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OBJECTIVE: This study sought to elucidate clinical and imaging findings predictive for malperfusion syndrome after blunt thoracic aortic injury (BTAI). SUMMARY BACKGROUND DATA: 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 50-99%. 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 two (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.
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BACKGROUND: Blunt aortic injury (BAI) and traumatic brain injury (TBI) are the leading causes of death after blunt trauma. The purposes of this study were to identify predictors of mortality for BAI and to examine the impact of procedural heparinization during thoracic endovascular aortic repair (TEVAR) on neurologic outcomes in patients with BAI/TBI. METHODS: Patients with BAI were identified over an 8 year period. Age, gender, severity of injury and shock, time to TEVAR, morbidity, and mortality were recorded and compared. Multivariable logistic regression (MLR) was performed to determine independent predictors of mortality. Youden's index determined optimal time to TEVAR. RESULTS: A total of 129 patients were identified. The majority (74%) were male with a median age and injury severity score (ISS) of 40 years and 29, respectively. Of these, 26 (20%) had a concomitant TBI. Patients with BAI/TBI had higher injury burden at presentation (ISS 37 vs. 29, P = 0.002; Glasgow Coma Scale [GCS] 6 vs. 15, P < 0.0001), underwent fewer TEVAR procedures (31 vs. 53%, P = 0.039), and suffered increased mortality (39 vs. 16%, P = 0.009). All TEVARs had procedural anticoagulation, including patients with TBI, without change in neurologic function. The optimal time to TEVAR was 14.8 hr. Mortality increased in TEVAR patients before 14.8 hr (8.7 vs. 0%, P = 0.210). MLR identified TEVAR as the only modifiable factor that reduced mortality (odds ratio 0.11; 95% confidence interval 0.03-0.45, P = 0.002). CONCLUSIONS: TEVAR use was identified as the only modifiable predictor of reduced mortality in patients with BAI. Delayed TEVAR with the use of procedural heparin provides a safe option regardless of TBI with improved survival and no difference in discharge neurologic function.
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Doenças da Aorta , Procedimentos Endovasculares , Lesões do Sistema Vascular , Ferimentos não Penetrantes , Anticoagulantes/efeitos adversos , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/lesões , Aorta Torácica/cirurgia , Doenças da Aorta/etiologia , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Masculino , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Lesões do Sistema Vascular/complicações , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/cirurgia , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/cirurgiaRESUMO
WHAT IS KNOWN AND OBJECTIVE: Stenotrophomonas maltophilia is an intrinsically multidrug-resistant (MDR) organism which commonly presents as a respiratory tract infection. S. maltophilia is typically treated with high-dose sulfamethoxazole/trimethoprim (SMX/TMP). However, SMX/TMP and other treatment options for S. maltophilia can be limited because of resistance, allergy, adverse events or unavailability of the drug; use of novel agents may be necessary to adequately treat this MDR infection and overcome these limitations. CASE DESCRIPTION: This small case series describes two patients who underwent treatment with tigecycline for ventilator-associated pneumonia (VAP) caused by S. maltophilia after admission to a trauma intensive care unit. At the time of admission for the two reported patients, a national drug shortage of intravenous (IV) SMX/TMP prevented its use. Tigecycline was chosen as a novel agent to treat S. maltophilia VAP based on culture and susceptibility data, and it was used successfully. Both patients showed clinical signs of improvement with eventual cure and discharge from the hospital after treatment with tigecycline, and one patient demonstrated confirmed microbiological cure with a negative repeat bronchoscopic bronchoalveolar lavage (BAL). WHAT IS NEW AND CONCLUSION: To our knowledge, this small case series is the first documentation of utilizing tigecycline to treat S. maltophilia VAP in the United States. Although it likely should not be considered as a first-line agent, tigecycline proved to be an effective treatment option in the two cases described in the setting of a national drug shortage of the drug of choice.
