Self-Inflicted Abdominal Stab Wounds Have a Higher Rate of Non-therapeutic Laparotomy/Laparoscopy and a Lower Risk of Injury.

BACKGROUND: The profile and management of self-inflicted abdominal stab wounds (SI-ASW) patients is still obscure. METHODS: The National Trauma Data Bank (2012) was queried for adults with abdominal stab wounds (n = 9544). Patients with SI-ASW (n = 1724) and non-SI-ASW (n = 7820) were compared. Predictors for non-therapeutic laparotomy/laparoscopy (non-TL) in SI-ASW patients were identified. RESULTS: SI-ASW patients were older, had more females and behavioral disorders, similar physiology, but a lower Injury Severity Score. They had more laparotomies overall (54 versus 48%, p < 0.0001) and more non-TL (42 versus 32%, p < 0.0001), but less injuries (43 versus 53%, p < 0.0001), although peritoneal violation rate was similar. Complications and mortality were similar. In the SI-ASW cohort, non-TL patients were more likely to be female and younger, and to have Glasgow Coma Scale (GCS) ≥13 and a higher systolic blood pressure. History of psychiatric, drug and alcohol disorders was associated with SI-ASW, but did not independently predict the need for treatment in adjusted models. CONCLUSION: Patients with SI-ASW underwent more non-TL than patients with non-SI-ASW. Female gender, younger age, and a higher GCS and systolic blood pressure predicted non-TL in this group.

Bicyclist Safety Behaviors in an Urban Northeastern, United States City: An Observational Study.

Bicycling is gaining popularity in the United States, and laws and safety recommendations are being established to keep bicyclists safer. To improve road safety for bicyclists, there is a need to characterize their compliance with road laws and safety behaviors. Adult bicyclists were observed at three high-traffic intersections in Boston, MA, with state recommendations of wearing a helmet and riding in a bike lane. State law compliance for displaying reflectors during the day and of a front light and a rear light/reflector at night, obeying traffic signals, and giving pedestrians the right of way was also observed. Variables were compared between personal and shared/rented bicyclists and analyzed by time of day. A total of 1,685 bicyclists were observed. Because of the speed of the bicyclists and obstructed views, only a sampling of 802 bicyclists was observed for reflectors/front light. Overall, 74% wore a helmet, 49% had reflectors/front lights, 95% rode in bike lanes, 87% obeyed traffic signals, and 99% gave the right of way to pedestrians. Compared with shared bicyclists (n = 122), personal bicyclists (n = 1563) had a higher helmet-wearing behaviors (77% vs. 39%, p = .0001). Shared bicyclists had a higher (p = .0001) compliance with reflectors/lights (100%) than personal bicyclists (39%, n = 265). Boston bicyclists ride in bike lanes, obey traffic signals, give pedestrians the right of way, and wear helmets while having suboptimal compliance with light/reflector use. Educational programs and stricter law enforcement aimed at these safety behaviors should be part of the effort to improve safety for all road users.

The initial response to the Boston marathon bombing: lessons learned to prepare for the next disaster.

OBJECTIVE: We discuss the strengths of the medical response to the Boston Marathon bombings that led to the excellent outcomes. Potential shortcomings were recognized, and lessons learned will provide a foundation for further improvements applicable to all institutions. BACKGROUND: Multiple casualty incidents from natural or man-made incidents remain a constant global threat. Adequate preparation and the appropriate alignment of resources with immediate needs remain the key to optimal outcomes. METHODS: A collaborative effort among Boston's trauma centers (2 level I adult, 3 combined level I adult/pediatric, 1 freestanding level I pediatric) examined the details and outcomes of the initial response. Each center entered its respective data into a central database (REDCap), and the data were analyzed to determine various prehospital and early in-hospital clinical and logistical parameters that collectively define the citywide medical response to the terrorist attack. RESULTS: A total of 281 people were injured, and 127 patients received care at the participating trauma centers on that day. There were 3 (1%) immediate fatalities at the scene and no in-hospital mortality. A majority of the patients admitted (66.6%) suffered lower extremity soft tissue and bony injuries, and 31 had evidence for exsanguinating hemorrhage, with field tourniquets in place in 26 patients. Of the 75 patients admitted, 54 underwent urgent surgical intervention and 12 (22%) underwent amputation of a lower extremity. CONCLUSIONS: Adequate preparation, rapid logistical response, short transport times, immediate access to operating rooms, methodical multidisciplinary care delivery, and good fortune contributed to excellent outcomes.

