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Patients prescribed higher opioid dosages are at increased risk of overdose and death without added pain reduction. Increases in opioid prescribing continue to fuel the epidemic. We hypothesized a comprehensive guideline to standardize opioid prescribing would decrease postdischarge dosages for patients experiencing trauma without requiring additional refills.This quasiexperimental study compared opioid prescribing by trauma providers before and after the implementation of a departmental guideline on April 1, 2019, aimed at aligning opioid prescription patterns with Centers for Disease Control and Prevention recommendations. Patients prescribed opioids before implementation were the control group, whereas patients prescribed opioids after were the intervention group. The primary outcome was the proportion of patients receiving ≥50 morphine milligram equivalents per day.We identified 293 and 280 patients experiencing trauma in the control and intervention groups, respectively. There were no differences between the groups' Injury Severity Score (P = .69) or the frequency of having a procedure performed (P = .80). Total morphine milligram equivalents and maximum morphine milligram equivalents per day were 16% and 25% lower, respectively, in the intervention group compared with the control group (P.001). The proportion of trauma patients prescribed ≥50 morphine milligram equivalents per day at discharge decreased from 57% to 18% after implementation (P.001). The proportion of trauma patients prescribed ≥90 morphine milligram equivalents per day also decreased, from 37% to 14% (P.001). There was no significant increase in the frequency of refill requests (P = .105) or refill prescriptions (P = .099) after discharge.A departmental guideline aimed at optimizing opioid prescription patterns successfully lowers the amount of morphine milligram equivalents prescribed to trauma patients and improves compliance with Centers for Disease Control and Prevention recommendations.

Approximately 20% of individuals who experience a traumatic injury will subsequently develop posttraumatic stress disorder (PTSD). Physical pain following traumatic injury has received increasing attention as both a distinct, functionally debilitating disorder and a comorbid symptom related to PTSD. Studies have demonstrated that both clinician-assessed injury severity and patient pain ratings can be important predictors of nonremitting PTSD; however, few have examined pain and PTSD alongside socioenvironmental factors. We postulated that both area- and individual-level socioeconomic circumstances and lifetime trauma history would be uniquely associated with PTSD symptoms and interact with the pain–PTSD association. To test these effects, pain and PTSD symptoms were assessed at four visits across a 1-year period in a sample of 219 traumatically injured participants recruited from a Level 1 trauma center. We used a hierarchal linear modeling approach to evaluate whether (a) patient-reported pain ratings were a better predictor of PTSD than clinician-assessed injury severity scores and (b) socioenvironmental factors, specifically neighborhood socioeconomic disadvantage, individual income, and lifetime trauma history, influenced the pain–PTSD association. Results demonstrated associations between patient-reported pain ratings, but not clinician-assessed injury severity scores, and PTSD symptoms, R(2(fvm)) = .65. There was a significant interaction between neighborhood socioeconomic disadvantage and pain such that higher disadvantage decreased the strength of the pain–PTSD association but only among White participants, R(2(fvm)) = .69. Future directions include testing this question in a larger, more diverse sample of trauma survivors (e.g., geographically diverse) and examining factors that may alleviate both pain and PTSD symptoms.

Older adult trauma is associated with high morbidity and mortality. Individuals older than 65 years are expected to make up more than 21% of the total population and almost 39% of trauma admissions by 2050. Our objective was to perform a national review of older adult trauma mortality and identify associated risk factors to highlight potential areas for improvement in quality of care.This is a retrospective cohort study of the National Trauma Data Bank including all patients age ≥65 years with at least one International Classification of Diseases, Ninth Revision, Clinical Modification trauma code admitted to a Level I or II US trauma center between 2007 and 2015. Variables examined included demographics, comorbidities, emergency department vitals, injury characteristics, and trauma center characteristics. Multilevel mixed-effect logistic regression was performed to identify independent risk factors of in-hospital mortality.There were 1,492,759 patients included in this study. The number of older adult trauma patients increased from 88,056 in 2007 to 158,929 in 2015 (p0.001). Adjusted in-hospital mortality decreased in 2014 to 2015 (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.86-0.91) when compared with 2007 to 2009. Admission to a university hospital was protective (OR, 0.83; 95% CI, 0.74-0.93) as compared with a community hospital admission. There was no difference in mortality risk between Level II and Level I admission (OR, 1.00; 95% CI, 0.92-1.08). The strongest trauma-related risk factor for in-patient mortality was pancreas/bowel injury (OR, 2.25; 95% CI, 2.04-2.49).Mortality in older trauma patients is decreasing over time, indicating an improvement in the quality of trauma care. The outcomes of university based hospitals can be used as national benchmarks to guide quality metrics.Therapeutic/Care Management, Level IV.