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Antibacterianos/uso terapêutico , Infecções por Bactérias Gram-Negativas/tratamento farmacológico , Pneumonia Associada à Ventilação Mecânica/tratamento farmacológico , Stenotrophomonas maltophilia/efeitos dos fármacos , Tigeciclina/uso terapêutico , Adulto , Humanos , Unidades de Terapia Intensiva , Masculino , Combinação Trimetoprima e Sulfametoxazol/provisão & distribuição , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , Ferimentos e Lesões/terapiaRESUMO
BACKGROUND: Achromobacter sp are nonfermenting Gram-negative bacilli (NFGNB) that rarely cause severe infections, including ventilator-associated pneumonia (VAP). Data on the treatment of Achromobacter pneumonia are very limited, and the organism has been associated with a high mortality rate. Thus, more data are needed on treating this organism. OBJECTIVE: To evaluate the treatment of Achromobacter VAP in critically ill trauma patients. METHODS: This retrospective, observational study evaluated critically ill trauma patients who developed Achromobacter VAP. A previously published pathway for the diagnosis and management of VAP was used according to routine patient care. This included the use of quantitative bronchoscopic bronchoalveolar lavage cultures to definitively diagnose VAP. RESULTS: A total of 37 episodes of Achromobacter VAP occurred in 34 trauma intensive care unit patients over a 15-year period. The most commonly used definitive antibiotics were imipenem/cilastatin, cefepime, or trimethoprim/sulfamethoxazole. The primary outcome of clinical success was achieved in 32 of 37 episodes (87%). This is similar to previous studies of other NFGNB VAP (eg, Pseudomonas, Acinetobacter) from the study center. Microbiological success was seen in 21 of 28 episodes (75%), and VAP-related mortality was 9% (3 of 34 patients). CONCLUSIONS: Achromobacter is a rare but potentially serious cause of VAP in critically ill patients. In this study, there was an acceptable success rate compared with other causes of NFGNB VAP in this patient population.
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Achromobacter , Antibacterianos/uso terapêutico , Infecções por Bactérias Gram-Negativas/tratamento farmacológico , Pneumonia Bacteriana/tratamento farmacológico , Pneumonia Associada à Ventilação Mecânica/tratamento farmacológico , Adulto , Estado Terminal/terapia , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
PURPOSE: To evaluate efficacy and safety of a novel device that combines an inferior vena cava (IVC) filter and central venous catheter (CVC) for prevention of pulmonary embolism (PE) in critically ill patients. MATERIALS AND METHODS: In a multicenter, prospective, single-arm clinical trial, the device was inserted at the bedside without fluoroscopy and subsequently retrieved before transfer from the intensive care unit (ICU). The primary efficacy endpoint was freedom from clinically significant PE or fatal PE 72 hours after device removal or discharge, whichever occurred first. Secondary endpoints were incidence of acute proximal deep venous thrombosis (DVT), catheter-related thrombosis, catheter-related bloodstream infections, major bleeding events, and clinically significant thrombus (occupying > 25% of volume of filter) detected by cavography before retrieval. RESULTS: The device was placed in 163 critically ill patients with contraindications to anticoagulation; 151 (93%) were critically ill trauma patients, 129 (85%) had head or spine trauma, and 102 (79%) had intracranial bleeding. The primary efficacy endpoint was achieved for all 163 (100%) patients (95% confidence interval [CI], 97.8%-100%, P < .01). Diagnosis of new or worsening acute proximal DVT was time dependent with 11 (7%) occurring during the first 7 days. There were no (0%) catheter-related bloodstream infections. There were 5 (3.1%) major bleeding events. Significant thrombus in the IVC filter occurred in 14 (8.6%) patients. Prophylactic anticoagulation was not initiated for a mean of 5.5 days ± 4.3 after ICU admission. CONCLUSIONS: This novel device prevented clinically significant and fatal PE among critically ill trauma patients with low risk of complications.
