty-seven (25%) patients sustained had a total of 50 internal injuries. There was a high incidence of noncorrelation between the location of the external injury and the internal structures that were damaged in patients with hard signs of vascular or aerodigestive injury. The use of the anatomic zones and their role in the workup of penetrating neck injury are questionable.

Purpose Because of the automated nature of knowledge, experts tend to omit information when describing a task. A potential solution is cognitive task analysis (CTA). The authors investigated the percentage of knowledge experts omitted when teaching a cricothyrotomy to determine the percentage of additional knowledge gained during a CTA interview. Method Three experts were videotaped teaching a cricothyrotomy in 2010 at the University of Southern California. After transcription, they participated in CTA interviews for the same procedure. Three additional surgeons were recruited to perform a CTA for the procedure, and a "gold standard" task list was created. Transcriptions from the teaching sessions were compared with the task list to identify omitted steps (both "what" and "how" to do). Transcripts from the CTA interviews were compared against the task list to determine the percentage of knowledge articulated by each expert during the initial "free recall" (unprompted) phase of the CTA interview versus the amount of knowledge gained by using CTA elicitation techniques (prompted). Results Experts omitted an average of 71% (10/14) of clinical knowledge steps, 51% (14/27) of action steps, and 73% (3.6/5) of decision steps. For action steps, experts described "how to do it" only 13% (3.6/27) of the time. The average number of steps that were described increased from 44% (20/46) when unprompted to 66% (31/46) when prompted. Conclusions This study supports previous research that experts unintentionally omit knowledge when describing a procedure. CTA is a useful method to extract automated knowledge and augment expert knowledge recall during teaching.

Background There is continued debate regarding the optimal period of bed-rest and in-hospital monitoring for non-operative management of solid organ injury following blunt trauma. Methods Single center, prospective, observational study of blunt solid organ injuries from 07/2014–02/2016, managed initially without surgical or angiographic intervention. Early ambulation was defined as ≤24 h. Results 79 patients met inclusion criteria, with 36 (45.6%) in the early ambulation group and 43 (54.4%) in the late ambulation group. There were zero complications in the early ambulation group, and three complications in the late ambulation group (complications, p = 0.246; further interventions, p = 0.498). Median ICU LOS was zero days and three days for early vs. late ambulation, p = 0.001. Median total LOS was two days and five days for early vs. late ambulation, p Conclusion Early ambulation is safe in patients undergoing non-operative management of their solid organ injury, and may result in a reduced length of stay.

IntroductionPrehospital endotracheal intubation (ETI) following traumatic brain injury in urban settings is controversial. Studies investigating admission arterial blood gas (ABG) patterns in these instances are scant.HypothesisOutcomes in patients subjected to divergent prehospital airway management options following severe head injury were studied.MethodsThis was a retrospective propensity-matched study in patients with isolated TBI (head Abbreviated Injury Scale (AIS) ≥ 3) and Glasgow Coma Scale (GCS) score of ≤ 8 admitted to a Level 1 urban trauma center from January 1, 2003 through October 31, 2011. Cases that had prehospital ETI were compared to controls subjected to oxygen by mask in a one to three ratio for demographics, mechanism of injury, tachycardia/hypotension, Injury Severity Score, type of intracranial lesion, and all major surgical interventions. Primary outcome was mortality and secondary outcomes included admission gas profile, in-hospital morbidity, ICU length of stay (ICU LOS) and hospital length of stay (HLOS).ResultsCases (n = 55) and controls (n = 165) had statistically similar prehospital and in-hospital variables after propensity matching. Mortality was significantly higher for the ETI group (69.1% vs 55.2% respectively, P = .011). There was no difference in pH, base deficit, and pCO2 on admission blood gases; however the ETI group had significantly lower pO2 (187 (SD = 14) vs 213 (SD = 13), P = .034). There was a significantly increased incidence of septic shock in the ETI group. Patients subjected to prehospital ETI had a longer HLOS and ICU LOS.ConclusionIn isolated severe traumatic brain injury, prehospital endotracheal intubation was associated with significantly higher adjusted mortality rate and worsened admission oxygenation. Further prospective validation of these findings is warranted.KaramanosE, TalvingP, SkiadaD, OsbyM, InabaK, LamL, AlbuzO, DemetriadesD. Is prehospital endotracheal intubation associated with improved outcomes in isolated severe head injury? A matched cohort analysis. Prehosp Disaster Med. 2013;28(6):1-5.

