Traumatic Thoracic Aortic Coarctation after Blunt Thoracic Aortic Injury Mandates Emergent Thoracic Endovascular Aortic Repair.

OBJECTIVE: This study sought to elucidate clinical and imaging findings predictive for malperfusion syndrome after blunt thoracic aortic injury (BTAI). BACKGROUND: There is limited literature on malperfusion syndrome after BTAI, and the timing of thoracic endovascular aortic repair (TEVAR) in patients with this condition has not been defined. METHODS: A retrospective analysis of prospectively collected data of patients with BTAI treated between January 2021 and October 2023. Clinical and thoracic aortic (TA) imaging data, time to TEVAR, in-hospital death, and malperfusion/reperfusion sequelae (paraplegia, renal/visceral/limb ischemia, and compartment syndromes) were assessed. Correlations between clinical and imaging findings, time to TEVAR, and outcomes were evaluated. RESULTS: Of the 19,203 trauma patients evaluated, 13,717 (71%) had blunt injuries and 77 (0.6%) had BTAI. The majority (67.5%) were male, with a median age of 40 years (IQR: 33-55). TEVAR was performed in 42 (54.5%) patients. Seven (9.1%) patients presented with clinical and TA imaging criteria for traumatic thoracic aortic coarctation (TTAC), including diminished/absent femoral pulses and TA luminal narrowing of 50% to 99%. The median time to TEVAR was 9 (IQR: 5-32), 11, and 4 hours for all non-TTAC and TTAC BTAI patients, respectively ( P =0.037). Only TTAC patients presented/developed malperfusion/reperfusion sequelae. In-hospital mortality rates were 7.8%, 5.8%, and 29% for all non-TTAC and TTAC BTAI patients, respectively ( P =0.09). Aortic-related mortality occurred in only 2 (2.6%) TTAC patients. CONCLUSIONS: Patients with clinical and TA imaging manifestations of TTAC are predisposed to malperfusion/reperfusion sequelae if TEVAR is delayed. We recommend the emergent repair of all BTAIs with TTAC.

Validation of Two Scoring Tools to Predict Risk of Augmented Renal Clearance in Trauma Patients.

INTRODUCTION: Augmented renal clearance (ARC) is prevalent in trauma populations. Identification is underrecognized by calculated creatinine clearance or estimated glomerular filtration rate equations. Predictive scores may assist with ARC identification. The goal of this study was to evaluate validity of the ARCTIC score and ARC Predictor to predict ARC in critically ill trauma patients. METHODS: This single center, retrospective study was performed at an academic level 1 trauma center. Critically ill adult trauma patients undergoing 24-h urine-collection were included. Patients with serum creatinine >1.5 mg/dL, kidney replacement therapy, suspected rhabdomyolysis, chronic kidney disease, or inaccurate urine collection were excluded. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for ARCTIC Score and ARC Predictor were calculated. Receiver operating characteristic curves were created for ARCTIC score and ARC Predictor models. RESULTS: One-hundred and twenty-two patients with ARC and 78 patients without ARC were included. The ARCTIC score sensitivity, specificity, PPV, and NPV were 89%, 54%, 75%, and 75%, respectively. The ARC Predictor demonstrated sensitivity, specificity, PPV, and NPV of 77%, 88%, 91%, and 71%, respectively. Regression analyses revealed both ARCTIC score ≥6 and ARC Predictor threshold >0.5 as significant risk factors for ARC in presence of traumatic brain injury, obesity, injury severity score, and negative nitrogen balance (ARCTIC ≥6: odds ratio 8.59 [95% confidence interval 3.90-18.92], P < 0.001; ARC Predictor >0.5: odds ratio 20.07 [95% confidence interval 8.53-47.19], P < 0.001). CONCLUSIONS: These findings corroborate validity of two pragmatic prediction tools to identify patients at high risk of ARC. Future studies evaluating correlations between ARCTIC score, ARC Predictor, and clinical outcomes are warranted.

Different but Equal: Outcomes of Prolonged Postanesthesia Care Unit Stay After Trauma Laparotomy.

