Management of Penetrating Traumatic Brain Injury: Operative versus Non-Operative Intervention.

BACKGROUND: Penetrating traumatic brain injury (pTBI) is the most lethal form of TBI, with mortality rates as high as 90%. This high mortality rate leads many providers to feel that the treatment of pTBI is futile. Contrary to this point of view, several studies have shown that victims of pTBI who present with a Glasgow Coma Scale (GCS) ≥6 have a reasonable chance of a meaningful outcome. This study sought to investigate outcomes of pTBI patients based on GCS score who underwent neurosurgical intervention (craniotomy or craniectomy) and compare them with patients who did not undergo surgical intervention. MATERIALS AND METHODS: The study represents a secondary analysis of the data that were collected from 2006 to 2016 from 17 institutions as part of a multi-center study, investigating clinical outcomes for adult patients sustaining pTBI and surviving >72 h. Patients were divided into those with GCS 3-5 and those with GCS ≥6. Within these groups, patients were stratified by whether they received surgical intervention, compared with standard non-surgical care. Patient level data (age and gender), clinical data (Injury Severity Score and Abbreviated Injury Score), GCS on admission, post-op infection rates, and outcomes data (mortality, length of stay [LOS], intensive care unit LOS) were collected. Both groups were compared using independent sample t-test or chi-squared test. RESULTS: Seven hundred twenty patients with pTBI were identified over 11 y, out of which 336 (46.7%) underwent surgery. The mean Injury Severity Score and Abbreviated Injury Score on admission were higher in the surgical intervention group than their non-surgical counterpart in patients with a GCS ≥6 (P < 0.0001). Patients with GCS of 3-5 with surgical intervention demonstrated a higher survival rate than non-surgical patients (P < 0.0001). In the GCS ≥6 group, surgical intervention did not impact near-term mortality. Intensive care unit LOS was significantly longer in the surgical intervention group in patients with GCS ≥ 6 (P < 0.0001) and GCS of 3-5 (P < 0.0001), as was total hospital LOS (P < 0.0001). Patients with a GCS 3-5 and ≥6 who underwent surgical intervention were more likely to develop a central nervous system infection (P = 0.016; P = 0.017). CONCLUSIONS: Surgical intervention in pTBI patients with GCS 3-5 results in improved mortality but comes at a cost of increased resource utilization in the form of longer LOS and higher infection rate. On the other hand, in patients with GCS ≥6, surgery does not provide significant benefits in patient survival. Future prospective studies providing insight as to the impact of surgery on the resource utilization and quality of survival would be beneficial in determining the need for surgical intervention in this population.

Do It to Them, Not to Me: Doctors' and Nurses' Personal Preferences Versus Recommendations for End-of-Life Care.

BACKGROUND: The emotional toll and financial cost of end-of-life care can be high. Existing literature suggests that medical providers often choose to forego many aggressive interventions and life-prolonging therapies for themselves. To further investigate this phenomenon, we compared how providers make medical decisions for themselves versus for relatives and unrelated patients. METHODS: Between 2016 and 2019, anonymous surveys were emailed to physicians (attendings, fellows, and residents), nurse practitioners, physician assistances, and nurses at two multifacility tertiary medical centers. Participants were asked to decide how likely they would offer a tracheostomy and feeding gastrostomy to a hypothetical patient with a devastating neurological injury and an uncertain prognosis. Participants were then asked to reconsider their decision if the patient was their own family member or if they themselves were the patient. The Kruskal-Wallis H, Mann-Whitney U, and Tukey tests were used to compare quantitative data. Statistical significance was set at P < 0.05. RESULTS: Seven hundred seventy-three surveys were completed with a 10% response rate at both institutions. Regardless of professional identity, age, or gender, providers were significantly more likely to recommend a tracheostomy and feeding gastrostomy to an unrelated patient than for themselves. Professional identity and age of the respondent did influence recommendations made to a family member. CONCLUSIONS: We demonstrate that medical practitioners make different end-of-life care decisions for themselves compared with others. It is worth investigating further why there is such a discrepancy between what medical providers choose for themselves compared with what they recommend for others.

The use of 3.15% chlorhexidine gluconate/70% alcohol hub disinfection to prevent central line-associated bloodstream infections in dialysis patients.

