Search

Background: Electric scooters are popular in Southern California due to their ease of use, affordability, and availability. The objective of this study was to characterize how hospital admissions and outcomes varied due to electric scooter injury among Southern California trauma centers., Study Design: Trauma registry data from 9 urban trauma centers were queried for patients sustaining injury while operating an electric scooter from January to December 2018. Data collection included patient demographics, diagnoses, interventions, and outcomes., Results: During the 1-year study period, 87 patients required trauma surgeon care due to scooter-related injury, with a mean age of 35.1 years; 71.3% were male with 20.7% and 17.2% of patients requiring ICU admission and a surgical intervention, respectively. One (1.1%) patient died. The head and face were most commonly injured, followed by the extremities. Helmet use was uncommon (71.3%). High variability in patient volume was noted, with 2 centers considered high-incidence and the remaining low-incidence., Conclusions: Injuries from electric scooter crashes are primarily to the head, face, and extremities, with approximately 1 in 5 patients requiring ICU admission and/or a surgical intervention. There is significant variation in patient volume among Southern California trauma centers that could affect the delivery of care with the abrupt introduction of this technology. Targeted public health interventions and policies might better address community use of the electric scooter., (Copyright © 2020 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Access to centers with extracorporeal membrane oxygenation (ECMO) capabilities varies by region and may affect overall outcomes. We assessed the outcomes of trauma patients requiring ECMO support and compared the overall survival of all patients with trauma at facilities with and without ECMO capabilities., Methods: A retrospective review of the National Trauma Data Bank was performed to identify all trauma patients receiving care at ECMO and non-ECMO centers. Baseline patient characteristics and outcomes were analyzed. Adjusted odds ratio (OR) was used to compare survival at ECMO and non-ECMO facilities., Results: Between 2007 and 2015, a total of 5 781 123 patients with trauma were identified with 1 983 986 (34%) admitted to an ECMO facility and 3 797 137 (66%) admitted to a non-ECMO facility. A total of 522 (0.03%) patients required ECMO. Both the number of patients with trauma requiring ECMO support and the number of trauma facilities utilizing ECMO increased over the 9-year-study period (4.9 to 13.8 patients per 100 000 admissions, and 18 to 77 centers, respectively). The mortality for ECMO patients was 40.5%. Patients with trauma admitted to ECMO facilities had more severe injuries (injury severity score: 9.0 vs 8.0; P < .001). The overall mortality was 3.3%. The adjusted OR for mortality associated with admission to an ECMO facility vs a non-ECMO facility was 0.96 (95% confidence interval: 0.95-0.97; adjusted P < .001)., Conclusions: The use of ECMO for patients with trauma is expanding. Our study demonstrates a survival benefit associated with admission to a facility with ECMO capabilities. Thus, access to ECMO is a potential quality metric for trauma centers., (© 2020 Wiley Periodicals, Inc.)

RCTs showed benefits in Lap repair of perforated peptic ulcer (PPU). The SWSC Multi-Center Trials Group sought to evaluate whether Lap omental patch repairs compared to Open improved outcomes in PPU in general practice. Data was collected from 9 SWSC Trial Group centers. Demographics, operative time, 30-day complications, length of stay and mortality were included. 461 PATIENTS: Open in 311(67%) patients, Lap in 132(28%) with 20(5%) patients converted from Lap to Open. Groups were similar at baseline. Significant variability was found between centers in their utilization of Lap (0-67%). Complications at 30 days were lower in Lap (18.5% vs. 27.5%, p < 0.05) as was unplanned re-operation (4.7% vs 14%, p < 0.05). Lap reduced LOS (6 vs 8 days, p < 0.001). Ileus was more in Lap (42% vs 18 p < 0.001) operative time was 14 min higher in Lap(p < 0.01) and admission to OR time was 4 h higher in Lap(<0.05). No significant difference readmission or mortality. Our results suggest Lap should be considered a first-line option in suitable PPU patients requiring omental patch repair in centers that have the capacity and resources 24/7., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: This study determined the prevalence of complicated appendicitis in elderly patients diagnosed preoperatively with uncomplicated appendicitis., Methods: Patients with a preoperative diagnosis of uncomplicated appendicitis at an academic hospital from 11/2013 to 05/2017 were reviewed. Patients ≥65 years were compared to those younger. Pathology reports were categorized as either uncomplicated or complicated (COMP). The primary outcome was the prevalence of COMP appendicitis., Results: The prevalence of COMP appendicitis increased with age after 20 years with an abrupt increase after 65 years. Patients ≥65 years were more likely to have COMP appendicitis (48.1% vs. 15.5%; OR: 5.1; p < 0.01) and prolonged stays (3.8 vs. 2.3 days; p < 0.01)., Conclusion: Nearly half of elderly patients had pathologic confirmation of complicated appendicitis despite no preoperative clinical or radiographic suspicion for complicated appendicitis. Nonoperative management of acute appendicitis in the elderly may not be appropriate due to the high rate of unexpected complicated appendicitis., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: International rotations with hands-on experience are commonly cited as a potential supplement to the current experience of surgical trainees in trauma; however, quantification of this experience remains unclear., Methods: A link to an online survey was distributed by electronic mail to physicians who rotated for any period of time at the Trauma Unit of the Groote-Shuur Hospital of the University of Cape Town from January 1, 2006, to December 2016., Results: Of 160 participants, 75 (47%) completed the survey. A high proportion (45%) had performed less than 25 trauma-related surgical procedures during their previous training. Most (56%) performed ≥ 10 trauma laparotomies and sternotomies/thoracotomies during their rotation, whereas 43% performed ≥ 5 vascular procedures. The level of perceived confidence in managing trauma patients increased significantly from a median of 3/10 to 7/10 ( P < .05)., Conclusion: Rotations at large-volume trauma centers abroad offer the opportunity for a hands-on operative experience and may enhance the confidence of surgical trainees. Further standardization of these opportunities may result in a larger-scale participation of graduate residents and fellows., (© 2019 Published by Elsevier Inc.)

Background: Although ejections from motor vehicles are considered a marker of a significant mechanism and a predictor of severe injuries and mortality, scant recent data exist to validate these outcomes. This study investigates whether ejections increase the mortality risk following a motor vehicle crash using data that reflect the introduction of new vehicles to the streets of a large city in the United States., Methods: The Trauma and Emergency Medicine Information System of Los Angeles County was queried for patients ≥ 16 years old admitted following a motor vehicle crash between 2002 and 2012. Ejected patients were compared to nonejected. Primary outcome was mortality. A logistic regression model was used to identify predictors of mortality and severe trauma., Results: A total of 9,742 (6.8%) met inclusion criteria. Of these, 449 (4.6%) were ejected; 368 (82.0%) were passengers and 81 (18.0%) were drivers. The rate of ejection decreased linearly (6.1% in 2002 to 3.4% in 2012). Compared to nonejected patients, ejected patients were more likely to require intensive care unit admission (43.7% vs 22.1%, P  < .01), have critical injuries (Injury Severity Score > 25) (24.2% vs 7.3%, P  <.01), require emergent surgery (16.3% vs 8.0%, P  <.01), and expire in the emergency department (3.6% vs 1.2%, P  <.01). Overall mortality was 3.6%: 9.6% for ejected and 3.3% for nonejected patients ( P  <.01). In a logistic regression model, ejection and extrication both predicted mortality (adjusted odds ratio: 1.83, P  <.01 and 1.87, P  <.01, respectively). Ejection also predicted critical injuries (Injury Severity Score > 25) with adjusted odds ratio of 2.48 ( P  <.01)., Conclusion: Ejections following motor vehicle crash have decreased throughout the years; however, they remain a marker of critical injuries and predictive of mortality., (© 2019 The Authors.)

