Every minute matters: Improving outcomes for penetrating trauma through prehospital advanced resuscitative care.

INTRODUCTION: Prehospital resuscitation with blood products is gaining popularity for patients with traumatic hemorrhage. The MEDEVAC trial demonstrated a survival benefit exclusively among patients who received blood or plasma within 15 minutes of air medical evacuation. In fast-paced urban EMS systems with a high incidence of penetrating trauma, mortality data based on the timing to first blood administration is scarce. We hypothesize a survival benefit in patients with severe hemorrhage when blood is administered within the first 15 minutes of EMS patient contact. METHODS: This was a retrospective analysis of a prospective database of prehospital blood (PHB) administration between 2021 and 2023 in an urban EMS system facing increasing rates of gun violence. PHB patients were compared to trauma registry controls from an era before prehospital blood utilization (2016-2019). Included were patients with penetrating injury and SBP ≤ 90 mmHg at initial EMS evaluation that received at least one unit of blood product after injury. Excluded were isolated head trauma or prehospital cardiac arrest. Time to initiation of blood administration before and after PHB implementation and in-hospital mortality were the primary variables of interest. RESULTS: A total of 143 patients (PHB = 61, controls = 82) were included for analysis. Median age was 34 years with no difference in demographics. Median scene and transport intervals were longer in the PHB cohort, with a 5-minute increase in total prehospital time. Time to administration of first unit of blood was significantly lower in the PHB vs. control group (8 min vs 27 min; p < 0.01). In-hospital mortality was lower in the PHB vs. control group (7% vs 29%; p < 0.01). When controlling for patient age, NISS, tachycardia on EMS evaluation, and total prehospital time interval, multivariate regression revealed an independent increase in mortality by 11% with each minute delay to blood administration following injury (OR 1.11, 95%CI 1.04-1.19). CONCLUSION: Compared to patients with penetrating trauma and hypotension who first received blood after hospital arrival, resuscitation with blood products was started 19 minutes earlier after initiation of a PHB program despite a 5-minute increase in prehospital time. A survival for early PHB use was demonstrated, with an 11% mortality increase for each minute delay to blood administration. Interventions such as PHB may improve patient outcomes by helping capture opportunities to improve trauma resuscitation closer to the point of injury. LEVEL OF EVIDENCE: Prospective, Level IV.

The Enneagram as a Tool for Resident Wellness and Correlation With Accreditation Council for Graduate Medical Education Milestone Achievements.

INTRODUCTION: The Enneagram is an ancient personality typing system developed to improve self-knowledge. Broken down into nine personality types, each is driven by a core motivating factor. Other personality assessments have been used to study the personality profile of surgeons. The purpose of this study is to evaluate the variability in Enneagram type among a single institution's general surgery residents. METHODS: All categorical general surgery residents at a single institution completed an online Enneagram assessment as part of a wellness initiative. Accreditation Council for Graduate Medical Education milestone levels for professionalism (PRO) and interpersonal and communication skills were collected for each resident's intern year. Milestone levels were compared between the nine Enneagram types. RESULTS: All nine Enneagram types were represented among surveyed residents. The most frequent Enneagram type was type 3 (20.69%). There was no significant difference between PRO (P = 0.322) and interpersonal and communication skills (P = 0.645) scores among residents distributed by Enneagram type. CONCLUSIONS: Regardless of core Enneagram type, general surgery residents in this study all achieved appropriate Accreditation Council for Graduate Medical Education milestone levels for entry level of training. The Enneagram can provide self-awareness and understanding of resident differences but does not impact initial assessment of competency in PRO and interpersonal communication skills.

Increasing the Rate of Venous Thromboembolism Chemoprophylaxis Administration Using the Electronic Medical Record.

