Early Antibiotic Administration is Independently Associated with Improved Survival in Traumatic Brain Injury.

BACKGROUND: Central and systemic immune dysfunction after traumatic brain injury (TBI) can lead to infectious-related complications, which may result in delayed mortality. The role of early empiric antibiotics after TBI has not been characterized to date, but is recommended in select cases to decrease complications. We aimed to determine the relationship between early antibiotic use and in-hospital mortality in TBI patients. METHODS: A retrospective review was conducted of TBI patients requiring ICU admission at an urban, academic, Level I trauma center from 01/2014 to 08/2016. Data collection included demographics, injury characteristics, details regarding antibiotic use, and outcomes. Early antibiotic administration was defined as any antibiotic given within 48 hs from admission. Patients given early antibiotics (EARLY) were compared to those who received their first dose later or did not receive any antibiotics (non-EARLY). RESULTS: Of the 488 TBI patients meeting inclusion criteria, 189 (38.7%) received early antibiotics. EARLY patients were younger (EARLY 54.2 versus non-EARLY 61.5 ys, P <0.01) and more likely to be male (71.4% versus 60.9%, P = 0.02). Injury severity scores (23.6 versus 17.2, P <0.01) and regional head abbreviated injury scale scores (3.9 versus 3.7, P <0.01) were significantly higher in patients who received early antibiotics. Unadjusted in-hospital mortality rates were similar, however EARLY was associated with a lower mortality rate (AOR 0.17, 95% CI: 0.07 - 0.43, adjusted P <0.01) after adjusting for confounders. CONCLUSIONS: Despite presenting with a higher injury burden, TBI patients who received early antibiotics had a lower associated mortality rate compared to their counterparts. Future investigations are necessary to understand the underlying mechanisms that result in this potential survival benefit.

Percutaneous Cholecystostomy Tube for Acute Cholecystitis: Quantifying Outcomes and Prognosis.

BACKGROUND: Percutaneous cholecystostomy tubes (PCT) are utilized in the management of acute cholecystitis in patients deemed unsuitable for surgery. However, the drive for these decisions and the outcomes remain understudied. We sought to characterize the practices and utilization of PCT and evaluate associated outcomes at an urban medical center. METHODS: Patients undergoing PCT placement over a 12-y study period ending May 2019 were reviewed. Demographics, clinical presentation, labs, imaging studies, and outcomes were abstracted. The primary and secondary outcomes were 30-d mortality and interval cholecystectomy, respectively. RESULTS: Two hundred and four patients met inclusion criteria: 59.3% were male with a median age of 67.5 y and a National Surgical Quality Improvement Program (NSQIP) risk of serious complication of 8.0%. Overall, 57.8% of patients were located in an intensive care unit setting. The majority (80.9%) had an ultrasound and 48.5% had a hepatobiliary iminodiacetic acid scan. The overall 30-d mortality was 31.9%: 41.5% for intensive care unit and 18.6% for ward patients (P < 0.01). Of patients surviving beyond 30 d (n = 139), the PCT was removed from 106 (76.3%), and a cholecystectomy was performed in 55 (39.6%) at a median interval of 58.0 d. A forward logistic regression identified total bilirubin (Adjusted Odds Ratio: 1.12, adjusted P < 0.01) and NSQIP risk of serious complication (Adjusted Odds Ratio: 1.16, adjusted P < 0.01) as the only predictors for 30-d mortality. CONCLUSIONS: Patients selected for PCT placement have a high mortality risk. Despite subsequent removal of the PCT, the majority of surviving patients did not undergo an interval cholecystectomy. Total bilirubin and NSQIP risk of serious complication are useful adjuncts in predicting 30-d mortality in these patients.

Outcomes Following Percutaneous Cholecystostomy Tube Placement for Acalculous Versus Calculous Cholecystitis.