PURPOSE: Preventing CLABSI events in the dialysis inpatient population represents significant challenges. Bacteremia associated with lines or grafts are common health-associated infections that lead to adverse patient outcomes. Dialysis patients represent a much higher infection risk due to health frequency needs, more frequent hospitalizations, multiple comorbidity issues, fistula functionality, and multiple attempts for line access leading to additional complications, costs, morbidity, and mortality. METHODS: An observational study was conducted including central line device days, CLABSI events, and possible confounding variables in admitted dialysis patients. All CLABSI data were identified according to the Centers for Disease Control and Prevention's National Healthcare Safety Network's definitions for CLABSIs. The intervention involved the removal of 70% alcohol swabs and alcohol hub disinfecting caps, then replacing with swabs containing 3.15% chlorhexidine gluconate/70% alcohol for central line hub disinfection and vascular graft access skin disinfection. RESULTS: The 5-year preintervention period (2008-2012) involved 7568 central line days, 11 CLABSI events, and a 1.45 per 1000 device day rate. The 6-month trial period involved 1559 central line days and no CLABSI events. The 5-year postimplementation period (2013-2017) involved 9787 central line days, 5 CLABSI events, and a 0.51 per 1000 device day rate. The postimplementation period represented a statistically significant (P value=0.0493) reduction with 65% fewer CLABSI events compared with the preimplementation period. LIMITATIONS: A limitation was variations in scrub time and dry time during central venous catheter hub access. While we were comparing 2 products, behavioral practices using these 2 products were possible influencers and represent a possible confounding variable. CONCLUSIONS: This study found that using alcohol with chlorhexidine gluconate prior to accessing central line hubs and vascular grafts allows for reduction in CLABSI events and sustains statistically significant lower CLABSI rates in the inpatient dialysis population. HIGHLIGHTS Using alcohol with chlorhexidine gluconate (CHG) before accessing central line hubs helps reduce central line-associated bloodstream infection (CLABSI) events Using alcohol with CHG before accessing vascular grafts helps reduce CLABSI events A statistically significant reduction (65%) in CLABSI events occurred after use. Statistically significant lower CLABSI rates are sustainable with use of alcohol with CHG.

Reducing Pressure Injury Incidence Using a Turn Team Assignment: Analysis of a Quality Improvement Project.

PURPOSE: The purpose of this study was to analyze outcomes of a quality improvement project that evaluated a turning intervention for prevention of facility-acquired pressure injuries. DESIGN: A descriptive correlational study design examined the effectiveness of using a "turn team assignment" on pressure injury incidence and staff perceptions. SUBJECTS AND SETTING: The study sample comprised RNs and patient care associates assigned to provide care for patients admitted on the first or any subsequent day of hospitalization to a surgical intensive care unit at a Midwest inner-city teaching hospital. METHODS: Direct observation by expert clinicians occurred in 2-hour increments over a 14-day period using an 11-item, unit-designed process improvement tool. We collected information regarding cueing, concurrent turning, independent turning in lieu of the cue, staff support, and possible barriers to turning and repositioning. Staff perceptions were collected using an online tool via survey. The survey utilized a 14-item questionnaire, and a 5-point Likert Scale to identify staff perceptions and beliefs about the turn team intervention. Pressure injury occurrences were measured using data from our monthly prevalence study. RESULTS: Pressure injury occurrences declined from 24.9% to 16.8% over the data collection period. There was a strong positive correlation between verbal cueing and turning (r = 0.815; P < .05). Staff perceptions supported preintervention education (64.3%) and cueing (93%; 78%) as effective interventions in completing patient turning. CONCLUSIONS: Findings suggest that turn team assignments using verbal cueing are an effective intervention that decreases pressure injury occurrence. This intervention required no increase in staffing personnel, making this type of intervention reasonable and effective in improving frequency of repositioning and decreasing pressure injury prevalence rates.

Comparison of carotid artery dimensions and lesion length measured by B-mode ultrasonography and quantitative angiography in patients with severe stenosis undergoing percutaneous revascularization.

BACKGROUND: To evaluate the correlation and agreement of the carotid artery landmarks necessary for carotid artery stenting obtained by B-mode ultrasonography (BMU), and by quantitative angiography (QCA) in patients with severe carotid artery stenosis. METHODS: In 75 patients undergoing carotid artery stenting, the distal common (CCA), proximal internal (ICA) carotid artery diameter, and lesion length were measured preoperatively by BMU, and intraoperatively by QCA. RESULTS: In 96% of the subjects, BMU imaging was adequate for interpretation. BMU and QCA Pearson correlation and Lin concordance coefficients were 0.75 (p < 0.001) and 0.959 (95% CI: 0.930 - 0.996), respectively, for CCA diameter, 0.88 (p < 0.001) and 0.954 (95% CI: 0.928-0.983), respectively, for ICA diameter, and 0.62 (p < 0.001) and 0.734 (95% CI: 0.719-0.760), respectively, for lesion length, with a 0.765 bias correction factor and a wider data scatter by Bland Altman plots showing shorter lesion length by BMU than by QCA. CONCLUSIONS: In patients with carotid artery stenosis, BMU can provide reliable distal CCA and proximal ICA diameters in comparison with QCA, whereas lesion length measured by BMU has an acceptable correlation, but a poor agreement with QCA.

