To the point: Utility of laparoscopy for operative management of stabbing abdominal trauma.

BACKGROUND: Algorithms for managing penetrating abdominal trauma are conflicting or vague regarding the role of laparoscopy. We hypothesized that laparoscopy is underutilized among hemodynamically stable patients with abdominal stab wounds. METHODS: Trauma Quality Improvement Program data (2016-2019) were used to identify stable (SBP ≥110 and GCS ≥13) patients ≥16yrs with stab wounds and an abdominal procedure within 24hr of admission. Patients with a non-abdominal AIS ≥3 or missing outcome information were excluded. Patients were analyzed based on index procedure approach: open, therapeutic laparoscopy (LAP), or LAP-conversion to open (LCO). Center, clinical characteristics and outcomes were compared according to surgical approach and abdominal AIS using non-parametric analysis. RESULTS: 5984 patients met inclusion criteria with 7 â€‹% and 8 â€‹% receiving therapeutic LAP and LCO, respectively. The conversion rate for patients initially treated with LAP was 54 â€‹%. Compared to conversion or open, therapeutic LAP patients had better outcomes including shorter ICU and hospital stays and less infection complications, but were younger and less injured. Assessing by abdominal AIS eliminated ISS differences, meanwhile LAP patients still had shorter hospital stays. At time of admission, 45 â€‹% of open patients met criteria for initial LAP opportunity as indicated by comparable clinical presentation as therapeutic laparoscopy patients. CONCLUSIONS: In hemodynamically stable patients, laparoscopy remains infrequently utilized despite its increasing inclusion in current guidelines. Additional opportunity exists for therapeutic laparoscopy in trauma, which appears to be a viable alternative to open surgery for select injuries from abdominal stab wounds. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Pediatric emergency resuscitative thoracotomy: A Western Trauma Association, Pediatric Trauma Society, and Eastern Association for the Surgery of Trauma collaborative critical decisions algorithm.

LEVEL OF EVIDENCE: Literature synthesis and expert opinion, Level V.

Blunt pancreatic trauma: A Western Trauma Association critical decisions algorithm.

BACKGROUND: The Western Trauma Association (WTA) has undertaken publication of best practice clinical practice guidelines on multiple trauma topics. These guidelines are based on scientific evidence, case reports, and best practices per expert opinion. Some of the topics covered by this consensus group do not have the ability to have randomized controlled studies completed because of complexity, ethical issues, financial considerations, or scarcity of experience and cases. Blunt pancreatic trauma falls under one of these clinically complex and rare scenarios. This algorithm is the result of an extensive literature review and input from the WTA membership and WTA Algorithm Committee members. METHODS: Multiple evidence-based guideline reviews, case reports, and expert opinion were compiled and reviewed. RESULTS: The algorithm is attached with detailed explanation of each step, supported by data if available. CONCLUSION: Blunt pancreatic trauma is rare and presents many treatment challenges.

Evaluation and management of traumatic pneumothorax: A Western Trauma Association critical decisions algorithm.

ABSTRACT: This is a recommended algorithm of the Western Trauma Association for the management of a traumatic pneumothorax. The current algorithm and recommendations are based on available published prospective cohort, observational, and retrospective studies and the expert opinion of the Western Trauma Association members. The algorithm and accompanying text represents a safe and reasonable approach to this common problem. We recognize that there may be variability in decision making, local resources, institutional consensus, and patient-specific factors that may require deviation from the algorithm presented. This annotated algorithm is meant to serve as a basis from which protocols at individual institutions can be developed or serve as a quick bedside reference for clinicians. LEVEL OF EVIDENCE: Consensus algorithm from the Western Trauma Association, Level V.

Multi-center validation of the Bowel Injury Predictive Score (BIPS) for the early identification of need to operate in blunt bowel and mesenteric injuries.

