Scanning the aged to minimize missed injury: An EAST multicenter study.

BACKGROUND: Despite the high incidence of blunt trauma in older adults, there is a lack of evidence-based guidance for computed tomography (CT) imaging in this population. We aimed to identify an algorithm to guide use of a Pan-Scan (Head/C-spine/Torso) or a Selective Scan (Head/C-spine ± Torso). We hypothesized that a patient's initial history and exam could be used to guide imaging. METHODS: We prospectively studied blunt trauma patients aged 65+ at 18 Level I/II trauma centers. Patients presenting >24 h after injury or who died upon arrival were excluded. We collected history and physical elements and final injury diagnoses. Injury diagnoses were categorized into CT body regions of Head/C-spine or Torso (chest, abdomen/pelvis, and T/L spine). Using machine learning and regression modeling as well as a priori clinical algorithms based, we tested various decision rules against our dataset. Our priority was to identify a simple rule which could be applied at the bedside, maximizing sensitivity (Sens) and negative predictive value (NPV) to minimize missed injuries. RESULTS: We enrolled 5,498 patients with 3,082 injuries. Nearly half (47.1%, n = 2,587) had an injury within the defined CT body regions. No rule to guide a Pan-Scan could be identified with suitable Sens/NPV for clinical use. A clinical algorithm to identify patients for Pan-Scan, using a combination of physical exam findings and specific high-risk criteria, was identified and had a Sens of 0.94 and NPV of 0.86 This rule would have identified injuries in all but 90 patients (1.6%) and would theoretically spare 11.9% (655) of blunt trauma patients a torso CT. CONCLUSIONS: Our findings advocate for Head/Cspine CT in all geriatric patients with the addition of torso CT in the setting of positive clinical findings and high-risk criteria. Prospective validation of this rule could lead to streamlined diagnostic care of this growing trauma population. LEVEL OF EVIDENCE: Level 2, Diagnostic Tests or Criteria.

In-hospital outcomes of intercostal nerve cryoablation and surgical stabilization of rib fractures.

BACKGROUND: Severe pain and pulmonary complications commonly follow rib fractures, both of which may be improved by surgical stabilization of rib fractures (SSRFs). However, significant postoperative pain still persists which may negatively impact in-hospital outcomes. Combining intercostal nerve cryoablation (INCA) with SSRF may improve those outcomes by further decreasing postoperative pain, opioid consumption, and pulmonary complications. The hypothesis is that INCA plus SSRF reduces opioids consumption compared with SSRF alone. METHODS: The retrospective analysis included trauma patients 18 years or older who underwent SSRF, with or without INCA, in a Level I trauma center between 2015 and 2021. Patients received INCA at the surgeons' discretion based on familiarity with the procedure and absence of contraindications. Patients without INCA were the historical control group. Reported data include demographics, mechanism and severity of injury, number of ribs stabilized, cryoablated nerves, intubation rates and duration of mechanical ventilation. The primary outcome was total morphine milligrams equivalent consumption. Secondary outcomes were intensive care unit length of stay, hospital length of stay, incidence of pneumonia, and tracheostomy rates, and discharge disposition. Long-term outcomes were examined up to 6 months for adverse events. RESULTS: Sixty-eight patients were included, with 44 receiving INCA. There were no differences in rates of pneumonia ( p = 0.106) or duration of mechanical ventilation ( p = 0.687), and hospital length of stay was similar between groups ( p = 0.059). However, the INCA group demonstrated lower total morphine milligrams equivalent ( p = 0.002), shorter intensive care unit length of stay ( p = 0.021), higher likelihood of home discharge ( p = 0.044), and lower rate of intubation ( p = 0.002) and tracheostomy ( p = 0.032). CONCLUSION: Combining INCA with SSRF may further improve in-hospital outcomes for patients with traumatic rib fractures. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Endovascular management of traumatic pseudoaneurysms.

