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BACKGROUND: No studies to date have evaluated the use of rigid plate fixation for emergent sternotomy in trauma patients. We evaluated our use of rigid plate fixation vs wire cerclage in patients requiring emergent sternotomy. We hypothesized there would be no difference in complications related to sternal closure between the two groups. METHODS: We performed a retrospective cohort study to include all patients who underwent emergent sternotomy from 1/1/2018 to 1/31/2021 and survived to have their sternum closed. Outcomes in patients closed with wire cerclage group (WC) were compared to patients who underwent rigid plate fixation (RPF). RESULTS: Twenty-two patients underwent emergent sternotomy. There were 11 patients in each group. There was no significant difference in admission demographics, ISS, or admission characteristics between the two groups. Complication rates related to closure (wound infection and hardware removal) were not significantly different (WC 27% vs RPF 9%, P = .58). Neither hospital length of stay (WC: 29 days vs RPF: 13 days, P = .13), ICU length of stay (WC: 6 days vs RPF: 7 days, P = .62), nor the number of ventilator days (WC: 3 days vs RPF: 1 day, P .11) were statistically different. All patients survived to discharge. DISCUSSION: This is the first study comparing RPF and WC for sternotomy closure in the setting of trauma. We found no difference in the rate of wound related complications. This study demonstrates the feasibility of rigid plate fixation for trauma sternotomy closure and lays the foundation for future prospective studies.
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Esternotomia , Esterno , Humanos , Estudos Prospectivos , Estudos Retrospectivos , Placas ÓsseasRESUMO
OBJECTIVES: Using rectal contrast computed tomography (CT) to identify traumatic colorectal injuries has become commonplace; however, these injuries remain relatively infrequent findings on CTs obtained for penetrating back and flank trauma. We conducted a meta-analysis to ascertain the efficacy of rectal contrast CT in identifying such injuries in victims penetrating injuries. METHODS: PubMed and Embase were queried for relevant articles between 1974 and 2022. Review articles, case studies, and non-English manuscripts were excluded. Studies without descriptive CT and operative findings were excluded. Positive scans refer to rectal contrast extravasation. Sensitivity and specificity of rectal contrast CT scans were calculated with aggregated CT findings that were cross-referenced with laparotomy findings. RESULTS: Only 8 manuscripts representing 506 patients quantified colorectal injuries and specified patients with rectal contrast extravasation. Seven patients with true colorectal injuries had no contrast extravasation on CT. There was one true positive scan. Another scan identified contrast extravasation, but laparotomy revealed no colorectal injury. Rectal contrast had sensitivity of 12.5%, specificity 99.8%, positive predictive value (PPV) 50%, negative predictive value (NPV) 99%, and a false negative rate of 88% in identifying colonic injuries. DISCUSSION: The summation of 8 manuscripts suggest that the addition of rectal contrast in identifying colonic and rectal injuries may be of limited utility given its poor sensitivity and may be unnecessary. In its absence, subtle clues such as hematomas, extraluminal air, IV-dye extravasation, and trajectory may be additional indicators of injury. Further investigations are required to demonstrate a true benefit for the addition of rectal contrast.
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Traumatismos Abdominais , Ferimentos Penetrantes , Humanos , Ferimentos Penetrantes/diagnóstico por imagem , Ferimentos Penetrantes/cirurgia , Tomografia Computadorizada por Raios X/métodos , Reto/diagnóstico por imagem , Valor Preditivo dos Testes , Traumatismos Abdominais/diagnóstico por imagem , Traumatismos Abdominais/cirurgia , Sensibilidade e Especificidade , Estudos RetrospectivosRESUMO
In health care, second victims are traumatized clinicians involved in unanticipated or untoward patient events. Programs that address second victim syndrome are sparse and its diagnosis often goes unrecognized. Consistently, literature has identified gaps in support resources, leading to compromised patient care and provider health. This project evaluates the need for second victim resources in trauma care providers at a tertiary public level 1 trauma hospital by electronically implementing a validated second victim survey over 5 weeks. Our results illustrate that second victim syndrome is prevalent among 57.1% of trauma care providers, of which 22.9% agree that second victim syndrome results in some form of undesirable work intentions.
