Transdiaphragmatic intercostal herniation in the setting of trauma.

Transdiaphragmatic intercostal herniation is a rare injury that can be associated with blunt trauma. Since its first documentation within the literature in 1946, there have been less than 50 cases reported. We present a case involving a 56-year old female who presented to our Trauma Center with transdiaphragmatic intercostal herniation caused by blunt trauma from a high-velocity T-bone vehicular collision. Upon presentation, she exhibited bilateral breath sounds; however, with labored breathing, chest pain, and hypoxia. The initial chest radiograph interpretation indicated the presence of "left lower lobe infiltrates", and subsequent computed tomography imaging identified "a small lateral hernia along the left mid abdomen". After initial resuscitation, her condition deteriorated, exhibiting respiratory distress and becoming increasingly hypercarbic, requiring intubation. Review of the imaging showed disruption of the left hemidiaphragm with intrathoracic herniation of colon and stomach through the thoracic wall between the ninth and tenth ribs. Consequently, a thoracotomy was performed in the operating room, revealing a large defect between the two ribs with disruption of the intercostal muscles and inferior displacement of rib space. Lung and omentum had herniated through the disrupted rib space and the diaphragmatic rupture was attenuated anteriorly, measuring 11x6cm. After reduction of the herniated organs, a biologic porcine mesh was placed and an intermediate complex closure of the thoracic wall hernia was performed. The patient was later extubated, recovered from her injuries with no complications and was discharged. With the low incidence of transdiaphragmatic intercostal herniation, there is no standardized surgical management. Recent literature suggests that these injuries should be managed with mesh, rather than sutures only, due to high rates of recurrence. Furthermore, diaphragmatic injuries may suffer a delay in diagnosis. Therefore, a high index of suspicion should be maintained in patients with respiratory distress following a blunt trauma, with close review of computed tomography.

Early Versus Late Feeding After Percutaneous Endoscopic Gastrostomy Placement in Trauma and Burn.

INTRODUCTION: Timing to resume feeds after percutaneous endoscopic gastrostomy (PEG) placement continues to vary among US trauma surgeons. The purpose of this study was to assess differences in meeting nutritional therapy goals and adverse outcomes with early versus late enteral feeding after PEG placement. METHODS: This retrospective review included 364 trauma and burn patients who underwent PEG placement. Data included patient characteristics, time to initiate feeds, rate feeds were resumed, % feed volume goals on postoperative days 0-7, and complications. Statistical analysis was performed comparing two groups (feeds ≤ 6 h versus > 6 h) and three subgroups (< 4 h, 4-6 h, ≥ 6 h) based on data quartiles. Chi-square/Fisher's exact test, independent-samples t-test, and one-way analysis of variance were used to analyze the data. RESULTS: Mean time to initiate feeds after PEG was 5.48 ± 4.79 h. Burn patients received early feeds in a larger proportion. A larger proportion of trauma patients received late feeds. The mean % of goal feed volume met on postoperative day 0 was higher in the early feeding group versus the late (P < 0.001). There were no differences in adverse events, even after subgroup analysis of those who received feeds < 4 h after PEG placement. CONCLUSIONS: Patients with early initiation of feeds after PEG placement achieve a higher percentage of goals on day 0 without an increased rate of adverse events. Unfortunately, patients routinely fall short of their target tube feeding goals.

Shot through the heart: A 17-year analysis of pre-hospital and hospital deaths from penetrating cardiac injuries.

BACKGROUND: Penetrating cardiac injuries (PCI) are often fatal despite rapid transport and treatment in the prehospital setting. Although many studies have identified risk factors for mortality, few studies have included non-transported field mortalities. This study analyzes penetrating cardiac injuries including hospital and coroner reports in the current era. METHODS: Seventeen years of data were reviewed, including the trauma center (TC) registry, medical records, and coroner reports from 2000-2016. PCI were graded using American Association for the Surgery of Trauma (AAST) cardiac organ injury score (COIS). Subjects were divided into three groups: field deaths, hospital deaths, and survivors to hospital discharge. The primary outcome is survival to hospital discharge overall and among those transported to the hospital. RESULTS: During the study period, 643 PCI patients were identified, with 52 excluded for inadequate data, leaving 591 for analysis. Mean age was 38.1 ± 17.5 years, and survivors (n=66) were significantly younger than field deaths (n=359) (32.6 ± 14.4 vs 41.1 ± 18.5, p<0.001). Stab wounds had higher survival than gunshot wounds (26.6% vs. 4.3%, p<0.001). COIS grades 4 to 6 (n=602) had lower survival than grades 1 to 3 (n=41) (8.3% vs. 39.0%, p<0.001). Survivors (n=66) had lower median COIS than patients who died in hospital (n=218) (4 vs. 5, p<0.001). Single chamber PCI had higher survival than multiple chamber PCI (13% vs. 5%, p=0.004).  The left ventricle is the most injured (n=177), and right ventricle PCI has the highest survival (p<0.001).  Of field deaths, left ventricular injuries had the highest single chamber mortality (60%), equaling multi-chamber PCI (60%). CONCLUSIONS: Survival to both TC evaluation and hospital discharge following PCI is influenced by many factors including age, mechanism, anatomic site, and grade. Despite advances in trauma care, survival has not appreciably improved.