Blood pressure regulation to prevent progression of blunt traumatic intracranial hemorrhage in stable patients.

BACKGROUND: Target blood pressure (BP) in stable (non-hypotensive) patients with acute isolated blunt traumatic intracranial hemorrhage (TICH) is unknown. To address this issue, our study correlated BP with radiological volumetric progression (RP) and neurological deterioration (ND) in these patients. METHODS: A retrospective review of hemodynamically stable adults (n = 184) with isolated TICH not requiring emergent surgery consecutively admitted to a Level I trauma center. BPs before admission computed tomography (CT) scan (CT1) and between CT1 and a follow-up CT (CT2) were correlated with TICH volume and Glasgow Coma Scale (GCS) during these time periods. Predictors for deterioration were studied. Primary outcomes were increased measured TICH and decreased GCS at the CT1-CT2 interval. RESULTS: Age (57 years), % male (73), ISS (17), % falls (77), comorbidities (1.2/pt), and % anticoagulation (20) were similar in patients with or without RP (n = 107, 58%) or ND (n = 34, 18%). By univariate analysis, RP patients had an average systolic (SBP), diastolic (DBP), and mean BP (MAP) similar to non-RP patients; whereas ND patients compared to non-ND patients had a higher mean admission DBP (p < 0.02) and MAP (p < 0.04), a higher mean admission peak MAP (p < 0.01) and DBP (p < 0.01), a higher CT1-CT2 interval peak DBP (p < 0.01) and peak MAP (p < 0.01), and a lower CT1-CT2 nadir SBP (p < 0.04). Spearman rank correlation test did not show association among average SBP, MAP, DBP, absolute or % change in BPs, and absolute or % change in TICH volumes in any phase. Multivariate analysis identified higher nadir admission SBP [adjusted odds ratio (AOR) 1.29 per 10 mmHg increase] and lower peak MAP during the CT1-CT2 period (AOR 0.71 per 10 mmHg decrease) as independent predictors of RP, and a peak DBP in the CT1-CT2 interval (AOR 1.48) as an independent predictor of ND. Other predictors of ND included bilateral admission TICH (AOR 3.31) and increased injury volume (AOR 1.36), while the number of comorbidities/patient (AOR 4.34), bilateral injury (AOR 3.12), and midline shift (AOR 4.34) predicted RD. CONCLUSIONS: A comprehensive dynamic analysis correlating repeated BP determinations with quantifiable repeated parameters of TICH deterioration (injury volume and GCS) did not demonstrate a clinically relevant protective target BP value. Current practices of BP control in this specific group of patients should be further investigated. LEVEL OF EVIDENCE III: Prognostic, Level II study.

The profile of blunt traumatic supratentorial cranial bleed types.

The characteristics of blunt traumatic supratentorial cranial bleed (STCB) types have not been directly compared. The National Trauma Data Bank (NTDB) 2014 was queried for adults with an isolated single STCB n = 57,278. Patients were grouped by STCB categories: subdural (SDH), subarachnoid (SAH), epidural (EDH), intraparenchymal (IPH), and intraventricular hemorrhage (IVH). Frequency, demographics, clinical characteristics, procedures, and outcomes were compared among groups. SDH was the most common STCB (53%) and occurred mostly in elderly patients after a fall (78%), 30% underwent craniotomy and their mortality was 7%. SAH occurred in 32% of patients and carried the lowest mortality (3%). SAH were least likely to have a severe brain injury (7%), and had the lowest Injury Severity Score (ISS, median 8) and complication rate (1%), as well as the shortest hospital length of stay (HLOS, 4.6 ±â€¯6.4 days). EDH was uncommon (2%), occurred in younger patients (median 35 years), and had the highest percentage of traffic related injuries (28%). While EDH patients presented with the poorest neurological status (16% Glasgow Coma Scale ≤ 8, ISS median 18) and were operated on more than any other STCB type (51%), their mortality was lower (4%) and they had the highest discharge to home rate (71%). IVH was the least common (2%), but most lethal (9%) STCB type. These patients had the highest HLOS and intensive care unit LOS, and the lowest craniotomy rate (21%). STCB types have different clinical course, and outcomes. Understanding these differences can be useful in managing patients with STB.