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Pessoal de Saúde , Erros Médicos , Atenção à Saúde , Humanos , Estresse Psicológico , Inquéritos e QuestionáriosRESUMO
BACKGROUND: This study sought to determine the contribution of self-inflicted injury-related deaths to local organ donation rates and analyze contributing factors. METHODS: A retrospective review of adult patients with traumatic self-inflicted injuries was performed at a Level I trauma center from 2013 to 2017. Data were obtained from the institutional trauma registry and cross-referenced with the local organ procurement organization (OPO). Referral rates were analyzed and outcomes, demographics and injury characteristics were compared between patients who underwent donation versus those who did not. RESULTS: 142 adult patients presented with traumatic self-inflicted injury, and 100 (70.4%) had referral calls made to the local OPO. These patients were predominantly male (83%), and gunshot injuries accounted for 75% of all mechanisms. Sixty-four percent had organ referrals versus tissue referrals (34%), and 17 (26.6%) of those patients went on to donate. The median number of organs procured was 4 [IQR 0-5]. In multivariate analysis, for each year increase in age, patients were less likely to have an organ referral (OR = .96 [95% CI .93-.99]; p = .0134) and less likely to undergo donation (OR = .95 [95% CI .90-.99]; p = .0308). CONCLUSIONS: Self-inflicted injury, though tragic, may provide a significant contribution to the limited organ donor registry.
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Transplante de Órgãos , Obtenção de Tecidos e Órgãos , Adulto , Feminino , Humanos , Masculino , Encaminhamento e Consulta , Estudos Retrospectivos , Doadores de TecidosRESUMO
Screening, brief intervention, and referral to treatment (SBIRT) is an intervention originally developed to prevent and deter substance abuse. Adaptation of the SBIRT model to prevent post-traumatic stress disorder (PTSD) may potentially reduce acute stress symptoms after traumatic injury. We conducted a prospective randomized control study of adult patients admitted for gunshot wounds. Patients were randomized to intervention (INT) vs. treatment as usual (TAU) groups. INT received the newly developed SBIRT Intervention for Trauma Patients (SITP)-a 15-minute session with elements of cognitive behavioral therapy techniques. SITP took place during the index hospitalization; both groups had followup at 30 and 90 days at which time a validated PTSD screening tool, PCL-5, was administered. Most of the 46 participants were young (mean age = 30.5y), male (91.3%), and black (86.9%). At three-month follow-up, SBIRT and TAU patients had similar physical healing scores but the SBIRT arm showed reductions in PTSD symptoms.
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Transtornos de Estresse Pós-Traumáticos , Transtornos Relacionados ao Uso de Substâncias , Ferimentos por Arma de Fogo , Adulto , Intervenção em Crise , Humanos , Masculino , Programas de Rastreamento/métodos , Estudos Prospectivos , Encaminhamento e Consulta , Transtornos de Estresse Pós-Traumáticos/diagnóstico , Transtornos de Estresse Pós-Traumáticos/etiologia , Transtornos de Estresse Pós-Traumáticos/prevenção & controle , Ferimentos por Arma de Fogo/complicações , Ferimentos por Arma de Fogo/terapiaRESUMO
BACKGROUND: Almost 20% of the US population are housing insecure (HI) due to inadequate living conditions, imbalanced costs to income, nonsustainable shelter, or overcrowding. Housing insecure and physical trauma share similar risk factors, but their direct association is not well elucidated. The objective of our study was to determine the prevalence of HI in survivors of traumatic injury. METHODS: We conducted a prospective cohort study at an urban, level 1 trauma center. A survey on social determinants of health was administered to adult patients, and demographic, injury specifics, and clinical outcomes data were collected. HI was defined by affirmative answers to questions related to history of homelessness or concern about sustainable shelter. The cohort was stratified by HI; groups were compared using the Mann-Whitney U and Fisher exact tests, as appropriate. RESULTS: Of 116 study participants, four were excluded due to missing data. Of the 112, 42 (37.8%) reported HI and most were black (69%) males (73.8%). There were no demographic differences between groups. Conversely, HI patients had a higher rate of penetrating traumatic injury (34.1% vs 14.5%, P-value = .03) and were significantly less educated compared to secure participants (P-value = .03) [no degree (26.2% vs 10.3%), high school degrees (21.4% vs 41.2%)] with concomitant illicit drug use (63.4% vs 27.9%, P < .001), and history of addiction (52.4% vs 7.2%, P < .001). CONCLUSION: HI far exceeds national averages in our cohort. Although difficult to ascertain a cause-effect relationship, HI may be a modifiable risk factor for trauma that negatively influences outcomes.
