Management of extremity fasciotomy sites prospective randomized evaluation of two techniques.

INTRODUCTION: Morbidity from the treatment of extremity compartment syndrome is underappreciated. Closure technique effectiveness has yet to be definitively established. METHODS: A randomized non-blinded prospective study was performed involving patients who underwent an extremity fasciotomy following trauma. Shoelace wounds were strapped with vessel loops under tension and VAC wounds were treated with a standard KCI VAC dressing. After randomization, patients returned to the OR every 96 h until primarily closed or skin grafted. RESULTS: 21 patients were consented for randomization with 11 (52%) successfully closed at the first re-operation. After interim analysis the study was closed early with 5/5 (100%) of wounds treated with the shoelace technique closed primarily and only 1/9 (11%) of VAC wounds closed primarily (p = 0.003). Overall primary closure was achieved in 74% of patients. CONCLUSIONS: Aggressive attempts at wound closure lead to an increased early closure rate. For wounds that remain open after the first re-operation, a simple shoelace technique is more successful than a wound VAC for achieving same hospital stay skin closure.

Impact of a Novel Preoperative Patient-centered Surgical Wellness Program.

OBJECTIVE: The objective of this study was to evaluate if a preoperative wellness bundle significantly decreases the risk of hospital acquired infections (HAI). BACKGROUND: HAI threaten patient outcomes and are a significant burden to the healthcare system. Preoperative wellness efforts may significantly decrease the risk of infections. METHODS: A group of 12,396 surgical patients received a wellness bundle in a roller bag during preoperative screening at an urban academic medical center. The wellness bundle consisted of a chlorhexidine bath solution, immuno-nutrition supplements, incentive spirometer, topical mupirocin for the nostrils, and smoking cessation information. Study staff performed structured patient interviews, observations, and standardized surveys at key intervals throughout the perioperative period. Statistics compare HAI outcomes of patients in the wellness program to a nonintervention group using the Fisher's exact test, logistic regression, and Poisson regression. RESULTS: Patients in the nonintervention and intervention groups were similar in demographics, comorbidity, and type of operations. Compliance with each element was high (80% mupirocin, 72% immuno-nutrition, 71% chlorhexidine bath, 67% spirometer). The intervention group had statistically significant reductions in surgical site infections, Clostridium difficile, catheter associated urinary tract infections, and patient safety indicator 90. CONCLUSIONS: A novel, preoperative, patient-centered wellness program dramatically reduced HAI in surgical patients at an urban academic medical center.

The Alvarado score should be used to reduce emergency department length of stay and radiation exposure in select patients with abdominal pain.

BACKGROUND: Abdominal pain is the common reason patients seek treatment in emergency departments (ED), and computed tomography (CT) is frequently used for diagnosis; however, length of stay (LOS) in the ED and risks of radiation remain a concern. The hypothesis of this study was the Alvarado score (AS) could be used to reduce CT scans and decrease ED LOS for patients with suspected acute appendicitis (AA). METHODS: A retrospective review of patients who underwent CT to rule out AA from January 1, 2015, to December 31, 2015, was performed. Patient demographics, medical history, ED documentation, operative interventions, complications, and LOS were all collected. Alvarado score was calculated from the medical record. Time to CT completion was calculated from times the patient was seen by ED staff, CT order, and CT report. RESULTS: Four hundred ninety-two patients (68.1% female; median age, 33 years) met the inclusion criteria. Most CT scans (70%) did not have findings consistent with AA. Median AS for AA on CT scan was 7, compared with 3 for negative CT (p < 0.001). One hundred percent of female patients with AS of 10 and males with AS of 9 or greater had AA confirmed by surgical pathology. Conversely, 5% or less of female patients with AS of 2 or less and 0% of male patients with AS of 1 or less were diagnosed with AA. One hundred six (21.5%) patients had an AS within these ranges and collectively spent 10,239 minutes in the ED from the time of the CT order until the radiologist's report. CONCLUSION: Males with an AS of 9 or greater and females with AS of 10 should be considered for treatment of AA without imaging. Males with AS of 1 or less and females with AS of 2 or less can be safely discharged with follow-up. Using AS, a significant proportion of patients can avoid the radiation risk, the increased cost, and increased ED LOS associated with CT. LEVEL OF EVIDENCE: Diagnostic IV, therapeutic IV.