Temperature Profiles of Sunlight-Exposed Surfaces in a Desert Climate: Determining the Risk for Pavement Burns.

Plentiful sunlight and high temperatures in desert climates cause burn injuries from contact with sun-exposed surfaces. The peak temperature, times, and surfaces of greatest risk are not well described. This work recorded temperature measurements of six materials in a desert climate. Surface temperatures of asphalt, brick, concrete, sand, porous rock, and galvanized metal were measured throughout the summer, along with ambient temperature, and sunlight intensity. Samples were placed in both shade and direct sunlight for evaluation of sunlight effect. Seventy-five thousand individual measurements were obtained from March to August 2020. Maximum recorded temperatures for sunlight-exposed porous rock were 170°F, asphalt 166°F, brick 152°F, concrete 144°F, metal 144°F, and sand 143°F, measured on August 6, 2020 at 2:10 pm, when ambient temperature was 120°F and solar irradiation 940 W/m2. Sunlight-exposed materials ranged 36 to 56°F higher than shaded materials measured at the same time. The highest daily temperatures were achieved between 2:00 and 4:00 pm due to maximum solar irradiance. Contour plots of surface temperature as a function of both solar irradiation and time of day were created for all materials tested. A computational fluid dynamics model was created to validate the data and serve as a predictive model based upon temperature and sunlight inputs. This information is useful to inform the public of the risks of contact burn due to sunlight-exposed surfaces in a desert climate.

A Pediatric Cervical Spine Clearance Guideline Leads to Fewer Unnecessary Computed Tomography Scans and Decreased Radiation Exposure.

OBJECTIVES: Physical examination and computed tomography (CT) are useful to rule out cervical spine injury (CSI). Computed tomography scans increase lifetime cancer risk in children from radiation exposure. Most CSI in children occur between the occiput and C4. We developed a cervical spine (C-spine) clearance guideline to reduce unnecessary CTs and radiation exposure in pediatric trauma patients. METHODS: A pediatric C-spine clearance guideline was implemented in September 2018 at our Level 2 Pediatric Trauma Center. Guidance included CT of C1 to C4 to scan only high-yield regions versus the entire C-spine and decrease radiation dose. A retrospective cohort study was conducted comparing preguideline and postguideline of all pediatric trauma patients younger than 8 years screened for CSI from July 2017 to December 2020. Primary endpoints included the following: number of full C-spine and C1 to C4 CT scans and radiation dose. Secondary endpoints were CSI rate and missed CSI. Results were compared using χ 2 and Wilcoxon rank-sum test with P < 0.05 significant. RESULTS: The review identified 726 patients: 273 preguideline and 453 postguideline. A similar rate of total C-spine CTs were done in both groups (23.1% vs 23.4%, P = 0.92). Full C-spine CTs were more common preguideline (22.7% vs 11.9%, P < 0.001), whereas C1 to C4 CT scans were more common post-guideline (11.5% vs 0.4%, P < 0.001). Magnetic resonance imaging utilization and CSIs identified were similar in both groups. The average radiation dose was lower postguideline (114 vs 265 mGy·cm -1 ; P < 0.001). There were no missed CSI. CONCLUSIONS: A pediatric C-spine clearance guideline led to increasing CT of C1 to C4 over full C-spine imaging, reducing the radiation dose in children. LEVEL OF EVIDENCE: Level IV, therapeutic.

Higher risk of auto versus pedestrian crashes in school-age children on school days.