BACKGROUND: Pseudoaneurysms (PAs) caused by traumatic injury to the arterial vasculature have a high risk of rupture, leading to life-threatening hemorrhage and mortality, requiring urgent treatment. The purpose of this study was to determine the technical and clinical outcomes of endovascular treatment of visceral and extremity traumatic pseudoaneurysms. METHODS: Clinical data were retrospectively collected from all patients presenting for endovascular treatment of PAs between September 2012 and September 2018 at a single academic level one trauma center. Technical success was defined as successful treatment of the PA with no residual filling on post-embolization angiogram. Clinical success was defined as technical successful treatment with no rebleeding throughout the follow-up period and no reintervention for the PA. RESULTS: Thirty-five patients (10F/25M), average age (± stdev) 41.7 ± 20.1 years, presented with PAs secondary to blunt (n = 31) or penetrating (n = 4) trauma. Time from trauma to intervention ranged from 2 h - 75 days (median: 4.4 h, IQR: 3.5-17.1 h) with 27 (77%) of PAs identified and treated within 24 h of trauma. Average hospitalization was 13.78 ± 13.4 days. Ten patients underwent surgery prior to intervention. PA number per patient ranged from 1 to 5 (multiple diffuse). PAs were located on the splenic (n = 12, 34.3%), pelvic (n = 11, 31.4%), hepatic (n = 9, 25.7%), upper extremity/axilla (n = 2, 5.7%), and renal arteries (n = 1, 2.9%). Technical success was 85.7%. Clinical success was 71.4%, for technical failure (n = 5), repeat embolization (n = 1) or post-IR surgical intervention (n = 4). There was no PA rebleeding or reintervention for any patient after discharge over the reported follow-up periods. Three patients died during the trauma hospitalization for reasons unrelated to the PAs. CONCLUSIONS: Endovascular treatment of traumatic visceral and extremity PAs is efficacious with minimal complication rates and low reintervention requirements.

Patients with gunshot wounds to the torso differ in risk of mortality depending on treating hospital.

Previous studies have had conflicting results when comparing risk of mortality in patients with gunshot wounds (GSWs) treated at Level-I and II trauma centers. However, the populations studied were restricted geographically. We hypothesized that patients presenting after a GSW to the torso at Level-I centers would have a shorter time to surgical intervention (exploratory laparotomy or thoracotomy) and a lower risk of mortality, compared to Level-IIs in a national database. The Trauma Quality Improvement Program (2010-2016) was queried for patients presenting to Level-I or II trauma center after a GSW to the torso. A multivariable logistic regression analysis was performed. From 17,965 patients with GSWs, 13,812 (76.8%) were treated at Level-Is and 4153 (23.2%) at Level-IIs. There was no difference in the injury severity score (ISS) (p = 0.55). The Level-I cohort had a higher rate of laparotomy (38.9% vs. 36.5%, p < 0.001) with a shorter median time to laparotomy (49 vs. 55 min, p < 0.001) but no difference in rate (p = 0.14) and time to thoracotomy (p = 0.62). After adjusting for covariates, only patients undergoing thoracotomy (OR = 0.66, CI = 0.47-0.95, p = 0.02) or those undergoing non-operative management (NOM) (OR = 0.85, CI = 0.74-0.98, p = 0.03) at a Level-I center had lower risk for death, compared to Level-II. Patients with torso GSWs managed with thoracotomy or NOM at a Level-I center have a lower risk of mortality, compared to a Level-II. Future prospective studies examining variations in practice, resources available and surgeon experience to account for these differences are warranted.

National analysis of testicular and scrotal trauma in the USA.

