Propranolol attenuates cognitive, learning, and memory deficits in a murine model of traumatic brain injury.

BACKGROUND: ß-blockers have been shown to improve survival after traumatic brain injury (TBI); however, the impact of continuous dosage of ß-blockers on cognitive function has not been elucidated. We hypothesized that a daily dose of propranolol can improve memory, learning, and cognitive function following TBI. STUDY DESIGN: Twenty male C57BL mice were subjected to a cortical-controlled moderate TBI. Two hours after TBI, animals were randomly allocated to either the ß-blocker group (n = 10) or the placebo group (n = 10). Mice in the ß-blocker group received intraperitoneal 4 mg/kg propranolol every 24 hours for 7 days while the placebo group received 4 mg/kg normal saline. Baseline novel object recognition and classic maze tests were done prior to TBI and then daily from Day 1 through 7 after TBI. Animals were sacrificed on Day 7. Serum biomarkers were measured using ELISA and brain sections were analyzed using western blot and hematoxylin and eosin staining. RESULTS: Both the ß-blocker and placebo groups had lower recognition index scores compared with the baseline following TBI. ß-blocker mice had significantly higher novel object recognition scores compared with placebo mice 2 days after TBI. The ß-blocker group required less time to complete the maze-test compared to placebo group after Day 4. There was no difference regarding the serum levels of IL-1ß, IL-6, and TNF-α. The ß-blocker group had lower levels of UCHL-1 and higher levels of Hsp-70 in brain lysate. Hematoxylin and eosin staining revealed that more neurons in the hippocampal-CA1 area underwent apoptosis in the placebo group compared with the ß-blocker group. CONCLUSION: Postinjury propranolol administration results in improved memory, learning and cognitive functions in a murine model of moderate TBI. Propranolol increases the expression of antiapoptotic protein (Hsp-70) and decreases cell death in the hippocampal-CA1 area compared with the placebo.

Risk Factors for Perforated Appendicitis in the Acute Care Surgery Era-Minimizing the Patient's Delayed Presentation Factor.

BACKGROUND: Numerous factors contribute to advanced disease or increased complications in patients with acute appendicitis (AA). This study aimed to identify risk factors associated with AA perforation, including the effect of system time (ST) delay, after controlling for patient time (PT) delay. In this study, PT was controlled (to less than or equal to 24 h) to better understand the effect of ST delay on AA perforation. METHODS: Medical records of patients who underwent surgery for AA at a tertiary referral hospital from October 2009 through September 2013 were reviewed. Data collected included demographics, body mass index, presence of fecalith, PT (i.e., duration of time from symptom onset to arrival in emergency department), and ST (i.e., duration of time from arrival in emergency department to operating room). AA was classified as simple (acute, nonperforated) versus advanced (gangrenous, perforated). RESULTS: Seven hundred forty-seven patients underwent surgery for AA. After excluding patients with PT > 24 h, 445 patients fit the study criteria, of which 358 patients with simple AA and 87 patients with advanced disease. Advanced appendicitis patients were older and had higher body mass index, longer PT, higher WBC, and higher incidence of fecaliths. Both groups had similar ST. Risk factors for advanced appendicitis after multiple regression analysis are age >50 y old, WBC >15,000, the presence of fecaliths, and PT delay >12 h. CONCLUSIONS: Once PT delay was limited to ≤24 h, the ST delay of >12 h did not adversely affect the incidence of advanced AA. Age >50 y, WBC >15,000, PT delay >12 h, and the presence of fecaliths were identified as risk factors associated with advanced AA.

Comparing Outcomes Between "Pull" Versus "Push" Percutaneous Endoscopic Gastrostomy in Acute Care Surgery: Under-Reported Pull Percutaneous Endoscopic Gastrostomy Incidence of Tube Dislodgement.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) complications are often under-reported in the literature, especially regarding the incidence of tube dislodgement (TD). TD can cause significant morbidity depending on its timing. We compared outcomes between "push" and "pull" PEGs. We hypothesized that push PEGs, because of its T-fasteners and balloon tip, would have a lower incidence of TD and complications compared with pull PEGs. METHODS: We performed a chart review of our prospectively maintained acute care surgery database for patients who underwent PEG tube placement from July 1, 2009 through June 30, 2013. Data regarding age, gender, body mass index, indications (trauma versus nontrauma), and complications (including TD) were extracted. Procedure-related complications were classified as either major if patients required an operative intervention or minor if they did not. We compared outcomes between pull PEG and push PEG. Multiple regression analysis was performed to identify risk factors associated with major complications. RESULTS: During the 4-y study period, 264 patients underwent pull PEGs and 59 underwent push PEGs. Age, gender, body mass index, and indications were similar between the two groups. The overall complications (major and minor) were similar (20% pull versus 22% push, P = 0.61). The incidence of TD was also similar (12% pull versus 9% push, P = 0.49). However, TD associated with major complications was higher in pull PEGs but was not statistically significant (6% pull versus 2% push, P = 0.21). Multiple regression analysis showed that dislodged pull PEG was associated with major complications (odds ratio 29.5; 95% confidence interval, 11.3-76.9; P < 0.001). CONCLUSIONS: The incidence of pull PEG TD associated with major complications is under-recognized. Specific measures should be undertaken to help prevent pull PEG TD. LEVEL OF EVIDENCE: IV, therapeutic.

