Contemporary management and time to revascularization in upper extremity arterial injury.

INTRODUCTION: Upper extremity arterial injury is associated with significant morbidity and mortality for trauma patients, but there is a paucity of data to guide the clinician in the management of these injuries. The goals of this review were to characterize the demographics, presentation, clinical management, and outcomes, and to evaluate how time to intervention associates with outcomes in trauma patients with upper extremity vascular injuries. METHODS: The National Trauma Data Bank (NTDB) Research Data Set for the years 2007-2016 was queried in order to identify adult patients (age ≥ 18) with an upper extremity arterial injury. Patients with brachiocephalic, subclavian, axillary, or brachial artery injury using the 1998 and 2005 versions of the Abbreviated Injury Scale were included. Patients with non-survivable injuries to the brain, traumatic amputation, or other major arterial injuries to the torso or lower extremities were excluded. RESULTS: The data from 7908 patients with upper extremity arterial injuries was reviewed. Of those, 5407 (68.4%) underwent repair of the injured artery. The median Injury Severity Score (ISS) was 10 (IQR = 7-18), and 7.7% of patients had a severe ISS (≥ 25). Median time to repair was 120 min (IQR = 60-240 min). Management was open repair in 52.3%, endovascular repair in 7.3%, and combined open and endovascular repairs in 8.8%; amputation occurred in 1.8% and non-operative management was used in 31.6% of patients. Blunt mechanism of injury, crush injury, concomitant fractures/dislocations, and nerve injuries were associated with amputation, whereas simultaneous venous injury was not. There was a significant decrease in the rate of amputation when patients undergoing surgical revascularization did so within 90 min of injury (P = 0.007). CONCLUSION: Injuries to arteries of the upper extremity are managed with open repair, endovascular repair, and, rarely, amputation. Expeditious transport to the operating room for revascularization is the key for limb salvage.

The Role of Endovascular Repair of Popliteal Arterial Injuries in the Acute Setting.

BACKGROUND: The role of endovascular surgery in the treatment of popliteal arterial injuries is not well established. As with other popliteal pathology, open repair has traditionally been considered the gold standard. As data has accumulated and technology advanced, however, a reassessment of the role of endovascular surgery is warranted. The aim of this study is to perform a noninferiority comparison of open versus endovascular management of traumatic popliteal injuries. Our hypothesis is that endovascular management is noninferior to open management of traumatic popliteal injuries. METHODS: The National Trauma Data Bank was searched for adult patients from 2002-2016 for isolated popliteal arterial injury. The study used a standard noninferiority methodology to compare rates of amputation and compartment syndrome between endovascular and open surgery. Margins for noninferiority were established using established published rates of complications: 17.1% for amputations and 23.0% for compartment syndrome. Endovascular intervention would be considered noninferior to open surgery if the lower bound confidence of the complication proportion (endo/open complication rate) was greater than the predefined noninferiority margin. RESULTS: A total of 3,698 patients met inclusion criteria, with blunt injury accounting for 2,117 (57%) and penetrating injury accounting for 1,581 (43%). Within the blunt group, 1,976 (93.3%) underwent open and 141 (6.7%) endovascular surgery. The rate of compartment syndrome (percentage and 95% confidence interval) after surgery for open repair was 9.9 (8.6-11.2) and 6.4 (3.2-11.3) for endovascular repair. The complication proportion is 64.6 (59.7-69.5). The rate of amputation for open repair was 15.7 (14.2-17.4) and 14.2 (9.2-20.6) for endovascular repair. The complication proportion is 90.4 (87.4-93.4). Within the penetrating group, 1,525 (96.5%) underwent open repair and 56 (3.5%) endovascular surgery. The rate of compartment syndrome after surgery for open repair was 14.9 (13.2-16.7) and 5.4 (1.5-13.6) for endovascular repair. The complication proportion is 36.2 (31.3-41.1). The rate of amputation for open repair was 4.3 (3.3-5.4) and 3.6 (0.7-11.0) for endovascular repair. The complication proportion is 83.7 (75.3-90.6). CONCLUSIONS: These data suggests that endovascular repair of popliteal artery injury may be noninferior to open repair with respect to limb preservation. Further examination of endovascular repair in popliteal artery injury is warranted.

Repair of the Iliac Arterial Injury in Trauma: An Endovascular Operation?