An update on nonoperative management of the spleen in adults.

Many patients with blunt splenic injury are considered for nonoperative management and, with proper selection, the success rate is high. This paper aims to provide an update on the treatments and dilemmas of nonoperative management of splenic injuries in adults and to offer suggestions that may improve both consensus and patient outcomes.

Penetrating cardiac injuries: A 36-year perspective at an urban, Level I trauma center.

BACKGROUND: This study evaluates patterns of injuries and outcomes from penetrating cardiac injuries (PCIs) at Grady Memorial Hospital, an urban, Level I trauma center in Atlanta, Georgia, over 36 years. METHODS: Patients sustaining PCIs were identified from the Trauma Registry of the American College of Surgeons and the Emory Department of Surgery database; data of patients who died prior to any therapy were excluded. Demographics and outcomes were compared over three time intervals: Period 1 (1975-1985; n = 113), Period 2 (1986-1996; n = 79), and Period 3 (2000-2010; n = 79). RESULTS: Two hundred seventy-one patients (86% were male; mean age, 33 years; initial base deficit = -11.3 mEq/L) sustained cardiac stab (SW, 60%) or gunshot wounds (GSW, 40%). Emergency department thoracotomy was performed in 67 (25%) of 271 patients. Overall mortality increased in the modern era (Period 1, 27%, vs. Period 2, 22%, vs. Period 3, 42%; p = 0.03) along with GSW mechanisms (Period 1, 32%, vs. Period 2, 33%, vs. Period 3, 57%; p = 0.001), GSW mortality (Period 1, 36%, vs. Period 2, 42%, vs. Period 3, 56%; p = 0.04), and multichamber injuries (Period 1, 12%, vs. Period 2, 10%, vs. Period 3, 34%; p< 0.001). In Period 3, GSWs (n = 45) resulted in multichamber injuries in 28 patients (62%) and multicavity injuries in 19 patients (42%). Surgeon-performed ultrasound accurately identified pericardial blood in 55 of 55 patients in Period 3. CONCLUSIONS: Increased frequency of GSWs in the past decade is associated with increased overall mortality, multichamber injuries, and multicavity injuries. Ultrasound is sensitive for detection of PCI. LEVEL OF EVIDENCE: Therapeutic study, level IV; epidemioligc study, level III.

Is there an impending loss of academically productive trauma surgical faculty? An analysis of 4,015 faculty.

OBJECTIVE: The aim of this work was to compare the academic impact of trauma surgery faculty relative to faculty in general surgery and other surgery subspecialties. METHODS: Scholarly metrics were determined for 4,015 faculty at the top 50 National Institutes of Health (NIH)-funded university-based departments and five hospital-based surgery departments. RESULTS: Overall, 317 trauma surgical faculty (8.2%) were identified. This compared to 703 other general surgical faculty (18.2%) and 2,830 other subspecialty surgical faculty (73.5%). The average size of the trauma surgical division was six faculty. Overall, 43% were assistant professors, 29% were associate professors, and 28% were full professors, while 3.1% had PhD, 2.5% had MD and PhD, and, 16.3% were division chiefs/directors. Compared with general surgery, there were no differences regarding faculty academic levels or leadership positions. Other surgical specialties had more full professors (39% vs. 28%; p < 0.05) and faculty with research degrees (PhD, 7.7%; and MD and PhD, 5.7%). Median publications/citations were lower, especially for junior trauma surgical faculty (T) compared with general surgery (G) and other (O) surgical specialties: assistant professors (T, 9 publications/76 citations vs. G, 13/138, and O, 18/241; p < 0.05), associate professors (T, 22/351 vs. G, 36/700, and O, 47/846; p < 0.05), and professors (T, 88/2,234 vs. G, 93/2193; p = NS [not significant for either publications/citations] and O, 99/2425; p = NS). Publications/Citations for division chiefs/directors were comparable with other specialties: T, 77/1,595 vs. G, 103/2,081 and O, 74/1,738; p = NS, but were lower for all nonchief faculty; T, 23/368 vs. G, 30/528 and O, 37/658; p < 0.05. Trauma surgical faculty were less likely to have current or former NIH funding than other surgical specialties (17 % vs. 27%; p < 0.05), and this included a lower rate of R01/U01/P01 funding (5.5% vs. 10.8%; p < 0.05). CONCLUSIONS: Senior trauma surgical faculty are as academically productive as other general surgical faculty and other surgical specialists. Junior trauma faculty, however, publish at a lower rate than other general surgery or subspecialty faculty. Causes of decreased academic productivity and lower NIH funding must be identified, understood, and addressed.