INTRODUCTION: Hospital overcrowding is common and can lead to delays in intensive care unit (ICU) admission, resulting in increased morbidity and mortality in medical and surgical patients. Data on delayed ICU admission are limited in the postsurgical trauma cohort. Damage control laparotomy with temporary abdominal closure (DCL-TAC) for severely injured patients is often followed by an aggressive early resuscitation phase, usually occurring in the ICU. We hypothesized that patients who underwent DCL-TAC with initial postanesthesia care unit (PACU) stay would have worse outcomes than those directly admitted to ICU. METHODS: A retrospective chart review identified all trauma patients who underwent DCL-TAC at a level 1 trauma center over a 5 y period. Demographics, injuries, and resuscitation markers at 12 and 24 h were collected. Patients were stratified by location after index laparotomy (PACU versus ICU) and compared. Outcomes included composite morbidity and mortality. Multivariable logistic regression was performed. RESULTS: Of the 561 patients undergoing DCL-TAC, 134 (24%) patients required PACU stay due to ICU bed shortage, and 427 (76%) patients were admitted directly to ICU. There was no difference in demographics, injury severity score, time to resuscitation, complications, or mortality between PACU and ICU groups. Only 46% of patients were resuscitated at 24 h; 76% underwent eventual primary fascial closure. Under-resuscitation at 24 h (adjusted odds ratio [AOR] 0.55; 95% confidence interval [CI] 0.31-0.95, P = 0.03), increased age (AOR 1.04; 95% CI 1.02-10.55, P < 0.0001), and increased injury severity score (AOR 1.04; 95% CI 1.02-1.07, P < 0.0001) were associated with mortality on multivariable logistic regression. The median time in PACU was 3 h. CONCLUSIONS: PACU hold is not associated with worse outcomes in patients undergoing DCL-TAC. While ICU was designed for the resuscitation of critically ill patients, PACU is an appropriate alternative when an ICU bed is unavailable.

Body Mass Index and Pharmacologic Venous Thromboembolism Prophylaxis in Traumatic Brain Injury.

INTRODUCTION: Patients with traumatic brain injury (TBI) are at risk for developing venous thromboembolic complications. Previous work suggests venous thromboembolism (VTE) prophylaxis with low molecular weight heparin (LMWH) is protective compared to unfractionated heparin (UH) in trauma patients. The purpose of this study was to evaluate the role of body mass index (BMI) and type of pharmacological VTE prophylaxis in patients who develop VTE with severe TBI. METHODS: Patients with a severe TBI who received VTE prophylaxis were queried from the 2019 American College of Surgeons Trauma Quality Improvement Program database. Demographics, injury characteristics, timing of VTE prophylaxis, and BMI were collected. Outcome measures include VTE, mortality, and neurosurgical interventions. RESULTS: Of the 39,520 patients with severe TBI included in the study, 25,671 received LMWH and 13,849 received UH. Multivariable logistic regression found patients with a BMI 25-29.9 kg/m2 (odds ratio [OR] 1.375; 95% confidence interval [CI] 1.180-1.603; P < 0.0001) and a BMI>30 kg/m2 (OR 1.831; 95% CI 1.570-2.137; P < 0.0001) were independent predictors of VTE. Patients with BMI of 25-29.9 kg/m2 (OR 1.145; 95% CI 1.016-1.289; P = 0.0265) have a higher risk of mortality. For every hour delay in initiation to VTE prophylaxis, patients were 0.2% more likely to develop VTE (OR 1.002; 95% CI 1.002-1.003; P < 0.0001). Patients treated with UH were more likely to develop VTE complications (OR 1.085; 95% CI 1.058-1.112; P < 0.0001) and have increased mortality (OR 1.116; 95% CI 1.094-1.139; P < 0.0001), regardless of BMI and time to initiation of prophylaxis, compared to patients treated with LMWH. CONCLUSIONS: In patients with severe TBI, higher BMI was associated with an increased risk of VTE and death. Delay in VTE prophylaxis initiation was associated with an increased risk of VTE. LMWH had a protective association with VTE.

Race and Socio-Economic Status Impact Withdrawal of Treatment in Young Traumatic Brain Injury.