BACKGROUND: This study examines the rates of pediatric auto versus pedestrian collision (APCs) and determined ages and periods of greatest risk. We hypothesized that the rate of APC in children would be higher on school days and in the timeframes correlating with travel to and from school. METHODS: Retrospective case-control study of APC on school and nonschool days for patients younger than 18 years at an urban Level II pediatric trauma center from January 2011 to November 2019. Frequency of APC by hour of the day was plotted overall, for school versus nonschool days and for age groups: 0 year to 4 years, 5 years to 9 years, 10 years to 13 years, and 14 years to 17 years. t Test was used with a p value less than 0.05, which was considered significant. RESULTS: There were 441 pediatric APC in the study period. Frequency of all APC was greater on school days (0.174 vs. 0.101; relative risk [RR], 1.72, p < 0.001), and APC with Injury Severity Score greater than 15 (0.039 vs. 0.024; p = 0.014; RR, 1.67; 95% confidence interval, 1.10-2.56). Comparing school day with nonschool day, the 0-year to 4-year group had no significant difference in APC frequency (0.021 vs. 0.014; p = 0.129), APC frequency was higher on school days in all other age groups: 5 years to 9 years (0.036 vs. 0.019; RR, 1.89; p = 0.0134), 10 years to 13 years (0.055 vs. 0.024; RR, 2.29; p < 0.001), and 14 years to 17 years (0.061 vs. 0.044; RR, 1.39; p = 0.045). The greatest increase in APC on school days was in the 10-year to 13-year age group. DISCUSSION: All school age children are at higher risk of APC on school days. The data support our hypothesis that children are at higher risk of APC during transit to and from school. The age 10-year to 13-year group had a 129% increase in APC frequency on school days. This age group should be a focus of injury prevention efforts. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level IV.

The Volume of Thoracic Irrigation Is Associated With Length of Stay in Patients With Traumatic Hemothorax.

INTRODUCTION: Irrigation of the thoracic cavity at tube thoracostomy (TT) placement may decrease the rate of a retained hemothorax (RHTX); however, other resource utilization outcomes have not yet been quantified. This study evaluated the association of thoracic irrigation during TT with the length of stay and outcomes in patients with traumatic hemothorax (HTX). METHODS: A retrospective chart review was performed of adult patients receiving a TT for HTX at a single, urban Level 1 Trauma Center from January 2019 to December 2020. Those who underwent irrigation during TT at the discretion of the trauma surgeon were compared to a control of standard TT without irrigation. Death within 30 d, as well as TTs, placed at outside hospitals, during traumatic arrest or thoracic procedures, and for isolated pneumothoraces were excluded. The primary outcome was the length of stay as hospital-free, ICU-free, and ventilator-free days (30-day benchmark). Subgroup analysis by irrigation volume was conducted using one-way ANOVA testing with P < 0.05 considered statistically significant. RESULTS: Eighty-two (41.4%) of 198 patients underwent irrigation during TT placement. Secondary interventions, thoracic infections, and TT duration were not statistically different in the irrigated cohort. Hospital-free and ICU-free days were higher in the irrigated patients than in the controls. Groups irrigated with ≥1000 mL had significant more hospital-free days (P = 0.007) than those receiving less than 1000 mL. CONCLUSIONS: Patients with traumatic HTX who underwent thoracic irrigation at the time of TT placement had decreased hospital and ICU days compared to standard TT placement alone. Specifically, our study demonstrated that patients irrigated with a volume of at least 1000 mL had greater hospital-free days compared to those irrigated with less than 1000 mL.

When Is It Safe to Feed After Surgical Feeding Tube Placement? A Survey of EAST Members.

INTRODUCTION: Many critically ill trauma and surgical patients require nutritional support. Patients needing long-term enteral access often undergo placement of surgical feeding tubes, including percutaneous endoscopic gastrostomy tube, laparoscopic gastrostomy tube, and open gastrostomy tube. This study was performed to determine national practice patterns for feeding after feeding tube placement. METHODS: A 16-question online survey was administered to members of the Eastern Association for the Surgery of Trauma via Qualtrics about feeding practices after placement of the feeding tube. Questions included demographics, training, current practice, annual procedural volume, timing to resume feeds: <2, 6, 12, or 24 h, methods to advance feeds, and reasons behind management decisions. For comparison, responses were grouped into "early" (≤6 h) and "late" (18-24 h) groups. The chi-square test was used, and P < 0.05 was significant. RESULTS: Five hundred sixteen Eastern Association for the Surgery of Trauma members completed the survey. Most (95%) respondents worked at a level 1 or 2 trauma center, and 68% are in academic practice. The most common feeding tube placement was percutaneous endoscopic gastrostomy (median = 25/y, interquartile range = 15-40). Responses showed variability in timing of when feeds were resumed after procedure. Early feeding was not affected by age (≤42 y), trauma center designation, volume, or training programs at the respondent's hospital. Graduates of surgical critical care fellowship were less likely to feed early (P = 0.043). CONCLUSIONS: There is wide variability in feeding practices after surgical feeding tube placement. Given the large quantity of procedures performed, a randomized controlled trial should be performed to determine the optimal timing to resume feeds in critically ill patients.