Object The Brain Trauma Foundation (BTF) has established guidelines for intracranial pressure (ICP) monitoring in severe traumatic brain injury (TBI). This study assessed compliance with these guidelines and the effect on outcomes. Methods This is a prospective, observational study including patients with severe blunt TBI (Glasgow Coma Scale score ≤ 8, head Abbreviated Injury Scale score ≥ 3) between January 2010 and December 2011. Demographics, clinical characteristics, laboratory profile, head CT scans, injury severity indices, and interventions were collected. The study population was stratified into 2 study groups: ICP monitoring and no ICP monitoring. Primary outcomes included compliance with BTF guidelines, overall in-hospital mortality, and mortality due to brain herniation. Secondary outcomes were ICU and hospital lengths of stay. Multiple regression analyses were deployed to determine the effect of ICP monitoring on outcomes. Results A total of 216 patients met the BTF guideline criteria for ICP monitoring. Compliance with BTF guidelines was 46.8% (101 patients). Patients with subarachnoid hemorrhage and those who underwent craniectomy/craniotomy were significantly more likely to undergo ICP monitoring. Hypotension, coagulopathy, and increasing age were negatively associated with the placement of ICP monitoring devices. The overall in-hospital mortality was significantly higher in patients who did not undergo ICP monitoring (53.9% vs 32.7%, adjusted p = 0.019). Similarly, mortality due to brain herniation was significantly higher for the group not undergoing ICP monitoring (21.7% vs 12.9%, adjusted p = 0.046). The ICU and hospital lengths of stay were significantly longer in patients subjected to ICP monitoring. Conclusions Compliance with BTF ICP monitoring guidelines in our study sample was 46.8%. Patients managed according to the BTF ICP guidelines experienced significantly improved survival.

BACKGROUND: Experimental data have demonstrated a potential survival benefit for animals undergoing splenectomy immediately after traumatic brain injury. The aim of this study was to investigate the effect of splenectomy on survival in patients with moderate or severe traumatic brain injury (TBI). METHODS: This is a National Trauma Data Bank (2002-2009) analysis and included patients sustaining moderate or severe blunt head trauma (head Abbreviated Injury Scale [AIS] score, 3-5), with an associated splenic injury and an exploratory laparotomy. The population was divided into two arms: those that had a splenectomy and those who did not. The primary outcome was in-hospital mortality. Logistic regression was performed to adjust for factors that were significantly different between the study groups. RESULTS: During the 9-year study period, 2,625 patients met the criteria for inclusion in the analysis. Of these, 1,450 (55%) had a splenectomy, and 1,175 (45%) did not. Mortality was 13% for the splenectomized compared with 9% for the nonsplenectomized population (p = 0.001). After logistic regression, mortality remained significantly higher in the splenectomized population (adjusted odds ratio [AOR], 1.62; 95% confidence interval [CI], 1.16-2.26; p = 0.005). After stratification according to the severity of brain injury, the association between splenectomy and increased mortality persisted for both patients with moderate head injury (8% vs. 6%; AOR, 2.43; 95% CI, 1.26-4.71; p = 0.008) and for patients with severe head injury (17% vs. 10%; AOR, 1.49; 95% CI, 1.03-2.19; p = 0.036). CONCLUSION: Splenectomy was independently associated with increased mortality in patients with moderate or severe TBI. This finding warrants further investigation regarding splenic preservation in patients with TBI. LEVEL OF EVIDENCE: Therapeutic study, level IV. Language: en