The profile of blunt traumatic infratentorial cranial bleed types.

Infratentorial traumatic intracranial bleeds (ICBs) are rare and the distribution of subtypes is unknown. To characterize this distribution the National Trauma Data Bank (NTDB) 2014 was queried for adults with single type infratentorial ICB, n = 1,821: subdural hemorrhage (SDH), subarachnoid hemorrhage (SAH), epidural hemorrhage (EDH), and intraparenchymal hemorrhage (IPH). Comparisons were made between the groups with statistical significance determined using chi squared and t-tests. SDH occurred in 29% of patients, mostly in elderly on anti-coagulants (13%) after a fall (77%), 42% of them underwent craniotomy, their mortality was the lowest (4%). SAH was the most common (56%) occurring mostly from traffic related injuries (27%). Furthermore, 9% of them had a severe head injury Glasgow Coma Scale ≤8 (GCS), but had the lowest Injury Severity Score (ISS, median 8) as well as a short hospital length of stay, 5.1 ±â€¯6.2 days. These patients were most likely to be discharged to home (64%). They had the lowest mortality (4%). EDH was the least common ICB (5%), occurred in younger patients (median age 49 years), and it had the highest percentage of associated injuries (13%). EDH patients presented with the poorest neurological status (26% GCS ≤8, ISS median 25) and were operated on more than any other ICB type (55%). EDH was the highest mortality (9%) ICB type and had a low discharge to home rate (58%). IPH was uncommon (10%). Infratentorial bleeds types have different clinical courses, and outcomes. Understanding these differences can be useful in managing these patients.

Adenosine deaminase acting on RNA 1 accelerates cell cycle through increased translation and activity of cyclin-dependent kinase 2.

Adenosine-to-inosine RNA editing has been recently implicated in the pathogenesis of inflammation through the upregulation of the editase adenosine deaminase acting on RNA 1 (ADAR1). Because cell proliferation is a key feature of the inflammatory process, the present study tested the hypothesis that overexpression of ADAR1 accelerates cell cycle. To that end, human embryonic kidney 293 cells were transiently transfected with ADAR1 or vector, and cell cycle was evaluated by fluorescence-activated cell sorter. Overexpression of wild-type ADAR1 decreased the proportion of G0-G1 cells (-19%, P<0.01, n=3), increased the percentage of S phase cells (+19%, P<0.01, n=3), and did not change the ratio of cells residing in the G2-M phase (n=3). This finding was supported by three observations. First, there was a parallel production in ADAR1-transfected cells of cyclin-dependent kinase (Cdk) 2 and cyclin A, a pivotal protein complex upregulated at the G1-S phase checkpoint, and of [p]-Histone H1, a marker of Cdk2 activity (+102%, P<0.01, n=3). Second, ADAR1-transfected cells displayed higher activity of the proliferation marker, 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-2H-tetrazolium bromide. Third, using anti-ADAR1 antibody, direct binding of ADAR1 to Cdk2 messenger RNA was demonstrated in ADAR1-transfected cells by protein-RNA cross-linking and immunoprecipitation (+974%, P<0.01, n=3). Finally, causal relationships between ADAR1 and Cdk2 were confirmed by a study with the Cdk2 inhibitor, kenpaullone, which prevented the ADAR1-induced shift from the G0-G1 to the S phase. Taken together, these data show that ADAR1 increases cell cycle by shifting cells from the G0-G1 to the S phase through the upregulation of Cdk2.

