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Background: The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) has been proposed as a diagnostic tool for necrotizing soft tissue infection (NSTI). However, its utility remains underreported, particularly in patients with comorbid conditions. The purpose of this study was to identify the test characteristics of LRINEC for patients with various comorbid conditions. Patients and Methods: We conducted a retrospective study including patients with suspected NSTI. Our study patients were then relegated into the subgroups; intravenous drug use (IVDU), end-stage liver disease (ESLD), and diabetes mellitus (DM). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a positive LRINEC score (≥ 6 or 8) were calculated in reference to intra-operative findings or results of the pathologic examination. Area under the curve (AUC) using receiver operating characteristic (ROC) plots were compared between each subgroup and the overall study population using DeLong test. Results: A total of 220 patients were included for the analysis. Overall, the sensitivity was 76%, specificity of 52%, PPV of 32%, and NPV of 88%. The subgroup analysis showed low PPVs in all subgroups. The DM and ESLD groups had a high NPV (90.5% and 88.0%, respectively), whereas NPV in the IVDU group was 70.6%. The AUC and DeLong test for the subgroups were 0.649 (p = 0.902) for ESLD, 0.699 (p = 0.683) for DM, and 0.565 (p = 0.034) for IVDU. Conclusions: The LRINEC can be a useful adjunct to rule out the diagnosis of NSTI with exception of IVDU. In contrast, further diagnostic workup might be still required in those patients with positive LRINEC.

Prevalence of abdominal compartment syndrome (ACS) is estimated to be 4%-17% in severely burned patients. Although decompressive laparotomy can be lifesaving for ACS patients, severe complications are associated with this technique, especially in burn populations. This study outlines a new technique of releasing intraabdominal pressure without resorting to decompressive laparotomy.Ten fresh tissue cadavers were studied; none of whom had had prior abdominal surgery. Using Veress needles, abdomens were insufflated to 30 mm Hg and subsequently connected to arterial pressure transducers. Two techniques were then used to incise fascia. First, large skin flaps were raised from a midline incision (n = 5). Second, small 2 cm cutdowns at the proximal and distal extent of midaxillary, subcostal, and inguinal incisional sites were made, followed by tunneling a subfascial plane using an aortic clamp with fascial incisions made through the grooves of a tunneled vein stripper (n = 5). Pressures were recorded in the sequence of incisions mentioned previously.The open midline flap technique decreased abdominal pressure from a mean pressure of 30 ± 1.8 mm Hg to 6.9 ± 5.0 mm Hg (P 0.01). The minimally invasive technique decreased intraabdominal pressure from 30 ± 0.9 to 5.8 ± 5.2 mm Hg (P 0.01). This technique significantly reduced intraabdominal pressure via extraperitoneal component separation and fascial release at the midaxillary, subxiphoid, and inguinal regions.This technique offers the benefit of reducing the morbidity, mortality, and complications associated with an open abdomen, which may be beneficial in the burn injury population.

Background Albeit low survival rates, resuscitative thoracotomy (RT) is considered standard for selected trauma patients. Because it has potential for rapid cardiopulmonary rescue, extracorporeal membrane oxygenation (ECMO) may augment RT. The aim of this study was to identify the impact of ECMO on trauma patients that recently underwent RT after injury. Study Design All patients who underwent RT were identified from the National Trauma Data Bank (2007-2017). Patients were excluded if they died within 60 minutes, underwent delayed ECMO, and/or had missing data. Delayed ECMO group was defined as those patients undergoing ECMO after 1 hour following RT. Results Out of 8 694 272 injured patients, 10 106 (.1%) underwent RT. Median age was 31 years [23-45], 86% male. Penetrating injury was the dominant mechanism (62%). Of these, .6% (23) underwent immediate ECMO. Extracorporeal membrane oxygenation patients were significantly younger (23[17-33] vs. 31[23-46], p .003) and had significantly higher chest abbreviated injury scale scores (5[4-5] vs. 3[3-4], P < .001). Extracorporeal membrane oxygenation patients achieved significantly higher rate of return of spontaneous circulation (96% vs. 70%, p .007) and had nonsignificant trend of improved mortality (52% vs. 63%, p .260). Conclusion Immediate ECMO may be a useful therapeutic modality after RT. It achieves higher ROSC rates with opportunity for improved survival. Future prospective study is warranted.

The optimal timing of VTE prophylaxis initiation after blunt solid organ injury is controversial. Retrospective studies suggest initiation ≤48 h is safe. This prospective study examined the safety and efficacy of early VTE prophylaxis initiation after nonoperative blunt solid organ injury. All patients >15 years of age presenting after blunt trauma (12/01/16–11/30/17) were prospectively screened. Patients were included if solid organ injury (liver, spleen, kidney) was diagnosed on admission CT scan and nonoperative management was planned. ED deaths, transfers, patients with pre-existing bleeding disorders or home antiplatelet/anticoagulant medications, and those who did not receive VTE prophylaxis were excluded. Demographics, injury/clinical data, type/timing of VTE prophylaxis initiation, and outcomes were collected. Patients were dichotomized into study groups based on VTE prophylaxis initiation time: Early (≤48 h) vs Late (>48 h after admission). Prophylaxis initiation was at the discretion of the attending trauma surgeon. The primary study outcome was VTE event rate. Secondary outcomes included hospital length of stay (LOS), intensive care unit (ICU) LOS, need for and volume of post-prophylaxis blood transfusion, need for delayed (post-prophylaxis) interventional radiology (IR) or operative intervention, failure of nonoperative management, and mortality. Outcomes were compared with univariate analysis. Multivariate analysis with logistic regression determined independent predictors of late VTE prophylaxis initiation. After exclusions, 118 patients were identified. Median ISS was 22 [IQR 14–26]. Median AAST grade of injury was 2 [IQR 2–3] for liver, 2 [IQR 1–3] for spleen, and 3 [IQR 2–3] for kidney. Compared to late prophylaxis patients (n = 57, 48%), early prophylaxis patients (n = 61, 52%) had significantly fewer DVTs (n = 0, 0% vs n = 5, 9%, p = 0.024) but similar rates of PE (n = 2, 3% vs n = 3, 5%, p = 0.672). TBI was the only significant risk factor for late prophylaxis (OR 0.22, p = 0.015). No patient in either group required delayed intervention (operative or IR) for bleeding. There was no difference in volume of post-prophylaxis blood transfusion. In this prospective study of patients with nonoperative blunt solid organ injuries, early (≤48 h) initiation of VTE prophylaxis resulted in a lower incidence of DVTs without an associated increase in bleeding or need for intervention. Early initiation of VTE prophylaxis is likely to be safe and beneficial for patients with blunt solid organ injury.

