Management of complex pediatric and adolescent liver trauma: adult vs pediatric level 1 trauma centers.

PURPOSE: Management of high-grade pediatric and adolescent liver trauma can be complex. Studies suggest that variation exists at adult (ATC) vs pediatric trauma centers (PTC); however, there is limited granular comparative data. We sought to describe and compare the management and outcomes of complex pediatric and adolescent liver trauma between a level 1 ATC and two PTCs in a large metropolitan city. METHODS: A retrospective review of pediatric and adolescent (age < 21 years) patients with American Association for the Surgery of Trauma (AAST) Grade 4 and 5 liver injuries managed at an ATC and PTCs between 2016 and 2022 was performed. Demographic, clinical, and outcome data were obtained at the ATC and PTCs. Primary outcomes included rates of operative management and use of interventional radiology (IR). Secondary outcomes included packed red blood cell (pRBC) utilization, intensive care unit (ICU) length of stay (LOS), and hospital LOS. RESULTS: One hundred forty-four patients were identified, seventy-five at the ATC and sixty-nine at the PTC. The cohort was predominantly black (65.5%) males (63.5%). Six injuries (8.7%) at the PTC and forty-five (60%) injuries at the ATC were penetrating trauma. Comparing only blunt trauma, ATC patients had higher Injury Severity Score (median 37 vs 26) and ages (20 years vs 9 years). ATC patients were more likely to undergo operative management (26.7% vs 11.0%, p = 0.016) and utilized IR more (51.9% vs 4.8%, p < 0.001) compared to the PTC. The patients managed at the ATC required higher rates of pRBC transfusions though not statistically significant (p = 0.06). There were no differences in mortality, ICU, or hospital LOS. CONCLUSION: Our retrospective review of high-grade pediatric and adolescent liver trauma demonstrated higher rates of IR and operating room use at the ATC compared to the PTC in the setting of higher Injury Severity Score and age. While the PTC successfully managed > 95% of Grade 4/5 liver injuries non-operatively, prospective data are needed to determine the optimal algorithm for management in the older adolescent population. LEVEL OF EVIDENCE: Level IV.

Cervical Spine Computed Tomography in Adolescent Blunt Trauma Patients: Are They Being Overutilized?

INTRODUCTION: Cervical spine computed tomography (CSCT) scans are used to evaluate cervical spine traumatic injuries; however, recent evidence demonstrates that adult trauma centers (ATCs) overutilize CSCT when evaluating adolescent patients. This leads to unnecessary radiation exposure. The aim of this study is to review a level 1 ATC's use of CSCT in the adolescent blunt trauma population. METHODS: A retrospective chart review was conducted of a level 1 ATC's trauma database. Blunt trauma patients between the ages of 11 and 18 who receive a CSCT between January 2015 to December 2019 were included. The primary outcome was the prevalence of positive findings on CSCT scans. Data were analyzed using Fischer-Exact analysis and multivariate logistic regression where appropriate. RESULTS: Three-hundred thirty-seven of 546 (61.7%) adolescent blunt trauma patients received CSCT. Of those, 68.2% (230) were male; the mean age was 16.6 ± 1.0 y old. Twenty-eight patients (8.3%) had a positive finding on CSCT. All patients with a positive CSCT failed the National Emergency X-Radiography Utilization study (NEXUS) criteria while 123 patients (36.5%) with a negative CSCT met NEXUS criteria. CONCLUSIONS: CSCT was overutilized in our trauma center. There is a low positive CSCT scan rate among adolescent patients, which aligns with the current literature. All patients with positive CSCT passed NEXUS criteria suggesting that a quality improvement project focusing on the use of the NEXUS criteria to assess the risk of cervical spine injury could potentially reduce the use of CSCT scans by nearly 40%.

The role of diagnostic laparoscopy for trauma at a high-volume level one center.

