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Trauma transfers are a common occurrence in rural areas, where critical access and lower-level trauma centers routinely transfer to tertiary care centers for specialized care. Transfers are non-therapeutic (NTT) when no specialist intervention occurs, leading to transfer that were futile (FT) or secondary overtriage (SOT). This study aimed to evaluate the prevalence of NTT among four trauma centers providing care to rural Appalachia.This retrospective review was performed at four, ACS verified, Level 1 trauma centers. All adult trauma patients, transferred during 2018 were included for analysis. Transfers were considered futile if in48 h the patient died or was discharged to hospice, without operative intervention. SOT transfers were discharged in48 h, without major intervention, with an ISS15. Cost analysis was performed to describe the impact of NTT on EMS use.4,189 patients were analyzed during the study period. 105 (2.5%) met criteria for futility. Futile patients had a median ISS of 25 (IQR 9-26), and 48% had an AIS head ≥4. These were significantly greater (p0.001) than non-futile transfers, median ISS 5 (IQR 2-9), 3% severe head injury. SOT occurred in 1371 (33%), median ISS of 5, and lower AIS scores by region. Isolated facial injuries resulted in 165 transfers. 13% of FT+SOT were admitted to the ICU. Only 22% of FT+SOT came from a trauma center. 68% were transported by ALS and 13% transported by air transport. FT+SOT traveled on average 70 miles from their home to receive care.Non-therapeutic transfers account for more than 1/3 of transfers in this rural environment. There was a significant use of advanced life support and aeromedical transport. The utility of these transfers should be questioned. With the recent increases in telehealth there is an opportunity for trauma systems to improve regional care and decrease transfers for futile cases.

Early video-assisted thorascopic surgery (VATS) is the recommended intervention for retained hemothorax in trauma patients. Alternative options, such as lytic therapy, to avoid surgery remain controversial. The purpose of this decision analysis was to assess expected costs associated with treatment strategies.A decision tree analysis estimated the expected costs of three initial treatment strategies: 1) VATS, 2) intrapleural tissue plasminogen activator (TPA) lytic therapy, and 3) intrapleural non-TPA lytic therapy. Probability parameters were estimated from published literature. Costs were based on National Inpatient Sample data and published estimates. Our model compared overall expected costs of admission for each strategy. Sensitivity analyses were conducted to explore the impact of parameter uncertainty on the optimal strategy.In the base case analysis, using TPA as the initial approach had the lowest total cost (U.S. $37,007) compared to VATS ($38,588). TPA remained the optimal initial approach regardless of the probability of complications after VATS. TPA was an optimal initial approach if TPA success rate was83% regardless of the failure rate with VATS. VATS was the optimal initial strategy if its total cost of admission was$33,900.Lower treatment costs with lytic therapy does not imply significantly lower total cost of trauma admission. However, an initial approach with TPA lytic therapy may be preferred for retained traumatic hemothorax to lower the total cost of admission given its high probability of avoiding the operating room with its resultant increased costs. Future studies should identify differences in quality of life after recovery from competing interventions.

The aim of this study was to identify a mortality benefit with the use of whole blood (WB) as part of the resuscitation of bleeding trauma patients.Blood component therapy (BCT) is the current standard for resuscitating trauma patients, with WB emerging as the blood product of choice. We hypothesized that the use of WB versus BCT alone would result in decreased mortality.We performed a 14-center, prospective observational study of trauma patients who received WB versus BCT during their resuscitation. We applied a generalized linear mixed-effects model with a random effect and controlled for age, sex, mechanism of injury (MOI), and injury severity score. All patients who received blood as part of their initial resuscitation were included. Primary outcome was mortality and secondary outcomes included acute kidney injury, deep vein thrombosis/pulmonary embolism, pulmonary complications, and bleeding complications.A total of 1623 [WB: 1180 (74%), BCT: 443(27%)] patients who sustained penetrating (53%) or blunt (47%) injury were included. Patients who received WB had a higher shock index (0.98 vs 0.83), more comorbidities, and more blunt MOI (all P0.05). After controlling for center, age, sex, MOI, and injury severity score, we found no differences in the rates of acute kidney injury, deep vein thrombosis/pulmonary embolism or pulmonary complications. WB patients were 9% less likely to experience bleeding complications and were 48% less likely to die than BCT patients ( P0.0001).Compared with BCT, the use of WB was associated with a 48% reduction in mortality in trauma patients. Our study supports the use of WB use in the resuscitation of trauma patients.

Geriatric patients who fall are among the most common mechanisms of injury presenting to trauma centers. We sought to quantify the impact of various comorbidities on length of stay (LOS) in these patients to identify areas for intervention. A level 1 trauma center’s registry was queried for patients ≥65 years old with fall related injuries admitted with LOS greater than 2 days. Over 7 years, 3714 patients were included. Mean age was 80.9 ± 8.7 years. All patients fell from heights of 6 feet or less. Median total LOS was 5 days, interquartile range [3,8]. Overall mortality rate was 3.3%. The most common comorbidities were cardiovascular (57.1%), musculoskeletal (31.4%), and diabetes (20.8%). Multivariate linear regression modeling LOS identified diabetes, pulmonary, and psychiatric diseases associated with longer lengths of stay ( P < .05). As trauma centers refine care for geriatric trauma patients, comorbidity management represents an opportunity for proactive intervention.

