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Background β-blockers have been shown to improve survival after traumatic brain injury (TBI); however, the impact of continuous dosage of β-blockers on cognitive function has not been elucidated. We hypothesized that a daily dose of propranolol can improve memory, learning, and cognitive function following TBI. Study design Twenty male C57BL mice were subjected to a cortical-controlled moderate TBI. Two hours after TBI, animals were randomly allocated to either the β-blocker group (n = 10) or the placebo group (n = 10). Mice in the β-blocker group received intraperitoneal 4 mg/kg propranolol every 24 hours for 7 days while the placebo group received 4 mg/kg normal saline. Baseline novel object recognition and classic maze tests were done prior to TBI and then daily from Day 1 through 7 after TBI. Animals were sacrificed on Day 7. Serum biomarkers were measured using ELISA and brain sections were analyzed using western blot and hematoxylin and eosin staining. Results Both the β-blocker and placebo groups had lower recognition index scores compared with the baseline following TBI. β-blocker mice had significantly higher novel object recognition scores compared with placebo mice 2 days after TBI. The β-blocker group required less time to complete the maze-test compared to placebo group after Day 4. There was no difference regarding the serum levels of IL-1β, IL-6, and TNF-α. The β-blocker group had lower levels of UCHL-1 and higher levels of Hsp-70 in brain lysate. Hematoxylin and eosin staining revealed that more neurons in the hippocampal-CA1 area underwent apoptosis in the placebo group compared with the β-blocker group. Conclusion Postinjury propranolol administration results in improved memory, learning and cognitive functions in a murine model of moderate TBI. Propranolol increases the expression of antiapoptotic protein (Hsp-70) and decreases cell death in the hippocampal-CA1 area compared with the placebo.

Background Numerous factors contribute to advanced disease or increased complications in patients with acute appendicitis (AA). This study aimed to identify risk factors associated with AA perforation, including the effect of system time (ST) delay, after controlling for patient time (PT) delay. In this study, PT was controlled (to less than or equal to 24 h) to better understand the effect of ST delay on AA perforation. Methods Medical records of patients who underwent surgery for AA at a tertiary referral hospital from October 2009 through September 2013 were reviewed. Data collected included demographics, body mass index, presence of fecalith, PT (i.e., duration of time from symptom onset to arrival in emergency department), and ST (i.e., duration of time from arrival in emergency department to operating room). AA was classified as simple (acute, nonperforated) versus advanced (gangrenous, perforated). Results Seven hundred forty-seven patients underwent surgery for AA. After excluding patients with PT > 24 h, 445 patients fit the study criteria, of which 358 patients with simple AA and 87 patients with advanced disease. Advanced appendicitis patients were older and had higher body mass index, longer PT, higher WBC, and higher incidence of fecaliths. Both groups had similar ST. Risk factors for advanced appendicitis after multiple regression analysis are age >50 y old, WBC >15,000, the presence of fecaliths, and PT delay >12 h. Conclusions Once PT delay was limited to ≤24 h, the ST delay of >12 h did not adversely affect the incidence of advanced AA. Age >50 y, WBC >15,000, PT delay >12 h, and the presence of fecaliths were identified as risk factors associated with advanced AA.

The effectiveness of 14-French (14F) pigtail catheters (PCs) compared to 32-40F chest tubes (CTs) in patients with traumatic hemothorax (HTX) and hemopneumothorax (HPTX) is becoming more well known but still lacking. The aim of our study was to analyze our cumulative experience and outcomes with PCs in patients with traumatic HTX/HPTX. We hypothesized that PCs would be as effective as CTs. Using our PC database, we analyzed all trauma patients who required chest drainage for HTX/HPTX from 2008 to 2014. Primary outcomes of interest, comparing PCs to CTs, included initial drainage output in milliliters (mL), tube insertion-related complications, and failure rate. For our statistical analysis, we used the unpaired Student’s t test, Chi-square test, and Wilcoxon rank-sum test. We defined statistical significance as P

INTRODUCTION The Patient Protection and Affordable Care Act (ACA) was implemented to guarantee financial coverage for health care for all Americans. The implementation of ACA is likely to influence the insurance status of Americans and reimbursement rates of trauma centers. The aim of this study was to assess the impact of ACA on the patient insurance status, hospital reimbursements, and clinical outcomes at a Level I trauma center. We hypothesized that there would be a significant decrease in the proportion of uninsured trauma patients visiting our Level I trauma center following the ACA, and this is associated with improved reimbursement. METHODS We performed a retrospective analysis of the trauma registry and financial database at our Level I trauma center for a 27-month (July 2012 to September 2014) period by quarters. Our outcome measures were change in insurance status, hospital reimbursement rates (total payments/expected payments), and clinical outcomes before and after ACA (March 31, 2014). Trend analysis was performed to assess trends in outcomes over each quarter (3 months). RESULTS A total of 9,892 patients were included in the study. The overall uninsured rate during the study period was 20.3%. Post-ACA period was associated with significantly lower uninsured rate (p < 0.001). During the same time, there was as a significant increase in the Medicaid patients (p = 0.009). This was associated with significantly improved hospital reimbursements (p < 0.001).On assessing clinical outcomes, there was no change in hospitalization (p = 0.07), operating room procedures (p = 0.99), mortality (p = 0.88), or complications (p = 0.20). Post-ACA period was also not associated with any change in the hospital (p = 0.28) or length of stay at intensive care unit (p = 0.66). CONCLUSION The implementation of ACA has led to a decrease in the number of uninsured trauma patients. There was a significant increase in Medicaid trauma patients. This was associated with an increase in hospital reimbursements that substantially improved the financial revenues. Despite the controversies, implementation of ACA has the potential to substantially improve the financial outcomes of trauma centers through Medicaid expansion. LEVEL OF EVIDENCE Economic and value-based evaluation, level III.

Background Nonoperative management of hemodynamically stable children with Solid Organ Injury (SOI) has become standard of care. The aim of this study is to identify differences in management of children with SOI treated at Adult Trauma Centers (ATC) versus Pediatric Trauma Centers (PTC). We hypothesized that patients treated at ATC would undergo more procedures than PTC. Methods Patients younger than 18 years old with isolated SOI (spleen, liver, kidney) who were treated at level I-II ATC or PTC were identified from the 2011–2012 National Trauma Data Bank. The primary outcome measure was the incidence of operative management. Data was analyzed using multivariate logistic regression analysis. Procedures were defined as surgery or transarterial embolization (TAE). Results 6799 children with SOI (spleen: 2375, liver: 2867, kidney: 1557) were included. Spleen surgery was performed more frequently at ATC than PTC {101 (7.7%) vs. 52 (4.9%); P=0.007}. After adjusting for potential confounders (grade of injury, age, gender and injury severity score), admission at ATC was associated with higher odds of splenic surgery (OR: 1.5, 95% CI: 1.02–2.25; p=0.03). 11 and 8 children underwent kidney and liver operations respectively. TAE was performed in 17 patients with splenic, 34 with liver and 14 with kidney trauma. There was no practice variation between ATC and PTC regarding kidney and liver operations or TAE incidence. Conclusions Operative management for SOI was more often performed at ATC. The presence of significant disparity in the management of children with splenic injuries justifies efforts to use these surgeries as a reported national quality indicator for trauma programs.

Background Multiple prior studies have suggested an association between survival and beta-blocker administration in patients with severe traumatic brain injury (TBI). However, it is unknown whether this benefit of beta-blockers is dependent on heart rate control. The aim of this study was to assess whether rate control affects survival in patients receiving metoprolol with severe TBI. Our hypothesis was that improved survival from beta-blockade would be associated with a reduction in heart rate. Methods We performed a 7-y retrospective analysis of all blunt TBI patients at a level-1 trauma center. Patients aged >16 y with head abbreviated injury scale 4 or 5, admitted to the intensive care unit (ICU) from the operating room or emergency room (ER), were included. Patients were stratified into two groups: metoprolol and no beta-blockers. Using propensity score matching, we matched the patients in two groups in a 1:1 ratio controlling for age, gender, race, admission vital signs, Glasgow coma scale, injury severity score, mean heart rate monitored during ICU admission, and standard deviation of heart rate during the ICU admission. Our primary outcome measure was mortality. Results A total of 914 patients met our inclusion criteria, of whom 189 received beta-blockers. A propensity-matched cohort of 356 patients (178: metoprolol and 178: no beta-blockers) was created. Patients receiving metoprolol had higher survival than those patients who did not receive beta-blockers (78% versus 68%; P = 0.04); however, there was no difference in the mean heart rate (89.9 ± 13.9 versus 89.9 ± 15; P = 0.99). Nor was there a difference in the mean of standard deviation of the heart rates (14.7 ± 6.3 versus 14.4 ± 6.5; P = 0.65) between the two groups. In Kaplan–Meier survival analysis, patients who received metoprolol had a survival advantage (P = 0.011) compared with patients who did not receive any beta-blockers. Conclusions Our study shows an association with improved survival in patients with severe TBI receiving metoprolol, and this effect appears to be independent of any reduction in heart rate. We suggest that beta-blockers should be administered to all severe TBI patients irregardless of any perceived beta-blockade effect on heart rate.