There is significant heterogeneity in pain outcomes following motor vehicle crashes (MVCs), such that a sizeable portion of individuals develop symptoms of chronic pain months after injury while others recover. Despite variable outcomes, the pathogenesis of chronic pain is currently unclear. Previous neuroimaging work implicates the dorsal anterior cingulate cortex (dACC) in adaptive control of pain, while prior resting state functional magnetic resonance imaging studies find increased functional connectivity (FC) between the dACC and regions involved in pain processing in those with chronic pain. Hyper-connectivity of the dACC to regions that mediate pain response may therefore relate to pain severity. The present study completed rsfMRI scans on N = 22 survivors of MVCs collected within 2 weeks of the incident to test whole-brain dACC-FC as a predictor of pain severity 6 months later. At 2 weeks, pain symptoms were predicted by positive connectivity between the dACC and the premotor cortex. Controlling for pain symptoms at 2 weeks, pain symptoms at 6 months were predicted by negative connectivity between the dACC and the precuneus. Previous research implicates the precuneus in the individual subjective awareness of pain. Given a relatively small sample size, approximately half of which did not experience chronic pain at 6 months, findings warrant replication. Nevertheless, this study provides preliminary evidence of enhanced dACC connectivity with motor regions and decreased connectivity with pain processing regions as immediate and prospective predictors of pain following MVC. Perspective This article presents evidence of distinct neural vulnerabilities that predict chronic pain in MVC survivors based on whole-brain connectivity with the dorsal anterior cingulate cortex.

BackgroundNonoperative management of adhesive small bowel obstruction (SBO) is successful in up to 80% of patients. Current recommendations advocate for computed tomography (CT) scan in all patients with SBO to supplement surgical decision-making. The hypothesis of this study was that cumulative findings on CT would predict the need for operative intervention in the setting of SBO.MethodsThis is an analysis of a retrospectively and prospectively collected adhesive SBO database over a 6-year period. A Bowel Ischemia Score (BIS) was developed based on the Eastern Association for the Surgery of Trauma guidelines of CT findings suggestive of bowel ischemia. One point was assigned for each of the six variables. Early operation was defined as surgery within 6 hours of CT scan.ResultsOf the 275 patients in the database, 249 (90.5%) underwent CT scan. The operative rate was 28.3% with a median time from CT to operation of 21 hours (Interquartile range 5.2-59.2 hours). Most patients (166/217, 76.4%) with a BIS of 0 or 1 were successfully managed nonoperatively, whereas the majority of those with a BIS of 3 required operative intervention (5/6, 83.3%). The discrimination (area under the receiver operating characteristic curve) of BIS for early surgery, any operative intervention, and small bowel resection were 0.83, 0.72, and 0.61, respectively.ConclusionThe cumulative signs of bowel ischemia on CT scan represented by BIS, rather than the presence or absence of any one finding, correlate with the need for early operative intervention.

The objective of this study was to assess the current practice pattern regarding posthospitalization follow-up of trauma patients among the members of the Eastern Association for the Surgery of Trauma (EAST). An anonymous online multiple-choice survey of EAST members in 2016 was conducted. Ten questions relating to the follow-up care of injured patients were presented to the Active, Senior, and Associate members of EAST. Data were screened for quantitative concerns prior to analysis. Of the 1,610 members surveyed, 289 responded (18%). Approximately 52% of respondents stated that their institution has a dedicated trauma follow-up clinic where most injured patients are seen after discharge. Less than 20% reported that nontrauma multidisciplinary providers are present in clinics. Most (89.5%) reported that follow-up is a single visit, unless a patient has long-standing issues. Only 3 respondents stated that patients are regularly seen 3+ months out from injury, and a significant minority (17.7%) acknowledged no set follow-up timeline. Only 3.6% of participants indicated that they have a psychologist embedded in the trauma team, and 11.5% reported that no system is currently in place to manage mental health. Despite more than 20 years of literature highlighting the long-term physical and mental health sequelae after trauma, these survey results demonstrate that there is a lack of standardized and multidisciplinary follow-up. Given the improvement in outcomes with the identification and treatment of these sequelae, greater attention should be paid to functional recovery, social and psychological well-being, and chronic pain.