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Cateteres Venosos Centrais , Embolia Pulmonar/etiologia , Embolia Pulmonar/prevenção & controle , Filtros de Veia Cava , Ferimentos e Lesões/complicações , Adulto , Cateteres Venosos Centrais/efeitos adversos , Estado Terminal , Remoção de Dispositivo , Segurança de Equipamentos , Feminino , Fluoroscopia , Humanos , Unidades de Terapia Intensiva , Masculino , Estudos Prospectivos , Fatores de Risco , Resultado do Tratamento , Estados Unidos , Filtros de Veia Cava/efeitos adversosRESUMO
BACKGROUND: Limited data exist on the role of adjunctive intraventricular (IVT) antibiotics for the treatment of central nervous system (CNS) infections in traumatic brain injury (TBI) patients. OBJECTIVE: To evaluate differences in CNS infection cure rates for TBI patients who received adjunctive IVT antibiotics compared with intravenous (IV) antibiotics alone. METHODS: We retrospectively identified patients with TBI and bacterial CNS infections admitted to the trauma intensive care unit (ICU) from 1997 to 2013. Study patients received IV and IVT antibiotics, and control patients received IV antibiotics alone. Clinical and microbiological cure rates were determined from patient records, in addition to ICU and hospital lengths of stay (LOSs), ventilator days, and hospital mortality. RESULTS: A total of 83 patients were enrolled (32 study and 51 control). The duration of IV antibiotics was similar in both groups (10 vs 12 days, P = 0.14), and the study group received IVT antibiotics for a median of 9 days. Microbiological cure rates were 84% and 82% in study and control groups, respectively (P = 0.95). Clinical cure rates were similar at all time points. No significant differences were seen in days of mechanical ventilation, ICU or hospital LOS, or hospital mortality. When only patients with external ventricular drains were compared, cure rates remained similar between groups. CONCLUSIONS: TBI patients with CNS infections had similar microbiological and clinical cure rates whether they were treated with adjunctive IVT antibiotics or IV antibiotics alone. Shorter than recommended durations of antibiotic therapy still resulted in acceptable cure rates and similar clinically relevant outcomes.
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Antibacterianos/uso terapêutico , Lesões Encefálicas/complicações , Infecções do Sistema Nervoso Central/tratamento farmacológico , Adulto , Lesões Encefálicas/mortalidade , Estudos de Casos e Controles , Infecções do Sistema Nervoso Central/complicações , Infecções do Sistema Nervoso Central/mortalidade , Estado Terminal , Feminino , Mortalidade Hospitalar , Humanos , Infusões Intraventriculares , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Respiração Artificial , Estudos RetrospectivosRESUMO
OBJECTIVE: To report the first case of Rhizobium radiobacter bacteremia in a critically ill trauma patient. CASE SUMMARY: A 36-year-old female trauma patient hospitalized at The Regional Medical Center at Memphis developed bacteremia due to Rhizobium radiobacter on hospital day 9. The central line catheter tip culture from the same hospital day was negative. No source for the R radiobacter bacteremia was identified. Empirical and definitive antibiotic therapy consisted of cefepime 2 g intravenously every 8 hours for at total of 8 days. On completion of antibiotics, the patient demonstrated clinical resolution by immediate defervescence and gradual normalization of her white blood cell count. She demonstrated microbiologic success of therapy with negative blood cultures on hospital days 22, 34, 45, and 61. She was discharged on hospital day 80. DISCUSSION: Rhizobium species are common soil and plant pathogens that rarely cause infections in humans. Previous reports of Rhizobium infections have been in immunocompromised patients; generally those with cancer or HIV infection. Intravenous catheters have commonly been cited as the source of infection. The trauma patient in this case constitutes a unique presentation of R radiobacter bacteremia when compared with other case reports. Her indwelling catheter was not the source of her infection, and her only identifiable risk factor for R radiobacter infection was hospitalization. However, she did possess potential reasons for development of an infection with an unusual organism such as R radiobacter. Potential immune modulating therapies included blood transfusions, opioid analgesics, benzodiazepines, general anesthetics, and surgical procedures. Finally, trauma itself has been associated with some degree of immunosuppression. All these issues may have placed the patient in this case at risk of an opportunistic infection like R radiobacter. CONCLUSION: Based on this case, R radiobacter may be considered a potential pathogen causing bacteremia in critically ill trauma patients.