We consider the problem of estimating the marginal mean of an incompletely observed variable and develop a multiple imputation approach. Using fully observed predictors, we first establish two working models: one predicts the missing outcome variable, and the other predicts the probability of missingness. The predictive scores from the two models are used to measure the similarity between the incomplete and observed cases. Based on the predictive scores, we construct a set of kernel weights for the observed cases, with higher weights indicating more similarity. Missing data are imputed by sampling from the observed cases with probability proportional to their kernel weights. The proposed approach can produce reasonable estimates for the marginal mean and has a double robustness property, provided that one of the two working models is correctly specified. It also shows some robustness against misspecification of both models. We demonstrate these patterns in a simulation study. In a real-data example, we analyze the total helicopter response time from injury in the Arizona emergency medical service data.

Blunt diaphragmatic rupture (BDR) is uncommon with a reported incidence range of 1%–2%. The true incidence is not known. Bilateral BDR is particularly rare. We presented a case of bilateral BDR and we think that the incidence is under-recognised thanks to an easily missed and difficult to diagnose right sided injury. Keywords: Blunt, Diaphragm, Bilateral, Injury

Background The standard approach to vascular trauma involves arterial exposure and reconstruction using either a vein or polytetrafluoroethylene graft. We have developed a novel technique to repairing arterial injuries by deploying commercially available vascular stents through an open approach, thus eliminating the need for suture anastomosis. The objective of this study was to evaluate the feasibility, stent deployment time (SDT), and stent patency of this technique in a ewe vascular injury model. Methods After proximal and distal control, a 2-cm superficial femoral arterial segment was resected in 8 Dorper ewes to simulate an arterial injury. Two stay sutures were placed in the 3- and 9-o'clock positions of the transected arterial ends to prevent further retraction. Ten milliliters of 10-IU/mL heparinized saline was flushed proximally and distally. An arteriotomy was then created 2.5 cm from the transected distal end through which we deployed Gore Viabahn stents with a 20% oversize and at least 1-cm overlap with the native vessel on either end. The arteriotomy was then closed with 3 (1) interrupted 6-0 Prolene sutures. The ewes were fed acetylsalicylic acid 325 mg daily. Duplex was performed at 2 months postoperatively to evaluate stent patency. SDT was defined as time from stay suture placement to arteriotomy closure. Results The 8 ewes weighed a mean (SD) of 34.4 (4.3) kg. The mean (SD) superficial femoral arterial was 4.3 (0.6) mm. Six 5 mm × 5 cm and two 6 mm × 5 cm Gore Viabahn stents were deployed. The mean (SD) SDT was 34 (19) minutes, with a trend toward less time with increasing experience (SDTmax, 60 minutes; SDTmin, 10 minutes). Duplex performed at 2 months postoperatively showed stent patency in five of eight stents. There was an association between increasing SDT and stent thrombosis. Conclusion Open deployment of commercially available vascular stents to treat vascular injuries is a conceptually sound and technically feasible alternative to standard open repair. Larger studies are needed to refine this technique and minimize stent complications, which are likely technical in nature.

Background Percutaneous endoscopic gastrostomy (PEG) complications are often under-reported in the literature, especially regarding the incidence of tube dislodgement (TD). TD can cause significant morbidity depending on its timing. We compared outcomes between “push” and “pull” PEGs. We hypothesized that push PEGs, because of its T-fasteners and balloon tip, would have a lower incidence of TD and complications compared with pull PEGs. Methods We performed a chart review of our prospectively maintained acute care surgery database for patients who underwent PEG tube placement from July 1, 2009 through June 30, 2013. Data regarding age, gender, body mass index, indications (trauma versus nontrauma), and complications (including TD) were extracted. Procedure-related complications were classified as either major if patients required an operative intervention or minor if they did not. We compared outcomes between pull PEG and push PEG. Multiple regression analysis was performed to identify risk factors associated with major complications. Results During the 4-y study period, 264 patients underwent pull PEGs and 59 underwent push PEGs. Age, gender, body mass index, and indications were similar between the two groups. The overall complications (major and minor) were similar (20% pull versus 22% push, P = 0.61). The incidence of TD was also similar (12% pull versus 9% push, P = 0.49). However, TD associated with major complications was higher in pull PEGs but was not statistically significant (6% pull versus 2% push, P = 0.21). Multiple regression analysis showed that dislodged pull PEG was associated with major complications (odds ratio 29.5; 95% confidence interval, 11.3-76.9; P Conclusions The incidence of pull PEG TD associated with major complications is under-recognized. Specific measures should be undertaken to help prevent pull PEG TD. Level of evidence IV, therapeutic.

Background Organ donation after cardiac death (DCD) is not optimal but still remains a valuable source of organ donation in trauma donors. The aim of this study was to assess national trends in DCD from trauma patients. Methods A 12-year (2002 to 2013) retrospective analysis of the United Network for Organ Sharing database was performed. Outcome measures were the following: proportion of DCD donors over the years and number and type of solid organs donated. Results DCD resulted in procurement of 16,248 solid organs from 8,724 donors. The number of organs donated per donor remained unchanged over the study period ( P = .1). DCD increased significantly from 3.1% in 2002 to 14.6% in 2013 ( P = .001). There was a significant increase in the proportion of kidney (2002: 3.4% vs 2013: 16.3%, P = .001) and liver (2002: 1.6% vs 2013: 5%, P = .041) donation among DCD donors over the study period. Conclusions DCD from trauma donors provides a significant source of solid organs. The proportion of DCD donors increased significantly over the last 12 years.

Hypopituitarism after hypovolemic shock is well established in certain patient cohorts. However; the effects of hemorrhagic shock on pituitary function in trauma patients remains unknown. The aim of this study was to assess pituitary hormone variations in trauma patients with hemorrhagic shock.Patients with acute traumatic hemorrhagic shock presenting to our level 1 trauma center were prospectively enrolled. Hemorrhagic shock was defined as systolic blood pressure (SBP) ≤ 90 mmHg on arrival or within 10 minutes of arrival in the emergency department, and requirement of ≥2 units of packed red blood cell transfusion. Serum cortisol and serum pituitary hormones (vasopressin [ADH], adrenocorticotrophic hormone [ACTH], thyroid stimulating hormone [TSH], follicular stimulating hormone [FSH], and luteinizing hormone [LH]) were measured in each patient on admission and at 24, 48, 72, and 96 hours after admission. Outcome measure was variation in pituitary hormones.A total of 42 patients were prospectively enrolled; mean age was 37 ± 12 years, mean SBP 85.4 ± 64.5 mmHg, and median Injury Severity Score was 26 (range 18 to 38). There was an increase in the levels of cortisol (p0.001), a decrease in the levels of ACTH (p0.001) and ADH (p0.001), but no change in the levels of LH (p = 0.30), FSH (p = 0.07), and TSH (p = 0.89) over 96 hours. Ten patients died during their hospital stay. Patients who died had higher mean admission ADH levels (p = 0.03), higher mean admission ACTH levels (p0.001), and lower mean admission cortisol levels (p = 0.04) compared with patients who survived.Acute hypopituitarism does not occur in trauma patients with acute hemorrhagic shock. In patients who died, there was a decrease in cortisol levels, which appears to be adrenal in origin.