Appendicitis usually manifests as either uncomplicated or complicated disease. Uncomplicated appendicitis is generally treated with an appendectomy without further antibiotic therapy. In contrast, complicated appendicitis can be treated in a myriad of ways. Nonoperative treatment has been proven to be effective but has variable failure rates. Operative management typically involves resection with postoperative antibiotics. The duration of antibiotic therapy is a topic of interest. Past studies have shown that a shorter duration of antibiotics (3-5 days) are equally as effective in treating intra-abdominal contamination. In the fall 2015, our practice pattern for antibiotic duration for acute complicated appendicitis changed to reflect this finding. The purpose of this study is to retrospectively review this change in practice.The aim of this study was to determine if a shorter duration of antibiotics for acute complicated appendicitis is as effective as a traditional longer duration of antibiotics with a historical cohort. We also aim to determine if the duration of stay improved with the shorter duration of antibiotics.Appendicitis cases documented after September 2015 until the present were identified. Study inclusion criteria included patients aged ≥18 and patients undergoing an appendectomy (open or laparoscopic). Exclusion criteria included patients age18, appendicitis cases not undergoing an operation, pregnant, or immunocompromised patients. Patient demographics, operation performed, pathology reports, antibiotic duration, duration of stay, infectious and postoperative complications, and 30-day readmission rates were collected through chart review. A sample of our treatment group prior to September 2015 was also obtained in a similar technique.The durations of stay between cohorts were not different; both were about 6.1 days. The duration of antibiotics was less in the post-2015 group (5.5 days vs 4.1 days, P = .005). The 30-day readmission rate was significantly less in the post-2015 group (16% vs 2%; P.017). Neither in hospital infectious complications nor types of complications were statistically significantly different between groups.This study shows that adherence to short duration antibiotic treatment appears to be effective in decreasing the 30-day readmission rate without increasing in hospital infectious complications. Short duration of antibiotics did not, however, decrease the duration of hospital stay.

BACKGROUNDAs more pneumothoraxes (PTX) are being identified on chest computed tomography (CT), the empiric trigger for tube thoracostomy (TT) versus observation remains unclear. We hypothesized that PTX measuring 35 mm or less on chest CT can be safely observed in both penetrating and blunt trauma m

Background Little effort has been made to address long-term quality of life, chronic pain (CP), posttraumatic stress disorder (PTSD), and functional disability in trauma survivors. This quality initiative was developed to determine feasibility of a coordinated, comprehensive, patient-centered follow-up clinic for those at risk for poor long-term outcomes. Methods A convenience sample from 649 hospitalized trauma patients at a Midwestern level 1 trauma center between February 2018 and August 2018 was screened for risk of PTSD and CP. Thirty-six patients were randomized into a standard follow-up clinic (standard of care [SOC]) (2-week postdischarge surgical clinic) or a new trauma quality of life clinic (TQOL). The TQOL was developed to provide comprehensive care to patients at high risk for PTSD (Injured Trauma Survivor Score, ≥2) and/or CP (discharge pain score, ≥4). Trauma quality of life clinic included a nurse practitioner or surgeon (physician), psychologist, social worker, and physical therapist at 1-week post discharge. All providers saw the patient independently, developed a care plan collaboratively, and communicated the plan to the patient. The SOC involved a visit only with a nurse practitioner or surgeon (medical doctor). Measures of pain, PTSD, depression, quality of life, physical functioning, and life satisfaction were completed at time of the TQOL/SOC or over the phone. Results There were no differences in demographics, readmissions, or emergency department visits after discharge between groups. However, no show rates were almost twice as high in SOC (40%) compared with TQOL (22%) and those in TQOL completed 23 additional psychology visits versus one psychology visit in SOC. This clinic structure is feasible for high-risk patients, and TQOL patients demonstrated improved engagement in their care. Conclusions A comprehensive multidisciplinary TQOL addressing issues affecting convalescence for trauma patients at high risk for developing PTSD and CP can improve follow-up rates to ensure patients are recovering successfully. Level of evidence Therapeutic, Level IV.

