Chest X-Ray Remains a Vital Component Prior to Tube Thoracostomy.

INTRODUCTION: The identification and treatment of traumatic pneumothorax (PTX) has long been a focus of bedside imaging in the trauma patient. While the emergence of bedside ultrasound (BUS) provides an opportunity for earlier detection, the need for tube thoracostomy (TT) based on bedside imaging, including BUS and supine AP chest X-ray (CXR) is less established in the medical literature. METHODS: Retrospective data from 2017 to 2020 were collected of all adult trauma activations at a level 1 rural trauma facility. Every adult patient included in this study received a CXR and BUS (eFast) upon arrival. The need for TT was determined by the emergency medicine attending or the trauma surgery attending evaluating the patient. McNemar's chi-squared test and conditional logistic regression analysis were performed comparing BUS, CXR, and the combination of BUS and CXR findings for the need for TT. Subgroup analyses were performed comparing BUS, CXR, and the combination of BUS and CXR for the detection of PTX compared to CT scan. RESULTS: Of the 12,244 patients who underwent trauma activation during this timeframe, 602 were included in the study. 74.9% were males with an age range of 36-63 years. Of the 602 patients, 210 received TT. Positive PTX was recorded with BUS in 128 (21%) patients with 16 false negatives (FNs) and 98 false positives (FPs), 100 (17%) PTX were identified with CXR with 114 FNs and 4 FPs, and 72 (11.9%) were noted on both CXR and BUS with 140 FNs and 2 FPs. The odds ratio of TT placement was 22 times with positive BUS alone (P < .0001, 95% CI: 10.9-43.47), 47 times with positive CXR alone (P < .0001, 95% CI: 16.99-127.5), and 70 times with both positive CXR and BUS (P < .0001, 95% CI: 17.08-288.4). CONCLUSION: A positive finding of PTX on BUS combined with CXR is more indicative of the need for TT in the trauma patient when compared with BUS or CXR alone.

Thoracic and Lumbar Spine Injury: Evidence-Based Diagnosis, Management, and Outcomes.

BACKGROUND: Traumatic thoracolumbar spine injuries are associated with significant morbidity and mortality. Targeted for non-spine specialist trauma surgeons, this systematic scoping review aimed to examine literature for up-to-date evidence on presentation, management, and outcomes of thoracolumbar spine injuries in adult trauma patients. METHODS: This review was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. We searched four bibliographic databases: PubMed, EMBASE, Web of Science, and the Cochrane Library. Eligible studies included experimental, observational, and evidence-synthesis articles evaluating patients with thoracic, lumbar, or thoracolumbar spine injury, published in English between January 1, 2010 and January 31, 2021. Studies which focused on animals, cadavers, cohorts with N <30, and pediatric cohorts (age <18 years old), as well as case studies, abstracts, and commentaries were excluded. RESULTS: A total of 2501 studies were screened, of which 326 unique studies were fully text reviewed and twelve aspects of injury management were identified and discussed: injury patterns, determination of injury status and imaging options, considerations in management, and patient quality of life. We found: (1) imaging is a necessary diagnostic tool, (2) no consensus exists for preferred injury characterization scoring systems, (3) operative management should be considered for unstable fractures, decompression, and deformity, and (4) certain patients experience significant burden following injury. DISCUSSION: In this systematic scoping review, we present the most up-to-date information regarding the management of traumatic thoracolumbar spine injuries. This allows non-specialist trauma surgeons to become more familiar with thoracolumbar spine injuries in trauma patients and provides a framework for their management.

Use of Thromboelastography in Assessment of Snake Bite Coagulopathy.

Background: Monitoring for envenomation coagulopathy following snake bites has traditionally involved using serial coagulation studies.Purpose: Thromboelastography (TEG), with its real-time assessment, could offer an alternative to standard of care. This study aims to evaluate the use of TEG with traditional coagulation labs in the assessment of snake bite coagulopathy.Research Design: A retrospective review of patients who presented to a level 1 trauma center between 2014 and 2020 with snake bite envenomation was conducted, comparing traditional coagulation studies to TEG plus coagulation studies.Results: The 12 patients who had studies within the stipulations of our review were tracked and subsequently progressed well clinically with no adverse effects and ultimately discharged home with an average hospital stay of 2.2 days.Conclusions: Our data suggests that patients can be observed clinically without needing repeat coagulation studies if initial TEG and TCS are within normal limits.