Avoiding excess fluid administration is necessary when managing critically ill surgical patients. The aim of this study was to delineate the current practices of IV electrolyte (IVE) replacement in a surgical ICU and quantify their contribution to the fluid balance (FB) status. Patients admitted to the surgical ICU over a six-month period were reviewed. Patients undergoing dialysis and those with ICU stay <72 hours were excluded. A total of 248 patients were included. The median age was 60 years, and 57 per cent were male. Overall, 1131 patient ICU days were analyzed. The median daily FB was 672 mL. IVEs were administered in 62 per cent of ICU days. In days that IVEs were used, negative FB was significantly less likely to be achieved (62% vs 69%, P = 0.02). The most commonly administered IVE was calcium (32% of ICU days); however, the largest volume of IVE was administered in the form of phosphorus (median 225 mL). Diuretics were administered in 17 per cent of ICU days. Patients who received diuretics were significantly more likely to receive IVE (70% vs 61%, P = 0.02). Administration of IVE may contribute to the daily positive FB of surgical ICU patients. Implementation of practices that can ameliorate this effect is encouraged.

Background: The aim of this study was to characterize the risk of a delayed intracranial hemorrhage (ICH) in trauma patients on direct-acting oral anticoagulants (DOACs)., Methods: Patients on DOACs admitted to two Level I Trauma Centers between 2014 and 2017 were reviewed. Only patients with a negative admission CT brain were included. The primary outcome was a delayed ICH., Results: Overall, 249 patients were included. The median age was 81 years with 82% undergoing a repeat CT. Three patients developed a delayed ICH (1.2%). One developed an ICH after receiving tissue plasminogen activator for a cerebrovascular accident after two negative CTs. Excluding this patient, the incidence dropped to 0.8%. None required neurosurgical intervention., Conclusion: For patients at risk for a TBI who are on DOACs, repeat cross-sectional imaging of the brain when the initial imaging is negative is not necessary. A period of clinical observation may be warranted., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Elderly patients are at high risk for mortality after injury, and prevention is imperative. Several studies have captured the value of traffic calming or environmental modifications; however, limited data support its use during focused times of the day to reduce pedestrian trauma. This study's aim was to identify when the elderly are more likely to be injured from pedestrian trauma. The Los Angeles County Trauma and Emergency Medicine Information System database was reviewed for all adult pedestrians who were struck by vehicles from 2000 to 2015. Elderly (≥65 years) patients were compared with nonelderly (range, 18-64 years) patients with respect to the time of admission and mortality. The proportion of elderly pedestrian injuries peaked between 9 and 10 am (23%). Compared with their nonelderly counterparts, the elderly were more likely to have a Glasgow Coma Scale ≤ 8 (11% vs 7%, P < 0.01), be hypotensive (6% vs 3%, P < 0.01), and have a higher Injury Severity Score (median 9 vs 5, P < 0.01). Mortality was significantly higher in the elderly (14% vs 4%, P < 0.01). Elderly pedestrians had an almost 5-fold higher adjusted odds ratio for death: 4.72 ( P < 0.01). Preventative strategies with lower speed limits or high surveillance during these hours in highly populated areas may result in a decreased incidence of these injuries.

Objective: The Department of Homeland Security launched the Stop the Bleed initiative, a campaign intended to teach bystanders hemorrhage control strategies. Despite the program's popularity, little is known about actions taken by participants afterwards. We sought to determine how often participants acquired the equipment that is necessary in applying the skills taught., Design: A standardized survey instrument was distributed to all American College of Surgeons Bleeding Control Basic (B-Con) class participants from 05/2017 to 01/2018. The instrument queried about the likelihood of applying skills and obtaining materials. A web-based survey was administered one month later inquiring whether materials were obtained and barriers that would prohibit acquisition., Setting: Academic, urban, Level I trauma center., Participants: Healthcare and nonhealthcare personnel., Results: There were 336 and 183 participants who completed the initial and subsequent web-based survey, respectively. Participants indicated a high likelihood of applying a tourniquet (95.5%), applying pressure (97.9%), and packing a wound (96.4%), if required. Additionally, 74.7% and 76.2% reported a high likelihood of obtaining a tourniquet and packing material, respectively. However, only 21.3% and 50.8% obtained a tourniquet and packing material, respectively, 1 month later. Cost, time, and accessibility of items during a time of need were cited to be common reasons for not obtaining these materials., Conclusions: Despite reporting a high likelihood of utilizing hemorrhage control skills upon completion of the B-Con class, few went on to acquire the materials needed to apply these skills among those who responded. These results may be impacted by loss of follow up and response bias. Developing strategies that allow for easy access to materials is imperative and may lead to both better implementation of the purposes of the program and improved dissemination of its principles within the community., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Neuromuscular blockade (NMB) is often utilized in the treatment of acute respiratory distress syndrome (ARDS). Its use for a period of 48 h has been shown to improve mortality in randomized control trials. We aimed to characterize outcomes associated with a prolonged NMB. We hypothesized that the duration of NMB would not be associated with increased mortality., Materials and Methods: This was a retrospective review from June 2014 to October 2016 of patients admitted to the surgical intensive care unit and receiving cisatracurium for ARDS. Patients paralyzed for ≤ 48 h (SHORT) were compared to those paralyzed for longer durations (LONG). Primary outcome was mortality. Parametric and nonparametric tests were utilized for the purposes of the comparison. A multivariate logistic regression model was utilized to adjust for differences., Results: Of 73 patients meeting inclusion criteria, 32 (44%) were SHORT and 41 (56%) LONG. Compared to the LONG cohort, those in SHORT were older (60 versus 52 years, P = 0.04) but were comparable with respect to sex, acute physiology and chronic health evaluation IV scores, presence of concurrent pneumonia, and the use of vasopressors. SHORT patients were less likely to require rescue therapy with inhaled nitric oxide (28% versus 66%, P < 0.01). Overall mortality was 60%. There was no difference in the adjusted odds for mortality (adjusted odds ratio: 0.57, P = 0.33). Secondary outcomes including deep venous thrombosis and pneumonia did not differ between the two groups., Conclusions: Extended NMB for ARDS was not associated with increased mortality. Discontinuation of this modality should not be based solely on the duration of therapy., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Warfarin is associated with poor outcomes after trauma, an effect correlated with elevations in the international normalized ratio (INR). In contrast, the novel oral anticoagulants (NOAs) have no validated laboratory measure to quantify coagulopathy. We sought to determine if use of NOAs was associated with elevated activated partial thromboplastin time (aPTT) or INR levels among trauma patients or increased clotting times on thromboelastography (TEG)., Methods: This was a post-hoc analysis of a prospective observational study across 16 trauma centers. Patients on dabigatran, rivaroxaban, or apixaban were included. Laboratory data were collected at admission and after reversal. Admission labs were compared between medication groups. Traditional measures of coagulopathy were compared with TEG results using Spearman's rank coefficient for correlation. Labs before and after reversal were also analyzed between medication groups., Results: 182 patients were enrolled between June 2013 and July 2015: 50 on dabigatran, 123 on rivaroxaban, and 34 apixaban. INR values were mildly elevated among patients on dabigatran (median 1.3, IQR 1.1-1.4) and rivaroxaban (median 1.3, IQR 1.1-1.6) compared with apixaban (median 1.1, IQR 1.0-1.2). Patients on dabigatran had slightly higher than normal aPTT values (median 35, IQR 29.8-46.3), whereas those on rivaroxaban and apixaban did not. Fifty patients had TEG results. The median values for R, alpha, MA and lysis were normal for all groups. Prothrombin time (PT) and aPTT had a high correlation in all groups (dabigatran p=0.0005, rivaroxaban p<0.0001, and apixaban p<0.0001). aPTT correlated with the R value on TEG in patients on dabigatran (p=0.0094) and rivaroxaban (p=0.0028) but not apixaban (p=0.2532). Reversal occurred in 14%, 25%, and 18% of dabigatran, rivaroxaban, and apixaban patients, respectively. Both traditional measures of coagulopathy and TEG remained within normal limits after reversal., Discussion: Neither traditional measures of coagulation nor TEG were able to detect coagulopathy in patients on NOAs., Level of Evidence: Level IV., Competing Interests: Competing interests: None declared.