High-grade liver injuries with contrast extravasation managed initially with interventional radiology versus observation: A secondary analysis of a WTA multicenter study.

BACKGROUND: High-grade liver injuries with extravasation (HGLI â€‹+ â€‹Extrav) are associated with morbidity/mortality. For low-grade injuries, an observation (OBS) first-strategy is beneficial over initial angiography (IR), however, it is unclear if OBS is safe for HGLI â€‹+ â€‹Extrav. Therefore, we evaluated the management of HGLI â€‹+ â€‹Extrav patients, hypothesizing IR patients will have decreased rates of operation and mortality. METHODS: HGLI â€‹+ â€‹Extrav patients managed with initial OBS or IR were included. The primary outcome was need for operation. Secondary outcomes included liver-related complications (LRCs) and mortality. RESULTS: From 59 patients, 23 (39.0%) were managed with OBS and 36 (61.0%) with IR. 75% of IR patients underwent angioembolization, whereas 13% of OBS patients underwent any IR, all undergoing angioembolization. IR patients had an increased rate of operation (13.9% vs. 0%, p â€‹= â€‹0.049), but no difference in LRCs (44.4% vs. 43.5%) or mortality (5.6% vs. 8.7%) versus OBS patients (both p â€‹> â€‹0.05). CONCLUSION: Over 60% of patients were managed with IR initially. IR patients had an increased rate of operation yet similar rates of LRCs and mortality, suggesting initial OBS reasonable in appropriately selected HGLI â€‹+ â€‹Extrav patients.

Grade 1 Internal Carotid Artery Blunt Cerebrovascular Injury Persistence Risks Stroke With Current Management: An EAST Multicenter Study.

BACKGROUND: Higher blunt cerebrovascular injury (BCVI) grade and lack of medical therapy are associated with stroke. Knowledge of stroke risk factors specific to individual grades may help tailor BCVI therapy to specific injury characteristics. METHODS: A post-hoc analysis of a 16 center, prospective, observational trial (2018-2020) was performed including grade 1 internal carotid artery (ICA) BCVI. Repeat imaging was considered the second imaging occurrence only. RESULTS: From 145 grade 1 ICA BCVI included, 8 (5.5%) suffered a stroke. Grade 1 ICA BCVI with stroke were more commonly treated with mixed anticoagulation and antiplatelet therapy (75.0% vs 9.6%, P <.001) and less commonly antiplatelet therapy (25.0% vs 82.5%, P = .001) compared to injuries without stroke. Of the 8 grade 1 ICA BCVI with stroke, 4 (50.0%) had stroke after medical therapy was started. In comparing injuries with resolution at repeat imaging to those without, stroke occurred in 7 (15.9%) injuries without resolution and 0 (0%) injuries with resolution (P = .005). At repeat imaging in grade 1 ICA BCVI with stroke, grade of injury was grade 1 in 2 injuries, grade 2 in 3 injuries, grade 3 in 1 injury, and grade 5 in one injury. DISCUSSION: While the stroke rate for grade 1 ICA BCVI is low overall, injury persistence appears to heighten stroke risk. Some strokes occurred despite initiation of medical therapy. Repeat imaging is needed in grade 1 ICA BCVI to evaluate for injury progression or resolution.

An observation-first strategy for liver injuries with "blush" on computed tomography is safe and effective.