Comparison and Utility of Intravenous Iodinated Contrast in Chest, Abdomen, Pelvis Computerized Tomography for Trauma Patients With Blunt Mechanism of Injury Before and After the May 9, 2022 Global Contrast Shortage at a Level II Trauma Center.

Background: Intravenous (IV) contrast improves the sensitivity and specificity of injury detection in computerized tomography (CT). Its use is recommended in the workup of trauma patients by the American College of Surgeons and American College of Radiology. On May 9, 2022, the Food and Drug Administration declared a shortage of iodinated contrast due to the COVID-19 pandemic. Although the shortage has ended, the temporary lack of IV contrast forced physicians to be prudent in ordering CT scans with IV contrast. We sought to determine if there was a change in the percentage of CT contrast studies performed during the contrast shortage and if this change affected patient outcomes.Methods: Retrospective chart review was performed on all adult tier 2 trauma patients at a 619-bed community-based level II trauma center who received CT chest, abdomen, and pelvis imaging as initial workup for blunt trauma from 5/9/2021-6/30/2021 (pre-shortage) and 5/9/2022-6/30/2022 (during shortage).Results: Patients were predominantly male with median age of 31-52 and of White or Hispanic ethnicity. Before the contrast shortage, all 110 trauma patients were scanned with contrast. During the shortage, 29 of 114 patients were scanned with contrast (P < 0.001). Injuries were identified in 59% of patients scanned with contrast (P < 0.001). There were no significant differences in blood transfusion needs, repeat CT, disposition, or mortality when comparing pre-shortage to during shortage or when comparing between non-contrast and contrast studies during the shortage.Discussion: There was a decrease in the percentage of CT contrast studies performed during the shortage. A higher percentage of injuries were identified in the patients scanned with contrast. However, there were no significant differences in patient outcomes. Certain trauma patients may be safely scanned without contrast.

Understanding Chest CT Scan Usage Among Adolescent Blunt Trauma Patients at Adult Trauma Centers.

PURPOSE: The utility of chest computed tomography (CCT) is not well established in the diagnostic algorithm of adolescent blunt trauma patients. Our study's aim was to review CCT usage in the initial evaluation of adolescent blunt trauma. METHODS: We retrospectively reviewed adolescent blunt trauma patients treated at our urban level 1 adult trauma center from 2015 to 2019. Our primary outcome was the rate of positive CCT findings. Univariate and multivariate logistic regression analyses were performed. RESULTS: There were 288 patients that met our inclusion criteria and 153 positive CCT and 135 negative CCT. There was no statistically significant difference between both groups in terms of age, gender, and race. Those with a positive CCT were found to have a statistically significant higher ISS than the negative CCT group (20.6 ± 12.3 vs 12.3 ± 7.6; P < .01). Those with a positive CCT were more likely to have a GCS <15 (40% vs 25%), have a positive CXR (38% vs 2%), have chest pain (16% vs 7%), and have an abnormal chest exam (27% vs 7%) than those with a negative CCT (P < .01). On multivariate analysis, positive CXR (P < .05, OR = 13.96) and ISS (P < .05, OR = 3.10) were independently associated with a positive CCT. CONCLUSION: While CCT may provide valuable information, clinical exam coupled with low-ionizing radiographic imaging (i.e., CXR) may sufficiently identify chest trauma after blunt mechanisms. This shift in management can potentially reduce the risk of radiation without compromising the care of adolescent trauma patients at adult trauma centers.

Is Traumatic Anterior Stove-In Chest Truly so Rare? A Single Institution Experience.

