The impact of a massive transfusion protocol (1:1:1) on major hepatic injuries: does it increase abdominal wall closure rates?

BACKGROUND: Massive transfusion protocols (MTPs) using high plasma and platelet ratios for exsanguinating trauma patients are increasingly popular. Major liver injuries often require massive resuscitations and immediate hemorrhage control. Current published literature describes outcomes among patients with mixed patterns of injury. We sought to identify the effects of an MTP on patients with major liver trauma. METHODS: Patients with grade 3, 4 or 5 liver injuries who required a massive blood component transfusion were analyzed. We compared patients with high plasma:red blood cell:platelet ratio (1:1:1) transfusions (2007-2009) with patients injured before the creation of an institutional MTP (2005-2007). RESULTS: Among 60 patients with major hepatic injuries, 35 (58%) underwent resuscitation after the implementation of an MTP. Patient and injury characteristics were similar between cohorts. Implementation of the MTP significantly improved plasma: red blood cell:platelet ratios and decreased crystalloid fluid resuscitation (p = 0.026). Rapid improvement in early acidosis and coagulopathy was superior with an MTP (p = 0.009). More patients in the MTP group also underwent primary abdominal fascial closure during their hospital stay (p = 0.021). This was most evident with grade 4 injuries (89% vs. 14%). The mean time to fascial closure was 4.2 days. The overall survival rate for all major liver injuries was not affected by an MTP (p = 0.61). CONCLUSION: The implementation of a formal MTP using high plasma and platelet ratios resulted in a substantial increase in abdominal wall approximation. This occurred concurrently to a decrease in the delivered volume of crystalloid fluid.

CONTEXTE: Les protocoles de transfusion massive (PTM) impliquant des rapports plasma:plaquettes élevés sont de plus en plus populaires pour traiter les patients atteints d'un traumatisme hémorragique. Les chirurgies majeures du foie requièrent souvent le déclenchement de protocoles de transfusion massive et une maîtrise immédiate de l'hémorragie. La littérature actuelle décrit les résultats chez des patients victimes de divers types de traumatismes. Nous avons voulu mesurer les effets d'un PTM sur les patients ayant subi un traumatisme majeur au foie. MÉTHODES: Nous avons analysé les dossiers de patients ayant subi des blessures au foie de grade 3, 4 ou 5 qui ont nécessité des transfusions massives de composants sanguins. Nous avons comparé les patients ayant nécessité des transfusions importantes de plasma, de culots globulaires et de plaquettes selon un rapport (1:1:1; 2007­2009) à des patients ayant subi leur traumatisme avant la mise en oeuvre d'un PTM par l'établissement (2005­2007). RÉSULTATS: Sur 50 patients ayant subi des lésions hépatiques majeures, 35 (58%) ont reçu des traitements de réanimation après la mise en place du PTM. Les caractéristiques propres aux patients et à leurs blessures étaient similaires entre les cohortes. L'application du PTM a significativement amélioré les rapports plasma:culots globulaires:plaquettes et réduit l'administration de cristalloïdes à des fins de réanimation liquidienne (p = 0,026). L'amélioration rapide de l'acidose naissante et de la coagulopathie a été meilleure avec le PTM (p = 0,009). Plus de patients du groupe soumis au PTM ont aussi subi une fermeture aponévrotique abdominale primaire durant leur séjour hospitalier (p = 0,021). Cela s'est surtout observé avec les lésions de grade 4 (89% c. 14%). Le délai moyen avant la fermeture aponévrotique a été de 4,2 jours. L'application du PTM n'a pas modifié le taux de survie global pour l'ensemble des traumatismes hépatiques majeurs (p = 0,61). CONCLUSION: La mise en place d'un PTM officiel reposant sur des rapports plasma et plaquettes élevés a donné lieu à une augmentation substantielle des fermetures de la paroi abdominale. Cela s'est produit en parallèle avec une diminution du volume de cristalloïdes administrés pour la réanimation liquidienne.

A decade's experience with balloon catheter tamponade for the emergency control of hemorrhage.