BACKGROUND: To provide a descriptive analysis of scrotal and testicular trauma in the USA. Additionally, we hypothesized that motorcycle collision would have a higher association with scrotal or testicular trauma and subsequent scrotal or testicular operation, compared to a bicycle collision. METHODS: The National Trauma Data Bank (2007-2015) was queried to identify adult male patients with scrotal or testicular trauma. A multivariable logistic regression analysis was performed. RESULTS: A total of 8,030 patients (0.23%) had scrotal/testicular injury, with 44.6% involved in blunt trauma. A penetrating mechanism occurred in 50.5% of cases, with assault by firearm (75.8%) being the most common. The median age of the patients was 31 years and the median injury severity score was 8. Most had isolated scrotal or testicular trauma (74.5%), with 48.3% requiring scrotal or testicular operation, most commonly repair of laceration (37.3%). Patients involved in a motorcycle collision had higher risk for scrotal/testicular trauma (OR=5.40, CI=4.40-6.61, p=0.0004) and subsequent scrotal/testicular surgery (OR=4.93, CI=3.82-6.36, p=0.0005), compared to bicycle collision. CONCLUSION: Scrotal or testicular trauma is rare but occurs most commonly after assault by firearm. Most patients only have isolated scrotal or testicular trauma, but nearly half require subsequent scrotal or testicular operation. Trauma patients presenting after a motorcycle collision have a higher association of scrotal or testicular trauma and subsequent surgery when compared to those involved in a bicycle collision.

DUI histories in intoxicated injured bicyclists.

INTRODUCTION: It has been well documented that the use of alcohol correlates with injury risk, especially in DUI (driving under the influence) and DWI (driving while intoxicated). Consumption of alcohol in patients presenting with bicycle-related injuries is associated with greater injury severity, longer hospitalization, and higher health care costs. We hypothesized that intoxicated patients operating a bicycle with traumatic injuries have previous DUI or DWI convictions and had lost their privilege to drive a motor vehicle, resorted to bicycling, and had continued alcohol consumption despite negative previous consequences. METHODS: We retrospectively collected data on injured bicyclists older than 18 years with positive blood alcohol content levels treated from the period January 2009 to June 2014 at a large Level 1 urban trauma center. We then matched each patient by name and date of birth and were able to obtain public criminal records through the Superior Court of California for the local of county. RESULTS: A total of 149 injured bicyclists with positive blood alcohol levels were identified. Their average blood alcohol content was 236.0 mg/dL, and their average age was 41 years. Sixty-six (44.2%) of these patients had prior DUI/DWI convictions with suspension of driving privileges. Ninety-five patients in this group (63.8%) had no health insurance, and 51 patients (34.2%) tested positive for other drugs. Intoxicated bicyclists trended toward longer hospital length compared with nonintoxicated bicyclists (4.60 vs. 3.44 days; p = 0.07). Three (0.02%) of 149 patients were charged with bicycling while intoxicated. CONCLUSION: Intoxicated bicyclists involved in trauma are more likely to have a previous DUI/DWI, have other drug use, tend to have longer hospital stays, and are less likely to have insurance. Bicycle safety education and behavior modification targeting DUI/DWI offenders are warranted. In order to promote injury prevention, resources to increase awareness of this underestimated public health issue should be promoted. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Effectiveness of the combat pelvic protection system in the prevention of genital and urinary tract injuries: An observational study.

BACKGROUND: Historically, the incidence of genital and urinary tract (GU) injuries in major conflicts has been approximately 5%. To mitigate the risk of blast injury to the external genitalia, the United States and United Kingdom issued protective overgarments and undergarments to troops deployed in support of Operation Enduring Freedom. These two systems combined constitute the pelvic protection system (PPS). Our hypothesis was that PPS use is associated with a reduction of GU injuries in subjects exposed to dismounted improvised explosive device blast injuries. METHODS: We identified two groups for comparison: those who were confirmed to have worn the PPS at time of injury (n = 58) and a historical control group who were confirmed as not wearing the PPS (non-PPS) (n = 61). Patients with any level of lower extremity amputation from dismounted improvised explosive device blast mechanism were included. The primary outcome measure was presence of a GU injury on admission. A univariate analysis assessing the strength of association with odds ratios and 95% confidence intervals was performed between the PPS and non-PPS groups. RESULTS: Mean Injury Severity Score (ISS) was higher in the PPS versus the non-PPS group (26.1 vs. 19.3, p = 0.0012). Overall, 31% of the patients in the PPS group sustained at least one GU injury versus 62.3% in the non-PPS group. The odds ratio of sustaining a GU injury in the PPS group as compared with the PPS group is 0.28 (31% vs. 62.3%; 95 % confidence interval, 0.62-0.12; p < 0.001). The most frequent injures were open scrotal/testes wounds, followed by open penis, and open bladder/urethra injuries. CONCLUSION: The use of the PPS is associated with a decreased odds ratio of GU injury. Despite a 31% absolute reduction, future work should focus on improved efficiency. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level IV; therapeutic study, level V.