BACKGROUND: Acute acalculous cholecystitis (AAC) is often diagnosed in critically ill patients. Percutaneous cholecystostomy tube (PCT) placement facilitates less invasive gallbladder decompression in patients who are poor surgical candidates. Specific guidelines for optimal management of AAC patients following PCT placement remain to be defined. We hypothesize that AAC patients are at lower risk of recurrent cholecystitis than acute calculous cholecystitis (ACC) patients and do not require cholecystectomy after PCT placement. METHODS: A retrospective review of patients who underwent PCT placement for AAC or ACC between 6/1/2007 and 5/31/2019 was performed. Primary outcome was recurrent cholecystitis and interval cholecystectomy for patients surviving 30 days after PCT placement. Secondary outcome was 30 day mortality. A cox regression model calculated the adjusted hazard ratio (AHR) for the outcomes. RESULTS: Eighty-four AAC and 85 ACC patients underwent PCT placement. Compared to ACC patients, more AAC patients were male (72.6 vs. 48.2%; p < 0.01), younger (median age 62 vs. 73 years; p < 0.01), and required intensive care (69.0 vs. 52.9%; p = 0.04), with lower median Charlson Comorbidity Index (4.0 vs. 6.0; p < 0.01). 30 day mortality was higher among AAC patients than ACC patients (45.2 vs. 21.2%; p < 0.01). 2/24 (8.3%) AAC patients and 5/31 (16.1%) ACC patients developed recurrent cholecystitis at a median 208.0 days (IQR:64.0-417.0) after PCT placement and 115.0 days (IQR:7.0-403.0) following PCT removal. Cox regression analysis demonstrated that AAC patients had lower likelihood of interval cholecystectomy compared to ACC patients (AHR 2.35; 95% CI:1.11,4.96). CONCLUSION: Recurrent cholecystitis is rare in patients surviving 30 days following PCT placement. When compared with ACC patients, fewer AAC patients require cholecystectomy.

Effects of the COVID-19 pandemic on pediatric trauma in Southern California.

PURPOSE: The COVID-19 pandemic resulted in increased penetrating trauma and decreased length of stay (LOS) amongst the adult trauma population, findings important for resource allocation. Studies regarding the pediatric trauma population are sparse and mostly single-center. This multicenter study examined pediatric trauma patients, hypothesizing increased penetrating trauma and decreased LOS after the 3/19/2020 stay-at-home (SAH) orders. METHODS: A multicenter retrospective analysis of trauma patients ≤ 17 years old presenting to 11 centers in California was performed. Demographic data, injury characteristics, and outcomes were collected. Patients were divided into three groups based on injury date: 3/19/2019-6/30/2019 (CONTROL), 1/1/2020-3/18/2020 (PRE), 3/19/2020-6/30/2020 (POST). POST was compared to PRE and CONTROL in separate analyses. RESULTS: 1677 patients were identified across all time periods (CONTROL: 631, PRE: 479, POST: 567). POST penetrating trauma rates were not significantly different compared to both PRE (11.3 vs. 9.0%, p = 0.219) and CONTROL (11.3 vs. 8.2%, p = 0.075), respectively. POST had a shorter mean LOS compared to PRE (2.4 vs. 3.3 days, p = 0.002) and CONTROL (2.4 vs. 3.4 days, p = 0.002). POST was also not significantly different than either group regarding intensive care unit (ICU) LOS, ventilator days, and mortality (all p > 0.05). CONCLUSIONS: This multicenter retrospective study demonstrated no difference in penetrating trauma rates among pediatric patients after SAH orders but did identify a shorter LOS.

A Systems-based Approach to Reduce Deep Venous Thrombosis and Pulmonary Embolism in Trauma Patients.

BACKGROUND: Venous thromboembolism (VTE) in trauma patients carries significant morbidity and mortality. We previously described how titrating enoxaparin dosing by anti-Xa trough levels was associated with a lower VTE rate. We combined this strategy with a higher initial enoxaparin dose for a majority of patients and modified the electronic medical record (EMR) to encourage immediate dosing. We sought to determine if this systems-based approach was associated with a decrease in VTE rate. STUDY DESIGN: A retrospective review was conducted of all trauma patients on prophylactic enoxaparin at an academic, Level I Trauma Center from 01/2013 to 05/2014 (PRE) and 06/2015 to 02/2018 (POST). The patients in PRE were prescribed enoxaparin 30 mg twice daily without dose adjustments. The patients in POST received 40 mg twice daily unless exclusion criteria applied, with doses titrated to maintain anti-Xa trough levels between 0.1 and 0.2 IU/mL. RESULTS: There were 478 patients in the PRE and 1306 in the POST. Compared to PRE, POST patients were of similar age and were as likely to present after blunt trauma, although POST patients had lower injury severity scores (10 vs. 9, p < 0.01). The overall VTE rate was lower in POST (6.9% vs. 3.6%, p < 0.01). The adjusted risk of VTE (AOR 0.61, adjusted p = 0.04) was lower in POST and POST was independently protective for VTE (AOR 0.54; p = 0.01). CONCLUSION: By implementing system changes to improve enoxaparin dosing after trauma, a significant reduction in VTE rate was observed. Wider application of this strategy should be considered.