Background The optimal treatment for complicated appendicitis remains controversial. We sought to compare clinical outcomes of patients with complicated appendicitis treated with an immediate operation or a trial of nonoperative management. Methods Adult patients (≥18 years) with complicated appendicitis were included. Patient characteristics and outcomes were compared between the immediate operation group and the nonoperative management group. Results A total of 101 patients met our inclusion criteria. Of those, 36 patients received an initial trial of nonoperative management with an 86.1% success rate. Patients who failed nonoperative management required significantly longer hospital stays than those in the immediate operation group (11 vs. 5 days). An immediate operation was performed in 65 patients. Open surgery was required in 9 patients (13.8%). Postoperatively, 7 patients (10.8%) required percutaneous drainage of intraabdominal abscess. Conclusions Nonoperative management was successful in the majority of patients with complicated appendicitis, whereas failure of nonoperative management was associated with prolonged hospital stay. Patients who underwent an immediate operation often required percutaneous drainage of intraabdominal abscess.

Background With no consensus on the optimal management strategy for asymptomatic retained bullet fragments (RBF), the emerging data on RBF lead toxicity have become an increasingly important issue. There are, however, a paucity of data on the magnitude of this problem. The aim of this study was to address this by characterizing the incidence and distribution of RBF. Methods A trauma registry was used to identify all patients sustaining a gunshot wound (GSW) from July 1, 2015, to June 31, 2016. After excluding deaths during the index admission, clinical demographics, injury characteristics, presence and location of RBF, management, and outcomes, were analyzed. Results Overall, 344 patients were admitted for a GSW; of which 298 (86.6%) of these were nonfatal. Of these, 225 (75.5%) had an RBF. During the index admission, 23 (10.2%) had complete RBF removal, 35 (15.6%) had partial, and 167 (74.2%) had no removal. Overall, 202 (89.8%) patients with nonfatal GSW were discharged with an RBF. The primary indication for RBF removal was immediate intraoperative accessibility (n = 39, 67.2%). The most common location for an RBF was in the soft tissue (n = 132, 58.7%). Of the patients discharged with an RBF, mean age was 29.5 years (range, 6.1-62.1 years), 187 (92.6%) were me, with a mean Injury Severity Score of 8.6 (range, 1-75). One hundred sixteen (57.4%) received follow-up, and of these, 13 (11.2%) returned with an RBF-related complication [infection (n = 4), pain (n = 7), fracture nonunion (n = 1), and bone erosion (n = 1)], with a mean time to complication of 130.2 days (range, 11-528 days). Four (3.4%) required RBF removal with a mean time to removal of 146.0 days (range, 10-534 days). Conclusion Retained bullet fragments are very common after a nonfatal GSW. During the index admission, only a minority are removed. Only a fraction of these are removed during follow-up for complications. As lead toxicity data accumulates, further follow-up studies are warranted. Level of evidence Prognostic and epidemiological, level III.

The use of extracorporeal membrane oxygenation (ECMO) in trauma patients with severe acute respiratory distress syndrome (ARDS) continues to evolve. The objective of this study was to perform a comparative analysis of trauma patients with ARDS who received ECMO to a propensity matched cohort of patients who underwent conventional management.The Trauma Quality Improvement Program (TQIP) database was queried from 2013 to 2016 for all patients with ARDS and those who received ECMO. Demographics, as well as clinical, injury, intervention, and outcome data were collected and analyzed. Patients with ARDS were divided into two groups, those who received ECMO and those who did not. A propensity score analysis was performed using the following criteria: age, gender, vital signs (HR, SBP) and GCS on admission, Injury Severity Score (ISS), and Abbreviated Injury Scale (AIS) score in several body regions. Outcomes between the groups were subsequently compared using univariate as well as Cox regression analyses. Secondary outcomes such as hospitalization (HLOS), ICU length-of-stay (LOS) and ventilation days stratified for patient demographics, timing of ECMO and anticoagulation status were compared.Over the 3-year study period, 8990 patients with ARDS were identified from the TQIP registry. Following exclusion, 3680 were included in the final analysis, of which 97 (2.6%) received ECMO. On univariate analysis following matching, patients who underwent ECMO had lower overall hospital mortality (23 vs 50%, p0.001) with higher rates of complications (p0.005), including longer HLOS. In those undergoing ECMO, early initiation (7 days) was associated with shorter HLOS, ICU LOS, and fewer ventilator days. No difference was observed between the two groups with regard to anticoagulation.Extracorporeal membrane oxygenation use in trauma patients with ARDS may be associated with improved survival, especially for young patients with thoracic injuries, early in the course of ARDS. Anticoagulation while on circuit was not associated with increased risk of hemorrhage or mortality, even in the setting of head injuries. The mortality benefit suggested with ECMO comes at the expense of a potential increase in complication rate and prolonged hospitalization.

The optimal imaging strategy in hemodynamically stable pediatric blunt trauma remains to be defined. The purpose of this study was to determine the differences between selective and liberal computed tomography (CT) strategy in a pediatric trauma population with respect to radiation exposure and outcomes.We performed a retrospective analysis of hemodynamically stable blunt pediatric trauma patients (≤16 y) who were admitted to a Level I trauma center between 2013-2016. Patients were stratified into selective and liberal imaging cohorts. Univariate and multivariate regression analyses were used to compare outcomes between the groups. Outcomes included radiation dose, hospital and ICU length of stay, complications and mortality.Of the 485 patients included, 176 underwent liberal and 309 selective CT imaging. The liberal cohort were more likely to be severely injured (ISS15: 34.1 versus 8.4%, P0.001). The odds of exposure to a radiation dose of15 mSv were higher with liberal scanning in patients with both ISS15 (OR 2.78, 95% CI 1.76-5.19, P0.001) and ISS ≤ 15 (OR 3.41, 95% CI 2.19-8.44, P0.001). Adjusted outcomes regarding mortality, ICU length of stay, and complications were similar between the cohorts.Selective CT imaging in hemodynamically stable blunt pediatric trauma patients was associated with reduced radiation exposure and similar outcomes when compared to a liberal CT strategy.