OBJECTIVE: Risk factors for mortality in patients with subdural hematoma (SDH) include poor Glasgow Coma Scale (GCS), pupil non-reactivity, and hemodynamic instability on presentation. Little is published regarding prognosticators of SDH in the elderly. This study aims to examine risk factors for hospital mortality and withdrawal of life-sustaining measures in an octogenarian population presenting with SDH. METHODS: A prospectively collected multi-center database of 3,279 TBI admissions to 45 different U.S. trauma centers between 2017–2019 was queried to identify patients >79 years old presenting with SDH. Factors collected included baseline demographic data, past medical history, antiplatelet/anticoagulant use, and clinical presentation (GCS, pupil reactivity, injury severity scale [ISS]). Primary outcome data included hospital mortality/discharge to hospice care and withdrawal of life-sustaining measures. Multivariate logistic regression analyses were used to identify factors independently associated with primary outcome variables. RESULTS: A total of 695 patients were isolated for analysis. Of the total cohort, the rate of hospital mortality or discharge to hospice care was 22% (n=150) and the rate of withdrawal of life-sustaining measures was 10% (n=66). A multivariate logistic regression model identified GCS 80 years with SDH. Pre-existing CHF may further predict withdrawal of life-sustaining measures.

Introduction Nonoperative management of hemodynamically stable patients with blunt splenic and/or hepatic injury has been widely accepted in the pediatric population. However, variability exists in the utilization and timing of repeat imaging to assess for delayed complications during index hospitalization. Recent level-IV evidence suggests that repeat imaging in children should be performed based on a patient’s clinical status rather than on a routine basis. The aim of this study is to examine the rate of delayed complications and interventions in pediatric trauma patients with blunt splenic and/or hepatic injuries who undergo repeat imaging prompted either by a clinical change (CC) or non-clinical change (NCC). Methods A 9-year (2011-2019), retrospective, dual-institution study was performed of children (0-17 years) with blunt splenic and/or hepatic injuries. Patients were grouped based on reason for repeat imaging: CC or NCC. The rate of organ-specific delayed complications and interventions was examined by reason for scan. Results A total of 307 injuries were included in the study period (174 splenic, 113 hepatic, and 20 both). Of 194 splenic injuries, 30(15.5%) underwent repeat imaging (CC = 19; NCC = 11). Of 133 hepatic injuries, 27(20.3%) underwent repeat imaging (CC = 21; NCC = 6). There was no difference in the incidence of organ-specific delayed complications between the CC and NCC groups. Of the 4 patients with complications necessitating intervention, only one was identified based on NCC. Conclusions Our data suggest routine repeat imaging is unnecessary in children with blunt splenic and/or hepatic injuries; therefore, practitioners may rely on a patient’s clinical change.

Background Intrapleural lytic therapy has been established as an important modality of treatment for many pleural disorders, including hemothorax and empyema. Retained traumatic hemothorax is a common and understudied subset of pleural disease. The current standard of care for retained traumatic hemothorax is operative management. The use of lytic therapy for avoidance of operative intervention in the trauma population has not been well established. Methods Randomized controlled trials (RCTs) and non-RCTs reporting operative intervention following the use of intrapleural lytic treatment for retained traumatic hemothorax were identified in the literature. The primary outcome was avoidance of surgery following treatment with any lytic agent. Meta-analysis was performed to pool the results of those studies. Subgroup analysis by type of lytic therapy and analysis of length of stay were also performed. Results One RCT and nine non-RCTs including 162 patients were pooled in the analysis. Avoidance of surgery following treatment with any lytic agent was found to be 87% (95% CI, 81%-92%). Tissue plasminogen activator resulted in 83% operative avoidance (95% CI, 71%-94%), and other, non-tissue plasminogen activator lytic agents resulted in 87% operative avoidance (95% CI, 82%-93%). The average length of stay for patients undergoing lytic therapy was 14.88 days (95% CI, 12.88-16.88). Conclusions Lytic therapy could reduce the need for operative intervention in trauma patients with retained traumatic hemothorax. RCTs are indicated to definitively evaluate the benefit of this approach.

Patients with obesity are also at risk for sarcopenia, which is difficult to recognize in this population. Our study examines whether sarcopenic-obesity (SO) is independently associated with mortality in trauma.Using a retrospective database, we performed logistic regression analysis. . Admission CT scans were used to identify SO by calculating the visceral fat to skeletal muscle ratio3.2.Of 883 patients, the prevalence of SO was 38% (333). Patients with SO were more likely to be male (79% versus 43%, p 0.001), older (mean 66.5 years versus 46.3 years, p 0.001), and less likely to have an injury severity score (ISS) ≥ 24 (43% versus 55%, p = 0.0003). Using multivariable logistic regression analysis, SO was independently associated with mortality (OR 2.8; 95% CI 1.6-4.8, p 0.001). Causal mediation analysis found admission hyperglycemia as a mediator for mortality.Sarcopenic obesity is an independent predictor of mortality in major trauma.

The average age and number of comorbidities is increasing among trauma patients. Primary care providers (PCPs) provide pre-injury diagnosis and management of comorbidities that may affect outcomes for injured patients. The role of primary care in trauma systems is currently unknown.Observational retrospective review of an institutional trauma databank from 2013 - 2019. PCP was extracted from the electronic medical record and combined with trauma data. Case-control matching was performed to compare outcomes between patients with and without primary care based on age, injury severity score, sex, and injury mechanism. Mann-Whitney U test, chi-square test, and multivariate regression described differences between subgroups. Primary outcome was difference in mortality rate for injured patients with and without PCPs.Within the study period, 19,096 patients were included. 6,626 (34.7%) had a PCP recorded. Of these, 2,158 were matched in a case-control design. Patients with PCPs had a lower mortality rate (1.6%) compared to patients without PCPs (3.6%, P0.01). PCP retention was associated with longer length of stay overall, equivalent rates of complications (5.4% vs. 5.7%, P = 0.63), and similar numbers of ICU and ventilator days. Multivariate logistic regression controlling for case-control factors, insurance, and comorbidities conferred an odds ratio of 2.58 (95% Confidence Interval: 1.59 - 4.19, P0.001) for survival to discharge.Pre-injury primary care significantly improves the odds of survival to discharge for injured patients. Prospective study of this relationship may identify strategies to promote primary care within health systems.