A Prospective Study of 7-Year Experience Using Percutaneous 14-French Pigtail Catheters for Traumatic Hemothorax/Hemopneumothorax at a Level-1 Trauma Center: Size Still Does Not Matter.

BACKGROUND: The effectiveness of 14-French (14F) pigtail catheters (PCs) compared to 32-40F chest tubes (CTs) in patients with traumatic hemothorax (HTX) and hemopneumothorax (HPTX) is becoming more well known but still lacking. The aim of our study was to analyze our cumulative experience and outcomes with PCs in patients with traumatic HTX/HPTX. We hypothesized that PCs would be as effective as CTs. METHODS: Using our PC database, we analyzed all trauma patients who required chest drainage for HTX/HPTX from 2008 to 2014. Primary outcomes of interest, comparing PCs to CTs, included initial drainage output in milliliters (mL), tube insertion-related complications, and failure rate. For our statistical analysis, we used the unpaired Student's t test, Chi-square test, and Wilcoxon rank-sum test. We defined statistical significance as P < 0.05. RESULTS: During the 7-year period, 496 trauma patients required chest drainage for traumatic HTX/HPTX: 307 by CTs and 189 by PCs. PC patients were older (52 ± 21 vs. 42 ± 19, P < 0.001), demonstrated a significantly higher occurrence of blunt trauma (86 vs. 55%, P ≤ 0.001), and had tubes placed in a non-emergent fashion (Day 1 [interquartile range (IQR) 1-3 days] for PC placement vs. Day 0 [IQR 0-1 days] for CT placement, P < 0.001). All primary outcomes of interest were similar, except that the initial drainage output for PCs was higher (425 mL [IQR 200-800 mL] vs. 300 mL [IQR 150-500], P < 0.001). Findings for subgroup analysis among emergent and non-emergent PC placement were also similar to CT placement. CONCLUSION: PCs had similar outcomes to CTs in terms of failure rate and tube insertion-related complications, and the initial drainage output from PCs was not inferior to that of CTs. The usage of PCs was, however, selective. A future multi-center study is needed to provide additional support and information for PC usage in traumatic HTX/HPTX.

Survival benefits of remote ischemic conditioning in sepsis.

BACKGROUND: Sepsis remains the leading cause of death in the surgical intensive care unit. Prior studies have demonstrated a survival benefit of remote ischemic conditioning (RIC) in many disease states. The aim of this study was to determine the effects of RIC on survival in sepsis in an animal model and to assess alterations in inflammatory biochemical profiles. We hypothesized that RIC alters inflammatory biochemical profiles resulting in decreased mortality in a septic mouse model. MATERIALS AND METHODS: Eight to 12 week C57BL/6 mice received intra-peritoneal injection of 12.5-mg/kg lipopolysaccharide (LPS). Septic animals in the experimental group underwent RIC at 0, 2, and 6 h after LPS by surgical exploration and alternate clamping of the femoral artery. Six 4-min cycles of ischemia-reperfusion were performed. Primary outcome was survival at 5-d after LPS injection. Secondary outcome was to assess the following serum cytokine levels: interferon-γ (IFN-γ), interleukin (IL)-10, IL-1ß, and tumor necrosis factoralpha (TNFα) at the baseline before LPS injection, 0 hour after LPS injection, and at 2, 4, 24 hours after induction of sepsis (RIC was performed at 2 h after LPS injection). Kaplan-Meier survival analysis and log-rank test were used. ANOVA test was used to compare cytokine measurements. RESULTS: We performed experiments on 44 mice: 14 sham and 30 RIC mice (10 at each time point). Overall survival was higher in the experimental group compared to the sham group (57% versus 21%; P = 0.02), with the highest survival rate observed in the 2-hour post-RIC group (70%). On Kaplan-Meier analysis, 2-h post-RIC group had increased survival at 5 days after LPS (P = 0.04) with hazard ratio of 0.3 (95% confidence interval = 0.09-0.98). In the RIC group, serum concentrations of IFN-γ, IL-10, IL-1ß, and TNFα peaked at 2 h after LPS and then decreased significantly over 24 hours (P < 0.0001) compared to the baseline. CONCLUSIONS: RIC improves survival in sepsis and has the potential for implementation in the clinical practice. Early implementation of RIC may play an immune-modulatory role in sepsis. Further studies are necessary to refine understanding of the observed survival benefits and its implications in sepsis management.