BACKGROUND: Endovascular therapy is effective for non-traumatic iliac arterial diseases. The role of endovascular surgery in traumatic iliac lesions is unclear. The aim of this study is to compare outcomes for open versus endovascular management of traumatic iliac injuries. MATERIALS AND METHODS: The National Trauma Data Bank was searched for patients from 2002to 2016 with iliac arterial injury. Patients were sorted by treatment modality (open versus endo) and mechanism (blunt versus penetrating) and matched using mangled extremity score variables. The proportion of patients undergoing amputation were compared using the chi-square test. RESULTS: In the blunt group, 1550 (82%) had endovascular and 342 (18%) had open repair. Endovascular repair was associated with a significantly lower amputation rate than open repair (0.6% versus 3.6%, P = 0.015) despite higher incidence of concomitant injuries. Venous injury was more frequent in the open group (13.7% versus 1.8%, P < 0.001). Within the penetrating group, 209 (22%) had endovascular and 755 (78%) had open repair. Again endovascular repair was associated with a lower amputation rate (0% versus 5.1%, P = 0.004). Patients undergoing endovascular repair had more severe extremity/orthopedic injury, with venous injury again associated with open repair (48.5% versus 37.4%, P = 0.03). CONCLUSIONS: Endovascular repair of iliac injuries was associated with a significantly lower rate of amputation than open surgery. Endovascular repair was associated with a higher incidence of several injuries, although open repair was associated with concomitant venous injury. Further work is required to delineate the benefit of endovascular intervention and role of venous injury in limb salvage.

Timing of intervention may influence outcomes in blunt injury to the carotid artery.

OBJECTIVE: Blunt carotid artery injury (BCI) is present in approximately 1.0% to 2.7% of all blunt trauma admissions and can result in significant morbidity and mortality. Management ranges from antithrombotic therapy alone to surgery, where potential indications include pseudoaneurysm, failed or contraindication to medical therapy, and progression of neurologic symptoms. Still, optimal management, including approach and timing, continues to be an active area for debate. The goal of this study was to assess the epidemiologic characteristics of BCI, and, after controlling for presenting features intrinsic to the data, compare outcomes based on management, operative approach, and timing of intervention. METHODS: A retrospective review was conducted of adult BCI patients identified within the National Trauma Data Bank from 2002 to 2016. The National Trauma Data Bank is the largest trauma database in the United States, collating data from each trauma admission for more than 900 trauma centers. Independent variables of interest included nonoperative versus operative management (OM); endovascular versus open intervention, and early (within 24 hours) versus delayed (after 24 hours) intervention. For each independent variable, groups were compared after propensity score matching to control for presenting factors and patterns of injury. RESULTS: There were 9190 patients who met the inclusion criteria, 812 of whom underwent operative intervention (open, n = 288; endovascular, n = 481, both: n = 43). During the review, there was no difference in proportion of OM over time, although there was a statistically significant decrease in the proportion of open intervention (0.48% per year; P < .05). For outcomes, operative versus nonoperative management (nOM) resulted in no difference in mortality, but the operative group demonstrated an increased risk of stroke (11.8% vs 6.5%), longer hospital and intensive care length of stay, and more days on mechanical ventilation (P < .001 for each). With regard to timing: mortality was increased for early intervention (early, 16% vs delayed, 6.3%; P < .001), which was predominantly driven by the endovascular cohort (early, 19.2% vs delayed, 2.5%; P < .001). CONCLUSIONS: In this study, there was no significant trend in the overall volume of operative or nOM; however, when considering approach to OM, there was a significant decrease in open procedures. Consistent with previous literature, injury to the neck, head, and chest was significant associated with BCI. Also outcomes demonstrated an increased prevalence of stroke after operative relative to nOM. Importantly, after critically assessing the timing to intervention, results strongly suggested that, if possible, intervention should be delayed for at least 24 hours.

Penetrating Injury to the Carotid Artery: Characterizing Presentation and Outcomes from the National Trauma Data Bank.