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Instabilidade Habitacional , Drogas Ilícitas , Adulto , Feminino , Humanos , Masculino , Prevalência , Estudos Prospectivos , SobreviventesRESUMO
Risks of intimate partner violence (IPV) escalated during the COVID-19 pandemic given mitigation measures, socioeconomic hardships, and isolation concerns. The objective of this study was to explore the impact of COVID-19 on the incidence of IPV. We conducted an interrupted time series analysis for IPV incidence at a single level 1 trauma center located in the United States. IPV cases were identified by triangulation of institutional data sources. There were 4,624 traumatic injuries of which 292 (6.3%) were due to IPV. IPV-related injury admissions increased 17% in the weeks following the COVID lockdown (RR = 1.17; 95% CI: 1.16, 1.19). Over a quarter of victims (27.4%) were male. Compared to before COVID, victims of IPV during the pandemic were younger (p = .04); no difference in mechanism or severity of injury was found. Our results suggest an ongoing need for universal IPV screening during health emergencies to avoid missed opportunities for IPV detection and referral to support services.
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COVID-19 , Violência por Parceiro Íntimo , COVID-19/epidemiologia , Controle de Doenças Transmissíveis , Feminino , Humanos , Análise de Séries Temporais Interrompida , Masculino , Pandemias , Centros de Traumatologia , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Food insecurity (FI) has been defined as a lack of consistent access to enough food for a healthy active lifestyle. As of 12.7% of the United States are suffering from FI, which has been correlated with increased hospital costs and poorer health outcomes. Currently, limited data exists examining the relationship between trauma populations and FI despite both having similar root causes. We sought to determine this and validate a screening tool for FI in this population. METHODS: A cross-sectional survey study of trauma patients was conducted at a level 1 trauma center in Atlanta, Georgia. Survey questions included the first two items of the Core Food Security Module. Zip codes were used to determine FI, defined by the USDA Food Access Research and compared to individual participant survey responses. Binary classification test metrics were calculated to validate the two items as a screening tool in this population. RESULTS: The cohort included 136 patients, of which the majority were black (60.3%) and male (60.3%). Thirty-one respondents affirmed food security (22.8%) despite over half (51.5%) living in a food insecure community. The sensitivity and specificity for this screening to predict FI were 25 and 80%, respectively. CONCLUSION: Although the specificity is high, this screening tool has a low sensitivity, accuracy, NPV, and PPV to determine food insecurity in this population. Community-level statistics suggests that food insecurity is a significant public problem amongst trauma patients. Prevention efforts should, therefore, aim to address both issues simultaneously.
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Insegurança Alimentar , Abastecimento de Alimentos , Estudos Transversais , Humanos , Masculino , Inquéritos e Questionários , Estados Unidos/epidemiologia , População UrbanaRESUMO
This review focuses on the interview and match process with the purpose of broadly reviewing challenges in the current surgical residency selection process, detailing potential solutions, and identifying future avenues of investigation.