Enterocutaneous fistulae (ECF) are abnormal communications between the gastrointestinal tract and skin that may occur following an abdominal operation and result in significant morbidity and even mortality. Standardized care of patients with ECF has not been implemented at the majority of tertiary hospitals. We sought to evaluate the benefits of a multidisciplinary team utilizing an evidence-based clinical treatment protocol for inpatient management of ECF.We performed an Institutional Review Board-approved retrospective analysis of outcomes after the implementation of an evidence-based clinical treatment protocol for patients admitted with ECF to the acute care surgical service at a large academic medical facility. Patients managed prior to the established protocol were considered part of the pre-protocol cohort (pre) while patients managed following implementation were included in the postprotocol cohort (post). A review of all eligible patients' hospital and clinic medical records was performed.In the pre cohort (n = 6), the average length of stay was 37 days, ranging from 16-67 days, with a 16% spontaneous closure rate and 60% requiring operative management for closure. A single patient was not offered surgery due to significant comorbidities. The post cohort (n = 13) demonstrated an average length of stay of just 16 days, ranging from 4 to 28 days, with an 84% spontaneous closure rate and 16% requiring operative closure.Utilization of a standardized treatment approach results in high spontaneous closure rates with a decreased hospital length of stay.

Background The need for extended postoperative antibiotics (Abx) for complicated (gangrenous or perforated) appendicitis (CA) remains unclear. We hypothesize that giving ≤24 h of Abx for CA is not inferior to a longer duration in preventing infectious complications after appendectomy. Methods In this post hoc analysis of a prospective multicenter study, only patients with intraoperative diagnosis of CA were included. ANOVA and Chi-squared tests were used to compare length of stay, 30-day readmission rates, surgical site infection (SSI), and intra-abdominal abscess (IAA) between patients receiving ≥96 h and ≤24 h of Abx. Results Of 751 patients with CA, 704 met inclusion criteria. Mean age was 48 (±17) y; 391 (56%) were male. A total of 185 (26%) received Abx for ≤24 h and 100 (14% of overall) received no Abx. 85 (12%) patients were lost to follow-up at 30 d postop. Twenty-seven (4%) patients developed an SSI (≤24 h = 5 (3%), ≥96 h = 22 (5%), P = 0.502) and 82 (13%) developed IAA (≤24 h = 11 (7%), ≥96 h = 71 (15%), P = 0.008) within 30d postop. Sixty-six (11%) patients underwent a secondary intervention for infection within 30 d postop. 41% of SSIs (11/27) and 60% (49/82) of IAA occurred during the index hospitalization. On the multivariate analysis, there was not any evidence of an association between the duration of Abx and an increased rate of SSI (P = 0.539), IAA (P = 0.274), emergency department visits (P = 0.509), readmission (P = 0.911), or secondary interventions (P = 0.523). Conclusions No evidence of an association between the duration of Abx (≤24 h versus ≥ 96 h) for complicated appendicitis and an increased rate of SSI was observed and ≤24 h duration was associated with shorter length of stay. Because of possible selection bias, adequately powered randomized trials are required to definitely prove noninferiority of shorter course Abx duration.

Small bowel obstruction (SBO) is a common condition leading to numerous hospital admissions and operations. Standardized care of adhesive SBO patients has not been widely implemented in hospital systems.A prospective cohort of SBO patients was compared to a historical cohort of SBO patients after implementation of a SBO protocol using evidence-based guidelines and Omnipaque, a low-osmolar water soluble contrast. Patients without a history of abdominal surgery were excluded and data was collected through chart review.Univariate analyses demonstrated a decrease in both LOS by 1.35 days and in the proportion of patients receiving surgery (37% vs 25%; p 0.05). There was a decrease in time to surgery, rate of SBR, and rate of complications, yet an increase in readmission, although these findings were not statistically significant.Utilizing an evidence-based SBO protocol can lead to shorter LOS and may result in fewer operations for adhesive SBO patients.

Fast-track protocols (FTPs) are used to decrease length of stay (LOS) and hospital costs for elective outpatient procedures. Few institutions have implemented FTP for urgent procedures such as laparoscopic cholecystectomy (LC) and laparoscopic appendectomy (LA). This is a retrospective single-institution cohort study including all patients undergoing urgent LC or LA between July 1, 2010 and May 1, 2013. Exclusion criteria included conversion to open procedure, perforated appendicitis, or procedure related to intra-abdominal injury. Analysis included a comparison of the three study groups: (1) before (PRE) and after (POST) implementation of the fast-track protocol (FTP), (2) fast-track cohort (FT) and non-fast-track cohort (NFT), and (3) those completing the fast-track pathway (FT-C) and those who began but failed to complete the pathway (FT-F). There were significant reductions in LOS between all study groups compared: between PRE (n = 256) and POST (n = 472) cohorts by half a day (2.0 vs. 1.5 days, p