BACKGROUND: Penetrating injury to the neck can be devastating because of the multiple vital structures in close proximity. In the event of injury to the carotid artery, there is a significantly increased likelihood of morbidity or mortality. The purpose of this study was to assess presenting characteristics associated with penetrating injury to the carotid artery and directly compare approaches to surgical management. METHODS: Data from the National Trauma Data Bank from 2002-2016 were accessed to evaluate adult patients sustaining penetrating injury to the common or internal carotid artery. Management (operative versus nonoperative) and surgical approach (open versus endovascular) were evaluated based on presentation characteristics, and outcomes were compared after propensity score matching. RESULTS: Three thousand three hundred ninety-one patients fitting inclusion criteria and surviving past the emergency department were included in analyses (nonoperative: 1,976 [58.3%] patients and operative: 1,415 [41.7%] patients). The operative group was further classified by intervention as open = 1,192 patients and endovascular: 154 patients. On presentation, the nonoperative group demonstrated significantly higher prevalence of coma (Glasgow Coma Scale ≤8: nonoperative = 49.3% versus operative = 40.8%, P < 0.001), severe overall injury burden (Injury Severity Score ≥25: nonoperative = 42.3% versus operative = 33.3%, P < 0.001), and severe head injury (Abbreviated Injury Score ≥ 3: nonoperative = 44.9% versus operative = 22.0%, P < 0.001). After propensity score matching, the nonoperative group demonstrated higher mortality (nonoperative = 28.9% versus operative = 18.5%, P < 0.001), and lower rates of stroke (nonoperative = 6.6% versus operative - = 10.5%, P < 0.001). There were no differences in outcomes relating to surgical approach. CONCLUSIONS: These results indicate that nonoperative patients often present with a more severe overall injury burden, particularly injury to the head, and not surprisingly, have higher rates of mortality. The lack of significant differences in outcomes relating to surgical approach indicates open versus endovascular invention should be individualized to the patient-for example, based on presenting characteristics and the location of the injury.

Differences in Facial Fracture Patterns in Pediatric Nonaccidental Trauma.

BACKGROUND: The purpose of this study was to characterize differences in facial fracture injury patterns among pediatric patients at highest risk of abusive head trauma/nonaccidental trauma (age ≤ 5 years). METHODS: Using the National Trauma Databank from 2007 to 2015, patients (age ≤ 5 years) suffering facial fractures were included. Demographics and injury characteristics were compared between those sustaining accidental versus nonaccidental trauma (NAT). RESULTS: Over 9 years 9741 patients were included with 193 patients (2.0%) suffering NAT. Nonaccidental trauma patients were younger (median [interquartile range]; 0 [0, 2] versus 3 [1, 4], P < 0.001), and more frequently were insured by Medicaid (76.7% versus 41.9%, P < 0.001). NAT patients were more likely to sustain mandible fractures (38.9% versus 21.1%, P < 0.001), but less likely to sustain maxilla (9.8% versus 18.3%, P = 0.003), or orbital fractures (31.1% versus 53.4%, P < 0.001). Nonaccidental trauma patients had fewer instances of multiple facial fracture sites (8.9% versus 22.6%, P < 0.001). Among those sustaining mandible fractures, NAT patients were more likely to sustain condylar fractures (75.8% versus 48.4%, P < 0.001), but less likely to sustain subcondylar fractures (0% versus 13.2%, P = 0.002), or angle fractures (1.6 versus 8.7%, P = 0.048). CONCLUSIONS: Differences exist in facial fracture patterns in accidental versus nonaccidental trauma within the pediatric population at highest risk for abusive head trauma. Specifically, NAT is associated with fractures of the mandibular condyle and involve fewer facial fracture sites. In the appropriate context, presence of these fractures/patterns should increase suspicion for NAT.

A Surgical Endovascular Trauma Service Increases Case Volume and Decreases Time to Hemostasis.

OBJECTIVES: The aim of this study was to evaluate the effect of a recently active endovascular trauma service (ETS) on case volume and time to hemostasis, as a complement to an existing interventional radiology (IR) service. SUMMARY BACKGROUND DATA: Endovascular techniques are vital for trauma care, but timely access can be a challenge. There is a paucity of data on the effect of a multispecialty team for delivery of endovascular hemorrhage control. METHODS: The electronic medical record of trauma patients undergoing endovascular procedures between 2013 and 2018 was queried for provider type (IR or ETS). Case volume and rates were expressed per 100 monthly admissions, normalizing for seasonal variation. Interrupted time series analysis was used to model the case rate pre- and post-introduction of the ETS. Admission-to-procedure-time data were collected for pelvic angioembolization as a marker of patients requiring emergency hemostasis. RESULTS: During 6 years, 1274 admission episodes required endovascular interventions. Overall case volume increased from 2.7 to 3.6 at a rate of 0.006 (P = 0.734) after introduction of the ETS. IR case volume decreased from 3.3 to 2.6 at a rate of 0.03 (P = 0.063). ETS case volume increased at a rate of 0.048 (P < 0.001), which was significantly different from the IR trend (P < 0.001). Median (interquartile range) time-to-procedure (hours) was significantly shorter for pelvic angioembolization [3.0 (4.4) vs 4.3 (3.6); P < 0.001] when ETS was compared to IR. CONCLUSION: A surgical ETS increases case volume and decreases time to hemostasis for trauma patients requiring time sensitive interventions. Further work is required to assess patient outcome following this change.