BACKGROUND: The role of minimally invasive surgery in trauma has continued to evolve over the past 20 years. Diagnostic laparoscopy (DL) has become increasingly utilized for the diagnosis and management of both blunt and penetrating injuries. OBJECTIVE: While the safety and feasibility of laparoscopy has been established for penetrating thoracoabdominal trauma, it remains a controversial tool for other injury patterns due to the concern for complications and missed injuries. We sought to examine the role of laparoscopy for the initial management of traumatic injuries at our urban Level 1 trauma center. METHODS: All trauma patients who underwent DL for blunt or penetrating trauma between 2009 and 2018 were retrospectively reviewed. Demographic data, indications for DL, injuries identified, rate of conversion to open surgery, and outcomes were evaluated. RESULTS: A total of 316 patients were included in the cohort. The mean age was 34.9 years old (± 13.7), mean GCS 14 (± 3), and median ISS 10 (4-18). A total of 110/316 patients (35%) sustained blunt injury and 206/316 patients (65%) sustained penetrating injury. Indications for DL included evaluation for peritoneal violation (152/316, 48%), free fluid without evidence of solid organ injury (52/316, 16%), evaluation of bowel injury (42/316, 13%), and evaluation for diaphragmatic injury (35/316, 11%). Of all DLs, 178/316 (56%) were negative for injury requiring intervention, which was 58% of blunt cases and 55% of penetrating cases. There were no missed injuries noted. Average hospital length of stay was significantly shorter for patients that underwent DL vs conversion to open exploration (2.2 days vs. 4.5 days, p < 0.05). CONCLUSION: In this single institution, retrospective study, the high volume of cases appears to show that DL is a reliable tool for detecting injury and avoiding potential negative or non-therapeutic laparotomies. However, when injuries were present, the high rate of conversion to open exploration suggests that its utility for therapeutic intervention warrants further study.

Trametinib prevents mesothelial-mesenchymal transition and ameliorates abdominal adhesion formation.

BACKGROUND: Intra-abdominal adhesions are a major cause of morbidity after abdominal or gynecologic surgery. However, knowledge about the pathogenic mechanism(s) is limited, and there are no effective treatments. Here, we investigated a mouse model of bowel adhesion formation and the effect(s) of an Federal Drug Administration-approved drug (trametinib) in preventing adhesion formation. MATERIALS AND METHODS: C57BL/6 mice were used to develop a consistent model of intra-abdominal adhesion formation by gentle cecal abrasion with mortality rates of <10%. Adhesion formation was analyzed histologically and immunochemically to characterize the expression of pro-fibrotic marker proteins seen in pathologic scaring and included alpha smooth muscle actin (αSMA) and fibronectin EDA (FNEDA) which arises from alternative splicing of the fibronectin messenger RNA resulting in different protein isoforms. Trichrome staining assessed collagen deposition. Quantitative polymerase chain reaction analysis of RNA isolated from adhesions by laser capture microscopy was carried out to assess pro-fibrotic gene expression. To block adhesion formation, trametinib was administered via a subcutaneous osmotic pump. RESULTS: Adhesions were seen as early as post-operative day 1 with extensive adhesions being formed and vascularized by day 5. The expression of the FNEDA isoform occurred first with subsequent expression of αSMA and collagen. The drug trametinib was chosen for in vivo studies because it effectively blocked the mesothelial to mesenchymal transition of rat mesothelium. Trametinib, at the highest dose used (3 mg/kg/d), prevented adhesion formation while at lower doses, adhesions were usually limited, as evidenced by the presence of FNEDA isoform but not αSMA. CONCLUSIONS: Cecal abrasion in mice is a reliable model to study abdominal adhesions, which can be ameliorated using the MEK1/2 inhibitor trametinib. While blocking adhesion formation at the cell and molecular levels, trametinib, at the therapeutic doses utilized, did not impair the wound healing at the laparotomy site.

Atypical Mycotic Aortic Aneurysms.

Mycotic aortic aneurysms are rare occurrences and such aneurysms associated with Streptococcus pneumoniae are seldom seen in the current antibiotic era. We present the unusual case of a 68-year-old healthy female with a Streptococcal mycotic abdominal aortic aneurysm of unknown etiology treated with antibiotics and open surgical intervention. Postoperative imaging revealed multiple new thoracic mycotic aortic aneurysms for which she was treated with thoracic endovascular aortic repair. Sequential abdominal and thoracic Streptococcal mycotic aortic aneurysms treated with a combination of open and endovascular surgery demonstrate a unique and rare case.

