An AAST-MITC analysis of pancreatic trauma: Staple or sew? Resect or drain?

INTRODUCTION: Pancreatic trauma results in high morbidity and mortality, in part caused by the delay in diagnosis and subsequent organ dysfunction. Optimal operative management strategies remain unclear. We therefore sought to determine CT accuracy in diagnosing pancreatic injury and the morbidity and mortality associated with varying operative strategies. METHODS: We created a multicenter, pancreatic trauma registry from 18 Level 1 and 2 trauma centers. Adult, blunt or penetrating injured patients from 2005 to 2012 were analyzed. Sensitivity and specificity of CT scan identification of main pancreatic duct injury was calculated against operative findings. Independent predictors for mortality, adult respiratory distress syndrome (ARDS), and pancreatic fistula and/or pseudocyst were identified through multivariate regression analysis. The association between outcomes and operative management was measured. RESULTS: We identified 704 pancreatic injury patients of whom 584 (83%) underwent a pancreas-related procedure. CT grade modestly correlated with OR grade (r 0.39) missing 10 ductal injuries (9 grade III, 1 grade IV) providing 78.7% sensitivity and 61.6% specificity. Independent predictors of mortality were age, Injury Severity Score (ISS), lactate, and number of packed red blood cells transfused. Independent predictors of ARDS were ISS, Glasgow Coma Scale score, and pancreatic fistula (OR 5.2, 2.6-10.1). Among grade III injuries (n = 158, 22.4%), the risk of pancreatic fistula/pseudocyst was reduced when the end of the pancreas was stapled (OR 0.21, 95% CI 0.05-0.9) compared with sewn and was not affected by duct stitch placement. Drainage alone in grades IV (n = 25) and V (n = 24) injuries carried increased risk of pancreatic fistula/pseudocyst (OR 8.3, 95% CI 2.2-32.9). CONCLUSION: CT is insufficiently sensitive to reliably identify pancreatic duct injury. Patients with grade III injuries should have their resection site stapled instead of sewn and a duct stitch is unnecessary. Further study is needed to determine if drainage alone should be employed in grades IV and V injuries. LEVEL OF EVIDENCE: Epidemiologic/Diagnostic study, level III.

A negative urinalysis is associated with a low likelihood of intra-abdominal injury after blunt abdominal trauma.

BACKGROUND: The utility of urinalysis (UA) to diagnose intra-abdominal (IA) or genitourinary (GU) injury after blunt trauma remains controversial. The purpose of this study was to determine the significance of UA in the blunt trauma patient. METHODS: A retrospective review of patients admitted for blunt abdominal trauma from 2011 to 2013. RESULTS: A total of 1,795 patients sustained blunt abdominal trauma: mean age of 44 ± 21 years; mean Injury Severity Score of 13 ± 10. Overall 810 patients had a negative UA (45%). Two patients (2/810 and .2%) had a GU injury and neither required intervention. Thirty-two patients (32/810 and 4.0%) had an IA injury, and 2 (2/810 and .02%) required intervention. The sensitivity for predicting GU injury requiring intervention was 1, and IA injury requiring intervention was .96. Negative predictive values were 1 and .99. CONCLUSIONS: A negative UA correlates with a low risk for GU and IA injury after blunt abdominal trauma. A negative UA should be evaluated prospectively as part of a clinical prediction score to rule out injury and avoid unnecessary radiation exposure from computed tomography imaging.

Clinical Utility of Chest Computed Tomography in Patients with Rib Fractures CT Chest and Rib Fractures.

