Endovascular treatment of axillosubclavian arterial injuries is a safe alternative to open repair.

BACKGROUND: Injuries to the axillosubclavian arteries are rare, comprising 5% of all extremity trauma. This study aims to examine contemporary outcomes of traumatic axillosubclavian injuries. METHODS: A retrospective review was performed on patients admitted with innominate, subclavian, and/or axillary artery injuries to a level 1 trauma center from 2011 to 2021. Patients undergoing endovascular repair were compared to those with open repair. RESULTS: Thirty two patients met inclusion criteria. Injuries were approached open in 22 (59%) cases and endovascular in 10 (27%). There was no difference in 30-day mortality or hospital length of stay between endovascular and open repair. Endovascular repairs had shorter operative times (1.9 vs 3.1 h, p = 0.009) and lower blood loss (72 vs 1662 mL, p < 0.001). CONCLUSIONS: Endovascular repair of axillosubclavian arterial injuries demonstrate similar outcomes to open repair. Significantly shorter operative times and lower blood loss suggest potential decreased morbidity.

Does autotransfusion from a contaminated trauma laparotomy field increase the risk of complications?

BACKGROUND: Autotransfusion (AT) in trauma laparotomy is limited by concern that enteric contamination (EC) increases complications, including infections. Our goal was to determine if AT use increases complications in trauma patients undergoing laparotomy with EC. METHODS: Trauma patients undergoing laparotomy from October 2011-November 2020 were reviewed. Patients were excluded if they did not receive blood in the operating room, did not have a full thickness hollow viscus injury, or died <24 h from admission. AT and non-AT patients were matched. Outcomes were compared. RESULTS: 185 patients were included, 60 received AT, and 46 pairs were matched. After matching, demographics were similar. No differences were noted in septic complications (33 vs 41%, p = 0.39), overall complications (59% vs 54%, p = 0.67), or mortality (13 vs 6%, p = 0.29). CONCLUSIONS: AT use in contaminated trauma laparotomy fields was not associated with a higher rate of complications.

Mortality in hypotensive trauma patients requiring laparotomy is related to degree of hypotension and provides evidence for focused interventions.

BACKGROUND: Mortality in hypotensive patients requiring laparotomy is reported to be 46% and essentially unchanged in 20 years. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been incorporated into resuscitation protocols in an attempt to decrease mortality, but REBOA can have significant complications and its use in this patient group has not been validated. This study sought to determine the mortality rate for hypotensive patients requiring laparotomy and to evaluate the mortality risk related to the degree of hypotension. Additionally, this study sought to determine if there was a presenting systolic blood pressure (SBP) that was associated with a sharp increase in mortality to target the appropriate patient group most likely to benefit from focused interventions such as REBOA. METHODS: The trauma registry at a level I trauma center was reviewed for patients undergoing emergent laparotomy from January 2007 to June 2020. Data included demographics, mechanism of injury, physiological data, Injury Severity Score, blood products transfused, and outcomes. Group comparisons were based on initial SBP (0 to 50 mm Hg, 60 to 69 mm Hg, 70 to 79 mm Hg, 80 to 89 mm Hg, and ≥90 mm Hg). RESULTS: During the study period, 52 016 trauma patients were treated and 1174 required laparotomy within 90 min of arrival; 424 had an initial SBP of <90 mm Hg. The overall mortality rate was 18%, but mortality increased as SBP decreased (≥90=9%, 80 to 89=20%, 70 to 79=21%, 60 to 69=48%, 0 to 59=66%). Mortality increased sharply with SBP of <70 mm Hg. DISCUSSION: Mortality rate increases with worsening hypotension and increases sharply with an SBP of <70 mm Hg. Further study on focused interventions such as REBOA should target this patient group. LEVEL OF EVIDENCE: Therapeutic/care management, level III.

Admission base deficit is superior to lactate in identifying shock and resuscitative needs in trauma patients.