Understanding Chest CT Scan Usage Among Adolescent Blunt Trauma Patients at Adult Trauma Centers.

PURPOSE: The utility of chest computed tomography (CCT) is not well established in the diagnostic algorithm of adolescent blunt trauma patients. Our study's aim was to review CCT usage in the initial evaluation of adolescent blunt trauma. METHODS: We retrospectively reviewed adolescent blunt trauma patients treated at our urban level 1 adult trauma center from 2015 to 2019. Our primary outcome was the rate of positive CCT findings. Univariate and multivariate logistic regression analyses were performed. RESULTS: There were 288 patients that met our inclusion criteria and 153 positive CCT and 135 negative CCT. There was no statistically significant difference between both groups in terms of age, gender, and race. Those with a positive CCT were found to have a statistically significant higher ISS than the negative CCT group (20.6 ± 12.3 vs 12.3 ± 7.6; P < .01). Those with a positive CCT were more likely to have a GCS <15 (40% vs 25%), have a positive CXR (38% vs 2%), have chest pain (16% vs 7%), and have an abnormal chest exam (27% vs 7%) than those with a negative CCT (P < .01). On multivariate analysis, positive CXR (P < .05, OR = 13.96) and ISS (P < .05, OR = 3.10) were independently associated with a positive CCT. CONCLUSION: While CCT may provide valuable information, clinical exam coupled with low-ionizing radiographic imaging (i.e., CXR) may sufficiently identify chest trauma after blunt mechanisms. This shift in management can potentially reduce the risk of radiation without compromising the care of adolescent trauma patients at adult trauma centers.

Understanding abdominal pelvic computerized tomography scan usage amongst adolescent blunt trauma patients treated at adult trauma centers.

INTRODUCTION: The algorithm for evaluating adolescent patients with blunt trauma includes abdominal pelvic CT (APCT). The aim of this study is to evaluate the utility of APCT in this context. METHODS: We performed a retrospective review of adolescent (11 to 18 years of age) blunt trauma patients at an urban adult level 1 trauma center from January 2015 to December 2019. The primary outcome was the prevalence of positive findings on APCT scan.  Additionally, clinical risk factors concerning for intra-abdominal injury were analyzed. RESULTS: There were 546 patients evaluated for blunt trauma and the prevalence of APCT within the population was 59.3% (95% CI 54.2%-64.9%). Of the patients who received APCT, 123 (37.9%) had positive findings on APCT. Only 25 patients (7.7% of those who underwent APCT) required abdominal surgery while 40 patients (12.3%) had intraabdominal injury that did not require surgery. Risk factors were present in 100% of patients with intraabdominal injury and absent in 28.7% of patients without intraabdominal injury. Abnormal abdominal exam, abnormal FAST, positive chest x-ray and elevated transaminases were independently associated with intraabdominal injury. CONCLUSIONS: Our study found that adolescent blunt trauma patients treated at our trauma center had a higher rate of APCT usage, but a comparable rate of positive findings when compared with the most recent literature. Future studies should focus on reducing the number of patients who undergo APCT despite an absence of clinical risk factors.

Understanding Head CT Scan Usage Amongst Adolescent Blunt Trauma Patients Treated at a Level 1 Adult Trauma Center.

BACKGROUND: Guidelines developed by the Pediatric Emergency Care Applied Research Network (PECARN) exist to reserve the use of head CT for pediatric patients with a high risk of head injury. However, CTs are still being overutilized especially at adult trauma centers. The aim of our study was to review our use of head CTs in adolescent blunt trauma patients. MATERIALS AND METHODS: Patients aged 11-18 who underwent head CT scans from 2016 to 2019 at our urban level 1 adult trauma center were included. Data was collected via electronic medical record and analyzed through retrospective chart review. RESULTS: Of the 285 patients requiring a head CT, 205 had a negative head CT (NHCT) and 80 patients had a positive head CT (PHCT). There was no difference in age, gender, race, and trauma mechanism between the groups. The PHCT group was found to be with a statistically significant higher likelihood of the Glasgow Coma Scale (GCS) < 15 (65% vs 23%; P < .01), abnormal head exam (70% vs 25%; P < .01), and loss of consciousness (85% vs 54%; P < .01) compared to the NHCT group. There were 44 patients who had low risk of head injury, based on the PECARN guidelines, and received a head CT. None of the patients had a positive head CT. CONCLUSION: Our study suggests that reinforcement of the PECARN guidelines should occur for ordering head CTs in adolescent blunt trauma patients. Future prospective studies are needed to validate the use of PECARN head CT guidelines in this patient population.

