Venous Thromboembolism Rates in Trauma Patients Significantly Increase With Missed Prophylactic Enoxaparin Doses.

Background: Current literature demonstrates prophylactic enoxaparin to be efficacious in reducing venous thromboembolism (VTE) rates without significantly increasing risk for bleeding complications. Despite this evidence, prophylactic enoxaparin doses are frequently withheld for surgery or procedures. This exploratory study aims to quantify the risk of a VTE event in trauma patients associated with missed doses of prophylactic enoxaparin. Methods: This retrospective cohort study evaluated trauma patients admitted to our Level 1 trauma center from January 1, 2012 to January 31, 2021. A 1:1 propensity match with ten variables was performed to compare patients receiving prophylactic enoxaparin that had a VTE and those that did not. The primary outcome was a VTE event. Results: 493 patients met inclusion criteria; 1:1 propensity score matching was performed resulting in a cohort of 184 patients. The percentage of patients that missed a prophylactic enoxaparin dose in the VTE group was higher than the no VTE group (34.8% vs 21.7%, P = 0.049). This is consistent when examining total missed doses (P = 0.038) and consecutively missed doses (P = 0.035). The odds of having a VTE for patients that missed at least one dose or more of enoxaparin are nearly two times greater (OR 1.92, 95% CI 0.997, 3.7). Conclusion: Missing enoxaparin doses significantly increases the risk of VTE in matched populations. Most prophylactic enoxaparin doses were held for procedures, and not for bleeding events. Trauma teams should carefully weigh the risk of bleeding complications associated with continuing enoxaparin prophylaxis against the significant thromboembolic risk of withholding it.

Association of timing and agent for venous thromboembolism prophylaxis in patients with severe traumatic brain injury on venous thromboembolism events, mortality, neurosurgical intervention, and discharge disposition.

BACKGROUND: Trauma patients are at increased risk for venous thromboembolism events (VTEs). The decision of when to initiate VTE chemoprophylaxis (VTEP) and with what agent remains controversial in patients with severe traumatic brain injury (TBI). METHODS: This comparative effectiveness study evaluated the impact of timing and agent for VTEP on outcomes for patients with severe TBI (Abbreviated Injury Scale head score of 3, 4, or 5). Data were collected at 35 Level 1 and 2 trauma centers from January 1, 2017, to June 1, 2022. Patients were placed into analysis cohorts: no VTEP, low-molecular-weight heparin (LMWH) ≤48 hours, LMWH >48 hours, heparin ≤48 hours, and heparin >48 hours. Propensity score matching accounting for patient factors and injury characteristics was used with logistic regression modeling to evaluate in-hospital mortality, VTEs, and discharge disposition. Neurosurgical intervention after initiation of VTEP was used to evaluate extension of intracranial hemorrhage. RESULTS: Of 12,879 patients, 32% had no VTEP, 36% had LMWH, and 32% had heparin. Overall mortality was 8.3% and lowest among patients receiving LMWH ≤48 hours (4.1%). Venous thromboembolism event rates were lower with use of LMWH (1.6% vs. 4.5%; odds ratio, 2.98; 95% confidence interval, 1.40-6.34; p = 0.005) without increasing mortality or neurosurgical interventions. Venous thromboembolism event rates were lower with early prophylaxis (2.0% vs. 3.5%; odds ratio, 1.76; 95% confidence interval, 1.15-2.71; p = 0.01) without increasing mortality ( p = 1.0). Early VTEP was associated with more nonfatal intracranial operations ( p < 0.001). However, patients undergoing neurosurgical intervention after VTEP initiation had no difference in rates of mortality, withdrawal of care, or unfavorable discharge disposition ( p = 0.7, p = 0.1, p = 0.5). CONCLUSION: In patients with severe TBI, LMWH usage was associated with lower VTE incidence without increasing mortality or neurosurgical interventions. Initiation of VTEP ≤48 hours decreased VTE incidence and increased nonfatal neurosurgical interventions without affecting mortality. Low-molecular-weight heparin is the preferred VTEP agent for severe TBI, and initiation ≤48 hours should be considered in relation to these risks and benefits. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Direct to Operating Room for Decompressive Craniotomy/Craniectomy in Patients With Traumatic Brain Injury.