Introduction Quality improvement initiatives have focused primarily on preventing in-hospital complications. Patients developing complications are at a greater risk of mortality; however, factors associated with failure-to-rescue (death after major complication) in trauma patients remain undefined. The aim of this study was to identify risk factors associated with failure-to-rescue in patients undergoing trauma laparotomy. Methods An -8-year, retrospective analysis of patients undergoing trauma laparotomy was performed. Patients who developed major in-hospital complications were included. Major complications were defined as respiratory, infectious, cardiac, renal, or development of compartment syndrome. Regression analysis was performed to identify independent factors associated with failure-to-rescue after we adjusted for demographics, mechanism of injury, abdominal abbreviated injury scale, initial vital signs, damage control laparotomy, and volume of crystalloids and blood products administered. Results A total of 1,029 patients were reviewed, of which 21% (n = 217) patients who developed major complications were included. The mean age was 39 ± 18 years, 82% were male, 61% had blunt trauma, and median abdominal abbreviated injury scale was 25 [16–34, interquartile range]. Respiratory complications (n = 77) followed by infectious complications (n = 75) were the most common complications. The failure-to-rescue rate was 15.7% (n = 34/217). Age, blunt trauma, severe head injury, uninsured status, and blood products administered on the second day were independent predictor for failure-to-rescue. Conclusion When major complications develop, age, uninsured status, severity of head injury, and prolonged resuscitation are associated independently with failure-to-rescue, whereas initial resuscitation, coagulopathy, and acidosis did not predict failure to rescue. Quality-of-care programs focus in patient level should be on improving the patient's insurance status, preventing secondary brain injury, and further development of resuscitation guidelines.

BACKGROUND: Differences in outcomes among trauma centers (TCs) and non-TCs (NTCs) in patients undergoing emergency general surgery (EGS) are well established. However; the impact of development of certified acute care surgery (ACS) programs on patient outcomes remains unknown. The aim of this study was to evaluate outcomes in patients undergoing EGS across TCs, NTCs, and TCs with ACS (ACS-TC). METHODS: National estimates for EGS procedures were abstracted from the National Inpatient Sample database. Patients undergoing emergent procedures (appendectomy, cholecystectomy, hernia repair, as well as small and large bowel resections) were included. TCs were identified based on American College of Surgeons' verification. ACS-TC programs were recorded from the American Association for the Surgery of Trauma. Outcome measures were hospital length of stay, complications, and mortality. Regression analysis was performed after adjusting for age, sex, race, Charlson comorbidity index, and type of procedure. RESULTS: A total of 131,410 patients undergoing EGS were analyzed. Patients managed in ACS-TCs had shorter hospital stay (p = 0.045) and lower complication rate (p = 0.041) compared with patients managed in both TCs and NTCs. There was no difference in mortality in patients managed across the groups; however, there was a trend toward lower mortality in patients managed in ACS-TCs in comparison with TCs (p = 0.064) and NTCs (p = 0.089). The overall hospital costs were lower for patients managed in ACS-TCs compared with TCs (p = 0.036). CONCLUSION: TCs with ACS have improved outcomes in EGS procedures compared with both TCs and non-TCs. ACS training with the associated infrastructure standards may contribute to these improved outcomes. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.

Management of traumatic brain injury (TBI) is focused on preventing secondary brain injury. Remote ischemic conditioning (RIC) is an established treatment modality that has been shown to improve patient outcomes secondary to inflammatory insults. The aim of our study was to assess whether RIC in trauma patients with severe TBI could reduce secondary brain injury.This prospective consented interventional trial included all TBI patients admitted to our Level 1 trauma center with an intracranial hemorrhage and a Glasgow Coma Scale (GCS) score of 8 or lower on admission. In each patient, four cycles of RIC were performed within 1 hour of admission. Each cycle consisted of 5 minutes of controlled upper limb (arm) ischemia followed by 5 minutes of reperfusion using a blood pressure cuff. Serum biomarkers of acute brain injury, S-100B, and neuron-specific enolase (NSE) were measured at 0, 6, and 24 hours. Outcome measure was reduction in the level of serum biomarkers after RIC.A total of 40 patients (RIC, 20; control, 20) were enrolled. The mean (SD) age was 46.15 (18.64) years, the median GCS score was 8 (interquartile range, 3-8), and the median head Abbreviated Injury Scale (AIS) score was 3 (interquartile range, 3-5), and there was no difference between the RIC and control groups in any of the baseline demographics or injury characteristics including the type and size of intracranial bleed or skull fracture patterns. There was no difference in the 0-hour S-100B (p = 0.9) and NSE (p = 0.72) level between the RIC and the control group. There was a significant reduction in the mean levels of S-100B (p = 0.01) and NSE (p = 0.04) at 6 hours and 24 hours in comparison with the 0-hour level in the RIC group.This study showed that RIC significantly decreased the standard biomarkers of acute brain injury in patients with severe TBI. Our study highlights the novel therapeutic role of RIC for preventing secondary brain insults in TBI patients.Therapeutic study, level III.

Background The current literature regarding hemorrhagic complications in patients on long-term antiplatelet therapy undergoing emergent laparoscopic cholecystectomy is limited. The aim of our study was to describe hemorrhagic complications in patients on prehospital aspirin (ASP) therapy undergoing emergent cholecystectomy. Methods We performed a 1-year retrospective analysis of our prospectively maintained acute care surgery database. The 2 groups (ASP group vs No ASP group) were matched in a 1:1 ratio for age, sex, previous abdominal surgeries, and comorbidities. Primary outcome measures were intraoperative hemorrhage, postoperative anemia, need for blood transfusion, and conversion to open cholecystectomy. Intraoperative hemorrhage was defined as intraoperative blood loss of ≥100 mL; postoperative anemia was defined by ≥2 g/dL drop in hemoglobin. Results A total of 112 (ASP: 56, no ASP: 56) patients were included in the analysis. The mean age was 65.9 ± 10 years, and 50% were male. There was no difference in age ( P = .9), sex ( P = .9), and comorbidities ( P = .7) between the 2 groups. There was no difference in intraoperative blood loss >100 mL ( P = .5), postoperative anemia ( P = .8), blood transfusion requirement ( P = .9), and conversion to open surgery ( P = .7) between patients on American Society of Anesthesiologists therapy and patients not on American Society of Anesthesiologists therapy. Conclusions Emergent laparoscopic cholecystectomy is a safe procedure in patients on long-term ASP. Prehospital use of ASP as an independent factor should not be used to delay emergent cholecystectomy.

Computed Tomography Angiography (CTA) is being used to identify traumatic intracranial aneurysms (TICA) in patients with findings such as skull fracture and intracranial haemorrhage on initial Computed Tomography (CT) scans after blunt traumatic brain injury (TBI). However, the incidence of TICA in patients with blunt TBI is unknown. The aim of this study is to report the incidence of TICA in patients with blunt TBI and to assess the utility of CTA in detecting these lesions.A 10-year retrospective study (2003-2012) was performed at a Level 1 trauma centre. All patients with blunt TBI who had an initial non-contrasted head CT scan and a follow-up head CTA were included. Head CTAs were then reviewed by a single investigator and TICAs were identified. The primary outcome measure was incidence of TICA in blunt TBI.A total of 10 257 patients with blunt TBI were identified, out of which 459 patients were included in the analysis. Mean age was 47.3 ± 22.5, the majority were male (65.1%) and median ISS was 16 [9-25]. Thirty-six patients (7.8%) had intracranial aneurysm, of which three patients (0.65%) had TICAs.The incidence of traumatic intracranial aneurysm was exceedingly low (0.65%) over 10-years. This study adds to the growing literature questioning the empiric use of CTA for detecting vascular injuries in patients with blunt TBI.