Evaluating Long-Term Outcomes of a High School-Based Impaired and Distracted Driving Prevention Program.

Motor vehicle crashes are one of the leading causes of death among teenagers. Many of these deaths are due to preventable causes, including impaired and distracted driving. You Drink, You Drive, You Lose (YDYDYL) is a prevention program to educate high school students about the consequences of impaired and distracted driving. YDYDYL was conducted at a public high school in Southern Nevada in March 2020. A secondary data analysis was conducted to compare knowledge and attitudes of previous participants with first-time participants. Independent-samples-t test and χ2 test/Fisher's exact test with post-contingency analysis were used to compare pre-event responses between students who had attended the program one year prior and students who had not. Significance was set at p < 0.05. A total of 349 students participated in the survey and were included for analysis; 177 had attended the program previously (50.7%) and 172 had not (49.3%). The mean age of previous participants and first-time participants was 16.2 (SD ± 1.06 years) and 14.9 (SD ± 0.92 years), respectively. Statistically significant differences in several self-reported baseline behaviors and attitudinal responses were found between the two groups; for example, 47.4% of previous participants compared to 29.4% of first-time participants disagreed that reading text messages only at a stop light was acceptable. Students were also asked how likely they were to intervene if a friend or family member was practicing unsafe driving behaviors; responses were similar between the two groups. The baseline behaviors and attitudes of participants regarding impaired and distracted driving were more protective among previous participants compared to first-time participants, suggesting the program results in long-term positive changes in behaviors and attitudes. The results of this secondary retrospective study may be useful for informing the implementation of future impaired and distracted driving prevention programs.

Skilled maneuvering: Evaluation of a young driver advanced training program.

BACKGROUND: Young drivers (YDs) are disproportionately injured and killed in motor vehicle crashes throughout the United States. Nationally, YDs aged 16 to 20 years constituted nearly 9% of all traffic-related fatalities in 2018. A Nevada Advanced Driver Training (ADT) program for YDs aims to reduce YD traffic injuries and fatalities through four modules taught by professional drivers. The program modules include classroom-based didactic lessons and hands-on driving exercises intended to improve safe driving knowledge and behaviors. The overarching purpose of this study was to determine if the Nevada ADT program achieved its objectives for improving safe driving knowledge and behaviors based on program-provided data. A secondary purpose of this study was to provide recommendations to improve program efficiency, delivery, and evaluation. The findings of this study would serve as a basis to develop and evaluate future ADT interventions. METHODS: The exploratory mixed methods outcome evaluation used secondary data collected during three weekend events in December 2018 and March 2019. The study population consisted of high school students with a driver's license or learner's permit. Pretests/posttests and preevent questionnaires on student driving history were matched and linked via personal identifiers. The pretests/posttests measured changes in knowledge of safe driving behaviors. This study used descriptive statistics, dependent samples t test, Pearson's r correlation coefficient, and χ2 (McNemar's test) with significance set at p = 0.05, 95% confidence interval. Statistical analysis was conducted using IBM SPSS version 24 (Armonk, NY). Qualitative data analysis consisted of content and thematic analysis. RESULTS: Responses from YD participants (N = 649) were provided for analysis. Aggregate YD participant knowledge of safe driving behaviors increased from a mean of 43.9% (pretest) to 74.9% (posttest). CONCLUSION: The program achieved its intended outcomes of improving safe driving knowledge and behaviors among its target population. LEVEL OF EVIDENCE: Prognostic/Epidemiologic, Level V.

Pediatric Trauma Arrival Times and the Swing Shift.