BACKGROUND: Balloon catheter tamponade is a valuable technique for arresting exsanguinating hemorrhage. Indications include (1) inaccessible major vascular injuries, (2) large cardiac injuries, and (3) deep solid organ parenchymal bleeding. Published literature is limited to small case series. The primary goal was to review a recent experience with balloon catheter use for emergency tamponade in a civilian trauma population. METHODS: All patients requiring emergency use of a balloon catheter to tamponade exsanguinating hemorrhage (1998-2009) were included. Patient demographics, injury characteristics, technique, and outcomes were analyzed. RESULTS: Of the 44 severely injured patients (82% presented with hemodynamic instability; mean base deficit=-20.4) who required balloon catheter tamponade, 23 of the balloons (52%) remained indwelling for more than 6 hours. Overall mortality depended on the site of injury/catheter placement and indwelling time (81% if <6 hours; 52% if ≥6 hours; p<0.05). Physiologic exhaustion was responsible for 76% of deaths in patients with short-term balloons. Mortality among patients with prolonged balloon catheter placement was 11%, 50%, and 88% for liver, abdominal vascular, and facial/pharyngeal injuries, respectively. Mean indwelling times for iliac, liver, and carotid injuries were 31 hours, 53 hours, and 78 hours, respectively. Overall survival rates were 67% (liver), 67% (extremity vascular), 50% (abdominal vascular), 38% (cardiac), and 8% (face). Techniques included Foley, Fogarty, Blakemore, and/or Penrose drains with concurrent red rubber Robinson catheters. Initial tamponade of bleeding structures was successful in 93% of patients. CONCLUSIONS: Balloon catheter tamponade can be used in multiple anatomic regions and for variable patterns of injury to arrest ongoing hemorrhage. Placement for central hepatic gunshot wounds is particularly useful. This technique remains a valuable tool in a surgeon's armamentarium.

Occult pneumothoraces in patients with penetrating trauma: Does mechanism matter?

BACKGROUND: Supine anteroposterior (AP) chest radiography is an insensitive test for detecting posttraumatic pneumothoraces (PTXs). Computed tomography (CT) often identifies occult pneumothoraces (OPTXs) not diagnosed by chest radiography. All previous literature describes the epidemiology of OPTX in patients with blunt polytrauma. Our goal was to identify the frequency of OPTXs in patients with penetrating trauma. METHODS: All patients with penetrating trauma admitted over a 10-year period to Grady Memorial Hospital with a PTX were identified. We reviewed patients' thoracoabdominal CT scans and corresponding chest radiographs. RESULTS: Records for 1121 (20%) patients with a PTX (penetrating mechanism) were audited; CT imaging was available for 146 (13%) patients. Of these, 127 (87%) had undergone upright chest radiography. The remainder (19 patients) had a supine AP chest radiograph. Fifteen (79%) of the PTXs detected on supine AP chest radiographs were occult. Only 10 (8%) were occult when an upright chest radiograph was used (p < 0.001). Posttraumatic PTXs were occult on chest radiographs in 17% (25/146) of patients. Fourteen (56%) patients with OPTXs underwent tube thoracostomy, compared with 95% (115/121) of patients with overt PTXs (p < 0.001). CONCLUSION: Up to 17% of all PTXs in patients injured by penetrating mechanisms will be missed by standard trauma chest radiographs. This increases to nearly 80% with supine AP chest radiographs. Upright chest radiography detects 92% of all PTXs and is available to most patients without spinal trauma. The frequency of tube thoracostomy use in patients with overt PTXs is significantly higher than for OPTXs in blunt and penetrating trauma.

Thoracic needle decompression for tension pneumothorax: clinical correlation with catheter length.

BACKGROUND: Tension pneumothorax requires emergent decompression. Unfortunately, some needle thoracostomies (NTs) are unsuccessful because of insufficient catheter length. All previous studies have used thickness of the chest wall (based on cadaver studies, ultrasonography or computed tomography [CT]) to extrapolate probable catheter effectiveness. The objective of this clinical study was to identify the frequency of NT failure with various catheter lengths. METHODS: We evaluated the records of all patients with severe blunt injury who had a prehospital NT before arrival at a level-1 trauma centre over a 48-month period. Patients were divided into 2 groups: helicopter (4.5-cm catheter sheath) and ground ambulance (3.2 cm) transport. Success of the NT was confirmed by the absence of a large pneumothorax on subsequent thoracic ultrasonography and CT. RESULTS: Needle thoracostomy decompression was attempted in 1.5% (142/9689) of patients. Among patients with blunt injuries, the incidence was 1.4% (101/7073). Patients transported by helicopter (74%) received a 4.5-cm sheath. The remainder (26% ground transport) received a 3.2-cm catheter. A minority in each group (helicopter 15%, ground 28%) underwent immediate chest tube insertion (before thoracic ultrasound) because of ongoing hemodynamic instability. Failure to decompress the pleural space by NT was observed via ultrasound and/or CT in 65% (17/26) of attempts with a 3.2-cm catheter, compared with only 4% (3/75) of attempts with a 4.5-cm catheter (p < 0.001). CONCLUSION: Tension pneumothorax decompression using a 3.2-cm catheter was unsuccessful in up to 65% of cases. When a larger 4.5-cm catheter was used, fewer procedures (4%) failed. Thoracic ultrasonography can be used to confirm NT placement.