BACKGROUND: Alcohol is known to be protective in patients with traumatic brain injury (TBI); however, its impact on the long-term cognitive function is unknown. We hypothesize that intoxication at the time of injury is associated with adverse long-term cognitive function in patients sustaining TBI. METHODS: We performed a 2-year retrospective study of all trauma patients with isolated TBI presenting to our Level I trauma center and discharged to a single rehabilitation facility. Patients with moderate-to-severe TBI (head Abbreviated Injury Scale [AIS] score ≥ 3), measured admission blood alcohol concentration, and measured cognitive function on hospital discharge and rehabilitation center discharge were included. Cognitive function was assessed using Functional Independence Measure (FIM) scores. Delta cognitive FIM was defined as the difference between rehabilitation center discharge and hospital discharge cognitive FIM scores. Multivariate linear regression was performed. RESULTS: A total of 64 patients were included. Mean (SD) age was 51.8 (23) years, median head AIS score was 3 (IQR, 3-5), and median Glasgow Coma Scale (GCS) score was 11 (IQR, 3-15). Mean (SD) cognitive FIM score on hospital discharge was 17 (6), and mean (SD) cognitive improvement was 8.6 (4.7). Sixty percent (n = 39) were under the influence of alcohol on admission, and the mean (SD) admission blood alcohol concentration was 132 (102).On multivariate linear regression analysis, admission blood alcohol concentration (β = -0.4; 95% confidence interval, -6.7 to -0.8; p = 0.01) and age (β = -0.13; 95% confidence interval, -0.2 to -0.04; p = 0.04) were negatively associated with improvement in long-term cognitive function. CONCLUSION: Alcohol intoxication at the time of injury is associated with lower improvement in long-term cognitive function. Older intoxicated patients are likely to have a lower cognitive improvement. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III. Language: en

To optimize neurosurgical resources, guidelines were developed at our institution, allowing the acute care surgeons to independently manage traumatic intracranial hemorrhage less than or equal to 4 mm. The aim of our study was to evaluate our established Brain Injury Guidelines (BIG 1 category) for managing patients with traumatic brain injury (TBI) without neurosurgical consultation.We formulated the BIG based on a 4-year retrospective chart review of all TBI patients presenting at our Level 1 trauma center. We then prospectively implemented our BIG 1 category to identify TBI patients that were to be managed without neurosurgical consultation (No-NC). Propensity scoring matched patients with No-NC to a similar cohort of patients managed with NC before the implementation of our BIG in a 1:1 ratio for demographics, severity of injury, and type and size of intracranial hemorrhage. Primary outcome measure was need for neurosurgical intervention and 30-day readmission rates.A total of 254 TBI patients (127 of NC and 127 of No-NC patients) were included in the analysis. The mean (SD) age was 40.8 (22.7) years, 63.4% (n = 161) were male, median Glasgow Coma Scale (GCS) score was 15 (range, 13-15), and median head Abbreviated Injury Scale (AIS) score was 2 (range, 2-3). There was no neurosurgical intervention or 30-day readmission in both the groups. In the No-NC group, 3.9% of the patients had postdischarge emergency department visits compared with 4.7% of the NC group (p = 0.5). All patients were discharged home from the emergency department.We validated our BIG and demonstrated that acute care surgeons can effectively care for minimally injured TBI patients with good outcomes. A national multi-institutional prospective evaluation is warranted.Therapeutic/care management, level IV.

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is a data collection methodology for measuring a patient's perception of his/her hospital experience, and it has been selected by the Centers of Medicare and Medicaid Services as the validated and transparent national survey tool with publicly available results. Since 2012, hospital reimbursements rates have been linked to HCAHPS data based on patient satisfaction scores. The aim of this study was, therefore, to assess whether HCAHPS scores of Level I trauma centers correlate with actual hospital performance.Retrospective analysis of the latest publicly available HCAHPS data (2014-2015) was performed. American College of Surgeons (ACS) verified Level I trauma centers for each state were identified from the ACS registry and then the following data points were collected for each hospital: HCAHPS linear mean scores regarding cleanliness of the hospital, doctor and nurse communication with the patient, staff responsiveness, pain management, overall hospital rating, and patient willingness to recommend the hospital. Our outcome measure were serious complication scores, failure-to-rescue (FTR) scores and readmission-after-discharge scores. Spearman correlation analysis was performed.A total of 119 ACS verified Level I trauma centers across 46 states were included. The median [IQR] overall hospital rating score for Level I trauma centers was 89 (87-90). The mean ± SD score for serious complication was 0.96 ± 0.266, FTR was 123.06 ± 22.5, and readmission after discharge was 15.71 ± 1.07. The Spearman correlation analysis showed that overall HCAHP-based hospital rating scores did not correlate with serious complications (correlation coefficient = 0.14 p = 0.125), FTR (correlation coefficient = -0.15 p = 0.073), or readmission after discharge (correlation coefficient = -0.18 p = 0.053).The findings of our study suggest that no correlation exists between HCAHPS patient satisfaction scores and hospital performance for Level I trauma centers. Consequently, the Centers of Medicare and Medicaid Services should reconsider hospital reimbursement decisions based on HCAHP patient satisfaction scores.Prognostic/epidemiologic study, level III; therapeutic study, level IV.

Direct laryngoscopy (DL) has long been the gold standard for tracheal intubation in emergency and trauma patients. Video laryngoscopy (VL) is increasingly used in many settings and the purpose of this study was to compare its effectiveness to direct laryngoscopy in trauma patients. Our hypothesis was that the success rate of VL would be higher than that of DL. Data were collected prospectively on all trauma patients, from January 2008 to June 2011, who were intubated emergently in an academic level I trauma center. After intubation, the physician that performed the intubation completed a structured data collection form that included demographics, complications, and the presence of difficult airway predictors. Our primary outcome measure was overall successful tracheal intubation, which was defined as successful intubation with the first device used. During the study period, 709 trauma patients were intubated by either VL or DL. VL was performed in 55 % of cases. The overall success rate of VL was 88 % compared to 83 % with DL (P = 0.05). Cervical (C-Spine) immobilization was predictive of higher initial success with VL (87 %) than with DL (80 %) (P

BACKGROUND Hypothermia is a known predictor of mortality in trauma patients; however, its impact on organ procurement has not been defined. The aim of this study was to assess the effect of hypothermia on organ procurement. We hypothesized that admission hypothermia impedes successful organ procurement. METHODS We performed a 5-year retrospective analysis of all trauma patients approached for organ donation. Hypothermia was defined as a core body temperature 36°C/97°F or less. The two groups (hypothermic [HT] vs. nonhypothermic [non-HT]) were matched in a 1:1 ratio using propensity score matching for age, sex, admission Glasgow Coma Scale (GCS) score, systolic blood pressure, international normalized ratio, and Injury Severity Score (ISS). Primary outcome measures were eligibility for organ donation and solid organ procurement. Secondary outcome measures were blood product and vasopressor requirements. RESULTS This study was composed of 537 brain-dead patients, of whom 416 (HT, 208; non-HT, 208) were included in the analysis. The mean (SD) age was 40.5 (23.7) years, 75% were male, mean (SD) temperature was 36.6°C (1.7°C), and mean (SD) systolic blood pressure was 75.35 (68.7) mm Hg. Patients who were hypothermic on presentation were less likely to be eligible for organ donation (44.7% vs. 96%, p ≤ 0.001), and they donated fewer organs per donor (p = 0.04). HT patients required more units of fresh frozen plasma (p = 0.04) and greater mean dose of dopamine (p = 0.03) and vasopressin (p = 0.03) compared with the non-HT patients. CONCLUSION Admission hypothermia is associated with decreased organ donation in potential organ donors independent of admission coagulopathy, hypotension, and injury severity. Early correction of hypothermia may improve organ donation in trauma patients. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level III.

BACKGROUND: Studies have proposed a neuroprotective role for alcohol (ETOH) in traumatic brain injury (TBI). We hypothesized that ETOH intoxication is associated with mortality in patients with severe TBI. METHODS: Version 7.2 of the National Trauma Data Bank (2007-2010) was queried for all patients with isolated blunt severe TBI (Head Abbreviated Injury Score ≥4) and blood ETOH levels recorded on admission. Primary outcome measure was mortality. Multivariate logistic regression analysis was performed to assess factors predicting mortality and in-hospital complications. RESULTS: A total of 23,983 patients with severe TBI were evaluated of which 22.8% (n = 5461) patients tested positive for ETOH intoxication. ETOH-positive patients were more likely to have in-hospital complications (P = 0.001) and have a higher mortality rate (P = 0.01). ETOH intoxication was an independent predictor for mortality (odds ratio: 1.2, 95% confidence interval: 1.1-2.1, P = 0.01) and development of in-hospital complications (odds ratio: 1.3, 95% confidence interval: 1.1-2.8, P = 0.009) in patients with isolated severe TBI. CONCLUSIONS: ETOH intoxication is an independent predictor for mortality in patients with severe TBI patients and is associated with higher complication rates. Our results from the National Trauma Data Standards differ from those previously reported. The proposed neuroprotective role of ETOH needs further clarification. Language: en