BACKGROUND: Base Deficit (BD) and lactate have been used as indicators of shock and resuscitation. This study was done to evaluate the utility of BD and lactate in identifying shock and resuscitative needs in trauma patients. METHODS: A prospective observational study was performed from 3/2014-12/2018. Data included demographics, admission systolic BP, ISS, BD, lactate, blood transfusion, and outcomes. BD and lactate were modeled continuously and categorically and compared. RESULTS: 2271 patients were included. BD and lactate were moderately correlated (r2 = 0.63 p < 0.001). On univariate regression, BD and lactate were associated with transfusion requirement and mortality (p < 0.001), but on multivariate regression, only BD was associated with transfusion requirement and mortality (OR = 1.2, p < 0.001; OR = 1.1, p < 0.001, respectively). BD discriminated better than lactate for hypotension, higher ISS, increased transfusion requirements and mortality. CONCLUSIONS: Admission BD and lactate levels are correlated following injury, but BD is superior to lactate in identifying shock, resuscitative needs and mortality in severely injured trauma patients.

Incidence of hyponatremia in patients given levetiracetam vs. phenytoin for early posttraumatic seizure prophylaxis.

BACKGROUND: Levetiracetam and phenytoin are comparable for acute posttraumatic seizure(PTS) prophylaxis. Levetiracetam-induced hyponatremia has been reported in non-trauma patients. We studied hyponatremia in posttraumatic intracranial hemorrhage(ICH) patients receiving either drug. METHODS: Retrospective review of patients with ICH receiving PTS prophylaxis was performed. Patients were categorized by degree of sodium nadir: normal, mild, moderate, or severe, and analyzed by levetiracetam versus phenytoin. Patients were matched 2:1 regarding age and injury severity score(ISS). Incidence and treatment for hyponatremia was examined. RESULTS: 1735 ICH patients received PTS prophylaxis over an 8-year period. After exclusions and matching, there were 282 phenytoin and 564 levetiracetam patients. Age, ISS and initial sodium were comparable between the matched cohorts. There was no clinically significant difference in the rate or degree of hyponatremia. Treatment was more common in levetiracetam patients. DISCUSSION: There was a small but clinically insignificant difference in the incidence of hyponatremia in traumatic ICH patients receiving levetiracetam vs. phenytoin for PTS prophylaxis. There was an increased rate of intervention for hyponatremia in the levetiracetam group, possibly due to a coincidental preventive paradigm shift.

Gastrobronchial Fistula after Robotic Repair of Traumatic Diaphragmatic Hernia.

Gastrobronchial fistulas are a rare occurrence in the literature. We report a case of a gastrobronchial fistula after robotic repair of a chronic traumatic diaphragmatic hernia. The patient had severe respiratory symptoms with multiple studies that were inconclusive. The fistula was ultimately discovered after an esophagogastroduodenoscopy (EGD). The patient underwent a left thoracotomy for takedown of his fistula and eventually recovered. Earlier EGD and a lower threshold for differential that included this diagnosis would have led to an earlier identification and treatment of a rare disease process.

Prospective evaluation of admission cortisol in trauma.