CONTEXT: Withdrawal of life-sustaining therapies (WDLST) in young individuals with traumatic brain injury (TBI) is an overwhelming situation often made more stressful by socioeconomic factors that shape health outcomes. Identifying these factors is crucial to developing equitable and goal-concordant care for patients and families. OBJECTIVES: We aimed to identify predictors of WDLST in young patients with 1-TBI. We hypothesized uninsured payment method, race, and co-morbid status are associated with WDLST. METHODS: We queried the 2021 Trauma Quality Improvement Program database for patients <45 years with TBI. Patients with WDLST were compared to patients without WDLST. Multivariable logistic regression (MLR) was performed. RESULTS: 61,115 patients were included, of whom 2,487 (4.1%) underwent WDLST. Patients in the WDLST cohort were older (29 vs 27, P<0.001), more likely to suffer from a penetrating mechanism (29% vs 11%, P<.0001), and have uninsured (22% vs 18%) or other payment method (5% vs 3%) when compared to the non-WDLST cohort. MLR identified age (AOR:1.019, 95% CI 1.014-1.024, P<.0001), non-Hispanic ethnicity (AOR:1.590, 95% CI 1.373-1.841, P<.0001), penetrating mechanism (AOR:3.075, 95% CI 2.727-3.467, P<.0001), systolic blood pressure (AOR: 0.992, 95% CI 0.990-0.993, P<0.0001), advanced directive (AOR:4.987, 95% CI 2.823-8.812, P<.0001), cirrhosis (AOR:3.854, 95% CI 2.641-5.625, P<.0001), disseminated cancer (AOR:6.595, 95% CI 2.370-18.357, P=0.0003), and interfacility transfer (AOR:1.457, 95% CI 1.295-1.640, P<0.0001) as factors associated with WDLST. Black patients were less likely to undergo WDLST when compared to white patients (AOR:0.687, 95% CI 0.603-0.782, P<.0001). CONCLUSION: The decision for WDLST in young patients with severe TBI may be influenced by cultural and socioeconomic factors in addition to clinical considerations.

Evaluation of a Novel Enteral Phosphorus Therapy with Enteral Nutrition during a National Intravenous Sodium Phosphate Shortage.

The purpose of this study was to evaluate the efficacy and safety of intragastric administration of small volumes of sodium enema solution containing phosphorus as phosphorus replacement therapy in critically ill patients with traumatic injuries who required continuous enteral nutrition. Adult patients (>17 years of age) who had a serum phosphorus concentration <3 mg/dL (0.97 mmol/L) were evaluated. Patients with a serum creatinine concentration >1.4 mg/dL (124 µmol/L) were excluded. Patients were given 20 mL of saline enema solution intragastrically, containing 34 mmol of phosphorus and mixed in 240 mL water. A total of 55% and 73% of patients who received one (n = 22) or two doses (n = 11) had an improvement in the serum phosphorus concentration, respectively. The serum phosphorus concentration increased from 2.5 [2.1, 2.8] mg/dL (0.81 [0.69, 0.90] mmol/L) to 2.9 [2.2, 3.0] mg/dL (0.94 [0.71, 0.97 mmol/L) for those who received two doses (p = 0.222). Excluding two patients with a marked decline in serum phosphorus by 1.3 mg/dL (0.32 mmol/L) resulted in an increase in the serum phosphorus concentration from 2.3 [2.0, 2.8] mg/dL (0.74 [0.65, 0.90] mmol/L) to 2.9 [2.5, 3.2] mg/dL (0.94 [0.81, 1.03] mmol/L; n = 9; p = 0.012). No significant adverse effects were noted. Our data indicated that intragastric phosphate administration using a small volume of saline enema solution improved the serum phosphorus concentrations in most patients.

Key Findings on Computed Tomography of the Head that Predict Death or the Need for Neurosurgical Intervention From Traumatic Brain Injury.

BACKGROUND: Traumatic brain injury (TBI) requires rapid management to avoid secondary injury or death. This study evaluated if a simple schema for quickly interpreting CT head (CTH) imaging by trauma surgeons and trainees could be validated to predict need for neurosurgical intervention (NSI) or death from TBI within 24 hours. METHODS: We retrospectively reviewed TBI patients presenting to our trauma center in 2020 with blunt mechanism and GCS ≤ 12. Primary independent variables were presence of 7 normal findings on CTH (CSF at foramen magnum, open fourth ventricle, CSF around quadrigeminal plate, CSF around cerebral peduncles, absence of midline shift, visible sulci/gyri, and gray-white differentiation). Trauma surgeons and trainees separately evaluated each patient's CTH, scoring findings as normal or abnormal. Primary outcome was NSI/death in 24 hours. RESULTS: Our population consisted of 444 patients; 21.4% received NSI or died within 24 hours. By trainees' interpretation, 5.8% of patients without abnormal findings had NSI/death vs 52.0% of patients with ≥1 abnormality; attending interpretation was 8.7% and 54.9%, respectively (P < .001). Sulci/gyri effacement, midline shift, and cerebral peduncle effacement maximized sensitivity and specificity for predicting NSI/death. Considering pooled results, when ≥1 of those 3 findings was abnormal, sensitivity was 77.89%, specificity was 80.80%, positive predictive value was 52.48%, and negative predictive value was 93.07%. DISCUSSION: Any single abnormality in this schema significantly predicted a large increase in NSI/death in 24 hours in TBI patients, and three particular findings were most predictive. This schema may help predict need for intervention and expedite management of moderate/severe TBI.