BACKGROUND: Chest CT is more sensitive than a chest X-ray (CXR) in diagnosing rib fractures; however, the clinical significance of these fractures remains unclear. OBJECTIVES: The purpose of this study was to determine the added diagnostic use of chest CT performed after CXR in patients with either known or suspected rib fractures secondary to blunt trauma. METHODS: Retrospective cohort study of blunt trauma patients with rib fractures at a level I trauma center that had both a CXR and a CT chest. The CT finding of ≥ 3 additional fractures in patients with ≤ 3 rib fractures on CXR was considered clinically meaningful. Student's t-test and chi-square analysis were used for comparison. RESULTS: We identified 499 patients with rib fractures: 93 (18.6%) had CXR only, 7 (1.4%) had chest CT only, and 399 (79.9%) had both CXR and chest CT. Among these 399 patients, a total of 1,969 rib fractures were identified: 1,467 (74.5%) were missed by CXR. The median number of additional fractures identified by CT was 3 (range, 4 - 15). Of 212 (53.1%) patients with a clinically meaningful increase in the number of fractures, 68 patients underwent one or more clinical interventions: 36 SICU admissions, 20 pain catheter placements, 23 epidural placements, and 3 SSRF. Additionally, 70 patients had a chest tube placed for retained hemothorax or occult pneumothorax. Overall, 138 patients (34.5%) had a change in clinical management based upon CT chest. CONCLUSIONS: The chest X-ray missed ~75% of rib fractures seen on chest CT. Although patients with a clinical meaningful increase in the number of rib fractures were more likely to be admitted to the intensive care unit, there was no associated improvement in pulmonary outcomes.

RibScore: A novel radiographic score based on fracture pattern that predicts pneumonia, respiratory failure, and tracheostomy.

BACKGROUND: There is currently no scoring system for rib fractures that relates detailed anatomic variables to patient outcomes. Our objective was to develop and validate a radiographic rib fracture scoring system based on computed tomographic chest findings. METHODS: We reviewed our trauma registry from September 2012 to April 2014 for all blunt trauma patients with one or more rib fractures visualized on chest computed tomography. We identified the following six candidate radiographic variables and tested their individual associations with pneumonia, respiratory failure, and tracheostomy: (1) six or more rib fractures, (2) bilateral fractures, (3) flail chest, (4) three or more severely (bicortical) displaced fractures, (5) first rib fracture, and (6) at least one fracture in all three anatomic areas (anterior, lateral, and posterior). We developed the "RibScore" by assigning 1 point for each variable, which was validated among the sample using univariate analyses, test performance characteristics, and the receiver operating characteristic area under the curve c statistic. RESULTS: A total of 385 patients with one or more rib fractures were identified; 274 (71.2%) were males, median age was 48 years, and median Injury Severity Score (ISS) was 17. Of these patients, 156 had six or more rib fractures, 120 had bilateral fractures, 46 had flail chest, 32 had three or more severely displaced fractures, 91 had a first rib fracture, and 58 had fractures in all three anatomic areas. Each RibScore component variable was associated with the three pulmonary outcomes by univariate analysis (p < 0.05). The median RibScore was 1 (range, 0-6). The distribution of the RibScore was as follows: score of 0, 41.9%); score of 1, 23.9%; score of 2, 15.4%; score of 3, 9.9%; score of 4, 7.6%; and score of five, 1.3%. RibScore was linearly associated with pneumonia (p < 0.01), acute respiratory failure (p < 0.01), and tracheostomy (p < 0.01). The receiver operating characteristic areas under the curve for the outcomes were 0.71, 0.71, and 0.75, respectively. CONCLUSION: The RibScore predicts adverse pulmonary outcomes and represents a standardized assessment of fracture severity that may be used for communication and prognostication of the severely injured trauma patient. LEVEL OF EVIDENCE: Prognostic study, level III.

Screening for Ventilator-Associated Pneumonia in the Surgical Intensive Care Unit: A Single-Institution Analysis of 1,013 Lower Respiratory Tract Cultures.