Drug and alcohol positivity of traumatically injured patients related to COVID-19 stay-at-home orders.

Background: COVID-19 related stay-at-home (SAH) orders created many economic and social stressors, possibly increasing the risk of drug/alcohol abuse in the community and trauma population.Objectives: Describe changes in alcohol/drug use in traumatically injured patients after SAH orders in California and evaluate demographic or injury pattern changes in alcohol or drug-positive patients.Methods: A retrospective analysis of 11 trauma centers in Southern California (1/1/2020-6/30/2020) was performed. Blood alcohol concentration, urine toxicology results, demographics, and injury characteristics were collected. Patients were grouped based on injury date - before SAH (PRE-SAH), immediately after SAH (POST-SAH), and a historical comparison (3/19/2019-6/30/2019) (CONTROL) - and compared in separate analyses. Groups were compared using chi-square tests for categorical variables and Mann-Whitney U tests for continuous variables.Results: 20,448 trauma patients (13,634 male, 6,814 female) were identified across three time-periods. The POST-SAH group had higher rates of any drug (26.2% vs. 21.6% and 24.7%, OR = 1.26 and 1.08, p < .001 and p = .035), amphetamine (10.4% vs. 7.5% and 9.3%, OR = 1.43 and 1.14, p < .001 and p = .023), tetrahydrocannabinol (THC) (13.8% vs. 11.0% and 11.4%, OR = 1.30 and 1.25, p < .001 and p < .001), and 3,4-methylenedioxy methamphetamine (MDMA) (0.8% vs. 0.4% and 0.2%, OR = 2.02 and 4.97, p = .003 and p < .001) positivity compared to PRE-SAH and CONTROL groups. Alcohol concentration and positivity were similar between groups (p > .05).Conclusion: This Southern California multicenter study demonstrated increased amphetamine, MDMA, and THC positivity in trauma patients after SAH, but no difference in alcohol positivity or blood concentration. Drug prevention strategies should continue to be adapted within and outside of hospitals during a pandemic.

Access to extracorporeal life support as a quality metric: Lessons from trauma.

BACKGROUND: Access to centers with extracorporeal membrane oxygenation (ECMO) capabilities varies by region and may affect overall outcomes. We assessed the outcomes of trauma patients requiring ECMO support and compared the overall survival of all patients with trauma at facilities with and without ECMO capabilities. METHODS: A retrospective review of the National Trauma Data Bank was performed to identify all trauma patients receiving care at ECMO and non-ECMO centers. Baseline patient characteristics and outcomes were analyzed. Adjusted odds ratio (OR) was used to compare survival at ECMO and non-ECMO facilities. RESULTS: Between 2007 and 2015, a total of 5 781 123 patients with trauma were identified with 1 983 986 (34%) admitted to an ECMO facility and 3 797 137 (66%) admitted to a non-ECMO facility. A total of 522 (0.03%) patients required ECMO. Both the number of patients with trauma requiring ECMO support and the number of trauma facilities utilizing ECMO increased over the 9-year-study period (4.9 to 13.8 patients per 100 000 admissions, and 18 to 77 centers, respectively). The mortality for ECMO patients was 40.5%. Patients with trauma admitted to ECMO facilities had more severe injuries (injury severity score: 9.0 vs 8.0; P < .001). The overall mortality was 3.3%. The adjusted OR for mortality associated with admission to an ECMO facility vs a non-ECMO facility was 0.96 (95% confidence interval: 0.95-0.97; adjusted P < .001). CONCLUSIONS: The use of ECMO for patients with trauma is expanding. Our study demonstrates a survival benefit associated with admission to a facility with ECMO capabilities. Thus, access to ECMO is a potential quality metric for trauma centers.