Improving geriatric trauma outcomes: A small step toward a big problem.

BACKGROUND: Because of the unique physiology and comorbidities of injured geriatric patients, specific interventions are needed to improve outcomes. The purpose of this study was to assess the effect of a change in triage criteria for injured geriatric patients evaluated at an American College of Surgeons Level I trauma center. METHODS: As of October 1, 2013, all injured patients 70 years or older were mandated to have the highest-level trauma activation upon emergency department (ED) arrival regardless of physiology or mechanism of injury. Patients admitted before that date were designated as PRE; those admitted after were designated as POST. The study period was from October 1, 2011, through April 30, 2015. Data collected included demographics, mechanism of injury, hypotension on admission, comorbidities, Injury Severity Score (ISS), ED length of stay (LOS), complications, and mortality. Bivariate and multivariable analyses were used to compare outcomes between the study groups (p < 0.05 was considered significant). χ or Fisher's exact test was used as appropriate for bivariate analyses of categorical variables; patients' ages were compared using the Wilcoxon rank-sum test. RESULTS: A total of 2,269 patients (mean, 80.63 years; mean ISS, 12.2; PRE, 1,271; POST, 933) were included in the study. On multivariable analysis, increasing age, higher ISS, and hypotension were associated with higher mortality. POST patients were more likely to have an ED LOS of 2 hours or shorter (odds ratio, 1.614; 95% confidence interval, 1.088-2.394) after controlling for hypotension, ISS, and comorbidities. POST mortality significantly decreased (odds ratio, 0.689; 95% confidence interval, 0.484-0.979). CONCLUSION: Based on age alone, the focused intervention of a higher level of trauma activation decreased ED LOS and mortality in injured geriatric patients. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.

Understanding the Barriers to Hiring and Promoting Women in Surgical Subspecialties.

BACKGROUND: The objective of this study was to characterize potential disparities in academic output, NIH-funding, and academic rank between male and female surgical faculty and identify subspecialties in which these differences may be more pronounced. STUDY DESIGN: Eighty metrics for 4,015 faculty members at the top-55 NIH-funded departments of surgery were collected. Demographic characteristics, NIH funding details, and scholarly output were analyzed. A new metric, academic velocity (V), reflecting recent citations is defined. RESULTS: Overall, 21.5% of surgical faculty are women. The percentage of female faculty is highest in science/research (41%) and surgical oncology (34%), and lowest in cardiothoracic surgery (9%). Female faculty are less likely to be full professors (22.7% vs 41.2%) and division chiefs (6.2% vs 13.6%). The fraction of women who are full professors is lowest in cardiothoracic surgery. Overall median numbers of publications/citations are lower for female faculty compared with male surgical faculty (21 of 364 vs 43 of 723, p < 0.001), and these differences are more pronounced for assistant professors. Current/previous NIH funding (21.3% vs 24%, p = NS) rates are similar between women and men, and surgical departments with more female full professors have higher NIH funding ranking (R(2) = 0.14, p < 0.05). In certain subspecialties, female associate and full professors outperform male counterparts. Overall, female authors have higher numbers of more recent citations. CONCLUSIONS: Subspecialty involvement and academic performance differences by sex vary greatly by subspecialty type and are most pronounced at the assistant professor level. Identification of potential barriers for entry of women into certain subspecialties, causes for the observed lower number of publications/citations among female assistant professors, and obstacles for attaining leadership roles need to be determined. We propose a new metric for assessment of publications/citations that can offset the effects of seniority differences between male and female faculty members.

Choice of motorcycle helmet makes a difference: a prospective observational study.

