Repeat computed tomography head scan is not indicated in trauma patients taking novel anticoagulation: A multicenter study.

BACKGROUND: The number of trauma patients on prehospital novel oral anticoagulants (NOACs) is increasing. After an initial negative computed tomography of the head (CTH), practice patterns are variable for obtaining repeat CTH to evaluate for delayed intracranial hemorrhage (ICH-d). However, the risks and outcomes of ICH-d for patients on NOACs are unclear. We hypothesized that, for these patients, the incidence of ICH-d is low, similar to that of warfarin, and when it occurs, it does not result in clinically significant worse outcomes. METHODS: Five level 1 trauma centers in Northern California participated in a retrospective review of anticoagulated trauma patients. Patients were included if their initial CTH was negative. Primary outcomes were incidence of ICH-d, neurosurgical intervention, and death. Patient factors associated with the outcome of ICH-d were determined by multivariable regression. RESULTS: From 2016 to 2018, 777 patients met the inclusion criteria (NOAC, n = 346; warfarin, n = 431), 54% of whom received a repeat CTH. Delayed intracranial hemorrhage incidence was 2.3% in the NOAC group and 4% in the warfarin group (p = 0.31). No NOAC patient with ICH-d required neurosurgical intervention or died because of their head injury. Two warfarin patients received neurosurgical intervention, and three died from their head injury. Head Abbreviated Injury Scale ≥3 was associated with increased odds of developing ICH-d (adjusted odds ratio, 32.70; p < 0.01). CONCLUSION: The incidence of ICH-d in patients taking NOAC is low. In this study, patients on NOACs who developed ICH-d after an initial negative CTH did not need neurosurgical intervention or die from their head injury. Repeat CTH in this patient population does not appear necessary. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.Therapeutic, level IV.

LAPRA-TY for laparoscopic repair of traumatic diaphragmatic hernia without intracorporeal knot tying.

CASE PRESENTATION: A 38-year-old man was brought in by ambulance as a trauma activation after sustaining a self-inflicted stab wound in the left upper quadrant with a kitchen knife. His primary survey was unremarkable and his vital signs were normal. Secondary survey revealed a 2 cm transverse stab wound inferior and medial to the left nipple. Extended focused assessment with sonography for trauma (FAST) did not show intra-abdominal or pericardial fluid and chest X-ray did not show a definite pneumothorax or hemothorax. WHAT WOULD YOU DO?: Wound exploration at bedside.Admit for observation and serial examinations.Exploratory laparotomy and open repair of traumatic diaphragmatic injury (TDI).Thoracotomy and open repair of TDI.Diagnostic laparoscopy and laparoscopic repair of TDI.

Trauma advanced practice provider programme development in an academic setting to optimize care coordination.

BACKGROUND: Benchmark data from the Trauma Quality Improvement Program (TQIP) identified an opportunity for improvement in our trauma programme. Our unexpected return to the intensive care unit (ICU) was found to be higher than the national averages and we also noticed that our readmission rate had increased. We chose to address these complications as continuous quality improvement projects. It was hypothesized that restructuring the workflow of the trauma advanced practice providers (APPs) to focus on the delivery of comprehensive clinical care would decrease return to ICU and readmission rates of trauma patients. METHODS: The development of the APP programme occurred from 2012 to 2014. First, APP daily shifts were extended to mirror the resident physicians' coverage. Second, the APPs' original job description was expanded from 'task-oriented' workflow to providing comprehensive clinical care. Third, the APPs were involved in the evaluation and decision-making process for transferring trauma patients from the ICU. Finally, the APPs implemented a new discharge process that included all information in a standardized format and a follow-up phone call 24-48 hours after discharge. The trauma registry at our verified, academic level I trauma center was use to assess our ICU and hospital readmission rates during the time we instituted the new APP workflow programme. RESULTS: In 2012, our ICU readmission rate was 5.7% (TQIP=1.9%) but then decreased to 4.4% in 2013 (TQIP=2.5%) and 2.1% in 2014 (TQIP=2.8%). Our hospital readmission rate was 2.0% in 2012 but then decreased to 1.38% and 0.96% over the next 2 years. CONCLUSIONS: After extending the APP service coverage, implementing a comprehensive clinical care model and standardizing the discharge process, our unplanned return to ICU rates have decreased to below the TQIP national average and hospital readmission rates have also decreased by half. LEVEL OF EVIDENCE: III.