Is it safe to admit patients with acute injuries to nonsurgical services? A retrospective review.

BACKGROUND: Given potential safety risks when admitting injured patients to nonsurgical services (NSS), the American College of Surgeons mandates trauma centers justification. However, evidence supporting this requirement is lacking. METHODS: Adult patients cleared for admission to a NSS at a level 1 trauma center between 2012 and 2014 were retrospectively reviewed. Patient demographic, injury, and outcome characteristics were compared between nonsurgical (NSA) and surgical admission patients and analyzed for predictive value. RESULTS: Compared with surgical admission patients, NSA patients were significantly older, had a higher number of comorbidities and/or patient and a lower Injury Severity Score, while hospital length of stay, complications, and missed injury and adjusted mortality rates were similar. NSA did not predict mortality whereas increased age, increased Injury Severity Score, and number of comorbidities and/or patient did. CONCLUSIONS: As all complications and mortalities were unrelated to injuries per se, admission to a NSS, after protocoled clearance by a trauma or Emergency Department attending, appears to be safe.

Do not roll the videotape: effects of the health insurance portability and accountability act and the law on trauma videotaping practices.

BACKGROUND: We hypothesized that trauma video practices would be affected as a result of Health Insurance Portability and Accountabilty Act (HIPAA) enactment. METHODS: A survey was distributed electronically to coordinators and/or directors of level 1 trauma centers. Centers were queried on demographics, trauma video use, and reasons for changes, if any, in their video practice patterns. Descriptive statistics and chi-square analysis were employed. RESULTS: Survey response rate was 75%. Prior to HIPAA, 58% of responding trauma centers used video compared to 18% now. On a Likert scale of 1-5, video analysis rated 3.80. For those using video currently, the most common purposes are education (91%) and quality assurance (83%). HIPAA has affected the way video is used at one third of these centers. Ten percent receive institutional review board approval for videotaping, 35% get patient consent, and more than half report capturing a poor patient outcome on tape. The most commonly cited reasons for stopping video use were HIPAA and legal concerns about patient privacy, consent, and discoverability (79%). Scarce resources were, in part, to blame at 70% of centers, while video technology was found to be ineffective at only 32%. CONCLUSIONS: A minority of level I trauma centers currently use video, although it is effective according to users. HIPAA and medicolegal concerns have affected its use at some centers and contributed to its abandonment at others.

Are resident work-hour limitations beneficial to the trauma profession?

In July 2003, work-hour restrictions were implemented by the Accreditation Council for Graduate Medical Education (ACGME) to limit resident duty hours. Attending surgeon work-hours have not been similarly reduced, and many trauma services have added emergency general surgery responsibilities. We hypothesized that trauma attending/resident work-hour disparity may disincentivize residents from selecting trauma careers and that trauma directors would view ACGME regulations negatively. We conducted a 6-month study of resident and in-house trauma attending self-reported hours at a level I trauma center and sent a questionnaire to 172 national level I trauma directors (TDs) regarding work-hours restrictions. TD survey response rate was 48 per cent; 100 per cent of 15 residents and 6 trauma faculty completed work-hour logs. Attending mean hours (87.1/ wk), monthly calls (5), and shifts > 30 hours exceeded that of all resident groups. Case volume was similar. Residents viewed their lifestyle more favorably than the lifestyle of the trauma attending (Likert score 3.6 +/- 0.5 vs Likert score 2.5 +/- 0.8, P = 0.0003). Seventy-one per cent cited attending work hours and lifestyle as a reason not to pursue a trauma career. Nationally, 80 per cent of trauma surgeons cover emergency general surgery; 40 per cent work greater than 80 hours weekly, compared with < 1 per cent of surgical trainees (P < 0.0001). Most TDs feel that residents do not spend more time reading (89%) or operating (96%); 68 per cent feel patient care has suffered as a result of duty-hours restrictions. Seventy-one per cent feel residents will not select trauma surgery as a career as a result of changes in duty hours. Perceived trauma attending/ resident work-hour disparity may disincentive trainees from trauma career selection. TDs view resident duty-hour restrictions negatively.