Weaker gun state laws are associated with higher rates of suicide secondary to firearms.

BACKGROUND: Firearm-related suicides comprise over two-thirds of gun-related violence in the United States, and gun laws and policies remain under scrutiny, with many advocating for revision of the regulatory map for lawful gun ownership, aiming at restricting access and distribution of these weapons. However, the quantitative relationship between how strict gun laws are and the incidence of firearm violence with their associated mortality is largely unknown. We therefore, sought to explore the impact of firearm law patterns among states on the incidence and outcomes of firearm-related suicide attempts, utilizing established objective criteria. METHODS: The National Inpatient Sample for the years 1998-2011 was queried for all firearm-related suicides. Discharge facilities were stratified into five categories (A, B, C, D, and F, with A representing states with the most strict and F representing states with the least strict laws) based on the Brady Campaign to prevent Gun Violence that assigns scorecards for every state. The primary outcomes were suicide attempts and in-hospital mortality per 100,000 populations by Brady state grade. RESULTS: During the 14-year study period, 34,994 subjects met inclusion criteria. The mean age was 42.0 years and 80.1% were male. A handgun was utilized by 51.8% of patients. The overall mortality was 33.3%. Overall, 22.0% had reported psychoses and 19.3% reported depression. After adjusting for confounding factors and using group A as reference, there were higher adjusted odds for suicide attempts for patients admitted in group C, D, and F category states (1.73, 2.09, and 1.65, respectively, all P < 0.001). CONCLUSIONS: Firearm-related suicide attempt injuries are more common in states with less strict gun laws, and these injuries tend to be associated with a higher mortality. Efforts aimed at nationwide standardization of firearm state laws are warranted, particularly for young adults and suicide-prone populations. LEVEL OF EVIDENCE: III. STUDY TYPE: Trauma Outcomes study.

Extended neuromuscular blockade in acute respiratory distress syndrome does not increase mortality.

BACKGROUND: Neuromuscular blockade (NMB) is often utilized in the treatment of acute respiratory distress syndrome (ARDS). Its use for a period of 48 h has been shown to improve mortality in randomized control trials. We aimed to characterize outcomes associated with a prolonged NMB. We hypothesized that the duration of NMB would not be associated with increased mortality. MATERIALS AND METHODS: This was a retrospective review from June 2014 to October 2016 of patients admitted to the surgical intensive care unit and receiving cisatracurium for ARDS. Patients paralyzed for ≤ 48 h (SHORT) were compared to those paralyzed for longer durations (LONG). Primary outcome was mortality. Parametric and nonparametric tests were utilized for the purposes of the comparison. A multivariate logistic regression model was utilized to adjust for differences. RESULTS: Of 73 patients meeting inclusion criteria, 32 (44%) were SHORT and 41 (56%) LONG. Compared to the LONG cohort, those in SHORT were older (60 versus 52 years, P = 0.04) but were comparable with respect to sex, acute physiology and chronic health evaluation IV scores, presence of concurrent pneumonia, and the use of vasopressors. SHORT patients were less likely to require rescue therapy with inhaled nitric oxide (28% versus 66%, P < 0.01). Overall mortality was 60%. There was no difference in the adjusted odds for mortality (adjusted odds ratio: 0.57, P = 0.33). Secondary outcomes including deep venous thrombosis and pneumonia did not differ between the two groups. CONCLUSIONS: Extended NMB for ARDS was not associated with increased mortality. Discontinuation of this modality should not be based solely on the duration of therapy.

The risk factors of venous thromboembolism in massively transfused patients.