BACKGROUND: Emergent decompressive craniotomy/craniectomy can be a lifesaving surgical intervention for select patients with traumatic brain injury. Prompt management is critical as early decompression can impact traumatic brain injury outcomes. OBJECTIVE: This study aims to describe the feasibility and clinical impact of a new pathway for transporting patients with severe traumatic brain injury directly to the operating room from the trauma bay for decompressive craniotomy/craniectomy. METHODS: This is a retrospective cohort preintervention and postintervention study of severe traumatic brain injury patients undergoing decompressive craniectomy/craniotomy at a Midwestern U.S. Level I trauma center between 2016 and 2022. In the new pathway, the in-house trauma surgeon takes the patient directly to the operating room with the neurosurgery advanced practice provider to drape and prepare the patient for surgery while the neurosurgeon is en route to the hospital. RESULTS: A total of 44 patients were studied, five (5/44, 11.4%) of which were in the preintervention group and 39 (39/44, 88.6%) in the postintervention group. The median arrival-to-operating room time was shorter in the postintervention cohort (1.4 hr) than in the preintervention cohort (1.5 hr). In examining night shifts only, the preintervention cohort had shorter arrival-to-operating room times (1.2 hr) than the postintervention cohort (1.5 hr). CONCLUSION: The study demonstrated that the new pathway is feasible and expedites patient transport to the operating room while awaiting the arrival of the on-call neurosurgeon.

Expecting the unexpected: incidental findings at a level 1 trauma center.

INTRODUCTION: Incidental findings on comprehensive imaging in the adult trauma population occur at rates as high as 54.8%. We sought to determine the incidence of potentially malignant or pre-malignant incidental findings in a high-volume level 1 trauma center and to evaluate follow-up recommendations. METHODS: This was a retrospective review of all patients with incidental findings on imaging who were admitted to the trauma service at our level 1 trauma center between January 1st, 2014, and October 1st, 2019. A multi-disciplinary team characterized findings as potentially malignant or pre-malignant. RESULTS: The study included 495 patients who had incidental findings, 410 of whom had potentially malignant or pre-malignant findings on imaging, resulting in a cumulative incidence of 6.6%. The mean age was 65 and 217 (52.9%) patients were male. The majority of "incidentalomas" were discovered on CT imaging (n=665, 98.1%); over half were solid (n=349, 51.5%), while 27.4% were cystic (n=186) in nature. The lungs (n=199, 29.4%), kidneys (n=154, 22.8%), liver (n=74, 10.9%), thyroid gland (n=58, 8.6%), and adrenal glands (n=53, 7.8%) harbored the most incidentalomas. Less than half of patients with incidental findings received specific follow-up recommendations on the radiologist's report (n=150, 39%). Sixty-one percent of patients (n=250) had their incidentalomas detailed in the discharge paperwork. CONCLUSION: The results of our study suggest that potentially malignant or pre-malignant incidental findings are common among trauma patients. Specific follow-up recommendations were not presented in 61% of the radiology reports, highlighting the need to standardize medical record capture of an incidentaloma to ensure adequate and appropriate follow-up.

Out of sight, out of mind? The impact on trauma patient opioid use when the medicine administration schedule is not displayed.

INTRODUCTION: The impact of a visual pain medication schedule on opioid use among hospitalized trauma patients is unknown. We examined whether removal of this displayed schedule would decrease oral morphine equivalent (OME) use. METHODS: This retrospective cohort study compared OME use in trauma patients in the inpatient setting before and after removing the patient-facing pain medication schedule that is typically displayed on the patient's white board for all trauma admissions. RESULTS: 707 patients were included. The control (n = 308, 43.6%) and intervention (n = 399, 56.4%) groups were similar in age (p = 0.06). There was no difference in total inpatient OME use between the control and intervention groups, median 50 (IQR: 22.5-118) vs 60 (IQR: 22.5-126), p = 0.79, respectively. No difference in total OME use was observed when patients were stratified by age, sex, race, ISS, and length of hospital stay. CONCLUSION: Removing a visual display of the pain medication schedule did not decrease OME use in inpatient trauma patients.

Hotter Than It Looks: A Retrospective Review of Patients With Cholecystitis and With Negative Imaging.

INTRODUCTION: Ultrasound is the gold standard for workup of cholecystitis in the emergency department, and findings heavily influence clinical decision-making. Patients with negative imaging for acute cholecystitis may be inappropriately sent home. The purpose of our study was to review the pathology and outcomes of patients presenting with biliary pain and negative ultrasound findings of acute cholecystitis. MATERIALS AND METHODS: Emergency department patients who underwent laparoscopic cholecystectomy between January 2015 and February 2019 were reviewed retrospectively. Only patients with negative or equivocal imaging were included. The primary outcome was the incidence of cholecystitis on final pathology. RESULTS: Two hundred fifty-seven patients underwent laparoscopic cholecystectomy. Pathology demonstrated cholecystitis in 84% of patients. Only 15% of patients had cholelithiasis without cholecystitis on pathology. The incidence of cholecystitis was similar in negative and equivocal imaging groups (84% versus 83%; P = 0.960). The median time from admission to the operating room was 12.1 h (interquartile range 7.1-18.3 h), and hospital length of stay was 1.2 d (interquartile range 0.8-1.7 d). CONCLUSIONS: This study found that patients with negative or equivocal imaging had cholecystitis on pathology. On review of patient outcomes, those patients who underwent surgical intervention had a low rate of complications and short hospital stay.