BACKGROUND: Although many states mandate that motorcyclists wear helmets, their laws do not indicate which type of helmet should be used. In addition, there are no prospective studies in the literature evaluating patterns of injuries as they relate to helmet type. The hypothesis in this study was that full-face helmets (FFHs) reduce craniofacial injuries associated with motorcycle collisions when compared with other helmet types. METHODS: A prospective observational study was conducted at a Level I trauma center to evaluate the efficacy of helmet types relative to craniofacial injuries. Data included patient demographics, helmet types, injuries, and outcomes. The incidences of facial fractures, skull fractures, and traumatic brain injuries (TBIs) were compared in patients wearing FFHs versus other helmet types (OH) during motorcycle crashes. RESULTS: From 2011 to 2012, 151 patients of motorcycle crashes (135 males, 16 female; mean age, 38.4 years; range, 19-74 years) whose helmet types were identified by health care providers were entered into the study. The distribution of helmets was 84 FFH and 67 OH (39 half and 28 modular). Facial fractures were present in 7% of the patients wearing FFH (95% confidence interval, 0.015-0.125) versus 27% (95% confidence interval, 0.164-0.376) of those wearing OH (p = 0.004). In addition skull fractures were present in 1% of the patients wearing FFH versus 8% in those wearing OH (p < 0.05). While there was a trend for patients wearing FFH to have a lower incidence of TBI (13% vs. 25% in those wearing OH), this was not statistically significant (p = 0.053). There were no differences in Injury Severity Score (ISS), length of stay, or mortality between the two groups. CONCLUSION: Victims of motorcycle crashes who are wearing FFH have a significant reduction in facial and skull fractures when compared with those wearing OH. Further studies will be needed to assess whether FFH will significantly decrease the incidence of TBI. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Emergency general surgery: definition and estimated burden of disease.

BACKGROUND: Acute care surgery encompasses trauma, surgical critical care, and emergency general surgery (EGS). While the first two components are well defined, the scope of EGS practice remains unclear. This article describes the work of the American Association for the Surgery of Trauma to define EGS. METHODS: A total of 621 unique International Classification of Diseases-9th Rev. (ICD-9) diagnosis codes were identified using billing data (calendar year 2011) from seven large academic medical centers that practice EGS. A modified Delphi methodology was used by the American Association for the Surgery of Trauma Committee on Severity Assessment and Patient Outcomes to review these codes and achieve consensus on the definition of primary EGS diagnosis codes. National Inpatient Sample data from 2009 were used to develop a national estimate of EGS burden of disease. RESULTS: Several unique ICD-9 codes were identified as primary EGS diagnoses. These encompass a wide spectrum of general surgery practice, including upper and lower gastrointestinal tract, hepatobiliary and pancreatic disease, soft tissue infections, and hernias. National Inpatient Sample estimates revealed over 4 million inpatient encounters nationally in 2009 for EGS diseases. CONCLUSION: This article provides the first list of ICD-9 diagnoses codes that define the scope of EGS based on current clinical practices. These findings have wide implications for EGS workforce training, access to care, and research.

Early subspecialization and perceived competence in surgical training: are residents ready?

BACKGROUND: In order to understand how current surgical residents feel about their training, a survey focused on perceptions regarding early entry into a subspecialty and the adequacy of training was sent to selected residency programs in general surgery (GS). STUDY DESIGN: A 36-item online anonymous survey was sent to the program directors of 55 GS programs. The national sample consisted of 1,515 PGY 1 to PGY 5 categorical residents. RESULTS: The response rate was 45%. Overall, 80% were planning on pursuing a fellowship. The majority (63%) believed that the Residency Review Committee for Surgery and the American Board of Surgery should consider the shift to early subspecialty training. Almost 70% of respondents preferred a 3-year basic track followed by a 3-year subspecialty track. In response to the survey item, "Do you think a 5-year GS residency fully prepares you to practice GS?", 38% of residents overall responded "no" or "unsure." This figure decreased with each increasing year of residency training, from PGY 1 (53.3%) to PGY 5 (23%). Finally, 71% of residents who answered "no" or "unsure" to the above question believe there should be a change to a track system. CONCLUSIONS: The choice of fellowship training for 80% of trainees partially reflects that 38% are not confident about their skills with 5 years of training in GS, including 23% of graduating chief residents. Training and certifying groups should update and strengthen the current curriculum for categorical residents in GS and continue their efforts to offer shortened independent or integrated residency training for those who will enter surgical specialties. Innovative solutions are needed to solve the logistic and financial problems involved.