Introduction: Venous thromboembolism (VTE) remains a leading cause of preventable harm among hospitalized patients. Pharmacologic VTE prophylaxis reduces the rate of in-hospital VTE by 60%, but medication administration is often missed for various reasons. Electronic medical record (EMR) prompts may be a useful tool to decrease withholding of critical VTE chemoprophylaxis medications. Methods: In August 2021, an EMR prompt was implemented at a tertiary referral academic medical center mandating nursing staff to contact a provider for approval before withholding VTE chemoprophylaxis. A pre-intervention group from August 2020 to August 2021 was compared to a post-intervention group from August 2021 to August 2022. Rates of VTE chemoprophylaxis withholding were compared between the groups with a P < .01 considered significant. Results: A total of 16,395 patients prescribed VTE chemoprophylaxis were reviewed, with 13,395 (81.7%) receiving low molecular weight heparin. Of the 16,395 patients included, 10,701 (65.3%) were medical and 5694 (34.7%) were surgical. Patients in the pre-intervention cohort (n = 8803) and post-intervention cohort (n = 7592) were similar in hospital length of stay and duration of DVT prophylaxis. In the post-intervention group, the frequency of surgical patients with at least one missed dose had increased by 4.2% (P = .002), with the trauma and acute care surgery (TACS) show an increase of 6.6% (P < .001). However, the frequency of medical patients and non-TACS patients with missed doses decreased by 3.1% (P = .002) and 1.0% (<.001), respectively. Conclusions: EMR prompts appear to be a low-cost intervention that increases the rate of VTE prophylaxis administration among medical and elective surgery patients.

A western trauma association multicenter comparison of mesh versus non-mesh repair of blunt traumatic abdominal wall hernias.

BACKGROUND: Blunt traumatic abdominal wall hernias (TAWH) occur in <1 % of trauma patients. Optimal repair techniques, such as mesh reinforcement, have not been studied in detail. We hypothesize that mesh use will be associated with increased surgical site infections (SSI) and not improve hernia recurrence. MATERIALS AND METHODS: A secondary analysis of the Western Trauma Association blunt TAWH multicenter study was performed. Patients who underwent TAWH repair during initial hospitalization (1/2012-12/2018) were included. Mesh repair patients were compared to primary repair patients (non-mesh). A logistic regression was conducted to assess risk factors for SSI. RESULTS: 157 patients underwent TAWH repair during index hospitalization with 51 (32.5 %) having mesh repair: 24 (45.3 %) synthetic and 29 (54.7 %) biologic. Mesh patients were more commonly smokers (43.1 % vs. 22.9 %, p = 0.016) and had a larger defect size (10 vs. 6 cm, p = 0.003). Mesh patients had a higher rate of SSI (25.5 % vs. 9.5 %, p = 0.016) compared to non-mesh patients, but a similar rate of recurrence (13.7 % vs. 10.5%, p = 0.742), hospital length of stay (LOS), and mortality. Mesh use (OR 3.66) and higher ISS (OR 1.06) were significant risk factors for SSI in a multivariable model. CONCLUSION: Mesh was used more frequently in flank TAWH and those with a larger defect size. Mesh use was associated with a higher incidence and risk of SSI but did not reduce the risk of hernia recurrence. When repairing TAWH mesh should be employed judiciously, and prospective randomized studies are needed to identify clear indications for mesh use in TAWH.

Early Surgical Stabilization of Rib Fractures is Feasible in Patients With Non-Urgent Operative Pelvic Injuries.

INTRODUCTION: The feasibility of prioritizing surgical stabilization of rib fractures (SSRF) in patients with other injuries is unknown. The purpose of this study was to evaluate the timing and outcomes of SSRF between patients with and without non-urgent operative pelvic injuries. PATIENTS AND METHODS: In this retrospective observational study, all patients between 2010 and 2020 who underwent SSRF (SSRF group) and those who underwent SSRF and non-urgent operative management of pelvic fractures (SSRF + P group) were included. Demographics, injury characteristics, operative details, and outcomes were compared between the 2 groups. RESULTS: Over 11 years, 154 SSRF patients were identified, with 143 patients in the SSRF group (93%) and 11 patients in the SSRF + P group (7%). Median number of rib fractures (7 vs 9, P = .04), total number of fractures (11 vs 15, P < .01), and flail segment (54% vs 91%, P = .02) were higher in SSRF + P group. Median time to SSRF was similar (0 vs 1 day, P = .20) between the 2 groups. Median time to pelvic fixation was 3 days in SSRF + P group and 8 out of 11 patients (73%) underwent SSRF prior to pelvic fixation. Median operative time (137 vs 178 mins, P = .14) and median number of ribs plated (4 vs 5, P = .05) were higher in SSRF + P group. There was no difference in SSRF-related complications, pelvic fracture-related complications from operative positioning, rates of pneumonia, or mortality between the 2 groups. CONCLUSIONS: SSRF can be performed early in patients with non-urgent operative pelvic injuries without a difference in pelvic fracture-related complications, SSRF-related complications, pneumonia, or mortality.