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Agrobacterium tumefaciens/efeitos dos fármacos , Antibacterianos/uso terapêutico , Bacteriemia/tratamento farmacológico , Cefalosporinas/uso terapêutico , Infecções Oportunistas/tratamento farmacológico , Ferimentos e Lesões/tratamento farmacológico , Adulto , Agrobacterium tumefaciens/isolamento & purificação , Antibacterianos/administração & dosagem , Bacteriemia/sangue , Bacteriemia/imunologia , Bacteriemia/microbiologia , Cefepima , Cefalosporinas/administração & dosagem , Estado Terminal , Feminino , Humanos , Infecções Oportunistas/sangue , Infecções Oportunistas/imunologia , Infecções Oportunistas/microbiologia , Resultado do Tratamento , Ferimentos e Lesões/sangue , Ferimentos e Lesões/imunologia , Ferimentos e Lesões/microbiologiaRESUMO
OBJECTIVE: To report a case of Chryseobacterium indologenes ventilator-associated pneumonia (VAP) in a critically ill trauma patient. CASE SUMMARY: This report describes a 66-year-old critically ill trauma patient who developed VAP, which was caused by C indologenes. The patient was injured in a riding lawn mower accident that trapped him underwater in a pond. The patient required surgery for intra-abdominal injuries and was mechanically ventilated in the trauma intensive care unit. On hospital day 5, the patient developed signs and symptoms of VAP. A diagnosis of C indologenes VAP was confirmed based on a quantitative culture from a bronchoscopic bronchoalveolar lavage. The patient's infection was successfully treated with moxifloxacin for 2 days followed by cefepime for 7 days. DISCUSSION: Formally known as Flavobacterium indologenes, C indologenes is a Gram-negative bacillus normally found in plants, soil, foodstuffs, and fresh and marine water sources. Recently, worldwide reports of C indologenes infections in humans have been increasing, though reports from the United States are still rare. Bacteremia and pneumonia are the most commonly reported infections, and most patients are immunocompromised. The current case differs from most previous reports because this patient was in the United States and did not have any traditional immunocompromised states (eg, transplant, cancer, HIV/AIDS, or corticosteroid use). CONCLUSION: This case report demonstrates that C indologenes can cause VAP in a trauma ICU patient.
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Antibacterianos/uso terapêutico , Compostos Aza/uso terapêutico , Cefalosporinas/uso terapêutico , Chryseobacterium , Infecções por Flavobacteriaceae/tratamento farmacológico , Pneumonia Associada à Ventilação Mecânica/tratamento farmacológico , Quinolinas/uso terapêutico , Idoso , Cefepima , Estado Terminal , Infecções por Flavobacteriaceae/diagnóstico por imagem , Fluoroquinolonas , Humanos , Unidades de Terapia Intensiva , Masculino , Moxifloxacina , Pneumonia Associada à Ventilação Mecânica/diagnóstico por imagem , Radiografia , Ferimentos e LesõesRESUMO
INTRODUCTION: Limited data suggest mild hypernatremia may be related to lower intracranial pressure (ICP) in patients with traumatic brain injury (TBI). The practice at the study center has been to use hypertonic saline (HTS) to generate a targeted serum sodium of 145 to 155 mEq/l in patients with TBI. The purpose of this study was to determine the relationship between serum sodium values and ICP, and to evaluate the acute effect of HTS on ICP. METHODS: A retrospective review of patients who were admitted to the trauma ICU for TBI, had an ICP monitor placed, and received at least one dose of HTS between January 2006 and March 2011 was performed. Data were collected for up to 120 hours after ICP monitor placement. The primary outcome was the relationship between serum sodium and maximum ICP. Secondary outcomes were the relationship between serum sodium and the mean number of daily interventions for ICP control, and the acute effect of HTS on ICP during the 6 hours after each dose. Linear regression was used to analyze the primary outcome. Analysis of variance on ranks and repeated measures analysis of variance were used to evaluate the number of interventions and the acute effect of HTS on ICP, respectively. RESULTS: Eighty-one patients were enrolled with mean ± standard deviation age of 36 ± 15 years and median Glasgow Coma Scale score of 7 (interquartile range, 4 to 7). A total of 1,230 serum sodium values (range, 118 to 174 mEq/l) and 