INTRODUCTION: The management of liver injuries in hemodynamically stable patients is variable and includes primary treatment strategies of observation (OBS), angiography (interventional radiology [IR]) with angioembolization (AE), or operative intervention (OR). We aimed to evaluate the management of patients with liver injuries with active extravasation on computed tomography (CT) imaging, hypothesizing that AE will have more complications without improving outcomes compared with OBS. METHODS: This is a prospective, multicenter, observational study. Patients who underwent CT within 2 hours after arrival with extravasation (e.g., blush) on imaging were included. Exclusion criteria included cirrhosis, nontraumatic hemorrhage, transfers from outside facilities, and pregnancy. No hemodynamic exclusion criteria were used. The primary outcome was liver-specific complications. Secondary outcomes include length of stay and mortality. Angioembolization patients were compared with patients treated without AE. Propensity score matching was used to match based on penetrating mechanism, liver injury severity, arrival vital signs, and early transfusion. RESULTS: Twenty-three centers enrolled 192 patients. Forty percent of patients (n = 77) were initially OBS. Eleven OBS patients (14%) failed nonoperative management and went to IR or OR. Sixty-one patients (32%) were managed with IR, and 42 (69%) of these had AE as an initial intervention. Fifty-four patients (28%) went to OR+/- IR. After propensity score matching (n = 34 per group), there was no difference in baseline characteristics between AE and OBS. The AE group experienced more complications with a higher rate of IR-placed drains for abscess or biloma (22% vs. 0%, p = 0.01) and an increased overall length of stay ( p = 0.01). No difference was noted in transfusions or mortality. CONCLUSION: Observation is highly effective with few requiring additional interventions. Angioembolization was associated with higher rate of secondary drain placement for abscesses or biloma. Given this, a trial of OBS and avoidance of empiric AE may be warranted in hemodynamically stable, liver-injured patient with extravasation on CT. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.

Cardiogenic shock secondary to severe acute ischemic mitral regurgitation managed with an Impella 2.5 percutaneous left ventricular assist device.

We report a case of a patient successfully treated with an Impella Recover LP 2.5 (ABIOMED, Danvers, MA) left ventricular assist device, in the setting of cardiogenic shock secondary to severe acute mitral regurgitation associated with an acute myocardial infarction.

Which Patients Receive Diagnostic Angiography? An EAST Multicenter Study Analysis of Internal Carotid Artery Blunt Cerebrovascular Injury.

BACKGROUND: Digital subtraction angiography (DSA) is the gold standard radiologic modality in blunt cerebrovascular injury (BCVI). However, computerized tomography angiography (CTA) is primarily used in modern practice with CTA's widespread availability and the decreased stroke rate with CTA use. The frequency and indications for DSA in BCVI is undefined. We hypothesized that DSA use in internal carotid artery (ICA) BCVI would be infrequent and dependent on radiologic features. METHODS: This was a post hoc analysis of an EAST multicenter, prospective, observational trial of 16 trauma centers for stroke factors in BCVI. ICA BCVI was divided into those undergoing DSA and not undergoing DSA (no-DSA). Only ICA BCVI was included. RESULTS: 332 ICA BCVI were included, 221 (66.6%) no-DSA and 111 (33.4%) DSA. Lower hospital trauma volume, non-urban environment, and non-academic status were associated with DSA use (all P ≤ .001). BCVI grade (P = .02) and presence of luminal stenosis (P = .005) were associated with DSA use while pseudoaneurysm presence was not. Median time to DSA was 1 hour. The most common indication for angiography was to determine the presence of injury in 71 (64%) ICA BCVI, followed by determining grade of injury in 16 (14.4%) and concerning imaging characteristics in 12 (10.8%). BCVI grade on initial imaging and on DSA were equivalent in 94 (84.7%) ICA BCVI. DISCUSSION: DSA is frequently used in ICA BCVI, primarily early in the hospital course for injury diagnosis and grade determination. DSA appears primarily driven by hospital type, BCVI grade, and luminal stenosis.

Endovascular Intervention in Internal Carotid Artery Blunt Cerebrovascular Injury: An EAST Multicenter Study.