BACKGROUND: Trauma center staff and trainees are often assigned to a day and night shift. However, for adult trauma, the swing shift has been found to offer superior clinical exposure compared with a standard day or night shift for trainees. We characterized patterns in pediatric trauma arrival times based on the hour, weekday, and month and studied whether or not the swing shift also maximizes exposure to hands-on experiences in managing pediatric trauma. METHODS: We performed a retrospective review of the trauma database at our urban, level 2 pediatric trauma center. We identified all the pediatric trauma activations in the last 13 years (2006-2018). A retrospective shift log was created, which included day (7:00 am to 7:00 pm), night (7:00 pm to 7:00 am), and swing (noon to midnight) shifts. The shifts were compared using the Wilcoxon match-pairs signed rank test. Weekends data were also compared with weekdays, and comparisons were also made for pediatric patients with Injury Severity Scores (ISS) >15. RESULTS: There were 3532 pediatric patients identified for our study. The swing shift had 1.98 times more activations than the night shift, and 1.33 more than the day shift (P < 0.001). The swing shift was also superior to both the day and night shifts for exposure to patients with Injury Severity Score greater than 15 (P < 0.001). Weekend days had 1.28 times more trauma than the weekdays (P < 0.001). Peak arrival time was between the hours of 3:00 pm and 9:00 pm, and patient age did not have an effect on this trend. CONCLUSIONS: Experience in managing pediatric trauma patients will improve for trainees who utilize the swing shift. In addition, the hours between 3:00 pm and 9:00 pm on weekends may represent a time of particularly high likelihood of pediatric trauma arrivals, which may require extra staff and hospital resources.Level of Evidence: Therapeutic Study, Level IV.

Early feeding after percutaneous endoscopic gastrostomy tube placement in patients who require trauma and surgical intensive care: A retrospective cohort study.

BACKGROUND: Critically ill patients experience interruptions in enteral nutrition (EN). For ventilated patients who undergo percutaneous endoscopic gastrostomy (PEG) tube placement, postprocedure fasting times vary from 1 to 24 h depending on the surgeon's preference. There is no evidence to support delayed feeding (DF) after PEG placement. This study's purpose was to determine if there is an increased complication rate associated with early feeding (EF) after PEG. METHODS: 150 adult ventilated patients in the trauma and surgical intensive care unit (TSICU) at a level I trauma center underwent PEG placement in March 2015 through May 2018 by one of six surgical intensivists. Retrospective review revealed variable post-PEG fasting practices: one started EN at 1 h, two started at 4 h, two started at 6 h, and one started at 24 h. Time to initiation of EN and complication rates were assessed. Patients were divided into EF (<4) and DF (≥4 h) groups. RESULTS: Median postprocedure fasting time was 5.5 h. The overall complication rate was 3.3%, with a feeding intolerance rate of 0.7% and aspiration rate of 0%. There was no difference in complication rate for EF (3.1%) as compared with DF (3.4%) (odds ratio, 0.92; 95% CI, 0.10-8.52; P = 0.7). CONCLUSION: Complication rates following PEG placement in ventilated TSICU patients are low and do not change with EF compared with DF. EF is probably safe.

Electronic Cigarette-Related Injuries Presenting to Five Large Burn Centers, 2015-2019.

Electronic cigarettes are advertised as safer alternatives to traditional cigarettes yet cause serious injury. U.S. burn centers have witnessed a rise in both inpatient and outpatient visits to treat thermal injuries related to their use. A multicenter retrospective chart review of American Burn Association burn registry data from five large burn centers was performed from January 2015 to July 2019 to identify patients with electronic cigarette-related injuries. A total of 127 patients were identified. Most sustained less than 10% total body surface area burns (mean 3.8%). Sixty-six percent sustained second-degree burns. Most patients (78%) were injured while using their device. Eighteen percent of patients reported spontaneous device combustion. Two patients were injured while changing their device battery, and two were injured modifying their device. Three percent were injured by secondhand mechanism. Burn injury was the most common injury pattern (100%), followed by blast injury (3.93%). Flame burns were the most common (70%) type of thermal injury; however, most patients sustained a combination-type injury secondary to multiple burn mechanisms. The most injured body region was the extremities. Silver sulfadiazine was the most common agent used in the initial management of thermal injuries. Sixty-three percent of patients did not require surgery. Of the 36% requiring surgery, 43.4% required skin grafting. Multiple surgeries were uncommon. Our data recognize electronic cigarette use as a public health problem with the potential to cause thermal injury and secondary trauma. Most patients are treated on an inpatient basis although most patients treated on an outpatient basis have good outcomes.