BACKGROUND: A low cortisol level has been shown to occur soon after trauma, and is associated with increased mortality. The purpose of this study was to investigate the impact of low cortisol levels in acute critically ill trauma patients. We hypothesized that patients would require increase vasopressor use, have a greater blood product administration, and increased mortality rate. METHODS: A blinded, prospective observational study was performed at an American College of Surgeons verified Level I trauma center. Adult patients who met trauma activation criteria, received initial treatment at Community Regional Medical Center and were admitted to the intensive care unit were included. Total serum cortisol levels were measured from the initial blood draw in the emergency department. Patients were categorized according to cortisol ≤15 µg/dL (severe low cortisol, SLC), 15.01-25 µg/dL (relative low cortisol, RLC), or >25 µg/dL (normal cortisol, NC) and compared on demographics, injury severity score, initial vital signs, blood product usage, vasopressor requirements, and mortality. RESULTS: Cortisol levels were ordered for 280 patients; 91 were excluded and 189 were included. Penetrating trauma accounted for 19% of injuries and blunt trauma for 81%. 22 patients (12%) had SLC, 83 (44%) had RLC, and 84 (44%) had NC. This study found patients with admission SLC had higher rates of vasopressor requirements, required more units of blood, and had a higher mortality rate than both the RLC and NC groups. CONCLUSION: Low cortisol level can be identified acutely after severe trauma. Trauma patients with SLC had larger blood product requirements, vasopressor use, and increase mortality. Initial cortisol levels are useful in identifying these high-risk patients. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Changes in splenic capsule with aging; beliefs and reality.

BACKGROUND: Research describing the splenic capsule and its effect on non-operative management of splenic injuries is limited. The aim of this study is to identify the current beliefs about the splenic capsule thickness and investigate changes in the splenic capsule with age. METHODS: Trauma Medical Directors were surveyed on their beliefs regarding splenic capsule thickness changes with age. Thicknesses of cadaveric splenic capsule samples were measured. RESULTS: The majority of trauma medical directors (59%) believe the capsule thickness decreases with age. There were 94 splenic specimens obtained. The splenic capsules of infants were thin and had a uniform layer of elastin fibers. With aging, the capsule becomes thick and develops a collagen layer. CONCLUSION: Most trauma directors believe the splenic capsule thickness decreases with age. However, our results demonstrate that the splenic capsule thickness increases during childhood but remains constant in adulthood.

The impact of obesity on severity of solid organ injury in the adult population at a Level I trauma center.

BACKGROUND: The obese (body mass index, BMI > 30) have been identified as a subgroup of patients in regards to traumatic injuries. A recent study found that high-grade hepatic injuries were more common in obese than non-obese pediatric patients. This study seeks to evaluate whether similar differences exist in the adult population and examine differences in operative versus non-operative management between the obese and non-obese in blunt abdominal trauma. METHODS: Patient with trauma evaluated at an American College of Surgeons verified Level I trauma center from February 2013 to November 2016 were retrospectively reviewed. All patients aged >18 years with blunt mechanism of injury and a BMI listed in the trauma registry were included. Patients were excluded for incomplete data, including BMI or inability to grade hepatic or splenic injury. Data collected included age, gender, BMI, injury severity score, hospital length of stay, procedures on liver or spleen, and mortality. Organ injuries were scored using the American Association for the Surgery of Trauma grading scales, and were determined by either imaging or intraoperative findings. Obesity was classified as BMI > 30 compared with non-obese with BMI < 30. RESULTS: During the study period, 9481 patients were included. There were 322 spleen injuries and 237 liver injuries, with 64 patients sustaining both liver and splenic injuries. No differences existed in the percentage of high-grade hepatic or splenic injuries between the obese and non-obese. Obese patients with liver injuries were more likely to have procedural intervention than non-obese liver injuries and had higher rates of mortality. No differences were found in intervention for splenic injury between obese and non-obese. CONCLUSIONS: Contrary to prior studies on adult and pediatric patients with trauma, this study found no difference between obese and non-obese patients in severity of solid organ injury after blunt abdominal trauma in the adult population. However, there was an increased rate of procedural intervention and mortality for obese patients with liver injuries. LEVEL OF EVIDENCE: 3.

A predictive grading scale for acute cholecystitis.