7,483 ICP values (range, 0 to 159 mmHg) were collected. There was no correlation between serum sodium and maximum ICP (R(2) = 0.0052). The overall mean ± standard deviation number of interventions for elevated ICP per day was 4.2 ± 2.9, 2.9 ± 2.0, and 2.6 ± 2.3 for patients with a mean serum sodium of < 145, 145 to 155, and > 155 mEq/l, respectively (P < 0.001). Regarding the acute effect of HTS on ICP, there was no statistical difference in mean ICP compared with baseline during hours 1 through 6 following HTS doses (baseline, 13.7 ± 8.4 mmHg; hour 1, 13.6 ± 8.3 mmHg; hour 2, 13.5 ± 8.8 mmHg; hour 3, 13.3 ± 8.7 mmHg; hour 4, 13.4 ± 8.7 mmHg; hour 5, 13.4 ± 8.3 mmHg; hour 6, 13.5 ± 8.3 mmHg; P = 0.84). CONCLUSIONS: Serum sodium concentrations did not correlate with ICP values. These results warrant further evaluation and possible reassessment of sodium goals for ICP management in patients with TBI.
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Traumatismos Craniocerebrais/sangue , Sistemas de Liberação de Medicamentos/métodos , Hipernatremia/sangue , Pressão Intracraniana/fisiologia , Solução Salina Hipertônica/administração & dosagem , Sódio/sangue , Adulto , Traumatismos Craniocerebrais/tratamento farmacológico , Feminino , Humanos , Hipernatremia/tratamento farmacológico , Pressão Intracraniana/efeitos dos fármacos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
BCVI remains a potentially devastating consequence of blunt-force trauma. However, over the past decades significant advances have been made in understanding the pathophysiology, risk factors, and natural history of BCVI. Given the initial asymptomatic period, there is time to diagnose and treat these lesions before the onset of neurologic insult. This early recognition and intervention greatly improves morbidity and mortality directly associated with BCVI. Screening criteria have been identified and reviewed. All patients at risk of BCVI, based on mechanism of injury and risk factors, should be rapidly evaluated for possible injury. It is the authors' current belief that even the newest generation of CT scanners has not been proved to reliably diagnose BCVI. Until further work is done to advance the technology of CTA and prove its equivalence to DSA, there exists too much potential neurologic morbidity and mortality for one to rely on CTA alone (Table 2). Given the variable, and often low, reported sensitivities of CTA, the cost analysis done by Kaye and colleagues [23] would also recommend initial DSA as being cost-effective in avoiding the long-term devastating sequelae of stroke. At the time of writing the authors recommend that CTA be included in an algorithm to evaluate BCVI, but the current data are too disparate with widely variable reported sensitivities, and the risk of missed injury and stroke too severe, to rely on CTA as the definitive diagnostic or screening test for BCVI. Rather, abnormal CTA findings should be added to the traditional screening criteria to identify patients at risk of BCVI; these patients should be evaluated with DSA for definitive screening. Adding abnormal CTA findings to the traditionally described BCVI screening criteria widens the criteria substantially, allowing identification of almost all of the elusive 20% of patients traditionally not identified with basic screening criteria. In addition, given the high specificity of CTA and the decreased morbidity of BCVI with rapid institution of treatment, the authors recommend beginning a low-dose heparin drip (if there are no contraindications to anticoagulation) based on CTA findings while awaiting the confirmatory DSA. Despite advances in CTA technology in recent years, DSA currently remains the gold standard for the diagnosis of BCVI. All patients with standard risk factors for BCVI, or abnormal findings on CTA, should undergo DSA as the screening test of choice for BCVI.
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Lesões das Artérias Carótidas/diagnóstico por imagem , Traumatismos Cranianos Fechados/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Artéria Vertebral/lesões , Ferimentos não Penetrantes/diagnóstico por imagem , Falso Aneurisma/diagnóstico por imagem , Angiografia Digital , Dissecação da Artéria Carótida Interna/diagnóstico por imagem , Angiografia Cerebral , Serviço Hospitalar de Emergência , HumanosRESUMO
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.