Acute care surgery has evolved to encompass the advanced management of complex nonhealing wounds. Biodebridement has the potential to improve the care of chronic wounds for acute care surgery patients, particularly for patients in the surgical intensive care unit (SICU) with hospital-acquired pressure injuries. A case report of biodebridement using larval maggot therapy in the SICU is presented to illustrate real-world application and progression in wound healing. A review of current research involving biodebridement was conducted. A septuagenarian gentleman sustained a fall resulting in cervical spine fractures with neurological deficits. The patient had a prolonged hospital course in the SICU, complicated by myocardial infarction, respiratory failure requiring tracheostomy, and development of a Stage IV sacral pressure ulcer. The wound base was sharply debrided several times and became refractory to conventional mechanical/chemical debridement techniques. The patient had a prohibitively high risk for the operating room but remained too sensate for further effective bedside debridement. Biodebridement was utilized to create a viable wound base, with improved appearance noted within 2 weeks. A review of the current literature shows biodebridement has numerous benefits in the management of chronic wounds. Biodebridement is a unique therapy that possesses great value for select patients in the SICU. In particular, patients who are too high risk for further operative intervention, but too sensate for ongoing bedside debridement and dressing changes, benefit significantly from this underutilized approach. Further research is needed to solidify the place of biodebridement in the surgical management of chronic nonhealing wounds.

OBJECTIVE Our objective was to investigate whether racial/ethnic-based or payer-based disparities existed in the transfer practices of pediatric trauma patients from adult trauma center (ATC) to pediatric trauma center (PTC) in Pennsylvania. METHODS Data on trauma patients aged 14 years or less initially evaluated at level I and II ATC were obtained from the Pennsylvania Trauma Outcome Study (2008-2012) (n = 3446). Generalized estimating equations regression analyses were used to evaluate predictors of subsequent transfer controlling for confounders and clustering. Recent literature has described racial and socioeconomic disparities in outcomes such as mortality after trauma; it is unknown whether these factors also influence the likelihood of subsequent interfacility transfer between ATC and PTC. RESULTS Patients identified as nonwhite comprised 36.1% of the study population. Those without insurance comprised 9.9% of the population. There were 2790 patients (77.4%) who were subsequently transferred. Nonwhite race (odds ratio [OR], 4.3), female sex (OR, 1.3), and lack of insurance (OR, 2.3) were associated with interfacility transfer. Additional factors were identified influencing likelihood of transfer (increased odds: younger age, intubated status, cranial, orthopedic, and solid organ injury; decreased odds: operative intervention at the initial trauma center) (P < 0.05 for all). CONCLUSIONS Although we assume that a desire for specialized care is the primary reason for transfer of injured children to PTCs, our analysis demonstrates that race, female sex, and lack of insurance are also associated with transfers from ATCs to PTCs for children younger than 15 years in Pennsylvania. Further research is needed to understand the basis of these health care disparities and their impact.

Objective Critically ill patients are at high risk for adverse events on transfer between intensive care unit and operating room. Patient safety concerns were raised within our institution during such transfers, and absence of a standardized patient handoff process was identified as an area of concern. Methods The current state of the patient transfer processes between the intensive care units (ICUs) and the operating rooms (ORs) was mapped and failure modes were identified. A multidisciplinary team was convened and a standardized handoff process and tool (checklist) was developed. Adherence to the process and care team satisfaction was assessed at the end of a 60-day pilot period. Results The process was successfully implemented hospital-wide covering all adult and pediatric ICUs. We observed a 90% compliance rate with ICU to the OR transfers and 95% compliance rate with transfers from OR to the ICU during the 60-day pilot period. The care team expressed overall satisfaction with the process and identified potential areas of improvement. Conclusion A standardized patient handoff process between the ICU and the ORs can be successfully implemented in a large academic medical center. Universal application of this quality improvement tool can reduce patient harm, improve communication between providers, and enhance patient safety.

Background Using 12 healthy adults, it was shown that a reduction in mean glucose concentration follows intermittent gastric feeds, not continuous: a desirable result for hospitalized patients. A numerical study comparing glucose dynamics after intermittent gastric and continuous post-pyloric feeds may inform the design of a similar clinical study in the critical care setting. Methods A mathematical model was used to construct a small virtual crossover study comparing intermittent gastric feeds and continuous post-pyloric feeds. The model, validated for eight diabetic patients, produced maximum glucose concentration, mean glucose concentration and glucose concentration standard deviation data. Simulations were repeated after renal insulin clearance was increased by 50%, a common physiologic alteration in critical illness. Five hypothetical patients with stress hyperglycemia also underwent simulation. Results Mean glucose concentration was significantly lower after intermittent gastric feeds in type 1 diabetics and in the stress hyperglycemia patients. Without insulin therapy, intermittent gastric feeds increased maximum glucose concentration more than continuous post-pyloric feeds, and glucose concentration standard deviation was largest after intermittent gastric feeds in all patients. Also, the continuous glucose concentration data suggests that the total amount of insulin required to treat patients with stress hyperglycemia would be least in the intermittent feed arm. Finally, data collection with a continuous glucose-monitoring device might be required to resolve maximum glucose and glucose standard deviation differences between the study arms. Conclusions This is the first examination of glucose dynamics following intermittent gastric feeds in a critical care setting. A small crossover clinical study could demonstrate that patients with stress hyperglycemia require less insulin following intermittent, not continuous, enteric feeds. Preliminary data from a clinical trial is reviewed and is found consistent with the results reported here.