Background Trauma centers are receiving increasing numbers of older trauma patients. There is a lack of literature on the outcomes for elderly trauma patients who undergo damage control laparotomy (DCL). We hypothesized that trauma centers with geriatric protocols would have better outcomes in elderly patients after DCL. Methods A retrospective chart review of consecutive adult trauma patients with DCL at 8 level 1 trauma centers was conducted from 2012 to 2018. Patients aged 40 or older were included. Age ≥ 55 years was defined as elderly. Demographics, injury information, clinical outcomes, including mortality, and complications were recorded. Univariate and multivariate analyses were performed. Results A total of 379 patients with DCLs were identified with an average age of 54.8 ± 0.4 years with 39.3% (n = 149/379) of patients aged ≥ 55. Geriatric protocols or a consulting geriatric service was present at 37.5% (n = 3/8) of institutions. Age ≥ 55 was a significant risk factor for in-hospital mortality (OR 2, 95% CI 1.0-4.0, P = .04). Institutions without dedicated geriatric trauma protocols/services had higher overall in-hospital mortality on both univariate (57.9% vs 34.3%, P = .02) and multivariate analyses (OR 2.1, 95% CI 1.3-3.4, P < .001). Conclusions Surgical management of older trauma patients remains a challenge. Geriatric protocols or dedicated services were found to be associated with improved outcomes. Future efforts should focus on standardizing the availability of these resources at trauma centers.

BACKGROUND: Autotaxin (ATX-secretory lysophospholipase D) is the primary lysophosphatidic acid (LPA) producing enzyme. LPA promotes endothelial hyper-permeability and microvascular dysfunction following cellular stress. OBJECTIVE: We sought to assess whether ATX inhibition would attenuate endothelial monolayer permeability after anoxia-reoxygenation (A-R) in vitro and attenuate the increase in hydraulic permeability observed after ischemia-reperfusion injury (IRI) in vivo. METHODS: A permeability assay assessed bovine endothelial monolayer permeability during anoxia-reoxygenation with/without administration of pipedimic acid, a specific inhibitor of ATX, administered either pre-anoxia or post-anoxia. Hydraulic permeability (Lp) of rat mesenteric post-capillary venules was evaluated after IRI, with and without ATX inhibition. Lastly, Lp was evaluated after the administration of ATX alone. RESULTS: Anoxia-reoxygenation increased monolayer permeability 4-fold (p

Background Severe liver injuries pose a challenge to trauma surgeons. While the use of hepatic angioembolization (HAE) has been evaluated as a component of the nonoperative management of liver injury, little is known about the efficacy of postoperative HAE in patients who require hemorrhage control laparotomy (HCL) for liver injury. The purpose of this study is to evaluate the impact of HAE following HCL on patient survival. Methods This is a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program database from January 2013 to December 2014. In propensity score matched (2:1) patients who underwent HCL-only or HCL + HAE, the impact of adjunctive use of HAE on patient survival was examined with the Cox proportional hazards regression analysis adjusting for transfusion requirement within 4 hours. We also performed a subgroup analysis in patients without severe traumatic brain injury (Abbreviated Injury Scale head ≤3). Results A total of 1,675 patients met our inclusion criteria. Of those, 75 (4.5%) patients underwent HAE after HCL (median hours to HAE, 5 hours after admission). In 225 propensity score-matched patients, the use of HAE following HCL was significantly associated with improved 24-hour mortality, but not in-hospital mortality. In the subgroup of patients without severe traumatic brain injury (n = 189), we observed significant survival benefits (24-hour and in-hospital mortality) associated with the adjunctive use of HAE. Conclusion The results of our study suggest that the adjunctive use of HAE might improve survival of patients who require HCL for liver injury. Further prospective study to determine the indication for postoperative HAE is still warranted. Level of evidence Therapeutic study, level III.

Angioembolization versus open control of traumatic pelvic hemorrhage is debated. We sought to compare outcomes between angioembolization and open internal iliac artery occlusion. A 14-year retrospective review (2004–2017) was performed at our academic Level I trauma center. All pelvic hemorrhage patients who underwent internal iliac artery angioembolization or silastic loop ligation via laparotomy were compared for outcomes. Patient demographics included vital signs, mechanism, and injury severity score (ISS). Outcomes included mortality (%), operating room visits, reoperation for hemorrhage (%), transfusion burden (units), and infection (%). A total of 163 trauma patients matched for age, ISS, mechanism, and cavitary involvement were included for analysis. Compared with silastic loop ligation (n = 51, mean ISS = 32 ± 14), patients who underwent angioembolization (n = 112, mean ISS = 30 ± 8.9) demonstrated decreased mortality (23% vs 57%, P < 0.01), made fewer operating room trips (mean = 2.2 vs 3.6 trips, P < 0.01), made fewer trips for pelvic (2.8 vs 11%, P = 0.05) and nonpelvic-related bleeding (3.6 vs 22%, P < 0.01), used fewer blood products [packed red blood cells, fresh-frozen plasma, platelets, and cryoprecipitate] ( P < 0.01 for all), and indicated a trend toward fewer infections (5.7% vs 14%, P = 0.07). Internal iliac artery angioembolization demonstrates lower mortality, lower reoperation rates, decreased transfusion burden, and a trend toward fewer infections compared with silastic loop ligation.

Focused assessment with Sonography for trauma (FAST) examination is essential to trauma triage. We sought to determine whether FASTs completed early in sequencing portend worse outcomes. A two-year review (2014–2015) of all trauma activations at our Level I trauma center was performed. Patients were matched at baseline and FAST times were compared. Outcomes included resuscitation time (RESUS-h), ventilation days (d), hospital length of stay (HLOS-d), ICU length of stay (LOS-d), survival (%), nosocomial infection rate (%), and venous thromboembolism complication rate (%). ED interventions included transfusions, crystalloid, antibiotics, central line placement, intubation, thoracostomy, thoracotomy, pelvic X-ray, and binder. One thousand, three hundred and twelve patients were included for analysis (mean age = 38 ± 19 years, mean Injury Severity Score = 12 ± 11, 21% penetrating). Compared with FASTs completed after the primary survey, early FASTs led to significantly more ventilation days ( P < 0.01), longer ICU length of stay ( P < 0.01), and a greater incidence of nosocomial infections ( P = 0.03). In the ED, early FASTs led to significantly more intubations ( P < 0.01) and transfusions ( P < 0.01) compared with late FASTs. FASTs completed before primary survey portend worse outcomes, with more ED interventions and equivocal results. FAST as a true adjunct to primary survey is recommended.