BACKGROUND: Use of endovascular intervention (EI) for blunt cerebrovascular injury (BCVI) is without consensus guidelines. Rates of EI use and radiographic characteristics of BCVI undergoing EI nationally are unknown. METHODS: A post-hoc analysis of a prospective, observational study at 16 U.S. trauma centers from 2018 to 2020 was conducted. Internal carotid artery (ICA) BCVI was included. The primary outcome was EI use. Multivariable logistic regression was performed for predictors of EI use. RESULTS: From 332 ICA BCVI included, 21 (6.3%) underwent EI. 0/145 (0%) grade 1, 8/101 (7.9%) grade 2, 12/51 (23.5%) grade 3, and 1/20 (5.0%) grade 4 ICA BCVI underwent EI. Stroke occurred in 6/21 (28.6%) ICA BCVI undergoing EI and in 33/311 (10.6%) not undergoing EI (P = .03), with all strokes with EI use occurring prior to or at the same time as EI. Percentage of luminal stenosis (37.75 vs 20.29%, P = .01) and median pseudoaneurysm size (9.00 mm vs 3.00 mm, P = .01) were greater in ICA BCVI undergoing EI. On logistic regression, only pseudoaneurysm size was associated with EI (odds ratio 1.205, 95% CI 1.035-1.404, P = .02). Of the 8 grade 2 ICA BCVI undergoing EI, 3/8 were grade 2 and 5/8 were grade 3 prior to EI. Of the 12 grade 3 ICA BCVI undergoing EI, 11/12 were grade 3 and 1/12 was a grade 2 ICA BCVI prior to EI. DISCUSSION: Pseudoaneurysm size is associated with use of EI for ICA BCVI. Stroke is more common in ICA BCVI with EI but did not occur after EI use.

Factors associated with stroke formation in blunt cerebrovascular injury: An EAST multicenter study.

BACKGROUND: Stroke risk factors after blunt cerebrovascular injury (BCVI) are ill-defined. We hypothesized that factors associated with stroke for BCVI would include medical therapy (i.e., Aspirin), radiographic features, and protocolization of care. METHODS: An Eastern Association for the Surgery of Trauma-sponsored, 16-center, prospective, observational trial was undertaken. Stroke risk factors were analyzed individually for vertebral artery (VA) and internal carotid artery (ICA) BCVI. Blunt cerebrovascular injuries were graded on the standard 1 to 5 scale. Data were from the initial hospitalization only. RESULTS: Seven hundred seventy-seven BCVIs were included. Stroke rate was 8.9% for all BCVIs, with an 11.7% rate of stroke for ICA BCVI and a 6.7% rate for VA BCVI. Use of a management protocol (p = 0.01), management by the trauma service (p = 0.04), antiplatelet therapy over the hospital stay (p < 0.001), and Aspirin therapy specifically over the hospital stay (p < 0.001) were more common in ICA BCVI without stroke compared with those with stroke. Antiplatelet therapy over the hospital stay (p < 0.001) and Aspirin therapy over the hospital stay (p < 0.001) were more common in VA BCVI without stroke than with stroke. Percentage luminal stenosis was higher in both ICA BCVI (p = 0.002) and VA BCVI (p < 0.001) with stroke. Decrease in percentage luminal stenosis (p < 0.001), resolution of intraluminal thrombus (p = 0.003), and new intraluminal thrombus (p = 0.001) were more common in ICA BCVI with stroke than without, while resolution of intraluminal thrombus (p = 0.03) and new intraluminal thrombus (p = 0.01) were more common in VA BCVI with stroke than without. CONCLUSION: Protocol-driven management by the trauma service, antiplatelet therapy (specifically Aspirin), and lower percentage luminal stenosis were associated with lower stroke rates, while resolution and development of intraluminal thrombus were associated with higher stroke rates. Further research will be needed to incorporate these risk factors into lesion specific BCVI management. LEVEL OF EVIDENCE: Prognostic and Epidemiologic, Level IV.

Does treatment delay for blunt cerebrovascular injury affect stroke rate?: An EAST multicenter study.

BACKGROUND: The purpose of this study was to analyze injury characteristics and stroke rates between blunt cerebrovascular injury (BCVI) with delayed vs non-delayed medical therapy. We hypothesized there would be increased stroke formation with delayed medical therapy. METHODS: This is a sub-analysis of a 16 center, prospective, observational trial on BCVI. Delayed medial therapy was defined as initiation >24 hours after admission. BCVI which did not receive medical therapy were excluded. Subgroups for injury presence were created using Abbreviated Injury Scale (AIS) score >0 for AIS categories. RESULTS: 636 BCVI were included. Median time to first medical therapy was 62 hours in the delayed group and 11 hours in the non-delayed group (p < 0.001). The injury severity score (ISS) was greater in the delayed group (24.0 vs the non-delayed group 22.0, p <  0.001) as was the median AIS head score (2.0 vs 1.0, p <  0.001). The overall stroke rate was not different between the delayed vs non-delayed groups respectively (9.7% vs 9.5%, p = 1.00). Further evaluation of carotid vs vertebral artery injury showed no difference in stroke rate, 13.6% and 13.2%, p = 1.00 vs 7.3% and 6.5%, p = 0.84. Additionally, within all AIS categories there was no difference in stroke rate between delayed and non-delayed medical therapy (all N.S.), with AIS head >0 13.8% vs 9.2%, p = 0.20 and AIS spine >0 11.0% vs 9.3%, p = 0.63 respectively. CONCLUSIONS: Modern BCVI therapy is administered early. BCVI with delayed therapy were more severely injured. However, a higher stroke rate was not seen with delayed therapy, even for BCVI with head or spine injuries. This data suggests with competing injuries or other clinical concerns there is not an increased stroke rate with necessary delays of medical treatment for BCVI.