Rapid transfer of trauma patients to a trauma center for definitive management is essential to increase survival. The utilization of helicopter transportation for this purpose remains heavily debated. The purpose of this study was to characterize the trends in helicopter transportations of trauma patients in the United States over the last decade. Subjects with a primary mode of either ground or helicopter transportation were selected from the National Trauma Data Bank datasets 2007 to 2015. Over this period, the proportion of patients transported by a helicopter decreased significantly in a linear fashion from 17 per cent in 2007 to 10.2 per cent in 2015 ( P < 0.001). The overall mortality of this population was 7.6 per cent and remained unchanged over the study period ( P = 0.545). Almost 3 of 10 subjects (29.4%) transported by a helicopter had an Injury Severity Score <9. The proportion of elderly (>65 years) patients requiring helicopter transportation increased by 69.1 per cent, whereas their associated mortality decreased by 21.5 per cent. The use of a helicopter for the transportation of trauma patients has significantly decreased over the last decade without any significant change in mortality, possibly indicating more effective utilization of available resources. Overtriage of patients with minor injuries remained relatively unchanged.

Introduction: Preventing secondary insult to the brain is imperative following traumatic brain injury (TBI). Although TBI does not preclude nonoperative management (NOM) of splenic injuries, development of hypotension in this setting may be detrimental and could therefore lead trauma surgeons to a lower threshold for operative intervention and a potentially higher risk of failure of NOM (FNOM). We hypothesized that the presence of a TBI in patients with blunt splenic injury would lead to a higher risk of FNOM., Methods: Patients with blunt splenic injury were selected from the National Trauma Data Bank research datasets from 2007 to 2011. TBI was defined as AIS head ≥ 3 and FNOM as patients who underwent a spleen-related operation after 2 h from admission. TBI patients were compared to those without head injury. The primary outcome was FNOM., Results: Of 47,713 patients identified, 41,436 (86.8%) underwent a trial of NOM. FNOM was identical (10.6 vs. 10.8%, p = 0.601) among patients with and without TBI. TBI patients had lower adjusted odds for FNOM (AOR 0.66, p < 0.001), even among those with a high-grade splenic injury (AOR 0.68, p < 0.001). No difference in adjusted mortality was noted when comparing TBI patients with and without FNOM (AOR 1.01, p = 0.95)., Conclusions: NOM of blunt splenic trauma in TBI patients has higher adjusted odds for success. This could be related to interventions targeting prevention of secondary brain injury. Further studies are required to identify those specific practices that lead to a higher success rate of NOM of splenic trauma in TBI patients.

Background: The presence of an abdominal seatbelt sign (ASBS) following a motor vehicle collision (MVC) is associated with a high risk for occult intra-abdominal injury, prompting imaging studies and a prolonged period of clinical observation. The aim of this study was to determine how a negative computed tomography (CT) of the abdomen/pelvis (A/P) can serve in the safe disposition of these patients. Our hypothesis was that in the setting of a negative CT, the presence of occult intra-abdominal injuries requiring a delayed intervention is extremely unlikely., Methods: The medical charts of patients admitted from January 2014 to December 2016 to a Level I trauma center following an MVC were reviewed for a documentation of an ASBS. Patients who did not have a CT A/P upon admission were excluded. The CT A/P of the remaining patients were then classified as negative if there were no findings of acute vascular, visceral or bony injury or positive if any of these findings was present. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of CT A/P for the presence of an intra-abdominal injury were calculated., Results: Over the 3-year study period, 1,108 patients were admitted after an MVC. Of those, 196 (17.7%) had an ASBS upon presentation and 183 (93.4%) of 196 underwent a CT A/P. A total of 114 (62.3%) of 183 had a negative CT A/P. These patients remained hospitalized for a median of 2 (1-35) days with none (0.0%) requiring a delayed laparotomy. The sensitivity of CT A/P in identifying patients requiring an exploratory laparotomy was 100.0%, specificity was 67.9%, NPV was 100.0%, and PPV was 21.7%. The negative likelihood ratio was 0.00., Conclusion: For patients with an ASBS following an MVC, a negative CT A/P may be sufficient for safe discharge from the emergency department without any need for additional clinical observation., Level of Evidence: Therapuetic, level IV.

Background: The purpose was to examine the incidence of positive cultures in a highly susceptible subset of trauma patients admitted to the surgical intensive care unit (SICU) for mechanical ventilation and to examine the impact of their timing on outcomes., Patients and Methods: A retrospective review was conducted of blunt trauma patients admitted to the SICU for mechanical ventilation at a level I trauma center over a five-year period. All urine, blood, and sputum cultures were abstracted. Patients with at least one positive culture were compared with those with negative or no cultures. The primary outcome was mortality. A Cox regression model with a time-dependent variable was utilized to calculate the adjusted hazard ratio (AHR)., Results: The median age of 635 patients meeting inclusion criteria was 46 and 74.2% were male. A total of 298 patients (46.9%) had at least one positive culture, with 28.9% occurring within two days of admission. Patients with positive cultures were more likely to be severely injured with an injury severity score (ISS) ≥16 (68.5% vs. 45.1%, p < 0.001). Overall mortality was 22%. Patients who had their first positive culture within two and three days from admission had a significantly higher AHR for mortality (AHR: 14.46, p < 0.001 and AHR: 10.59, p = 0.028, respectively) compared to patients with a positive culture at day six or later., Conclusions: Early positive cultures are common among trauma patients requiring mechanical ventilation and are associated with higher mortality. Early identification with "damage control cultures" obtained on admission to aid with early targeted treatment might be justified.

Background: Adequate venous thromboembolism (VTE) prophylaxis is essential after trauma, especially in patients with lower extremity and/or pelvic fractures. We sought to investigate if prophylactic enoxaparin dosed by anti-Xa trough levels could reduce clinically evident VTE in trauma patients with lower extremity or pelvic injury., Methods: Prospective data was collected on trauma patients admitted for at least two days with any lower extremity and/or pelvic fracture and who received enoxaparin for VTE prophylaxis between October 2013 and January 2016. Patients in the control cohort received enoxaparin at 30 mg twice daily. Patients in the adjustment cohort had anti-Xa trough levels measured after three or more consecutive doses of enoxaparin. Those with a trough level of 0.1 IU/mL or lower had their dosage increased by 10-mg increments., Results: Of the 159 patients included, 58 (36.5%) were monitored with anti-Xa trough levels. The cohorts were similar in age, sex, regional AIS, ISS score, ICU and hospital length of stay, proportion of patients with diagnostic testing for VTE, and time to first enoxaparin dose. Initial enoxaparin dosing in the majority of patients (84.5%) who had anti-Xa trough levels measured was subprophylactic. Patients receiving enoxaparin dosed by anti-Xa trough level had a significantly lower VTE rate than those who did not (1.7% v. 13.9%, p = 0.03)., Conclusions: Prophylactic enoxaparin adjusted by anti-factor Xa level may lead to a decreased rate of clinically evident VTE among trauma patients with lower extremity and/or pelvic fractures. Our findings indicate that the initial dose of enoxaparin was frequently too low., (Copyright © 2018 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Beta blockers, a class of medications that inhibit endogenous catecholamines interaction with beta adrenergic receptors, are often administered to patients hospitalized after traumatic brain injury (TBI). We tested the hypothesis that beta blocker use after TBI is associated with lower mortality, and secondarily compared propranolol to other beta blockers., Methods: The American Association for the Surgery of Trauma Clinical Trial Group conducted a multi-institutional, prospective, observational trial in which adult TBI patients who required intensive care unit admission were compared based on beta blocker administration., Results: From January 2015 to January 2017, 2,252 patients were analyzed from 15 trauma centers in the United States and Canada with 49.7% receiving beta blockers. Most patients (56.3%) received the first beta blocker dose by hospital day 1. Those patients who received beta blockers were older (56.7 years vs. 48.6 years, p < 0.001) and had higher head Abbreviated Injury Scale scores (3.6 vs. 3.4, p < 0.001). Similarities were noted when comparing sex, admission hypotension, mean Injury Severity Score, and mean Glasgow Coma Scale. Unadjusted mortality was lower for patients receiving beta blockers (13.8% vs. 17.7%, p = 0.013). Multivariable regression determined that beta blockers were associated with lower mortality (adjusted odds ratio, 0.35; p < 0.001), and propranolol was superior to other beta blockers (adjusted odds ratio, 0.51, p = 0.010). A Cox-regression model using a time-dependent variable demonstrated a survival benefit for patients receiving beta blockers (adjusted hazard ratio, 0.42, p < 0.001) and propranolol was superior to other beta blockers (adjusted hazard ratio, 0.50, p = 0.003)., Conclusion: Administration of beta blockers after TBI was associated with improved survival, before and after adjusting for the more severe injuries observed in the treatment cohort. This study provides a robust evaluation of the effects of beta blockers on TBI outcomes that supports the initiation of a multi-institutional randomized control trial., Level of Evidence: Therapeutic/care management, level III.