Extended Prophylactic Antibiotics in Penetrating Neck Aerodigestive Injuries Are Not Associated with Improved Outcomes.

Background: Literature currently supports the limited use of prophylactic antibiotics within the trauma population. However, data supporting limited (≤24 h) or extended (>24 h) use in penetrating aerodigestive neck injuries is lacking. We sought to describe the role of prophylactic antibiotics in this population and hypothesized there was no reduction in complications for patients on extended prophylactic antibiotics. Methods: Using a single-center trauma registry, patients with penetrating aerodigestive neck injuries were identified over a 5-year period. Demographics, injuries, management, and prophylactic antibiotic utilization were collected. Patients were stratified by the utilization of extended prophylactic antibiotics. Outcomes included infection, leak, reinterventions, and mortality. Results: Of 436 patients with penetrating neck injuries, 72 (17%) patients were identified with aerodigestive injuries. Forty-one (57%) patients received extended (>24 h) prophylactic antibiotics, whereas 31 (43%) received limited (≤24 h) prophylactic antibiotics. There was no difference in the patient demographics or injury severity score between the two groups. Extended prophylactic antibiotic use was associated with higher rates of infection (22% vs. 3%, p = 0.036) and leak (15% vs. 0%, p = 0.034) and no difference in reintervention (20% vs. 3%, p = 0.068) or mortality (10% vs. 13%, p = 0.719) compared with limited prophylactic antibiotics. Median duration of extended antibiotic use was 7 days. Operative intervention was equivalent across extended prophylactic antibiotics and limited antibiotics groups (59% vs. 58%, p = 0.968). Conclusions: There is insufficient evidence to support the extended (>24 h) use of prophylactic antibiotics in patients with penetrating neck aerodigestive injuries.

Risk Factors for Venous Thromboembolism and Eventual Amputation in Traumatic Femoral and Iliac Vein Injuries: A Trauma Quality Improvement Program Analysis.

BACKGROUND: Iliac and femoral venous injuries represent a challenging dilemma in trauma surgery with mixed results. Venous restoration of outflow (via repair or bypass) has been previously identified as having higher rates of VTE (venous thromboembolism) compared to ligation. We hypothesized that rates of VTE and eventual amputation were similar whether restoration of venous outflow vs ligation was performed at initial operation. METHODS: Patients in the 2019-2021 National Trauma Data Bank with iliac and femoral vein injuries were abstracted and analyzed. The primary outcomes of interest were in-hospital lower extremity amputation and VTE. RESULTS: A total of 2642 patients with operatively managed iliac and femoral vein injuries were identified VTE was found in 10.8% of patients. Multivariable logistic regression was performed and identified bowel injury, higher ISS, older age, open repair, and longer time to VTE prophylaxis initiation as independent predictors of VTE. Amputation was required in 4.2% of patients. Multivariable logistic regression identified arterial or nerve injury, femur or tibia fracture, venous ligation, percutaneous intervention, fasciotomy, bowel injury, and higher ISS as independent factors of amputation. CONCLUSION: Venous restoration was not an independent predictor of VTE. Venous ligation on index operation was the only modifiable independent predictor of amputation identified on regression analysis.

Directed work-up of select penetrating neck injuries is safe: Hard signs continue to soften.