Introduction: Limited options exist for cardiovascular support of the trauma patient in extremis. This patient population offers challenges that are often considered insurmountable. This article identifies a heterogeneous group of trauma patients in extremis who may benefit from extracorporeal membrane oxygenation. Methods: Data were sourced from the medical records of all patients placed on extracorporeal membrane oxygenation following trauma at a Level I Trauma Center between 1 December 2016 and 1 December 2017. Results: All patients were male (N = 7), mostly with blunt injuries (n = 5), with an average age of 41 years and with an average Injury Severity Scores of 33 (median = 34). Two out of seven patients survived (28.5%). Survivors tended to have a longer duration on extracorporeal membrane oxygenation (13.5 vs 3.8 days), had extracorporeal membrane oxygenation initiated later (15 vs 7.8 days), and had suffered a blunt injury. Two patients were initiated on veno-arterial extracorporeal membrane oxygenation (both non-survivors) and five were initiated on veno-venous extracorporeal membrane oxygenation (two survivors, three non-survivors). Five patients were heparinized immediately (one survivor, four non-survivors), and two patients were heparinized after clotting was noted in the circuit (one survivor, one non-survivor). Three of the seven (42.8%) patients suffered cardiac arrest either prior to, or during, the initiation of extracorporeal membrane oxygenation (all non-survivors). Discussion: Extracorporeal membrane oxygenation use in the trauma patient in extremis is not standard; however, this article demonstrates that extracorporeal membrane oxygenation is feasible in a complex, heterogeneous patient population when treated at designated centers.

Angioembolization (AE) is widely used for hemorrhagic control in patients with pelvic fracture. The latest version of the Resources for Optimal Care of the Injured Patient issued by the American College of Surgeons Committee on Trauma requires interventional radiologists to be available within 30 minutes to perform an emergency AE. However, the impact of time-to-AE on patient outcomes remains unknown. We hypothesized that a longer time-to-AE would be significantly associated with increased mortality in patients with pelvic fracture.This is a 2-year retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program database from January 2013 to December 2014. We included adult patients (age ≥ 18 years) with blunt pelvic fracture who underwent pelvic AE within 4 hours of hospital admission. Patients who required any hemorrhage control surgery for associated injuries within 4 hours were excluded. Hierarchical logistic regression was performed to evaluate the impact of time-to-AE on in-hospital and 24-hour mortality.A total of 181 patients were included for analysis. The median age was 54 years (interquartile range, 38-68) and 69.6% were male. The median injury severity score was 34 (interquartile range, 27-43). Overall in-hospital mortality rate was 21.0%. The median packed red blood cell transfusions within 4 and 24 hours after admission were 4 and 6 units, respectively. After adjusting for other covariates in a hierarchical logistic regression model, a longer time-to-pelvic AE was significantly associated with increased in-hospital mortality (odds ratio, 1.79 for each hour; 95% confidence interval, 1.11-2.91; p = 0.018).The current study showed an increased risk of in-hospital mortality related to a prolonged time-to-AE for hemorrhagic control following pelvic fractures. Our results suggest that all trauma centers should allocate resources to minimize delays in performing pelvic AE.Therapeutic/care management, level IV.

Mirizzi syndrome (MS) is an uncommon complication of cholelithiasis caused by extrinsic biliary compression by stones in the gallbladder infundibulum or cystic duct. The purpose of this study was to evaluate the outcomes associated with a laparoscopic approach to this disease process. This is a 10-year, retrospective study conducted at two academic medical centers with established acute care surgery practices. Patients with a diagnosis of MS confirmed intraoperatively were included. Eighty-eight patients with MS were identified with 55 (62.5%) being type 1. Twenty six (29.5%) patients, all type 1, underwent successful laparoscopic cholecystectomy. Of the 62 patients that underwent open cholecystectomy, 27.3 per cent had a laparoscopy converted to open procedure. There was no significant difference in overall complications (19.2 vs 29%) among those undergoing laparoscopic versus open cholecystectomy. Length of stay was lower in patients that had a laparoscopic approach ( P = 0.001). Laparoscopic cholecystectomy can safely be attempted in type 1 MS and seems to be associated with fewer overall complications and shorter length of stay compared with an open approach.

Background A well-defined means of organizing surgeons based on functional capabilities in disaster response has been lacking. We sought to create a pilot registry of surgeons, organized by functional capacities, available to respond to disasters in conjunction with the American College of Surgeons Operation Giving Back and to better understand their participation in disaster medicine training. Methods The authors conducted a survey of the members of the American Association for the Surgery of Trauma and the Eastern Association for the Surgery of Trauma aimed at establishing a pilot registry of qualified trauma surgeons available to respond to disasters. Data from the surveys were analyzed retrospectively for surgical and subspecialty training, board certification, disaster response training, and military or civilian disaster experience to better understand the respondents' functional capacities and disaster training backgrounds. Results Of 211 respondents, 96% self-identified as trauma surgeons, whereas 87% and 89% reported active practice in acute care surgery and/or critical care. Nearly all had primary board certifications in general surgery (93%), and many had additional certifications in surgical critical care (65%). While many reported participation in American College of Surgeons-sponsored trauma courses, only 30% of those surveyed received disaster-specific training in Federal Emergency Management Agency courses, and even fewer received training in the Disaster Management and Emergency Preparedness course. Few had military (26%) or civilian (19%) experience in disaster response. Conclusions This initiative complements efforts to organize a registry of trauma surgeons who are qualified and willing to respond in all aspects of disaster response. While trauma surgeons are optimally positioned to provide a wide range of surgical expertise in a disaster, this study further demonstrated the lack of a universally accepted disaster training program for surgeons willing to respond to mass casualty incidents. Standardized disaster response training for surgeons remains a challenge for the future. Level of evidence Care management, level IV.

Objective The incidence of morbidity and mortality for iliac vascular injuries in the literature are likely overestimated owing to associated injuries. Data for isolated iliac vascular injuries are very limited. No large studies have reported the incidence of morbidity for repair versus ligation of isolated iliac vein injuries. Methods Patients in the National Trauma Data Bank (NTDB; 2007-2012) with at least one iliac vascular injury were analyzed. Isolated iliac vessels were defined as cases with Abbreviated Injury Scale severity score of greater than 3 for extraabdominal injuries and an Organ Injury Scale grade of greater than 3 for intraabdominal injuries. Results Overall, 6262 iliac vascular injuries (2809 penetrating, 3453 blunt) were identified in 271,076 patients with abdominal trauma (2.3%). There were 3379 patients (1841 penetrating, 1538 blunt) with isolated iliac vascular injuries (1.2%) and 557 patients (514 penetrating, 43 blunt) with combined iliac artery and vein injuries (0.2%). The 30-day mortality rate was 16.5% for isolated iliac vein injury, 19.3% for isolated iliac artery injury, and 48.7% for combined isolated iliac artery and vein injury. The 30-day mortality rate was 23.4% for isolated iliac vascular injuries compared with 39.0% for nonisolated iliac vascular injuries ( P P = .875), pulmonary embolism (repair, 1.8%; ligation, 0.5%; P = .38), fasciotomy (repair, 9.3%; ligation, 14.6%; P = .094), amputation (repair, 1.8%; ligation, 2.6%; P = .738), acute kidney injury (repair, 5.8%; ligation, 4.7%; P = .627). Multivariate logistic regression demonstrated that ligation of isolated iliac vein injuries had an odds ratio of 2.2 for mortality compared with repair (95% confidence interval, 1.08-4.66). Conclusions Isolated iliac vascular injuries are associated with a high incidence of mortality, especially for combined venous and arterial injury, but mortality is significantly lower than in patients with nonisolated iliac vascular injuries. In patients with isolated iliac vein injuries, mortality was higher in patients who underwent ligation compared with repair; however, the rates of deep venous thrombosis, pulmonary embolism, fasciotomy, amputation, and acute kidney injury were not different between the treatment groups. These data lend credence to the assessment that repair of iliac vein injuries is preferable to ligation whenever feasible.