BACKGROUND: Acute cholecystitis presents in a spectrum of severity, where acute disease may be complicated by severe inflammation, gangrene, and perforation. The goal of this study is to outline an evidence-based grading scale that predicts patient outcomes after laparoscopic cholecystectomy (LC). METHODS: A retrospective review of all patients with a preoperative diagnosis of acute cholecystitis who underwent LC from August 2011 until June 2015 at a tertiary-level hospital was performed. Patients who underwent elective cholecystectomy, incidental cholecystectomy, a planned open cholecystectomy, had gallstone pancreatitis or choledocholithiasis, and those admitted to a non-surgical service were excluded. Severity of disease was obtained from operative and pathology reports, and patients were classified according to the following grading scale:Grade I: symptomatic cholelithiasis.Grade II: acute/chronic cholecystitis.Grade III: gangrenous/necrotizing cholecystitis.Grade IV: gallbladder perforation or abscess.The groups were compared on age, gender, body mass index, severity of gallbladder disease, presence of preoperative systemic inflammatory response syndrome, hospital length of stay, length of operation, complications within 30 days, conversion to open rate, and cost of hospitalization. RESULTS: During the study period, 1252 patients who underwent laparoscopic cholecystectomy were analyzed; 677 met inclusion criteria. The most common grade was grade 2, which was present in 80% of patients, followed by grade 3, which was found in 16% of patients. Grade 4 cholecystitis occurred in 1.2% of patients and grade 1 occurred in 3.2% of patients. There were statistically significant increases in age, presence of preoperative systemic inflammatory response syndrome, hospital length of stay, conversion to open rate, cost of hospitalization, and length of operation with increased cholecystitis grade. CONCLUSIONS: The proposed grading scale is an accurate predictor of duration of operation, conversion to open rate, hospital length of stay, and cost of hospitalization. LEVEL OF EVIDENCE: III. STUDY TYPE: Prognostic.

After the embo: predicting non-hemorrhagic indications for splenectomy after angioembolization in patients with blunt trauma.

BACKGROUND: Successful non-operative management (NOM) of blunt splenic trauma is enhanced with splenic angioembolization (SAE). Patients may still require splenectomy post-SAE for splenic infarction/necrosis. Prior studies have used white blood cell count (WBC), platelet count (PLT), and PLT:WBC ratio after splenectomy to predict complications, but none have evaluated these findings prior to splenectomy in patients who have undergone SAE. Changes in these values may indicate clinically significant splenic infarction, facilitating management of these patients. METHODS: Patients admitted to an American College of Surgeons verified level 1 trauma center from January 2007 to August 2017 who underwent SAE were identified. Patients with successful NOM after SAE (SAE/NOM) were compared with those requiring splenectomy (SAE/SPLEN). Data included demographics, splenic injury grade, Injury Severity Score (ISS), time to SAE and splenectomy, intensive care unit and hospital length of stay (LOS), and complete blood count. Lab values were analyzed immediately post-SAE (time 1) and day 5 post-SAE (or day of discharge) for SAE/NOM patients and day of SPLEN for SAE/SPLEN patients (time 2). Data were analyzed using Mann-Whitney U, χ2 tests, and receiver operating characteristic (ROC) curves with significance attributed to P<0.05. RESULTS: Of 124 patients undergoing SAE, 16 (13%) later required SPLEN for infarction/necrosis at a median of 5 days post-SAE (IQR: 3-10 days). SAE/SPLEN and SAE/NOM patients did not differ by age, gender, ISS, or grade of splenic injury. SAE/SPLEN patients had longer hospital LOS (23 vs. 10 days, P<0.001). WBC, PLT, and PLT:WBC ratio did not differ between the groups at time 1. At time 2, WBC was higher and PLT:WBC ratio was lower in SAE/SPLEN patients. Using ROC curves at time 2, the area under the curve was 0.90 (P<0.001) for WBC and 0.71 (P<0.007) for PLT:WBC ratio. DISCUSSION: Patients requiring splenectomy for clinically significant infarction/necrosis after SAE develop leukocytosis and decreased PLT:WBC ratio when compared with SAE/NOM patients. Monitoring these parameters allows more prompt diagnosis and operative intervention. LEVEL OF EVIDENCE: Therapeutic/care management, level III.