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BACKGROUND: Suicide is a major public health issue with root causes including psychological, economical, and societal factors. METHODS: Retrospective review identified self-inflicted traumatic injuries (SITIs) at Grady Health System between 2009 and 2017. Patients were categorized by penetrating or blunt mechanism of injury (MOI). Outcomes included hospital length of stay (HLOS) and ventilator duration, mortality, and location of death. RESULTS: 678 patients in total were identified. Penetrating MOI was most prevalent (n = 474). Patients with a blunt MOI were significantly younger (32 Y vs. 37 Y; P < .0001). Psychiatric illness was equally common between MOI at more than 50%. Penetrating traumas required longer ventilator times (1 D vs. 0 D; P < .0001) but shorter overall HLOS (4 D vs. 6 D; P = .0013). Mortality was twice as high in the penetrating group (29.8% vs. 11.8%; P < .0001). CONCLUSION: Self-inflicted traumatic injuries occurred most often among younger adults and those with history of psychiatric illness. Penetrating traumas result in worse outcomes. Self-inflicted traumatic injuries carry high morbidity and mortality. Improved prevention strategies targeting high-risk groups are needed.
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Transtornos Mentais , Ferimentos Penetrantes , Adulto , Hospitais Urbanos , Humanos , Tempo de Internação , Transtornos Mentais/epidemiologia , Estudos Retrospectivos , Ferimentos Penetrantes/epidemiologiaRESUMO
BACKGROUND: Pelvic angioembolization (AE) is a mainstay in the treatment algorithm for pelvic hemorrhage from pelvic fractures. Nonselective AE refers to embolization of the bilateral internal iliac arteries (IIAs) proximally rather than embolization of their tributaries distally. The aim of this study was to quantify the effect of nonselective pelvic AE on pelvic venous flow in a swine model. We hypothesized that internal iliac vein (IIV) flow following IIA AE is reduced by half. METHODS: Nine Yorkshire swine underwent nonselective right IIA gelfoam AE, followed by left. Pelvic arterial and venous diameter, velocity, and flow were recorded at baseline, after right IIA AE and after left IIA AE. Linear mixed-effect model and signed rank test were used to evaluate significant changes between the three time points. RESULTS: Eight swine (77.8 ± 7.1 kg) underwent successful nonselective IIA AE based on achieving arterial resistive index of 1.0. One case was aborted because of technical difficulties. Compared with baseline, right IIV flow rate dropped by 36% ± 29% (p < 0.05) and 54% ± 29% (p < 0.01) following right and left IIA AE, respectively. Right IIA AE had no initial effect on left IIV flow (0.37% ± 99%, p = 0.95). However, after left IIA AE, left IIV flow reduced by 54% ± 27% (p < 0.01). Internal iliac artery AE had no effect on the external iliac arterial or venous flow rates and no effect on inferior vena cava flow rate. CONCLUSION: The effect of unilateral and bilateral IIA AE on IIV flow appears to be additive. Despite bilateral IIA AE, pelvic venous flow is diminished but not absent. There is abundant collateral circulation between the external and internal iliac vascular systems. Arterial embolization may reduce venous flow and improve on resuscitation efforts in those with unstable pelvic fractures. LEVEL OF EVIDENCE: Prognostic, level IV.