Characteristics of hardware failure in patients undergoing surgical stabilization of rib fractures: A Chest Wall Injury Society multicenter study.

BACKGROUND: Surgical stabilization of rib fractures (SSRF) is increasingly used for severe rib fractures/flail chest. There are no reports discussing mechanisms of failure of implanted hardware, its clinical presentation, or consequences. The purpose of this study was to evaluate the incidence, presenting signs, and clinical sequela of hardware failure after SSRF. METHODS: A multicenter, retrospective study was performed by a group of surgeons with a large SSRF case volume. All cases with known hardware failure from January 1, 2010, to December 31, 2017, were included. The surgeon's experience at the time of hardware implantation, specific implant used, number of failures the surgeon had experienced with the same system, and time from implantation to hardware failure were recorded. Additionally, patient demographics, including age, comorbid conditions, and number and location of rib fractures were recorded. Symptomatology associated with hardware failure and need for explant and/or reimplantation of hardware was also recorded. Nonparametric statistical tests were used to compare cohorts. RESULTS: Of 1,224 patients who underwent SSRF, 38 patients with 233 rib fractures and 279 fracture segments experienced hardware failure and were enrolled in the study. Twelve patients presented more than 3 months following injury. Median age was 54 years old and 34% were active smokers. One hundred forty-four plates were implanted with a median of four plates per patient. Median number of SSRF cases by each surgeon was 100 (range, 1-280). Fractures and hardware failure were most frequent in the anterolateral/lateral region. Hardware failure was mostly due to screw migration and plate fracture. Hardware failure was asymptomatic in 40% and presented as pain in 42% of cases. Fifty-five percent of the cases required explantation of hardware, and only 10% required SSRF again. There was no difference between the acute and chronic fracture cohorts. CONCLUSION: Hardware failure after SSRF is rare and often asymptomatic. When present, it rarely requires redo SSRF. LEVEL OF EVIDENCE: Therapeutic, level V.

The danger zone: Injuries and conditions associated with immediately fatal motorcycle crashes in the state of Michigan.

BACKGROUND: Immediately fatal motorcycle crashes have not been well characterized. This study catalogues injuries sustained in fatal motorcycle crashes and assesses the impact of crash conditions on injury patterns. METHODS: Autopsy records from the office of the medical examiner of Kent County, MI and publicly available traffic reports were queried for information pertaining to motorcyclists declared dead on-scene between January 1, 2007, and December 31, 2016. RESULTS: A total of 71 autopsies of on-scene motorcycle crash fatalities were identified. The two most prevalent injuries were traumatic brain injury (TBI) (85%) and rib fractures (79%). The majority of fatalities occurred in daylight hours (54.3%) and in a 55 mph speed limit zone (63.8%). CONCLUSIONS: This study provides a catalogue of the injuries sustained in immediately fatal motorcycle crashes and the associated conditions. Advocacy efforts that highlight the risks associated with motorcycle riding and that promote safe riding practices are warranted.

The impact of the repeal of Michigan's universal helmet law on traumatic brain injury: A statewide analysis.

BACKGROUND: In April of 2012, Michigan repealed its 35-year-old universal motorcycle helmet law in favor of a partial helmet law, which permits motorcyclists older than 21 years old with sufficient insurance and experience to drive un-helmeted. We evaluated the clinical impact of the repeal. METHODS: The Michigan Trauma Quality Improvement Program's trauma database was queried for motorcycle crash patients between 1/1/09-4/12/12 and between 4/13/12-12/31/14. RESULTS: There were 1970 patients in the pre-repeal analysis and 2673 patients in the post-repeal analysis. Following the repeal, patients were more likely to be un-helmeted (p < 0.001) and to have a traumatic brain injury (p < 0.001). Patients were also more likely to require neurosurgical interventions (relative risk 1.4, p = 0.011). CONCLUSION: Following the repeal of the universal helmet law, there has been a significant increase in traumatic brain injuries and neurosurgical interventions. This analysis highlights another detrimental impact of the repeal of the universal helmet law.

Pre-injury polypharmacy predicts mortality in isolated severe traumatic brain injury patients.

BACKGROUND: The use of 5 or more medications is defined as polypharmacy (PPM). The clinical impact of PPM on the isolated severe traumatic brain injury (TBI) patient has not been defined. METHODS: A retrospective cohort study was performed at our academic level 1 trauma center examining patients with isolated TBI. Pre-injury medications were reviewed, and inhospital mortality was the primary measured outcome. RESULTS: There were 698 patients with an isolated TBI over the 5-year study period; 177 (25.4%) patients reported pre-injury PPM. There were 18 (10.2%) deaths in the PPM cohort and 24 (4.6%) deaths in the non-PPM cohort (P < .0001). Stepwise logistic regression analysis revealed a 2.3 times greater risk of mortality in the PPM patients (P = .019). CONCLUSIONS: Pre-injury PPM increases mortality in patients with isolated severe TBI. This knowledge may provide opportunities for intervention in this population.