BACKGROUND: Massive transfusion protocols (MTPs) are necessary for hemodynamically unstable trauma patients with active bleeding. Thrombotic events have been associated with blood transfusion; however, the risk factors for the development of venous thromboembolism (VTE) in trauma patients receiving MTP are unknown. METHODS: A retrospective review was conducted by reviewing the electronic medical records of all trauma patients admitted to a Level I trauma center who received MTP from 2011 to 2016. Data were collected on patient demographics, mechanism of injury, injury severity scores, quantity of blood products transfused during MTP activation, incidence of VTE, intensive care unit length of stay (LOS), hospital LOS, and ventilator days. The primary outcome was VTE. RESULTS: Of the 59 patients who had MTP activated, 15 (25.4%) developed a VTE during their hospital admission. Patients who developed VTE were compared with those who did not. Age (40 y versus 35 y, P = 0.59), sex (60% versus 73% male, P = 0.52), and mechanism of injury (47% versus 59% blunt, P = 0.40) were similar. Intensive care unit LOS, hospital LOS, and ventilator days were longer in the patients who were diagnosed with a VTE. Multivariable analysis revealed an increase in the odds for developing a VTE with increasing packed red blood cell transfusion (adjusted odds ratio = 2.61, P = 0.03). CONCLUSIONS: The risk for VTE in trauma patients requiring massive transfusion is proportional to the number of packed red blood cells transfused. Liberal screening protocols and maintenance of a high index of suspicion for VTE in these high-risk patients is justified.

Impact of early positive cultures in the elderly with traumatic brain injury.

BACKGROUND: Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in the United States, especially in the elderly, who have the highest rates of TBI-related hospitalizations and deaths among all age groups. Sepsis is one of many risk factors that is associated with higher mortality and longer length of hospital stay in this population partially due to the immunosuppressive effects of TBI. The significance of early indicators of infection, such as a positive blood, sputum, or urine culture, is not well described. The purpose of this study was to determine if early positive cultures predict higher mortality in elderly patients with TBI. METHODS: All trauma patients aged ≥65 years with TBI, admitted between January 1, 2009 and December 31, 2013 to the surgical intensive care unit, were retrospectively reviewed. Clinical data including results from sputum, blood, and urine cultures were reviewed. RESULTS: Overall, 288 elderly patients with TBI were identified, and 92 (32%) had a positive culture. Patients with positive cultures had longer intensive care unit (median 6.0 versus 2.0 days, P < 0.001) and ventilation days (median 7.0 versus 2.0 days, P < 0.001). Patients who had positive cultures within 2-3 days of admission had a higher adjusted hazard ratio for mortality than those patients who had positive cultures after 6 or more days. CONCLUSIONS: In elderly patients with TBI, early positive cultures are associated with a higher risk of mortality. Further research is required to determine the role of obtaining cultures on admission in this subpopulation of trauma patients.

Nonoperative Management of Blunt Splenic Trauma in Patients with Traumatic Brain Injury: Feasibility and Outcomes.

INTRODUCTION: Preventing secondary insult to the brain is imperative following traumatic brain injury (TBI). Although TBI does not preclude nonoperative management (NOM) of splenic injuries, development of hypotension in this setting may be detrimental and could therefore lead trauma surgeons to a lower threshold for operative intervention and a potentially higher risk of failure of NOM (FNOM). We hypothesized that the presence of a TBI in patients with blunt splenic injury would lead to a higher risk of FNOM. METHODS: Patients with blunt splenic injury were selected from the National Trauma Data Bank research datasets from 2007 to 2011. TBI was defined as AIS head ≥ 3 and FNOM as patients who underwent a spleen-related operation after 2 h from admission. TBI patients were compared to those without head injury. The primary outcome was FNOM. RESULTS: Of 47,713 patients identified, 41,436 (86.8%) underwent a trial of NOM. FNOM was identical (10.6 vs. 10.8%, p = 0.601) among patients with and without TBI. TBI patients had lower adjusted odds for FNOM (AOR 0.66, p < 0.001), even among those with a high-grade splenic injury (AOR 0.68, p < 0.001). No difference in adjusted mortality was noted when comparing TBI patients with and without FNOM (AOR 1.01, p = 0.95). CONCLUSIONS: NOM of blunt splenic trauma in TBI patients has higher adjusted odds for success. This could be related to interventions targeting prevention of secondary brain injury. Further studies are required to identify those specific practices that lead to a higher success rate of NOM of splenic trauma in TBI patients.