A method for the long-term cultivation of mammalian cells in the absence of oxygen: Characterization of cell replication, hypoxia-inducible factor expression and reactive oxygen species production.

The center of tumors, stem cell niches and mucosal surfaces all represent areas of the body that are reported to be anoxic. However, long-term study of anoxic cell physiology is hindered by the lack of a sustainable method permitting cell cultivation in the complete absence of oxygen. A novel methodology was developed that enabled anoxic cell cultivation (17d maximum time tested) and cell passage. In the absence of oxygen, cell morphology is significantly altered. All cells tested exhibited morphologic changes, i.e., a combination of tethered (monolayer-like) and runagate (suspension-like) morphologies. Both morphologies replicated (Vero and HeLa cells tested) and could be passaged anaerobically. In the absence of exogenous oxygen, anoxic cells produced reactive oxygen species (ROS). Anaerobic runagate HeLa and Vero cells increased ROS production from day 3 to day 10 by 2- and 3-fold, respectively. In contrast, anoxic tethered HeLa and Vero cells either showed no significant change in ROS production between days 3 and 10 or exhibited a 3-fold decrease in ROS, respectively. Detection of ROS was inversely related to detection of hypoxia-inducible factor-1α (HIF1) mRNA and HIF-1 protein expression which cycled over a 10-day period. This methodology has broad applications for the study of tumor and stem cell physiology as well as gastrointestinal cell-microbiome interactions. In addition, sustainable anaerobic cell culture may lead to the identification of novel pathways and targets for chemotherapeutic drug development.

Base deficit is superior to lactate in trauma.

BACKGROUND: Base Deficit (BD) and lactate have been used as indicators of shock and resuscitation. This study was done to determine the association of BD and lactate and to determine if one is superior. METHODS: A retrospective review from 3/2014-12/2016 was performed. Data included demographics, systolic BP, ISS, BD, lactate, blood transfusion, and outcomes. BD and lactate were modeled continuously and categorically and compared. RESULTS: 1191 patients were included. BD and lactate correlated strongly (r = -0.76 p < 0.001). Higher lactate and more negative BD were associated with transfusion and mortality. On multivariate regression, only BD was associated with transfusion (OR = 0.8, p < 0.001). As a categorical variable, worsening BD was associated with decreased BP, higher ISS, increased transfusions and worse outcomes. CONCLUSIONS: BD and lactate are strongly related. BD was superior to lactate in assessing the need for transfusion. The BD categories discriminate high risk trauma patients better than lactate.

Attempting to validate the overtriage/undertriage matrix at a Level I trauma center.

BACKGROUND: The Optimal Resources Document mandates trauma activation based on injury mechanism, physiologic and anatomic criteria and recommends using the overtriage/undertriage matrix (Matrix) to evaluate the appropriateness of trauma team activation. The purpose of this study was to assess the effectiveness of the Matrix method by comparing patients appropriately triaged with those undertriaged. We hypothesized that these two groups are different, and Matrix does not discriminate the needs or outcomes of these different groups of patients. METHODS: Trauma registry data, from January 2013 to December 2015, at a Level I trauma center, were reviewed. Overtriage and undertriage rates were calculated by Matrix. Patients with Injury Severity Score (ISS) of 16 or greater were classified by activation level (full, limited, consultation), and triage category by Matrix. Patients in the limited activation and consultation groups were compared with patients with full activation by demographics, injuries, initial vital signs, procedures, delays to procedure, intensive care unit admission, length of stay, and mortality. RESULTS: Seven thousand thirty-one patients met activation criteria. Compliance with American College of Surgeons tiered activation criteria was 99%. The Matrix overtriage rate was 45% and undertriage was 24%. Of 2,282 patients with an ISS of 16 or greater, 1,026 were appropriately triaged (full activation), and 1,256 were undertriaged. Undertriaged patients had better Glasgow Coma Scale score, blood pressure, and base deficit than patients with full activation. Intensive care unit admission, hospital stays, and mortality were lower in the undertriaged group. The undertriaged group required fewer operative interventions with fewer delays to procedure. CONCLUSION: Despite having an ISS of 16 or greater, patients with limited activations were dissimilar to patients with full activation. Level of activation and triage are not equivalent. The American College of Surgeons Committee on Trauma full and tiered activation criteria are a robust means to have the appropriate personnel present based on the available prehospital information. Evaluation of the process of care, regardless of level of activation, should be used to evaluate trauma center performance. LEVEL OF EVIDENCE: Therapeutic and care management, level III.