Background Traumatic injury to the pancreas is rare but is associated with significant morbidity and mortality, including fistula, sepsis, and death. There are currently no practice management guidelines for the medical and surgical management of traumatic pancreatic injuries. The overall objective of this article is to provide evidence-based recommendations for the physician who is presented with traumatic injury to the pancreas. Methods The MEDLINE database using PubMed was searched to identify English language articles published from January 1965 to December 2014 regarding adult patients with pancreatic injuries. A systematic review of the literature was performed, and the Grading of Recommendations Assessment, Development and Evaluation framework was used to formulate evidence-based recommendations. Results Three hundred nineteen articles were identified. Of these, 52 articles underwent full text review, and 37 were selected for guideline construction. Conclusion Patients with grade I/II injuries tend to have fewer complications; for these, we conditionally recommend nonoperative or nonresectional management. For grade III/IV injuries identified on computed tomography or at operation, we conditionally recommend pancreatic resection. We conditionally recommend against the routine use of octreotide for postoperative pancreatic fistula prophylaxis. No recommendations could be made regarding the following two topics: optimal surgical management of grade V injuries, and the need for routine splenectomy with distal pancreatectomy. Level of evidence Systematic review, level III.

Background Trauma care providers often face a dilemma regarding anticoagulation therapy initiation in patients with traumatic brain injury owing to the associated risks of traumatic brain injury progression. The aims of this study were the following: (1) to describe the current practice of anticoagulation therapy in traumatic brain injury patients and their outcomes and (2) to identify factors associated with the progression of traumatic brain injury after anticoagulation therapy. Methods In this multicenter prospective observational study, we included computed tomography–proven traumatic brain injury patients who received anticoagulation therapy within 30 days of hospital admission. Our primary outcome was the incidence of clinically significant progression of traumatic brain injury after anticoagulation therapy initiation. Results A total of 168 patients were enrolled more than 22 months. Atrial fibrillation and venous thromboembolism were the most common pre-injury and postinjury anticoagulation therapy indications, respectively. Overall, 16 patients (9.6%) experienced clinically significant traumatic brain injury progression after anticoagulation therapy, out of which 9 (5.4%) patients subsequently required neurosurgical interventions. Between patients with clinical progression of traumatic brain injury and patients who showed no such progression, there were no significant differences in the baseline demographics and severity of traumatic brain injury. However, anticoagulation therapy was initiated significantly earlier in patients of the deterioration group than those of the no-deterioration group (4.5 days vs 11 days, P = .015). In a multiple logistic regression model, patients who received anticoagulation therapy later after injury had significantly lower risk of clinically significant traumatic brain injury progression (odds ratio: 0.915 for each day, 95% confidence interval: 0.841–0.995, P = .037). Conclusion Our results suggest that early anticoagulation therapy is associated with higher risk of traumatic brain injury progression, thus a balance between bleeding and thromboembolic risks should be carefully evaluated in each case before initiating anticoagulation therapy.

OBJECTIVES: In the elderly population, hyperglycemia is associated with increased rates of infections, length of hospital stay (LOS) and mortality. However, there is a lack of informative studies addressing the drivers of hyperglycemia. We hypothesized that central obesity has an effect on hyperglycemia. Therefore, our objective is to investigate whether central obesity predicts hyperglycemia within the first 48 hours of admission in elderly trauma patients admitted to the ICU. METHODS: Our trauma registry was queried for all trauma patients aged 65 and older from 2012 to 2018 with an intensive care unit (ICU) LOS of at least 3 days. CT scan images were reviewed for visceral fat area, waist circumference to height ratio (WCHR), waist circumference to hip ratio (WHR) and the presence of sarcopenia, which has been implicated in adverse outcomes of trauma, in the presence or absence of obesity. RESULTS: Of 320 elderly patients, 7% developed infections, 3% developed stroke, 52% had an increased ICU LOS >6 days, and 48% had an increased total hospital LOS >14 d. The prevalence of sarcopenia was 26%, increased visceral fat area >200 cm(2) was 87%, WCHR >0.65 was 25%, and WHR >1 was 54% All of these factors except sarcopenia were significant predictors of hyperglycemia >140 mg/dL (OR: 4.0, 95% CI: 2.53–6.46), (OR: 2.45, 95% CI: 1.47–4.16) and (OR: 3.1, 95% CI: 1.93–4.9) respectively. A total of 143 patients (45%) had an average glucose >140 mg/dL within the first 48 hours after admission and this was independently associated with infections (OR: 2.64, 95% CI: 1.06–7.13), stroke (OR: 5.88, 95% CI: 1.48–38.96), increased ICU LOS (OR: 1.87, 95% CI: 1.20–2.94) and increased hospital LOS (OR: 1.59, 95% CI: 1.02–2.48). CONCLUSIONS: Central obesity independently predicts hyperglycemia in geriatric trauma patients. The influence of metabolic stressors related to adiposity may drive elevated glucose levels and could represent a novel target for future outcomes studies in geriatric critical illness FUNDING SOURCES: None.