Surgical Team Assessment Training: improving surgical teams during deployment.

BACKGROUND: Simulation and team training are accepted as critical patient safety strategies to improve team performance and can help achieve better outcomes. Standardized and realistic drills conducted by skilled physicians and nurses who demonstrate consistent use of principles which enhance communication and teamwork increase the likelihood of improved clinical outcomes. METHODS: Two, 4-member surgeon/nurse teams traveled to 8 Army surgical resuscitation medical treatment facilities in Iraq during July and August 2011. At each site, a new program called Surgical Team Assessment Training was introduced and implemented to 220 military personnel. Two multi-patient scenarios were designed to test resuscitative and operating room medical decision-making, communication, and co-ordination of care. In addition, 2 hours of didactic instruction emphasized principles of TeamSTEPPS applied to emergency and operating rooms during care of patients with multiple, complex traumatic injuries. Anonymous surveys were completed by participants following the training. RESULTS: Participants were significantly more likely to rate this training as very helpful following training compared with their opinion before participation (53% vs 37%, P < .05). Seventy-seven percent felt that it would improve overall patient outcomes, 78% said it would likely contribute to saving lives in combat, and 98% felt it should be provided to military Emergency Medicine and Surgical residents. CONCLUSIONS: Surgical Team Assessment Training can be successfully implemented in an austere, hostile environment and improve trauma team function by incorporating simulation training models and TeamSTEPPs concepts. Expansion of this program for predeployment and resident training is currently under investigation based on the extremely positive responses.

Performance improvement evaluation of forward aeromedical evacuation platforms in Operation Enduring Freedom.

BACKGROUND: The following three helicopter-based medical evacuation platforms operate in Southern Afghanistan: the US Army emergency medical technician (basic)-led DUSTOFF, US Air Force paramedic-led PEDRO, and UK physician-led medical emergency response team (MERT). Nearly 90% of battlefield deaths occur in the prehospital phase, comparative outcomes for these en route care platforms are unknown. The objective of this investigation was to characterize the nature of injuries in patients transported by three evacuation platforms. In addition, it aimed to compare observed versus predicted mortality among these provider groups. METHODS: A performance improvement study involving 975 coalition patients injured in Southern Afghanistan, transported from the point of injury to a military hospital, was performed. All patients were alive on admission with prehospital documentation recorded in the US Department of Defense Trauma Registry from June 2009 to June 2011. The main outcome measure was in-hospital mortality and observed versus predicted (Trauma and Injury Severity Score [TRISS]) survival were the primary end points. RESULTS: MERT transported more amputation and polytrauma casualties and included patients with higher mean Injury Severity Score (ISS) compared with PEDRO and DUSTOFF (16 [13] vs. 11 [10] and 10 [10] respectively; p < 0.001). DUSTOFF was excluded from the subgroup analysis owing to insufficient numbers of severely injured casualties with only one death. The overall mortality for MERT and PEDRO was similar (4.2% vs. 4.6%, p = 0.967). Stratifying by ISS, there was lower mortality in MERT compared with PEDRO in the range of 20 to 29 (4.8% vs. 16.2%, p = 0.021). The observed mortality among PEDRO casualties was as predicted with the exception of the range of 20 to 29, while mortality in MERT was lower than predicted for all ISS groups with greater than 10. CONCLUSION: MERT achieves greater than predicted survival, which may be related to the additional capabilities onboard. This supports the adoption of a versatile medical evacuation system with scalable crew and equipment configurations that adapt to meet the medical, tactical, and operational needs of future conflicts.