Five-Year Follow-Up of Patients With Radio-Contrast-Induced Acute Renal Injury: Can Intravenous Sodium Bicarbonate Improve Long-Term Outcomes?

BACKGROUND/PURPOSE: Radiocontrast-induced acute kidney injury (RAKI) is a frequent complication during angiography and is associated with adverse prognosis. Most of the studies evaluating the long-term outcome of patients with RAKI are based on institutional registries. This is the first prospective study to evaluate the 5-year outcomes of patients with RAKI, and assess the effect of sodium bicarbonate (SB) in the long-term outcomes of patients with chronic kidney disease (CKD) undergoing non-emergent coronary angiography. MATERIALS/METHODS: 382 CKD stage III-IV patients undergoing elective non-emergent coronary angiography were randomized to SB (n = 192) or normal saline (NS) solution (n = 190). Incidence of RAKI, in-hospital, 1- and 5-year mortality and renal replacement therapy (RRT), and 5-year major adverse renal and cardiovascular events (MARCE) were compared between groups. Outcomes of patient with and without RAKI were compared after five-years of prospective follow-up. Multivariate predictors of RAKI and death at 5-years were determined. RESULTS: The use of SB did not improve the incidence of RAKI, in-hospital outcomes, survival, and freedom from RRT or MARCE after 5-years of follow-up. Patients that developed RAKI had a significantly higher mortality at 1-year [8.9% Vs. 1.2%] and 5-years (36% Vs. 11%) (P < 0.01). CONCLUSIONS: Hydration with SB showed no benefit compared to NS in preventing RAKI. The use of SB was not superior to NS after 5-years of follow-up regarding MARCE, survival or freedom of RRT. Five-year mortality among patients who developed RAKI remains high, and further research is needed to find the best preventive strategy for this high-risk group of patients. SUMMARY: Radiocontrast-induced acute-kidney-injury (RAKI) is associated with poor long-term outcomes in observational and short-term studies. Hydration with sodium bicarbonate (SB) had been evaluated in the prevention of RAKI; but its long-term effect has not been evaluated. We randomized 382 high high-risk patients undergoing coronary angiography to SB or normal saline following them for five years. SB showed no benefit in preventing RAKI, decreasing major adverse renal and cardiovascular events, improving survival or freedom from dialysis after 5-years. This is the first study to follow patients with RAKI for a period of 5-years, showing a significantly higher mortality in this group of patients.

Critical traumatic brain injury is associated with worse coagulopathy.

OBJECTIVES: As thromboelastography (TEG) becomes the standard of care in patients with hemorrhagic shock (HS), an association between concomitant traumatic brain injury (TBI) and coagulopathy by TEG parameters is not well understood and is thus investigated. METHODS: Retrospective analysis of trauma registry data at a single level 1 trauma center of 772 patients admitted with head Abbreviated Injury Scale (AIS) score of 3 and TEG studies between 2014 and 2017. Patients were stratified to moderate-severe TBI by head AIS scores of 3 and 4 (435 patients) and critical TBI by head AIS score of 5 (328 patients). Hemorrhagic shock was defined by base deficit of 4 or shock index of 0.9. Statistical analysis with unpaired t tests compared patients with critical TBI with patients with moderate-severe TBI, and patients were grouped by presence or absence of HS. A comparison of TBI data with conventional coagulation studies was also evaluated. RESULTS: In the setting of HS, critical TBI versus moderate-severe TBI was associated with longer R time (p = 0.004), longer K time (p < 0.05), less acute angle (p = 0.001), and lower clot strength and stability (maximum amplitude [MA]) (p = 0.01). Worse TBI did not correlate with increased fibrinolysis by clot lysis measured by the percentage decrease in amplitude at 30 minutes after MA (p = 0.3). Prothrombin time and international normalized ratio failed to demonstrate more severe coagulopathy, while partial thromboplastin time was found to correlate with severity of TBI (p = 0.01). In patients with critical TBI, the presence of HS correlated with a statistically significant worsening of all parameters (p < 0.05) except for clot lysis measured by the percentage decrease in amplitude at 30 minutes after MA (LY-30). CONCLUSION: Thromboelastography demonstrates that, with and without hemorrhagic shock, critical TBI correlates with a significant worsening of traumatic coagulopathy in comparison with moderate/severe TBI. In HS, critical TBI correlates with impaired clot initiation, impaired clot kinetics, and impaired platelet-associated clot strength and stability versus parameters found in moderate-severe TBI. Hemorrhagic shock correlates with worse traumatic coagulopathy in all evaluated patient groups with TBI. Conventional coagulation studies underestimate TBI-associated coagulopathy. Traumatic brain injury-associated coagulopathy is not associated with fibrinolysis. LEVEL OF EVIDENCE: Prognostic/epidemiological, level IV; prognostic/epidemiological, level III.