INTRODUCTION: The Bowel Injury Prediction Score (BIPS) is a tool for identifying patients at risk for blunt bowel and mesenteric injury (BBMI) requiring surgery. BIPS is calculated by assigning one point for each of the following: (1) WBC ≥ 17,000, (2) abdominal tenderness, and (3) injury grade ≥ 4 (mesenteric contusion or hematoma with bowel wall thickening or adjacent interloop fluid collection) on CT scan. A total score ≥ 2 is associated with BBMI requiring surgery. We aimed to validate the BIPS as a predictor for patients with BBMIs requiring operative intervention in a multi-center prospective study. MATERIALS AND METHODS: Patients were prospectively enrolled at 15 U.S. trauma centers following blunt trauma with suspicion of BBMI on CT scan between July 1, 2018 and July 31, 2019. The BIPS was calculated for each patient enrolled in the study. RESULTS: Of 313 patients, 38% had BBMI requiring operative intervention. Patients were significantly more likely to require surgery in the presence of abdominal tenderness (OR, 3.6; 95% CI, 1.6-8.0) and CT grade ≥ 4 (OR, 11.7; 95% CI, 5.7-23.7). Patients with a BIPS ≥ 2 were more than ten times more likely to require laparotomy than those with a BIPS < 2 (OR, 10.1; 95% CI, 5.0-20.4). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a BIPS ≥ 2 for BBMI requiring surgery was 72% (CI 0.6-0.8), 78% (CI 0.7-0.8), 67% (CI 0.6-0.8), and 82% (CI 0.8-0.9), respectively. The AUROC curve for BIPS ≥ 2 was 0.75. The sensitivity, specificity, PPV, and NPV of a BIPS ≥ 2 for BBMI requiring surgery in patients with severe alteration in mental status (GCS 3-8) was 70% (CI 0.5-0.9), 92% (CI 0.8-1.0), 82% (CI 0.6-1.0), and 86% (CI 0.7-1.0), respectively. CONCLUSION: This prospective multi-center trial validates BIPS as a predictor of BBMI requiring surgery. Calculation of BIPS during the initial evaluation of trauma patients is a useful adjunct to help general surgeons taking trauma call determine operative versus non-operative management of patients with BBMI including those with severe alteration in mental status.

Cervical spine evaluation and clearance in the intoxicated patient: A prospective Western Trauma Association Multi-Institutional Trial and Survey.

BACKGROUND: Intoxication often prevents clinical clearance of the cervical spine (Csp) after trauma leading to prolonged immobilization even with a normal computed tomography (CT) scan. We evaluated the accuracy of CT at detecting clinically significant Csp injury, and surveyed participants on related opinions and practice. METHODS: A prospective multicenter study (2013-2015) at 17 centers. All adult blunt trauma patients underwent structured clinical examination and imaging including a Csp CT, with follow-up thru discharge. alcohol- and drug-intoxicated patients (TOX+) were identified by serum and/or urine testing. Primary outcomes included the incidence and type of Csp injuries, the accuracy of CT scan, and the impact of TOX+ on the time to Csp clearance. A 36-item survey querying local protocols, practices, and opinions in the TOX+ population was administered. RESULTS: Ten thousand one hundred ninety-one patients were prospectively enrolled and underwent CT Csp during the initial trauma evaluation. The majority were men (67%), had vehicular trauma or falls (83%), with mean age of 48 years, and mean Injury Severity Score (ISS) of 11. The overall incidence of Csp injury was 10.6%. TOX+ comprised 30% of the cohort (19% EtOH only, 6% drug only, and 5% both). TOX+ were significantly younger (41 years vs. 51 years; p < 0.01) but with similar mean Injury Severity Score (11) and Glasgow Coma Scale score (13). The TOX+ cohort had a lower incidence of Csp injury versus nonintoxicated (8.4% vs. 11.5%; p < 0.01). In the TOX+ group, CT had a sensitivity of 94%, specificity of 99.5%, and negative predictive value (NPV) of 99.5% for all Csp injuries. For clinically significant injuries, the NPV was 99.9%, and there were no unstable Csp injuries missed by CT (NPV, 100%). When CT Csp was negative, TOX+ led to longer immobilization versus sober patients (mean, 8 hours vs. 2 hours; p < 0.01), and prolonged immobilization (>12 hrs) in 25%. The survey showed marked variations in protocols, definitions, and Csp clearance practices among participating centers, although 100% indicated willingness to change practice based on these data. CONCLUSION: For intoxicated patients undergoing Csp imaging, CT scan was highly accurate and reliable for identifying clinically significant spine injuries, and had a 100% NPV for identifying unstable injuries. CT-based clearance in TOX+ patients appears safe and may avoid unnecessary prolonged immobilization. There was wide disparity in practices, definitions, and opinions among the participating centers. LEVEL OF EVIDENCE: Diagnostic tests or criteria, level II.