Characterization of Age-Related Injury Patterns and Surgical Treatment of Pediatric Facial Fractures: Analysis of the National Trauma Data Bank.

BACKGROUND: Presentation of pediatric facial fractures varies widely and many injuries are encountered infrequently by most practitioners. This study summarizes injury patterns in a large cohort of facial fractures and their subsequent surgical management. METHODS: Demographic and clinical characteristics of patients 18 years of age or younger admitted between 2009 and 2015 to trauma centers participating in the National Trauma Data Bank were examined. Craniofacial fractures and reconstructive procedures performed at index admission were selected based on ICD-9 and AIS codes. A multivariable analysis was used to determine independent determinants of surgical repair. RESULTS: Out of 60,094 pediatric patients evaluated in the US emergency departments, 48,821 patients were admitted and underwent open treatment (n = 8364; 17.1%) or closed treatment (n = 4244; 8.7%) of facial fractures. Falls were the most common mechanism of injury in infants and toddlers (<2-year-old, 44.4%, P <0.001), while motor vehicle collisions (32.9%, P <0.001) and assault (22.1%, P <0.001) were most commonly seen in adolescents (12-18-year-old). The frequency and odds of repair of facial fractures increased with advancing age, more so with open than closed treatment in adolescents (73.0%) as compared to infants and toddlers (50.3%). Children who sustained mandible fractures are the most likely to require surgical treatment at index-admission (odds ratio = 13.9, 95% confidence interval 13.1-14.8, P <0.001). CONCLUSIONS: Population-based data shows that pediatric fracture patterns and associated early repair vary significantly with age. Patient demographics and hospital characteristics are significant determinants of surgical treatment that should be related to clinical outcomes in future studies.

Contemporary Characterization of Injury Patterns, Initial Management, and Disparities in Treatment of Facial Fractures Using the National Trauma Data Bank.

BACKGROUND: Contemporary description of facial fracture patterns and factors associated with early operative intervention at trauma centers is lacking. The purpose of this study was to characterize injuries and initial treatment patterns of patients suffering from facial fractures. METHODS: Using the National Trauma Databank from 2007 to 2015, patients suffering from facial fractures were included. Demographics, injury characteristics, and outcomes including operative interventions were assessed. RESULTS: Over 9 years, 626,270 patients were included: 74.5% were male, 39.0% suffered traumatic brain injury (TBI), and 23.3% severe noncraniofacial injuries (chest, abdomen, and/or extremity Abbreviated Injury Score ≥3). A total of 537,594 (85.8%) patients were admitted and 184,206 (34.3%) underwent operations for their facial injuries during the index hospitalization. The frequency and patterns of fractures varied by age, sex, race, and mechanism of injury. Operative intervention rates were highest for mandible (63.2%) and lowest for orbit fractures (1.0%). Multiple regression revealed that multiple factors were independently associated with the odds of early fracture repair including: female versus male (odds ratio [95% confidence interval]: 0.96 [0.94-0.98]), age >65 versus <18 years (0.62 [0.59-0.64]), non-white race (0.95 [0.94-0.97]), uninsured versus Medicaid (0.88 [0.86-0.90]), hospital bed size (>600 vs ≤200 beds, 1.67 [1.61-1.73]), TBI (0.70 [0.69-0.71]), and C-spine injury (0.93 [0.90-0.96]). CONCLUSIONS: Facial fractures are common among many demographic cohorts, and multiple patient and injury-specific factors influenced fracture patterns and management. Early operative intervention was highest for mandible fractures and lowest for orbit fractures. Multiple factors including age, sex, insurance status, hospital characteristics, and race/ethnicity were independently associated with early operative intervention, highlighting disparities in care.

Does insurance status matter at a public, level I trauma center?