BACKGROUND: The adverse effects of liver cirrhosis on outcomes following trauma has been established in retrospective series. In this study, however, we set out to evaluate prospectively the in-hospital outcome measures in this subgroup of trauma patients. METHODS: Prospective observational study of all patients admitted to the surgical intensive care unit of a Level I trauma center from January 2008 to December 2011. Cirrhotic trauma cases were matched with noncirrhotic controls in a 1:2 ratio. Matching criteria included age, sex, injury mechanism, vital signs at admission, Abbreviated Injury Scale (AIS) score for all body regions, and Injury Severity Score (ISS). Outcomes included in-hospital morbidity and mortality. RESULTS: During the 4-year study period, 92 (0.8%) of the 12,102 trauma admissions had liver cirrhosis. After matching, no differences with regard to demographic and clinical injury characteristics were noted comparing the cases and controls. The overall complication rate in cases and controls was 31.5% and 7.1%, respectively ( pG 0.001). In-hospital mortality was significantly higher for cirrhotic patients compared with their noncirrhotic counterparts (20.7 vs. 6.5%, p = 0.001). Within the cirrhotic group, mortality increased significantly from 8.0% in Child-Pugh Class A to 32.3% in Class B and 45.5% in Class C ( p = 0.003). Likewise, mortality was significantly higher for patients with a Model for End-Stage Liver Disease (MELD) score of 10 or greater versus less than 10 (30.0% vs. 9.5%; odds ratio, 4.07; 95% confidence interval, 1.23Y13.45; p =0 .016). CONCLUSION: In this prospective investigation, liver cirrhosis is associated with adverse outcomes following trauma. Both stepwise increasing Child-Pugh and MELD scores predicted adjusted adverse outcomes. Injured patients with cirrhosis warrant aggressive monitoring and instant treatment after injury. (J Trauma Acute Care Surg. 2013;75: 699Y703. Copyright* 2013

BACKGROUND Rhabdomyolysis following trauma has been associated with renal impairment. Nevertheless, the literature is scant in risk assessment of acute kidney injury (AKI) and survival in children experiencing posttraumatic rhabdomyolysis. METHODS After institutional review board approval was obtained, the registry of an urban trauma center was reviewed for pediatric (age < 18 years) trauma admissions with available creatine kinase (CK) values. Variables extracted included demographics and trauma severity indices along with serum creatine, CK, and Blood Urea Nitrogen (BUN) values. AKI was defined per pediatric RIFLE (Risk, Injury, Failure, Loss, End stage) definition. Regression models were deployed to determine the independent risk factors for AKI and CK levels. RESULTS Overall, 521 patients constituted the study sample. AKI occurred in 70 patients (13.4%), with correlation to CK values in excess of 3,000 IU/L (41.4% vs. 4.9%, adjusted p < 0.001). Independent risk factors for AKI proved to be CK level of 3,000 or greater (adjusted odds ratio [AOR], 11.02; 95% confidence interval [CI], 4.56-26.64; p < 0.001), Injury Severity Score (ISS) of 15 or less (AOR, 0.25; 95% CI, 0.10-0.61), Glasgow Coma Scale (GCS) score of 8 or less (AOR, 15.00; 95% CI, 4.98-44.94), abdominal Abbreviated Injury Scale (AIS) score of 3 or less (AOR, 3.14; 95% CI, 1.04-5.36), imaging studies with contrast of 3 or less (AOR, 3.81; 95% CI, 1.37-10.57), blunt mechanism of injury (AOR, 2.76; 95% CI, 1.17-6.49), administration of nephrotoxic agents (AOR, 4.81; 95% CI, 1.23-18.79), and requirement for fluids administration in the emergency department (AOR, 2.36; 95% CI, 1.04-5.36). Mortality in the study sample with CK values of 3,000 or greater versus less than 3,000 IU/L did not reach statistical significance (25.0% vs. 9.3%, adjusted p = 0.787). CONCLUSION AKI in pediatric posttraumatic rhabdomyolysis occurs in 13% of trauma patients. CK values of 3,000 IU/L or greater pose a significant adjusted risk for AKI. Aggressive monitoring of CK values in pediatric trauma patients is warranted. LEVEL OF EVIDENCE Prognostic study, level III.

For critically injured patients requiring a massive transfusion, the optimal plasma fibrinogen level is unknown. The purpose of this study was to examine the impact of the fibrinogen level on mortality. We hypothesized that decreasing fibrinogen levels are associated with worse outcomes.All patients undergoing a massive transfusion from January 2000 through December 2011 were retrospectively identified. Those with a fibrinogen level measured on admission to the surgical ICU were analyzed according to their fibrinogen level (normal [≥180 mg/dL], abnormal [≥101 to180 mg/dL], and critical [≤100 mg/dL]). Primary outcome was death. Multivariate analysis evaluated the impact of fibrinogen on survival.There were 260 patients who met inclusion criteria. Ninety-two patients had normal admission fibrinogen levels, 114 had abnormal levels, and 54 patients had critical levels. Patients with a critical fibrinogen level had significantly higher mortality at 24 hours compared with patients with abnormal (31.5% vs 5.3%; adj. p0.001) and normal fibrinogen levels (31.5% vs 4.3%; adjusted p0.001). Patients with a critical fibrinogen level had significantly higher in-hospital mortality compared with patients with abnormal (51.9% vs 25.4%; adjusted p = 0.013) and normal fibrinogen levels (51.9% vs 18.5%; adjusted p0.001). A critical fibrinogen level was the most important independent predictor of mortality (p = 0.012).For patients undergoing a massive transfusion after injury, as the fibrinogen level increased, a stepwise improvement in survival was noted. A fibrinogen level ≤100 mg/dL was a strong independent risk factor for death. The impact of an aggressive fibrinogen replacement strategy using readily available products warrants further prospective evaluation.