The trauma bay chest radiograph in stable blunt-trauma patients: do we really need it?

The current study evaluates the need for trauma bay chest radiographs (CXR) in stable blunt-trauma patients who are scheduled for chest computed tomography (CCT). A retrospective review of 157 randomly selected, stable, adult blunt-trauma patients who were admitted to a level I trauma center between 2000 and 2002, who underwent both CXR and CCT (GE Light-Speed Scanner), was performed. Stable patients were defined as unintubated, normotensive (SBP > 100 mm Hg), and without hypoxia (O2 saturation > 90%). No interventions were conducted in the trauma bay based on chest radiograph findings. Among 95 patients with a "normal" CXR, 38 patients (40%) were found on CCT to have traumatic injuries. Among 62 patients with an "abnormal" CXR, 18 (29%) were found to be normal on CCT. Of the remaining 44 patients, 34 had additional findings on CCT. In 32 patients, CCT led to changes in management. CCT was more sensitive in diagnosing thoracic injuries and led to significant changes in management. We feel that CXR could be safely eliminated in favor of CCT in stable blunt-trauma patients.

Magnitude of rib fracture displacement predicts opioid requirements.

INTRODUCTION: It is unknown whether the magnitude of rib fracture (RF) displacement predicts pain medication requirements in blunt chest trauma patients. METHODS: Adult blunt RF patients undergoing computed tomography (CT) of the chest admitted to an urban Level 1 trauma center (2007-2012) were retrospectively reviewed. Pain management in those with displaced RF (DRF), nondisplaced RF (NDRF), or combined DRF and NDRF (CRF) was compared by univariate analysis. Linear regression models were developed to determine whether total opioid requirements [expressed as log morphine equianalgesic dose (MED)] could be predicted by the magnitude of RF displacement (expressed as the sum of the Euclidean distance of all displaced RF) or number of RF, after adjusting for patient and injury characteristics. RESULTS: There were 245 patients, of whom 39 (16%) had DRF only, 77 (31%) had NDRF only, and 129 (53%) had CRF. Opioids were given to 224 patients (91%). Compared to DRF (mean, 1.7 RF per patient) and NDRF patients (2.4 RF per patient), those with CRF (6.8 RF per patient) were older and had more RF per patient and a higher Injury Severity Score (ISS) and MED (251 vs 53 and 105 mg, respectively, p < 0.0001 and p = 0.0045). They also more frequently received patient-controlled analgesia. Patients with displaced RF had a lower mean ISS and MED and received more epidural analgesia compared with patients with NDRF. Total MED was associated with both the magnitude of RF displacement (p < 0.0001) and the number of RF (p < 0.0001). Every 5-mm increase in total displacement predicted a 6.3% increase in mean MED (p = 0.0035), while every additional RF predicted an 11.2% increase in MED (p = 0.0001). These associations included adjustment for age, ISS, and presence of chest tubes. CONCLUSION: The magnitude of RF displacement and the number of RF predicted opioid requirements. This information may assist in anticipating patients with blunt RF who might have higher analgesic requirements. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Displacement Patterns of Blunt Rib Fractures and Their Relationship to Thoracic Coinjuries: Minimal Displacements Count.