Validation of a field spinal motion restriction protocol in a level I trauma center.

BACKGROUND: Spinal motion restriction (SMR) after traumatic injury has been a mainstay of prehospital trauma care for more than 3 decades. Recent guidelines recommend a selective approach with cervical spine clearance in the field when criteria are met. MATERIALS AND METHODS: In January 2014, the Department of Health Services of the City of Los Angeles, California, implemented revised guidelines for cervical SMR after blunt mechanism trauma. Adult patients (aged ≥18 y) with an initial Glasgow Coma Scale (GCS) score of ≥13 presented to a single level I trauma center after blunt mechanism trauma over the following 1-y period were retrospectively reviewed. Demographics, injury data, and prehospital data were collected. Cervical spine injury (CSI) was identified by International Classification of Disease, Ninth Revision, codes. RESULTS: Emergency medical services transported 1111 patients to the emergency department who sustained blunt trauma. Patients were excluded if they refused c-collar placement or if documentation was incomplete. A total of 997 patients were included in our analysis with 172 (17.2%) who were selective cleared of SMR per protocol. The rate of Spinal Cord Injury was 2.2% (22/997) overall and 1.2% (2/172) in patients without SMR. The sensitivity and specificity of the protocol are 90.9% (95% confidence interval: 69.4-98.4) and 17.4% (95% confidence interval: 15.1-20.0), respectively, for CSI. Patients with CSI who arrived without immobilization having met field clearance guidelines, were managed without intervention, and had no neurologic compromise. CONCLUSIONS: Guidelines for cervical SMR have high sensitivity and low specificity to identify CSI. When patients with injuries were not placed on motion restrictions, there were no negative clinical outcomes.

Extubation to high-flow nasal cannula in critically ill surgical patients.

BACKGROUND: High-flow nasal cannula (HFNC) is increasingly used to reduce reintubations in patients with respiratory failure. Benefits include providing positive end expiratory pressure, reducing anatomical dead space, and decreasing work of breathing. We sought to compare outcomes of critically ill surgical patients extubated to HFNC versus conventional therapy. METHODS: A retrospective review was conducted in the surgical intensive care unit of an academic center during August 2015 to February 2016. Data including demographics, ventilator days, oxygen therapy after extubation, reintubation rates, surgical intensive care unit and hospital length of stay, and mortality were collected. Self and palliative extubations were excluded. Characteristics and outcomes, with the primary outcome being reintubation, were compared between those extubated to HFNC versus cool mist/nasal cannula (CM/NC). RESULTS: Of the 184 patients analyzed, 46 were extubated to HFNC and 138 to CM/NC. Mean age and days on ventilation before extubation were 57.8 years and 4.3 days, respectively. Both cohorts were similar in age, sex, and had a similar prevalence of cardiopulmonary diagnoses at admission. Although prior to extubation HFNC had lengthier ventilation requirements (7.1 versus 3.4 days, P < 0.01) and ICU stays (7.8 versus 4.1 days, P < 0.01), the rate of reintubation was similar to CM/NC (6.5% versus 13.8%, P = 0.19). Multivariable analysis demonstrated HFNC to be associated with a lower risk of reintubation (adjusted odds ratio = 0.15, P = 0.02). Mortality rates were similar. CONCLUSIONS: Ventilated patients at risk for recurrent respiratory failure have reduced reintubation rates when extubated to HFNC. Patients with prolonged intubation or those with high-risk comorbidities may benefit from extubation to HFNC.

Does Beta-Blockade Reduce the Risk of Depression in Patients with Isolated Severe Extracranial Injuries?