Are Self-Inflicted Stab Wounds Less Severe Than Assaults? Analysis of Injury and Severity by Intent.

BACKGROUND: Although there is evidence that self-inflicted abdominal stab wounds are less severe than those from assault, it is unclear if this is true in other anatomic regions. This study compares severity and injury pattern between self-inflicted stab wounds (SISWs) and wounds from assault (ASW). MATERIALS AND METHODS: Stab wounds from our level I trauma registry from 2013 to 2018 were reviewed. Data included age, gender, self-inflicted versus assault, psychiatric or substance use history, anatomic location, operative intervention, injury severity, length of stay, and outcomes. RESULTS: Over the study period, 1390 patients were identified. History of psychiatric diagnoses or previous suicide attempts was more frequent in SISWs (47% versus 6.5%, P < 0.01; 35% versus 0.4%, P < 0.01). SISWs had a higher incidence of wounds to the neck and abdomen (44% versus 11%, P < 0.01; and 34% versus 26%, P = 0.02). Overall, injuries from ASW had a higher injury severity score, but more procedures were performed on SISWs (46% versus 34%, P < 0.01). SISWs to the neck were more likely to undergo procedures (26% versus 15%, P = 0.04). Median hospital charges were higher in patients with SISWs ($58.6 K versus $39.4 K, P < 0.01). CONCLUSIONS: SISWs have a distinct pattern of injuries, more commonly to the neck and abdomen, when compared with injuries resulting from ASW. The patients with SISWs have a higher rate of procedures, longer length of stay, and higher hospital charges despite low injury severity overall.

Characteristics of survivors of civilian public mass shootings: An Eastern Association for the Surgery of Trauma multicenter study.

BACKGROUND: Firearm injury remains a public health crisis. Whereas there have been studies evaluating causes of death in victims of civilian public mass shootings (CPMSs), there are no large studies evaluating injuries sustained and treatments rendered in survivors. The purpose of this study was to describe these characteristics to inform ideal preparation for these events. METHODS: A multicenter, retrospective study of CPMS survivors who were treated at designated trauma centers from July 1, 1999 to December 31, 2017, was performed. Prehospital and hospital variables were collected. Data are reported as median (25th percentile, 75th percentile interquartile range), and statistical analyses were carried out using Mann-Whitney U, χ2, and Kruskal-Wallis tests. Patients who died before discharge from the hospital were excluded. RESULTS: Thirty-one events involving 191 patients were studied. The median number of patients seen per event was 20 (5, 106), distance to each hospital was 6 (6, 10) miles, time to arrival was 56 (37, 90) minutes, number of wounds per patient was 1 (1, 2), and Injury Severity Score was 5 (1, 17). The most common injuries were extremity fracture (37%) and lung parenchyma (14%). Twenty-nine percent of patients did not receive paramedic-level prehospital treatment. Following arrival to the hospital, 27% were discharged from the emergency department, 32% were taken directly to the operating room/interventional radiology, 16% were admitted to the intensive care unit, and 25% were admitted to the ward. Forty percent did not require advanced treatment within 12 hours. The most common operations performed within 12 hours of arrival were orthopedic (15%) and laparotomy (15%). The most common specialties consulted were orthopedics (38%) and mental health (17%). CONCLUSION: Few CPMS survivors are critically injured. There is significant delay between shooting and transport. Revised triage criteria and a focus on rapid transport of the few severely injured patients are needed. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Early Characteristics and Progression of Blunt Traumatic Aortic Injuries at a Single Level I Trauma Center.