Displacement patterns of rib fractures (RF) and their association with thoracic coinjuries and outcomes are unknown. This is a retrospective review of adult patients with blunt closed RF who underwent chest CT at a Level I trauma center (2007-2012). Displacement patterns of RF were compared among the three-dimensional planes using CT images. An analysis of receiver operating characteristic (ROC) curves was performed to identify displacements in each plane most strongly associated with chest coinjuries. Univariate analysis was used to find association of displaced RF with hospital course and outcome. There were 1127 RF (245 patients, most in ribs 3-9, 45 per cent displaced). Axial displacement was the most common, with odds ratios 7.20 and 2.13 compared with cranio-caudal, and impaction-separation (along rib axis) movement, respectively. Axial displacement thresholds performed well with hemothorax (2.8 mm, ROC = 0.74), pneumothorax (2.6 mm, ROC = 0.70), hemopneumothorax (3.1 mm, ROC = 0.77), flail chest (3.4 mm, ROC = 0.80), and chest tube placement (2.8 mm, ROC = 0.75). RF displacement was associated with increased days on mechanical ventilation and hospital length of stay. In conclusion, even minimal RF displacement is associated with increased risk of chest coinjuries and chest tube placement, and displacements correlated with increased days on mechanical ventilation and hospital length of stay. Future studies are required to investigate these associations, especially in relationship to the indications for rib plating.

Variability in interhospital trauma data coding and scoring: A challenge to the accuracy of aggregated trauma registries.

BACKGROUND: Analyses of data aggregated in state and national trauma registries provide the platform for clinical, research, development, and quality improvement efforts in trauma systems. However, the interhospital variability and accuracy in data abstraction and coding have not yet been directly evaluated. METHODS: This multi-institutional, Web-based, anonymous study examines interhospital variability and accuracy in data coding and scoring by registrars. Eighty-two American College of Surgeons (ACS)/state-verified Level I and II trauma centers were invited to determine different data elements including diagnostic, procedure, and Abbreviated Injury Scale (AIS) coding as well as selected National Trauma Data Bank definitions for the same fictitious case. Variability and accuracy in data entries were assessed by the maximal percent agreement among the registrars for the tested data elements, and 95% confidence intervals were computed to compare this level of agreement to the ideal value of 100%. Variability and accuracy in all elements were compared (χ testing) based on Trauma Quality Improvement Program (TQIP) membership, level of trauma center, ACS verification, and registrar's certifications. RESULTS: Fifty registrars (61%) completed the survey. The overall accuracy for all tested elements was 64%. Variability was noted in all examined parameters except for the place of occurrence code in all groups and the lower extremity AIS code in Level II trauma centers and in the Certified Specialist in Trauma Registry- and Certified Abbreviated Injury Scale Specialist-certified registrar groups. No differences in variability were noted when groups were compared based on TQIP membership, level of center, ACS verification, and registrar's certifications, except for prehospital Glasgow Coma Scale (GCS), where TQIP respondents agreed more than non-TQIP centers (p = 0.004). CONCLUSION: There is variability and inaccuracy in interhospital data coding and scoring of injury information. This finding casts doubt on the validity of registry data used in all aspects of trauma care and injury surveillance.

MOB-1 and TNF-alpha interact to induce microvascular lung injury.

We have recently identified the alpha-chemokine mob-1 as a highly inducible gene in several rat models of microvascular lung injury, whose expression was suppressed by inhibition of tumor necrosis TNF-alpha (TNF-alpha). This work provides further insight into the relationship between mob-1 and TNF-alpha in the development of lung injury assessed by pulmonary edema and leukosequestration. First, pulmonary mob-1 and TNF-alpha were upregulated in animals subjected to lung injury produced by the intratracheal administration of recombinant TNF-alpha and recombinant mob-1, respectively. Second, mob-1 inhibition by intratracheal anti-mob-1 antibody attenuated lung injury induced by recombinant TNF-alpha. Third, pretreatment with anti-TNF-alpha monoclonal antibody administered intratracheally abrogated recombinant mob-1-induced microvascular lung injury. In vitro, mob-1 and TNF-alpha increased each other's production in RAW 264.7 cells and mob-1 or TNF-alpha inhibition prevented endotoxin-induced upregulation of TNF-alpha or mob-1, respectively, from these cells. Together, these data suggest that mob-1 and TNF-alpha interact to promote lung inflammation.

Characterization of a murine model of endotoxin-induced acute lung injury.