Background Institutional variation in outcome of patients with do-not-resuscitate (DNR) orders has not been well described in the setting of trauma. The purpose of this study was to assess the impact of trauma center designation on outcome of patients with DNR orders. Materials and methods A statewide trauma database (Pennsylvania Trauma Outcome Study) was used for the analysis. Characteristics of patients with DNR orders were compared between state-designated level 1 and 2 trauma centers. Inhospital mortality and major complication rates were compared using hierarchical logistic regression models that included a random effect for trauma centers. We adjusted for a number of potential confounders and allowed for nonlinearity in injury severity score and age in these models. Results A total of 106,291 patients (14 level 1 and 11 level 2 trauma centers) were identified in the Pennsylvania Trauma Outcome Study database between 2007 and 2011. We included 5953 patients with DNR orders (5.6%). Although more severely injured patients with comorbid disease were made DNR in level 1 trauma centers, trauma center designation level was not a significant factor for inhospital mortality of patients with DNR orders (odds ratio, 1.33; 95% confidence interval, 0.81–2.18; P = 0.26). Level 1 trauma centers were significantly associated with a higher rate of major complications (odds ratio, 1.75; 95% confidence interval, 1.11–2.75; P = 0.016). Conclusions Inhospital mortality of patients with DNR orders was not significantly associated with trauma designation level after adjusting for case mix. More aggressive treatment or other unknown factors may have resulted in a significantly higher complication rate at level 1 trauma centers.

Introduction: We hypothesized that critically ill medical patients would require less insulin when fed intermittently. Methods: First, 26 patients were randomized to receive intermittent or continuous gastric feeds. Once at goal nutrition, data were collected for the first 4-hr data collection period. Next, the enteral feed type was switched, goal nutrition was repeated, and a second 4-h data collection period was completed. The primary endpoint was the total amount of insulin infused; secondary endpoints were glucose concentration mean, maximum, minimum, and standard deviation, as well as episodes of hypoglycemia. Results: Sixteen of the 26 patients successfully completed the protocol. One patient experienced a large, rapid, and sustained decline in insulin requirement from liver failure, creating a bias of lesser insulin in the intermittent arm; this patient was removed from the analysis. For the remaining 15 patients, the average total amount of insulin infused was 1.4 U/patient/h less following intermittent feeds: P =0.027, 95% confidence interval (0.02, 11.17), and effect size 0.6. Secondary endpoints were statistically similar. Conclusions: Critically ill medical patients who require an insulin infusion have a reduced insulin requirement when fed intermittently, whereas dysglycemia metrics are not adversely affected. A larger clinical study is required to confirm these findings.

Intrapleural lytic therapy has been established as an important modality of treatment for many pleural disorders, including hemothorax and empyema. Retained traumatic hemothorax is a common and understudied subset of pleural disease. The current standard of care for retained traumatic hemothorax is operative management. The use of lytic therapy for avoidance of operative intervention in the trauma population has not been well established.Randomized controlled trials (RCTs) and non-RCTs reporting operative intervention following the use of intrapleural lytic treatment for retained traumatic hemothorax were identified in the literature. The primary outcome was avoidance of surgery following treatment with any lytic agent. Meta-analysis was performed to pool the results of those studies. Subgroup analysis by type of lytic therapy and analysis of length of stay were also performed.One RCT and nine non-RCTs including 162 patients were pooled in the analysis. Avoidance of surgery following treatment with any lytic agent was found to be 87% (95% CI, 81%-92%). Tissue plasminogen activator resulted in 83% operative avoidance (95% CI, 71%-94%), and other, non-tissue plasminogen activator lytic agents resulted in 87% operative avoidance (95% CI, 82%-93%). The average length of stay for patients undergoing lytic therapy was 14.88 days (95% CI, 12.88-16.88).Lytic therapy could reduce the need for operative intervention in trauma patients with retained traumatic hemothorax. RCTs are indicated to definitively evaluate the benefit of this approach.

Background: Optimal management of non–critically ill patients with diabetes maintained on continuous enteral feeding (CEN) is poorly defined. Subcutaneous (SQ) lispro and SQ regular insulin were compared in a simulated type 1 and type 2 diabetic patient receiving CEN. Method: A glucose-insulin feedback mathematical model was employed to simulate type 1 and type 2 diabetic patients on CEN. Each patient received 25 SQ injections of regular insulin or insulin lispro, ranging from 0-6 U. Primary endpoints were the change in mean glucose concentration (MGC) and change in glucose variability (GV); hypoglycemic episodes were also reported. The model was first validated against patient data. Results: Both SQ insulin preparations linearly decreased MGC, however, SQ regular insulin decreased GV whereas SQ lispro tended to increase GV. Hourly glucose concentration measurements were needed to capture the increase in GV. In the type 2 diabetic patient, “rebound hyperglycemia” occurred after SQ lispro was rapidly metabolized. Although neither SQ insulin preparation caused hypoglycemia, SQ lispro significantly lowered MGC compared to SQ regular insulin. Thus, it may be more likely to cause hypoglycemia. Analyses of the detailed glucose concentration versus time data suggest that the inferior performance of lispro resulted from its shorter duration of action. Finally, the effects of both insulin preparations persisted beyond their duration of actions in the type 2 diabetic patient. Conclusions: Subcutaneous regular insulin may be the short-acting insulin preparation of choice for this subset of diabetic patients. Clinical trial is required before a definitive recommendation can be made.