A novel herpesvirus was detected in sun bears ( Helarctos malayanus) with oral squamous cell carcinoma. Five captive sun bears from 4 institutions in the United States presented with oral lesions ranging from erythema and mild erosions to nodular, ulcerated masses. All 5 were diagnosed with squamous cell carcinoma. The tumors were treated with surgical resection but recurrence, local extension, or appearance of new lesions was noted in all cases. Intralesional chemotherapy was administered in 2 cases, and the nonsteroidal anti-inflammatory drug piroxicam was administered in 3 cases. Virus was detected in 4 of the 5 bears’ tissue samples using a consensus herpesvirus polymerase chain reaction. Nucleotide sequencing and phylogenetic analysis showed that this herpesvirus is in the subfamily Gammaherpesvirinae and distinct from other known herpesviruses. The association between the herpesvirus and squamous cell carcinoma is unknown. The current study presents a novel gammaherpesvirus within the order Ursidae, with the name Ursid herpesvirus 1 proposed.

The purpose of this study was to analyze the accuracy of capillary blood glucose (CBG) against laboratory blood glucose (LBG) in critically ill trauma patients during the shock state.All critically ill trauma patients admitted to the Surgical Intensive Care Unit at the Los Angeles County + University of Southern California Medical Center requiring blood glucose monitoring from January 2007 to December 2008 were included. Accuracy of CBG was compared against LBG during shock and non-shock states. Shock was defined as either systolic blood pressure90 mm Hg or mean arterial pressure70 mm Hg and the need for vasopressor therapy. The Bland-Altman method was used to determine the agreement between CBG and LBG during shock and non-shock states. CBG values were considered to disagree significantly with LBG values when the difference exceeded 15%.During the 2-y study period, a total of 1215 patients were admitted to the Surgical Intensive Care Unit. Overall, the mean age was 38.4 ± 20.9 y, 79.6% (967) were male, and 75.0% (911) sustained blunt trauma. A total of 1935 paired samples of CBG and LBG were included in this analysis (367 during shock and 1568 during non-shock). During shock, the mean difference between CBG and LBG levels was 13.4 mg/dL (95% CI, -15.4 to 42.2 mg/dL), and the limits of agreement were -27.1 and 53.9 mg/dL. A total of 136 CBG values (37.1%) differed from the LBG values by more than 15%. During non-shock, the mean difference between CBG and LBG levels was 12.6 mg/dL (95% CI, -19.9 to 32.5 mg/dL), and the limits of agreement were -20.6 and 45.8 mg/dL. A total of 639 CGB values (40.8%) differed from the LBG values by more than 15%. Agreement was lowest among hypoglycemic readings in both shock and non-shock states.There is poor correlation between the capillary and laboratory glucose values in both shock and non-shock states.

Intraosseous (IO) needle placement is an alternative for patients with difficult venous access. The purpose of this retrospective study was to examine indications and outcomes associated with IO use at a Level 1 trauma center (January 2008–May 2015). Data points included demographics, time to insertion, intravenous (IV) access points, indications, infusions, hospital and intensive care unit length of stay, and mortality. Of 68 patients with IO insertion analyzed (63.2% blunt trauma, 29.4% penetrating trauma, and 7.4% medical), 56 per cent were hypotensive on arrival and 38.2 per cent asystolic. The most common indications for IO infusion were difficult IV access (69%) and rapid sequence intubation (20.6%). The median time to IO access was three minutes. IV access was gained after IO in 72.1 per cent of patients. Through IO access, 30.9 per cent patients received crystalloid, 29.4 per cent received Advanced Care Life Support (ACLS) medications, 25 per cent rapid sequence intubation medications, 20.6 per cent blood products, and 2.9 per cent seizure medications. Overall, 80.9 per cent were intubated in the Emergency Department (ED), 26.5 per cent had ED thoracotomy, and 20.6 per cent had a laparotomy. Median crystalloid infused through IO was 180 cc in pediatric patients and 1 L in adults, respectively. Extravasation, the most common complication, was experienced by 7.4 per cent of patients. Inhospital mortality was 72.9 per cent. IO access should be considered when there is a need for rapid intervention requiring vascular access.