Background: The use of vasopressors (VP) in the resuscitation of massively transfused trauma patients might be considered a marker of inadequate resuscitation. We sought to characterize the utilization of VP in patients receiving massive transfusion and examine the association of their use with mortality., Methods: Trauma patients admitted from January 2011 to October 2016 receiving massive transfusion, defined as 3 units of pRBC within the first hour from admission, were selected for analysis. Demographics, admission vital signs and labs, use of VP, surgical interventions and outcomes were collected. Standard statistical tools were utilized., Results: Over the 5-year study period, 120 trauma patients met inclusion criteria. The median age was 39 years with 77% being male and 41% sustaining a penetrating injury. Patients who received VP [VP (+)] were more likely to have a lower admission GCS (median 4.5 vs. 14.0, p <0.01) and less likely to have a penetrating injury (31% vs. 54%, p=0.02). The overall mortality was 49% and significantly higher in the VP (+) cohort (60% vs. 34%, AHR: 9.9, adjusted p=0.03). Mortality increased in a stepwise fashion with increasing number of VP utilized, starting at 34% for no VP, to 78% for 3 VP, and 100% for 5 or more. The majority of deaths in the VP (-) group (88%) occurred within one day from admission. For the VP (+) group, 57% of deaths occurred within one day, with the remaining 43% occurring at a later time., Conclusion: In the era of massive transfusion protocols, vasopressors are commonly utilized in exsanguinating trauma patients and their use is associated with a higher mortality risk. Deaths in patients receiving vasopressors are more likely to occur later compared to those in patients who do not receive vasopressors. Further research to characterize the role of these agents in the resuscitation of trauma patients is required., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Introduction: Rigid cervical collars are routinely placed in the pre-hospital setting after significant blunt trauma. Patients who are deemed competent by field personnel (Glasgow Coma Scale (GCS) ≥13, no major distracting injury and not grossly intoxicated) may refuse cervical collar placement., Material and Methods: A retrospective review was conducted of all adult trauma patients presenting to a Level 1 trauma center after blunt trauma with a GCS≥13 and no distracting injury or gross intoxication from January 2014 to December 2014. Pre-hospital data was collected from emergency medical service reports and hospital data from patient charts. Cervical spine injury was identified by International Classification of Disease-9th Revision codes. Patients refusing cervical spine immobilization prior to arrival are compared to those who were compliant., Results: A total of 629 patients met inclusion criteria. Cervical spine immobilization was refused by 28 patients, while 601 complied. There were 16 cervical spine injuries (2.5%), with 3 (10.7%) in noncompliant patients and 13 (2.2%) among those who were complaint (p = 0.03)., Conclusion: The incidence of cervical spine injuries in patients refusing cervical collar immobilization is higher than in compliant patients. Patients arriving for initial evaluation having refused cervical collar immobilization should be treated with caution., (Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Patients with traumatic brain injury (TBI) are often resuscitated with crystalloids in the emergency department (ED) to maintain cerebral perfusion. The purpose of this study was to evaluate whether crystalloid resuscitation volume impacts mortality in TBI patients. This was a retrospective study of trauma patients with head abbreviated injury scale score ≥2, who received crystalloids during ED resuscitation between 2004 and 2013. Clinical characteristics and volume of crystalloids received in the ED were collected. Patients who received <2 L of crystalloids were categorized as low volume (LOW), whereas those who received ≥2 L were considered high volume (HIGH). Mortality and outcomes were compared. Multivariable regression analysis was used to determine the odds of mortality while controlling for confounders. Over 10 years, 875 patients met inclusion criteria. Overall mortality was 12.5 per cent. Seven hundred and forty-two (85%) were in the LOW cohort and 133 (15%) in the HIGH cohort. Gender and age were similar between the groups. The HIGH cohort had lower admission systolic blood pressure (128 vs 138 mm Hg, P = 0.001), lower Glasgow coma scale score (10 vs 12, P < 0.001), higher head abbreviated injury scale (3.8 vs 3.3, P < 0.001), and higher injury severity score (25 vs 18, P < 0.001). The LOW group had a lower unadjusted mortality (10 vs 26%, P < 0.001). Multivariable analysis adjusting for confounders demonstrated that those resuscitated with ≥2 L of crystalloids had increased odds of mortality (adjusted odds ratio 2.25, P = 0.005). Higher volume crystalloid resuscitation after TBI is associated with increased mortality, thus limited resuscitation for TBI patients may be indicated.

Although guidelines for the performance of an emergency department thoracotomy (EDT) are available, high level evidence remains scarce potentially leading to variation in decisions and practices among trauma surgeons. The National Trauma Databank was queried for all subjects who died in the emergency department (ED) between 2007 and 2011. Trauma centers were divided into four quartiles based on the rate of EDT among ED deaths. A total of 31,623 subjects admitted to 729 trauma centers met inclusion criteria. Most of of these centers (n = 328, 53%) never performed an EDT during the study period. Very few outlier centers (1.1%) performed this procedure in 50.0 per cent or more of all patients who died in the ED. Trauma centers in the highest quartiles in performing EDT were more likely to intervene with both surgical and nonsurgical procedures in patients who died in the ED, independent of the performance of an EDT. There are significant variations among trauma centers in the management of trauma patients who expire in the ED. Further research at a national level toward standardizing the management of the trauma patient in extremis and the decision to perform an EDT is necessary, given the extremely low survival associated with this procedure.

Background: Approximately half of trauma patients develop post-traumatic depression. It is suggested that beta-blockade impairs trauma memory recollection, reducing depressive symptoms. This study investigates the effect of early beta-blockade on depression following severe traumatic injuries in patients without significant brain injury., Methods: Patients were identified by retrospectively reviewing the trauma registry at an urban university hospital between 2007 and 2011. Severe extracranial injuries were defined as extracranial injuries with Abbreviated Injury Scale score ≥3, intracranial Abbreviated Injury Scale score <3 and an Injury Severity Score ≥16. In-hospital deaths and patients prescribed antidepressant therapy ≤1 year prior to admission were excluded. Patients were stratified into groups based on pre-admission beta-blocker status. The primary outcome was post-traumatic depression, defined as receiving antidepressants ≤1 year following trauma., Results: Five hundred and ninety-six patients met the inclusion criteria with 11.4% prescribed pre-admission beta-blockade. Patients receiving beta-blockers were significantly older (57 ± 18 vs. 42 ± 17 years, p < 0.001) with lower Glasgow Coma Scale score (12 ± 3 vs. 14 ± 2, p < 0.001). The beta-blocked cohort spent significantly longer in hospital (21 ± 20 vs. 15 ± 17 days, p < 0.01) and intensive care (4 ± 7 vs. 3 ± 5 days, p = 0.01). A forward logistic regression model was applied and predicted lack of beta-blockade to be associated with increased risk of depression (OR 2.7, 95% CI 1.1-7.2, p = 0.04). After adjusting for group differences, patients lacking beta-blockers demonstrated an increased risk of depression (AOR 3.3, 95% CI 1.2-8.6, p = 0.02)., Conclusions: Pre-admission beta-blockade is associated with a significantly reduced risk of depression following severe traumatic injury. Further investigation is needed to determine the beneficial effects of beta-blockade in these instances.