INTRODUCTION: Management of penetrating neck injuries (PNIs) has evolved over time, more frequently relying on increased utilization of diagnostic imaging studies. Directed work-up with computed tomography imaging has resulted in increased use of angiography and decreased operative interventions. We sought to evaluate management strategies after directed work-up, hypothesizing increased use of non-operative therapeutic interventions and lower mortality after directed work-up. METHODS: Patients with PNI from 2017 to 2022 were identified from a single-center trauma registry. Demographics, injuries, physical exam findings, diagnostic studies and interventions were collected. Patients were stratified by presence of hard signs and management strategy [directed work-up (DW) and immediate operative intervention (OR)] and compared. Outcomes included therapeutic non-operative intervention [endovascular stent, embolization, dual antiplatelet therapy (DAPT), or anticoagulation (AC)], non-therapeutic neck exploration, length of stay (LOS), and mortality. RESULTS: Of 436 patients with PNI, 143 (33%) patients had vascular and/or aerodigestive injuries. Of these, 115 (80%) patients underwent DW and 28 (20%) patients underwent OR. There were no differences in demographics or injury severity score between groups. Patients in the DW group were more likely to undergo vascular stent or embolization (p = 0.040) and had fewer non-therapeutic neck explorations (p = 0.0009), compared to the OR group. There were no differences in post-intervention stroke, leak, or mortality. Sixty percent of patients with vascular hard signs and 78% of patients with aerodigestive hard signs underwent DW. CONCLUSIONS: Directed work-up in select patients with PNI is associated with fewer non-therapeutic neck explorations. There was no difference in mortality. Selective use of endovascular management, AC and DAPT is safe.

Clinical decompensation after trauma laparotomy: It's probably not a pulmonary embolus.

Introduction Computed Tomography (CT) to rule out pulmonary embolus (PE) is often ordered during post-trauma laparotomy clinical decompensation (CD) involving fever, tachycardia, tachypnea, and/or leukocytosis. We hypothesize this diagnostic modality is low-yield in the postoperative period when surgery-related sequelae are more probable. Methods This is a single-center retrospective cohort study of patients who underwent trauma laparotomy and had subsequent CT for CD from March 19, 2019 to June 30, 2022. Descriptive statistics and multiple logistic regression were performed. The primary outcome was saddle and lobar PE incidence. Results 1032 adult patients underwent trauma laparotomy with 434 undergoing CT for CD: 137 CT abdomen and pelvis only, 30 CTPE, 265 both. The majority (80.2 %) was male, age 33[interquartile range (IQR) 24-45], suffered penetrating mechanism (57 %), and had ISS 23[IQR16-30]. Injuries at laparotomy included 47 % solid organ, 62 % GI tract, 7 % biliary, 11 % vascular, and 42 % other. 176 (41 %) required damage control laparotomy. Median time to CT post-laparotomy was 174 h [111-235] with saddle and lobar PE in 3 (1 %), peripheral PE 18 (5 %), and abdominal abscess, leak, fluid, or pseudoaneurysm in 222 (51 %). Clinical management was altered (40 %) by antibiotics, therapeutic anticoagulation, drainage, aspiration, filter, thrombectomy, or surgical operation. Patients for whom CT findings changed management were more likely to have had GI tract surgery (69% vs 57 %, p = 0.021), higher white blood cell (WBC) (16.4 [13.1-20.5] vs 15.1 [9.9-19.5], p = 0.002), more hours between CT and laparotomy (184 [141-245] vs 162 [89-230], p = 0.002), and lower mortality (2% vs 8 %, p = 0.008). In-hospital mortality was 5 %; none were PE-related. Predictors of clinical intervention required based on CT imaging were GI tract injury (AOR: 1.65, p = 0.0182), and elevated WBC (AOR: 1.038, p = 0.010 Conclusion Saddle and lobar PE incidence post-trauma laparotomy is low. SIRS-type symptoms prompting postoperative CT commonly have no procedural or antibiotic requirement. Postoperative decompensation is more likely related post-operative complications, and less likely a PE.

Management of Extraperitoneal Bladder Injuries in Patients With Pelvic Fractures.