BACKGROUND: Refinement of criteria for both screening and initiation of empiric therapy in ventilator-associated pneumonia (VAP) will minimize antibiotic overuse. We hypothesized that variables within the commonly used Clinical Pulmonary Infection Score (CPIS) have unfavorable test performance characteristics. METHODS: Consecutive bronchoalveolar lavage (BAL) cultures obtained from surgical intensive care unit patients were abstracted (2009-2012). Ventilator-associated pneumonia was defined as ≥10(5) cfu/mL. The CPIS both without (CPISclinical) and with (CPISclinical+GS) the result of gram stain (GS) was calculated. Test performance characteristics for the sample, as well as several subgroups, were compared. RESULTS: One thousand thirteen lower respiratory tract cultures from 492 patients were analyzed; 438 (43.2%) of cultures were classified as VAP, and 310 of 492 patients (62.4%) had ≥1 episode of VAP. Both CPISclinical and CPISclinical+GS had poor discrimination for VAP (Receiver-operating characteristic area under the curve=0.55 and 0.66, respectively). Sensitivity of CPISclinical using a threshold of >6 was 21%; the lowest threshold for CPISclinical for which the sensitivity was at least 85% was 3. The highest sensitivity among the individual CPIS components was new CXR infiltrate (91.1%). Among the subset of cultures sent during the early VAP window (days intubated 2-5), organisms on GS had a sensitivity of 93.3%. The CPISclinical, CPISclinical+GS, organisms, and neutrophils on GS parameters all became less accurate in both the late VAP window and when screening for recurrent VAP. Every case of VAP had at least one of the following: 1) fever; 2) new CXR infiltrate, or 3) organisms on GS. CONCLUSION: In this series of BALs, traditional screening tools for VAP missed the majority of microbiological confirmed cases. Screening based on either new CXR infiltrate or fever yielded an acceptably high sensitivity. The only scenario identified in which empiric antibiotics could be withheld safely was the absence of organisms on GS in the early VAP window.

Predictors of the necessity for early tracheostomy in patients with acute cervical spinal cord injury: a 15-year experience.

BACKGROUND: The need for mechanical ventilation (MV) after spinal cord injury (SCI) is a risk factor for prolonged critical care. The "purpose" of this study was to identify the level of cervical SCI that requires MV, thereby defining candidates for tracheostomy. METHODS: Patients with cervical SCI over a 15-year period were reviewed. RESULTS: One hundred sixty-three patients sustained cervical SCI. Of 76 complete injuries, 91% required MV for greater than 48 hours. By injury level, MV incidence was 100% for C2-4, 91% for C5, 79% for C6, and 80% for C7. Only one quarter of patients with incomplete SCI required MV for greater than 48 hours; Glascow Coma Score and Injury Severity Score were significantly worse compared with patients not requiring MV. CONCLUSIONS: Factors influencing the decision for tracheostomy in cervical SCI patients include the presence of a complete SCI, anatomic level of injury, Glascow Coma Score, Injury Severity Score, and associated thoracic injury. Patients with complete cervical SCI often require prolonged MV. Conversely, the minority of incomplete SCI required MV; the need for tracheostomy was likely performed for associated injuries. Utilizing identified factors permits a thoughtful approach to tracheostomy in this patient population.

Early repeat imaging is not warranted for high-grade blunt cerebrovascular injuries.