Importance: While assault is commonly reported or suspected in children with traumatic wounds, a recent overview of these injuries, especially those requiring trauma surgery consultation is lacking in the literature., Objectives: Explore the incidence, demographics and injury patterns of children presenting to trauma centers following an assault., Design: Retrospective review of the National Trauma Data Bank 2007 to 2011., Setting and Participants: Subjects up to 18 years old with "assault" reported as the intent of injury. Patients were divided into infants (<2 years), young children (2-5 years), children (6-11 years), and adolescents (12-18 years)., Main Outcomes and Measures: Mechanism of injury, injury severity and mortality based on age groups and race., Results: Of 609,207 children, 58,299 (9.6%) were victims of an assault. The median age was 16 years and 81% were male, with a median injury severity score (ISS) of 8. The majority of patients were adolescents (76%), followed by infants (17%) and young children (4%). There was a stepwise increase in the proportion of assaulted Black children with increasing age (23.2% for infants and up to 46.7% for adolescents, trend p < 0.01, effect size: 0.175) while the opposite applied for White children (46.0% for infants and down to 19.5% for adolescents, trend p < 0.01, effect size: -0.230). With increasing age, White subjects had the highest trend of being assaulted during an unarmed fight or brawl (p < 0.01, effect size: 0.393), while for Black victims the highest trend was noted for assault with a firearm (p < 0.01, effect size: 0.323). Almost 2 out of 3 infants sustained severe head trauma (59%). The overall mortality was 8%, highest among young children, where it reached 16% (p < 0.01)., Conclusions: Up to 10% of children admitted following trauma are victims of assault with traumatic brain injuries predominant in infants and firearm injuries predominant in adolescents. Injury patterns largely correlate to age and race. Assault in children is associated with a high mortality risk. These data highlight the magnitude of the problem and calls for further involvement of trauma surgeons to improve outcomes, bring awareness and promote preventative strategies to eliminate assault in children., (Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: The number of anticoagulated trauma patients is increasing. Trauma patients on warfarin have been found to have poor outcomes, particularly after intracranial hemorrhage (ICH). However, the effect of novel oral anticoagulants (NOAs) on trauma outcomes is unknown. We hypothesized that patients on NOAs would have higher rates of ICH, ICH progression, and death compared with patients on traditional anticoagulant and antiplatelet agents., Methods: This was a prospective observational trial across 16 trauma centers. Inclusion criteria was any trauma patient admitted on aspirin, clopidogrel, warfarin, dabigatran, rivaroxaban, or apixaban. Demographic data, admission vital signs, mechanism of injury, injury severity scores, laboratory values, and interventions were collected. Outcomes included ICH, progression of ICH, and death., Results: A total of 1,847 patients were enrolled between July 2013 and June 2015. Mean age was 74.9 years (SD ± 13.8), 46% were female, 77% were non-Hispanic white. At least one comorbidity was reported in 94% of patients. Blunt trauma accounted for 99% of patients, and the median Injury Severity Score was 9 (interquartile range, 4-14). 50% of patients were on antiplatelet agents, 33% on warfarin, 10% on NOAs, and 7% on combination therapy or subcutaneous agents.Patients taking NOAs were not at higher risk for ICH on univariate (24% vs. 31%) or multivariate analysis (incidence rate ratio, 0.78; confidence interval 0.61-1.01, p = 0.05). Compared with all other agents, patients on aspirin (90%, 81 mg; 10%, 325 mg) had the highest rate (35%) and risk (incidence rate ratio, 1.27; confidence interval, 1.13-1.43; p < 0.001) of ICH. Progression of ICH occurred in 17% of patients and was not different between medication groups. Study mortality was 7% and was not significantly different between groups on univariate or multivariate analysis., Conclusion: Patients on NOAs were not at higher risk for ICH, ICH progression, or death., Level of Evidence: Prognostic/epidemiologic study, level III.

Background: Liberal emergency department (ED) resuscitation after trauma may lead to uncontrolled hemorrhage, reduced organ perfusion, and compartment syndrome. Recent guidelines reduced the standard starting point for crystalloid resuscitation from 2 L to 1 L and emphasized "balanced" resuscitation. The purpose of this study was to characterize how an urban, Level 1 trauma center has responded to changes in crystalloid resuscitation practices over time and to describe associated patient outcomes., Methods: This is a retrospective review of trauma patients who sustained moderate to severe injury (ISS > 9) and received crystalloid resuscitation in the ED during 1/2004-12/2013 at an urban, Level 1 trauma center. Patient data collected included age, gender, Glasgow Coma Scale (GCS) score, initial systolic blood pressure (SBP), mechanism of injury, regional Abbreviated Injury Scale (AIS) score, Injury Severity Score (ISS), volume of blood products and crystalloids administered in the ED. Patients who received <2 L of crystalloid were considered low-volume while those who received ≥2 L were high-volume patients. Clinical characteristics and outcomes were compared between high- and low-volume cohorts, and multivariate regression was used to adjust for confounders. Trend analysis examined changes in variables over time., Results: 1571 moderate to severely injured patients received crystalloid resuscitation; 1282 (82%) were low-volume and 289 (18%) were high-volume. Compared to high-volume patients, low-volume patients presented with a higher median SBP (134 vs. 122 mmHg, p < 0.001) and GCS (15 vs. 14, p < 0.001). Low-volume patients also had lower median ISS (15 vs. 19, p < 0.001). Unadjusted mortality was lower in the low-volume cohort (7% vs. 19%, p < 0.001). Multivariate analysis demonstrated that high-volume patients had increased odds of mortality compared to low-volume patients (AOR 1.88, p = 0.008). Decreased rates of high-volume resuscitation and overall mortality were demonstrated over the 10-year study period., Conclusions: The observed decrease in high-volume crystalloid resuscitations in the ED paralleled a reduction in mortality over the ten-year period. In addition, adjusted mortality was higher in those receiving high-volume resuscitation., (Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Importance: Trauma patients are at high risk for developing venous thromboembolism (VTE). The VTE rate when enoxaparin sodium is dosed by anti-factor Xa (anti-Xa) trough level is not well described., Objective: To determine whether targeting a prophylactic anti-Xa trough level by adjusting the enoxaparin dose would reduce the VTE rate in trauma patients., Design, Setting, and Participants: Single-institution, historic vs prospective cohort comparison study at an urban, academic, level I trauma center. The prospective cohort was enrolled from August 2014 to May 2015 and compared with a historic cohort admitted from August 2013 to May 2014. Trauma patients who received enoxaparin adjusted by anti-Xa trough level (adjustment group) were compared with those who received enoxaparin sodium at a dosage of 30 mg twice daily (control group). Patients were excluded if they were younger than 18 years, had a length of hospital stay less than 2 days, or had preexisting deep vein thrombosis. Patients were excluded from the adjustment group for changes in the choice of thromboprophylaxis (heparin, enoxaparin once-daily dosing, early ambulation), hospital discharge before initial trough levels could be drawn, or incorrect timing of trough levels., Exposures: Anti-Xa trough levels were monitored in patients in the adjustment group receiving 3 or more consecutive doses of enoxaparin sodium, 30 mg twice daily. Patients with a trough level of 0.1 IU/mL or lower received enoxaparin sodium increased by 10-mg increments. After providing 3 adjusted doses of enoxaparin, the trough level was redrawn and the dosage was adjusted as necessary. Patients in the control group received enoxaparin sodium at a dosage of 30 mg twice daily without adjustments., Main Outcomes and Measures: Rates of symptomatic VTE (deep vein thrombosis and pulmonary embolism, confirmed by duplex ultrasonography and chest computed tomographic angiography, respectively) and bleeding risk., Results: A total of 205 patients (mean [SD] age, 41.3 [18.2] years; 75.1% male) were studied, 87 in the adjustment group and 118 in the control group, with similar baseline characteristics and injury profiles. Subprophylactic anti-Xa troughs were noted in 73 of 87 patients (83.9%) in the adjustment group, and the majority of patients (57 of 87 patients [65.5%]) required dosage adjustment of enoxaparin sodium to 40 mg twice daily. Incidence of VTE was significantly lower in the adjustment group than in the control group (1.1% vs 7.6%, respectively; P = .046). When the adjustment group was compared with the control group, no significant difference was noted in the rate of packed red blood cell transfusion (6.9% vs 12.7%, respectively; P = .18) or mean (SD) hematocrit at discharge (34.5% [6.3%] vs 33.4% [6.8%], respectively [to convert to proportion of 1.0, multiply by 0.01]; P = .19)., Conclusions and Relevance: In this study, subprophylactic anti-Xa trough levels were common in trauma patients. Enoxaparin dosage adjustment may lead to a reduced rate of VTE without an increased risk of bleeding.