Acute care surgery: now that we have built it, will they come?

BACKGROUND: Concern over lack of resident interest caused by the nonoperative nature and compromised lifestyle associated with a career as a "trauma surgeon" has led to the emergence of a new acute care surgery (ACS) specialty. This study examined the opinions of current general surgical residents about training and careers in this new field. METHODS: A 36-item online anonymous survey regarding ACS was sent to the program directors of 55 randomly selected general surgery (GS) training programs for distribution to their categorical residents. The national sample consisted of 1,515 PGY 1 to 5 trainees. RESULTS: Response rate was 45%. More than 90% of residents had an appropriate understanding of the components of ACS as generally described (trauma, surgical critical care, and emergency GS). Nearly half (46%) of all respondents have considered ACS as a career. Overall, ACS ranked as the second most appealing career ahead of surgical critical care and trauma but behind GS. Most residents believed that ACS offers better or equivalent case complexity (88%), scope of practice (84%), case volume (75%), and level of reimbursement (69%) compared with GS alone. Respondents who answered ACS had a better scope of practice (61% vs. 36%), lifestyle as an attending surgeon (77% vs. 34%), or level of reimbursement (83% vs. 38%) compared with GS were twice as likely (p < 0.0001) to have considered ACS as a career. Overall, 40% of the residents believed that ACS offers a worse lifestyle in comparison with GS. CONCLUSION: These results suggest that there is notable interest in the emerging specialty of ACS. The level of resident interest in ACS as a fellowship and career may be increased by marketing those aspects of practice, which are viewed positively and addressing negative perceptions related to lifestyle. It may be appealing to add an elective GS component to certain ACS practice options.

Modern management of penetrating tracheal injuries.

Complications after tracheal repair in the past have included wound infections, tracheal stenosis, "spitting" of sutures, and tracheoesophageal fistulas. Modern operative approaches have significantly decreased the incidence of these complications. We conducted retrospective data collection using the TRACS database. Changes that preceded the time interval of the study included the following: 1) an emphasis on clinical (rather than endoscopic) recognition of injury; 2) minimal peritracheal dissection and repair with absorbable sutures; 3) limited use of "protective" tracheostomies; and 4) use of muscle buttresses to cover tracheal repairs, especially in patients with combined injuries. From 1997 to 2010, 22 patients were treated for wounds to the trachea (cervical 20, thoracic 2). The mechanism of injury was a gunshot wound in 15 patients and a stab wound in seven. A clinical diagnosis of the need for cervical operation or of a tracheal injury was made in 19 patients (86%), whereas three patients had positive diagnostic studies. Direct tracheal repair (No. 19) or evaluation of a superficial injury (No. 1) was performed in 20 patients, and three (15%) had a tracheostomy performed. Combined injuries were present in 12 patients (55%), most commonly to the esophagus (10 of 12 [83%]), and 10 of these 12 patients had vascularized buttresses applied to the tracheal repair. There were seven significant complications in patients with combined injuries to the esophagus or carotid artery. One patient (4.5%) died. Patients with penetrating tracheal injuries most commonly present with overt findings. Modern techniques of repair have eliminated many of the complications noted in the past.

Outcomes after massive transfusion in nontrauma patients in the era of damage control resuscitation.