Temporary intravascular shunts: when are we really using them according to the NTDB?

Temporary intravascular shunts (TIVS) are synthetic intraluminal conduits that maintain arterial and/or venous blood flow. This technique can be used for: 1) replantation; 2) open extremity fractures with extensive soft tissue and arterial injuries; or 3) damage control (extremity/truncal). The literature defining TIVS is composed exclusively of small case series (primarily penetrating injuries). Our goal was to identify the injured population who actually undergoes TIVS using the National Trauma Data Bank (2001 to 2005). TIVS were placed in 395 patients (mean Injury Severity Score = 26; initial hemodynamic instability = 24%; mean based deficit = -7.2; mortality = 14%). Blunt mechanisms caused 64 per cent (251 of 395) of cases. Penetrating injuries were primarily gunshot wounds (97%). Concurrent severe extremity fractures and/or soft tissue defects were present in 185 (74%) blunt-injured patients. Only six of 111 centers performing TIVS used this technique five or more times. Only three centers used TIVS more than 10 times. The volume of TIVS use was similar across the study period (P > 0.05). TIVS is primarily used in blunt motor vehicle collision trauma with concurrent severe extremity fractures and soft tissue injuries. This provides distal perfusion while surgeons assess/fixate the limb. TIVS are placed relatively uncommonly by a large number of trauma centers with a few hospitals using them much more frequently for penetrating injuries.

A caveat to the performance of pericardial ultrasound in patients with penetrating cardiac wounds.

BACKGROUND: The pericardial window in a focused assessment with sonography for trauma (FAST) examination is highly accurate for detecting hemopericardium and, therefore, associated cardiac injury. A series of patients with false-negative pericardial ultrasound examinations, who were subsequently diagnosed with cardiac lacerations after presenting with stab wounds, are described. METHODS: All patients with a normal pericardial ultrasound examination, despite subsequent diagnosis of a cardiac injury, are described (2005-2008). RESULTS: Five patients with stab wounds to the precodium displayed initial and repeatedly normal pericardial windows on a FAST examination. Each patient was eventually diagnosed with a penetrating cardiac injury and concurrent laceration of their pericardial sac. This combination of injuries allowed decompression of blood from the cardiac injury into the thoracic cavity and, therefore, prevented accumulation of a hemopericardium. CONCLUSIONS: The pericardial component of the FAST examination is commonly used for patients who present with penetrating wounds to the precordium. In cases of concurrent lacerations of the pericardial sac, pericardial ultrasound may not detect a cardiac injury because of associated decompression into the thoracic cavity.

The nephrotic syndrome: an unusual case of multiple embolic events.

The nephrotic syndrome is an unusual cause of the hypercoaguable state and thromboembolic complications. Here we report the case of a 42-year-old woman with nephrotic syndrome who presented with a pulseless lower extremity and a midpole renal infarct requiring urgent embolectomy of the leg. During her embolic evaluation, she was found to have an intracardiac thrombus. Over the course of her hospitalization, she developed a pulseless upper extremity and required an embolectomy of her arm. We believe that this represents the first case report of a patient with nephrotic syndrome, intracardiac thrombus, and evidence of embolization to 3 sites: kidney, arm, and leg.

Management of extremity fasciotomy sites prospective randomized evaluation of two techniques.