Minimally invasive is maximally effective: Diagnostic and therapeutic laparoscopy for penetrating abdominal injuries.

BACKGROUND: Laparoscopic techniques have evolved, allowing increased capabilities within most subspecialties of general surgery, but have failed to gain traction managing injured patients. We hypothesized that laparoscopy is effective in the diagnosis and treatment of penetrating abdominal injuries. METHODS: We retrospectively reviewed patients undergoing abdominal exploration following penetrating trauma at our Level 1 trauma center during a 6-year period from January 1, 2008, to December 31, 2013. Demographic and resuscitation data were obtained from our trauma registry. Charts were reviewed for operative details, hospital course, and complications. Hospital length of stay (LOS) and complications were primary end points. Patients were classified as having nontherapeutic diagnostic laparoscopy (DL), nontherapeutic diagnostic celiotomy (DC), therapeutic laparoscopy (TL), or therapeutic celiotomy (TC). TL patients were case-matched 2:1 with TC patients having similar intra-abdominal injuries. RESULTS: A total of 518 patients, including 281 patients (55%) with stab wounds and 237 patients (45%) with gunshot wounds, were identified. Celiotomy was performed in 380 patients (73%), laparoscopy in 138 (27%), with 44 (32%) converted to celiotomy. Nontherapeutic explorations were compared including 70 DLs and 46 DCs with similar injury severity. LOS was shorter in DLs compared with DCs (1 day vs. 4 days, p < 0.001). There were no missed injuries. Therapeutic explorations were compared by matching all TL patients 2:1 to TC patients with similar type and severity of injuries. Twenty-four patients underwent TL compared with 48 TC patients in the case matched group. LOS was shorter in the TL group than in the TC group (4 days vs. 2 days, p < 0.001). Wound infections were more common with open exploration (10.4% vs. 0%, p = 0.002), and more patients developed ileus or small bowel obstruction after open exploration (9.4% vs. 1.1%, p = 0.018). CONCLUSION: Laparoscopy is safe and accurate in penetrating abdominal injuries. The use of laparoscopy resulted in shorter hospitalization, fewer postoperative wound infection and ileus complications, as well as no missed injuries. LEVEL OF EVIDENCE: Therapeutic study, level IV.

The effect of shock resuscitation fluids on apoptosis.

BACKGROUND: Recent data suggest that the type of resuscitation fluid used to treat hemorrhagic shock contributes to cellular dysfunction METHODS: Rats were hemorrhaged, exposed to a hypovolemic shock period for 75 minutes, and then resuscitated for 1 hour. Treatment animals were assigned randomly to lactate Ringer's solution, normal saline solution, bicarbonate Ringer's solution, hypertonic saline solution, rat plasma solution, ketone Ringer's solution, or nonresuscitation. After resuscitation, lung and liver samples were collected and evaluated for apoptosis by using ligation-mediated polymerase chain reaction. RESULTS: Nonresuscitated shock rats had significantly higher levels of apoptosis in lung and liver. Rats treated with normal saline solution, bicarbonate Ringer's solution, ketone Ringer's solution, and hypertonic saline solution had significantly lower levels of apoptosis in lung compared with nonresuscitated animals. Rats treated with bicarbonate Ringer's solution and ketone Ringer's solution had significantly lower levels of apoptosis in liver tissue when compared with nonresuscitated animals. CONCLUSIONS: Cellular damage results from hemorrhagic shock. The use of resuscitation fluids decreases apoptosis during shock.