Does routine postoperative contrast radiography improve outcomes for patients with perforated peptic ulcer? A multicenter retrospective cohort study.

BACKGROUND: Perforated peptic ulcer is a morbid emergency general surgery condition. Best practices for postoperative care remain undefined. Surgical dogma preaches practices such as peritoneal drain placement, prolonged nil per os, and routine postoperative enteral contrast imaging despite a lack of evidence. We aimed to evaluate the role of postoperative enteral contrast imaging in postoperative perforated peptic ulcer care. Our primary objective was to assess effects of routine postoperative enteral contrast imaging on early detection of clinically significant leaks. METHODS: We conducted a multicenter retrospective cohort study of patients who underwent repair of perforated peptic ulcer between July 2016 and June 2018. We compared outcomes between those who underwent routine postoperative enteral contrast imaging and those who did not. RESULTS: Our analysis included 95 patients who underwent primary/omental patch repair. The mean age was 60 years, and 54% were male. Thirteen (14%) had a leak. Eighty percent of patients had a drain placed. Nine patients had leaks diagnosed based on bilious drain output without routine postoperative enteral contrast imaging. Use of routine postoperative enteral contrast imaging varied significantly between institutions (30%-87%). Two late leaks after initial normal postoperative enteral contrast imaging were confirmed by imaging after a clinical change triggered the second study. Two patients had contained leaks identified by routine postoperative enteral contrast imaging but remained clinically well. Duration of hospital stay was longer in those who received routine postoperative enteral contrast imaging (12 vs 6 days, median; P = .000). CONCLUSION: Routine postoperative enteral contrast imaging after perforated peptic ulcer repair likely does not improve the detection of clinically significant leaks and is associated with increased duration of hospital stay.

Surgical Faculty Perception of Service-Based Advanced Practice Provider Impact: A Southwestern Surgical Congress Multicenter Survey.

BACKGROUND: A previous single-center survey of trauma and general surgery faculty demonstrated perceived positive impact of trauma and surgical subspecialty service-based advanced practice providers (SB APPs). The aim of this multicenter survey was to further validate these findings. METHODS: Faculty surgeons on teams that employ SB APPs at 8 academic centers completed an electronic survey querying perception about advanced practice provider (APP) competency and impact. RESULTS: Respondents agreed that SB APPs decrease workload (88%), length of stay (72%), contribute to continuity (92%), facilitate care coordination (87%), enhance patient satisfaction (88%), and contribute to best practice/safe patient care (83%). Fewer agreed that APPs contribute to resident education (50%) and quality improvement (QI)/research (36%). Although 93% acknowledged variability in the APP level of function, 91% reported trusting their clinical judgment. CONCLUSION: This study supports the perception that SB APPs have a positive impact on patient care and quality indicators. Areas for potential improvement include APP contribution to resident education and research/QI initiatives.

Is Opioid Prescribing Driving Trauma Recidivism or Is Trauma Driving Opioid Use?

In the past 30 years, opioid prescription rates have quadrupled and hospital admissions for overdose are rising. Previous studies have focused on alcohol use and trauma recidivism, however rarely evaluating recidivism and opioid use. We hypothesized there is an association between opioid use and trauma recidivism. This is a retrospective review of patients with multiple admissions for traumatic injury. Demographics, opioid toxicology screen (TS) results, and injury characteristics were collected. Statistical analysis was performed with chi-squared and Poisson regression models. One thousand six hundred forty-nine patients (age ≥18 years) had multiple trauma admissions. Seven hundred nine patients had TS data for both admissions. Thirty-one per cent (218) were TS positive on the 1st admission compared with 34 per cent (244) on their 2nd admission. Fifty-five per cent of patients who were TS positive on the 1st admission were positive on their 2nd admission, whereas 25 per cent who were TS negative on the 1st admission were subsequently positive on their 2nd admission (P < 0.0001). Patients who were TS positive on the subsequent admission were less severely injured than TS negative patients (Injury Severity Score > 15, 26.3% vs 22.3%, P = 0.04). The only significant risk factor for being TS positive on the 2nd admission was being TS positive on the 1st admission (relative risk = 2.18, P < 0.001). A previous history of opioid use is the strongest predictor of recurrent use in recidivists.