The impact of patient protection and Affordable Care Act on trauma care: A step in the right direction.

INTRODUCTION: The Patient Protection and Affordable Care Act (ACA) was implemented to guarantee financial coverage for health care for all Americans. The implementation of ACA is likely to influence the insurance status of Americans and reimbursement rates of trauma centers. The aim of this study was to assess the impact of ACA on the patient insurance status, hospital reimbursements, and clinical outcomes at a Level I trauma center. We hypothesized that there would be a significant decrease in the proportion of uninsured trauma patients visiting our Level I trauma center following the ACA, and this is associated with improved reimbursement. METHODS: We performed a retrospective analysis of the trauma registry and financial database at our Level I trauma center for a 27-month (July 2012 to September 2014) period by quarters. Our outcome measures were change in insurance status, hospital reimbursement rates (total payments/expected payments), and clinical outcomes before and after ACA (March 31, 2014). Trend analysis was performed to assess trends in outcomes over each quarter (3 months). RESULTS: A total of 9,892 patients were included in the study. The overall uninsured rate during the study period was 20.3%. Post-ACA period was associated with significantly lower uninsured rate (p < 0.001). During the same time, there was as a significant increase in the Medicaid patients (p = 0.009). This was associated with significantly improved hospital reimbursements (p < 0.001).On assessing clinical outcomes, there was no change in hospitalization (p = 0.07), operating room procedures (p = 0.99), mortality (p = 0.88), or complications (p = 0.20). Post-ACA period was also not associated with any change in the hospital (p = 0.28) or length of stay at intensive care unit (p = 0.66). CONCLUSION: The implementation of ACA has led to a decrease in the number of uninsured trauma patients. There was a significant increase in Medicaid trauma patients. This was associated with an increase in hospital reimbursements that substantially improved the financial revenues. Despite the controversies, implementation of ACA has the potential to substantially improve the financial outcomes of trauma centers through Medicaid expansion. LEVEL OF EVIDENCE: Economic and value-based evaluation, level III.

Early surgical intervention and its impact on patients presenting with necrotizing soft tissue infections: A single academic center experience.

OBJECTIVES: Early diagnosis and emergent surgical debridement of necrotizing soft tissue infections (NSTIs) remains the cornerstone of care. We aimed to study the effect of early surgery on patients' outcomes and, in particular, on hospital length of stay (LOS) and Intensive Care Unit (ICU) LOS. MATERIALS AND METHODS: Over a 6-year period (January 2003 through December 2008), we analyzed the records of patients with NSTIs. We divided patients into two groups based on the time of surgery (i.e., the interval from being diagnosed and surgical intervention): Early (<6 h) and late (≥6 h) intervention groups. For these two groups, we compared baseline demographic characteristics, symptoms, and outcomes. For our statistical analysis, we used the Student's t-test and Pearson Chi-square (χ(2)) test. To evaluate the clinical predictors of early diagnosis of NSTIs, we performed multivariate logistic regression analysis. RESULTS: In the study population (n = 87; 62% males and 38% females), age, gender, wound locations, and comorbidities were comparable in the two groups. Except for higher proportion of crepitus, the clinical presentations showed no significant differences between the two groups. There were significantly shorter hospital LOS and ICU LOS in the early than late intervention group. The overall mortality rate in our study patients with NSTIs was 12.5%, but early intervention group had a mortality of 7.5%, but this did not reach statistical significance. CONCLUSIONS: Our findings show that early surgery, within the first 6 h after being diagnosed, improves in-hospital outcomes in patients with NSTIs.

Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury: a national trauma data bank analysis.