Atraumatic Acute Paraspinal Compartment Syndrome in a Patient With McArdle's Disease.

A 60-year-old male presented to the emergency room with complaints of back pain overlying the left lumbar area and ipsilateral thigh numbness. The left erector spinae musculature was rigid, tense, and painful to palpation. An elevated serum creatine kinase was identified, and a computed tomography scan showed evidence of left paraspinal musculature congestion. Past medical/surgical history was significant for McArdle's disease and bilateral forearm fasciotomies. The patient underwent lumbosacral fasciotomy with no obvious myonecrosis. The patient was discharged home after skin closure and has since been seen in clinic with no residual pain or change in baseline functional status. This case may represent the first reported atraumatic exertional lumbar compartment syndrome in a patient with McArdle's disease. Prompt operative intervention was effective in this case of acute atraumatic paraspinal compartment syndrome and resulted in an excellent functional outcome.

Hypofibrinogenemic Massive Transfusion Trauma Patients Experience Worse Outcomes.

INTRODUCTION: Uncontrolled hemorrhage accounts for up to 40% of trauma-related mortality. Previous reports demonstrate that decreased fibrinogen levels during traumatic hemorrhage are associated with worse outcomes. Cryoprecipitate is used to replace fibrinogen for patients in hemorrhagic shock undergoing massive transfusion (MT), though the optimal ratio of cryoprecipitate to fresh frozen plasma (FFP), packed red blood cells (PRBCs), and platelets remains undefined. The purpose of this study is to investigate the effect of admission fibrinogen level and the use of cryoprecipitate on outcomes in trauma patients undergoing MT. METHODS: A prospective practice management guideline was established to obtain fibrinogen levels on adult trauma patients undergoing MT at a level I trauma center from December 2019 to December 2021. Ten units of cryoprecipitate were administered every other round of MT. Thromboelastography (TEG) was also obtained at the initiation and completion of MT. Patient demographic, injury, transfusion, and outcome data were collected. Hypofibrinogenemic (<200 mg/dL) patients at initiation of MT were compared to patients with a level of 200 mg/dL or greater. RESULTS: A total of 96 out of 130 patients met criteria and underwent MT with a median admission fibrinogen of 170.5 mg/dL. Hypofibrinogenemia was associated with elevated INR (1.26 vs 1.13, P < .001) and abnormal TEG including decreased alpha angle (68.1 vs 73.3, P < .001), increased K time (1.7 vs 1.1, P < .001), and decreased max amplitude (58 vs 66, P < .001). Patients with hypofibrinogenemia received more PRBC (10 vs 7 U, P = .002), FFP (9 vs 6 U, P = .003), and platelets (2 vs 1 U, P = .004) during MT. Hypofibrinogenemic patients demonstrated greater mortality than patients with normal levels (50% vs 23.5%, P = .021). Older age, decreased GCS, and elevated injury severity score (ISS) were risk factors for mortality. Increased fibrinogen was associated with lower odds of mortality (P = .001). Age, ISS, and fibrinogen level remained significantly associated with mortality in a multivariable analysis. Overall, fibrinogen in post-MT survivors showed an increase in median level compared to admission (231 vs 177.5 mg/dL, P < .001). CONCLUSION: Trauma patients undergoing MT with decreased admission fibrinogen demonstrate increased mortality. Other mortality risk factors include older age, decreased GCS, and higher ISS. Patients with increased fibrinogen levels had lower odds of mortality in a multivariable model. Post-MT survivors demonstrated significantly higher fibrinogen levels than pre-MT patients. Hypofibrinogenemic patients also had worse TEG parameters and required more PRBCs, FFP, and platelets during MT. Further studies are needed to assess the optimal volume of fibrinogen replacement with cryoprecipitate during MT to improve trauma patient mortality.

Small Bowel Intussusception Secondary to Malignant Melanoma 11 Years After Melanoma-In-Situ Excision.