INTRODUCTION: The anterior stove-in chest (ASIC) is a rare form of flail chest involving bilateral rib or sternal fractures resulting in an unstable chest wall that caves into the thoracic cavity. Given ASIC has only been described in a handful of case reports, this study sought to review our institution's experience in the surgical management of ASIC injuries. METHODS: A retrospective review of patients with ASIC was conducted at our level I trauma center from 1//2021 to 3//2023. Information pertaining to patient demographics, fracture pattern, operative management, and outcomes was obtained and compared across patients in the case series. RESULTS: 6 patients met inclusion criteria, all males aged 37-78 years. 5 suffered motor vehicle collisions, and 1 was a pedestrian struck by an automobile. The median injury severity score was 28. All received ORIF within 5 days of admission, most commonly for ongoing respiratory distress. Patients 2 and 4 underwent bilateral ORIF of the ribs and sternum while patients 1, 5, and 6 underwent left-sided repair. Patient 3 required ORIF of left ribs and the sternum to stabilize their injuries. 5 of 6 patients were liberated from the ventilator and survived to discharge. CONCLUSIONS: This study demonstrates successful operative management of 6 patients with ASIC and suggests that early operative intervention with ORIF for affected segments may improve respiratory mechanics, ability to wean from the ventilator, and overall survival. Further research is needed to generate standardized guidelines for the management of this uncommon and complex thoracic injury.

Washington State Assault Weapon Firearm Violence Before and After Firearm Legislation Reform.

BACKGROUND: In January of 2019, Washington State (WA) passed Initiative 1639 making it illegal for persons <21 years-old to buy assault weapons (AWs). This study aimed to evaluate the effects of WA-1639 on firearm-related incidents involving AWs by those <21 years-old in WA, hypothesizing a decrease in incidents after WA-1639. METHODS: Retrospective (2016-2021) data on firearm violence (FV) events were gathered from the Gun Violence Archive. The rate of FV was weighted per 100,000 people. Total monthly incidents, injuries, and deaths were compared pre-law (January 2016-December 2018) vs post-law (January 2019-December 2021) implementation. Mann-Whitney U tests and Poisson's regression were used for analysis. RESULTS: From 4091 FV incidents (2210 (54.02%) pre-law vs 1881 (45.98%) post-law), 50 involved AWs pre- (2.3%) and 15 (.8%) post-law. Of these, 11 were committed by subjects <21 years-old pre-law and only one occurred post-law. Total incidents of FV (z = -3.80, P < .001), AW incidents (z = -4.28, P < .001), and AW incidents involving someone <21 years-old (z = -3.01, P < .01) decreased post-law. Additionally, regression analysis demonstrated the incident rate ratio (IRR) of all FV (1.23, 95% CI [1.10-1.38], P < .001), all AW FV incidents (3.42, 95% CI [1.70-6.89], P = .001), and AW incidents by subjects <21 years-old (11.53, 95% CI [1.52-87.26], P = .02) were greater pre-law vs post-law. DISCUSSION: Following implementation of WA-1639, there was a significant decrease in FV incidents and those involving AWs by individuals <21 years-old. This suggests targeted firearm legislation may help curtail FV. Further studies evaluating FV after legislation implementation in other states is needed to confirm these findings.

Contemporary Outcomes and Patterns of Injury Associated With Parachuting Accidents.

BACKGROUND: Skydiving is an increasingly popular recreational activity in the United States and worldwide. While it is considered a high-risk sport, the United States Parachute Association reported a fatality of .28 per 100 000 jumps in 2022. Although mortality rates are low, the true rate of survivable injuries is unknown. Injuries requiring hospitalization are not uncommon and may be underreported in the literature. Anticipating these injuries and analyzing short-term outcomes following parachuting accidents would be useful for the development of mitigation strategies and to increase the safety of jumpers. METHODS: A retrospective cohort review of 126 consecutive patients presenting to a Level II Trauma Center after skydiving accidents between 2016 and 2023. Patient baseline characteristics, patterns of injury, surgical procedures, and in-hospital outcomes were reviewed. RESULTS: A total of 126 patients were included. One hundred and seventeen patients (93%) presented immediately following the accident, 65 (51.6%) were trauma activations, and 14 (11.1%) patients experienced loss of consciousness. Fractures of the lower extremity occurred in 57 (45%), fractures of the spine 48 (38%), upper extremity 13 (10%), pelvis 11 (9%). Of the spinal injuries, 10 injuries occurred in the cervical spine, 16 thoracic, 22 lumbar, 5 sacral, and 3 coccygeal spine. Eleven patients (9%) suffered multilevel spine injuries. Mean injury severity score was 7 (range 0-75). A third of patients required at least 1 surgical procedure (n = 43, 34%). Median length stay was 2 days (IQR 1, 5). Of patients who survived to our trauma center, there were two mortalities, both due to catastrophic intracranial hemorrhage. DISCUSSION: Although the 30-day mortality rate for patient who presented to our trauma center is low, it can bear significant risks including major injury. The most common injuries were lower extremity and spinal in origin with a third of patients overall requiring at least one operation.