OBJECTIVES: The most widely accepted grading system for blunt traumatic aortic injury (BTAI) by the Society of Vascular Surgery (SVS) recommends endovascular repair for grade 2 and greater. Non-operative management in grade 2 injuries has been shown to be reasonable in certain circumstances. The natural history of low-grade injuries (1, 2) when managed non-operatively is not well defined. METHODS: Utilizing our trauma registry, patients from 2013 to 2016 with blunt traumatic injury who underwent initial computed tomography were identified. Aortic pathology was graded and grouped by SVS classification. Clinical courses were reviewed for timing of interventions, repeat imaging, concurrent injuries, and outcomes. Analysis of variance and Chi-square tests of significance were utilized to compare between groups. RESULTS: Out of 10,178 patients, we identified 32 with BTAI (grade: 1 (n = 13), 2 (n = 5), 3 (n = 3), 4 (n = 11)). High-grade injuries (3, 4) resulted only from motor vehicle, motorcycle, and pedestrian mechanisms. Initially, 9 patients (28%) required intervention, 5 (16%) were treated non-operatively, and 18 (56%) underwent repeat imaging. On repeat imaging, injuries that did not resolve remained stable and no injuries were found to progress. Of these patients, 9 (50%) required delayed intervention and 9 (50%) successfully underwent non-operative management. Patients with low-grade injuries were more likely to have successful non-operative management than those with high-grade injuries (72% vs 7%; p < 0.01). CONCLUSIONS: While low-grade injuries generally have good outcomes, some ultimately do require delayed intervention, and short-term imaging is not reliable in identifying these cases.

Too Big, Too Small or Just Right? Why the 28 French Chest Tube Is the Best Size.

BACKGROUND: Tube thoracostomy is a commonly performed procedure in trauma patients. The optimal chest tube size is unknown. This study measures chest tube drainage in a controlled laboratory setting and compares measured flowrates to those predicted by the Hagen-Poiseuille equation. MATERIALS AND METHODS: A model of massive hemothorax was created, consisting of a basin containing synthetic blood substitute (aqueous Glycerin and Xanthan gum) and a standard pleur-evac setup at -20 cm H2O suction. Flow measurements were calculated by measuring the time to drain 2L of blood substitute from the basin. Chest tube sizes tested were 20F, 24F, 28F, 32F, and 36F. Thoracostomy opening was modeled using custom built device that represents two ribs, with the distance between varied 2 to 12 mm. Flowrate increases were compared against predicted increases according to the Hagen-Poiseuille equation. Percent of predicted increase was calculated, both incremental increase and using 20F tube benchmark. RESULTS: All tubes were occluded at a 2 mm thoracostomy opening. At 3 mm, 32F and 36F were occluded while smaller tubes were patent. Tubes 28F and larger exhibited high speed and consistent flowrates, even after decreasing thoracostomy opening down to 7 mm, while flowrates rapidly decreased at opening smaller than 7 mm. Smaller 24F and 20F tubes exhibited highly variable flowrates through the system. Maximum flowrates were 21.7, 36.8, 49.6, 55.6, and 61.0 mL/s for 20F-36F tubes, respectively. The incremental increase in flow ratio for increasing chest tube size was 1.69 (20F to 24F), 1.35 (24F to 28F), 1.12 (28F to 32F), and 1.10 (32F to 36F). CONCLUSIONS: The 28F chest tube exhibited high and consistent velocity, while smaller tubes were slower and more variable. Larger tubes offered only slightly higher flowrates. The 28F is a good balance of reasonable size and high flowrate and is likely the optimal size for most clinical applications.

Cervical Spine Injury is Rare in Self-Inflicted Craniofacial Gunshot Wounds: An Institutional Review and Comparison to the US National Trauma Data Bank (NTDB).

BACKGROUND: Cadaveric and older radiographic studies suggest that concurrent cervical spine fractures are rare in gunshot wounds (GSWs) to the head. Despite this knowledge, patients with craniofacial GSWs often arrive with spinal motion restriction (SMR) in place. This study quantifies the incidence of cervical spine injuries in GSWs to the head, identified using computerized tomography (CT). Fracture frequency is hypothesized to be lower in self-inflicted (SI) injuries. METHODS: Isolated craniofacial GSWs were queried from this Level I trauma center registry from 2013-2017 and the US National Trauma Data Bank (NTDB) from 2012-2016 (head or face abbreviated injury scale [AIS] >2). Datasets included age, gender, SI versus not, cervical spine injury, spinal surgery, and mortality. For this hospital's data, prehospital factors, SMR, and CTs performed were assessed. Statistical evaluation was done with Stata software, with P <.05 significant. RESULTS: Two-hundred forty-one patients from this hospital (mean age 39; 85% male; 66% SI) and 5,849 from the NTDB (mean age 38; 84% male; 53% SI) were included. For both cohorts, SI patients were older (P < .01) and had increased mortality (P < .01). Overall, cervical spine fractures occurred in 3.7%, with 5.4% requiring spinal surgery (0.2% of all patients). The frequency of fracture was five-fold greater in non-SI (P < .05). Locally, SMR was present in 121 (50.2%) prior to arrival with six collars (2.5%) placed in the trauma bay. Frequency of SMR was similar regardless of SI status (49.0% versus 51.0%; P = not significant) but less frequent in hypotensive patients and those receiving cardiopulmonary resuscitation (CPR). The presence of SMR was associated with an increased use of CT of the cervical spine (80.0% versus 33.0%; P < .01). CONCLUSION: Cervical spine fractures were identified in less than four percent of isolated GSWs to the head and face, more frequently in non-SI cases. Prehospital SMR should be avoided in cases consistent with SI injury, and for all others, SMR should be discontinued once CT imaging is completed with negative results.