BACKGROUND: The significance of posttraumatic stress disorder (PTSD) in trauma patients is well recognized. The impact trauma surgeons endure in managing critical trauma cases is unknown. The aim of our study was to assess the incidence of PTSD among trauma surgeons and identify risk factors associated with the development of PTSD. METHODS: We surveyed all members of the American Association for Surgery of Trauma and the Eastern Association for Surgery of Trauma using an established PTSD screening test (PTSD Checklist Civilian [PCL-C]). A PCL-C score of 35 or higher (sensitivity 9 85%) was used as the cutoff for the development of PTSD symptoms and a PCL-C score of 44 or higher for the diagnosis of PTSD. Multivariate logistic regression was performed. RESULTS: There were 453 respondents with a 41% response rate. PTSD symptoms were present in 40% (n = 181) of the trauma surgeons, and 15% (n = 68) of the trauma surgeons met the diagnostic criteria for PTSD. Male trauma surgeons (odds ratio [OR], 2; 95% confidence interval [CI], 1.2Y3.1) operating more than 15 cases per month (OR, 3; 95% CI, 1.2Y8), having more than seven call duties per month (OR, 2.6; 95% CI, 1.2Y6), and with less than 4 hours of relaxation per day (OR, 7; 95% CI, 1.4Y35) were more likely to develop symptoms of PTSD. Diagnosis of PTSD was common in trauma surgeons managing more than 5 critical cases per call duty (OR, 7; 95% CI, 1.1Y8). Salary, years of clinical practice, and previous military experience were predictive for neither the development of PTSD symptoms nor the diagnosis of PTSD. CONCLUSION: Both symptoms and the diagnosis of PTSD are common among trauma surgeons. Defining the factors that predispose trauma surgeons to PTSD may be of benefit to the patients and the profession. The data from this survey will be useful to major national trauma surgery associations for developing targeted interventions. (J Trauma Acute Care Surg. 2014;77: 148Y154. Copyright * 2014 by Lippincott Williams & Wilkins)

Background A definitive consensus on the standardization of practice of a routine repeat head CT (RHCT) scan in patients with traumatic intracranial hemorrhage is lacking. We hypothesized that in examinable patients without neurologic deterioration, RHCT scan does not lead to neurosurgical intervention (craniotomy/craniectomy). Study Design This was a 3-year prospective cohort analysis of patients aged 18 years and older, without antiplatelet or anticoagulation therapy, presenting to our level 1 trauma center with intracranial hemorrhage on initial head CT and a follow-up RHCT. Neurosurgical intervention was defined by craniotomy/craniectomy. Neurologic deterioration was defined as altered mental status, focal neurologic deficits, and/or pupillary changes. Results A total of 1,129 patients were included. Routine RHCT was performed in 1,099 patients. The progression rate was 19.7% (216 of 1,099), with subsequent neurosurgical intervention in 4 patients. Four patients had an abnormal neurologic examination, with a Glasgow Coma Scale (GCS) of ≤8 requiring intubation. Thirty patients had an RHCT secondary to neurologic deterioration; 53% (16 of 30) had progression on RHCT, of which 75% (12 of 16) required neurosurgical intervention. There was an association between deterioration in neurologic examination and need for neurosurgical intervention (odds ratio 3.98; 95% CI 1.7 to 9.1). The negative predictive value of a deteriorating neurologic examination in predicting the need for neurosurgical intervention was 100% in patients with GCS > 8. Conclusions Routine repeat head CT scan is not warranted in patients with normal neurologic examination. Routine repeat head CT scan does not supplement the need for neurologic examination for determining management in patients with traumatic brain injury.

The development of coagulopathy of trauma is multifactorial associated with hypoperfusion and consumption of coagulation factors. Previous studies have compared the role of factor replacement versus FPP for reversal of trauma coagulopathy. The purpose of our study was to determine the time to correction of coagulopathy and blood product requirement in patients who received PCC+FFP compared with patients who received FFP alone.We performed a retrospective analysis of a prospectively maintained database of all coagulopathic (INR ≥ 1.5) trauma patients presenting to our level I trauma center during a 2-years period (2011-2012). Patients were stratified into two groups: patients who received PCC+FFP and patients who received FFP alone. Patients in the two groups were matched in a 1:3 (PCC+FFP:FFP) ratio using propensity score matching for demographics, injury severity, vital parameters, and initial INR. The two groups were then compared for: correction of INR, time to correction of INR, thromboembolic complications, mortality, and cost of therapy.A total of 252 were included in the analysis [PCC+FFP:63; FFP:189]. The mean age was 44 ± 20 years; 70 % were male, with a median ISS score of 27 [16-38]. PCC use was associated with an accelerated correction of INR (394 vs. 1,050 min; p 0.001), reduction in requirement of pack red blood cell (6.6 vs. 10 units; p 0.001) and FFP (2.8 vs. 3.9 units; p 0.01), and decline in mortality (23 vs. 28%; p 0.04). PCC+FFP use was associated with a higher cost of therapy ($1,470 ± 845 vs. 1,171 ± 949; p 0.01) but lower overall cost of transfusion ($7,110 ± 1,068 vs. 9,571 ± 1,524; p 0.01) compared with FFP therapy alone.PCC in conjunction with FFP rapidly corrects INR in a matched cohort of trauma patients not on warfarin therapy compared with FFP therapy alone. The use of PCC as an adjunct to FFP therapy is associated with reduction of blood product requirement and also lowers overall cost.

Protocols call for the start of hormonal therapy with levothyroxine after the declaration of brain death. As the hormonal perturbations occur during the process of brain death, the role of the early initiation of levothyroxine therapy (LT) to salvage organs is not well defined. The aim of this study was to evaluate the impact of early LT (before the declaration of brain death) on the number of solid organs procured per donor.We performed an 8-year retrospective analysis of all trauma patients who progressed to brain death. Patients who consented for organ donation, received LT, and donated solid organs were included. Patients were dichotomized into two groups: early LT group, patients who received LT before the declaration of brain death, and late LT group, those who received LT after brain death. The two groups were compared for differences in demographics, clinical characteristics, need for vasopressor, and number of solid organ donation.A total of 100 solid organ donors were identified of which, 41% (n=77) donors who received LT therapy were included. LT before the declaration of brain death was initiated in 37 patients compared with 40 patients who had it started after the declaration of brain death. There was no difference in demographics between the two groups except that patients in the early LT group were more likely to be hypotensive on presentation (54% vs. 25%, p = 0.001). Early LT therapy was associated with an increase in solid organ procurement rate (odds ratio, 1.9; 95% confidence interval, 1.4-2.7; p = 0.01). Sixty-seven patients donated a total of 291 solid organs.The early use of LT and aggressive blood product resuscitation was associated with a significantly higher number of solid organs donated per donor. Earlier use of LT before the declaration of brain death may be considered in potential organ donors.Therapeutic/care management study, level IV.

Coagulopathy is a defined barrier for organ donation in patients with lethal traumatic brain injuries. The purpose of this study was to document our experience with the use of prothrombin complex concentrate (PCC) to facilitate organ donation in patients with lethal traumatic brain injuries. We performed a 4-year retrospective analysis of all patients with devastating gunshot wounds to the brain. The data were analyzed for demographics, change in international normalized ratio (INR), and subsequent organ donation. The primary end point was organ donation. Eighty-eight patients with lethal traumatic brain injury were identified from the trauma registry of whom 13 were coagulopathic at the time of admission (mean INR 2.2 ± 0.8). Of these 13 patients, 10 patients received PCC in an effort to reverse their coagulopathy. Mean INR before PCC administration was 2.01 ± 0.7 and 1.1 ± 0.7 after administration ( P < 0.006). Correction of coagulopathy was attained in 70 per cent (seven of 10) patients. Of these seven patients, consent for donation was obtained in six patients and resulted in 19 solid organs being procured. The cost of PCC per patient was $1022 ± 544. PCC effectively reveres coagulopathy associated with lethal traumatic brain injury and enabled patients to proceed to organ donation. Although various methodologies exist for the treatment of coagulopathy to facilitate organ donation, PCC provides a rapid and cost-effective therapy for reversal of coagulopathy in patients with lethal traumatic brain injuries.