Delayed splenic hemorrhage: Myth or mystery? A Western Trauma Association multicenter study.

BACKGROUND: Multi-detector computed tomography imaging is now the reference standard for identifying solid organ injuries, with a high sensitivity and specificity. However, delayed splenic hemorrhage (DSH), defined as no identified injury to the spleen on the index scan but delayed bleeding from a splenic injury, has been reported. We hypothesized that the occurrence of DSH would be minimized by utilization of modern imaging techniques. METHODS: Data was retrospectively collected from 2006 to 2016 in 12 adult Level I and II trauma centers. All patients had an initial CT scan demonstrating no splenic injury but subsequently were diagnosed with splenic bleeding. Demographic, injury characteristics, imaging parameters and results, interventions and outcomes were collected. RESULTS: Of 6867 patients with splenic injuries, 32 cases (0.4%) of blunt splenic hemorrage were identified. Patients were primarily male, had blunt trauma, severely injured (ISS 32 (9-57) and with associated injuries. Injuries of all grades were identified up to 16 days following admission. Overall, half of patients required splenectomy. All index images were obtained using multi-detector CT (16-320 slice). Secondary review of imaging by two trauma radiologists judged 72% (n = 23) of scans as suboptimal. This was due to poor scan quality primary from artifact(23), single phase contrast imaging (16), and/or poor contrast bolus timing or volume (6). Notably, only 28% of scans in patients with DSH were performed with optimal scanning techniques. CONCLUSION: This is the largest reported series of DSH in the era of modern imaging. Although the incidence of DSH is low, it still occurs despite the use of multi-detector imaging and when present, is associated with a high rate of splenectomy. Most cases of DSH can be attributed to missed diagnosis from suboptimal index imaging and ultimately be avoided.

Infection after penetrating brain injury-An Eastern Association for the Surgery of Trauma multicenter study oral presentation at the 32nd annual meeting of the Eastern Association for the Surgery of Trauma, January 15-19, 2019, in Austin, Texas.

BACKGROUND: Fatality rates following penetrating traumatic brain injury (pTBI) are extremely high and survivors are often left with significant disability. Infection following pTBI is associated with worse morbidity. The modern rates of central nervous system infections (INF) in civilian survivors are unknown. This study sought to determine the rate of and risk factors for INF following pTBI and to determine the impact of antibiotic prophylaxis. METHODS: Seventeen institutions submitted adult patients with pTBI and survival of more than 72 hours from 2006 to 2016. Patients were stratified by the presence or absence of infection and the use or omission of prophylactic antibiotics. Study was powered at 85% to detect a difference in infection rate of 5%. Primary endpoint was the impact of prophylactic antibiotics on INF. Mantel-Haenszel χ and Wilcoxon's rank-sum tests were used to compare categorical and nonparametric variables. Significance greater than p = 0.2 was included in a logistic regression adjusted for center. RESULTS: Seven hundred sixty-three patients with pTBI were identified over 11 years. 7% (n = 51) of patients developed an INF. Sixty-six percent of INF patients received prophylactic antibiotics. Sixty-two percent of all patients received one dose or greater of prophylactic antibiotics and 50% of patients received extended antibiotics. Degree of dural penetration did not appear to impact the incidence of INF (p = 0.8) nor did trajectory through the oropharynx (p = 0.18). Controlling for other variables, there was no statistically significant difference in INF with the use of prophylactic antibiotics (p = 0.5). Infection was higher in patients with intracerebral pressure monitors (4% vs. 12%; p = <0.001) and in patients with surgical intervention (10% vs. 3%; p < 0.001). CONCLUSION: There is no reduction in INF with prophylactic antibiotics in pTBI. Surgical intervention and invasive intracerebral pressure monitoring appear to be risk factors for INF regardless of prophylactic use. LEVEL OF EVIDENCE: Therapeutic, level IV.