There are little data regarding the use of massive transfusion protocols (MTP) outside of the trauma setting. This study compares the use of an MTP between trauma and non-trauma (NT) patients. Data were collected for trauma and NT patients from the prospectively maintained MTP database at a Level I trauma center over a 4-year period. Massive transfusion was defined as ≥ 10 units packed red blood cells (PRBCs) in a 24-hour period. Of 439 MTP activations, 37 (8%) were NT patients (64% male; mean age = 51 years, initial base deficit = -10.8). Activations were for gastrointestinal bleeding (n = 18), bleeding during surgery (n = 13), obstetrical complications (n = 5), and ruptured aortic aneurysm (n = 1). Over-activation of MTP (<10 units PRBCs/24 hours) was higher in NT than trauma patients (19/37, 51% vs 118/284, 29%, P < 0.01). For massive transfusion patients, 24-hour mortality was higher in NT compared with trauma patients (10/17, 59% vs 100/284, 35%, P = 0.05), but there was no difference in 30-day mortality (10/17, 59% vs 144/284, 51%, P = 0.51). With over-activation in 51% of NT patients, MTP usage outside of trauma is inefficient. Outcomes in NT patients were worse than trauma patients, which may be related to the underlying disease processes.

Base deficit as a marker of survival after traumatic injury: consistent across changing patient populations and resuscitation paradigms.

BACKGROUND: Damage control resuscitation (DCR) has improved outcomes in severely injured patients. In civilian centers, massive transfusion protocols (MTPs) represent the most formal application of DCR principles, ensuring early, accurate delivery of high fixed ratios of blood components. Recent data suggest that DCR may also help address early trauma-induced coagulopathy. Finally, base deficit (BD) is a long-recognized and simple early prognostic marker of survival after injury. METHODS: Outcomes of patients with admission BD data resuscitated during the DCR era (2007-2010) were compared with previously published data (1995-2003) of patients cared for before the DCR era (pre-DCR). Patients were considered to have no hypoperfusion (BD, >-6), mild (BD, -6 to -14.9), moderate (BD, -15 to -23.9), or severe hypoperfusion (BD, <-24). RESULTS: Of 6,767 patients, 4,561 were treated in the pre-DCR era and 2,206 in the DCR era. Of the latter, 218 (9.8%) represented activations of the MTP. DCR patients tended to be slightly older, more likely victims of penetrating trauma, and slightly more severely injured as measured by trauma scores and BD. Despite these differences, overall survival was unchanged in the two eras (86.4% vs. 85.7%, p = 0.67), and survival curves stratified by mechanism of injury were nearly identical. Patients with severe BD who were resuscitated using the MTP, however, experienced a substantial increase in survival compared with pre-DCR counterparts. CONCLUSION: Despite limited adoption of formal DCR, overall survival after injury, stratified by BD, is identical in the modern era. Patients with severely deranged physiology, however, experience better outcomes. BD remains a consistent predictor of mortality after traumatic injury. Predicted survival depends more on the energy level of the injury (stab wound vs. nonstab wound) than the mechanism of injury (blunt vs. penetrating).

Uncrossmatched blood transfusions for trauma patients in the emergency department: incidence, outcomes and recommendations.

BACKGROUND: Early transfusion of blood products for severely injured patients can improve volume depletion, acidosis, dilution and coagulopathy. There is concern that some patients are unnecessarily exposed to the risks of emergent transfusion with uncrossmatched red blood cell products (URBC) in the emergency department (ED). The goal of this study was to evaluate the transfusion practices in our ED among all patients who received URBC. METHODS: We analyzed all injured patients transfused at least 1 URBC in the ED at a level-1 trauma centre between Jan. 15, 2007, and Jan. 14, 2008. Demographics, injuries and outcomes were reported. We used standard statistical methodology. RESULTS: At least 1 URBC product was transfused into 153 patients (5% of all patients, mean 2.6 products) in the ED (median Injury Severity Score [ISS] 28; hemodynamic instability 94%). Sixty-four percent of patients proceeded to an emergent operation and 17% required massive transfusion. The overall mortality rate was 45%, which increased to 52% and 100% in patients who received 4 and 5 or more URBC products, respectively. Nonsurvivors had a higher median ISS (p=0.017), received more URBC in the ED (p=0.006) and possessed more major vascular injuries (p<0.001). Among nonsurvivors, 67% died of uncontrollable hemorrhage. Unnecessary URBC transfusions in the ED occurred in 7% of patients. CONCLUSION: Overtransfusion was minimal based on clinical acumen triggers. Early transfer of patients receiving URBC products in the ED to the operating room, intensive care unit or angiography suite for ongoing resuscitation and definitive hemorrhage control must be strongly considered.