Failure to rescue (FTR), defined as any death after the development of in-hospital complications, is an important quality measure, but the relationship with age after a traumatic injury, has not been well defined. We sought to examine whether older trauma patients are at higher risk for FTR. The National Trauma Databank (NTDB) research datasets 2007 to 2011 were queried for patients ≥16 years who had any reported complication. Those who survived (non-FTR) were compared with those who did not (FTR) using a forward logistic regression model. Overall, 218,986 subjects met inclusion criteria of those, 201,358 (91.2%) survived their complication (non-FTR) and 17,628 (8.8%) died (FTR). A forward logistic regression identified age 65 to 89 years as the strongest predictor of FTR [adjusted odds ratio (AOR) 95% confidence interval (CI): 6.58 (6.11, 7.08), P < 0.001]. Using age group 16 to 45 years as the reference group, the adjusted risk for FTR increased with increasing age in a stepwise fashion [AOR (95 % CI): 1.94 (1.80, 2.09) for age 46 to 65 years, 6.78 (6.19, 7.42) for age 66 to 89 years and 27.58 [21.81, 34.87] for age ≥90 years]. The adjusted risk of FTR also increased in a stepwise fashion with increasing number of complications, reaching AOR (95 per cent CI) of 2.25 (2.07, 2.45), P < 0.001 for ≥4 complications. The risk of failure to rescue increases with age and number of complications. Strategies which track this quality measure to encourage early recognition and treatment of complications in the elderly are necessary.

The risk of de novo Crohn's disease (CD) after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) versus inflammatory bowel disease unclassified (IBDU) or indeterminate colitis (IC) remains debatable. Here, we present updated results after long-term follow-up of a previously studied cohort of 334 patients with UC, IBDU, or IC who underwent IPAA during a 10-year period ending 2007. Of 334 study patients, 56 per cent were male and median age was 38 years (range: 8-81). Patients were classified as UC (n = 237) or IBDU (n = 97) preoperatively and UC (n = 236) or IC (n = 98) postoperatively. After a median follow-up of 76 months (range: 3-236), 63 patients (19%) developed CD within a median of 22 months (range: 1-213) from ileostomy closure compared with the previously published 40 patients (12%) with 26-month follow-up (P = 0.01). The development of de novo CD was similar for patients undergoing IPAA for UC (n = 40; 17%), IBDU (n = 21; 22%) or those classified as having UC (n = 42; 18%) or IC (n = 19; 19%) postoperatively; P > 0.05. Thus, patients with IBDU and IC can expect equivalent long-term outcome to patients with UC after IPAA. Pouch failure occurred in 13 (4%) study patients and was equal among all four groups.

Background: The source of coagulopathy in traumatic brain injury (TBI) is multifactorial and may include adrenergic stimulation. The aim of this study was to assess coagulopathy after TBI using thromboelastography (TEG), and to investigate the implications of β-adrenergic receptor knockout., Methods: Adult male wild type c57/bl6 (WT) and β1/β2-adrenergic receptor knockout (BKO) mice were assigned to either TBI (WT-TBI, BKO-TBI) or sham injury (WT-sham, BKO-sham). Mice assigned to TBI were subject to controlled cortical impact (CCI). At 24 h post-injury, whole blood samples were obtained and taken immediately for TEG., Results: At 24 h after injury, a trend toward increased fibrinolysis was seen in WT-TBI compared to WT-sham although this did not reach significance (EPL 8.1 vs. 0 %, p = 0.18). No differences were noted in fibrinolysis in BKO-TBI compared to BKO-sham (LY30 2.6 vs. 2.5 %, p = 0.61; EPL 3.4 vs. 2.9 %, p = 0.61). In addition BKO-TBI demonstrated increased clot strength compared to BKO-sham (MA 76.6 vs. 68.6, p = 0.03; G 18.2 vs. 11.3, p = 0.03)., Conclusions: In a mouse TBI model, WT mice sustaining TBI demonstrated a trend toward increased fibrinolysis at 24 h after injury while BKO mice did not. These findings suggest β-blockade may attenuate the coagulopathy of TBI and minimize progression of intracranial hemorrhage by reducing fibrinolysis and increasing clot strength.

Background: Supratherapeutic vancomycin trough levels are common after trauma and associated with both increased acute kidney injury (AKI) and mortality. We sought to limit the adverse effects of vancomycin in trauma patients through more frequent trough monitoring., Methods: Beginning in January 2011, trauma patients treated with vancomycin had trough levels (VT) monitored daily until steady state was reached. Trauma patients admitted from January 2011 to May 2015 (POST) were compared with those admitted from January 2006 to December 2010 (PRE). Inclusion criteria required administration of intravenous vancomycin, admission serum creatinine (SCr), and SCr within 72 hours of highest VT. Acute kidney injury was defined as an increase in SCr of at least 0.3 mg/dL or 50% from admission to post-vancomycin administration. Those in the POST group were prospectively followed up until discharge or death., Results: Two hundred sixty-three patients met inclusion criteria in the PRE-phase and 115 in the POST-phase. The two groups were similar in age, gender, race, body mass index, pre-existing comorbidities, admission systolic blood pressure, Glasgow Coma Scale, and head Abbreviated Injury Scale. Injury Severity Score was higher in the POST cohort (18 PRE vs. 25 POST, p < 0.001). Compared with PRE, the POST cohort had lower rates of supratherapeutic VT (>20 mg/L) (34.6% PRE vs. 22.6% POST, p = 0.02) and AKI (30.4% PRE vs. 19.1% POST, p = 0.026). After adjusting for confounders, the POST group had a significantly lower risk of AKI with an adjusted odds ratio of 0.457 (p = 0.027). There was a trend toward decreased mortality in the POST cohort, but this did not reach significance (10% PRE vs. 5.2% POST, p = 0.162)., Conclusions: A reduction in AKI was observed in trauma patients with daily vancomycin trough levels monitored until steady state. Increased awareness regarding closer surveillance of VT in trauma patients may limit the incidence of vancomycin-related nephrotoxicity., Level of Evidence: Therapeutic study, level IV.

Objective: To determine factors associated with response to inpatient rehabilitation treatment among TBI patients., Setting: Inpatient rehabilitation service at a Level I trauma center., Participants: Moderate-severe TBI patients ages ≥ 18years old admitted between January 1, 2002 and December 31, 2012., Main Measures: Response to inpatient rehabilitation, measured by the Functional Independence Measure (FIM) score., Design: Retrospective cohort study., Results: Of 1,984 patients treated for TBI, 184 (10.8%) underwent inpatient rehabilitation. The largest proportion of patients improved in mobility (98.9%), followed by self-care (93.7%), communication/social cognition (84.0%), and sphincter control (65.7%). Of these, 99 (53.8%) improved by 2 or more levels of functional independence and were considered rehabilitation responders. Responders were younger (53.1 years vs. 63.8, p < 0.01), had longer average rehabilitation stays (15.4 days vs. 12.2, p < 0.01), and were less likely to have an admission SBP <100 mmHg (7.1% vs. 17.1%, p = 0.01). On multivariate analysis, normotension at admission (AOR 0.06, p = 0.01) and longer rehabilitation LOS (AOR 1.11, p < 0.01) were associated with a response to inpatient rehabilitation., Conclusion: Of the TBI patients who qualified for same-center inpatient rehabilitation, approximately half responded to treatment. Longer rehabilitation time and normotension at admission predicted response to rehabilitation. Further efforts are necessary to identify and optimize TBI patients for inpatient rehabilitation.