BACKGROUND: Nonoperative management of hemodynamically stable children with Solid Organ Injury (SOI) has become standard of care. The aim of this study is to identify differences in management of children with SOI treated at Adult Trauma Centers (ATC) versus Pediatric Trauma Centers (PTC). We hypothesized that patients treated at ATC would undergo more procedures than PTC. METHODS: Patients younger than 18 years old with isolated SOI (spleen, liver, kidney) who were treated at level I-II ATC or PTC were identified from the 2011-2012 National Trauma Data Bank. The primary outcome measure was the incidence of operative management. Data was analyzed using multivariate logistic regression analysis. Procedures were defined as surgery or transarterial embolization (TAE). RESULTS: 6799 children with SOI (spleen: 2375, liver: 2867, kidney: 1557) were included. Spleen surgery was performed more frequently at ATC than PTC {101 (7.7%) vs. 52 (4.9%); P=0.007}. After adjusting for potential confounders (grade of injury, age, gender and injury severity score), admission at ATC was associated with higher odds of splenic surgery (OR: 1.5, 95% CI: 1.02-2.25; p=0.03). 11 and 8 children underwent kidney and liver operations respectively. TAE was performed in 17 patients with splenic, 34 with liver and 14 with kidney trauma. There was no practice variation between ATC and PTC regarding kidney and liver operations or TAE incidence. CONCLUSIONS: Operative management for SOI was more often performed at ATC. The presence of significant disparity in the management of children with splenic injuries justifies efforts to use these surgeries as a reported national quality indicator for trauma programs.

Hips don't lie: Waist-to-hip ratio in trauma patients.

BACKGROUND: Obesity measured by body mass index (BMI) is known to be associated with worse outcomes in trauma patients. Recent studies have assessed the impact of distribution of body fat measured by waist-hip ratio (WHR) on outcomes in nontrauma patients. The aim of this study was to assess the impact of distribution of body fat (WHR) on outcomes in trauma patients. METHODS: A 6-month (June to November 2013) prospective cohort analysis of all admitted trauma patients was performed at our Level 1 trauma center. WHR was measured in each patient on the first day of hospital admission. Patients were stratified into two groups: patients with WHR of 1 or greater and patients with WHR of less than 1. Outcome measures were complications and in-hospital mortality. Complications were defined as infectious, pulmonary, and renal complications. Regression and correlation analyses were performed. RESULTS: A total of 240 patients were enrolled, of which 28.8% patients (n = 69) had WHR of 1 or greater. WHR had a weak correlation with BMI (R = 0.231, R = 0.481). Eighteen percent (n = 43) of the patients developed complications, and the mortality rate was 10% (n = 24). Patients with a WHR of 1 or greater were more likely to develop in-hospital complications (32% vs. 13%, p = 0.001) and had a higher mortality rate (24% vs. 4%, p = 0.001) compared with the patients with a WHR of less than 1. In multivariate analysis, a WHR of 1 or greater was an independent predictor for the development of complications (odds ratio, 3.1; 95% confidence interval 1.08-9.2; p = 0.03) and mortality (odds ratio, 13.1; 95% confidence interval, 1.1-70; p = 0.04). CONCLUSION: Distribution of body fat as measured by WHR independently predicts mortality and complications in trauma patients. WHR is better than BMI in predicting adverse outcomes in trauma patients. Assessing the fat distribution pattern in trauma patients may help improve patient outcomes through focused targeted intervention. LEVEL OF EVIDENCE: Prognostic study, level II.

The elimination of anastomosis in open trauma vascular reconstruction: A novel technique using an animal model.

BACKGROUND: The standard approach to vascular trauma involves arterial exposure and reconstruction using either a vein or polytetrafluoroethylene graft. We have developed a novel technique to repairing arterial injuries by deploying commercially available vascular stents through an open approach, thus eliminating the need for suture anastomosis. The objective of this study was to evaluate the feasibility, stent deployment time (SDT), and stent patency of this technique in a ewe vascular injury model. METHODS: After proximal and distal control, a 2-cm superficial femoral arterial segment was resected in 8 Dorper ewes to simulate an arterial injury. Two stay sutures were placed in the 3- and 9-o'clock positions of the transected arterial ends to prevent further retraction. Ten milliliters of 10-IU/mL heparinized saline was flushed proximally and distally. An arteriotomy was then created 2.5 cm from the transected distal end through which we deployed Gore Viabahn stents with a 20% oversize and at least 1-cm overlap with the native vessel on either end. The arteriotomy was then closed with 3 (1) interrupted 6-0 Prolene sutures. The ewes were fed acetylsalicylic acid 325 mg daily. Duplex was performed at 2 months postoperatively to evaluate stent patency. SDT was defined as time from stay suture placement to arteriotomy closure. RESULTS: The 8 ewes weighed a mean (SD) of 34.4 (4.3) kg. The mean (SD) superficial femoral arterial was 4.3 (0.6) mm. Six 5 mm × 5 cm and two 6 mm × 5 cm Gore Viabahn stents were deployed. The mean (SD) SDT was 34 (19) minutes, with a trend toward less time with increasing experience (SDTmax, 60 minutes; SDTmin, 10 minutes). Duplex performed at 2 months postoperatively showed stent patency in five of eight stents. There was an association between increasing SDT and stent thrombosis. CONCLUSION: Open deployment of commercially available vascular stents to treat vascular injuries is a conceptually sound and technically feasible alternative to standard open repair. Larger studies are needed to refine this technique and minimize stent complications, which are likely technical in nature.