We compared observed postoperative outcomes from laparoscopic cholecystectomy performed for acute cholecystitis (AC) to outcomes predicted by the ACS-NSQIP risk calculator.We also noted and compared any differences in observed outcomes across the different Tokyo Guidelines (TG) levels of AC severity.We hypothesized that ACS-NSQIP would accurately predict complications and length of stay (LOS) and that increased TG severity levels would correlate with more complications, increased conversion to open surgery, and longer LOS. A review of all patients who underwent laparoscopic cholecystectomy for acute cholecystitis over eighteen months was performed. ACS-NSQIP predicted a complication rate of 4.6% (11% found) and LOS of 0.73 days (2.5 found), p

Many studies report on the incidence of chronic pain. However, deficiencies exist in prior research making it difficult to generalize results to trauma patients. This study evaluated the incidence of chronic pain in trauma patients at 4 months posttrauma and effect chronic pain has on life interference. The incidence of chronic pain was present in 79.2% of trauma patients 4 months posttrauma and a strong positive correlation (n = 80, r = 0.79, P < 0.001) existed between chronic pain severity and the effect on life interference. Chronic pain is prevalent and causes significant life interference in traumatically injured patients.

Strategies for the management of small bowel obstructions have changed significantly over the years. Nonoperative medical management has become the mainstay of treatment of many small bowel obstructions. However, the key to the management of small bowel obstructions is identifying those patients who need surgical intervention. Identification of those at risk for bowel ischemia and bowel death is an art as much as it is a science. Using the current literature and the past knowledge regarding small bowel obstructions, the clinician must carefully identify the signs and symptoms that suggest the need for operative intervention. Classification of the obstruction, history and physical examination, imaging, response to decompression and resuscitation, and resolution or progression of symptoms are the key factors influencing the management of small bowel obstructions.

Open abdominal wounds with enterocutaneous fistulae present health care providers and patients with complex wound management issues. Frequently, large wounds with exposed bowel are present and require the utilization of multiple wound care modalities to provide a method of control and isolation of fistula effluent to allow for maximum wound healing. This case study presents a unique approach to management of low-output enterocutaneous fistula with an open abdominal wound. Through the use of negative pressure wound therapy, a standard surgical drain, and optimized nutrition, fistula drainage was redirected and the abdominal wound healed, leaving a drain-controlled.

It is unclear what causes chronic pain in traumatically injured hospitalized adults. A total of 101 patients admitted to a level 1 trauma center completed interviews during their inpatient stay and at 4 months, and data on biologic, psychologic, and sociologic variables were collected. Statistical analysis used hierarchical logistical regression,χ, and independent-samples t tests. Prevalence of chronic pain at 4 months was 79.2%. Those with chronic pain at 4 months had more posttraumatic stress disorder, anxiety, and depression. High initial pain score was the only significant predictor of chronic pain. Initial pain intensity predicts chronic pain.

Opiate use for chronic pain is becoming increasingly controversial. There has been a shift away from supporting the use of opiates for treatment of chronic pain. In addition to lack of effectiveness, concerns for adverse clinical outcomes, addiction, and death have provided the impetus for this change. The purpose of this study was to investigate the percent of trauma patients still using opiates, their pain levels, and psychological outcomes 4 months posttrauma. This was a study to evaluate chronic pain at 4 months posttrauma in 101 participants from a single level 1 trauma center. Eighty of the 101 participants developed chronic pain 4 months after their initial traumatic injury (79%). Of those who developed chronic pain, 27 (26%) were still using opiates. Those using narcotics at 4 months posttrauma had significantly more pain, life interference, depression, and anxiety. Posttraumatic stress disorder (PTSD) was not significantly influenced by narcotic use in this analysis. However, the mean associated with those using narcotics was higher and diagnostic for PTSD. Those taking opiates did not have significantly better relief from their pain using treatments or medications than those not using opiates (F = 8, P = .08). These findings bring into question the appropriate use of opiates for chronic pain and the possible exacerbating effects on pain and psychopathology in traumatically injured patients. Perspective This article identifies data that provide evidence that narcotic pain medication needs to be used carefully in traumatically injured patients with chronic pain, especially in those individuals with comorbid psychological pathology.