Repeal of the Michigan helmet law: the evolving clinical impact.

BACKGROUND: Michigan repealed a 35-year mandatory helmet law in April 2012. We examined the impact of this legislation on a level 1 trauma center. METHODS: A retrospective cohort study comparing the 7-month period before and the 3 motorcycle seasons after the helmet law repeal. RESULTS: A total of 345 patients were included in the study. Nonhelmeted riders increased from 7% to 28% after the repeal. Nonhelmeted crash scene fatalities were higher after the repeal (14% vs 68%). The nonhelmeted cohort had significantly higher in-patient mortality (10% vs 3%), injury severity score (19 vs 14.5) and abbreviated injury scale head (2.2 vs 1.3). Non-helmeted riders also had increased alcohol use, intensive care unit length of stay and need for mechanical ventilation. The median hospital cost for the non-helmeted cohort was higher (P < .05). CONCLUSIONS: The impact of the Michigan helmet law repeal continues to evolve. Three years after this legislative change, we are now observing increased injury severity score, higher in-patient mortality, and worse neurologic injury.

The impact of tree-stand falls on a Level 1 trauma center in West Michigan.

BACKGROUND: Falls from tree stands are common during the hunting season. We examined the impact of this injury mechanism on a Level 1 trauma center in West Michigan. METHODS: Retrospective cohort study examining tree-stand fall patients between 2001 and 2013. RESULTS: A total of 193 patients were included. Less than 3% of patients were wearing a harness. Falls from greater than 20 feet were associated with a higher injury severity score (P = .018). The injury severity score and Glasgow coma scale of the normal weight and overweight (OW) groups were the same. Overall 91.3% of normal weight patients were discharged home vs 63.5% of OW patients (P = .009). Median rehab stay was 12 days (3 to 92), and median charge was $24,048 (2,398 to 134,752). CONCLUSIONS: Tree-stand falls cause significant injury, especially from heights greater than 20 feet. OW patients more frequently require rehabilitation. The infrequent use of safety harnesses is alarming.

Repeal of the Michigan helmet law: early clinical impacts.

BACKGROUND: Michigan repealed a 35-year mandatory helmet law on April 13, 2012. We examined the early clinical impacts at a level 1 trauma center in West Michigan. METHODS: Retrospective cohort study comparing outcomes among motorcycle crash victims in a 7-month period before and after the helmet law repeal. RESULTS: One hundred ninety-two patients were included. After the repeal, nonhelmeted motorcyclists rose from 7% to 29% (P < .01). There was no difference in mortality rate after admission; however, crash scene fatalities increased significantly. Intensive care unit length of stay, mechanical ventilation time, and cost of stay were also higher in the nonhelmeted cohort (P < .05). CONCLUSIONS: Our study highlights the negative ramifications of repealing a mandatory helmet law. Motorcyclists not wearing helmets increased significantly in a short period of time. Nonhelmeted motorcyclists more frequently died on the scene, spent more time in the intensive care unit, required longer ventilator support, and had higher medical costs.

Recombinant factor VIIa (NovoSeven RT) use in high risk cardiac surgery.

OBJECTIVE: The use of recombinant factor VIIa (rFVIIa) (NovoSeven RT(®)) to establish hemostasis during massive perioperative bleeding in cardiac surgery has been explored in several retrospective studies. While early results are promising, a paucity of data leaves many questions about its safety profile. We sought to further define its use and associated outcomes in a large cohort study at a single institution. METHODS: A retrospective cohort study design was used, in which 236 patients received rFVIIa for bleeding after cardiac surgery. These patients were matched with a cohort of 213 subjects, who had similar operations during the same period of time. Primary end points included thrombo-embolic events, mortality, incidence of re-operation, use of blood products, and patient disposition at 30 days. Statistical significance was assessed at p < 0.05. RESULTS: There was no statistically significant difference in the incidence of stroke (3.4%, 1.9%; p = 0.32), renal failure (8.5%, 7.0%; p = 0.57), or 30-day mortality (7.7%, 4.3%; p = 0.14) between the rFVIIa and the control groups, respectively. The rFVIIa group did experience a higher rate of re-operation for bleeding (11.0%, 1.9%; p = 0.0001) and had a two-fold increase in the use of each of the following: cryoprecipitate, fresh-frozen plasma, platelets, and packed red blood cells, relative to the control group (p < 0.00001). CONCLUSIONS: rFVIIa is an effective hemostatic agent for intractable bleeding in high-risk cardiac surgery with an acceptable safety profile. rFVIIa does not appear to be associated with increased postoperative complications, including thrombo-embolic events and death.