It is becoming a standard practice that any "positive" identification of a radiographic intracranial injury requires transfer of the patient to a trauma center for observation and repeat head computed tomography (RHCT). The purpose of this study was to define guidelines-based on each patient's history, physical examination, and initial head CT findings-regarding which patients require a period of observation, RHCT, or neurosurgical consultation.In our retrospective cohort analysis, we reviewed the records of 3,803 blunt traumatic brain injury patients during a 4-year period. We classified patients according to neurologic examination results, use of intoxicants, anticoagulation status, and initial head CT findings. We then developed brain injury guidelines (BIG) based on the individual patient's need for observation or hospitalization, RHCT, or neurosurgical consultation.A total of 1,232 patients had an abnormal head CT finding. In the BIG 1 category, no patients worsened clinically or radiographically or required any intervention. BIG 2 category had radiographic worsening in 2.6% of the patients. All patients who required neurosurgical intervention (13%) were in BIG 3. There was excellent agreement between assigned BIG and verified BIG. κ statistic is equal to 0.98.We have proposed BIG based on patient's history, neurologic examination, and findings of initial head CT scan. These guidelines must be used as supplement to good clinical examination while managing patients with traumatic brain injury. Prospective validation of the BIG is warranted before its widespread implementation.Epidemiologic study, level III.

segment is the segment of people older than 85 years. 2 Given these changing population demographics, it has become imperative for health care professionals to integrate the understanding of the physiology of aging in their clinical practice. In recent years, there has been an increase in number of elderly patients presenting to hospital with a disease state requiring operative intervention. 3 In fact, the aging population is responsible for more than half of the total number of surgeries performed in the United States. 3 Since most older adults have one or more chronic conditions, are taking several medications, and frequently experience functional impairments, surgeons are performing operations on patients who are older and sicker, with complex health care needs. Clues about the patients’ physiologic reserve, their vulnerability to intraoperative or postoperative complications, and their short- and long-term prognoses are invaluable. However, neither the rate nor the extent of decline in physiologic function among aging is uniform. Heterogeneity that exists among aging individuals is based on their individual physiologic reserve, that is, the amalgamation of intrinsic host factors such as age, sex, nutritional status, functional capacity, hormonal balance, and any preexisting medical conditions that might increase their morbidity and mortality after stressful events. 4 This has given rise to the concept of ‘‘frailty’’ and its operational counterparts, ‘‘the frailty index’’ (FI) and ‘‘frailty scores’’ (FS). The concept of frailty is well established in the geriatric literature; however, the implementation of this concept in surgery is still evolving. In this article, we review the relevance of the concept of frailty in surgery, especially its role in identifying vulnerable surgical patients, improving patient care, and decreasing hospital costs. In addition, we have tried to simplify the concept of frailty and FI to expand the spectrum of its understanding and application.

Smartphones can be used to record and transmit high-quality clinical photographs. The aim of this study was to describe our experience with smartphone telephotography in the care of trauma patients. We hypothesized that smartphone telephotography can be safely and effectively implemented on a trauma service.We performed a 2-year (January 2011-December 2012) prospective analysis of all patient photographs recorded by members of our trauma team at our Level I trauma center. All members of the trauma team recorded patient photographs and e-mailed them to a secure e-mail account. An administrative assistant uploaded a copy of each photgrapho into the patient's electronic medical record. We assessed the number of photographs collected and uploaded, as well as the success, failure, and complication rates.Our trauma team sent 7,200 photographs to a secure e-mail account. Of those, 6,120 (85%) were considered, after an initial review, to be of good quality. Of these, 3,320 photographs (54%) were successfully uploaded into a patient's electronic medical record; the remaining 2,800 photographs lacked adequate labeling and could not be uploaded. The average interval to uploading was 3 months. In total, 10 photographs were uploaded into the wrong patient's electronic medical record, for an error rate of 0.003%. We received only three complaints during the study period.Telephotography can be safely and effectively implemented in trauma clinical practice. Fears of Health Insurance Portability and Accountability Act violations are not valid, as the incidence of patient complaints is minimal when telephotography is implemented under strict guidelines and rules. Dedicated administrative personnel are essential for effective implementation of smartphone photography.

Senate Bill 1108 (SB-1108) allows adult citizens to carry concealed weapons without a permit and without completion of a training course. It is unclear whether the law creates a "deterrent factor" to criminals or whether it escalates gun-related violence. We hypothesized that the enactment of SB-1108 resulted in an increase in gun-related injuries and deaths (GRIDs) in southern Arizona.We performed a retrospective cohort study spanning 24 months before (prelaw) and after (postlaw) SB-1108. We collected injury and death data and overall crime and accident trends. Injured patients were dichotomized based on whether their injuries were intentional (iGRIDs) or accidental (aGRIDs). The primary outcome was any GRID. To determine proportional differences in GRIDs between the two periods, we performed χ analyses. For each subgroup, we calculated relative risk (RR).The number of national and state background checks for firearms purchases increased in the postlaw period (national and state p0.001); that increase was proportionately reflected in a relative increase in state firearm purchase in the postlaw period (1.50% prelaw vs. 1.59% postlaw, p0.001). Overall, victims of events potentially involving guns had an 11% increased risk of being injured or killed by a firearm (p = 0.036) The proportion of iGRIDs to overall city violent crime remained the same during the two periods (9.74% prelaw vs. 10.36% postlaw; RR, 1.06; 95% confidence interval, 0.96-1.17). However, in the postlaw period, the proportion of gun-related homicides increased by 27% after SB-1108 (RR, 1.27; 95% confidence interval, 1.02-1.58).Both nationally and statewide, firearm purchases increased after the passage of SB-1108. Although the proportion of iGRIDs to overall city violent crime remained the same, the proportion of gun-related homicides increased. Liberalization of gun access is associated with an increase in fatalities from guns.Epidemiologic study, level III.

BACKGROUND: The rate of mortality and factors predicting worst outcomes in the geriatric population presenting with trauma are not well established. This study aimed to examine mortality rates in severe and extremely severe injured individuals 65 years or older and to identify the predictors of mortality based on available evidence in the literature. METHODS: We performed a systematic literature search on studies reporting mortality and severity of injury in geriatric trauma patients using MEDLINE, PubMed, and Web of Science. RESULTS: An overall mortality rate of 14.8% (95% confidence interval [CI], 9.8Y21.7%) in geriatric trauma patients was observed. Increasing age and severity of injury were found to be associated with higher mortality rates in this patient population. Combined odds of dying in those older than 74 years was 1.67 (95% CI, 1.34Y2.08) compared with the elderly population aged 65 years to 74 years. However, the odds of dying in patients 85 years and older compared with those of 75 years to 84 years was not different (odds ratio, 1.23; 95% CI, 0.99Y1.52). A pooled mortality rate of 26.5% (95% CI, 23.4Y29.8%) was observed in the severely injured (Injury Severity Score [ISS] Q 16) geriatric trauma patients. Compared with those with mild or moderate injury, the odds of mortality in severe and extremely severe injuries were 9.5 (95% CI, 6.3Y14.5) and 52.3 (95% CI, 32.0Y85.5; p e 0.0001), respectively. Low systolic blood pressure had a pooled odds of 2.16 (95% CI, 1.59Y2.94) for mortality. CONCLUSION: Overall mortality rate among the geriatric population presenting with trauma is higher than among the adult trauma population. Patients older than 74 years experiencing traumatic injuries are at a higher risk for mortality than the younger geriatric group. However, the trauma-related mortality sustains the same rate after the age of 74 years without any further increase. Moreover, severe and extremely severe injuries and low systolic blood pressure at the presentation among geriatric trauma patients are significant risk factors for mortality. (J Trauma Acute Care Surg. 2014;76: 894Y901. Copyright* 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Systematic review and meta-analysis, level IV.

Multiple studies have demonstrated a linear association between advancing age and mortality after injury. An inflection point, or an age at which outcomes begin to differ, has not been previously described. We hypothesized that the relationship between age and mortality after injury is non-linear and an inflection point exists. We performed a retrospective cohort analysis at our urban level I center from 2007 through 2009. All patients aged 65 years and older with the admission diagnosis of injury were included. Non-parametric logistic regression was used to identify the functional form between mortality and age. Multivariate logistic regression was utilized to explore the association between age and mortality. Age 65 years was used as the reference. Significance was defined as p

Background Gunshot wounds to the brain are the most lethal of all firearm injuries, with reported survival rates of 10% to 15%. The aim of this study was to determine outcomes in patients with gunshot wounds to the brain, presenting to our institution over time. We hypothesized that aggressive management can increase survival and the rate of organ donation in patients with gunshot wounds to the brain. Study Design We analyzed all patients with gunshot wounds to the brain presenting to our level 1 trauma center over a 5-year period. Aggressive management was defined as resuscitation with blood products, hyperosmolar therapy, and/or prothrombin complex concentrate (PCC). The primary outcome was survival and the secondary outcome was organ donation. Results There were 132 patients with gunshot wounds to the brain, and the survival rates increased incrementally every year, from 10% in 2008 to 46% in 2011, with the adoption of aggressive management. Among survivors, 40% (16 of 40) of the patients had bi-hemispheric injuries. Aggressive management with blood products (p = 0.02) and hyperosmolar therapy (p = 0.01) was independently associated with survival. Of the survivors, 20% had a Glasgow Coma Scale score ≥ 13 at hospital discharge. In patients who died (n = 92), 56% patients were eligible for organ donation, and they donated 60 organs. Conclusions Aggressive management is associated with significant improvement in survival and organ procurement in patients with gunshot wounds to the brain. The bias of resource use can no longer be used to preclude trauma surgeons from abandoning aggressive attempts to save patients with gunshot wound to the brain.