Increased glucose variability (GV) is an independent risk factor for mortality in the critically ill; unfortunately, the optimal insulin therapy that minimizes GV is not known. We simulate the glucose–insulin feedback system to study how stress hyperglycemia (SH) states, taken to be a non-uniform group of physiologic disorders with varying insulin resistance (IR) and similar levels of hyperglycemia, respond to the type and dose of subcutaneous (SQ) insulin. Two groups of 100 virtual patients are studied: those receiving and those not receiving continuous enteral feeds. Stress hyperglycemia was facilitated by doubling the gluconeogenesis rate and IR was stepwise varied from a borderline to a high value. Lispro and regular insulin were simulated with dosages that ranged from 0 to 6 units; the resulting GV was analyzed after each insulin injection. The numerical model used consists of a set of non-linear differential equations with two time delays and five adjustable parameters. The results show that regular insulin decreased GV in both patient groups and rarely caused hypoglycemia. With continuous enteral feeds and borderline to mild IR, Lispro showed minimal effect on GV; however, rebound hyperglycemia that increased GV occurred when the IR was moderate to high. Without a nutritional source, Lispro worsened GV through frequent hypoglycemia episodes as the injection dose increased. The inferior performance of Lispro is a result of its rapid absorption profile; half of its duration of action is similar to the glucose ultradian period. Clinical trials are needed to examine whether these numerical results represent the glucose–insulin dynamics that occur in intensive care units, and if such dynamics are present, their clinical effects should be evaluated.

Background The care of the critically ill trauma patients is provided by intensivists with various base specialties of training. The purpose of this study was to investigate the impact of intensivists’ base specialty of training on the disparity of care process and patient outcome. Methods We performed a retrospective review of an institutional trauma registry at an academic level 1 trauma center. Two intensive care unit teams staffed by either board-certified surgery or anesthesiology intensivists were assigned to manage critically ill trauma patients. Both teams provided care, collaborating with a trauma surgeon in house. We compared patient characteristics, care processes, and outcomes between surgery and anesthesiology groups using Wilcoxon tests or chi-square tests, as appropriate. Results We identified a total of 620 patients. Patient baseline characteristics including age, sex, transfer status, injury type, injury severity score, and Glasgow coma scale were similar between groups. We found no significant difference in care processes and outcomes between groups. In a logistic regression model, intensivists’ base specialty of training was not a significant factor for mortality (odds ratio, 1.46; 95% confidence interval; 0.79–2.80; P = 0.22) and major complication (odds ratio, 1.11; 95% confidence interval, 0.73–1.67; P = 0.63). Conclusions Intensive care unit teams collaborating with trauma surgeons had minimal disparity of care processes and similar patient outcomes regardless of intensivists’ base specialty of training.

Background Globally, the compliance of resident work-hour restrictions has no impact on trauma outcome. However, the effect of protected education time (PET), during which residents are unavailable to respond to trauma patients, has not been studied. We hypothesized that PET has no impact on the outcome of trauma patients. Methods We conducted a retrospective review of relevant patients at an academic level I trauma center. During PET, a trauma attending and advanced practice providers (APPs) responded to trauma activations. PGY1, 3, and 4 residents were also available at all other times. The outcome of new trauma patient activations during Thursday morning 3-hours resident PET was compared with same time period on other weekdays (non-PET) using a univariate and multivariate analysis. Results From January 2005 to April 2010, a total of 5968 trauma patients were entered in the registry. Of these, 178 patients (2.98%) were included for study (37 PET and 141 non-PET). The mean injury severity score (ISS) was 16.2. Although no significant difference were identified in mortality, complications, or length of stay (LOS), we do see that length of emergency department stay (ED-LOS) tends to be longer during PET, although not significantly (314 vs 381 minutes, p = 0.74). On the multiple logistic regression model, PET was not a significant factor of complications, LOS, or ED-LOS. Conclusions Few trauma activations occur during PET. New trauma activations can be staffed safely by trauma activations and APPs. However, there could be some delays in transferring patients to appropriate disposition. Additional study is required to determine the effect of PET on existing trauma inpatients.

Placement of prophylactic inferior vena cava filters (pIVCFs) for the prevention of pulmonary embolism (PE) in high-risk trauma patients (HRTPs) are widely practiced despite the lack of Level I data supporting this use. We report the 2-year interim analysis of the Filters in Trauma pilot study.This is a single institution, prospective randomized controlled pilot feasibility study in a Level I trauma center. HRTPs were identified for pIVCF placement by the Eastern Association for the Surgery of Trauma guidelines. From November 2008 to November 2010, HRTPs were enrolled and randomized to either pIVCF or no pIVCF. All patients received pharmacologic prophylaxis when safe. Primary outcomes included feasibility objectives and secondary outcomes were incidence of PE, deep vein thrombosis (DVT), and death.Thirty-four of 38 enrolled patients were eligible for analysis. The baseline sociodemographic characteristics were balanced between the both groups. Results of the feasibility objectives included: time from admission to enrollment (mean, 47.4 hours ± 22.0 hours), time from enrollment to randomization (mean, 4.8 hours ± 9.1 hours), time from randomization to IVCF placement (mean, 16.9 hours ± 9.2 hours), adherence to weekly compression ultrasound within first month (IVCF group = 44.4%; non-IVCF group = 62.5%), and 1-month clinical follow-up (IVCF group = 83.3%; non-IVCF group = 100%). At 6-month follow-up, one PE in the nonfilter group and one DVT in the filter group had occurred. One non-PE-related death occurred in the filter group. Barriers to enrollment included inability to obtain informed consent due to patient refusal or no next of kin identified and delayed notification of eligibility status.Our pilot study demonstrates for the first time that a randomized controlled trial evaluating the efficacy of pIVCFs in trauma patients is feasible. This pilot data will be used to inform the design of a multicenter randomized controlled trial to determine the incidence of PE and DVT in HRTPs receiving pIVCFs versus no pIVCF.