INTRODUCTION: Morbidity from the treatment of extremity compartment syndrome is underappreciated. Closure technique effectiveness has yet to be definitively established. METHODS: A randomized non-blinded prospective study was performed involving patients who underwent an extremity fasciotomy following trauma. Shoelace wounds were strapped with vessel loops under tension and VAC wounds were treated with a standard KCI VAC dressing. After randomization, patients returned to the OR every 96 h until primarily closed or skin grafted. RESULTS: 21 patients were consented for randomization with 11 (52%) successfully closed at the first re-operation. After interim analysis the study was closed early with 5/5 (100%) of wounds treated with the shoelace technique closed primarily and only 1/9 (11%) of VAC wounds closed primarily (p = 0.003). Overall primary closure was achieved in 74% of patients. CONCLUSIONS: Aggressive attempts at wound closure lead to an increased early closure rate. For wounds that remain open after the first re-operation, a simple shoelace technique is more successful than a wound VAC for achieving same hospital stay skin closure.

Evaluation of the Georgia trauma system using the American College of Surgeons Needs Based Assessment of Trauma Systems tool.

BACKGROUND: The American College of Surgeons Needs Based Assessment of Trauma Systems (NBATS) tool was developed to help determine the optimal regional distribution of designated trauma centers (DTC). The objectives of our current study were to compare the current distribution of DTCs in Georgia with the recommended allocation as calculated by the NBATS tool and to see if the NBATS tool identified similar areas of need as defined by our previous analysis using the International Classification of Diseases, Ninth Revision, Clinical Modification Injury Severity Score (ICISS). METHODS: Population counts were acquired from US Census publications. Transportation times were estimated using digitized roadmaps and patient zip codes. The number of severely injured patients was obtained from the Georgia Discharge Data System for 2010 to 2014. Severely injured patients were identified using two measures: ICISS<0.85 and Injury Severity Score >15. RESULTS: The Georgia trauma system includes 19 level I, II, or III adult DTCs. The NBATS guidelines recommend 21; however, the distribution differs from what exists in the state. The existing DTCs exactly matched the NBATS recommended number of level I, II, or III DTCs in 2 of 10 trauma service areas (TSAs), exceeded the number recommended in 3 of 10 TSAs, and was below the number recommended in 5 of 10 TSAs. Densely populated, or urban, areas tend to be associated with a higher number of existing centers compared with the NBATS recommendation. Other less densely populated TSAs are characterized by large rural expanses with a single urban core where a DTC is located. The identified areas of need were similar to the ones identified in the previous gap analysis of the state using the ICISS methodology. DISCUSSION: The tool appears to underestimate the number of centers needed in extensive and densely populated areas, but recommends additional centers in geographically expansive rural areas. The tool signifies a preliminary step in assessing the need for state-wide inpatient trauma center services. LEVEL OF EVIDENCE: Economic, level IV.

The accuracy of thoracic ultrasound for detection of pneumothorax is not sustained over time: a preliminary study.

BACKGROUND: Ultrasound has proven to be very accurate in the diagnosis of pneumothorax in the trauma suite. It is unknown whether this accuracy is maintained over time in patients with a thoracostomy (TT) in place. METHODS: Hospitalized patients with a TT placed to treat a traumatic pneumothorax underwent serial daily bedside surgeon-performed ultrasound by 1 of 2 experienced surgeon sonographers who were unaware of concomitant X-ray findings. Results were compared with daily chest X-ray films. Data collected included size and day of placement of the chest tube, as well as the results of the serial ultrasounds and the comparative X-ray films. RESULTS: Fourteen patients (78% men, mean age 33 years) sustained traumatic pneumothorax. The causes included stab wound (9), gunshot wound (3), and rib fracture (2). They underwent 126 (median 7) ultrasound evaluations and were followed between 4 and 26 (median 7) days after injury. Of these exams, 95 had a concomitant chest X-ray film within 1 hour of the ultrasound, thus 190 hemithoraces could be analyzed. Eighty-two ultrasounds were performed for hemithoraces that had no injury or TT in place and all 82 revealed normal pleural sliding. No pneumothoraces were noted on concomitant chest X-ray films (100% accuracy). One hundred eight ultrasounds were performed for hemithoraces that had a TT in place. For the first 24 hours, accuracy remained 100%. After 24 hours, however, sensitivity of ultrasound diagnosis of pneumothorax fell to 55%, specificity fell to 70%, positive predictive value to 43%, and negative predictive value to 79%. This led to an overall accuracy rate for ultrasound examination after 24 hours of 65%. CONCLUSIONS: Ultrasound evaluation for pneumothorax is very accurate for the first 24 hours after insertion of a TT, but the accuracy, especially the positive predictive value, is not sustained over time, possibly as a result of the formation of intrapleural adhesions.