BACKGROUND Injuries sustained by civilians from interaction with police are a polarizing contemporary sociopolitical issue. Few comprehensive studies have been published using national hospital-based data. The aim of this study was to examine the epidemiology of these injuries to better understand this mechanism of injury. METHODS Patients entered into the National Trauma Data Bank (NTDB) (January 2007 to December 2012) with E-codes E970.0 to E976.0 (International Classification of Diseases, Ninth Revision, Clinical Modification), identifying injuries associated with law enforcement in the course of legal action, were enrolled. Patients' demographics, injury characteristics, procedures, and outcomes were collected and analyzed. Patients injured by other civilians (E960.0-E968.0) were used for comparison. RESULTS Of 4,146,428 patients in the NTDB, 7,203 (0.17%) were injured during interaction with police. The numbers of patients in consecutive study years were 858, 1,103, 1,148, 1,274, 1,316, and 1,504. The incidence of these injuries was stable over time (0.17-0.18%) (p = 0.129). Patients had a median age of 31 years (range, 0-108), and 94.3% were male. Median injury severity score was 9 (interquartile range [IQR], 4-17). The most common mechanism of injury was gunshot wound (44%).Patients were white, 43%; black, 30%; Hispanic, 17%; Asian, 1%; and Other, 9%. As a proportion of the total race-specific NTDB trauma population, there was an average of 1.13 white patients, 2.71 Hispanic patients, and 3.83 black patients per 1,000. Mechanism, injury severity score, and outcomes did not vary by race. Compared to patients injured by civilians, patients injured by police are more likely to be white (43% vs 25%, p < 0.001) and injured by gunshot wounds (44% vs 32%, p < 0.001). CONCLUSIONS Based on data from trauma centers across the United States, the rate of injuries sustained during interactions with police has been stable over time. Gunshot wounds are the most common mechanism of injury. Proportionally, black patients are the most frequently injured race. When compared to patients injured by civilians, however, patients injured by police are more likely to be white. This study provides a step toward a better understanding of police-associated injuries. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

Draining the chest cavity with two chest tubes after thoracotomy for trauma is controversial. This article aims to determine whether using two tubes after thoracotomy for trauma is more effective than using a single tube. A 9-year retrospective review (2007–2015) was performed at our academic level I trauma center. All patients who underwent trauma thoracotomy (unilateral and bilateral) were included for analysis (n = 99). Patients with incomplete data, pediatric patients (age < 18), pregnant patients, and early deaths (

BACKGROUND Splenic artery embolization (SAE) has gained increasing acceptance as an important adjunct in the treatment of splenic injuries. Residual immunologic function of the spleen after embolization and its consequences on early infectious complications still remain intensely debated. The purpose of this study was to compare SAE and splenectomy (SP) in terms of early in-hospital infectious complications and outcomes. METHODS Two-year retrospective Trauma Quality Improvement Program database prognostic study. Patients with grade IV to V splenic injury requiring SAE or SP were included in the final analysis. Examined variables were demographics, mechanism of injury, Abbreviated Injury Scale (AIS), Injury Severity Score, Organ Injury Scale, admission vital signs, blood transfusion in the first 24 hours, early infectious complications, and outcomes. Multivariate analysis adjusted for patient and injury-related variables was used to identify independent predictors for infectious complication and mortality. RESULTS During the study period, 4,063 patients with a grade IV to V splenic injury managed with SAE or SP were included in the study. SAE was performed in 461 (11.3%) patients. The early infectious complication rate was 23.1% in the SP group and 11.7% in the SAE group (p < 0.001). Stepwise logistic regression analysis identified age 65 years or older, Glasgow Coma Scale (GCS) score less than 9, Head AIS score of 3 or greater, SP, and blood transfusion in the first 24 hours as independent predictors for early infectious complications. The unadjusted overall mortality was 12.7% in the SP group and 5.4% in the SAE group (p < 0.001). Age 65 years or older, GCS score less than 9, hypotension, head AIS score of 3 or greater, and blood transfusion in the first 24 hours were independent risk factor for mortality. SP was not an independent risk factor in terms of mortality. Subgroup analysis in patients with isolated splenic injury showed age 65 years or older, GCS score less than 9, and blood transfusion in the first 24 hours as independent factors associated with early infection. CONCLUSION Our study supports the effectiveness of SAE in hemodynamically stable patients with a grade IV to V splenic injury. SP is associated with an increased risk of early infectious complications but is not an independent risk for mortality. LEVEL OF EVIDENCE Therapeutic study, level IV.

Helmet use in a motorcycle collision has been shown to reduce head injury and death. Its protective effect on the cervical spine (C-spine), however, remains unclear. The objective of this study was to explore the relationship between helmet use and C-spine injuries.Retrospective National Trauma Data Bank (NTDB) study. All motorcycle collisions between 2007 and 2014 involving either a driver or passenger were included. Data collected included demographics, vital signs, Abbreviated Injury Scale (AIS), Injury Severity Score (ISS) and specific injuries. The primary outcome was the prevalence of C-spine injuries. Secondary outcomes included were overall mortality, ventilation days, intensive care unit length of stay (LOS), total hospital LOS, and in-hospital complications.A total of 270,525 patients were included. Helmets were worn by 57.6% of motorcyclists. The non-helmeted group was found to have a higher incidence of head injury with head AIS2 (27.6% vs 14.8%, p0.001). Univariate analysis showed a higher prevalence of C-spine injuries in the non-helmeted group (10.4% vs 9.4%, p0.001), with a higher proportion of severe C-spine injuries with AIS2 (3.2% vs 2.6%, p0.001). Additionally, traumatic brain injury (TBI) was found to be two times higher in the non-helmeted group (20.7% vs 10.9%, p0.001). Multiple logistic regression showed helmet use to be an independent protective factor against mortality (OR=0.832, 95% CI 0.781-0.887, p0.001). Although statistically significant in univariate analysis, helmet use was not associated with C-spine injuries after adjusting for relevant covariates. However, helmet use reduced the risk of severe head injuries by almost 50% (OR=0.488, 95% CI 0.475-0.500, p0.001).Helmet use reduces the risk of head injury and death among motorcyclists; however, no association with C-spine injuries could be detected.