Prehospital Needle Decompression of Suspected Tension Pneumothorax: Outcomes and Consequences.

Tension pneumothorax (TPT) identified in the prehospital setting requires prehospital needle decompression (PHND). This study aimed to evaluate complications from PHND when it was performed without meeting clinical criteria. A retrospective review was performed of patients undergoing (PHND) from 2016 through 2022 at a level 1 trauma center. Patient data who received PHND were reviewed. Of 115 patients, 85 did not meet at least one clinical criterion for PHND. The majority of patients in this cohort 76 (89%) required a chest tube and 22 (25%) had an iatrogenic pneumothorax from PHND. 5 patients (6%) were admitted due to iatrogenic PHND. Two vascular injuries in this population were directly due to PHND and required emergency operative repair. This study shows the negative consequences of PHND when performed without clear indications. Several patients underwent unnecessary procedures with significant clinical consequences.

Firearm Violence Involving Adults 65 and Older During the Novel Coronavirus Disease Pandemic.

BACKGROUND: Rates of firearm violence (FV) surged during the COVID-19 pandemic. However, there is a paucity of data regarding older adults (OAs) (≥65 years old). This study aimed to evaluate patterns of FV against OAs before and after the COVID-19 pandemic, hypothesizing decreased firearm incidents, injuries, and deaths for OAs due to restricted social movement. METHODS: Retrospective (2016-2021) data for OAs were obtained from the Gun Violence Archive. The rate of FV was weighted per 10,000 OAs using annual population data from the United States Census Bureau. Mann-Whitney U tests were performed to compare annual firearm incidence rates, number of OAs killed, and number of OAs injured from 2016-2020 to 2021. RESULTS: From 944 OA-involved shootings, 842 died in 2021. The median total firearm incidents per month per 10,000 OAs decreased in 2021 vs 2016 (.65 vs .38, P < .001), 2017 (.63 vs .38, P < .001), 2018 (.61 vs .38, P < .001), 2019 (.39 vs .38, P = .003), and 2020 (.43 vs .38, P = .012). However, there was an increased median number of OAs killed in 2021 vs 2020 (.38 vs .38, P = .009), but no difference from 2016-2019 vs 2021 (all P > .05). The median number of firearm injuries decreased from 2017 to 2021 (.21 vs .19, P = .001) and 2020 to 2021 (.19 vs .19 P < .001). DISCUSSION: Firearm incidents involving OAs decreased in 2021 compared to pre-pandemic years; however, there was a slight increase in deaths compared to 2020. This may reflect increased social isolation; however, future research is needed to understand why this occurred.

Outcomes of Injured Patients Before and After the Institution of a Third-Tier Activation at a Level 1 Trauma Center.