BACKGROUND: The current management for blunt cerebrovascular injuries (BCVIs) includes repeat imaging 7 days to 10 days after initial diagnosis. This recommendation, however, has not been systematically evaluated. The purpose of this study was to evaluate the impact of early repeat imaging on treatment course. We hypothesized that a minority of patients with high-grade injuries (Grades III and IV) have complete resolution of their injuries early in their treatment course and hence repeat imaging does not alter their therapy. METHODS: Our prospective BCVI database was queried from January 1, 1997, to January 1, 2013. Injuries were graded according to the Denver scale. Injuries, treatment, and imaging results were analyzed. BCVI healing was defined as a complete resolution of the injury. RESULTS: During the 16-year study, 582 patients sustained 829 BCVIs; there were 420 carotid artery injuries and 409 vertebral artery injuries. The majority (78%) received antithrombotic therapy. For the 296 carotid artery injuries (70%) with repeat imaging, there was complete healing of the injury in 56% of Grade I, 20% of Grade II, 5% of Grade III, and 0% of Grade IV injuries. For the 255 vertebral artery injuries (62%) with repeat imaging, there was a resolution of the injury in 56% of Grade I, 17% of Grade II, 14% of Grade III, and 3% of Grade IV injuries. For BCVIs overall, there was healing documented in 56% of Grade I, 18% of Grade II, 8% of Grade III, and 2% of Grade IV injuries. CONCLUSION: Injury grade of BCVIs is associated with the healing rate of the injury. While approximately half of Grade I BCVIs resolved, only 7% of all high-grade injuries healed. Early repeat imaging may not be warranted in high-grade BCVI; the vast majority of injuries do not resolve. The cost, radiation, and transport risk of early repeat imaging should be weighed against the potential treatment impact for individual patients. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.

Trauma remains a surgical disease from cradle to grave.

BACKGROUND: A dramatic rise in nonoperative management of many blunt and some penetrating traumatic injuries has occurred during the past four decades. This trend has lead some to suggest that trauma is no longer a surgical disease. We questioned what role the trauma surgeon plays in the care of the injured patient. We hypothesized that surgical intervention and judgment are still often required in both injured children and adults. METHODS: We queried the trauma databases at two academic Level I trauma centers (adult and pediatric) for all patients admitted for trauma who underwent an inpatient operation between July 1, 2009, and June, 31, 2013, as well as those patients with "potentially operative injury." Potentially operative injury was defined as the presence of liver or splenic laceration of any grade or hemothorax in patients who did not undergo an inpatient operation. For analysis, we divided patients into groups based on age. We differentiated infants (0-1 years), toddlers (2-5 years), school-aged children (6-12 years), adolescents (13-15 years), young adults (16-21 years), adults (22-40 years), middle-aged adults (41-50 years), late middle-aged adults (51-64 years), and elderly (>65 years). Data collected included demographic information and number of operations performed in each patient based on surgical service (neurosurgery, trauma surgery, orthopedic surgery, and other surgical services). RESULTS: During this 4-year study period, 11,611 patients were admitted to the trauma service, 6,334 (54.6%) of whom underwent an inpatient operation and another 492 (4.2%) of whom had potentially operative injury. Across all age groups, orthopedic procedures accounted for the greatest percentage of inpatient procedures (>70% of inpatient operations performed). Neurosurgical intervention accounted for less than 10% of inpatient surgical interventions, and general surgical procedures performed by trauma surgeons accounted for 17.1%. More than half of all general surgical procedures were performed in the patients who required a hospital stay of more than 7 days (67.2% among all patients). CONCLUSION: More than half of patients admitted following traumatic injury require operative intervention. This rate remains stable across all age groups. Our data emphasize the continued need for surgeons to stay engaged in the care of the trauma patient, particularly those most critically injured patients who will require prolonged hospital stay. LEVEL OF EVIDENCE: Epidemiologic study, level III. Care management study, level IV.

A multicenter, randomized clinical trial of IV iron supplementation for anemia of traumatic critical illness*.