Small bowel is a well-described site of malignant melanoma; however, it is a rare cause of intussusception. A patient presented with malignant melanoma causing jejunojejunal intussusception 11 years after resection of melanoma-in-situ. The patient was managed with exploration and resection. Despite complete resection of melanoma-in-situ and limited literature about its metastatic potential, malignant melanoma as a lead point for intussusception should be on the differential for any patient with pertinent history. To our knowledge, this appears to be the first case of melanoma-in-situ causing small bowel intussusception.

Methicillin-Resistant Staphylococcus aureus Nasal Swab Is Insufficient to Withhold Empiric Methicillin-Resistant Staphylococcus aureus Pneumonia Coverage in a Trauma Population.

INTRODUCTION: Methicillin-resistant staphylococcus aureus (MRSA) nasal colonization is a predictor of MRSA pneumonia in intensive care unit (ICU) patients. Negative nasal swabs have shown up to a 97% negative predictive value for MRSA pneumonia in nontrauma populations, though little investigation has been pursued in trauma patients. MATERIALS AND METHODS: All trauma patients admitted to the ICU from April 2018 to February 2019 were screened for MRSA colonization by nasal swab. Patients with suspicion for pneumonia underwent bronchoalveolar lavage or quantitative sputum culture and were started on empiric antibiotic therapy based on the swab result. Swab-positive patients were started on empiric MRSA coverage and swab-negative patients were not. RESULTS: MRSA nasal swab screening was performed in 601 trauma ICU patients. Ninety-six patients subsequently underwent pneumonia workup and were started on an empiric antibiotic regimen based on nasal swab results. Seventeen (17.7%) patients were MRSA nasal swab positive on screening, and 22 (22.9%) patients subsequently had significant growth of MRSA on quantitative respiratory culture. The sensitivity of nasal swab was 50.0% and the specificity was 91.9%. Eleven patients had a negative MRSA nasal swab but a positive MRSA pneumonia (11.5%). Patients with inadequate antibiotic coverage had statistically longer hospital length of stay, ICU length of stay, ventilator days, and rates of unplanned intubation compared to patients with adequate antibiotic coverage. CONCLUSIONS: Nasal swab screening was not sensitive enough in a trauma population with a high endemic incidence of MRSA colonization to warrant withholding empiric antibiotic MRSA coverage in patients with suspected pneumonia.

Risk factors for recurrence in blunt traumatic abdominal wall hernias: A secondary analysis of a Western Trauma association multicenter study.

BACKGROUND: Few studies have investigated risk factors for recurrence of blunt traumatic abdominal wall hernias (TAWH). METHODS: Twenty trauma centers identified repaired TAWH from January 2012 to December 2018. Logistic regression was used to investigate risk factors for recurrence. RESULTS: TAWH were repaired in 175 patients with 21 (12.0%) known recurrences. No difference was found in location, defect size, or median time to repair between the recurrence and non-recurrence groups. Mesh use was not protective of recurrence. Female sex, injury severity score (ISS), emergency laparotomy (EL), and bowel resection were associated with hernia recurrence. Bowel resection remained significant in a multivariable model. CONCLUSION: Female sex, ISS, EL, and bowel resection were identified as risk factors for hernia recurrence. Mesh use and time to repair were not associated with recurrence. Surgeons should be mindful of these risk factors but could attempt acute repair in the setting of appropriate physiologic parameters.

Early pneumonia diagnosis decreases ventilator-associated pneumonia rates in trauma population.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a source of morbidity and mortality for trauma patients. Aspiration events are also common because of traumatic brain injury, altered mental status, or facial trauma. In patients requiring mechanical ventilation, early pneumonias (EPs) may be erroneously classified as ventilator associated. METHODS: A prospective early bronchoscopy protocol was implemented from January 2020 to January 2022. Trauma patients intubated before arrival or within 48 hours of admission underwent bronchoalveolar lavage (BAL) within 24 hours of intubation. Patients with more than 100,000 colony-forming units on BAL were considered to have EP. RESULTS: A total of 117 patients underwent early BAL. Ninety-three (79.5%) had some growth on BAL with 36 (30.8%) meeting criteria for EP. For the total study population, 29 patients (24.8%) were diagnosed with VAP later in their hospital course, 12 of which had previously been diagnosed with EP. Of EP patients (n = 36), 21 (58.3%) were treated with antibiotics based on clinical signs of infection. Of EP patients who had a later pneumonia diagnosed by BAL (n = 12), seven (58.3%) grew the same organism from their initial BAL. When these patients were excluded from VAP calculation, the rate was reduced by 27.6%. Patients with EP had a higher rate of smoking history (41.7% vs. 19.8%, p < 0.001) compared with patients without EP. There was no difference in median hospital length of stay, intensive care unit length of stay, ventilator days, or mortality between the two cohorts. CONCLUSION: Early pneumonia is common in trauma patients intubated within the first 48 hours of admission and screening with early BAL identifies patients with aspiration or pretraumatic indicators of pneumonia. Accounting for these patients with early BAL significantly reduces reported VAP rates. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Ultrasound may safely replace chest radiograph after tube thoracostomy removal in trauma patients.