Cervical spinal clearance: A prospective Western Trauma Association Multi-institutional Trial.

BACKGROUND: For blunt trauma patients who have failed the NEXUS (National Emergency X-Radiography Utilization Study) low-risk criteria, the adequacy of computed tomography (CT) as the definitive imaging modality for clearance remains controversial. The purpose of this study was to prospectively evaluate the accuracy of CT for the detection of clinically significant cervical spine (C-spine) injury. METHODS: This was a prospective multicenter observational study (September 2013 to March 2015) at 18 North American trauma centers. All adult (≥18 years old) blunt trauma patients underwent a structured clinical examination. NEXUS failures underwent a CT of the C-spine with clinical follow-up to discharge. The primary outcome measure was sensitivity and specificity of CT for clinically significant injuries requiring surgical stabilization, halo, or cervical-thoracic orthotic placement using the criterion standard of final diagnosis at the time of discharge, incorporating all imaging and operative findings. RESULTS: Ten thousand seven hundred sixty-five patients met inclusion criteria, 489 (4.5%) were excluded (previous spinal instrumentation or outside hospital transfer); 10,276 patients (4,660 [45.3%] unevaluable/distracting injuries, 5,040 [49.0%] midline C-spine tenderness, 576 [5.6%] neurologic symptoms) were prospectively enrolled: mean age, 48.1 years (range, 18-110 years); systolic blood pressure 138 (SD, 26) mm Hg; median, Glasgow Coma Scale score, 15 (IQR, 14-15); Injury Severity Score, 9 (IQR, 4-16). Overall, 198 (1.9%) had a clinically significant C-spine injury requiring surgery (153 [1.5%]) or halo (25 [0.2%]) or cervical-thoracic orthotic placement (20 [0.2%]). The sensitivity and specificity for clinically significant injury were 98.5% and 91.0% with a negative predictive value of 99.97%. There were three (0.03%) false-negative CT scans that missed a clinically significant injury, all had a focal neurologic abnormality on their index clinical examination consistent with central cord syndrome, and two of three scans showed severe degenerative disease. CONCLUSIONS: For patients requiring acute imaging for their C-spine after blunt trauma, CT was effective for ruling out clinically significant injury with a sensitivity of 98.5%. For patients with an abnormal neurologic examination as the trigger for imaging, there is a small but clinically significant incidence of a missed injury, and further imaging with magnetic resonance imaging is warranted. LEVEL OF EVIDENCE: Diagnostic tests, level II.

Does resuscitation with plasma increase the risk of venous thromboembolism?

BACKGROUND: Resuscitation with blood products improves survival in patients with traumatic hemorrhage. However, the risk of venous thromboembolic (VTE) complications associated with fresh frozen plasma (FFP) resuscitation is unknown. We hypothesized that a higher ratio of FFP to packed red blood cells (PRBCs) given during acute resuscitation increases the risk of VTE independent of severity of injury and shock. METHODS: The records of patients admitted from April 2007 to December 2011 who had surveillance lower extremity duplex ultrasounds were retrospectively reviewed. Patients who received at least 1 U of PRBCs within 24 hours of admission were included. Patients who died without VTE were excluded. The relationship between FFP and VTE was evaluated using logistic regression. RESULTS: A total of 381 patients met inclusion criteria, of whom 77 (20.2%) developed VTE. In patients who required less than 4 U of PRBCs, increasing units of FFP were associated with an increasing risk for VTE, with each unit of FFP having an adjusted odds ratio of 1.27 (95% confidence interval, 1.04-1.54, p = 0.015). Conversely, in patients who required four or greater units of PRBCs, FFP in equal or greater ratios than PRBCs was not associated with VTE. CONCLUSION: Each unit of FFP increased VTE risk by 25% in patients who required less than 4 U of PRBCs. In patients who required 4 U or greater PRBCs, FFP administration conferred no increased risk of VTE. This suggests that FFP should be used cautiously when early hemodynamic stability can be achieved with less than 4 U of PRBCs. LEVEL OF EVIDENCE: Care management study, level III.