Background: Field intubation (FI) by emergency medical service personnel on severely injured trauma patients remains a contentious practice. Clinical studies suggest an association between FI and adverse outcomes in patients with traumatic brain injury. Military tactical emergency casualty care recommends deferring intubation and providing supplemental oxygenation until reaching a more equipped destination. In addition, animal models with penetrating hemorrhagic shock demonstrate increased acidosis with intubation before resuscitation. The purpose of this study was to evaluate the impact of FI on outcomes in trauma patients with hemorrhagic shock requiring massive transfusion., Methods: The Los Angeles County Trauma System Database was retrospectively queried for all trauma patients 16 years or older with hemorrhagic shock requiring massive transfusion (≥6 U packed red blood cells in the first 24 hours) between January 1, 2012, and June 30, 2014. Demographics, clinical and transfusion data, and outcomes were compared between patients who received FI and those who did not (NO-FI). Multivariate regression analysis was used to adjust for confounders., Results: Of 552 trauma patients meeting inclusion criteria, 63 (11%) received FI, and the remaining 489 (89%) were NO-FI. Age, sex, and incidence of blunt injury were similar between the FI and the NO-FI group. The FI cohort presented with a lower median Glasgow Coma Scale (GCS) score (3 vs. 14, p < 0.001), a lower median systolic blood pressure (86 mm Hg vs. 104 mm Hg, p < 0.001), and a higher median Injury Severity Score (ISS) (41 vs. 29, p < 0.001). Mortality was significantly higher in FI patients (83% vs. 43%, p < 0.001). Transfusion patterns and total field times were similar in both groups. After adjusting for confounders, FI patients had increased odds of mortality (adjusted odds ratio, 2.89; 95% confidence interval, 1.08-7.78; p = 0.035). In addition, FI was identified as an independent predictor of mortality (adjusted odds ratio, 3.41; 95% confidence interval, 1.35-8.59; p = 0.009)., Conclusion: FI may be associated with higher mortality in trauma patients with hemorrhagic shock requiring massive transfusion. Less invasive airway interventions and rapid transport might improve outcomes for these patients., Level of Evidence: Therapeutic study, level IV; epidemiologic study, level III.

Stab wounds (SW) to the abdomen traditionally require urgent exploration when associated with shock, evisceration, or peritonitis. Hemodynamically stable patients without evisceration may benefit from serial exams even with peritonitis. We compared patients taken directly to the operating room with abdominal SWs (ED-OR) to those admitted for serial exams (ADMIT). We retrospectively reviewed hemodynamically stable patients presenting with any abdominal SW between January 2000 and December 2012. Exclusions included evidence of evisceration, systolic blood pressure ≤110 mm Hg, or blood transfusion. NON-THER was defined as abdominal exploration without identification of intra-abdominal injury requiring repair. Of 142 patients included, 104 were ED-OR and 38 were ADMIT. When ED-OR was compared with ADMIT, abdominal Abbreviated Injury Score was higher (2.4 vs 2.1; P = 0.01) and hospital length of stay was longer (4.8 vs 3.3 days; P = 0.04). Incidence of NON-THER was higher in ED-OR cohort (71% vs 13%; P ≤ 0.001). In a regression model, ED-OR was a predictor of NON-THER (adjusted odds ratio 16.6; P < 0.001). One patient from ED-OR expired after complications from NON-THER. There were no deaths in the ADMIT group. For those patients with abdominal SWs who present with systolic blood pressure ≥110 mm Hg, no blood product transfusion in the emergency department and lacking evisceration, admission for serial abdominal exams may be preferred regardless of abdominal exam.

Objective: The objective of this study was to examine the ability of Focused Assessment Using Sonography for Trauma (FAST) to discriminate between survivors and nonsurvivors undergoing resuscitative thoracotomy (RT)., Background: RT is a high-risk, low-salvage procedure performed in arresting trauma patients with poorly defined indications., Methods: Patients undergoing RT from 10/2010 to 05/2014 were prospectively enrolled. A FAST examination including parasternal/subxiphoid cardiac views was performed before or concurrent with RT. The result was captured as adequate or inadequate with presence or absence of pericardial fluid and/or cardiac motion. A sensitivity analysis utilizing the primary outcome measure of survival to discharge or organ donation was performed., Results: Overall, 187 patients arrived in traumatic arrest and underwent FAST. Median age 31 (1-84), 84.5% male, 51.3% penetrating. Loss of vital signs occurred at the scene in 48.1%, en-route in 23.5%, and in the ED in 28.3%. Emergent left thoracotomy was performed in 77.5% and clamshell thoracotomy in 22.5%. Sustained cardiac activity was regained in 48.1%. However, overall survival was only 3.2%. An additional 1.6% progressed to organ donation. FAST was inadequate in 3.7%, 28.9% demonstrated cardiac motion and 8.6% pericardial fluid. Cardiac motion on FAST was 100% sensitive and 73.7% specific for the identification of survivors and organ donors., Conclusions: With a high degree of sensitivity for the detection of potential survivors after traumatic arrest, FAST represents an effective method of separating those that do not warrant the risk and resource burden of RT from those who may survive. The likelihood of survival if pericardial fluid and cardiac motion were both absent was zero.

Background: The purpose of the current study was to investigate the effect of early adrenergic hyperactivity as manifested by prehospital (emergency medical service [EMS]) hypertension on outcomes of traumatic brain injury (TBI) patients and to develop a prognostic model of the presence of TBI based on EMS and admission (emergency department [ED]) hypertension., Methods: This study is a retrospective review of the 2007 to 2008 National Trauma Data Bank including blunt trauma patients 15 years or older with available EMS and ED vital signs. Patients with head Abbreviated Injury Scale (AIS) score of 3 or greater were selected, and mortality was examined within EMS systolic blood pressure (SBP) groups: lower than 100 mm Hg, 110 mm Hg to 150 mm Hg, 160 mm Hg to 180 mm Hg, and 190 mm Hg to 230 mm Hg. A forward logistic regression model including the EMS heart rate, EMS SBP, EMS Glasgow Coma Scale (GCS) score, ED heart rate, and ED SBP was used to identify predictors of a TBI in patients with ED GCS score of less than or equal to 8, 9 to 13, and 14 to 15., Results: For the 5-year study period, 315,242 patients met inclusion criteria. Adjusted odds for mortality increased in a stepwise fashion with increasing EMS SBP compared with patients with normal EMS SBP (adjusted odds ratio [95% confidence interval], 1.33 [1.22-1.44], p < 0.001, for EMS SBP of 160-180 mm Hg and 1.97 [1.76-2.21], p < 0.001, for EMS SBP of 190-230 mm Hg). A 7-point scoring system was developed for each ED GCS score group to predict the presence of a TBI. EMS SBP of greater than 150 mm Hg and ED SBP of greater than 150 mm Hg were both predictive of the presence of a TBI in patients with ED GCS score of 8 or less and in patients with ED GCS score of 9 to 13 or 14 to 15, respectively., Conclusion: Prehospital hypertension in TBI is associated with a higher mortality risk. Early hypertension in the prehospital setting and at admission can be used to predict the presence of such injuries. These findings may have important early triage and treatment implications., Level of Evidence: Prognostic study, level III.

Patients sustaining traumatic injuries are at risk for development of rhabdomyolysis. The effect of obesity on this risk is unknown. This study attempted to characterize the role of obesity in the development of rhabdomyolysis after trauma. This was a retrospective review of all trauma patients with creatine kinase (CK) levels admitted to the surgical intensive care unit (SICU) at a Level I trauma center from February 2011 until July 2013. Patients were divided based on their body mass index (BMI): overweight/obese group with BMI 25 kg/m(2) or greater and nonoverweight/obese group with BMI less than 25 kg/m(2). Primary outcome was CK greater than 10,000 U/L. During the 30-month study period, 198 trauma patients with available CK levels were admitted to the SICU. The majority (27.8%) of patients were involved in a motor vehicle collision. There were 96 patients (48.4%) with BMI 25 kg/m(2) or greater and 102 (51.5%) with BMI less than 25 kg/m(2). There was no difference in creatinine levels between the two groups (1.5 ± 1.2 mg/dL vs 1.5 ± 1.4 mg/dL, P = 0.83). BMI 25 kg/m(2) or greater was independently associated with the development of CK greater than 10,000 U/L (14.6 vs 4.9%; adjusted odds ratio, 3.03; P = 0.04). Patients with BMI 25 kg/m(2) or greater are at a significantly higher risk for rhabdomyolysis after trauma. Aggressive CK level monitoring to prevent rhabdomyolysis in this population is strongly encouraged.

