Use of Andexanet Alfa for Factor Xa Inhibitor Reversal in US Verified Trauma Centers: A National Survey.

Direct oral factor Xa inhibitors are replacing vitamin K-dependent antagonists as anticoagulation treatment in many clinical scenarios. Trauma centers are noting an increase in patients presenting on these medications. The 2018 Food and Drug Administration approval of andexanet alfa provides an alternative anticoagulation reversal. Barriers may limit utilization of new medications including a lack of grade 1A evidence supporting the use of prothrombin complex concentrate (PCC) versus andexanet alfa and cost. To evaluate barriers of andexanet alfa utilization by trauma surgeons, a 15-question survey was conducted. There was a 9% completion rate (n = 89). The results revealed 23.5% would choose andexanet alfa as first-line treatment in children, and 25.8% as first-line treatment in adults. The majority of respondents, 64.7% and 67.4%, would use PCC preferentially in children and adults, respectively. Respondents indicated that cost burden was an overriding factor (76.3%); 42.4% cited lack of high-level efficacy data of andexanet alfa for reversal of factor Xa inhibitors. Additional double-blinded multi-institutional randomized controlled trials comparing 4F-PCC and andexanet alfa for factor Xa inhibitor reversal are needed to support efficacy especially with the increased cost associated.

The Impact of Screening for Perioperative ICU Admission in Geriatric Hip Fracture Patients: A Retrospective Analysis.

BACKGROUND: Hip fracture patients are a subset of trauma patients with high peri-operative mortality. To mitigate the mortality risk, the use of predictive scoring systems (e.g., RSI or Nomograms) for risk stratification and monitoring of high-risk patients in the intensive care unit (ICU) has been proposed. Screening patients for ICU admission with relatively low-cost tools may achieve high-quality, low-cost care. The aim of this study was to assess the effectiveness and feasibility of screening postoperative hip fracture patients for ICU admission. METHODS: This is a retrospective single-site study comparing two groups of patients, before and after implementation of a hip fracture postoperative screening intervention in a level 1 trauma center in the United States. All hip fracture patients > 55 years of age admitted to the hospital between January 2021 and May 2023 were included. Trauma team members assessed and screened patients postoperatively in the post-anesthesia care unit (PACU), ordering standardized tests, including laboratory tests, a chest x-ray, and electrocardiogram (EKG). Assessment of the effect of the intervention included a comparison of a number of major adverse events (MAEs), mortality, planned and unplanned ICU admissions, ICU length of stay (LOS), and hospital LOS between pre- and post-intervention groups. Propensity score (PS) estimates were used to compare outcomes between the matched participants in the sample. A predictive model for ICU admission for the overall sample was estimated, and discriminative ability was assessed with an area under the curve (AUC) receiver operator characteristics (ROC) analysis. Lastly, feasibility was assessed by compliance with screening intervention and charges per patient related to the intervention. RESULTS: The sample consisted of 290 patients in the pre-intervention and 180 patients in the post-intervention groups, respectively, with a mean age of 81.4 ± (9.9) years. There was a significant increase (p<0.01) in planned ICU admissions (OR=2.387, 95% CI (1.430, 3.983)) after screening protocol implementation. There was no significant difference between the pre-intervention group and post-intervention group in the number of MAEs (p=0.392), mortality (p=0.591), ICU LOS (p=0.617), and hospital LOS (p=0.151). When the PS-matched sample (n=424) was analyzed, there was a significant decrease (p=0.45) in unplanned ICU admissions (OR=6.40, 95% CI (0.81, 50.95)) after protocol implementation. Anticoagulants, emergency department (ED) respiratory rate (RR), injury severity score (ISS), number of comorbidities, substance use disorder (SAD), peripheral artery disease (PAD), and chronic obstructive pulmonary disease (COPD) were significant predictors of ICU admission (p=0.002, 0.022, 0.030, 0.034, 0.039, 0.039, and 0.042), respectively, and, demonstrated the discriminative ability between high and low risk for ICU admission (AUC=0.597, 0.587, 0.581, 0.578, 0.513, and 0.587, respectively). The screening intervention was achievable with 99% compliance (Kappa estimate 0.94) among trauma team members with an average charge of $282 per patient. CONCLUSION: The addition of a postoperative screening intervention for hip fracture patients > 55 years of age is achievable and decreases unplanned ICU admissions in matched samples. Presenting clinical indicators and comorbidities are associated with ICU admission and provide sufficient discriminatory ability as criteria for ICU admission.