Prevalence of Domestic Violence Among Trauma Patients.

IMPORTANCE: Domestic violence is an extremely underreported crime and a growing social problem in the United States. However, the true burden of the problem remains unknown. OBJECTIVE: To assess the reported prevalence of domestic violence among trauma patients. DESIGN, SETTING, AND PARTICIPANTS: A 6-year (2007-2012) retrospective analysis of the prospectively maintained National Trauma Data Bank. Trauma patients who experienced domestic violence and who presented to trauma centers participating in the National Trauma Data Bank were identified using International Classification of Diseases, Ninth Revision diagnosis codes (995.80-995.85, 995.50, 995.52-995.55, and 995.59) and E codes (E967.0-E967.9). Patients were stratified by age into 3 groups: children (≤18 years), adults (19-54 years), and elderly patients (≥55 years). Trend analysis was performed on April 10, 2014, to assess the reported prevalence of domestic violence over the years. PARTICIPANTS: Trauma patients presenting to trauma centers participating in the National Trauma Data Bank. MAIN OUTCOMES AND MEASURES: To assess the reported prevalence of domestic violence among trauma patients. RESULTS: A total of 16 575 trauma patients who experienced domestic violence were included. Of these trauma patients, 10 224 (61.7%) were children, 5503 (33.2%) were adults, and 848 (5.1%) were elderly patients. The mean (SD) age was 15.9 (20.6), the mean (SD) Injury Severity Score was 10.9 (9.6), and 8397 (50.7%) were male patients. Head injuries (46.8% of patients) and extremity fractures (31.2% of patients) were the most common injuries. A total of 12 515 patients (75.1%) were discharged home, and the overall mortality rate was 5.9% (n = 980). The overall reported prevalence of domestic violence among trauma patients was 5.7 cases per 1000 trauma center discharges. The prevalence of domestic violence increased among children (14.0 cases per 1000 trauma center discharges in 2007 to 18.5 case per 1000 trauma center discharges in 2012; P = .001) and adults (3.2 cases per 1000 discharges in 2007 to 4.5 cases per 1000 discharges in 2012; P = .001) over the 6-year period and remained unchanged for elderly patients (0.8 cases per 1000 discharges in 2007 to 0.96 cases per 1000 discharges in 2012; P = .09). On subanalysis of adults and elderly patients, the prevalence of domestic violence increased among both female (4.6 cases per 1000 discharges in 2007 to 5.3 cases per 1000 discharges in 2012; P = .001) and male patients (1.5 cases per 1000 discharges in 2007 to 2.8 cases per 1000 discharges in 2012; P = .001). CONCLUSIONS AND RELEVANCE: Domestic violence is prevalent among trauma patients. Over the years, the reported prevalence of domestic violence has been increasing among children and adults, and continues to remain high among female trauma patients. A robust mandatory screening for evaluating domestic violence among trauma patients, along with a focused national intervention, is warranted.

Increasing organ donation after cardiac death in trauma patients.

BACKGROUND: Organ donation after cardiac death (DCD) is not optimal but still remains a valuable source of organ donation in trauma donors. The aim of this study was to assess national trends in DCD from trauma patients. METHODS: A 12-year (2002 to 2013) retrospective analysis of the United Network for Organ Sharing database was performed. Outcome measures were the following: proportion of DCD donors over the years and number and type of solid organs donated. RESULTS: DCD resulted in procurement of 16,248 solid organs from 8,724 donors. The number of organs donated per donor remained unchanged over the study period (P = .1). DCD increased significantly from 3.1% in 2002 to 14.6% in 2013 (P = .001). There was a significant increase in the proportion of kidney (2002: 3.4% vs 2013: 16.3%, P = .001) and liver (2002: 1.6% vs 2013: 5%, P = .041) donation among DCD donors over the study period. CONCLUSIONS: DCD from trauma donors provides a significant source of solid organs. The proportion of DCD donors increased significantly over the last 12 years.