BACKGROUND: It has previously been demonstrated that a lack of insurance impedes access to health care services and may affect outcome after acute medical events. Very little data exists on the impact of insurance status on outcomes after traumatic injury. The purpose of this study was to determine whether insurance status has an impact on the outcomes of trauma patients admitted to a publicly funded county level I trauma center. PATIENTS: This is a retrospective study of adult trauma patients (aged 18 years or older) admitted between January 1,1998, and December 31, 2005. Patients transferred out within 1 week of injury were excluded. Variables examined included demographics, insurance status, mechanism of injury, Injury Severity Score, Abbreviated Injury Scales, Glasgow Coma Scale, procedures performed, and outcomes. Logistic regression was used to determine independent risk factors for mortality. RESULTS: Sixty-eight percent of the 29,829 patients admitted were uninsured. Uninsured patients were younger (36 versus 41, p < 0.0001) and less severely injured (Injury Severity Score 8 versus 10, p < 0.0001) but had a significantly higher mortality rate (7.0% versus 4.9%, p < 0.0001) compared with insured counterparts. Logistic regression identified uninsured status as an independent risk factor for mortality (AOR, 3.4; 95% confidence interval, 2.9-4.1; p < 0.0001). There was significant disparity between the mortality rates for uninsured and insured patients within the Black (7.1% versus 3.3%, p < 0.0001) and Hispanic (6.5% versus 4.1%, p < 0.0001) populations. No such mortality difference was observed in the white (7.2% versus 6.9%, p = 0.7) and Asian (9.7% versus 9.2%, p = 0.8) populations. CONCLUSION: Despite being younger and less severely injured, uninsured trauma patients had a significantly higher mortality rate. The etiology of this discrepancy is unclear and warrants further investigation.

An international fellowship in trauma research and the potential benefits for fellows, sponsoring institution, and the global trauma community.

For over a decade, the Los Angeles County/University of Southern California Hospital has supported an international fellowship in trauma that provides research experience, education, and opportunity for clinical observation at a high-volume American College of Surgeons (ACS) designated Level I trauma center. We performed a descriptive study of the design, implementation, and results of an international fellowship in trauma and critical care. Fellows from 27 countries throughout the world have actively engaged in trauma research at Los Angeles County/University of Southern California Hospital. Our program involves intensive education and clinical observation components designed to facilitate dissemination of evidence-based trauma practices throughout the world by graduates. The majority of alumni responding to a survey returned to their countries of origin, remaining active in trauma care and research. Motivation for participation varied, but former fellows universally rated their experience highly and stated they would recommend the program to their colleagues. An international research fellowship in trauma and critical care provides foreign medical trainees opportunities for exposure to research and evidence-based practices at a high-volume trauma center. The program is designed to be beneficial to both the participating fellow and sponsoring institution; and is constructed to effectively promote improved trauma education and the dissemination of quality trauma practices internationally.

Prospective evaluation of a predictive model of mortality in patients with isolated head injury.

BACKGROUND: In a previous retrospective study, we developed a predictive model of survival in isolated head injuries based on easily available parameters such as age, mechanism of injury, Glasgow Coma Scale, and head Abbreviated Injury Scale (AIS). The purpose of the present study is to prospectively evaluate this predictive model. METHODS: Isolated head injuries admitted to a Level I urban trauma center were prospectively accrued from May 1, 2006 through April 30, 2007. Age, mechanism of injury, Glasgow Coma Scale, head AIS, and survival status were recorded for each patient. Patients with extracranial AIS >3, head AIS = 6, or hypotension were excluded. These data were entered into our previously developed predictive model and the percentage of correct classification was used to measure how well the predictive model predicted outcome. Sensitivity, specificity, positive and negative predictive values, and their 95% confidence intervals were calculated and compared with values obtained from our original, retrospective study. RESULTS: Seven hundred eighty-six patients met the criteria for inclusion in the study with an overall mortality of 5.8% (46 patients). When entered into our predictive model, the percentage of correct classification rate was 92% compared with the 94% rate seen in the original study, which is better than other available predictive tools based on combined scoring systems such as the Trauma and Injury Severity Score methodology. CONCLUSION: When evaluated prospectively, our predictive model has similar accuracy in predicting survival of all patients with head trauma as our original retrospective study and performs better than other predictive models such as the Trauma and Injury Severity Score methodology. This study demonstrates that a simple table based on easily obtained admission patient characteristics can rapidly provide information about the probability of survival in patients with head injuries.

Accuracy of the Ventilator Automated Displayed Respiratory Mechanics in Passive and Active Breathing Conditions: A Bench Study.