INTRODUCTION: A chest radiograph (CXR) is routinely obtained in trauma patients following tube thoracostomy (TT) removal to assess for residual pneumothorax (PTX). New literature supports the deference of a radiograph after routine removal procedure. However, many surgeons have hesitated to adopt this practice due to concern for patient welfare and medicolegal implications. Ultrasound (US) is a portable imaging modality which may be performed rapidly, without radiation exposure, and at minimal cost. We hypothesized that transitioning from CXR to US following TT removal in trauma patients would prove safe and provide superior detection of residual PTX. MATERIALS AND METHODS: A practice management guideline was established calling for the performance of a CXR and bedside US 2 h after TT removal in all adult trauma patients diagnosed with PTX at a level 1 trauma center. Surgical interns completed a 30-minute, US training course utilizing a handheld US device. US findings were interpreted and documented by the surgical interns. CXRs were interpreted by staff radiologists blinded to US findings. Data was retrospectively collected and analyzed. RESULTS: Eighty-nine patients met inclusion criteria. Thirteen (15%) post removal PTX were identified on both US and CXR. An additional 11 (12%) PTX were identified on CXR, and 5 (6%) were identified via US, for a total of 29 PTX (33%). One patient required re-intervention; the recurrent PTX was detected by both US and CXR. For all patients, using CXR as the standard, US displayed a sensitivity of 54.2%, specificity of 92.3%, negative predictive value of 84.5%, and positive predictive value of 72.2%. The cost of care for the study cohort may have been reduced over $9,000 should US alone have been employed. CONCLUSION: Bedside US may be an acceptable alternative to CXR to assess for recurrent PTX following trauma TT removal.

Analysis of Admission Thromboelastogram Profiles in 1369 Male and Female Trauma Patients.

INTRODUCTION: Recent studies have demonstrated a hypercoagulable thromboelastrogram (TEG) in female trauma patients compared with males, conferring a possible survival advantage. We hypothesized that TEG profiles would reveal a relative hypercoagulable state in female compared with male trauma patients. METHODS: A prospective review was conducted on all adult trauma patients admitted to the trauma service at an American College of Surgeons-verified level I trauma center from December 2019 to June 2021 who, per our institutional protocol, received a thrombelastotgraphy on their initial arrival to the trauma center if classified as a level I or II trauma activation. The thromboelastography values of male and female trauma patients were compared as the primary outcome variables of interest. The secondary outcomes investigated were hospital length of stay, surgical interventions, and ventilatory requirement. RESULTS: A total of 1369 patients met inclusion criteria, with 878 (64.1%) male and 491 (35.9%) female. Female patients had a higher median alpha angle (74.8 versus 72.6°, P < 0.001), maximum amplitude (69.3 versus 66.2 mm, P < 0.001), and shorter median K time (1.0 versus 1.2 s, P < 0.001). Female patients had a shorter hospital length of stay (4 versus 5 d, P < 0.001), had a lower rate of surgical intervention (14.6% versus 25.5%, P < 0.001), and had lower rates of mechanical ventilation (19.3% versus 39.5%, P < 0.001). CONCLUSIONS: Female trauma patients were found to have hypercoagulable indices on TEG at the time of initial trauma evaluation compared with males. Intrinsic differences in sex coagulation profiles should be further investigated to optimize modern resuscitation strategies.

Management of blunt traumatic abdominal wall hernias: A Western Trauma Association multicenter study.