OBJECTIVE: To evaluate the efficacy of IV iron supplementation of anemic, critically ill trauma patients. DESIGN: Multicenter, randomized, single-blind, placebo-controlled trial. SETTING: Four trauma ICUs. PATIENTS: Anemic (hemoglobin < 12 g/dL) trauma patients enrolled within 72 hours of ICU admission and with an expected ICU length of stay of more than or equal to 5 days. INTERVENTIONS: Randomization to iron sucrose 100 mg IV or placebo thrice weekly for up to 2 weeks. MEASUREMENTS AND MAIN RESULTS: A total of 150 patients were enrolled. Baseline iron markers were consistent with functional iron deficiency: 134 patients (89.3%) were hypoferremic, 51 (34.0%) were hyperferritinemic, and 64 (42.7%) demonstrated iron-deficient erythropoiesis as evidenced by an elevated erythrocyte zinc protoporphyrin concentration. The median baseline transferrin saturation was 8% (range, 2-58%). In the subgroup of patients who received all six doses of study drug (n = 57), the serum ferritin concentration increased significantly for the iron as compared with placebo group on both day 7 (808.0 ng/mL vs 457.0 ng/mL, respectively, p < 0.01) and day 14 (1,046.0 ng/mL vs 551.5 ng/mL, respectively, p < 0.01). There was no significant difference between groups in transferrin saturation, erythrocyte zinc protoporphyrin concentration, hemoglobin concentration, or packed RBC transfusion requirement. There was no significant difference between groups in the risk of infection, length of stay, or mortality. CONCLUSIONS: Iron supplementation increased the serum ferritin concentration significantly, but it had no discernible effect on transferrin saturation, iron-deficient erythropoiesis, hemoglobin concentration, or packed RBC transfusion requirement. Based on these data, routine IV iron supplementation of anemic, critically ill trauma patients cannot be recommended (NCT 01180894).

Intra-abdominal injury following blunt trauma becomes clinically apparent within 9 hours.

BACKGROUND: The diagnosis of blunt abdominal trauma can be challenging and resource intensive. Observation with serial clinical assessments plays a major role in the evaluation of these patients, but the time required for intra-abdominal injury to become clinically apparent is unknown. The purpose of this study was to determine the amount of time required for an intra-abdominal injury to become clinically apparent after blunt abdominal trauma via physical examination or commonly followed clinical values. METHODS: A retrospective review of patients who sustained blunt trauma resulting in intra-abdominal injury between June 2010 and June 2012 at a Level 1 academic trauma center was performed. Patient demographics, injuries, and the amount of time from emergency department admission to sign or symptom development and subsequent diagnosis were recorded. All diagnoses were made by computed tomography or at the time of surgery. Patient transfers from other hospitals were excluded. RESULTS: Of 3,574 blunt trauma patients admitted to the hospital, 285 (8%) experienced intra-abdominal injuries. The mean (SD) age was 36 (17) years, the majority were male (194 patients, 68%) and the mean (SD) Injury Severity Score (ISS) was 21 (14). The mean (SD) time from admission to diagnosis via computed tomography or surgery was 74 (55) minutes. Eighty patients (28%) required either surgery (78 patients, 17%) or radiographic embolization (2 patients, 0.7%) for their injury. All patients who required intervention demonstrated a sign or symptom of their intra-abdominal injury within 60 minutes of arrival, although two patients were intervened upon in a delayed fashion. All patients with a blunt intra-abdominal injury manifested a clinical sign or symptom of their intra-abdominal injury, resulting in their diagnosis within 8 hours 25 minutes of arrival to the hospital. CONCLUSION: All diagnosed intra-abdominal injuries from blunt trauma manifested clinical signs or symptoms that could prompt imaging or intervention, leading to their diagnosis within 8 hours 25 minutes of arrival to the hospital. All patients who required an intervention for their injury manifested a sign or symptom of their injury within 60 minutes of arrival. LEVEL OF EVIDENCE: Therapeutic study, level IV. Epidemiologic study, level III.

Emergency department pericardial drainage for penetrating cardiac wounds is a viable option for stabilization.

BACKGROUND: Penetrating cardiac injuries (PCI) causing tamponade causes subendocardial ischemia, arrhythmias, and cardiac arrest. Pericardial drainage is an important principle, but where drainage should be performed is debated. We hypothesize that drainage in the emergency department (ED) does not delay definitive repair. METHODS: Over a 16-year period, patients sustaining PCI were reviewed. RESULTS: Seventy-eight patients with PCI survived to the operating room (OR), with 39 undergoing ED thoracotomy. An additional 39 patients underwent pericardial drainage, 17 (44%) in the ED and 22 in the OR. Comparing the ED with OR pericardial drainage groups, they had a similar ED systolic pressure (99 ± 25 vs 99 ± 34), heart rate (103 ± 16 vs 85 ± 37), median time to the OR (20 vs 22 min), and mortality (12% vs 23%). CONCLUSIONS: ED pericardial drainage for PCI did not appear to delay operation and had an acceptably low mortality rate. Pericardial drainage is a viable option for stabilization before definitive surgery when surgical intervention is not immediately available in the hemodynamically marginal patient.