Double jeopardy: Successful management of a traumatic ascending aortic pseudoaneurysm with concurrent subdural hematoma.

We present the case of a 59-year-old male who sustained an ascending aortic injury and a subdural hematoma after a head on collision. After undergoing emergent craniotomy for evacuation of the subdural hematoma, he was maintained with strict blood pressure control. Once able to be safely anticoagulated, he underwent replacement of the ascending aorta. This exceedingly rare case was managed by a multidisciplinary team approach that led to an optimal outcome given his disastrous multi-traumatic injuries.

Internal hernia of caecum through the foramen of Winslow.

Internal hernias through the foramen of Winslow are very rare. An 80-year-old female patient presented with epigastric and right upper quadrant pain associated with abdominal distention, nausea and vomiting for 1 day. A CT scan showed an internal hernia with terminal ileum and caecum identified within the lesser sac. The diagnosis was confirmed by laparotomy. A right hemicolectomy was performed to prevent further recurrence. We reviewed case reports with the same presentation by searching the Pubmed database using the keywords: 'foramen Winslow hernia, cecum'. We identified 23 publications. Our review extracted the following information: presentation, anatomical findings, pathological causes and surgical management. Misdiagnosis was common due to the limitations of plain abdominal X-rays. Abdominal CT scan is now the preferred radiological study and is more effective in establishing a diagnosis. Surgical treatment options varied. Right hemicolectomy has emerged as the preferred procedure to decrease the rate of recurrence.

CT scan incidental findings in trauma patients: does it impact hospital length of stay?

BACKGROUND: CT scans are heavily relied on for assessment of solid organ injuries complementing clinical examination. These CT scans could also reveal pathologies not related to trauma called incidental findings. We aimed to evaluate the frequency of these findings and their outcome on hospital services. METHODS: A retrospective chart review of prospectively collected data of the emergency department's trauma database from January 2005 to December 2011 to evaluate incidental findings on CT scans on trauma admissions. These incidental findings were divided into three classes: class 1-minor degenerative, non-degenerative, normal variants or congenital finding that does not require further investigation or workup; class 2-findings not requiring urgent intervention with scheduled outpatient follow-up and class 3-all findings that require urgent evaluation/further investigation during the same hospital admission. One-year follow-up was done to review hospital length of stay, trauma clinic follow-up and post-trauma surgery. RESULTS: Of 1000 charts reviewed, 957 were selected after 43 patients were excluded due to incomplete documentation. Of the 957 patients, 385 (40%) were found to have incidental findings. A total of 560 incidental findings were found on the CT scan reports with one-third of patients having multiple findings (144 patients, 37.4%). The largest number of incidental findings were in class 2. The incidental group had significantly longer length of stay after adjusted multivariate analysis (8.7±0.48 vs 6.7±0.55, p=0.005). CONCLUSION: The incidental findings are commonly found during CT imaging in trauma centers and our rate was 40%. Appropriate documentation, communication and follow-up of those findings is necessary. A classification system for these findings practiced nationwide will aid in categorizing the urgency of continued follow-up. This also will help decrease the length of hospital stay and healthcare cost. LEVEL OF EVIDENCE: Level 4.

Identification of Risk Factors for Cervical Spine Injury from Pediatric Trauma Registry.

BACKGROUND: Cervical spine injuries are rare in children. Our goal is to establish guidelines for cervical spine clearance that are practical for our pediatric population, and, in the process, to reduce the risk of radiation exposure from unnecessary advanced imaging. METHODS: We retrospectively reviewed the records from the registries of two pediatric trauma centers from the past 11 years (January 2002 to June 2013). Patients aged 1 month to 17 years, who had a CT scan of the cervical spine due to trauma indication for possible cervical spine injury, were evaluated. RESULTS: Three risk factors were identified as being significant for the presence of a cervical spine injury. Patients who sustained a cervical spine injury were more likely to be male (p = 0.0261), were more severely injured with a higher injury severity score (ISS 16.39 ± 15.79 injured vs. 8.7 ± 9.4 uninjured), and presented with neck tenderness (p = 0.0001). CONCLUSION: In our study, significant cervical spine injury is related to male gender, higher ISS and neck tenderness.