BACKGROUND: Approximately half of trauma patients develop post-traumatic depression. It is suggested that beta-blockade impairs trauma memory recollection, reducing depressive symptoms. This study investigates the effect of early beta-blockade on depression following severe traumatic injuries in patients without significant brain injury. METHODS: Patients were identified by retrospectively reviewing the trauma registry at an urban university hospital between 2007 and 2011. Severe extracranial injuries were defined as extracranial injuries with Abbreviated Injury Scale score ≥3, intracranial Abbreviated Injury Scale score <3 and an Injury Severity Score ≥16. In-hospital deaths and patients prescribed antidepressant therapy ≤1 year prior to admission were excluded. Patients were stratified into groups based on pre-admission beta-blocker status. The primary outcome was post-traumatic depression, defined as receiving antidepressants ≤1 year following trauma. RESULTS: Five hundred and ninety-six patients met the inclusion criteria with 11.4% prescribed pre-admission beta-blockade. Patients receiving beta-blockers were significantly older (57 ± 18 vs. 42 ± 17 years, p < 0.001) with lower Glasgow Coma Scale score (12 ± 3 vs. 14 ± 2, p < 0.001). The beta-blocked cohort spent significantly longer in hospital (21 ± 20 vs. 15 ± 17 days, p < 0.01) and intensive care (4 ± 7 vs. 3 ± 5 days, p = 0.01). A forward logistic regression model was applied and predicted lack of beta-blockade to be associated with increased risk of depression (OR 2.7, 95% CI 1.1-7.2, p = 0.04). After adjusting for group differences, patients lacking beta-blockers demonstrated an increased risk of depression (AOR 3.3, 95% CI 1.2-8.6, p = 0.02). CONCLUSIONS: Pre-admission beta-blockade is associated with a significantly reduced risk of depression following severe traumatic injury. Further investigation is needed to determine the beneficial effects of beta-blockade in these instances.

The Influence of Collagen Impregnation of a Knitted Dacron Patch Used in Carotid Endarterectomy.

BACKGROUND: In selected populations, carotid endarterectomy (CEA) reduces long-term stroke risk. Studies have shown increased risk of restenosis with use of a collagen-impregnated Dacron patch compared to a polytetrafluorethylene patch. There is concern that collagen impregnation may initiate thrombosis or promote restenosis due to platelet activation. We performed a retrospective analysis of our CEA experience with routine patching using knitted Dacron patches with (Hemashield) and without (Sauvage) collagen impregnation. METHODS: Our database was queried for all CEAs between January 2006 and December 2010. Seven surgeons performed 655 CEAs. Patients were excluded if no patch was used (n = 1), a primary CEA was performed before study period or by other surgeons (n = 11), or the patch type was indeterminable (n = 38). Demographics, clinical data, and outcomes were compared between the collagen-impregnated (C, Hemashield) group and non-collagen-impregnated (NC, Sauvage) group. RESULTS: A total of 605 CEAs were analyzed (395 C and 210 NC). Demographics were similar except for coronary artery disease (C 54.3% vs. NC 41.6%, P = 0.003). There was no statistically significant difference in 30-day (C 99.7% vs. NC 99.5%, P > 0.99) or 5-year survival (C 80.0% vs. NC 83.7%, P = 0.26) or 30-day stroke rate (C 0.3% vs. NC 1.0%, P = 0.28). No late ipsilateral strokes occurred during 5-year follow-up. The 5-year freedom from restenosis >30% (C 85.3% vs. NC 86.4%, P = 0.33), restenosis >50% (C 94.5% vs. NC 95.5%, P = 0.44), and restenosis >70% (C 98.6% vs. NC 98.9%, P = 0.73) were similar. Two patients underwent carotid stenting for restenosis >70%. Two patients (both in the C group) developed occlusion of the carotid artery. CONCLUSIONS: The thrombosis and restenosis rates in the 2 groups were similar. This suggests that collagen-impregnated patches do not initiate thrombosis or increase restenosis rates after CEA.

The elderly patient with spinal injury: treat or transfer?