BACKGROUND: New-generation ventilators display dynamic measures of respiratory mechanics, such as compliance, resistance, and auto-PEEP. Knowledge of the respiratory mechanics is paramount to clinicians at the bedside. These calculations are obtained automatically by using the least squares fitting method of the equation of motion. The accuracy of these calculations in static and dynamic conditions have not been fully validated or examined in different clinical conditions or various ventilator modes. METHODS: A bench study was performed by using a lung simulator to compare the ventilator automated calculations during passive and active conditions. Three clinical scenarios (normal, COPD, and ARDS) were simulated with known compliances and resistance set per respective condition: normal (compliance 50 mL/cm H2O, resistance 10 cm H2O/L/s), COPD (compliance 60 mL/cm H2O, resistance 22 cm H2O/L/s), and ARDS (compliance 30 mL/cm H2O, and resistance 13 cm H2O/L/s). Each scenario was subjected to 4 different muscle pressures (Pmus): 0, -5, -10, and -15 cm H2O. All the experiments were done using adaptive support ventilation. The resulting automated dynamic calculations of compliance and resistance were then compared based on the clinical scenarios. RESULTS: There was a small bias (average error) and level of agreement in the passive conditions in all the experiments; however, these errors and levels of agreement got progressively higher proportional to the increased Pmus. There was a strong positive correlation between Pmus and compliance measured as well as a strong negative correlation between Pmus and resistance measured. CONCLUSIONS: Automated displayed calculations of respiratory mechanics were not dependable or accurate in active breathing conditions. The calculations were clinically more reliable in passive conditions. We propose different methods of calculating Pmus, which, if incorporated into the calculations, would improve the accuracy of respiratory mechanics made via the least squares fitting method in actively breathing conditions.

Blunt Thoracic Aortic Injury: Endovascular Repair Is Now the Standard.

BACKGROUND: Incidence and treatment of blunt thoracic aortic injury (BTAI) has evolved, likely from improved imaging and emergence of endovascular techniques; however, multicenter data demonstrating this are lacking. We examined trends in incidence, management, and outcomes in BTAI. STUDY DESIGN: The American College of Surgeons National Trauma Databank (2003 to 2013) was used to identify adults with BTAI. Management was categorized as nonoperative repair, open aortic repair (OAR), or thoracic endovascular repair (TEVAR). Outcomes included demographics, management, and outcomes. RESULTS: There were 3,774 patients. Median age was 46.0 years (interquartile range [IQR] 29.3, 62.0 years), with 70.8% males, and median Injury Severity Score (ISS) of 34.0 (IQR 26.0, 45.0). The number of BTAIs diagnosed over the decade increased 196.8% (p < 0.001), median ISS decreased from 38 to 33 (p < 0.001), and significantly more patients were treated at a level I trauma center (p < 0.001). After FDA approval of TEVAR devices, there was a significant increase in endovascular repair overall (1.0% to 30.6%, p < 0.001) and in those treated operatively (0.0% to 94.9%, p < 0.001), with a marked decrease in OAR. Use of TEVAR was associated with significantly reduced median ICU LOS (9.0 vs 12.0 days, p = 0.048) and mortality (9.3% vs 16.6%; p = 0.015) compared with OAR. In modern BTAI care, TEVAR has nearly completely replaced OAR. CONCLUSIONS: The diagnosis of BTAI has increased, likely due to more sensitive imaging. Nearly 70% of patients get nonoperative care. Treatment with TEVAR improves outcomes relative to OAR. Part of the proportional increase in TEVAR use may represent overtreatment of lower grade BTAI amenable to medical management, and warrants further investigation.

Small volume resuscitation with 20% albumin in intensive care: physiological effects : The SWIPE randomised clinical trial.

PURPOSE: We set out to assess the resuscitation fluid requirements and physiological and clinical responses of intensive care unit (ICU) patients resuscitated with 20% albumin versus 4-5% albumin. METHODS: We performed a randomised controlled trial in 321 adult patients requiring fluid resuscitation within 48 h of admission to three ICUs in Australia and the UK. RESULTS: The cumulative volume of resuscitation fluid at 48 h (primary outcome) was lower in the 20% albumin group than in the 4-5% albumin group [median difference - 600 ml, 95% confidence interval (CI) - 800 to - 400; P < 0.001]. The 20% albumin group had lower cumulative fluid balance at 48 h (mean difference - 576 ml, 95% CI - 1033 to - 119; P = 0.01). Peak albumin levels were higher but sodium and chloride levels lower in the 20% albumin group. Median (interquartile range) duration of mechanical ventilation was 12.0 h (7.6, 33.1) in the 20% albumin group and 15.3 h (7.7, 58.1) in the 4-5% albumin group (P = 0.13); the proportion of patients commenced on renal replacement therapy after randomization was 3.3% and 4.2% (P = 0.67), respectively, and the proportion discharged alive from ICU was 97.4% and 91.1% (P = 0.02). CONCLUSIONS: Resuscitation with 20% albumin decreased resuscitation fluid requirements, minimized positive early fluid balance and was not associated with any evidence of harm compared with 4-5% albumin. These findings support the safety of further exploration of resuscitation with 20% albumin in larger randomised trials. TRIAL REGISTRATION: http://www.anzctr.org.au . Identifier ACTRN12615000349549.