BACKGROUND: The management of extraperitoneal bladder injuries (EBIs) when present with concomitant pelvic fractures is controversial. Current evidence is divided between supporting non-operative management with catheter drainage compared to operative management of bladder injury. The purpose of this study was to evaluate current management of EBI in the setting of pelvic fractures at our institution. We hypothesize there is no difference between operative and non-operative groups. METHODS: Retrospective review of patients with concomitant bladder injuries and pelvic fractures at a level 1 trauma center from 2017 to 2022 was performed. Demographics, injury characteristics, management strategies, and complications were collected. Patients were stratified by management (cystorrhaphy vs non-operative) and compared. RESULTS: Of 90 patients with bladder injuries and pelvic fractures, 50 patients (56%) presented with EBI, 26 patients (29%) presented with only intraperitoneal injuries, and 14 patients (16%) presented with a combined injury. Of patients with EBI, 18 (36%) underwent cystorrhaphy and 32 (64%) underwent non-operative management. There was no difference in demographics, orthopedic pelvic operative intervention, length of stay, or mortality between groups. Patients in the operative cohort had more bladder leaks [7 (39%) vs 4 (13%), P = .0406], compared to those in the non-operative cohort. Composite complications [7 (39%) vs 7 (22%), P = .1984] were similar between groups. CONCLUSIONS: Patients with EBI and pelvic fractures who underwent cystorrhaphy had more bladder leaks on follow-up imaging, although there was no difference in composite complications, when compared to those who underwent non-operative management.

Outcomes and Predictors of Delayed Intervention After Renal Trauma.

INTRODUCTION: Historically, a zone II hematoma mandated exploration after penetrating trauma, but this has been challenged given potentially higher nephrectomy rates and the advent of therapeutic endovascular and endoscopic interventions. We hypothesized penetrating mechanism was not a predictor for delayed intervention in the modern era. METHODS: This single-center, retrospective study included renal trauma patients from 3/2019 to 6/2022. Our institutional practice is selective exploration of zone II hematomas for active bleeding and expanding hematoma only, regardless of mechanism. Descriptive statistics and multivariable logistic regression (MLR) were performed. RESULTS: One-hundred and forty-four patients were identified, with median age 32 years (IQR:23,49), 66% blunt mechanism, and injury severity score 17(IQR:11,26). Forty-three (30%) required operative intervention, and of the 20 that had a zone II exploration, 3 (15%) underwent renorrhaphy and 17 (85%) underwent nephrectomy. Penetrating patients more frequently underwent immediate operative intervention (67%vs10%,P < .0001), required nephrectomy (27%vs5%,P = .0003), and were less likely to undergo pre-intervention CT (51%vs96%,P < .0001) compared to blunt patients. Delayed renal interventions were higher in penetrating (33%vs13%,P = .004) with no difference in mortality or length of stay compared to blunt mechanism. Ureteral stent placement and renal embolization were the most common delayed interventions. On MLR, the only independent predictor for delayed intervention was need for initial operative intervention (OR 3.803;95%CI:1.612-8.975,P = .0023). Four (3%) required delayed nephrectomy, of which only one underwent initial operative intervention without zone 2 exploration. CONCLUSIONS: The most common delayed interventions after renal trauma were renal embolization and ureteral stent. Penetrating mechanism was not a predictor of delayed renal intervention in a trauma center that manages zone II retroperitoneal hematomas similarly regardless of mechanism.

Surgical and procedural antibiotic prophylaxis in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee clinical consensus document.

The use of prophylactic measures, including perioperative antibiotics, for the prevention of surgical site infections is a standard of care across surgical specialties. Unfortunately, the routine guidelines used for routine procedures do not always account for many of the factors encountered with urgent/emergent operations and critically ill or high-risk patients. This clinical consensus document created by the American Association for the Surgery of Trauma Critical Care Committee is one of a three-part series and reviews surgical and procedural antibiotic prophylaxis in the surgical intensive care unit. The purpose of this clinical consensus document is to provide practical recommendations, based on expert opinion, to assist intensive care providers with decision-making for surgical prophylaxis. We specifically evaluate the current state of periprocedural antibiotic management of external ventricular drains, orthopedic operations (closed and open fractures, silver dressings, local, antimicrobial adjuncts, spine surgery, subfascial drains), abdominal operations (bowel injury and open abdomen), and bedside procedures (thoracostomy tube, gastrostomy tube, tracheostomy).

Clinical Implications of Over- and Under-Triage Using Need for Trauma Intervention and Cribari Indices.