BACKGROUND: The purpose of this investigation was to delineate whether elderly patients with spinal injuries benefit from transfers to higher level trauma centers. METHODS: Retrospective review of the National Trauma Data Bank 2007 to 2011, including patients > 65 (y) with any spinal fracture and/or spinal cord injury from a blunt mechanism. Patients who were transferred to level I and II centers from other facilities were compared to those admitted and received their definitive treatment at level III or other centers. RESULTS: Of 3,313,117 eligible patients, 43,637 (1.3%) met inclusion criteria: 19,588 (44.9%) were transferred to level I-II centers, and 24,049 (55.1%) received definitive treatment at level III or other centers. Most of the patients (95.8%) had a spinal fracture without a spinal cord injury. Transferred patients were more likely to require an intensive care unit admission (48.5% versus 36.0%, P < 0.001) and ventilatory support (16.1% versus 13.3%, P < 0.001). Mortality for the entire cohort was 7.7% (8.6% versus 7.1%, P < 0.001) and significantly higher, at 21.7% for patients with a spinal cord injury (22.3% versus 21.0%, P < 0.001). After adjusting for all available covariates, there was no difference in the adjusted mortality between patients transferred to higher level centers and those treated at lower level centers (adjusted odds ratio [95% confidence interval]: 1.05 [0.95-1.17], P = 0.325). CONCLUSIONS: Transfer of elderly patients with spinal injuries to higher level trauma centers is not associated with improved survival. Future studies should explore the justifications used for these transfers and focus on other outcome measures such as functional status to determine the potential benefit from such practices.

Prospective evaluation of early propranolol after traumatic brain injury.

BACKGROUND: Although beta-adrenergic receptor blockade may improve outcomes after traumatic brain injury (TBI), its early use is not routine. We hypothesize that judicious early low-dose propranolol after TBI (EPAT) will improve outcomes without altering bradycardia or hypotensive events. METHODS: We conducted a prospective, observational study on all patients who presented with moderate-to-severe TBI from March 2010-August 2013. Ten initial patients did not receive propranolol (control). Subsequent patients received propranolol at 1-mg intravenous every 6 h starting within 12 h of intensive care unit (ICU) admission (EPAT) for a minimum of 48 h. Heart rate and blood pressure were recorded hourly for the first 72 h. Bradycardia and hypotensive events, mortality, and length of stay (LOS) were compared between cohorts to determine significant differences. RESULTS: Thirty-eight patients were enrolled; 10 control and 28 EPAT. The two cohorts were similar when compared by gender, emergency department (ED) systolic blood pressure, ED heart rate, and mortality. ED Glasgow coma scale was lower (4.2 versus 10.7, P < 0.01) and injury severity score higher in control. EPAT patients received a mean of 10 ± 14 doses of propranolol. Hypotensive events were similar between cohorts, whereas bradycardia events were higher in control (5.8 versus 1.6, P = 0.05). ICU LOS (15.4 versus 30.4 d, P = 0.02) and hospital LOS (10 versus 19.1 d, P = 0.05) were lower in EPAT. Mortality rates were similar between groups (10% versus 10.7%, P = 0.9). The administration of propranolol led to no recorded complications. CONCLUSIONS: Although bradycardia and hypotensive events occur early after TBI, low-dose intravenous propranolol does not increase their number or severity. Early use of propranolol after TBI appears to be safe and may be associated with decreased ICU and hospital LOS.

Heart rate in pediatric trauma: rethink your strategy.

BACKGROUND: The optimal heart rate (HR) for children after trauma is based on values derived at rest for a given age. As the stages of shock are based in part on HR, a better understanding of how HR varies after trauma is necessary. Admission HRs of pediatric trauma patients were analyzed to determine which ranges were associated with lowest mortality. MATERIALS AND METHODS: The National Trauma Data Bank was used to evaluate all injured patients ages 1-14 years admitted between 2007 and 2011. Patients were stratified into eight groups based on age. Clinical characteristics and outcomes were recorded, and regression analysis was used to determine mortality odds ratios (ORs) for HR ranges within each age group. RESULTS: A total of 214,254 pediatric trauma patients met inclusion criteria. The average admission HR and systolic blood pressure were 104.7 and 120.4, respectively. Overall mortality was 0.8%. The HR range associated with lowest mortality varied across age groups and, in children ages 7-14, was narrower than accepted resting HR ranges. The lowest risk of mortality for patients ages 5-14 was captured at HR 80-99. CONCLUSIONS: The HR associated with lowest mortality after pediatric trauma frequently differs from resting HR. Our data suggest that a 7y old with an HR of 115 bpm may be in stage III shock, whereas traditional HR ranges suggest that this is a normal rate for this child. Knowing when HR is critically high or low in the pediatric trauma population will better guide treatment.