Injuries after skiing and snowboarding accidents lead to an estimated 7,000 hospital admissions annually and present a significant burden to the health care system. The epidemiology, injury patterns, hospital resource utilization, and outcomes associated with these severe injuries need further characterization.The National Trauma Data Bank was queried for the period 2007 to 2014 for admissions with Injury Severity Score15 and International Classification of Diseases Codes-9th Revision codes 885.3 (fall from skis, n = 1,353) and 885.4 (fall from snowboard, n = 1,216). Demographics, emergency department data, diagnosis and procedure codes, and outcomes were abstracted from the database.Severe (Injury Severity Score15) ski-associated and snowboard-associated injuries differed with respect to age distribution (median age, 38; interquartile range, 19-59 for skiers and median age, 20; interquartile range, 16-25 for snowboarders; p0.001) and sex (78.9% and 86.4% males, respectively, p0.001). Traumatic brain injury was common for both sports (56.8% of skiers vs. 46.6% of snowboarders, p0.001). Injuries to the spine (28.9%), chest (37.6%), and abdomen (35.0%) were also common. Eighty percent of patients used emergency medical services (50% ambulance, 30% helicopter) with a median emergency medical services transport time of 84 minutes. 50.8% of patients required interhospital transport. 43.2% of injuries required surgical intervention (21.3% orthopedic, 12.5% neurosurgical, 10.5% thoracic, 7.8% abdominal). Median hospital length of stay was 5.0 days. 60.0% of patients required intensive care unit admission with median intensive care unit length of stay 3.0 days. Overall mortality was 4.0% for skiers and 1.9% for snowboarders.Severe injuries after ski and snowboard accidents are associated with significant morbidity and mortality. Differences in injury patterns, risk factors for severe injury, and resource utilization require further study. Increased resource allocation to alpine trauma systems is warranted.Prognostic/epidemiologic, level III.

Trauma training in general surgery residency is undergoing an evolution. Hour restrictions, the growth of subspecialty care, and the trend toward nonoperative management have altered resident exposure to operative trauma. We sought to identify trends in resident trauma training since the inception of the 80-hour workweek.The Accreditation Council for General Medical Education Case Log Statistical Reports for Surgery was abstracted for general surgery resident trauma operative volume for the years 1999-2014. Resident trauma experience (operative caseload [OC]) was compared before inception of the 80-hour workweek (1999-2002) to after the 80-hour workweek began (2003 to current).A trend toward decreased operative trauma for general surgery residents was observed (mean OC [before 80-hour workweek vs. 80-hour workweek], 39,252 ± 1,065.2 cases vs. 36,065 ± 1,291.8; p = 0.06). Trauma laparotomies increased (range, 5,446-9,364 cases) with corresponding decreases in vascular trauma (4,704 to 799 cases), neck explorations (1,876 to 1,370 cases), and thoracotomies (2,507 to 2,284 cases). By comparison, an increase in vascular/integrated cases was noted (mean OC [before 80-hour workweek vs. 80-hour workweek], 845 ± 44.2 vs. 1,465 ± 88.4 cases; p0.01). Resident deficiencies analyzed by time period (before 80-hour workweek vs. 80-hour workweek) demonstrated deficiencies in thoracic, abdominal, solid organ, and extremity-vascular trauma domains (p0.01 for each). Nontrauma cases were also on the decline, specifically in open thoracic, vascular, and solid organ surgery (p0.05 for each). Both 1- and 2-year fellowships offset deficiencies in trauma education.Based on the data, an alarming number of graduates complete training with substantially less experience in defined trauma categories. Because of a decline in operative trauma volume, advanced fellowship training should be encouraged specifically for those interested in a career in trauma and acute care surgery.

BACKGROUND/AIMS: The role of percutaneous drainage in Hinchey Ib and II diverticulitis is controversial. The aim of the present study was to clarify the indications for percutaneous drainage in such circumstances. MATERIALS AND METHODS: This was a single-center retrospective review at an academic tertiary care hospital. All Hinchey Ib and II diverticulitis cases admitted from 2012 to 2014 were considered. RESULTS: Overall, 104 (78%) patients underwent successful conservative treatment, whereas 30 (22%) patients underwent surgery during admission. During the index admission, abscess drainage was performed in 21 patients, of which 19 patients were successfully managed without surgery on the index admission and two patients ultimately required surgery. Elective versus same-admission surgery resulted in an increase use of laparoscopy (p=0.01), higher rate of restoration of gastrointestinal continuity with the index operation (p=0.04), and lower rate of diverting stoma formation (p

BACKGROUND: Phosphatidylserine (PS) is normally confined in an energy-dependent manner to the inner leaflet of the lipid cell membrane. During cellular stress PS is exteriorized to the outer layer, initiating a cascade of events. Because cellular stress is often accompanied by decreased energy levels and because maintaining PS asymmetry is an energy-dependent process, it would make sense that cellular stress associated with decreased energy levels is also associated with PS exteriorization that ultimately leads to endothelial cell dysfunction. Our hypothesis was that anoxia-reoxygenation (A-R) is associated with decreased ATP levels, increased PS exteriorization on endothelial cell membranes, and increased endothelial cell membrane permeability. METHODS: The effect on ATP levels during anoxia-reoxygenation was measured via colorimetric assay in cultured cells. To measure the effect of A-R on PS levels, cultured cells underwent A-R and exteriorized PS levels and also total cell PS were measured via biofluorescence assay. Finally, we measured endothelial cell monolayer permeability to albumin after A-R. RESULTS: ATP levels in cell culture decreased 27% from baseline after A-R (p

Focused assessment with Sonography for trauma (FAST) examination is essential to trauma triage. We sought to determine whether FASTs completed early in sequencing portend worse outcomes. A two-year review (2014-2015) of all trauma activations at our Level I trauma center was performed. Patients were matched at baseline and FAST times were compared. Outcomes included resuscitation time (RESUS-h), ventilation days (d), hospital length of stay (HLOS-d), ICU length of stay (LOS-d), survival (%), nosocomial infection rate (%), and venous thromboembolism complication rate (%). ED interventions included transfusions, crystalloid, antibiotics, central line placement, intubation, thoracostomy, thoracotomy, pelvic X-ray, and binder. One thousand, three hundred and twelve patients were included for analysis (mean age = 38 ± 19 years, mean Injury Severity Score = 12 ± 11, 21% penetrating). Compared with FASTs completed after the primary survey, early FASTs led to significantly more ventilation days (