BACKGROUND: Need for Trauma Intervention (NFTI) score was proposed to help identify injured trauma patients while minimizing under (UT) and over triage (OT). Using a national database, we aimed to describe UT and OT of NFTI vs standard Cribari method (CM) and hypothesized triage sensitivity remains poor. METHODS: The 2021 Trauma Quality Improvement Program (TQIP) database was queried. Demographics, mechanism, verification level, interfacility transfer (IF), and level of activation were collected. Patients were stratified by both NFTI [+ vs -] and CM [Injury severity score (ISS) < 15 vs > 15]. UT was defined as NFTI + or ISS >15 without full trauma activation. RESULTS: 1,030,526 patients were identified in TQIP. 84,969 were UT and 97,262 were OT using NFTI while 94,020 were UT and 108,823 were OT using CM. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of NFTI is 49%, 89%, 45%, and 90%, respectively vs 43%, 87%, 39%, and 89% of CM, respectively. Age was higher in the UT group using both scores (52 vs 42, P < .0001 and 54 vs 42, P < .0001, respectively). Using MLR, level 2 and 3 verification, blunt mechanism, female, IF, and older age were associated with UT in both NFTI and CM. Level 1 verification, penetrating mechanism, male, no IF, and younger age were associated with OT. CONCLUSIONS: Current prehospital triage criteria have poor sensitivity for identifying severely injured trauma patients by both NFTI and CM. UT increases as age of the patient increases. Further studies are needed to improve triage.

Enteral feeding tolerance during pharmacologic neuromuscular blockade.

A common misperception is that critically ill patients who receive paralytic therapy will not tolerate enteral nutrition. As a result, some clinicians empirically withhold enteral feedings for critically ill patients who receive neuromuscular blocker pharmacotherapy (NMB). The intent of this review is to examine the evidence regarding enteral feeding tolerance for critically ill patients given NMB. Studies evaluating enteral feeding during paralytic therapy are provided and critiqued. Evidence examining enteral feeding tolerance during NMB is limited. Enteral feeding intolerance is more likely attributable to the underlying illnesses and concurrent opioid analgesia, sedation, and vasopressor therapies. Most critically ill patients can be successfully fed during NMB. Prokinetic pharmacotherapy may be warranted in some patients.

Management of Penetrating Cardiac Injuries With Pericardial Window and Drainage in Select Patients.

BACKGROUND: Management of penetrating chest injuries with a positive pericardial window (PW) are presumed cardiac injuries and traditionally result in sternotomy. However, there is some evidence in the literature that select patients can be managed with PW, lavage, and drainage (PWLD). METHODS: All patients with penetrating chest trauma who underwent PW and/or sternotomy over a 5-year period were identified. Patients were stratified by operative intervention [PW + sternotomy vs PWLD] and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of therapeutic sternotomy. RESULTS: Of the 146 patients who underwent PW and/or sternotomy included in the study, 126 patients underwent PW, 39 underwent sternotomy, and 10 underwent PWLD. There was no difference in demographics, LOS, ICU LOS, vent days, or mortality in patients who underwent PW + sternotomy, compared to patients who underwent PWLD. In the PWLD group, one patient returned to the OR for recurrent pericardial effusion and no patients required sternotomy. Multivariable logistic regression identified ISS as an independent predictor of therapeutic sternotomy (OR 1.160; 95% CI 1.006-1.338, P = .0616). Interestingly, positive FAST, significant CT findings, and trajectory were not predictors of therapeutic sternotomy. There were 7 patients with a left hemothorax and negative FAST found to have a positive PW and cardiac injury mandating sternotomy and repair. CONCLUSION: Penetrating cardiac injury can be managed with PWLD in select patients. Positive FAST, significant findings on CT, and trajectory do not mandate sternotomy. A negative FAST in the setting of a hemothorax does not rule out a cardiac injury.

Delayed Tracheostomy After Cervical Fixation is Not Associated With Improved Outcomes: A Trauma Quality Improvement Program Analysis.