A Decade Evaluation of a State Trauma System: Has Access to Inpatient Trauma Care at Designated Trauma Centers Improved?

Recently, the trauma center component of the Georgia trauma system was evaluated demonstrating a 10 per cent probability of increased survival for severely injured patients treated at designated trauma centers (DTCs) versus nontrauma centers. The purpose of this study was to determine the effectiveness of a state trauma system to provide access to inpatient trauma care at DTCs for its residents. We reviewed 371,786 patients from the state's discharge database and identified 255,657 treated at either a DTC or a nontrauma center between 2003 and 2012. Injury severity was assigned using the International Classification Injury Severity Score method. Injury was categorized as mild, moderate, or severe. Patients were also categorized by age and injury type. Access improved over time in all severity levels, age groups, and injury types. Although elderly had the largest improvement in access, still only 70 per cent were treated at a DTC. During the study period, increases were noted for all age groups, injury severity levels, and types of injury. A closer examination of the injured elderly population is needed to determine the cause of lower utilization by this age group. Overall, the state's trauma system continues to mature by providing patients with increased access to treatment at DTCs.

Successful Incorporation of Performance Based Payments for Trauma Center Readiness Costs into the Georgia Trauma System.

As quality and outcomes have moved to the fore front of medicine in this era of healthcare reform, a state trauma system Performance Based Payments (PBP) program has been incorporated into trauma center readiness funding. The purpose of this study was to evaluate the impact of a PBP on trauma center revenue. From 2010 to 2016, a percentage of readiness costs funding to trauma centers was placed in a PBP and withheld until the PBP criteria were completed. To introduce the concept, only three performance criteria and 10 per cent of readiness costs funding were tied to PBP in 2010. The PBP has evolved over the last several years to now include specific criteria by level of designation with an increase to 50 per cent of readiness costs funding being tied to PBP criteria. Final PBP distribution to trauma centers was based on the number of performance criteria completed. During 2016, the PBP criteria for Level I and II trauma centers included participation in official state meetings/conference calls, required attendance to American College of Surgeons state chapter meetings, Trauma Quality Improvement Program, registry reports, and surgeon participation in Peer Review Committee and trauma alert response times. Over the seven-year study period, $36,261,469 was available for readiness funds with $11,534,512 eligible for the PBP. Only $636,383 (6%) was withheld from trauma centers. A performance-based program was successfully incorporated into trauma center readiness funding, supporting state performance measures without adversely affecting the trauma center revenue. Future PBP criteria may be aligned to designation standards and clinical quality performance metrics.

Reassessing the cardiac box: A comprehensive evaluation of the relationship between thoracic gunshot wounds and cardiac injury.

BACKGROUND: High-energy missiles can cause cardiac injury regardless of entrance site. This study assesses the adequacy of the anatomic borders of the current "cardiac box" to predict cardiac injury. METHODS: Retrospective autopsy review was performed to identify patients with penetrating torso gunshot wounds (GSWs) 2011 to 2013. Using a circumferential grid system around the thorax, logistic regression analysis was performed to detect differences in rates of cardiac injury from entrance/exit wounds in the "cardiac box" versus the same for entrance/exit wounds outside the box. Analysis was repeated to identify regions to compare risk of cardiac injury between the current cardiac box and other regions of the thorax. RESULTS: Over the study period, 263 patients (89% men; mean age, 34 years; median injuries/person, 2) sustained 735 wounds (80% GSWs), and 239 patients with 620 GSWs were identified for study. Of these, 95 (34%) injured the heart. Of the 257 GSWs entering the cardiac box, 31% caused cardiac injury, whereas 21% GSWs outside the cardiac box (n = 67) penetrated the heart, suggesting that the current "cardiac box" is a poor predictor of cardiac injury relative to the thoracic non-"cardiac box" regions (relative risk [RR], 0.96; p = 0.82). The regions from the anterior to posterior midline of the left thorax provided the highest positive predictive value (41%) with high sensitivity (90%) while minimizing false-positives, making this region the most statistically significant discriminator of cardiac injury (RR, 2.9; p = 0.01). CONCLUSION: For GSWs, the current cardiac box is inadequate to discriminate whether a GSW will cause a cardiac injury. As expected, entrance wounds nearest to the heart are the most likely to result in cardiac injury, but, from a clinical standpoint, it is best to think outside the "box" for GSWs to the thorax. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Factors affecting mortality after penetrating cardiac injuries: 10-year experience at urban level I trauma center.