BACKGROUND: Blunt traumatic abdominal wall hernias (TAWH) occur in approximately 15,000 patients per year. Limited data are available to guide the timing of surgical intervention or the feasibility of nonoperative management. METHODS: A retrospective study of patients presenting with blunt TAWH from January 2012 through December 2018 was conducted. Patient demographic, surgical, and outcomes data were collected from 20 institutions through the Western Trauma Association Multicenter Trials Committee. RESULTS: Two hundred and eighty-one patients with TAWH were identified. One hundred and seventy-six (62.6%) patients underwent operative hernia repair, and 105 (37.4%) patients underwent nonoperative management. Of those undergoing surgical intervention, 157 (89.3%) were repaired during the index hospitalization, and 19 (10.7%) underwent delayed repair. Bowel injury was identified in 95 (33.8%) patients with the majority occurring with rectus and flank hernias (82.1%) as compared with lumbar hernias (15.8%). Overall hernia recurrence rate was 12.0% (n = 21). Nonoperative patients had a higher Injury Severity Score (24.4 vs. 19.4, p = 0.010), head Abbreviated Injury Scale score (1.1 vs. 0.6, p = 0.006), and mortality rate (11.4% vs. 4.0%, p = 0.031). Patients who underwent late repair had lower rates of primary fascial repair (46.4% vs. 77.1%, p = 0.012) and higher rates of mesh use (78.9% vs. 32.5%, p < 0.001). Recurrence rate was not statistically different between the late and early repair groups (15.8% vs. 11.5%, p = 0.869). CONCLUSION: This report is the largest series and first multicenter study to investigate TAWHs. Bowel injury was identified in over 30% of TAWH cases indicating a significant need for immediate laparotomy. In other cases, operative management may be deferred in specific patients with other life-threatening injuries, or in stable patients with concern for bowel injury. Hernia recurrence was not different between the late and early repair groups. LEVEL OF EVIDENCE: Therapeutic/care management, Level IV.

Social Media in Surgery.

Social media has become a permeating form of communication with billions of daily users. Twitter in particular has become a tool for the surgical community to engage with other providers, as well as patients, through active online discussions, sharing of research, and highlighting opportunities for community outreach. Twitter can help with personal branding, mentorship, and international collaboration on multiple types of academic endeavors. Likewise, institutional and residency programs can harness the power of social media to develop an online presence and aid in resident recruitment.

Late Operative Rib Fixation is Inferior to Nonoperative Management.

BACKGROUND: Operative rib fixation (ORF) of traumatic rib fractures has been shown to decrease hospital length of stay (LOS), ventilator days, and mortality. ORF performed within 1 day of admission has been shown to have favorable outcomes compared to later ORF. This report examines the ORF experience over 10 years at a level I trauma center. METHODS: ORF patients from January 2007-January 2018 were matched to nonoperative controls in a 1:2 ratio based on age, injury severity score (ISS), chest Abbreviated Injury Score (AIS), and head AIS. Patient demographic, injury, and outcome data were collected from the trauma registry and medical records. Hospital day of ORF was identified for each ORF patient. Hospital LOS, ICU LOS, ventilator days, and mortality were compared against matched nonoperative controls. RESULTS: Ninety-five ORF patients were matched to 190 nonoperative patients. ORF patients had a higher number of rib fractures (9.6 vs 6.4, P < .001). ORF patients with short time to operation (0-2 days) had a shorter average hospital stay than those with delayed operations (11.8 vs 12.6 vs 13.4 vs 19.6 days, P = .003). ORF patients with operations performed 3-4 days and >6 days after admission also had statistically significant longer ICU LOS and ventilator days. Patient mortality was higher when ORF was performed after 6 days. DISCUSSION: Early ORF may improve pulmonary function, patient outcomes, and decrease LOS. Shifting practice toward early fixation may help further solidify the benefits of this procedure in the treatment of blunt chest trauma.

A Comparison of Prehospital Nonphysician and Hospital Physician Placed Tube Thoracostomy.