The risk of venous thromboembolism (VTE) for patients taking an antiplatelet agent is largely unknown. This study aimed to investigate the association between antiplatelet agent use before admission with the risk of in-hospital VTE in surgical intensive care unit (ICU) patients. A retrospective review of all patients admitted to the surgical ICU at a Level I trauma center over 30 months was performed. Patients who underwent diagnostic imaging for VTE were selected. Patients were divided based on whether or not antiplatelet agents were used before admission (APTA vs NAPTA). The primary outcome was VTE occurrence. A forward logistic regression model was used to identify factors independently associated with the primary outcome. During the study period, 461 (24%) patients met inclusion criteria: 70 (15%) APTA and 391 (85%) NAPTA. After adjusting for confounding factors, APTA patients were at a significantly higher risk for developing VTE (59 vs 40%; adjusted odds ratio, 1.8; 95% confidence interval, 1.0 to 3.0; adjusted P = 0.04). Whether or not antiplatelet agents were resumed during the hospital stay and the day on which they were resumed did not affect VTE risk. In conclusion, surgical ICU patients receiving antiplatelet agents before admission are at a significantly higher risk for development of VTE.

Background: Vancomycin-resistant Enterococcus (VRE) screening is routine practice in many intensive care units despite the question of its clinical significance. The value of VRE screening at predicting subsequent VRE or other hospital-acquired infection (HAI) is unknown. The purpose of this investigation was to examine the rate of subsequent VRE HAI in patients undergoing VRE screening., Methods: This study was conducted in a 24-bed surgical intensive care unit (SICU) at a Level I trauma center. Patients admitted to the SICU between February and August 2011 who had rectal swab for VRE screening within 72 hours were followed prospectively for the development of VRE and other HAIs. Demographics, clinical characteristics, and infection rates were compared between VRE-positive and VRE-negative patients. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of VRE screening for predicting subsequent VRE HAI were calculated., Results: A total of 341 patients had VRE screening within 72 hours of SICU admission, with 32 VRE-positive (9%) and 309 VRE-negative (91%) patients. VRE-positive patients had a higher incidence of any HAI (78% vs. 35%, p < 0.001). Eight VRE-positive patients (25%) developed VRE HAI compared with only 3 VRE-negative patients (1%) (p < 0.001). VRE screening had a 73% sensitivity, 93% specificity, 25% PPV, and 99% NPV for determining subsequent VRE HAI., Conclusion: VRE colonization was present in 9% of SICU patients at admission. Negative VRE screen result had a high specificity and NPV for the development of subsequent VRE HAI. Empiric treatment of VRE infection may be unnecessary in VRE-negative patients., Level of Evidence: Prognostic/epidemiologic study, level III. Therapeutic study, level IV.

Introduction: Lyophilization may facilitate production of a safe, portable, easily storable, and transportable source of platelets for bleeding patients. The objective of this study was to examine the impact of lyophilized human and porcine platelets in a swine liver injury model of nonsurgical hemorrhage., Methods: Anesthetized pigs (40 kg) had a controlled 35% total blood volume bleed from the right jugular vein followed by cooling to 35°C and resuscitation with Ringer's lactate to achieve a 3:1 blood withdrawal resuscitation. Through a midline laparotomy, the liver was injured with two standardized 5 × 5-cm grids with lacerations 1 cm apart and 0.5 cm deep. After 2 min of uncontrolled hemorrhage, the animals were treated with placebo (n = 5), lyophilized human (n = 5, HP), or swine platelets (n = 5, SP). At 15 min, shed blood was calculated. The animals then underwent abdominal closure. At 48 h, the animals were killed for histopathologic evaluation of the lung, kidney, and heart., Results: Intraoperative blood loss at 15 min was significantly higher in the HP arm (SP: 4.9 ± 2.9 mL/kg, HP: 12.3 ± 4.7 mL/kg, and control: 6.1 ± 2.5 mL/kg; P = 0.013). Mortality at 48 h was 20% in all three arms, due to uncontrolled intra-abdominal bleeding. At the time the animals were killed, SP animals had a significantly higher hematocrit (SP: 22.0% ± 3.0%, HP: 15.1% ± 4.9%, and control: 13.9% ± 0.6%; P = 0.026). No significant difference was found in platelet count (SP: 319.3 ± 62.1 × 10(3)/µL, HP:361.5 ± 133.6 × 10(3)/µL, and control: 242.7 ± 42.5 × 10(3)/µL; P = 0.259). Histopathology of kidneys, lungs, and heart demonstrated no evidence of thromboembolic complications., Conclusion: In this swine model of liver injury, human lyophilized platelets increased intraoperative blood loss. With the use of species-specific lyophilized platelets, however, this effect was abolished, with a decrease in blood loss at 48 h after injury.

Background: The value of routinely testing bladder repair integrity with a cystogram before urinary catheter removal is unclear. The purpose of this study was to prospectively evaluate the utility of routine postoperative cystogram after traumatic bladder injury., Methods: All patients sustaining a bladder injury requiring operative repair at two Level I trauma centers were prospectively enrolled during a 62-month study period ending on January 2011. Injury demographics, imaging data, and outcomes were extracted. All patients were evaluated with either a plain or a computed tomography cystogram., Results: A total of 127 patients were enrolled (mean [SD] age, 30.4 [13.5] years; blunt trauma, 63.8%, mean [SD] Injury Severity Score [ISS], 17.7 [10.6]). A total of 75 patients (59.1%) had an intraperitoneal (IP) bladder injury, 44 (34.6%) had an extraperitoneal (EP) bladder injury, and 8 had a (6.3%) combined IP/EP bladder injury. All patients with IP and IP/EP injuries (n = 83) underwent operative repair and a postoperative cystogram at 8.6 (1.8) days (range, 5-13 days). Sixty-nine IP injuries (83.1%) were simple (dome or body disruption/penetrating injury), while 14 (16.9%) were complex (trigone/requiring ureter implantation). There were no deaths during the follow-up period. With the exception of one patient (1.2%) with a complex injury requiring ureteric implantation, there were no leaks demonstrated on postoperative cystogram, and the urinary catheters were successfully removed., Conclusion: In this prospective evaluation of the role of bladder evaluation after operative repair, routine use of follow-up cystograms for simple injuries did not impact clinical management. For complex repairs to the trigone or those requiring ureter implantation, a follow-up cystogram should be obtained before catheter removal., Level of Evidence: Diagnostic study, level II.

Background: In asymptomatic patients with penetrating thoracic trauma and a normal initial chest x-ray, successive prospective trials have decreased the minimum observation period required for exclusion of significant injury from 6 to 3 h. Despite the quality of these studies, this interval remains arbitrary and the true requisite observation time for safe discharge remains unknown. The current study evaluates the ability of "early" repeat chest x-ray, at intervals approaching 1 h, to exclude clinically significant injury., Methods: Eighty-eight, asymptomatic patients with penetrating chest trauma and normal initial chest radiographs were prospectively enrolled in this study. All patients received an "early" follow-up chest x-ray, at a median interval of 1 h and 34 min (interquartile range: 1 h 35 min to 2 h 22 min), and a second repeat x-ray at a "delayed" interval no earlier than 3 h postadmission. Radiographic abnormalities in clinically stable patients were followed with serial examination and repeat imaging for a minimum of 6 h. All patients received both "early" and "delayed" repeat CXRs with no patient discharged before full assessment., Results: One of the 88 patients with initially normal chest x-ray underwent tube thoracostomy at the discretion of the attending surgeon before any repeat imaging. Of the remaining patients, 4 of 87 (4.6 %) demonstrated radiographic abnormalities on "early" repeat imaging. Two patients had pneumothoraces, successfully managed without intervention; the remaining two demonstrated evidence of hemothorax, subsequently undergoing tube thoracostomy. Two more patients (2.3 %) developed pneumothoraces on "delayed" imaging, both successfully observed without intervention., Conclusions: In asymptomatic patients with penetrating thoracic trauma and normal initial chest radiographs, "early" repeat chest x-ray, at intervals approaching 1 h, appears sufficient to exclude clinically significant pathology and to allow safe patient discharge.