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Implante de Prótese Vascular/métodos , Procedimentos Endovasculares/métodos , Hemorragia/terapia , Artéria Ilíaca/cirurgia , Pelve/irrigação sanguínea , Animais , Aorta Abdominal/cirurgia , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Modelos Animais de Doenças , Procedimentos Endovasculares/instrumentação , Feminino , Fraturas Ósseas/complicações , Hemorragia/prevenção & controle , Artéria Ilíaca/fisiopatologia , Masculino , Ossos Pélvicos/lesões , Ossos Pélvicos/patologia , SuínosRESUMO
INTRODUCTION: Food insecurity (FI), defined as inadequate access to affordable and quality nutrition, has negative health consequences. FI and violence share similar root causes. The aim of this study was to determine the association of FI with gunshot injury (GSI) incidence. METHODS: We performed a retrospective review of all patients from 2012 to 2018 who sustained a GSI. Food access data was abstracted from the US Department of Agriculture. We analyzed the impact of FI, low food access (LA), and low food access with no vehicle (LANV) on the incidence of GSI using Poisson regression. We also compared high-risk zip codes for GSI, FI, LA, and LANV using geospatial analysis. RESULTS: There were 1700 patients in our cohort from 33 different zip codes. The median incidence of GSI per zip code was 142 (85-164); 5 zip codes comprised 50% of all GSI events. FI (incidence rate ratio [IRR] 4.05, 95% CI 3.98-4.13, P < .0001), LA (IRR 2.97, 95% CI 2.92-3.03. P < .0001), and LANV (IRR 2.58, 95% CI 2.55-2.62, P < .0001) were significant predictors of GSI incidence. The FI model was superior to the LA and LANV models. Geospatial analysis demonstrated that both FI (P < .0001) and LANV (P < .0001) were significantly associated with GSI, while LA was not (P > .05). CONCLUSION: FI is an independent risk factor for GSI incidence. Additionally, a majority of GSI events occur in a minority of communities. These data provide a novel opportunity for social services to guide future violence prevention strategies.
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Abastecimento de Alimentos/estatística & dados numéricos , Violência com Arma de Fogo/estatística & dados numéricos , Ferimentos por Arma de Fogo/epidemiologia , Adulto , Feminino , Seguimentos , Humanos , Incidência , Masculino , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologia , Ferimentos por Arma de Fogo/prevenção & controle , Adulto JovemRESUMO
Mass casualty events (MCE) are an infrequent occurrence to most daily healthcare systems however these incidents are the causation for new hospital preparedness and the development of coordinated emergency services. The broad support and operational plans outside the hospital include emergency medical services, local law enforcement, government agencies, and city officials. Modern-day hospital disaster preparedness goals include scheduled training for healthcare personnel to ensure effective and accurate triage for a high-volume of injured patients. This MDT collaboration strengthens the emergency response to optimize the delivery of life-saving care during MCEs. This review identifies the clinical importance of the interdisciplinary team interactions and the lessons learned from past MCE experiences, strengthening healthcare system readiness for such critical incidents.
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Studies have shown that monocytes are hyporesponsive and that dendritic cells (DCs) are depleted in burn patients. We have recently shown in a mouse model that burn injury alters the transcriptional regulation in bone marrow progenitors and inhibits myeloid-derived DC (mDC) production. In the present study, using human burn patient peripheral blood mononuclear cells, we have shown an overexpression of MafB with a corresponding reduction in peripheral blood mononuclear cell-derived mDCs. We isolated mononuclear cells from burn patient (2368% TBSA) and control volunteer peripheral blood samples by Ficoll gradient centrifugation and cultured mDCs by using a standard ex vivo culture system. Fluorescence-activated cell sorter analysis was used to select myeloid cells based on the cell surface expression of CD45+. The mDC fraction was identified by the expression of human leukocyte antigen (HLA)-DR+CD11c+, and we found a significant reduction in HLA-DR+ leukocytes for up to 4 weeks postburn. MafB expression was then examined in HLA-DR+CD14+ monocytes. Burn injury alters the phenotype of CD14+ monocytes augmenting MafB expression and reducing their differentiation into mDCs. MafB was then silenced in ex vivo culture prior to DC differentiation by using small interfering RNA technique. MafB gene silencing improved the differentiation potential of CD14+ cells into mDCs, increasing the percentage of mDCs by >75%. Furthermore, GATA-1+ and HLA-DR+ mDCs were increased following MafB silencing. Although burn injury augments the number of peripheral blood monocytes, the frequency of mDC is reduced. This impairment is likely secondary to the down-regulation of mDC differentiation by high MafB-expressing monocytes following burn injury.