Intraabdominal injury is common in blunt trauma patients who sustain spinal cord injury.

The evaluation of the abdomen in patients with spinal cord injury (SCI) is challenging for obvious reasons. There are very little data on the incidence and complications of patients who sustain SCI with concomitant intraabdominal injury (IAI). To determine the incidence and outcomes of IAI in blunt trauma patients with SCI, a trauma registry and record review was performed between January 1998 and December 2005. Baseline demographic data, Injury Severity Score, and associated IAI were collected. Two groups were established and outcomes were analyzed based on the presence or absence of IAI. Intraabdominal and hollow viscus injures were found in 15 per cent and 6 per cent, respectively, of 292 patients with blunt SCI. The presence of intraabdominal injury varied according to the level of the SCI: 10 per cent of cervical, 23 per cent of thoracic, and 18 per cent of lumbar SCI. The overall mortality was 16 per cent. The presence of intraabdominal injury was associated with longer intensive care unit length of stay (13 versus 6 days, P < 0.01), hospital length of stay (23 versus 18 days, P < 0.05), higher complication rate (46% versus 33%, P = 0.09), and higher mortality (44% versus 11%, P < 0.01) when compared with patients with SCI without IAI. Intraabdominal injuries are common in blunt SCI. Liberal evaluation with computed tomography is necessary to identify injuries early.

Time of day variation in door-to-balloon time for STEMI patients in Los Angeles County: does time of day make a difference?

OBJECTIVE: Evaluate treatment times and clinical outcome in a consecutive series of ST segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) in Los Angeles County. BACKGROUND: Primary PCI for STEMI is beneficial if performed in a timely manner. Conflicting data exist regarding potential treatment delays for primary PCI performed during off hours. METHODS: The Emergency Medical Services STEMI Receiving Center Database was queried from 2007 to 2009 to identify patients with a pre-hospital ECG showing STEMI who underwent PCI. On-hour PCI (On-hour Group, n = 1324) was defined as PCI occurring from 8 am to 5 pm and off-hour PCI (Off-hour Group, n = 922) was defined as occurring from 5 pm to 8 am. Treatment times, length of stay, vascular complications, achievement of TIMI 3 flow and in-hospital mortality were evaluated. RESULTS: Off-hours PCI occurred in 41% of patients. Medical contact to door time was similar in the Off-hour Group compared to the On-hour Group, 20.7 ± 14.6 versus 20.3 ± 12.3 min, respectively, P = 0.47. In patients with available data (n = 1366), the door-to-catheterization laboratory (CL) activation time was significantly shorter in the On-hour Group as compared to the Off-hour Group, -4.9 ± 11.9 versus -0.2 ± 27.5 min, respectively, P < 0.0001. Door-to-balloon time was significantly longer in the Off-hour Group compared to the On-hour Group, 74 ± 35 versus 60 ± 26 min respectively, P < 0.0001. Length of stay, vascular complications, final TIMI 3 flow and in-hospital mortality were similar between both groups. CONCLUSIONS: In STEMI patients receiving primary PCI in Los Angeles County, off-hour PCI was common. Short-term clinical outcomes were similar despite longer door-to-balloon time in patients receiving off-hour PCI. The longer door-to-balloon time in the off-hour PCI patients were partly explained by longer door-to-CL activation time.

Does age matter? The relationship between age and mortality in penetrating trauma.