Certified acute care surgery programs improve outcomes in patients undergoing emergency surgery: A nationwide analysis.

BACKGROUND: Differences in outcomes among trauma centers (TCs) and non-TCs (NTCs) in patients undergoing emergency general surgery (EGS) are well established. However; the impact of development of certified acute care surgery (ACS) programs on patient outcomes remains unknown. The aim of this study was to evaluate outcomes in patients undergoing EGS across TCs, NTCs, and TCs with ACS (ACS-TC). METHODS: National estimates for EGS procedures were abstracted from the National Inpatient Sample database. Patients undergoing emergent procedures (appendectomy, cholecystectomy, hernia repair, as well as small and large bowel resections) were included. TCs were identified based on American College of Surgeons' verification. ACS-TC programs were recorded from the American Association for the Surgery of Trauma. Outcome measures were hospital length of stay, complications, and mortality. Regression analysis was performed after adjusting for age, sex, race, Charlson comorbidity index, and type of procedure. RESULTS: A total of 131,410 patients undergoing EGS were analyzed. Patients managed in ACS-TCs had shorter hospital stay (p = 0.045) and lower complication rate (p = 0.041) compared with patients managed in both TCs and NTCs. There was no difference in mortality in patients managed across the groups; however, there was a trend toward lower mortality in patients managed in ACS-TCs in comparison with TCs (p = 0.064) and NTCs (p = 0.089). The overall hospital costs were lower for patients managed in ACS-TCs compared with TCs (p = 0.036). CONCLUSION: TCs with ACS have improved outcomes in EGS procedures compared with both TCs and non-TCs. ACS training with the associated infrastructure standards may contribute to these improved outcomes. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.

Factors associated with failure-to-rescue in patients undergoing trauma laparotomy.

INTRODUCTION: Quality improvement initiatives have focused primarily on preventing in-hospital complications. Patients developing complications are at a greater risk of mortality; however, factors associated with failure-to-rescue (death after major complication) in trauma patients remain undefined. The aim of this study was to identify risk factors associated with failure-to-rescue in patients undergoing trauma laparotomy. METHODS: An -8-year, retrospective analysis of patients undergoing trauma laparotomy was performed. Patients who developed major in-hospital complications were included. Major complications were defined as respiratory, infectious, cardiac, renal, or development of compartment syndrome. Regression analysis was performed to identify independent factors associated with failure-to-rescue after we adjusted for demographics, mechanism of injury, abdominal abbreviated injury scale, initial vital signs, damage control laparotomy, and volume of crystalloids and blood products administered. RESULTS: A total of 1,029 patients were reviewed, of which 21% (n = 217) patients who developed major complications were included. The mean age was 39 ± 18 years, 82% were male, 61% had blunt trauma, and median abdominal abbreviated injury scale was 25 [16-34, interquartile range]. Respiratory complications (n = 77) followed by infectious complications (n = 75) were the most common complications. The failure-to-rescue rate was 15.7% (n = 34/217). Age, blunt trauma, severe head injury, uninsured status, and blood products administered on the second day were independent predictor for failure-to-rescue. CONCLUSION: When major complications develop, age, uninsured status, severity of head injury, and prolonged resuscitation are associated independently with failure-to-rescue, whereas initial resuscitation, coagulopathy, and acidosis did not predict failure to rescue. Quality-of-care programs focus in patient level should be on improving the patient's insurance status, preventing secondary brain injury, and further development of resuscitation guidelines.

Secondary brain injury in trauma patients: the effects of remote ischemic conditioning.