BACKGROUND: Prehospital chest decompression can be a lifesaving procedure in severe chest trauma. Studies investigating prehospital chest decompression are mostly European where physicians are assigned to prehospital care units. This report is one of the first to compare demographics and outcomes in patients undergoing prehospital chest decompression by trained aeromedical nonphysician personnel to hospital chest decompression by physicians. METHODS: Prehospital tube thoracostomy (PTT) patients were identified from January 2014 to January 2019 and were matched in a 1:2 ratio based on age, Injury Severity Score (ISS), and chest Abbreviated Injury Score (AIS) to patients who underwent hospital tube thoracostomy (HTT) within 24 hours of admission. RESULTS: Forty-nine PTT patients were matched to 98 HTT patients. PTT patients had lower admission Glasgow Coma Scale (GCS), a higher rate of pre-chest tube needle decompression, and higher level 1 trauma activation. PTT were placed sooner (21.9 vs 157.0 minutes, P < .001). Rates of tube malposition, organ injury, tube dislodgement, empyema, and hospital-acquired pneumonia over the course of hospital admission were not significantly different between the 2 groups. PTT patients had longer intensive care unit length of stay (LOS), but similar hospital LOS, and overall mortality. DISCUSSION: This report demonstrates that PTT is performed sooner than hospital placed tubes. Complication rates associated with tube thoracostomy and patient outcomes were not statistically different between PTT and HTT groups.

Management of Esophageal Lung in a Patient With VACTERL Anomalies.

Esophageal lung is a rare type of bronchopulmonary foregut malformation where an anomalous main bronchus arises from the esophagus rather than the trachea. This differentiates from an esophageal bronchus where a lobar bronchus arises from the esophagus. Fewer than 30 of these anomalies have been reported in the literature. A female infant was born at 35 weeks gestational age and found to have multiple congenital abnormalities including cleft palate, long-gap esophageal atresia, tracheoesophageal fistula (TEF), imperforate anus, and renal anomalies. She initially underwent thoracoscopic ligation of TEF with colostomy and mucus fistula creation. Bronchoscopy found no right mainstem bronchus, and subsequent computed tomography scan was consistent with possible esophageal bronchus. Esophagoscopy through the gastrostomy discovered a fistulous connection between the distal esophagus and anomalous main right bronchus.Right thoracotomy with pneumonectomy of the hypoplastic lung was performed. She subsequently underwent vaginostomy for hydrometrocolpos. Her proximal esophagus was diverted with a cervical esophagostomy for control of secretions. She also required tracheotomy and is currently at home on minimal ventilator settings awaiting staged reconstruction.Esophageal lung is a rare congenital abnormality with few reported cases. Surgical treatment with pneumonectomy is often required, and pediatric surgeons should be familiar with these congenital bronchopulmonary malformations.

Modified Need for Trauma Intervention Criteria Reduces Cribari Trauma Overtriage Rate.

INTRODUCTION: The American College of Surgeons Committee on Trauma (ACS-CoT) sets standards for appropriate trauma activation criteria. Overtriage and undertriage rates are traditionally determined by the Cribari matrix using the Injury Severity Score (ISS). In 2016, the Need for Trauma Intervention (NFTI) criteria were developed by Baylor University Medical Center to overcome weaknesses in the Cribari matrix methodology. METHODS: A retrospective review of trauma triage rates was conducted from March 2018 to February 2019. Overtriage rates were calculated using the Cribari matrix and then further evaluated using modified NFTI (MNFTI) criteria. Overtriaged patients meeting MNFTI criteria were considered appropriately triaged and deleted from the overtriage category, and adjusted triage rates were determined. Demographic, injury, and outcome data were compared between MNFTI-positive and MNFTI-negative groups. A logistic regression analysis was performed to assess for predictors of patient mortality. RESULTS: Using the Cribari matrix, 248 patients were identified as overtriaged. Of these, 133 (53.6%) were found to meet MNFTI criteria. The average monthly overtriage rate was reduced from 55% using the Cribari matrix to 26% after applying the MNFTI criteria. Within the Cribari overtriage patient group, MNFTI-positive patients had significantly longer hospital length of stay (LOS) (3.7 vs. 6.0 days, p = .016), intensive care unit LOS (1.2 vs. 4.2 days, p < .001), and ventilator days (0.6 vs. 1.6 days, p = .002) than MNFTI-negative patients. A multivariable logistic regression analysis found that meeting any of the MNFTI criteria significantly increased the odds of mortality (OR = 10.38; 95% CI [3.87, 27.84], p < .001). CONCLUSIONS: Discharge ISS may not accurately reflect the patient's acuity on presentation. Applying MNFTI criteria to the Cribari matrix improved overtriage rates and may more accurately reflect need for full trauma team activation. Patients meeting MNFTI criteria had worse outcomes overall and had a 10-fold increase in the odds of mortality.