BACKGROUND: Despite the lethality of injuries to the heart, optimizing factors that impact mortality for victims that do survive to reach the hospital is critical. METHODS: From 2003 to 2012, prehospital data, injury characteristics, and clinical patient factors were analyzed for victims with penetrating cardiac injuries (PCIs) at an urban, level I trauma center. RESULTS: Over the 10-year study, 80 PCI patients survived to reach the hospital. Of the 21 factors analyzed, prehospital cardiopulmonary resuscitation (odds ratio [OR] = 30), scene time greater than 10 minutes (OR = 58), resuscitative thoracotomy (OR = 19), and massive left hemothorax (OR = 15) had the greatest impact on mortality. Cardiac tamponade physiology demonstrated a "protective" effect for survivors to the hospital (OR = .08). CONCLUSIONS: Trauma surgeons can improve mortality after PCI by minimizing time to the operating room for early control of hemorrhage. In PCI patients, tamponade may provide a physiologic advantage (lower mortality) compared to exsanguination.

Injury to the conduction system: management of life-threatening arrhythmias after penetrating cardiac trauma.

BACKGROUND: Life-threatening conduction abnormalities after penetrating cardiac injuries (PCIs) are rare, and rapid identification and treatment of these arrhythmias are critical to survival. This study highlights diagnosis and management strategies for conduction abnormalities after PCI. METHODS: Patients with life-threatening arrhythmias after PCI were identified at an urban, level I trauma center registry. RESULTS: Seventy-one patients survived to reach the hospital after PCI. Of these, 3 (4%) survivors (male = 3, mean age 41.3, median injury severity score = 25) had critical conduction abnormalities after cardiorrhaphy. All patients had multichamber and atrioventricular nodal injury. After initial cardiorrhaphy and control of hemorrhage, all patients had sustained hypotension with bradycardia from complete heart block. Two patients had ventricular septal defects requiring repair. All 3 patients survived. CONCLUSIONS: Rapid recognition of injury to the cardiac conduction system after PCI as a source of sustained hypotension is essential to early restoration of cardiac function and survival.

Penetrating cardiac injuries: A 36-year perspective at an urban, Level I trauma center.

BACKGROUND: This study evaluates patterns of injuries and outcomes from penetrating cardiac injuries (PCIs) at Grady Memorial Hospital, an urban, Level I trauma center in Atlanta, Georgia, over 36 years. METHODS: Patients sustaining PCIs were identified from the Trauma Registry of the American College of Surgeons and the Emory Department of Surgery database; data of patients who died prior to any therapy were excluded. Demographics and outcomes were compared over three time intervals: Period 1 (1975-1985; n = 113), Period 2 (1986-1996; n = 79), and Period 3 (2000-2010; n = 79). RESULTS: Two hundred seventy-one patients (86% were male; mean age, 33 years; initial base deficit = -11.3 mEq/L) sustained cardiac stab (SW, 60%) or gunshot wounds (GSW, 40%). Emergency department thoracotomy was performed in 67 (25%) of 271 patients. Overall mortality increased in the modern era (Period 1, 27%, vs. Period 2, 22%, vs. Period 3, 42%; p = 0.03) along with GSW mechanisms (Period 1, 32%, vs. Period 2, 33%, vs. Period 3, 57%; p = 0.001), GSW mortality (Period 1, 36%, vs. Period 2, 42%, vs. Period 3, 56%; p = 0.04), and multichamber injuries (Period 1, 12%, vs. Period 2, 10%, vs. Period 3, 34%; p< 0.001). In Period 3, GSWs (n = 45) resulted in multichamber injuries in 28 patients (62%) and multicavity injuries in 19 patients (42%). Surgeon-performed ultrasound accurately identified pericardial blood in 55 of 55 patients in Period 3. CONCLUSIONS: Increased frequency of GSWs in the past decade is associated with increased overall mortality, multichamber injuries, and multicavity injuries. Ultrasound is sensitive for detection of PCI. LEVEL OF EVIDENCE: Therapeutic study, level IV; epidemioligc study, level III.