Background: Nonoperative management (NOM) of blunt splenic injuries (BSIs) has been used with increasing frequency in adult patients. There are currently no definitive guidelines established for how long BSI patients should be monitored for failure of NOM after injury. Methods: This study was performed to ascertain the length of inpatient observation needed to capture most failures, and to identify factors associated with failure of NOM. We utilized the National Trauma Data Bank to determine time to failure after BSI. Results: During the 5-year study period, 23,532 patients were identified with BSI, of which 2,366 (10% overall) were taken directly to surgery (within 2 hours of arrival). Of 21,166 patients initially managed nonoperatively, 18,506 were successful (79% of all-comers). Patients with isolated BSI are currently monitored ∼5 days as inpatients. Of patients failing NOM, 95% failed during the first 72 hours, and monitoring 2 additional days saw only 1.5% more failures. Factors influencing success of NOM included computed tomographic injury grade, severity of patient injury, and American College of Surgeons designation of trauma center. Importantly, patients who failed NOM did not seem to have detrimental outcomes when compared with patients with successful NOM. No statistically significant predictive variables could be identified that would help predict patients who would go on to fail NOM. Conclusions: We conclude that at least 80% of BSI can be managed successfully with NOM, and that patients should be monitored as inpatients for failure after BSI for 3 to 5 days.

Sepsis mortality may be improved by early recognition and appropriate treatment based on evidence-based guidelines. An intervention was developed that focused on earlier identification of sepsis, early antimicrobial administration, and an educational program that was disseminated throughout all hospital units and services. There were 1331 patients with sepsis during the intervention period and 1401 patients with sepsis during the control period. After controlling for expected mortality, patients in the intervention period had 30% lower odds of dying (odds ratio = 0.70, 95% confidence interval [CI] = 0.57 to 0.84). They also had 1.07 fewer days on average in the intensive care unit (95% CI = -1.98 to -0.16), 2.15 fewer hospital days (95% CI = -3.45 to -0.86), and incurred on average $1949 less in hospital costs, although the effect on costs was not statistically significant. Continued incremental improvement and sustainment is anticipated through organizational oversight, continued education, and initiation of an automated electronic sepsis alert function.

Increasing attention has been directed towards operative rib fixation of traumatic flail chest; reported benefits include more rapid weaning from the ventilator, decreased intensive care unit stays, decreased complications and improved functional results. The outcomes of this surgical intervention in patients with osteogenesis imperfecta, a rare condition characterized by low bone density and bone fragility, are unknown. This case demonstrates that, in the management of traumatic flail chest in a patient with osteogenesis imperfecta, surgical fixation can be successful and should be considered early.

Importance In trauma populations, improvements in outcome are documented in institutions with higher case volumes. However, it is not known whether improved outcomes are attributable to the case volume within specific higher-risk groups, such as the elderly, or to the case volume among all trauma patients treated by an institution. Objective To test the hypothesis that outcomes of trauma care for geriatric patients are affected differently by the volume of geriatric cases and nongeriatric cases of an institution. Design, Setting, and Participants This retrospective cohort study using a statewide trauma registry was set in state-designated levels 1 and 2 trauma centers in Pennsylvania. It included 39 431 eligible geriatric trauma patients (aged >65 years) in the Pennsylvania Trauma Outcomes Study. Main Outcomes and Measures In-hospital mortality, major complications, and mortality after major complications (failure to rescue). Results Between 2001 and 2010, 39 431 geriatric trauma patients and 105 046 nongeriatric patients were captured in a review of outcomes in 20 state-designated levels 1 and 2 trauma centers. Larger volumes of geriatric trauma patients were significantly associated with lower odds of in-hospital mortality, major complications, and failure to rescue. In contrast, larger nongeriatric trauma volumes were significantly associated with higher odds of major complications in geriatric patients. Conclusions and Relevance Higher rates of in-hospital mortality, major complications, and failure to rescue were associated with lower volumes of geriatric trauma care and paradoxically with higher volumes of trauma care for younger patients. These findings offer the possibility that outcomes might be improved with differentiated pathways of care for geriatric trauma patients.

During the course of the last 30 years, several authors have contributed their clinical experience to the literature in an effort to describe the various management strategies for the appropriate use of the open abdomen technique. There remains a great degree of heterogeneity in the patient population, and the surgical techniques described. The open abdomen technique has been used in both military and civilian trauma and vascular and general surgery emergencies. Given the lack of consistent practice, the Eastern Association for the Surgery of Trauma (EAST) Practice Management Guidelines Committee convened a study group to establish recommendations for the use of open abdomen techniques in both trauma and nontrauma surgery. This has been a major undertaking and has been divided into two parts. The EAST practice management guidelines for the open abdomen part 1 “Damage Control” have been published.1 During the development of the open abdomen part II “Management of the Open Abdomen,” the current literature remains contentious at best, current methods of treatment continue to change rapidly, and patient populations are so heterogeneous that clear recommendations could not be provided. What follows is a thorough review of the current literature for the management of the open abdomen: part 2 “Management of the Open Abdomen” and provides clinical direction regarding the following specific topics.

