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.

The Impact of Relocating a Trauma Center: Observations on Patient Injury Demographics and Resident Volumes.

Introduction Changing the physical zip code location of an academic trauma center may affect the distribution and surgical volume of its trauma patients. General surgical residency case log requirements may also be affected. This study describes the impact of moving a level I trauma center to a different zip code location, on the hospital and resident trauma case volumes. Methods This retrospective analysis included all patients within the local trauma registry across two fiscal years representing the pre- and post-move timeframes. Variables collected included patient basic sociodemographic and injury information, trauma activation level and transfer status, management (operative management [OPM] versus non-operative management [NOPM]), and resident case logs. Results During fiscal years 2016-2017 and 2017-2018, 3,025 patients were included. Pre-move and post-move trauma volumes were 1,208 and 1,817 respectively. Post-move changes demonstrated differences in basic sociodemographics, with differences in age (six years older), a shift toward white and away from black (12.89%), and males being seen more frequently (11.87%). Injury severity score distribution shifted (7.72%) towards less severe trauma scores (<15), the percentage of patients with blunt trauma (4.19%) and falls increased (ground level and greater than 1 meter, 9.78%) while the number of patients considered full activations were decreased (15.67%). Proportions of OPM and NOPM trauma cases remained unchanged with the exception of a reduction in emergent operative trauma (3.1%). Resident case logs requirements were met both pre- and post-move. Conclusion Relocating the trauma center to a different zip code location did not negatively impact our resident case volumes. Total trauma volumes were increased, with a shift in the demographics and severity distribution of injuries.

Defining a specialty through its literature: A bibliometric analysis of acute care surgery 2005 to 2020.

Background: Acute care surgery (ACS) has grown and evolved since it was conceived in 2005. However, ACS is not recognized in the National Library of Medicine's Medical Subject Heading thesaurus. This article uses bibliometrics to help define an identity for ACS as a subspecialty of surgery and argue for its addition to the Medical Subject Heading thesaurus. Methods: The terms "Acute Care Surgery," "Wounds and Injuries," "General Surgery," and "Critical Care" were searched with and without the Text Word [TW] modifier using PubMed. The intersections of search sets were identified with the AND conjunction to determine the proportion of ACS literature relevant to each subject term and calculate the penetration of ACS as a keyword term into each subject domain. Results: A [Medical Subject Heading] limited search on the term "Acute Care Surgery" yielded a predictable return of 0 article. Search of the cohesive term "Acute Care Surgery" [All Fields], restricted to MEDLINE-indexed, English-language articles yielded 2,351 articles published between 2005 and 2020, inclusive. Using ACS as [Text Word] yielded 517 articles. There was a progressive increase in the rate of annual publications. The frequency of subject terms in the ACS [All Fields] set was as follows: Critical Care, 49.70%; General Surgery, 23.26%; and Wounds and Injuries, 20.88%. The frequency of subject terms in the ACS [TW] set was as follows: Critical Care, 32.88%; General Surgery, 43.52%; and Wounds and Injuries, 15.28%. Of this set, 8.32% of articles were not tagged or did not contain a reference to any of these 3 major subjects. Conclusion: This study demonstrates that ACS as a subject matter is being increasingly expressed in the literature. Adding ACS as a dedicated term into the National Library of Medicine's Medical Subject Heading thesaurus of controlled vocabulary as a specialty of Surgery would facilitate indexing and retrieval of the literature most relevant to acute care surgeons.

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.

Clinical Characteristics Associated With Higher Enoxaparin Dosing Requirements for Venous Thromboembolism Prophylaxis in Trauma Patients.

INTRODUCTION: Enoxaparin dosed by an anti-Xa trough level is effective at reducing venous thromboembolism (VTE) in trauma patients. We identified the patient characteristics associated with higher enoxaparin dosing based on anti-Xa trough levels. METHODS: A retrospective review was conducted on trauma patients admitted between August 2014 and February 2018 who received enoxaparin dosed by the anti-Xa trough level. Patients who received enoxaparin < 50 mg every 12 hours were compared to those who required ≥ 50 mg every 12 hours. RESULTS: Of the 246 patients included, 32 (13.0%) required enoxaparin ≥ 50 mg every 12 hours to achieve the prophylactic trough level. Factors associated with a higher dose of enoxaparin were male (96.8% vs. 3.2%, P < .01), younger age (39.5 vs. 52.7 years, P < .01), higher creatinine clearance (CrCl) (125.9 vs. 93.7 mL/min, P < .01), higher body surface area (2 m2 vs. 1.8 m2, P < .01), and higher injury severity score (18.4 vs. 10.8, P < .01). Height, weight, and body mass index were not significant factors. On regression analysis, CrCl was the only independent predictor for higher enoxaparin dose. There was an increased deep venous thrombosis rate in the higher dose cohort (12.5% vs. 0, P < .01) but no significant differences in transfusion rates. CONCLUSION: Trauma patients who require higher enoxaparin doses to achieve prophylactic anti-Xa trough levels have a higher CrCl. Patients with high CrCl may benefit from an initial higher dose of enoxaparin to achieve a target anti-Xa level in a shorter time interval to decrease VTE risk.

Which Trauma Patients Require Lower Enoxaparin Dosing for Venous Thromboembolism Prophylaxis?

Trauma patients have a high risk for venous thromboembolism (VTE) such that an increased enoxaparin dose is necessary to reduce related complications. Given that most trauma patients require an enoxaparin dose of at least 40 mg every 12 hours for VTE prophylaxis, we sought to identify which patients require enoxaparin 30 mg every 12 hours and hypothesized that both weight and low creatinine clearance (CrCl) would more likely determine enoxaparin dosing than age, body mass index (BMI), or body surface area (BSA). Single institution data were collected on trauma patients between August 2014 and February 2018 to compare trauma patients who required enoxaparin 30 mg to those who required ≥40 mg every 12 hours. Of the 245 patients included, 86 (35.1%) required enoxaparin at 30 mg to achieve the goal anti-factor Xa trough level. Factors associated with low dose enoxaparin were older age (59.6 vs. 46.2 years, P ≤ .01) and lower CrCl (81.5 mL/min vs. 93.7 mL/min, P ≤ .01). Weight, BSA, and BMI did not alter the dose of enoxaparin. A regression model determined that only CrCl predicted the need for low dose enoxaparin (adjusted odds ratio .982, 95% CI: .975-.990, P < .01). Although an initial dose of enoxaparin 40 mg is appropriate for most trauma patients, patients with low CrCl should receive 30 mg. Increased age and low weight were not associated with the need for a lower enoxaparin dose.