Missing Bullets: Bullet Embolization Case Series and Review of the Literature.

PURPOSE: Bullet embolization is a rare but dangerous phenomenon. Based on the location of embolization, migration of bullets can cause limb or intra-abdominal ischemia, pulmonary infarction, cardiac valve injury, or cerebrovascular accident. Bullet emboli can present a diagnostic challenge given the varied nature of complications based on location of embolization, which may not coincide with the site of initial injury. The purpose of this study is to present several cases of bullet embolization from our busy urban trauma center and make recommendations for management. METHODS: We present 3 cases of bullet embolization seen in injured patients at our Level 1 trauma center. We describe our management of these injuries and make recommendations for management in the context of our institutional experience and comment on the available literature regarding bullet embolization. RESULTS: Two of our patients presented in extremis and required operative intervention to achieve stability. The intravascular missile was discovered intraoperatively in one patient and removed in the operating room, while the missile was discovered on postoperative imaging in another patient and again removed operatively after an unsuccessful attempt at minimally invasive retrieval. Our third patient remained hemodynamically stable throughout his hospitalization and had endovascular management of his bullet embolus. CONCLUSION: Bullet emboli present a challenging complication of penetrating trauma. We recommend removal of all arterial bullet emboli and those within the pulmonary venous system. In hemodynamically stable patients, we recommend initial attempts of endovascular retrieval followed by open surgical removal. We recommend open removal in cases of hemodynamic instability.

Hepatic Arterioportal Fistula Following Liver Trauma: Case Series and Review of the Literature.

PURPOSE: Hepatic arterioportal fistula (HAPF) is an uncommon complication of hepatic trauma, which can manifest with abdominal pain and the sequelae of portal hypertension months to years after injury. The purpose of this study is to present cases of HAPF from our busy urban trauma center and make recommendations for management. METHODS: One hundred and twenty-seven patients with high-grade penetrating liver injuries (American Association for the Surgery of Trauma [AAST] - Grades IV-V) between January 2019 and October 2022 were retrospectively reviewed. Five patients were identified with an acute hepatic arterioportal fistula following abdominal trauma from our ACS-verified adult Level 1 trauma center. Institutional experience with overall surgical management is described and reviewed with the current literature. RESULTS: Four of our patients presented in hemorrhagic shock requiring emergent operative intervention. The first patient had postoperative angiography and coil embolization of the HAPF. Patients 2 through 4 underwent damage control laparotomy with temporary abdominal closure followed by postoperative transarterial embolization with gelatin sponge particles (Gelfoam) or combined Gelfoam/n-butyl cyanoacrylate. The final patient went directly for angiography and Gelfoam embolization after identification of the HAPF. All 5 patients had resolution of HAPF on follow-up imaging with continued post management for traumatic injuries. CONCLUSION: Hepatic arterioportal fistula can present as a complication of hepatic injury and manifest with significant hemodynamic aberrations. Although surgical intervention was required to achieve hemorrhage control in almost all cases, management of HAPF in the setting of high-grade liver injuries was achieved successfully with modern endovascular techniques. A multidisciplinary approach to such injuries is necessary to optimize care in the acute setting following traumatic injury.

Cultural and Linguistic Adaptations of Stop the Bleed in Multi-Ethnic Refugee Communities.