To efficiently capture evaluation and management (EM) and procedural billing in our surgical intensive care unit (SICU), we have developed an electronic billing system that links to the electronic medical record (EMR). In this system, only notes electronically signed and coded by an attending generate billing charges. We hypothesized that capture of missed billing during nighttime and weekends might be sufficient to subsidize 24/7 in-house attending coverage.A retrospective chart EMR review was performed of the EMRs for all SICU patients during a 2-month period. Note type, date, time, attending signature, and coding were analyzed. Notes without attending signature, diagnosis, or current procedural terminology (CPT) code were considered incomplete and identified as "missed billing."Four hundred and forty-three patients had 465 admissions generating 2,896 notes. Overall, 76% of notes were signed and coded by an attending and billed. Incomplete (not billed) notes represented an overall missed billing opportunity of $159,138 for the 2-month time period (approximately $954,000 annually). Unbilled EM encounters during weekdays totaled $54,758, whereas unbilled EM and procedures from weeknights and weekends totaled $88,408 ($44,566 and $43,842, respectively). Missed billing after-hours thus represents approximately $530K annually, extrapolating to approximately $220K in collections from our payer mix. Surprisingly, missed EM and procedural billing during weekdays totaled $70,730 (approximately $425K billing, approximately $170K collections annually), and typically represented patients seen, but transferred from the SICU before attending documentation was completed.Capture of nighttime and weekend ICU collections alone may be insufficient to add faculty or incentivize in-house coverage, but could certainly complement other in-house derived revenues to such ends. In addition, missed daytime billing in busy modern ICUs can be substantial, and use of an EMR to identify missed billing opportunities can help create solutions to recover these revenues.

Objective Our primary concern when modifying the Mount Carmel Medical Center surgical residency to comply with the “80-hour work week” was the effect on operative experience. Our goal was to measure the impact that work-hour restrictions have on operative volumes and to evaluate the potential benefit of a night rotation to minimize the number of “lost operations.” Design Categorical surgical residents (PGY I-IV) recorded missed surgical procedures on post-call days from September 1, 2002 to March 31, 2004. The data collection is split between the pre-night rotation (September 1, 2002 to March 31, 2003) and post-night rotation (April 1, 2003 to March 31, 2004) periods. The post-night rotation period is further divided to account for the end of the academic year. Previous graduate operative logs were reviewed for comparison. Setting Mount Carmel Health System is a tertiary referral, community-based hospital in Columbus, Ohio. Participants Categorical general surgery residents (Postgraduate Years I to V). Results In the 7-month period, extending from September 1, 2002 to March 31, 2003, the average number of missed cases for successive levels was PGY I: 21, PGY II: 31, PGY III: 26, and PGY IV: 40. From April 1, 2003 to June 30, 2003, the average number of missed cases for successive levels was PGY I: 3, PGY II: 7, PGY III: 5, and PGY IV: 6. From July 1, 2003 to March 31, 2004, the average number of missed cases for successive levels was PGY I: 34, PGY II: 8, PGY III: 14, and PGY IV: 30. Before the implementation of a night rotation, residents were projected to miss an average of 202 operations over 4 years. After implementation of a night rotation, the projected loss would drop to 107 operations over 4 years. Conclusions Work-hour restrictions result in a significant decrease in operative experience. This detriment can be partially alleviated with the institution of a night rotation to better regulate in-house call.

Background The critically ill can have persistent dysglycemia during the “subacute” recovery phase of their illness because of altered gene expression; it is also not uncommon for these patients to receive continuous enteral nutrition during this time. The optimal short-acting subcutaneous insulin therapy that should be used in this clinical scenario, however, is unknown. Our aim was to conduct a qualitative numerical study of the glucose-insulin dynamics within this patient population to answer the above question. This analysis may help clinicians design a relevant clinical trial. Methods Eight virtual patients with stress hyperglycemia were simulated by means of a mathematical model. Each virtual patient had a different combination of insulin resistance and insulin deficiency that defined their unique stress hyperglycemia state; the rate of gluconeogenesis was also doubled. The patients received 25 injections of subcutaneous regular or Lispro insulin (0-6 U) with 3 rates of continuous nutrition. The main outcome measurements were the change in mean glucose concentration, the change in glucose variability, and hypoglycemic episodes. These end points were interpreted by how the ultradian oscillations of glucose concentration were affected by each insulin preparation. Results Subcutaneous regular insulin lowered both mean glucose concentrations and glucose variability in a linear fashion. No hypoglycemic episodes were noted. Although subcutaneous Lispro insulin lowered mean glucose concentrations, glucose variability increased in a nonlinear fashion. In patients with high insulin resistance and nutrition at goal, “rebound hyperglycemia” was noted after the insulin analog was rapidly metabolized. When the nutritional source was removed, hypoglycemia tended to occur at higher Lispro insulin doses. Finally, patients with severe insulin resistance seemed the most sensitive to insulin concentration changes. Conclusions Subcutaneous regular insulin consistently lowered mean glucose concentrations and glucose variability; its linear dose-response curve rendered the preparation better suited for a sliding-scale protocol. The longer duration of action of subcutaneous regular insulin resulted in better glycemic-control metrics for patients who were continuously postprandial. Clinical trials are needed to examine whether these numerical results represent the glucose-insulin dynamics that occur in intensive care units; if present, their clinical effects should be evaluated.