BACKGROUND: Management of traumatic brain injury (TBI) is focused on preventing secondary brain injury. Remote ischemic conditioning (RIC) is an established treatment modality that has been shown to improve patient outcomes secondary to inflammatory insults. The aim of our study was to assess whether RIC in trauma patients with severe TBI could reduce secondary brain injury. METHODS: This prospective consented interventional trial included all TBI patients admitted to our Level 1 trauma center with an intracranial hemorrhage and a Glasgow Coma Scale (GCS) score of 8 or lower on admission. In each patient, four cycles of RIC were performed within 1 hour of admission. Each cycle consisted of 5 minutes of controlled upper limb (arm) ischemia followed by 5 minutes of reperfusion using a blood pressure cuff. Serum biomarkers of acute brain injury, S-100B, and neuron-specific enolase (NSE) were measured at 0, 6, and 24 hours. Outcome measure was reduction in the level of serum biomarkers after RIC. RESULTS: A total of 40 patients (RIC, 20; control, 20) were enrolled. The mean (SD) age was 46.15 (18.64) years, the median GCS score was 8 (interquartile range, 3-8), and the median head Abbreviated Injury Scale (AIS) score was 3 (interquartile range, 3-5), and there was no difference between the RIC and control groups in any of the baseline demographics or injury characteristics including the type and size of intracranial bleed or skull fracture patterns. There was no difference in the 0-hour S-100B (p = 0.9) and NSE (p = 0.72) level between the RIC and the control group. There was a significant reduction in the mean levels of S-100B (p = 0.01) and NSE (p = 0.04) at 6 hours and 24 hours in comparison with the 0-hour level in the RIC group. CONCLUSION: This study showed that RIC significantly decreased the standard biomarkers of acute brain injury in patients with severe TBI. Our study highlights the novel therapeutic role of RIC for preventing secondary brain insults in TBI patients. LEVEL OF EVIDENCE: Therapeutic study, level III.

Adverse effects of admission blood alcohol on long-term cognitive function in patients with traumatic brain injury.

BACKGROUND: Alcohol is known to be protective in patients with traumatic brain injury (TBI); however, its impact on the long-term cognitive function is unknown. We hypothesize that intoxication at the time of injury is associated with adverse long-term cognitive function in patients sustaining TBI. METHODS: We performed a 2-year retrospective study of all trauma patients with isolated TBI presenting to our Level I trauma center and discharged to a single rehabilitation facility. Patients with moderate-to-severe TBI (head Abbreviated Injury Scale [AIS] score ≥ 3), measured admission blood alcohol concentration, and measured cognitive function on hospital discharge and rehabilitation center discharge were included. Cognitive function was assessed using Functional Independence Measure (FIM) scores. Delta cognitive FIM was defined as the difference between rehabilitation center discharge and hospital discharge cognitive FIM scores. Multivariate linear regression was performed. RESULTS: A total of 64 patients were included. Mean (SD) age was 51.8 (23) years, median head AIS score was 3 (IQR, 3-5), and median Glasgow Coma Scale (GCS) score was 11 (IQR, 3-15). Mean (SD) cognitive FIM score on hospital discharge was 17 (6), and mean (SD) cognitive improvement was 8.6 (4.7). Sixty percent (n = 39) were under the influence of alcohol on admission, and the mean (SD) admission blood alcohol concentration was 132 (102).On multivariate linear regression analysis, admission blood alcohol concentration (ß = -0.4; 95% confidence interval, -6.7 to -0.8; p = 0.01) and age (ß = -0.13; 95% confidence interval, -0.2 to -0.04; p = 0.04) were negatively associated with improvement in long-term cognitive function. CONCLUSION: Alcohol intoxication at the time of injury is associated with lower improvement in long-term cognitive function. Older intoxicated patients are likely to have a lower cognitive improvement. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

Overuse of helicopter transport in the minimally injured: A health care system problem that should be corrected.

BACKGROUND: Mortality benefit has been demonstrated for trauma patients transported via helicopter but at great cost. This study identified patients who did not benefit from helicopter transport to our facility and demonstrates potential cost savings when transported instead by ground. METHODS: We performed a 6-year (2007-2013) retrospective analysis of all trauma patients presenting to our center. Patients with a known mode of transfer were included in the study. Patients with missing data and those who were dead on arrival were excluded from the study. Patients were then dichotomized into helicopter transfer and ground transfer groups. A subanalysis was performed between minimally injured patients (ISS < 5) in both the groups after propensity score matching for demographics, injury severity parameters, and admission vital parameters. Groups were then compared for hospital and emergency department length of stay, early discharge, and mortality. RESULTS: Of 5,202 transferred patients, 18.9% (981) were transferred via helicopter and 76.7% (3,992) were transferred via ground transport. Helicopter-transferred patients had longer hospital (p = 0.001) and intensive care unit (p = 0.001) stays. There was no difference in mortality between the groups (p = 0.6).On subanalysis of minimally injured patients there was no difference in hospital length of stay (p = 0.1) and early discharge (p = 0.6) between the helicopter transfer and ground transfer group. Average helicopter transfer cost at our center was $18,000, totaling $4,860,000 for 270 minimally injured helicopter-transferred patients. CONCLUSION: Nearly one third of patients transported by helicopter were minimally injured. Policies to identify patients who do not benefit from helicopter transport should be developed. Significant reduction in transport cost can be made by judicious selection of patients. Education to physicians calling for transport and identification of alternate means of transportation would be both safe and financially beneficial to our system. LEVEL OF EVIDENCE: Epidemiologic study, level III. Therapeutic study, level IV.