INTRODUCTION: Stop the Bleed (STB), and other trainings that promote health education in basic trauma management techniques, is offered mostly in English and Spanish in the United States. Limited access to injury prevention training may contribute to inequities in health outcomes for individuals with limited English proficiency (LEP). Our study aims to determine the feasibility and effectiveness of STB training in 4 languages spoken in a super diverse refugee settlement community, Clarkston, GA. METHODS: Written STB educational materials were culturally adapted, translated, and back translated into 4 languages: Arabic, Burmese, Somali, and Swahili. Four 90-minute in-person STB trainings were conducted by medical personnel with community-based interpreters at a central and familiar location in the Clarkston community. Pre- and post-tests were administered in participant's preferred language to evaluate change in knowledge and beliefs as well as the effectiveness of the training method. RESULTS: A total of 46 community members were trained in STB, the majority of which were women (63%). Participants demonstrated improvement in their knowledge, confidence, and comfort using STB techniques. Participants reported that 2 aspects of the training were particularly beneficial: the presence of language concordant interpreters from the community and small group hands on sessions that allowed for practicing STB techniques. CONCLUSION: Cultural and linguistic adaptation of STB training is a feasible, cost-effective, and effective method for disseminating life-saving information and trauma education to immigrant populations who have LEP. Expansion of community training and partnerships to support the needs of diverse communities is both necessary and urgent.

Trends in Adolescent Firearm-Related Injury: A Time Series Analysis.

BACKGROUND: Firearm-related injury (FRI) became the leading cause of death among children/adolescents in 2019. PURPOSE: This study sought to determine changes over time in the population of adolescents affected by FRI in Atlanta, Georgia, such that high risk cohorts could be identified. RESEARCH DESIGN: City-wide retrospective cohort review. STUDY SAMPLE: Adolescent victims (age 11-21 years of age) of FRI, defined by ICD9/10 codes, in Atlanta, Georgia. DATA ANALYSIS: Descriptive, multivariate and time series analysis. RESULTS: There were 1,453 adolescent FRI victims in this time period, predominantly Black (86%) and male (86.6%). Unintentional injury was higher among ages 11-14 years (43.1%) compared to 15-17 years (10.2%) and 18-21 years (9.3%) (P < .01). FRI affecting females increased at a rate of 8.1 injuries/year (P < .01), and unintentional injuries increased at by 7.6/year (P < .01). Mortality declined from 16% in 2016 to 7.7% in 2021. CONCLUSION: Our data provides evidence for firearm policy reform. Interventions should target prevention of intentional injury among AQ4 females and seek to reverse the trend in unintentional injuries.

Optimizing Transitions of Care and Enhancing Surgical Education on Acute Care Surgery: A Multi-Institutional Survey Study.

OBJECTIVE: Critically ill and injured patients are routinely managed on the Trauma and Acute Care Surgery (ACS) service and receive care from numerous residents during hospital admission. The Clinical Learning Environment Review (CLER) program established by the ACGME identified variability in resident transitions of care (TC) while observing quality care and patient safety concerns. The aim of our multi-institutional study was to review surgical trainees' impressions of a specialty-specific handoff format in order to optimize patient care and enhance surgical education on the ACS service. DESIGN: A survey study was conducted with a voluntary electronic 20-item questionnaire that utilized a 5 point Likert scale regarding TC among resident peers, supervised handoffs by trauma attendings, and surgical education. It also allowed for open-ended responses regarding perceived advantages and disadvantages of handoffs. SETTING: Ten American College of Surgeons-verified Level 1 adult trauma centers. PARTICIPANTS: All general surgery residents and trauma/acute/surgical critical care fellows were surveyed. RESULTS: The study task was completed by 147 postgraduate trainees (125 residents, 14 ACS fellows, and 8 surgical critical care fellows) with a response rate of 61%. Institutional responses included: university hospital (67%), community hospital-university affiliate (16%), and private hospital-university affiliate (17%). A majority of respondents were satisfied with morning TC (62.6%) while approximately half were satisfied with evening TC (52.4%). Respondees believe supervised handoffs improved TC and prevented patient care delays (80.9% and 74.8%, respectively). A total of 35% of trainees utilized the open-ended response field to highlight specific best practices of their home institutions. CONCLUSIONS: Surgical trainees view ACS morning handoff as an effective standard to provide the highest level of clinical care and an opportunity to enhance surgical knowledge. As TC continue to be a focus of certifying bodies, identifying best practices and opportunities for improvement are critical to optimizing quality patient care and surgical education.

Increases in adolescent firearm injuries were associated with school closures during COVID-19.