Day versus night laparoscopic cholecystectomy for acute cholecystitis: A comparison of outcomes and cost.

BACKGROUND: Recent studies have suggested higher complication and conversion to open rates for nighttime laparoscopic cholecystectomy (LC) and recommend against the practice. We hypothesize that patients undergoing night LC for acute cholecystitis have decreased hospital length of stay and cost with no difference in complication and conversion rates. METHODS: A retrospective review of patients with acute cholecystitis who underwent LC from October 2011 through June 2015 was performed. Complication rates, length of stay, and cost of hospitalization were compared between patients undergoing day cholecystectomy and night cholecystectomy. RESULTS: Complication rates and costs did not differ between the day and night groups. Length of stay was shorter in the night group (2.4 vs 2.8 days, p = 0.002). CONCLUSIONS: Performing LC for acute cholecystitis during night-time hours does not increase risk of complications and decreases length of stay.

Survey of American College of Surgeons Committee on trauma members on firearm injury: Consensus and opportunities.

BACKGROUND: In the United States, there is a perceived divide regarding the benefits and risks of firearm ownership. The American College of Surgeons Committee on Trauma Injury Prevention and Control Committee designed a survey to evaluate Committee on Trauma (COT) member attitudes about firearm ownership, freedom, responsibility, physician-patient freedom and policy, with the objective of using survey results to inform firearm injury prevention policy development. METHODS: A 32-question survey was sent to 254 current U.S. COT members by email using Qualtrics. SPSS was used for χ exact tests and nonparametric tests, with statistical significance being less than 0.05. RESULTS: Our response rate was 93%, 43% of COT members have firearm(s) in their home, 88% believe that the American College of Surgeons should give the highest or a high priority to reducing firearm-related injuries, 86% believe health care professionals should be allowed to counsel patients on firearms safety, 94% support federal funding for firearms injury prevention research. The COT participants were asked to provide their opinion on the American College of Surgeons initiating advocacy efforts and there was 90% or greater agreement on 7 of 15 and 80% or greater on 10 of 15 initiatives. CONCLUSION: The COT surgeons agree on: (1) the importance of formally addressing firearm injury prevention, (2) allowing federal funds to support research on firearms injury prevention, (3) retaining the ability of health care professionals to counsel patients on firearms-related injury prevention, and (4) the majority of policy initiatives targeted to reduce interpersonal violence and firearm injury. It is incumbent on trauma and injury prevention organizations to leverage these consensus-based results to initiate prevention, advocacy, and other efforts to decrease firearms injury and death. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level I; therapeutic care, level II.

Current outcomes of blunt open pelvic fractures: how modern advances in trauma care may decrease mortality.