BACKGROUND: Patients with unstable cervical spine (C-spine) fractures are at a significant risk of respiratory failure. There is no consensus on the optimal timing of tracheostomy in the setting of recent operative cervical fixation (OCF). This study evaluated the impact of tracheostomy timing on surgical site infections (SSIs) in patients undergoing OCF and tracheostomy. METHODS: Trauma Quality Improvement Program (TQIP) was used to identify patients with isolated cervical spine injuries who underwent OCF and tracheostomy between 2017 and 2019. Early tracheostomy (<7 days from OCF) was compared with delayed tracheostomy (≥7 days from OCF). Logistic regressions identified variables associated with SSI, morbidity, and mortality. Pearson correlations evaluated time to tracheostomy and length of stay (LOS). RESULTS: Of 1438 patients included, 20 had SSI (1.4%). There was no difference in SSI between early vs delayed tracheostomy (1.6% vs 1.2%, P = .5077). Delayed tracheostomy was associated with increased ICU LOS (23.0 vs 17.0 days, P < .0001), ventilator days (19.0 vs 15.0, P < .0001), and hospital LOS (29.0 vs 22.0 days, P < .0001). Increased ICU LOS was associated with SSI (OR 1.017; CI 0.999-1.032; P = .0273). Increased time to tracheostomy was associated with increased morbidity (OR 1.003; CI 1.002-1.004; P < .0001) on multivariable analysis. Time from OCF to tracheostomy correlated with ICU LOS (r (1354) = .35, P < .0001), ventilator days (r (1312) = .25, P < .0001), and hospital LOS (r (1355) = .25, P < .0001). CONCLUSION: In this TQIP study, delayed tracheostomy after OCF was associated with longer ICU LOS and increased morbidity without increased SSI. This supports the TQIP best practice guidelines recommending that tracheostomy should not be delayed for concern of increased SSI risk.

Gastric feeding intolerance in critically ill patients during sustained pharmacologic neuromuscular blockade.

BACKGROUND: The purpose of this study was to assess gastric feeding intolerance for critically ill patients who received sustained neuromuscular blocker (NMB) pharmacotherapy. METHODS: Adult patients (>17 years of age) admitted to the trauma intensive care unit who received continuous intravenous NMB pharmacotherapy (rocuronium, cisatracurium, vecuronium, or pancuronium) for ≥48 h during continuous intragastric enteral nutrition (EN) were retrospectively evaluated. Gastric feeding intolerance was defined by initiation of a prokinetic agent (metoclopramide, erythromycin, or both) for an elevated gastric residual volume (GRV) >300 ml and with distention of the abdomen by physical examination, observation of regurgitation or emesis, temporary discontinuation of EN with low intermittent gastric suctioning, or initiation of parenteral nutrition (PN). Patients were evaluated for gastric feeding intolerance for the first 3 days of combined EN and NMB pharmacotherapy. A P value < 0.05 was considered statistically significant. RESULTS: Ten patients of the 47 patients (21%) were intolerant to EN during NMB pharmacotherapy. No statistically or clinically relevant differences in patient characteristics were found between patients who tolerated EN vs those who experienced gastric feeding intolerance, except for a higher median maximum GRV of 125 ml (28, 200) vs 300 (250, 400) ml, respectively (P < 0.001). Five patients responded to prokinetic therapy and five required PN. CONCLUSION: Most patients tolerated intragastric EN during sustained NMB pharmacotherapy. Presence of NMB pharmacotherapy is not an absolute contraindication for EN.

Radiographic and Clinical Predictors of Therapeutic Pelvic Angiography.

BACKGROUND: Pelvic fractures are often complicated by hemorrhage contributing to morbidity and mortality. Management of these patients is multifaceted and computed tomography (CT) imaging plays an integral diagnostic role. The purpose of this study was to identify radiographic and clinical predictors of therapeutic angiography in patients with blunt pelvic fractures. METHODS: All patients with blunt pelvic fractures who underwent angiography following admission CT scan were identified over a 6-year period. A radiologist reviewed the CT scans to identify potential predictors of pelvic hemorrhage. Patients were stratified by intervention [therapeutic angiography (TA) vs non-therapeutic angiography (NTA)] and compared. Multivariable logistic regression (MLR) was performed to determine independent predictors of TA. Youden's index was used to identify the optimal value of selected predictors identified on MLR. RESULTS: 177 patients were identified: 42% underwent TA and 58% underwent NTA. Patients undergoing TA were more likely to have a higher injury burden and greater resuscitative transfusion requirements, display both a brighter blush density on arterial phase CT and a larger % change in arterial to venous phase blush density. The optimal arterial blush density was determined to be 250 HU. MLR identified pre-angiography transfusion requirements (OR 1.175; 95% CI 1.054-1.311, P = .0189) and arterial blush density (OR 1.011; 95% CI 1.005-1.016, P < .0001) as independent predictors of therapeutic angiography. CONCLUSION: CT imaging remains vital in assessing patients with pelvic fractures and associated hemorrhage following blunt trauma. For patients requiring multiple resuscitative transfusions with CT findings of an arterial blush measuring ≥250 HU, early angiography should be the preferred approach.