Endotoxin-induced microvascular lung injury in mice is a commonly used experimental model of the acute respiratory distress syndrome (ARDS). The present paper aimed to characterize this popular model in a comprehensive and systematic fashion. Male C57bl/6 mice (n = 5) were administered an LD55 dose of E. coli endotoxin (15 mg/kg, i.p.), and lungs were harvested at several time points and evaluated for injury as well as for expression of a variety of inflammatory mediators. Endotoxin induced many features characteristic of acute microvascular lung injury. These included early (1-2 h) expression of inflammatory mediators (IL-1alpha, IL-1beta, IL-4, IL-6, IL-10, TNF-alpha, interferon-alpha, interferon gamma, and MCP-1) and leukocyte accumulation in lung tissue (lung myeloperoxidase activity 18.5 +/- 7.8 U/g tissue, P < 0.05), followed by pulmonary edema (lung water content index 17.4% +/- 2.5%, P < 0.05) and mortality. Histopathological evaluation of lung tissue was compatible with these findings. The characterization of this murine model of endotoxin-induced microvascular injury will facilitate its utilization in ARDS research.

The saliva strip test is an accurate method to determine blood alcohol concentration in trauma patients.

OBJECTIVES: To determine the accuracy of alcohol saliva testing (AST) in trauma patients. METHODS: Blood alcohol concentration (BAC) was measured by using both AST (QED A350; STC Technologies, Bethlehem, PA) and blood serum levels in 100 trauma patients admitted to the emergency department of an urban Level 1 trauma center. RESULTS: All 41 patients who tested positive for BAC on AST (mean [+/-SD]: 167.9 +/- 16.16; range: 20-350 mg/dL) also tested positive on serum determination (mean: 197.6 +/- 13.79; range: 22-446 mg/dL). Correlation between the two positive tests was significant (0.879, p < 0.001). Of the remaining 61 patients, 59 tested negative on both tests, while two patients with BACs of <30 mg/dL tested negative on the AST. For 18 patients with blood in the oropharynx, there was a correlation of 0.976 (p < 0.001, two-tailed) between serum and AST tests. CONCLUSIONS: The AST method of measuring BAC in trauma patients is accurate. Blood in the oral cavity did not appear to affect the accuracy of the test.

Trends in trauma surgery: analysis of the American Association for the Surgery of Trauma program 1939-2012.

BACKGROUND: Major trauma-related clinical and basic science innovations have been presented at American Association for the Surgery of Trauma (AAST) annual meetings since its establishment in 1938. Thus, an analysis of all podium presentations was performed to identify historical and current trends in trauma surgery. METHODS: All abstract books of the annual meetings of the AAST from 1939 (first meeting) to 2012 were identified except for 1943 and 1945 (no meeting because of World War II) and 1946 (not found). A master list of abstracts (n = 3,637) was generated in Excel. Abstracts were assigned to 14 different categories, and the percentage of each category was tabulated per year. Trend lines were then generated using a mean of 10 zones. In addition, the year in which major clinical and basic science advancements were first presented was recorded. RESULTS: Overall, most (20%) AAST presentations have been related to the resuscitation, shock, infection, inflammation, immunology, endocrinology, and metabolism category. This has been followed by the orthopedic (18%) and the torso (chest and abdomen) trauma categories (15%). The trend for each category over time was identified. Prominent trends included a bell-shaped curve for torso, vascular, and genitourinary injuries; a progressive decrease in orthopedic topics; and an increase in critical care topics since the 1970s and in resuscitation/infection/shock and trauma system presentations since the 1980s. First presentations of key topics were identified (n = 163) and tabulated in a chronological order. CONCLUSION: Analysis of all oral AAST presentations identified trends and significant milestones in trauma care and research. In its 75 years of existence, the AAST annual meeting remains the forum in which major developments in trauma care and scientific knowledge are presented and disseminated.

Management and outcome of patients with blunt splenic injury and preexisting liver cirrhosis.