Death after discharge: predictors of mortality in older brain-injured patients.

BACKGROUND: Older patients with traumatic brain injury (TBI) may be at high risk of death after hospitalization. The purpose of this study was to characterize long-term mortality of older TBI patients who survived to discharge. We hypothesized that predictors of postdischarge mortality differed from those of inpatient mortality. METHODS: A retrospective cohort study was performed on TBI patients older than 55 years admitted to our Level I trauma center between July 1, 2006, and December 31, 2011. Postdischarge deaths were identified by matching patient data with local vital records up to December 31, 2011, when data collection was terminated (censoring). Patients were categorized by age, comorbidities, history of preinjury anticoagulant/prescription antiplatelet agent therapy, injury severity indices, initial TBI type, prehospital living status, discharge location, and discharge condition. The effect of risk factors on postdischarge mortality was evaluated by Cox proportional hazards modeling. RESULTS: Of 353 patients, 322 (91.2%) survived to discharge. Postdischarge mortality was 19.8% (n = 63) for the study period. Of the postdischarge deaths, 54.0% died within 6 months of discharge, and 68.3% died within 1 year. Median days to death after discharge or censoring were 149 and 410, respectively. Factors associated with death after discharge included age, preinjury anticoagulant use, higher number of Charlson comorbidities, discharge to a long-term care facility, and severe disability. Factors related to injury severity (i.e., Injury Severity Score [ISS], initial Glasgow Coma Scale [GCS] score) and preinjury prescription antiplatelet agent use, previously found to predict inpatient death, did not predict postdischarge mortality. CONCLUSION: Older TBI patients who survive to discharge have a significant risk of death within 1 year. Predictors of postdischarge mortality and inpatient death differ. Death after discharge is largely a function of overall health status. Monitoring health status and continued aggressive management of comorbidities after discharge may be essential in determining long-term outcomes. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Isolated traumatic brain injury and venous thromboembolism.

BACKGROUND: Traumatic brain injury (TBI) is considered an independent risk factor of venous thromboembolism (VTE). However, the role of TBI severity in VTE risk has not been determined. We hypothesized that increased severity of brain injury in patients with isolated TBI (iTBI) is associated with an increased incidence of VTE. METHODS: The records of patients admitted from June 2006 to December 2011 were reviewed for injury data, VTE risk factors, results of lower extremity surveillance ultrasound, and severity of TBI. Patients were identified by DRG International Classification of Diseases-9th Rev. codes for TBI, and only those with a nonhead Abbreviated Injury Scale (AIS) score of 1 or lower, indicating minimal associated injury, were included. The association of iTBI and VTE was determined using a case-control design. Among iTBI patients, those diagnosed with VTE (cases) were matched for age, sex, and admission year to those without VTE (controls). Data were analyzed using conditional logistic regression. RESULTS: There were 345 iTBI patients: 41 cases (12%) and 304 controls (88%). A total of 151 controls could not be matched to an appropriate case and were excluded. Of the remaining 153 controls, 1 to 16 controls were matched to each of the 41 VTE cases. Compared with the controls, the cases had a higher mean head-AIS score (4.4 vs. 3.9, p = 0.001) and overall Injury Severity Score (20.4 vs. 16.8, p = 0.001). Following adjustment for all factors found to be associated with VTE (ventilator days, central line placement, operative time > 2 hours, chemoprophylaxis, history of VTE, and history of cancer), the cases were significantly more likely to have a greater head injury severity (head-AIS score ≥ 5; odds ratio, 5.25; 95% confidence interval, 1.59-17.30; p = 0.006). CONCLUSION: The incidence of VTE in iTBI patients was significantly associated with the severity of TBI. VTE surveillance protocols may be warranted in these high-risk patients, as early detection of VTE could guide subsequent therapy. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.