An acute care surgery dilemma: emergent laparoscopic cholecystectomy in patients on aspirin therapy.

BACKGROUND: The current literature regarding hemorrhagic complications in patients on long-term antiplatelet therapy undergoing emergent laparoscopic cholecystectomy is limited. The aim of our study was to describe hemorrhagic complications in patients on prehospital aspirin (ASP) therapy undergoing emergent cholecystectomy. METHODS: We performed a 1-year retrospective analysis of our prospectively maintained acute care surgery database. The 2 groups (ASP group vs No ASP group) were matched in a 1:1 ratio for age, sex, previous abdominal surgeries, and comorbidities. Primary outcome measures were intraoperative hemorrhage, postoperative anemia, need for blood transfusion, and conversion to open cholecystectomy. Intraoperative hemorrhage was defined as intraoperative blood loss of ≥ 100 mL; postoperative anemia was defined by ≥ 2 g/dL drop in hemoglobin. RESULTS: A total of 112 (ASP: 56, no ASP: 56) patients were included in the analysis. The mean age was 65.9 ± 10 years, and 50% were male. There was no difference in age (P = .9), sex (P = .9), and comorbidities (P = .7) between the 2 groups. There was no difference in intraoperative blood loss >100 mL (P = .5), postoperative anemia (P = .8), blood transfusion requirement (P = .9), and conversion to open surgery (P = .7) between patients on American Society of Anesthesiologists therapy and patients not on American Society of Anesthesiologists therapy. CONCLUSIONS: Emergent laparoscopic cholecystectomy is a safe procedure in patients on long-term ASP. Prehospital use of ASP as an independent factor should not be used to delay emergent cholecystectomy.

Clinical outcomes in patients on preinjury ibuprofen with traumatic brain injury.

BACKGROUND: The aim of our study was to evaluate the clinical outcomes in patients on preinjury Ibuprofen with traumatic brain injury. METHODS: We performed a 2-year analysis of all patients on prehospital Ibuprofen with traumatic brain injury and intracranial hemorrhage. Patients on preinjury Ibuprofen were matched using propensity score matching to patients not on Ibuprofen in a 1:2 ratio for age, Glasgow Coma Scale, head-abbreviated injury scale, injury severity score, International Normalized Ratio, and neurologic examination. Outcome measures were progression on repeat head computed tomography (RHCT) and neurosurgical intervention. RESULTS: A total of 195 matched (Ibuprofen 65, no-Ibuprofen 130) patients were included. There was no difference in the progression on RHCT (Ibuprofen 18% vs. no-Ibuprofen 24%; P = .50). The neurosurgical intervention rate was 18.9% (n = 37). There was no difference for need for neurosurgical intervention (26% vs. 16%; P = .10) between the 2 groups. CONCLUSIONS: In a matched cohort of trauma patients, preinjury Ibuprofen use was not associated with progression of initial intracranial hemorrhage and the need for neurosurgical intervention. Preinjury use of Ibuprofen as an independent variable should not warrant the need for a routine RHCT scan.

A comparison of video laryngoscopy to direct laryngoscopy for the emergency intubation of trauma patients.

BACKGROUND: Direct laryngoscopy (DL) has long been the gold standard for tracheal intubation in emergency and trauma patients. Video laryngoscopy (VL) is increasingly used in many settings and the purpose of this study was to compare its effectiveness to direct laryngoscopy in trauma patients. Our hypothesis was that the success rate of VL would be higher than that of DL. METHODS: Data were collected prospectively on all trauma patients, from January 2008 to June 2011, who were intubated emergently in an academic level I trauma center. After intubation, the physician that performed the intubation completed a structured data collection form that included demographics, complications, and the presence of difficult airway predictors. Our primary outcome measure was overall successful tracheal intubation, which was defined as successful intubation with the first device used. RESULTS: During the study period, 709 trauma patients were intubated by either VL or DL. VL was performed in 55% of cases. The overall success rate of VL was 88% compared to 83% with DL (P = 0.05). Cervical (C-Spine) immobilization was predictive of higher initial success with VL (87%) than with DL (80%) (P < 0.05). In multivariate regression analysis DL was associated with higher risk of intubation failure compared to VL (OR 1.82, CI: 1.15-2.86). CONCLUSIONS: In trauma patients intubated emergently, VL had a significantly higher success rate than DL. These data suggest that, in select circumstances, VL is superior to DL for the intubation of trauma patients with difficult airways.