Angioembolization

The utility of prehospital thoracic needle decompression (ND) for tension physiology in the civilian setting continues to be debated. We attempted to provide objective evidence for clinical improvement when ND is performed and determine whether technical success is associated with provider factors. We also attempted to determine whether certain clinical scenarios are more predictive than others of successful improvement in symptoms when ND is performed.Prehospital ND data acquired from one air ambulance service serving 79 trauma centers consisted of 143 patients (n = 143; ND attempts = 172). Demographic and clinical outcome data were retrospectively reviewed. Patients were stratified by prehospital characteristics and indications. Objective outcomes were measured as improvement in vital signs, subjective patient assessment, and physical examination findings. Univariate analysis was performed using chi-square for variable proportions and unpaired Student's t-test for variable means; p.05 was considered statistically significant.The success rate of ND performed for hypoxia (70.5%) was notably higher than ND performed for hemodynamic instability (20.3%; p.01) or cardiac arrest (0%; p.01). Compared to vital sign parameters, clinical examination findings as part of the indication for ND did not reliably predict technical success (p.52 for all indications). No difference was observed comparing registered nurse versus paramedic (p = .23), diameter of catheter (p.13 for all), or length of catheter (p = .12).Prehospital ND should be considered in the appropriate clinical setting. Outcomes are less reliable in cases of cardiopulmonary arrest or hypotension with respiratory symptoms; however, this should not deter prehospital providers from attempting ND when clinically indicated. Additionally, the success rate of prehospital ND does not appear to be related to catheter type or the role of the performing provider.

Patients with adhesive small bowel obstruction (ASBO) often develop intraabdominal free fluid (IFF). While IFF is a finding on abdominopelvic computed tomography (CT) associated with the need for surgical intervention, many patients with IFF can be still managed non-operatively. A previous study suggested that a higher red blood cell count of IFF is highly predictive of strangulated ASBO. We hypothesized that radiodensity in IFF (Hounsfield unit (HU)) on CT would predict the need for surgical intervention.Patients with clinicoradiological evidence of ASBO between January 2009 and December 2013 were identified. In patients with IFF 3 cmA total of 318 patients with ASBO (median age 52 years, 56.0 % male) were identified. Of 111 patients who had IFF on CT, 55.9 % underwent therapeutic laparotomy and 15.3 % required bowel resection. Radiodensity of IFF in the operative group was significantly higher than that in the non-operative group (18.2 vs. 7.0 HU, p 0.01). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of high-density IFF (10 HU) to predict the need for surgical intervention were 83.9, 65.3, 75.4, 76.2, and 75.6 %, respectively.High-density IFF on CT was significantly associated with the need for surgical intervention in patients with ASBO. Prospective study to validate the predictive value of high-density IFF on CT will be warranted.

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.

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.

Firearm injuries are now the third leading cause of death in children. Understanding the circumstances surrounding pediatric firearm injuries will allow for targeted injury prevention efforts. We hypothesized that younger children are more likely to be victims of unintentional firearm injury.A multicenter, retrospective review of patients18 years old who sustained firearm injuries in Los Angeles County from 2006 to 2015 was performed. Unintentional injuries were defined as accidental firearm discharge without violent intent. Intentional injuries were defined as firearm discharge with intent to injure (including suicide).After review of 304 pediatric firearm injuries, 206 had sufficient narrative to determine intent with 10% of injuries classified as unintentional. Unintentional injuries were more common in younger children, more frequently caused by a firearm from within the home, and more likely to involve friend/family (all p 0.05). Intentional injuries were associated with more injuries and accounted for all deaths in our study cohort.In pediatric firearm injury, younger children are more susceptible to unintentional injuries, but intentional injuries are more common overall. Future interventions need to target both intentional violence in older children and unintentional firearm injury in young children if the frequency is to be reduced.Epidemiologic study.Level III.

INTRODUCTION: Translocation of phosphatidylserine from the inner leaflet to the outer leaflet of the endothelial membrane via phospholipid scramblase-1 (PLSCR1) is an apoptotic signal responsible for the loss of endothelial barrier integrity after ischemia-reperfusion injury. We hypothesized that inhibiting phosphatidylserine expression on endothelial cells would attenuate ischemia-reperfusion (IRI) induced increases in hydraulic permeability (L(p)). METHODS: Mesenteric hydraulic permeability (L(p)) was measured in rat post-capillary mesenteric venules subjected to IRI via superior mesenteric artery (SMA) occlusion (45 minutes) and release (300 minutes) in conjunction with several inhibitors of phosphatidylserine exposure as follows: 1) inhibition of PLSCR1 translocation (DTE - dithioerythritol, n=3), 2) inhibition of PLSCR1 membrane trafficking (2-BP - 2-bromopalmitate, n=3), and 3) inhibition of ion exchange necessary for PLSCR1 function (DIDS - 4,4′-Diisothiocyano-2,2′-stilbenedisulfonic acid, n=3). Under the same IRI conditions, rats were also administered targeted inhibitors of phosphatidylserine exposure including knockdown of phospholipid scramblase-1 (n=3) using RNA interference (RNAi), and as a potential therapeutic tool Diannexin, a selective phosphatidylserine blocker (n=3). RESULTS: During IRI net hydraulic permeability (L(p)) increased by 80% (p

Background The distribution of trauma deaths was classically described as trimodal. With advances in both technology and trauma systems, this was reevaluated and found to be bimodal in the early 2000s. Over the last decade there have been continued improvements in trauma and intensive care unit (ICU) care, related to damage control techniques and evidence based ICU pathways. A better understanding of the distribution of trauma deaths may be used to improve trauma systems. This study aimed to evaluate the contemporary distribution of trauma deaths after the widespread implementation of modern trauma and critical care principles. Methods This study included patients entered in the NTDB from 2008 to 2014. For dead patients, hospital length of stay was equated to time until death. Additional data was collected to include demographics, mechanism of injury, Injury Severity Score, and Abbreviated Injury Scale score. Histograms were plotted to demonstrate peaks in deaths. Survival analysis was performed with Kaplan-Meier curves and Gehan-Breslow generalized Wilcoxon tests. Results 4,185,009 patients were analyzed. Thirty-four percent of all deaths occurred within the first 24 hours of admission. The factors most associated with death in the first 24 hours were severe abdominal trauma (73%), penetrating trauma (55%), and severe extremity trauma (58%). Among patients with penetrating trauma and an abdominal Abbreviated Injury Scale score of 4 or higher, 83% of deaths occurred within 24 hours. When plotted, the distribution of deaths was seen to fall rapidly after the first 24 hours and continued to be flat for 30 days in all subgroups analyzed. Conclusion In this study, the distribution of trauma deaths no longer appears to be trimodal. This may reflect advances in trauma and ICU care, and the widespread adaption of damage control principles. Early deaths, however, remains a significant challenge, specifically from non-compressible abdominal hemorrhage and extremity trauma. Primary prevention and early hemorrhage control must continue to be a focus of research and trauma systems. Level of evidence Epidemiologic, level IV.