A 21-year history of all-terrain vehicle injuries: has anything changed?

BACKGROUND: All-terrain vehicle (ATV)-related injuries have increased. The purpose of this study was to determine if the increase in injuries correlates with the expiration of government mandates. METHODS: ATV-injured patients admitted to a level I trauma center were reviewed over the years 1985-1999 and 2000-2005. Several demographic variables and injuries sustained were analyzed. RESULTS: There were a total of 433 injuries, which increased from 164 between 1985 and 1999, to 269 between 2000 and 2005. By comparing the time periods we observed a decrease in closed-head injury (53.6% vs 27.5%; P < .001), spinal cord injury (11.6% vs 5.2%; P < .05), and soft-tissue injury (62.8% vs 45.3%; P < .01), but an increase in long-bone fractures (18.9% vs 33.0%; P < .05). No differences were observed in other injuries. CONCLUSIONS: The number of patients sustaining ATV-related injuries has increased and correlates with the expiration of government mandates. Even though ATVs remain dangerous, injury prevention strategies such as helmet laws may be having a positive impact.

Traumatismos de páncreas: diagnóstico y tratamiento / Pancreatic trauma: diagnosis and treatment

Los traumatismos de páncreas son infrecuentes; representan, aproximadamente, el 4 porciento de las lesiones abdominales pero conllevan una tasa de morbimortalidad significativa, razón por la cual es primordial su reconocimiento y tratamiento precoz.El objetivo de este trabajo es presentar una descripción de la perspectiva histórica y de la correcta clasificación y manejo de la lesión pancreática. Asimismo, describimos los métodos de diagnóstico a nuestro alcance para la evaluación del traumatismo pancreático, y la importancia de un conocimiento amplio de las técnicas quirúrgicas más utilizadas. Por último, se hace un análisis profundo de los rangos de morbilidad y mortalidad de estas lesiones basándonos en una extensa revisión de la literatura actual, y aportando nuestra experiencia en el manejo de este tipo de lesiones en un centro de trauma urbano de nivel I.

Factores pronósticos del síndrome de exanguinación para el control de lesiones / Factors predicting institution of damage control in the exanguination syndrome

Introducción: El trauma es una epidemia en las sociedades modernas. La causa de muerte más frecuente en pacientes traumatizados es la pérdida masiva de sangre, lo cual puede ocurrir en el lugar mismo del trauma o después de aplicar medidas de reanimación en los servicios de urgencias. El objetivo de este trabajo es la revisión de los pacientes con diagnóstico de pérdida sanguínea masiva atendidos en un servicio de trauma de referencia en Estados Unidos.Materiales y métodos: Se realizó una revisión de los registros clínicos de los pacientes con diagnóstico de pérdida masiva de sangre (sangrado>2000 ml en el intraoperatorio o necesidad de transfusión de más de 1500 ml) en el Centro de Trauma del Hospital del Condado de Los Ángeles de la University of Southern California (Los Angeles County and University of Southern California Medical Center). Se recolectó la información de las variables demográficas, clínicas y de gravedad del trauma, lo mismo que los desenlaces de morbimortalidad. Se realizó un análisis para determinar los factores de riesgo relacionados con la muerte. Resultados: Se incluyeron 548 pacientes...

Lesiones vasculares abdominales. El desafío del cirujano de trauma / Abdominal vascular lesions. The trauma surgeon´s challenge

Introducción: Las lesiones vasculares abdominales presentan los mayores índices de mortalidad y morbilidad entre todas las lesiones que puede sufrir una persona con trauma severo. Método: Revisión de la clínica, diagnóstico, vías de abordaje y tratamiento de los pacientes con lesiones vasculares intraabdominales, con base en la experiencia en el manejo de 302 enfermos...

Diagnostic peritoneal aspiration--the foster child of DPL: a prospective observational study.