BACKGROUND: We hypothesized that the addition of a third-level trauma activation would improve outcomes by formalizing an evaluation process for patients in need of urgent evaluation who did not meet the criteria for full or partial trauma alert activation. METHODS: Admission records for all trauma patients admitted between 2000 and 2021 were obtained. The gamma alert trauma activation was implemented in 2011. A washout period of 6 months was used to account for adjustment to the new protocol. Propensity score matching was performed based on ISS scores, age, injury mechanism, and best-validated comorbidities to create a balanced patient distribution. Patients with missing data were excluded from this study. The association between era and outcomes was determined using logistic and linear regression analyses. RESULTS: The matched cohort was well balanced (SMD <.1, all balanced covariates) and included 18,572 patients. Patients in the gamma alert era had decreased ED dwell time, hospital length of stay, and intensive care unit (ICU) length of stay. Readmission rates and rates of upgrade to ICU status were reduced in the gamma alert era. This era was also associated with lower rates of renal failure, UTI, and pneumonia. There was no significant difference in mortality following implementation of the gamma alert. DISCUSSION: Implementation of the gamma alert was associated with an improvement in ED dwell times, fewer unplanned admissions to the ICU, decreased readmissions, and a reduction in other in-hospital events. We believe that this reflects improved triage of patients to the ICU and more effective care of trauma patients.

Type-O Blood Is Not Associated With Elevated Mortality After Trauma: A North American Cohort Study.

BACKGROUND: Recent studies have presented contradictory findings on the relationship between blood type and mortality in trauma patients. Using the largest population in a study of this type to date, we hypothesized that ABO genotype and Rhesus status would influence trauma-related mortality and morbidity given the relationship between blood type and hemostasis. METHODS: Data from all trauma patients admitted to level I and level II trauma centers in one city over a five-year period was retrospectively analyzed. Patients were stratified by ABO type. Patient demographics and outcomes were then assessed. Chi-squared and Fisher's exact tests were used to analyze categorical variables. Continuous variables were analyzed using ANOVA or Kruskal-Wallis tests as appropriate. Logistic regression was used to determine independent associations for 28-day mortality and complications. RESULTS: Of 5249 patients, severe injury (ISS >15) was present in 1469. Approximately one-quarter of patients with severe injury received blood products within the first 24 hours. There were no significant variations in demographics or complications between patients of different blood types. Univariate and multivariable regression analysis showed no association between blood type and mortality. However, penetrating injury, lower GCS, higher ISS, blood transfusion within 24 hours, and Asian descent were associated with higher overall mortality. CONCLUSIONS: In contrast to previous studies, we found no evidence of an association between blood type and mortality. However, our findings suggest that patients of Asian descent may be at higher risk for mortality following trauma. Further research is warranted to explore this observation.

Maternal and Neonatal Outcomes of Gunshot Wounds in Pregnancy: A Systematic Review of Case Reports.

A systematic review was performed to compare adverse maternal and neonatal outcomes among pregnant patients with gunshot wounds (GSW) to the abdominopelvic vs other region(s) at > 20 weeks gestation. A search of Medline Ovid, Elsevier Embase, EBSCO CINAHL, and Cochrane Library in July 2022 and reference searches resulted in 1742 studies, which were screened. The 41 included studies reported outcomes for 59 pregnant patients with GSW, of which 31 (52.5%) had an isolated abdominopelvic GSW and 28 (47.5%) had an extremity, thorax, head/neck, back/spine, poly-site, or other/unknown GSW. Stillbirth occurred in 26.7% of abdominopelvic GSW and 26% of non-abdominopelvic GSW. Maternal death occurred in 3.7% of abdominopelvic GSW and 10.7% of non-abdominopelvic GSW. Neonatal death occurred in 9.1% of abdominopelvic GSW and 5.3% of non-abdominopelvic GSW. Further research is needed to standardize the approach for the evaluation and management of patients with GSW in pregnancy.

Early Pharmacologic Therapy in Patients With Blunt Cerebrovascular Injury and TBI: Is it Safe and Effective? An EAST Multicenter Study.