Outcomes in patients with gunshot wounds to the brain.

INTRODUCTION: Gunshot wounds to the brain (GSWB) confer high lethality and uncertain recovery. It is unclear which patients benefit from aggressive resuscitation, and furthermore whether patients with GSWB undergoing cardiopulmonary resuscitation (CPR) have potential for survival or organ donation. Therefore, we sought to determine the rates of survival and organ donation, as well as identify factors associated with both outcomes in patients with GSWB undergoing CPR. METHODS: We performed a retrospective, multicenter study at 25 US trauma centers including dates between June 1, 2011 and December 31, 2017. Patients were included if they suffered isolated GSWB and required CPR at a referring hospital, in the field, or in the trauma resuscitation room. Patients were excluded for significant torso or extremity injuries, or if pregnant. Binomial regression models were used to determine predictors of survival/organ donation. RESULTS: 825 patients met study criteria; the majority were male (87.6%) with a mean age of 36.5 years. Most (67%) underwent CPR in the field and 2.1% (n=17) survived to discharge. Of the non-survivors, 17.5% (n=141) were considered eligible donors, with a donation rate of 58.9% (n=83) in this group. Regression models found several predictors of survival. Hormone replacement was predictive of both survival and organ donation. CONCLUSION: We found that GSWB requiring CPR during trauma resuscitation was associated with a 2.1% survival rate and overall organ donation rate of 10.3%. Several factors appear to be favorably associated with survival, although predictions are uncertain due to the low number of survivors in this patient population. Hormone replacement was predictive of both survival and organ donation. These results are a starting point for determining appropriate treatment algorithms for this devastating clinical condition. LEVEL OF EVIDENCE: Level II.

Effect of prehospital tourniquets on resuscitation in extremity arterial trauma.

BACKGROUND: Timely tourniquet placement may limit ongoing hemorrhage and reduce the need for blood products. This study evaluates if prehospital tourniquet application altered the initial transfusion needs in arterial injuries when compared with a non-tourniquet control group. METHODS: Extremity arterial injuries were queried from our level I trauma center registry from 2013 to 2017. The characteristics of the cohort with prehospital tourniquet placement (TQ+) were described in terms of tourniquet use, duration, and frequency over time. These cases were matched 1:1 by the artery injured, demographics, Injury Severity Score, and mechanism of injury to patients arriving without a tourniquet (TQ-). The primary outcome was transfusion within the first 24 hours, with secondary outcomes of morbidity (rhabdomyolysis, renal failure, compartment syndrome), amputation (initial vs. delayed), and length of stay. Statistical tests included t-test and χ2 for continuous and categorical variables, respectively, with p<0.05 considered as significant. RESULTS: Extremity arterial injuries occurred in 192 patients, with 69 (36%) having prehospital tourniquet placement for an average of 78 minutes. Tourniquet use increased over time from 9% (2013) to 62% (2017). TQ+ patients were predominantly male (81%), with a mean age of 35.0 years. Forty-six (67%) received blood transfusion within the first 24 hours. In the matched comparison (n=69 pairs), TQ+ patients had higher initial heart rate (110 vs. 100, p=0.02), frequency of transfusion (67% vs. 48%, p<0.01), and initial amputations (23% vs. 6%, p<0.01). TQ+ patients had increased frequency of initial amputation regardless of upper (n=43 pairs) versus lower (n=26 pairs) extremity involvement; however, only upper extremity TQ+ patients had increased transfusion frequency and volume. No difference was observed in morbidity, length of stay, and mortality with tourniquet use. DISCUSSION: Tourniquet use has increased over time in patients with extremity arterial injuries. Patients having prehospital tourniquets required a higher frequency of transfusion and initial amputation, without an increase in complications. LEVEL OF EVIDENCE: Therapeutic study, level IV.