BACKGROUND: The abdomen is routinely considered as a possible source of bleeding in hypotensive and unevaluable blunt multitrauma patients. These patients are often unstable to be transported for abdominal computed tomography (CT). Emerging data on Focused Assessment with Sonography for Trauma (FAST) exam questions its initially reported high accuracy. We hypothesized that Diagnostic Peritoneal Aspiration (DPA), without a full lavage, accurately detects intraperitoneal blood if present in sufficient volume to cause hypotension and warrant emergent operation. METHODS: Over 24 months (July 2002-June 2004), 62 severe blunt trauma patients (Injury Severity Score: 32+/-17) with admission systolic blood pressure equal to or less than 90 mmHg were enrolled prospectively. Percutaneous DPA was performed after FAST. Aspiration of any quantity of blood was considered a positive test. Sensitivity and specificity of DPA and FAST were calculated against findings from abdominal CT, laparotomy, or autopsy. RESULTS: Twenty-two patients (35%) required emergent laparotomy and 39 (63%) died. DPA was performed in less than 1 min with no complications. Sensitivity and specificity of DPA was 89% and 100%, respectively, whereas for FAST it was 50% and 95%. Two (3%) false negative DPA were recorded; one patient had a minor liver laceration with 250 ml of free blood and the other a leaking retroperitoneal pelvic hematoma in the presence of cirrhosis with 600 ml of bloody ascitic fluid. There were no false positive DPA. Nine (14.5%) false negative and two (3%) false positive FAST were recorded in patients who were found to have at laparotomy 1575+/-1070 ml of hemoperitoneum on average. CONCLUSIONS: Percutaneous DPA is accurate, rapid, safe, and superior to FAST for the diagnosis of abdominal blood as the source of hemodynamic instability, requiring emergent surgery, in blunt multitrauma patients.

Superior mesenteric venous injuries: to ligate or to repair remains the question.

BACKGROUND: Superior mesenteric vein injuries are rare and incur high mortality. Given their low incidence, little data exist delineating indications for when to institute primary repair versus ligation. The purposes of this study are to review our institutional experience, to determine the additive effect on mortality of associated vascular injuries, to correlate mortality with the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury and to examine and define the indications and outcomes for primary repair versus ligation. MATERIAL: Retrospective 156 months study (January 1992 through December 2004) in a large Level I urban trauma center of all patients admitted with superior mesenteric vein injuries. Patients were stratified, according to surgical technique employed to deal with their injuries, into those undergoing primary repair versus ligation to determine outcomes and define the surgical indications of these methods. The main outcome measure was overall survival. Cases of survival were stratified according to surgical method: primary repair versus ligation. RESULTS: There were 51 patients with a mean Injury Severity Score of 25 +/- 12. Mechanism of injury was penetrating for 38 (76%), blunt for 13 (24%), and patients undergoing emergency department thoracotomy for 4 (8%). Surgical management was ligation for 30 (59%), primary repair for 16 (31%), and 5 (10%) patients were exsanguinated before repair. The overall survival rate was 24/50 (47%). The survival rate excluding patients undergoing emergency department thoracotomy was 51%. The survival rate excluding patients that sustained greater than 3 to 4 associated vessels injured was 65%. The survival rates of patients with superior mesenteric vein and superior mesenteric artery was 55% and superior mesenteric vein and portal vein (PV) was 40%. The survival rate of patients with isolated superior mesenteric vein injuries was 55%. Mortality stratified to AAST-OIS grade III, 44%; grade IV, 42%; and grade V, 42%. Survival rates stratified to method of management consisted of primary repair (60%) versus ligation (40%). CONCLUSIONS: SMV injuries are highly lethal. Multiple associated vessel injuries increase mortality. Mortality correlates well with the American Association for the Surgery of Trauma-Organ Injury Scale for abdominal vascular injuries. Patients undergoing primary repair have higher survival rates (63%) and lesser numbers of associated vascular and nonvascular injuries; whereas those undergoing ligation have a smaller survival rate (40%) and higher number of associated vascular and nonvascular injuries. Ligation appears to be safe and should be selected for hemodynamically unstable patients with a large number of associated injuries.