BACKGROUND: Blunt cerebrovascular injury (BCVI) with concurrent traumatic brain injury (TBI) presents increased risk of both ischemic stroke and bleeding. This study investigated the safety and survival benefit of BCVI treatment (antithrombotic and/or anticoagulant therapy) in this population. We hypothesized that treatment would be associated with fewer and later strokes in patients with BCVI and TBI without increasing bleeding complications. METHODS: Patients with head AIS >0 were selected from a database of BCVI patients previously obtained for an observational trial. A Kaplan-Meier analysis compared stroke survival in patients who received BCVI treatment to those who did not. Logistic regression was used to evaluate for confounding variables. RESULTS: Of 488 patients, 347 (71.1%) received BCVI treatment and 141 (28.9%) did not. BCVI treatment was given at a median of 31 h post-admission. BCVI treatment was associated with lower stroke rate (4.9% vs 24.1%, P < .001 and longer stroke-free survival (P < .001), but also less severe systemic injury. Logistic regression identified motor GCS and BCVI treatment as the only predictors of stroke. No patients experienced worsening TBI because of treatment. DISCUSSION: Patients with BCVI and TBI who did not receive BCVI treatment had an increased rate of stroke early in their hospital stay, though this effect may be confounded by worse motor deficits and systemic injuries. BCVI treatment within 2-3 days of admission may be safe for patients with mean head AIS of 2.6. Future prospective trials are needed to confirm these findings and determine optimal timing of BCVI treatment in TBI patients with BCVI.

More Harm Than Good: It is Time to Reconsider Prophylactic Fasciotomy in Lower-Extremity Vascular Injury.

INTRODUCTION: Four-compartment calf fasciotomy (CF) can be limb-saving. Prophylactic fasciotomy (PP) is advised in high-risk situations to prevent limb loss. Calf fasciotomy can cause significant morbidity, particularly if performed unnecessarily. We hypothesized that selective use of fasciotomies (SF) after lower-extremity vascular injury would lead to a lower rate of overall fasciotomies without an increase in limb complications than prophylactic fasciotomies (PFs). METHODS: Trauma patients who sustained lower-extremity vascular injury that required operative repair at a high-volume trauma center were retrospectively reviewed and grouped by SF or PF (2016-2022). SF were individuals who were observed and underwent CF only if signs of compartment syndrome developed, whereas PF were individuals who underwent CF without signs of compartment syndrome. The primary outcome was amputation rate. Secondary outcomes were fasciotomy rate, need for reoperative vascular surgery, and clinical characteristics predisposing use of PF. RESULTS: Of 101 overall patients, 30 patients (29.4%) had PF. Of the remaining 71 (SF group), 43.7% (n = 31) were spared CF. The median time from injury to vascular repair in both groups was the same (7 hours, P = .15). There was no difference in rate of vascular reoperation per group (PF = 26.7% vs SF = 23.9%, P = .77). The only clinical characteristic associated with PF was need for arterial shunt (OR 4.2, P = .028). CONCLUSIONS: In trauma patients with lower-extremity vascular injury undergoing vascular repair, selective use of fasciotomy can spare almost half of patients the need for fasciotomy without an increase in limb complications.

Assessing Futile Trauma Transfers in Rural Appalachia Following a Regional Health Care System Consolidation.

This study sought to define and analyze rates of futile trauma transfers (FTTs) after the consolidation of two rural level 1 trauma centers into one. Data was extracted from the regional trauma registry for a period of 5 years (2017-2022) for all trauma patients transferred into our level 1 trauma center (n = 3369). An FTT was defined as a transfer that (1) received no major interventions and (2) died or was discharged to a hospice facility within 72 hours. Out of the 3369 transfer patients analyzed during the 33-month pre-consolidation and 33-month post-consolidation periods, 34 patients met the criteria of an FTT within the transfer-to-discharge window. The pre-consolidation category contained 12, and the post-consolidation category contained 22. Chi-square analysis indicated no significant difference in FTT rate between categories. Furthermore, the post-consolidation FTT rate of 1.1% remained consistent with the estimated national average of 1.5%.

The Effect of a Hip Fragility Pathway on Outcomes of Ground Level Falls in the Elderly.