BACKGROUND: Open pelvic fracture, caused by a blunt mechanism, is an uncommon injury with a high mortality rate. In 2008, evidence-based algorithm for managing pelvic fractures in unstable patients was published by the Western Trauma Association (WTA). The use of massive transfusion protocols has become widespread as has the availability and use of pelvic angiography. The purpose of this study was to evaluate the outcome of open pelvic fractures in association with related advances in trauma care. METHODS: A retrospective review was performed, at an American College of Surgeon verified level I trauma center, of patients with blunt open pelvic fractures from January 2010 to April 2016. The WTA algorithm, including massive transfusion protocol, and pelvic angiography were uniformly used. Data collected included injury severity score, demographic data, transfusion requirements, use of pelvic angiography, length of stay, and disposition. Data were compared with a similar study from 2005. RESULTS: During the study period, 1505 patients with pelvic fractures were analyzed; 87 (6%) patients had open pelvic fractures. Of these, 25 were from blunt mechanisms and made up the study population. Patients in both studies had similar injury severity scores, ages, Glasgow Coma Scale, and gender distributions. Use of angiography was higher (44% vs. 16%; P=0.011) and mortality was lower (16% vs. 45%; P=0.014) than in the 2005 study. CONCLUSIONS: Changes in trauma care for patients with open blunt pelvic fracture include the use of an evidence-based algorithm, massive transfusion protocols and increased use of angioembolization. Mortality for open pelvic fractures has decreased with these advances. LEVEL OF EVIDENCE: Level IV.

This too shall pass: A study of ingested sharp foreign bodies.

BACKGROUND: Gastrointestinal foreign body (GFB) ingestion is a common problem and often results in surgical consultation. Current literature is limited to case reports and fails to provide data regarding the management of sharp GFB ingestion. We hypothesized that patients who ingest sharp objects rarely have perforation or obstruction requiring surgical intervention. METHODS: Patients presenting with GFBs from January 2005 to December 2015 at a level 1 trauma center with an acute care surgery program were retrospectively reviewed. Exclusion criteria were leaving without being seen, noningested GFB, unknown or blunt GFB, or if the GFB was not found on imaging. Data collected included patient demographics, length of stay, imaging, and interventions that were performed. RESULTS: During the study period, there were 1,164 patients with 1,245 hospital visits for GFBs; 995 visits were excluded, resulting in 169 sharp GFB ingestion patients with 192 visits included in our study. The average age was 31. Sixty-five percent were men, and 41% were incarcerated. The average length of stay was 3 days, which was longer in patients with psychiatric holds and consultations. Of the 169 patients, 116 (69%) had no intervention and did not return for complications. Fifty-five endoscopies were performed with GFB removal in 30 cases. Seven patients (4%) underwent surgery, five of which had peritonitis. When evaluating the total study cohort, 134 (79%) of the patients had no procedure or a negative procedure. Patients requiring surgery had significantly larger objects (6 ± 3 cm) than those who had endoscopy (3 ± 2 cm) or no procedure (2 ± 1 cm). CONCLUSION: Surgical intervention occurred in only seven (4%) patients with sharp GFB ingestions, and 79% of the patients required no intervention. Barring an acute abdomen or esophageal sharp GFBs, patients can be discharged with return precautions, admitted for necessary psychiatric care, or returned to custody for patients seeking secondary gain. Upper gastrointestinal larger GFBs should be removed endoscopically when possible. LEVEL OF EVIDENCE: Therapeutic/care management study, level V.

Time is now: venous thromboembolism prophylaxis in blunt splenic injury.

BACKGROUND: The safety and timing of venous thromboembolism (VTE) prophylaxis in patients with blunt splenic injuries is not well known. We hypothesized that early initiation of VTE prophylaxis does not increase failure of nonoperative management or transfusion requirements in these patients. METHODS: A retrospective review of trauma patients with blunt splenic injury was performed. Patients were compared based on initiation and timing of VTE prophylaxis (<24 hours, 24 to 48 hours, 48 to 72 hours, and >72 hours). Patients who received VTE prophylaxis were matched with those who did not. Primary outcomes included were operation or angioembolization. RESULTS: A total of 497 patients (256 received VTE prophylaxis and 241 did not) were included. There was no difference in the number of interventions based on presence of or time to VTE prophylaxis initiation. CONCLUSIONS: Early initiation (<48 hours) of VTE prophylaxis is safe in patients with blunt splenic injuries treated nonoperatively, and may be safe as early as 24 hours.