Anticoagulation agents are proven risk factors for intracranial hemorrhage (ICH) in traumatic brain injury (TBI). The aim of our study is to describe the epidemiology of prehospital coumadin, aspirin, and Plavix (CAP) patients with ICH and evaluate the use of repeat head computed tomography (CT) in this group. We performed a retrospective study from our trauma registry. All patients with intracranial hemorrhage on initial CT with prehospital CAP therapy were included. Demographics, CT scan findings, number of repeat CT scans, progressive findings, and neuro-surgical intervention were abstracted. A comparison between prehospital CAP and no-CAP patients was done using χ2 and Mann-Whitney U test. A total of 1606 patients with blunt TBI charts were reviewed of whom 508 patients had intracranial bleeding on initial CT scan and 72 were on prehospital CAP therapy. CAP patients were older ( P < 0.001), had higher Injury Severity Score and head Abbreviated Injury Scores on admission ( P < 0.001), were more likely to present with an abnormal neurologic examination ( P = 0.004), and had higher hospital and intensive care unit lengths of stay ( P < 0.005). Eighty-four per cent of patients were on antiplatelet therapy and 27 per cent were on warfarin. The CAP patients have a threefold increase in the rate of worsening repeat head CT (26 vs 9%, P < 0.05). Prehospital CAP therapy is high risk for progression of bleeding on repeat head CT. Routine repeat head CT remains an important component in this patient population and can provide useful information.

The frailty index (FI) has been shown to predict outcomes in geriatric patients. However, FI has never been applied as a prognostic measure after trauma. The aim of our study was to identify hospital admission factors predicting discharge disposition in geriatric trauma patients.We performed a 1-year prospective study at our Level 1 trauma center. All trauma patients 65 years or older were enrolled. FI was calculated using 50 preadmission variables. Patient's discharge disposition was dichotomized as favorable outcome (discharge home, rehabilitation) or unfavorable outcomes (discharge to skilled nursing facility, death). Multivariate logistic regression was performed to identify factors that predict unfavorable outcome.A total of 100 patients were enrolled, with a mean (SD) age of 76.51 (8.5) years, 59% being males, median Injury Severity Score (ISS) of 14 (range, 9-18), median head Abbreviated Injury Scale (h-AIS) score of 2 (2-3), and median Glasgow Coma Scale (GCS) score of 13 (12-15). Of the patients, 69% had favorable outcome, and 31% had unfavorable outcome. On univariate analysis, FI was found to be a significant predictor for unfavorable outcome (odds ratio, 1.8; 95% confidence interval, 1.2-2.3). After adjusting for age, ISS, and GCS score in a multivariate regression model, FI remained a strong predictor for unfavorable discharge disposition (odds ratio, 1.3; 95% confidence interval, 1.1-1.8).The concept of frailty can be implemented in geriatric trauma patients with similar results as those of nontrauma and nonsurgical patients. FI is a significant predictor of unfavorable discharge disposition and should be an integral part of the assessment tools to determine discharge disposition for geriatric trauma patients.Prognostic study, level II.

One third of US adults are obese. The impact of obesity on outcomes after blunt traumatic injury has been studied with discrepant results. The aim of our study was to evaluate outcomes in morbidly obese patients after blunt trauma. We hypothesized that morbidly obese patients have adverse outcomes as compared with nonobese patients after blunt traumatic injury.We performed a retrospective analysis of all blunt trauma patients (≥18 years) using the National Trauma Data Bank for years 2007 to 2010. Patients with recorded comorbidity of morbid obesity (body mass index ≥ 40) were identified. Patients transferred, dead on arrival, and with isolated traumatic brain injury were excluded. Propensity score matching was used to match morbidly obese patients to non-morbidly obese patients (body mass index40) in a 1:1 ratio based on age, sex, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), and systolic blood pressure on presentation. The primary outcome was mortality, and the secondary outcome was hospital complications.A total of 32,780 patients (morbidly obese, 16,390; nonobese, 16,390) were included in the study. Morbidly obese patients were more likely to have in-hospital complications (odds ratio [OR], 1.8, 95% confidence interval [CI], 1.6-1.9), longer hospital stay (OR, 1.2; 95% CI, 1.1-1.3), and longer intensive care unit stay (OR, 1.15; 95% CI, 1.09-1.2). The overall mortality rate was 2.8% (n = 851). Mortality was higher in morbidly obese patients compared with the nonobese patients (3.0 vs. 2.2; OR, 1.4; 95% CI, 1.1-1.5).In a cohort of matched patients, morbid obesity is a risk factor for the development of in-hospital complications and mortality after blunt traumatic injury. The results of our study call for attention through focused injury prevention efforts. Future studies are needed to help define the consequences of obesity that influence outcomes.Prognostic study, level III.

The current prehospital standard of care using a large bore intravenous catheter for tension pneumothorax (tPTX) decompression is associated with a high failure rate. We developed a modified Veress needle (mVN) for this condition. The purpose of this study was to evaluate the effectiveness and safety of the mVN as compared with a 14-gauge needle thoracostomy (NT) in a swine tPTX model.tPTX was created in 16 adult swine via thoracic CO2 insufflation to 15 mm Hg. After tension physiology was achieved, defined as a 50% reduction of cardiac output, the swine were randomized to undergo either mVN or NT decompression. Failure to restore 80% baseline systolic blood pressure within 5 minutes resulted in crossover to the alternate device. The success rate of each device, death, and need for crossover were analyzed using χ.Forty-three tension events were created in 16 swine (24 mVN, 19 NT) at 15 mm Hg of intrathoracic pressure with a mean CO2 volume of 3.8 L. tPTX resulted in a 48% decline of systolic blood pressure from baseline and 73% decline of cardiac output, and 42% had equalization of central venous pressure with pulmonary capillary wedge pressure. All tension events randomized to mVN were successfully rescued within a mean (SD) of 70 (86) seconds. NT resulted in four successful decompressions (21%) within a mean (SD) of 157 (96) seconds. Four swine (21%) died within 5 minutes of NT decompression. The persistent tension events where the swine survived past 5 minutes (11 of 19 NTs) underwent crossover mVN decompression, yielding 100% rescue. Neither the mVN nor the NT was associated with inadvertent injuries to the viscera.Thoracic insufflation produced a reliable and highly reproducible model of tPTX. The mVN is vastly superior to NT for effective and safe tPTX decompression and physiologic recovery. Further research should be invested in the mVN for device refinement and replacement of NT in the field.

Alcohol use may alter mental status and vital signs in injured patients, leading to increased testing during emergency department (ED) evaluation. We hypothesized that alcohol use increases the hospital charges when caring for these injured patients.The National Hospital Ambulatory Medical Care Survey collects weighted population-based estimates of ED use. We analyzed injury-related visits of adult patients, and resource use and admission rates were compared by the presence of alcohol.Alcohol was involved in 6.0% of injury-related ED visits. Alcohol-present patients arrived by ambulance more frequently (45% vs 21%, P.001), had a 26% longer ED stay (211 vs 167 minutes, P.001), and underwent more diagnostic testing. They were twice as likely to be admitted (14.0% vs 6.5%, P.001). Additional ED charges were over $217 million.Patients with alcohol-related injuries use significantly more resources, with a significant added financial burden. Insurance companies in many states can deny coverage for injuries caused by alcohol use, shifting these expenses to trauma centers.