Draining the chest cavity with two chest tubes after thoracotomy for trauma is controversial. This article aims to determine whether using two tubes after thoracotomy for trauma is more effective than using a single tube. A 9-year retrospective review (2007-2015) was performed at our academic level I trauma center. All patients who underwent trauma thoracotomy (unilateral and bilateral) were included for analysis (n = 99). Patients with incomplete data, pediatric patients (age18), pregnant patients, and early deaths (24 hours) were excluded. When analyzed by chest cavity, dual tubes have increased drainage bilaterally (P = 0.008) and require more days to clear the right chest (P = 0.002). Patients with dual tubes bilaterally are associated with increased intensive care unit length of stay (P = 0.05) and ventilator days (P = 0.04). Although dual chest tube insertion achieves greater drainage, it comes at the cost of increased time to clear the chest and is associated with worse outcomes in bilateral injuries. One chest tube may be sufficient post-trauma thoracotomy; routine placement of two chest tubes is not recommended.

Shock Index (SI = heart rate/systolic blood pressure) predicts outcomes among trauma patients. Studies have also shown that the change in SI between the field and Emergency Department (ED) arrival (Delta SI) predicts mortality in trauma. Given the lack of reliable prehospital data, Delta SI may more accurately prognosticate if used within the ED. All trauma patients arriving to our Level I trauma center in 2014 were reviewed. Patients were matched for age, gender, mechanism of injury, and injury severity score. SI and ED Delta SI were calculated. ED Delta SI >0.1 and ≤0.1 defined the study groups. Pregnant patients, pediatric patients, and patients with incomplete data were excluded. Outcomes included intensive care unit (ICU) length of stay, blood products, and mortality. A total of 2591 patients were identified (n = 1294 patients analyzed). After matching, patients with ED Delta SI >0.1 had greater mortality (6.6 vs 2.6%, P = 0.010), need for blood transfusion (1764 vs 565 cc, P < 0.001), and ICU length of stay (5.6 vs 3.8 days, P = 0.014) compared with patients with ED Delta SI ≤0.1. In conclusion, ED Delta SI >0.1 is associated with increased mortality, need for blood transfusion, and ICU length of stay. Delta SI may be superior to traditional SI for trauma outcome prognostication.

Equivocal focused abdominal sonography for trauma (FAST) examinations confound decision-making for trauma surgeons. We sought to determine whether the equivocal FAST (defined as any nonconcordant result) has a deleterious effect on trauma outcomes. A 2-year review (2014–2015) of all trauma activations at our Level I trauma center was performed. Patients were matched at baseline and FAST results were compared. Outcomes included resuscitation time (h), ventilation days (d), hospital length of stay (HLOS-d), ICU length-of-stay, and survival (%). In addition, skill level of the sonographer was stratified by novice (postgraduate year (PGY) years 1–3) or expert skill levels (PGY-4/fellow or attending). A total of 1,027 patients were included. Compared with concordant FAST examinations, equivocal FASTs were associated with increased HLOS (14.1 vs 10.6, P = 0.05), higher mortality (9.8 vs 3.7%, P = 0.02), decreased positive predictive value in the right upper quadrant (RUQ) (55 vs 79%, P = 0.02) and left upper quadrant (LUQ) (50 vs 83%, P < 0.01) and significantly decreased specificity in the thoracic (83 vs 98%), RUQ (80 vs 98%), LUQ (86 vs 99%), and pelvic (88 vs 98%) windows (P < 0.01 for all). A trend of greater positive predictive value in the thoracic window (100 vs 81%, P = 0.09) among PGY-4/fellow and attending providers compared with PGY levels 1–3 was observed. Equivocal FASTs portend worse outcomes than concordant FASTs because of high false-negative rates, specifically in the thoracic region and the upper quadrants. Lower thresholds for intervention are recommended.

For detailed descriptions of the anatomy of the adult larynx and trachea, please refer to surgical anatomy in Chapter 3: Open Tracheostomy and Chapter 4: Cricothyroidotomy. There are anatomical differences between the adult and pediatric airway that merit emphasis. In children less than 10–12 years of age the airway is small and the cartilaginous prominences can be subtle on palpation. Some anatomical features in children, such as larger tongue/mouth ratio, smaller pharynx, larger floppy epiglottis, anterior vocal cords/larynx, narrower cricoid cartilage, and softer tracheal rings, make endotracheal intubation more difficult than in adults. In older children and adolescents, the laryngeal prominence at the upper border of the thyroid cartilage is easily felt, with the cricothyroid membrane palpated immediately inferior to the thyroid cartilage. In infants and younger children, the laryngeal prominence is not developed, and the thyroid cartilage is not easily identified. A better method to identify the cricothyroid membrane is to begin at the tracheal rings and palpate superiorly to locate the prominence of the cricoid cartilage. The cricothyroid membrane resides superiorly. If the cricothyroid membrane cannot be identified, percutaneous transtracheal needle ventilation (TTNV) can be safely performed by inserting the needle between the tracheal rings.

Intraosseous (IO) infusion is based on the principle that medullary veins of long bones remain patent during shock and hypovolemia. IO infusion sites include the humerus, proximal tibia, distal femur, and manubrium.

Coagulopathy management in the surgical ICU (SICU) requires early recognition and rapid treatment of the underlying hemostatic disturbance. The degree of prothrombotic and/or antithrombotic tendency can be assessed by conventional coagulation testing (PT/PTT/INR), but recent literature suggests that point-of-care viscoelastic testing (TEG/ROTEM) may allow for more rapid, accurate, and timely diagnosis and treatment. While acquired states of coagulopathy due to traumatic bleeding or postoperative hemorrhage are more common in the SICU, the surgical intensivist must be able to identify and treat the commonly inherited coagulopathies in the ICU: heparin-induced thrombocytopenia (HIT), von Willebrand disease (VWD), hemophilia, and clotting factor deficiencies.