Fragility hip fractures result from low energy mechanisms and are associated with morbidity and mortality, especially in the elderly. We examined outcomes 2 years before and after implementation of a fragility fracture program. The pathway involves emergency department clearance and admission by a medical service with orthopedic consultation. Demographics include age, gender, fracture location, injury severity score (ISS), and ASA. Outcomes include DVT/PE, mortality, disposition, non-operative rate, ICU admission, time to surgery (TTS), length of stay (LOS), and admission service. 777 patients were included (383 PRE/394 POS). POS patients were slightly younger. Trauma admission decreased and LOS and TTS increased. There were no other demographic or outcome differences. Although TTS increased, it remained under 48 hours. Length of stay increase was possibly a reflection of COVID-19. Decreased trauma admission demonstrates pathway adherence. Further studies need to be conducted to verify that quality care can be maintained after initiation of a hip fragility pathway.

Impact of Trauma Verification Level on Management and Outcomes of Combined Traumatic Brain and Solid Organ Injuries: An NTDB Retrospective Review.

BACKGROUND: Level-I and level-II trauma centers are required to offer equivalent resources since "The Orange Book." This study evaluates differences between level-I and level-II management of solid organ injury (SOI) with traumatic brain injury (TBI). METHODS: We conducted a retrospective review of the National Trauma Data Banks from 2013 to 2021 of adult (≥18 years), blunt trauma patients with both TBI and SOI treated at level-I or level-II trauma centers. RESULTS: 48,479 TBI and SOI patients were identified, 32,611 (67.3%) at level-I centers. Unadjusted incidence of laparotomy was higher at level I (14.5% vs 11.7%, P < 0.001), and angiography rates were similar (3.3% vs 3.4%, P 0.717). Sub-group analysis of stable patients (SBP ≥100) showed an increase in nonoperative management at level II (87.3% vs 88.7%, P < 0.001) and decrease in laparotomy (9.9% vs 8.3%, P < 0.001). On logistic regression (LR), severe TBI, high-grade SOI, and level I trauma status were predictors of laparotomy. Logistic regression showed mild/moderate TBI with high-grade SOI and level II were associated with use of angiography. Unadjusted mortality rates were slightly different (14.8% vs 13.4%, P < 0.001), but there was no association with trauma level on LR. DISCUSSION: Nonoperative management was seen more at level-II centers with laparotomy at level I. Subgroup analysis showed no difference in mortality in trauma levels. Matched patients for level I and II showed no statistical difference in management. Patients were treated similarly at both levels with similar outcomes and mortality.

Thyrotoxicosis Presenting as an Acute Abdomen.

Abdominal pain continues to be a common chief complaint in the emergency setting. While this presentation can be non-specific, there are certain findings that warrant immediate surgical intervention. Portal venous gas on imaging in the setting of peritonitis and sepsis is one such finding. Thyrotoxicosis on the other hand is an uncommon diagnosis that is associated with non-specific symptoms resulting in delayed diagnosis, a clinical scenario that can lead to significant morbidity and mortality. Here, we present a rare case of a patient who presented with signs and symptoms of peritonitis and portal venous gas on CT scan that was taken emergently to the operating room. No intraabdominal pathology was identified. The patient was later diagnosed with thyrotoxicosis, the presumed cause of the acute abdomen presentation.

Extracorporeal Membrane Oxygenation During Surgical Stabilization of Rib Fractures in Successful Management of Severe Blunt Chest Trauma.

Early surgical stabilization of rib fracture (SSRF) improves outcomes in patients with flail physiology and severely displaced fractures. We present two cases of patients with severe chest injury and large flail segment who underwent SSRF while on veno-venous extracorporeal membrane oxygenation (VV-ECMO). The patients developed respiratory failure within 24 hours of admission requiring VV-ECMO. The extent of their chest wall injury limited pulmonary mechanics prohibiting transition off VV-ECMO. Therefore, SSRF was performed on hospital days 2 and 3 and while on VV-ECMO support. Stabilizing the chest wall allowed for improved ventilation and successful decannulation from VV-ECMO on postoperative days 3 and 4. Ultimately, both achieved a functional recovery and were discharged home. These cases demonstrate a unique thoracic damage control strategy wherein SSRF is performed while on VV-ECMO. Improving chest stability and pulmonary mechanics with SSRF allowed for safe transition off VV-ECMO and achieved a favorable long-term outcome.