Hypercoagulability following blunt solid abdominal organ injury: when to initiate anticoagulation.

BACKGROUND: The optimal time to initiate venous thromboembolism pharmacoprophylaxis after blunt abdominal solid organ injury is unknown. METHODS: Postinjury coagulation status was characterized using thromboelastography (TEG) in trauma patients with blunt abdominal solid organ injuries; TEG was divided into 12-hour intervals up to 72 hours. RESULTS: Forty-two of 304 patients (13.8%) identified underwent multiple postinjury thromboelastographic studies. Age (P = .45), gender (P = .45), and solid organ injury grade (P = .71) were similar between TEG and non-TEG patients. TEG patients had higher Injury Severity Scores compared with non-TEG patients (33.2 vs 18.3, respectively, P < .01). Among the TEG patients, the shear elastic modulus strength and maximum amplitude values began in the normal range within the first 12-hour interval after injury, increased linearly, and crossed into the hypercoagulable range at 48 hours (15.1 ± 1.9 Kd/cs and 57.6 ± 1.6 mm, respectively; P < .01, analysis of variance). CONCLUSIONS: Patients sustaining blunt abdominal solid organ injuries transition to a hypercoagulable state approximately 48 hours after injury. In the absence of contraindications, pharmacoprophylaxis should be considered before this time for effective venous thromboembolism prevention.

A negative urinalysis rules out catheter-associated urinary tract infection in trauma patients in the intensive care unit.

BACKGROUND: Urinary tract infection (UTI) in trauma patients is associated with increased mortality. Whether the urinalysis (UA) is an adequate test for a urinary source of fever in the ICU trauma patient has not been demonstrated. We hypothesized that the UA is a valuable screen for UTI in the febrile, critically ill trauma patient. STUDY DESIGN: All trauma ICU patients in our surgical ICU who had a fever (temperature >38.0°C), urinary catheter, UA, and a urine culture between January 1, 2011 and December 13, 2011 were reviewed. A positive UA was defined as positive leukocyte esterase, positive nitrite, WBC > 10/high power field, or presence of bacteria. A positive urine culture was defined as growth of ≥10(5) colony forming units (cfu) of an organism irrespective of the UA result or ≥10(3) cfu in the setting of a positive UA. A UTI was defined as positive urine culture without an alternative cause of the fever. RESULTS: There were 232 UAs from 112 patients that met criteria. The majority (75%) of patients were men; the mean age was 40 (±16) years. Of the 232 UAs, 90 (38.7%) were positive. There were 14 UTIs. The sensitivity, specificity, positive predictive value, and negative predictive value of the UA for UTI were 100%, 65.1%, 15.5%, and 100%, respectively. CONCLUSIONS: A negative UA reliably excludes a catheter-associated UTI in the febrile, trauma ICU patient with a 100% negative predictive value, and it can rapidly direct the clinician toward more likely sources of fever and reduce unnecessary urine cultures.

Perioperative management of peripheral vascular trauma.

Peripheral vascular trauma is not uncommon in the civilian setting, and it can be uniquely challenging because of the limited time during which intervention can salvage an ischemic extremity. Injuries can be from a blunt or penetrating mechanism, and these injuries can be isolated or can be in the setting of a complex multisystem trauma. The intent of this review is to discuss the perioperative management of peripheral vascular trauma with an emphasis of predicting, preventing, and managing common postoperative complications.