Communication among healthcare providers continues to change, and 90% of healthcare providers are now carrying cellular phones. Compared with pagers, the rate and amount of information immediately available via cellular phones are far superior. Wireless devices such as smartphones are ideal in acute trauma settings as they can transfer patient information quickly in a coordinate manner to all the team members responsible for patient care.A questionnaire survey was distributed among all the trauma surgeons, surgery residents, and nurse practitioners who were a part of the trauma surgery team at a Level 1 trauma center. Answers to each question were recorded on a 5-point Likert scale. The completed survey questionnaires were analyzed using Statistical Package for Social Sciences software (SPSS version 17; SPSS, Inc., Chicago, IL).The respondents had an overall positive experience with the usage of the third-generation (3G) smartphones, with 94% of respondents in favor of having wireless means of communication at a Level 1 trauma center. Of respondents, 78% found the device very user friendly, 98% stated that use of smartphones had improved the speed and quality of communication, 96% indicated that 3G smartphones were a useful teaching tool, 90% of the individuals felt there was improvement in the physician's response time to both routine and critical patients, and 88% of respondents were aware of the rules and regulations of the Health Insurance Portability and Accountability Act.Smartphones in an acute trauma setting are easy to use and improve the means of communication among the team members by providing accurate and reliable information in real time. Smartphones are effective in patient follow-up and as a teaching tool. Strict rules need to be used to govern the use of smartphones to secure the safety and secrecy of patient information.

BACKGROUND: Coagulopathy in patients with traumatic brain injury (TBI) is a well-studied concept. Prothrombin complex concentrate (PCC) has been shown to be an effective treatment modality for correction of TBI coagulopathy. However, its use and effectiveness compared with recombinant factor VII (rFVIIa) in TBI has not been established. The purpose of this study was to compare PCC and rFVIIa for the correction of TBI coagulopathy. METHODS: All patients with a TBI and an induced or acquired coagulopathy whom received rFVIIa or PCC at our Level I trauma center during a 4-year period were reviewed. Data collected included demographics, changes in international normalized ratio and blood products transfusion, craniotomy rates, and time to neurosurgical intervention, thromboembolic complications, and mortality differences. RESULTS: The study was composed of 85 TBI patients, of whom 64 patients received PCC while 21 patients received rFVIIa. PCC group were more likely to be on coumadin (44% vs. 14%, p = 0.01). There was a significant decline in packed red blood cell transfusion and fresh frozen plasma after PCC administration (p < 0.01). There was no statistically significant difference in the craniotomy rate (28% vs. 10 %, p = 0.1) or the mean time to intervention between the two groups (201 [33] vs. 230 [10], p = 0.9). Mortality rates were lower in the PCC group compared with rFVIIa (67% vs. 47%, p = 0.02). Subsequent thromboembolic event was seen in one patient on rFVIIa. Mean cost of treatment per patient on PCC was $1,007 compared with $5,757 for rFVIIa (p < 0.01). CONCLUSION: PCC is safe and effective for treating coagulopathy in TBI patients, while reducing costs and resource use. PCC should be considered as an effective therapy to treat both acquired and induced coagulopathy in TBI with or without prehospital coumadin use. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Early seizures after severe traumatic brain injury (TBI) have a reported incidence of up to 15 %. Prophylaxis for early seizures using 1 week of phenytoin is considered standard of care for seizure prevention. However, many centers have substituted the anticonvulsant levetiracetam without good data on the efficacy of this approach. Our hypothesis was that the treatment with levetiracetam is not effective in preventing early post-traumatic seizures. All trauma patients sustaining a TBI from January 2007 to December 2009 at an urban level-one trauma center were retrospectively analyzed. Seizures were identified from a prospectively gathered morbidity database and anticonvulsant use from the pharmacy database. Statistical comparisons were made by Chi square, t tests, and logistic regression modeling. Patients who received levetiracetam prophylaxis were matched 1:1 using propensity score matching with those who did not receive the drug. 5551 trauma patients suffered a TBI during the study period, with an overall seizure rate of 0.7 % (39/5551). Of the total population, 1795 were diagnosed with severe TBI (Head AIS score 3–5). Seizures were 25 times more likely in the severe TBI group than in the non-severe group [2.0 % (36/1795) vs. 0.08 % (3/3756); OR 25.6; 95 % CI 7.8–83.2; p

BACKGROUND: During the last century, the management of blunt force trauma to the liver has changed from observation and expectant management in the early part of the 1900s to mainly operative intervention, to the current practice of selective operative and nonoperative management. These issues were first addressed by the Eastern Association for the Surgery of Trauma in the Practice Management Guidelines for Nonoperative Management of Blunt Injury to the Liver and Spleen published online in 2003. Since that time, a large volume of literature on these topics has been published requiring a reevaluation of the previous Eastern Association for the Surgery of Trauma guideline. METHODS: The National Library of Medicine and the National Institutes of Health MEDLINE database were searched using PubMed (www.pubmed.gov). The search was designed to identify English-language citations published after 1996 (the last year included in the previous guideline) using the keywords liver injury and blunt abdominal trauma. RESULTS: One hundred seventy-six articles were reviewed, of which 94 were used to create the current practice management guideline for the selective nonoperative management of blunt hepatic injury. CONCLUSION: Most original hepatic guidelines remained valid and were incorporated into the greatly expanded current guidelines as appropriate. Nonoperative management of blunt hepatic injuries currently is the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury or patient age. Nonoperative management of blunt hepatic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and an operating room available for urgent laparotomy. Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention. Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt hepatic injuries. Repeated imaging should be guided by a patient’s clinical status. Adjunctive therapies like angiography, percutaneous drainage, endoscopy/endoscopic retrograde cholangiopancreatography and laparoscopy remain important adjuncts to nonoperative management of hepatic injuries. Despite the explosion of literature on this topic, many questions regarding nonoperative management of blunt hepatic injuries remain without conclusive answers in the literature. (J Trauma Acute Care Surg. 2012;73: S288YS293.

BACKGROUND For patients who present to the emergency department (ED) with symptomatic cholelithiasis, surgery is indicated only if they are diagnosed of acute cholecystitis (AC). We hypothesized that, because preoperative signs and diagnostic tests are not sensitive enough to diagnose AC, coupled with the potential health care burden of non-AC gallbladder, surgery may be offered sooner. METHODS We prospectively evaluated 200 patients who presented to ED with clinical suspicion of gallbladder disease, including a right upper quadrant/epigastric abdominal pain and cholelithiasis, and who underwent laparoscopic cholecystectomy. We correlated the preoperative clinical findings, including ultrasonography results, with the surgeon's intraoperative assessment (OR-GB) and with the pathology report (PA-GB). A multiple logistic regression model was performed. RESULTS Of the gallbladders, 116 were declared AC by OR-GB but only 54 by PA-GB, (r = 0.31, p < 0.001). The median time to surgery was 17 hours; 75% of the patients underwent surgery within 24 hours. The sensitivity of ultrasonography for AC according to PA-GB was 38%, and 16% when combined all preoperative findings. Both figures dropped to 27% and 11% when correlated to OR-GB. Our regression identified persistent abdominal pain, positive ultrasonography result, and a body mass index of greater than 40 to be significant predictors of AC according to PA-GB; however, only the persistent abdominal pain remained significant according to OR-GB. CONCLUSION The study confirmed the lack of sensitivity of signs and diagnostic tools to diagnose AC. Because of the acute care surgery model, we believe that the approach to the patients who present to the ED with suspected gallbladder disease is to offer them surgery as soon as feasible, with or without AC. This approach will avoid an unnecessary delay as well as quickly relieve patient's pain and suffering; the health care system will benefit from a cost-effective reduction in number of outpatient referrals and repeated ED visits. LEVEL OF EVIDENCE Diagnostic study, level II.

The use of the "open abdomen" as a technique in the management of the complex surgical patient stems from the concept of damage control. Damage control principles underscore the importance of an abbreviated laparotomy focused on control of hemorrhage and gastrointestinal contamination in patients presenting with significant physiologic compromise. Definitive repair of injuries is postponed and the abdomen is temporarily "closed" using one of a number of different techniques. The ultimate goal is formal abdominal fascial closure within 48-72 hours of the initial laparotomy. Frequently, daily trips to the operating room are required for incremental closure of the abdominal fascia. However, in some cases, fascial closure is not possible secondary to ongoing visceral edema and loss of the peritoneal domain. In these cases, the patient is left with an "open abdomen" until skin grafting over the exposed peritoneal organs can be performed. Patients with an open abdomen have peritoneal contents exposed to the atmosphere and require a complex dressing to maintain fascial domain and provide protection to exposed organs. These patients are typically critically ill and managed in the intensive care unit early in the disease process. The open abdomen has become an important tool for the management of physiologically unstable patients requiring emergent abdominal surgical procedures. These patients present unique challenges to the critical care and nutrition support teams. Careful attention to fluid and electrolyte management, meticulous wound care, prevention of enteroatmospheric fistula, and individualized nutrition support therapy are essential to successful recovery in this patient population.