Heterogeneity in Trauma Registry Data Quality: Implications for Regional and National Performance Improvement in Trauma.

BACKGROUND: Led by the American College of Surgeons Trauma Quality Improvement Program, performance improvement efforts have expanded to regional and national levels. The American College of Surgeons Trauma Quality Improvement Program recommends 5 audit filters to identify records with erroneous data, and the Georgia Committee on Trauma instituted standardized audit filter analysis in all Level I and II trauma centers in the state. STUDY DESIGN: Audit filter reports were performed from July 2013 to September 2014. Records were reviewed to determine whether there was erroneous data abstraction. Percent yield was defined as number of errors divided by number of charts captured. RESULTS: Twelve centers submitted complete datasets. During 15 months, 21,115 patient records were subjected to analysis. Audit filter captured 2,901 (14%) records and review yielded 549 (2.5%) records with erroneous data. Audit filter 1 had the highest number of records identified and audit filter 3 had the highest percent yield. Individual center error rates ranged from 0.4% to 5.2%. When comparing quarters 1 and 2 with quarters 4 and 5, there were 7 of 12 centers with substantial decreases in error rates. The most common missed complications were pneumonia, urinary tract infection, and acute renal failure. The most common missed comorbidities were hypertension, diabetes, and substance abuse. CONCLUSIONS: In Georgia, the prevalence of erroneous data in trauma registries varies among centers, leading to heterogeneity in data quality, and suggests that targeted educational opportunities exist at the institutional level. Standardized audit filter assessment improved data quality in the majority of participating centers.

The outcome of open pelvic fractures in the modern era.

BACKGROUND: Recent series have reported that the mortality rate of open pelvic fractures has decreased to < 10%. These injuries are often associated with intra-abdominal visceral damage, although few series have documented the prognostic significance of this injury complex. METHODS: A retrospective review in an urban level I trauma center of all patients who sustained open pelvic fracture between 1995 and 2004. RESULTS: Forty-four patients were identified as having sustained open pelvic fracture. Average Injury Severity Score was 30, with 77% of patients having a score > or = 16. Overall mortality was 45% (n = 20): 11 early deaths and 9 late deaths at an average of 17 days. Vertical shear injuries, although rare, were universally fatal. Other risk factors for overall mortality included revised trauma score, Injury Severity Score, transfusion requirement, Faringer zones I or II injury, Gustilo grade III soft tissue injury, need for therapeutic angiography, and presence of intra-abdominal injury, the latter of which conferred 89% mortality. Risk factors for late deaths also included pelvic sepsis, which occurred in 5 patients and was fatal in 3 (60%). CONCLUSIONS: The morbidity of open pelvic fractures remains high. Associated intra-abdominal injury or active arterial bleeding requiring therapeutic angiography is associated with a grim prognosis. There is a continuing need for new therapeutic approaches to this injury complex.

An analysis of the effectiveness of a state trauma system: treatment at designated trauma centers is associated with an increased probability of survival.

BACKGROUND: States struggle to continue support for recruitment, funding and development of designated trauma centers (DTCs). The purpose of this study was to evaluate the probability of survival for injured patients treated at DTCs versus nontrauma centers. METHODS: We reviewed 188,348 patients from the state's hospital discharge database and identified 13,953 severely injured patients admitted to either a DTC or a nontrauma center between 2008 and 2012. DRG International Classification of Diseases-9th Rev. Injury Severity Scores (ICISS), an accepted indicator of injury severity, was assigned to each patient. Severe injury was defined as an ICISS less than 0.85 (indicating ≥15% probability of mortality). Three subgroups of the severely injured patients were defined as most critical, intermediate critical, and least critical. A full information maximum likelihood bivariate probit model was used to determine the differences in the probability of survival for matched cohorts. RESULTS: After controlling for injury severity, injury type, patient demographics, the presence of comorbidities, as well as insurance type and status, severely injured patients treated at a DTC have a 10% increased probability of survival. The largest improvement was seen in the intermediate subgroup. CONCLUSION: Treatment of severely injured patients at a DTC is associated with an improved probability of survival. This argues for continued resources in support of DTCs within a defined statewide network. LEVEL OF EVIDENCE: Epidemiologic study, level III.