BACKGROUND: Mitigation measures, including school closures, were enacted to protect the public during the COVID-19 pandemic. However, the negative effects of mitigation measures are not fully known. Adolescents are uniquely vulnerable to policy changes since many depend on schools for physical, mental, and/or nutritional support.  This study explores the statistical relationships between school closures and adolescent firearm injuries (AFI) during the pandemic. METHODS: Data were drawn from a collaborative registry of 4 trauma centers in Atlanta, GA (2 adult and 2 pediatric). Firearm injuries affecting adolescents aged 11-21 years from 1/1/2016 to 6/30/2021 were evaluated. Local economic and COVID data were obtained from the Bureau of Labor Statistics and the Georgia Department of Health. Linear models of AFI were created based on COVID cases, school closure, unemployment, and wage changes. RESULTS: There were 1,330 AFI at Atlanta trauma centers during the study period, 1,130 of whom resided in the 10 metro counties. A significant spike in injuries was observed during Spring 2020. A season-adjusted time series of AFI was found to be non- stationary (p = 0.60). After adjustment for unemployment, seasonal variation, wage changes, county baseline injury rate, and county-level COVID incidence, each additional day of unplanned school closure in Atlanta was associated with 0.69 (95% CI 0.34- 1.04, p < 0.001) additional AFIs across the city. CONCLUSION: AFI increased during the COVID pandemic. This rise in violence is statistically attributable in part to school closures after adjustment for COVID cases, unemployment, and seasonal variation. These findings reinforce the need to consider the direct implications on public health and adolescent safety when implementing public policy.

Vaccination after spleen embolization: A practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Angioembolization is an important adjunct in the non-operative management of adult trauma patients with splenic injury. Multiple studies have shown that angioembolization may increase the non-operative splenic salvage rate for patients with high-grade splenic injuries. We performed a systematic review and developed evidence-based recommendations regarding the need for post-splenectomy vaccinations after splenic embolization in trauma patients. METHODS: A systematic review and meta-analysis of currently available evidence were performed utilizing the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. RESULTS: Nine studies were identified and analyzed. A total of 240 embolization patients were compared to 443 control patients who neither underwent splenectomy nor were embolized. There was no statistical difference between the splenic immune function of embolized and control patients. In addition, a total of 3974 splenectomy patients was compared with 686 embolization patients. Embolization patients had fewer infectious complications and a greater degree of preserved splenic immune function. CONCLUSION: In adult trauma patients who have undergone splenic angioembolization, we conditionally recommend against routine post-splenectomy vaccinations. STUDY TYPE: systematic review/meta-analysis Level of evidence: level III.

Second Victim Syndrome in Trauma Practitioners and Other Ancillary Staff.

In health care, second victims are traumatized clinicians involved in unanticipated or untoward patient events. Programs that address second victim syndrome are sparse and its diagnosis often goes unrecognized. Consistently, literature has identified gaps in support resources, leading to compromised patient care and provider health. This project evaluates the need for second victim resources in trauma care providers at a tertiary public level 1 trauma hospital by electronically implementing a validated second victim survey over 5 weeks. Our results illustrate that second victim syndrome is prevalent among 57.1% of trauma care providers, of which 22.9% agree that second victim syndrome results in some form of undesirable work intentions.

Comparative effectiveness of pelvic arterial embolization versus laparotomy in adults with pelvic injuries: A National Trauma Data Bank analysis.

PURPOSE: To compare the clinical outcomes and trends of arterial embolization (AE) versus laparotomy which are used in the management of pelvic trauma. MATERIALS AND METHODS: Adult patients with pelvic injuries were identified using the National Trauma Data Bank (NTDB) from 2007 to 2015. Patients with non-pelvic life-threatening injuries were excluded. Patients were grouped in operatively managed pelvic ring injuries, laparotomy ± fixation, AE ± fixation, and laparotomy and AE ± fixation. Using a linear mixed regression and logistic regression models, hospital length of stay (LOS), ICU days, ventilator days, and mortality for different therapies were compared. A propensity score weighting method was used to further eliminate treatment selection bias in the study sample and compare the outcomes between AE and laparotomy. RESULTS: Of 7473 pelvic trauma patients, 1226 (16.4%) patients were only operatively managed. 3730 patients (49.9%) underwent laparotomy, 2136 underwent AE (28.6%), and 381 (5.1%) patients underwent both laparotomy and AE. The year of injury, patient age, gender, race, severity of injury and presence of shock were found to be predictors of receipt of different therapies (P < 0.001 for all). When correcting for these confounding factors, the mortality rate was lower in the AE group compared to the laparotomy group 6.6% vs. 20.6% (P < 0.001). Additionally, LOS and ICU days were shorter for the AE group than the laparotomy group (P < 0.001). CONCLUSION: AE in patients with pelvic injuries is associated with lower mortality, as well as shorter LOS and ICU stays compared to laparotomy.