PURPOSE: Trauma is a significant cause of mortality among elderly patients, with blunt mechanisms accounting for the majority of deaths in this population. Penetrating trauma promises to evolve as an increasingly important aetiology of mortality in the elderly; particularly as the age composition of the overall population continues to shift. Unfortunately, very little data regarding outcomes following penetrating trauma in the elderly exists. The purpose of this study was to define the relationship between age and mortality following penetrating injuries and determine if differences between outcomes of elderly patients sustaining penetrating and blunt trauma exist. METHODS: After IRB approval, we conducted a retrospective trauma registry review at an urban Level 1 trauma centre between January 1, 1998 and December 31, 2005. Demographic, injury, and mortality data for all patients were recorded. The relationship between age and mortality for both blunt and penetrating injuries was examined by comparison of age-specific mortality and relative risk of mortality for both mechanisms at 10 year age intervals. Additionally, the relative risk and 95% confidence interval for mortality in each age group were compared. RESULTS: There were 26,333 blunt trauma admissions and 8843 penetrating trauma admissions during the 8-year study period. The mortality following both blunt and penetrating trauma remained stable until the age of 55 and increased steadily thereafter. When differences in mortality following blunt and penetrating mechanisms were examined, the overall mortality of penetrating trauma was found to be 2.63 times that of blunt (11.0% vs. 4.2%, RR 2.63; 95% CI: 2.42, 2.85, p<0.0001). After adjustment for age and other confounding factors, the relative risk of mortality due to penetrating mechanisms was 1.65 (95% CI: 0.88, 2.89, p=0.10) that of blunt mechanism counterparts. Although statistically higher in penetrating trauma, the relative risk of mortality between penetrating and blunt trauma decreased with increasing age. CONCLUSION: The mortality rate with respect to penetrating trauma remains relatively constant until the age of 55, increasing thereafter. When compared to blunt trauma, the relationship between age and mortality in penetrating trauma is similar except that the relative mortality in penetrating trauma is significantly higher for each age group.

Severe traumatic brain injury: is there a gender difference in mortality?

BACKGROUND: Emerging evidence suggests that male and female nervous systems respond differently to traumatic brain injury (TBI). The objective of this study was to examine outcomes between the sexes after TBI. PATIENTS AND METHODS: A retrospective review of all severe TBI patients admitted between January and December 2005 was performed. Isolated severe TBI was defined as a head abbreviated injury score greater than 3 with an abbreviated injury score of 3 or less for other anatomic regions. The population was stratified into age subgroups (<14 y, 14-44 y, 45-54 y, and > or =55 y). Logistic regression was used to identify independent predictors of mortality. RESULTS: A total of 1,807 TBI patients were admitted. The mortality was significantly higher for women (43.2% vs 36.2%, P < .01) with an adjusted odds ratio of 1.4 (95% confidence interval, 1.1-1.9, P < .05). After stratification, only women age 55 and older had a significant difference in mortality (odds ratio, 1.71; 95% confidence interval, 1.11-2.62, P = .02). CONCLUSIONS: Female sex (particularly those age > or =55 y) is associated independently with higher mortality in isolated severe TBI. This increased mortality of postmenopausal women after isolated TBI may suggest a hormonal influence and warrants further investigation.

Predictors of positive angiography in pelvic fractures: a prospective study.

BACKGROUND: Severe pelvic fractures continue to be a major problem for trauma surgeons. Early identification of patients who would benefit from therapeutic angiographic embolization (AE) of pelvic bleeding would be beneficial. We hope to identify simple risk factors that would pinpoint patients who would benefit from therapeutic AE. STUDY DESIGN: This is a prospective observational study at an academic Level I trauma center. All blunt trauma patients with a pelvic fracture admitted from December 2003 to February 2007 were included. AE was performed for hemodynamic instability (systolic blood pressure < 100 mmHg), fracture pattern (sacroiliac joint [SIJ] disruption, butterfly, open book), or CT demonstrating a large pelvic hematoma. AE was considered therapeutic if contrast extravasation was noted and addressed with embolization. Main outcomes measures were positive angiography and mortality. Stepwise logistic regression was performed to identify predictors of therapeutic AE. A predictive model was built based on these independent risk factors to estimate the probability of a therapeutic AE. RESULTS: One hundred thirty-seven (23%) of 603 patients with pelvic fractures had angiography. Therapeutic AE was performed in 85 patients (62%). Indications for angiography included hemodynamic instability (58%), fracture pattern (26%), and CT findings (9%). Nineteen patients (22%) with therapeutic AE had no hypotension or tachycardia. Independent predictors for therapeutic AE were SIJ disruption (odds ratio [OR]: 4.5; 95% CI, 1.6 to 12.6; p = 0.005), female gender (OR: 3.9; 95% CI, 1.5 to 10.0; p = 0.005), and duration (in minutes) of systolic blood pressure < 100 mmHg (OR: 1.4; 95% CI, 1.1 to 1.9; p = 0.007). CONCLUSIONS: Presence of SIJ disruption, female gender, and duration of hypotension can reliably predict patients who would benefit from AE. This predictive model can help early identification of patients who would benefit from pelvic angiography.