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BackgroundSplenic artery embolization (SAE) is increasingly favored for adult blunt splenic injury management. We compared SAE to other splenic injury management strategies using robust statistical techniques.Materials and methodsUnivariate analyses of demographics and outcomes were performed for four patient groups: observation, SAE, splenic surgery, splenic surgery + SAE in the American College of Surgeons Trauma Quality Program (TQIP) database. To address nonlinear associations of ED vital signs with mortality, multivariable spline-based logistic regression models with interaction terms between hemodynamic status and management strategy and either splenic Abbreviated Injury Score (AIS) or Injury Severity Score (ISS), were generated.ResultsIn 44,187 splenic injury patients meeting study inclusion criteria, the most common management strategy was observation alone (77.9%). The observation group had median spleen AIS of 2, ISS 20, with 6.3% mortality; SAE (2.6%) had median spleen AIS3, ISS 24, with 6.6% mortality; splenic surgery (22.4%) AIS4, ISS 29, with 15.4% mortality; and splenic surgery + SAE (0.04%) AIS4, ISS 29, with 15.2% mortality. In multivariable models, SAE had lower predicted probability of mortality than surgery over most initial ED systolic blood pressures (SBPs). At all spleen AIS, SAE had lower predicted mortality than surgery. SAE had lower mortality than surgery except at very high ISS, where it was comparable. SAE had lower predicted mortality than observation management at spleen AIS≥3. In subgroup analysis of patients without severe multi-system injuries, predicted mortality did not differ by management strategy.ConclusionsSAE is associated with decreased mortality at spleen AIS 3-5. The benefits of SAE appear to be largely for spleen AIS 3-5 in the setting of severe (AIS≥3) multi-system injuries.

Objectives Selective prehospital cervical spine motion restriction (C-SMR) following blunt trauma has increasingly been used by emergency medical service (EMS) providers. We determined rates of prehospital C-SMR and concomitant radiographic injury patterns.Methods A retrospective trauma registry and chart review was conducted for all adult blunt trauma patients who were transported by EMS and hospitalized with radiographic cervical spine injuries from 2011 to 2019 at a level 1 trauma center.Results Of 658 admitted blunt trauma patients with confirmed cervical spine injury by imaging, 117 (17.8%) did not receive prehospital C-SMR. Patients without prehospital C-SMR were significantly older (76 vs 54 years), more often had low fall as mechanism of injury (59.8% vs 15.9%) and had lower Injury Severity Score (10 vs 17). Patients without C-SMR (Non-SMR) experienced the full array of cervical spine injury types and locations. While the non-SMR patients most often had dens fractures,C-SMR patients most often had C7 fractures; frequencies of fractures at the remaining vertebral levels were comparable. On MRI, cervical spinal cord (8.5% vs 19.6%) and ligamentous injuries (5.1% vs 12.6%) occurred less often in non-SMR patients. Approximately 8.5% of non-SMR patients and 20% of C-SMR patients required cervical spine surgery.Conclusion Patients without prehospital C-SMR demonstrate a broad array of cervical spine injuries. While the rates of certain cervical injuries are lower in prehospital non-SMR patients, they are not insignificant.Level of evidence Level III.

Objective: Examine the possible beneficial effects of early, D-dimer driven anticoagulation in preventing thrombotic complications and improving the overall outcomes of COVID-19 intubated patients.Methods: To address COVID-19 hypercoagulability, we developed a clinical protocol to escalate anticoagulation based on serum D-dimer levels. We retrospectively reviewed all our first 240 intubated patients with COVID-19. Of the 240, 195 were stratified into patients treated based on this protocol (ON-protocol, n = 91) and the control group, patients who received standard thromboprophylaxis (OFF-protocol, n = 104). All patients were admitted to the Stony Brook University Hospital intensive care units (ICUs) between February 7th, 2020 and May 17, 2020 and were otherwise treated in the same manner for all aspects of COVID-19 disease.Results: We found that the overall mortality was significantly lower ON-protocol compared to OFF-protocol (27.47 vs. 58.66%, P < 0.001). Average maximum D-dimer levels were significantly lower in the ON-protocol group (7,553 vs. 12,343 ng/mL), as was serum creatinine (2.2 vs. 2.8 mg/dL). Patients with poorly controlled D-dimer levels had higher rates of kidney dysfunction and mortality. Transfusion requirements and serious bleeding events were similar between groups. To address any possible between-group differences, we performed a propensity-matched analysis of 124 of the subjects (62 matched pairs, ON-protocol and OFF-protocol), which showed similar findings (31 vs. 57% overall mortality in the ON-protocol and OFF-protocol group, respectively).Conclusions: D-dimer-driven anticoagulation appears to be safe in patients with COVID-19 infection and is associated with improved survival.What This Paper Adds: It has been shown that hypercoagulability in patients with severe COVID-19 infection leads to thromboembolic complications and organ dysfunction. Anticoagulation has been variably administered to these patients, but it is unknown whether routine or escalated thromboprophylaxis provides a survival benefit. Our data shows that escalated D-dimer driven anticoagulation is associated with improved organ function and overall survival in intubated COVID-19 ICU patients at our institution. Importantly, we found that timely escalation of this anticoagulation is critical in preventing organ dysfunction and mortality in patients with severe COVID-19 infection.