Superior Mesenteric Artery and Vein Injuries: Operative Strategies and Outcomes.

Traumatic injuries to the mesenteric vessels are rare and often lethal. Visceral vessels, such as the superior mesenteric artery (SMA) and vein (SMV), supply blood to the small and large bowel by a rich system of collaterals. Because fewer than 100 such injuries have been described in the literature, they pose challenges in both diagnosis and management and can unfortunately result in high mortality rates. Prompt diagnosis, surgical intervention, and resuscitation can lead to improved outcomes. Here, we review the literature surrounding traumatic injuries of the SMA/SMV and discuss management strategies.

Screening, Brief Intervention, and Referral to Treatment to Prevent Post-Traumatic Stress Disorder After Gunshot Wounds.

Screening, brief intervention, and referral to treatment (SBIRT) is an intervention originally developed to prevent and deter substance abuse. Adaptation of the SBIRT model to prevent post-traumatic stress disorder (PTSD) may potentially reduce acute stress symptoms after traumatic injury. We conducted a prospective randomized control study of adult patients admitted for gunshot wounds. Patients were randomized to intervention (INT) vs. treatment as usual (TAU) groups. INT received the newly developed SBIRT Intervention for Trauma Patients (SITP)-a 15-minute session with elements of cognitive behavioral therapy techniques. SITP took place during the index hospitalization; both groups had followup at 30 and 90 days at which time a validated PTSD screening tool, PCL-5, was administered. Most of the 46 participants were young (mean age = 30.5y), male (91.3%), and black (86.9%). At three-month follow-up, SBIRT and TAU patients had similar physical healing scores but the SBIRT arm showed reductions in PTSD symptoms.

Is Blush on CT Scan in Patients With Pelvic Fracture Associated With Embolization Rates and Outcomes?

INTRODUCTION: In trauma patients with pelvic fractures, computed tomography (CT) scans are a critical tool to evaluate life-threatening hemorrhage. Contrast extravasation, or "blush", on CT may be a sign of bleeding, prompting a consult for angiography and possible embolization. However, the utility of blush on CT is controversial. We sought to evaluate our experience with patients who sustained pelvic fractures and had blush on CT. METHOD: A retrospective review was performed for all patients with blunt pelvic fractures between January 1, 2017 and December 31, 2018. Demographic, clinical, radiographic, and injury data were obtained. Comparison of mortality, hospital length of stay (LOS), and intensive care unit (ICU) LOS was performed for 3 subgroups: angio versus no angio; embo versus no embo; prophylactic embo versus therapeutic embo. We also calculated the sensitivity, specify, positive predictive value (PPV), and negative predictive value (NPV) of CT blush to predict the need for embolization. RESULTS: 889 patients were found to have a blunt pelvic fracture. 51 patients had blush on CT scan. 29 (56.9%) underwent angiography. 17 (58.6%) of these 29 patients were found to have extravasation and were embolized. 12 patients had an angio with no extravasation, and 6 of these patients (50%) underwent prophylactic embolization. No significant difference was found for hospital LOS, ICU LOS, or mortality in our 3 groups. Sensitivity, specificity, PPV, and NPV for CT blush were 74%, 96%, 33%, 99%, respectively. CONCLUSION: Patients with active extravasation undergoing embolization had similar outcomes to patients without active extravasation. Blush on CT scan had low sensitivity and low PPV but high specificity and high NPV. Future studies need to include careful attention to the CT protocol utilized as well as patient selection.