BACKGROUND: The response of liver cirrhosis (LC) patients to abdominal trauma, including blunt splenic injury (BSI) is unfavorable. To better understand the response to BSI in LC patients, the present study reviewed a much larger group of such patients, derived from the National Trauma Data Bank. METHODS: The National Trauma Data Bank was queried for 2002 to 2010, and all adult BSI patients without severe brain trauma were identified. LC and non-LC patients were compared using nonoperative management (NOM) failure and mortality as primary outcomes. Predictors of these outcomes in LC patients were identified. RESULTS: Of the 77,753 identified BSI patients, 289 (0.37%) had LC. Overall, 90% of the patients underwent initial NOM (86% in LC and 90% in non-LC patients, p = 0.091) with a global 90% success rate. Compared with non-LC patients, LC patients had a lower NOM success rate (83% vs. 90%, p = 0.004) despite increased use of splenic artery angioembolization (13% vs. 8%, p = 0.001). LC patients also had more complications per patient, an increased hospital and intensive care unit lengths of stay, and a higher mortality (22% vs. 6%, p < 0.0001), which was independent of the treatment paradigm. In the LC group, mortality in those who underwent immediate surgery was 35% versus 46% in failed NOM (p = 0.418) and 14% (p = 0.019) in successful NOM patients. LC patients who did not require surgery were more likely to survive than those who had surgery alone (adjusted odds ratio [AOR], 0.30). Preexisting coagulopathy (AOR, 3.28) and Grade 4 to 5 BSI (AOR, 11.6) predicted NOM failure in LC patients, whereas male sex (AOR, 4.34), hypotension (AOR, 3.15), preexisting coagulopathy (AOR, 3.06), and Glasgow Coma Scale (GCS) score of less than 13 (AOR, 6.33) predicted mortality. CONCLUSION: LC patients have a higher rate of complications, mortality, and NOM failure compared with non-LC patients. Because LC patients with failed NOM have a mortality rate similar to those undergoing immediate surgery, judgment must be exerted in selecting initial management options. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Admission patterns of stable patients with isolated orthopedic or neurosurgical injuries.

OBJECTIVE: Although the disposition of stable patients with isolated orthopedic or neurosurgical injuries affects care and resource utilization, no guidelines for optimal admission are available. This study aims to provide the platform for developing such guidelines for these patients by characterizing their admission patterns in trauma centers (TCs). METHODS: This study is a Web-based survey of Trauma Medical Directors of Level I and Level II American College of Surgeons (ACS)-verified TCs. RESULTS: E-questionnaire was sent to 234 (98%) of 240 ACS-verified Level I and Level II TCs, and 122 (52%) responded. Responses indicate that stable patients with isolated orthopedic injuries and no indication or with an indication for emergent surgery are mostly (58 vs. 31%, p < 0.0001, 59 vs. 37%, p < 0.0001) admitted to the trauma service (TS). Conversely, when surgery was urgent, patients are equally admitted to the TS and orthopedic service (OS). When specific injuries were queried, patients with closed pelvic fractures are mostly admitted to the TS (81 vs. 18%, p < 0.0001), whereas patients with upper extremity injuries are preferentially admitted to the OS (58% vs. 31%, p < 0.05). Patients with isolated lower extremity fractures are equally admitted to the two services. Patients with isolated major traumatic brain injury (TBI) are mostly (78.6% vs. 21.4%, p < 0.0001) admitted to the TS, regardless of the need for emergent surgery. Similarly, most patients with minor TBI are admitted to the TS, independent of the presence of CT scan findings. The majority (73.9% vs. 26.1%, p < 0.0001) of patients with isolated spine injury are admitted to the TS, independent of the level of injury, the presence of multilevel injury, an indication for surgery, or the existence of neurological deficits. CONCLUSION: Most stable patients with isolated neurosurgical injuries in ACS-verified Level I and Level II TCs are initially admitted to the TS. The admission of patients with isolated orthopedic injuries is selective. These findings can facilitate investigating the clinical, logistical, and financial effect of this practice.