Thrombosis is a devastating complication after repair of traumatic vascular injury. Although thrombosis rates have been described, the value of anticoagulation in preventing postrepair thrombosis is unknown. We hypothesize that postoperative anticoagulation reduces thrombosis rates. A total of 1524 consecutive patients with traumatic arterial injuries from January 2005 to June 2015 were identified, and 381 patients underwent the following repair types: direct suture of vessel wall, primary anastomosis, extra-anatomic reconstruction, tissue and synthetic interposition reconstruction. Twenty six patients received postoperative heparin at therapeutic levels, and 29 patients received postoperative aspirin for five consecutive days. The heparin and aspirin groups were matched with patients without postoperative anticoagulation by the following variables: anatomic arterial injury, type of vascular repair, and age. These groups were then compared using the following outcome measures: mortality, thrombosis of repaired vessel, amputation, hemorrhage, cerebral vascular accident, and extremity compartment syndrome. The demographics between the heparin, aspirin, and respectively matched groups were not statistically different. There was no statistically significant difference in the rate of thrombosis, bleeding, compartment syndrome, cerebral vascular accident, limb amputation, or mortality. Although there was no increase in bleeding complications with the use of heparin or aspirin, there was also no impact on the rate of thrombosis.

BACKGROUND Recent studies suggest that the neutrophil-lymphocyte ratio (NLR) as a marker of inflammation is associated with mortality in surgical patients. The aim of this study was to determine the prognostic impact of NLR in critically ill trauma patients. METHODS This is a retrospective cohort study involving all trauma patients 16 years or older admitted to the surgical intensive care unit of a Level 1 trauma center (January 2013 to January 2014). The predictive capacity of NLR on mortality was assessed using a receiver operating characteristic curve analysis. To identify the effect of the NLR on survival, a separate log-rank test was used. Multivariable Cox proportional hazard modeling was used to identify independent predictors of mortality. RESULTS During the study period, 1,356 patients met inclusion criteria. Of these, 74% were male, 86% sustained blunt trauma, and the median age was 49 years (interquartile range [IQR], 35). The median Glasgow Coma Scale (GCS) score and Injury Severity Score (ISS) were 15 (IQR, 3) and 13 (IQR, 14), respectively. With the use of the receiver operating characteristic curve analyses at intensive care unit Days 2 and 5, optimal NLR cutoff values of 8.19 and 7.92 were calculated by maximizing the Youden index. Kaplan-Meier curves revealed an NLR greater than or equal to these cutoff values as a marker for increased in-hospital mortality (p < 0.001, log-rank test). The Cox regression model demonstrated that an NLR greater than 8.19 and 7.92 are independently associated with in-hospital mortality at Days 2 and 5, respectively (hazard ratio, 1.602 [p = 0.019] and 3.758 [p < 0.001]). CONCLUSION NLR is associated with mortality in critically ill trauma patients. Prospective validation of its role as a predictive marker for outcomes is warranted. LEVEL OF EVIDENCE Prognostic study, level III.

Thoracic endovascular aortic repair (TEVAR) can be complicated by graft collapse, endoleaks, and stent migration. The incidence of these complications and other outcomes is poorly understood in young trauma victims who receive endovascular aortic repair of blunt thoracic aortic injury (BTAI). A 29-year-old pedestrian was struck by a vehicle resulting in polytrauma including BTAI with transection distal to the left subclavian artery origin. The patient underwent successful TEVAR. Nine months later, the patient developed transient paresthesia below the waist that progressed to bilateral lower extremity paralysis and malperfusion syndrome below the diaphragm including nonpalpable pulses in the lower extremities, acute renal failure, and ischemic colitis. Imaging demonstrated near occlusive thrombosis of the distal end of the thoracic endograft. An emergent axillobifemoral bypass resolved the organ malperfusion and acute limb ischemia. Patients who have undergone TEVAR for BTAI may develop asymptomatic or symptomatic intragraft thrombosis. In patients presenting with malperfusion syndrome below the diaphragm, extra-anatomic bypass can expeditiously resolve symptoms until definitive treatment can be performed. Oversizing of thoracic stents in trauma patient may lead to intragraft thrombosis.