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Embolização Terapêutica , Fraturas Ósseas , Ossos Pélvicos , Angiografia , Embolização Terapêutica/métodos , Fraturas Ósseas/complicações , Fraturas Ósseas/diagnóstico por imagem , Fraturas Ósseas/terapia , Hemorragia/diagnóstico por imagem , Hemorragia/etiologia , Humanos , Ossos Pélvicos/diagnóstico por imagem , Ossos Pélvicos/lesões , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
BACKGROUND: The Federal Assault Weapons Ban (FAWB) was in effect from 1994 to 2004. We sought to examine its impact on firearm-related homicides. METHODS: All firearm-related homicides occurring in three metropolitan United States cities were analyzed during the decade preceding (PRE), during (BAN), and after (POST) the FAWB. Files were obtained from the Federal Bureau of Investigation. Rates of firearm-related homicides were stratified by year and compared using simple linear regression. RESULTS: 21,327 firearm-related homicides were analyzed. The median number of firearm-related homicides per year decreased from 333 (PRE) to 199 (BAN) (p = 0.008). This effect persisted following expiration of the ban (BAN 199 vs POST 206, p = 0.429). The rate of firearm-related homicides per 1 M population also decreased from 119.4 in 1985 to 49.2 in 2014 (ß = -2.73, p < 0.0001). CONCLUSIONS: During the FAWB, there was a significant decrease in firearm-related homicides in three of the most dangerous cities, underscoring the need for better directed prevention efforts.
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Armas de Fogo , Suicídio , Ferimentos por Arma de Fogo , Homicídio , Humanos , Modelos Lineares , Registros , Estados Unidos/epidemiologia , Ferimentos por Arma de Fogo/epidemiologia , Ferimentos por Arma de Fogo/prevenção & controleRESUMO
BACKGROUND: Gun violence remains a significant public health problem. Although gun violence prevention efforts mostly target homicides, nationally, two-thirds of all firearm deaths are suicides. The purpose of this study was to define patterns of firearm-related deaths and examine the effect of population size. STUDY DESIGN: All firearm-related deaths in the US between 1999 and 2016 were analyzed. Homicides and suicides were obtained from the Federal Bureau of Investigation and the Centers for Disease Control and Prevention, respectively, comprising the database. For each state, the largest metropolitan city by population and a corresponding small urban city were selected. Firearm-related deaths were stratified by type and city size and compared. Rates of firearm-related homicides and suicides per 1 million population were stratified by year and compared over time using simple linear regression. RESULTS: 544,749 firearm-related deaths occurred across the US over the study period (38% homicides, 62% suicides). The median rate of firearm-related suicides was significantly greater than firearm-related homicides regardless of city size and across the US. Linear regression analysis failed to identify a significant change in the rate of firearm-related homicides over the study period. However, the rate of firearm-related suicides increased significantly regardless of city size between 1999 and 2016. CONCLUSION: Although homicides account for the majority of firearm-related deaths in metropolitan areas, suicides constitute a disproportionate number in smaller urban areas. Although the rate of homicides has stabilized, the rate of firearm-related suicides continues to increase significantly, underscoring the need for better direct prevention efforts and public health policy.
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Armas de Fogo , Prevenção do Suicídio , Ferimentos por Arma de Fogo , Causas de Morte , Homicídio/prevenção & controle , Humanos , Violência , Ferimentos por Arma de Fogo/epidemiologia , Ferimentos por Arma de Fogo/prevenção & controleRESUMO
BACKGROUND: Venous thromboembolism (VTE) is a common cause of serious morbidity and mortality. While chemoprophylaxis decreases VTE, there is the theoretical risk of increased hemorrhagic complications. The purpose of this study was to evaluate the impact of preoperative anticoagulation on VTE and bleeding complications in patients with blunt pelvic fractures requiring operative fixation. METHODS: Patients with blunt pelvic fractures requiring operative fixation over 10.5 years were identified. Patients were stratified by age, severity of shock, operative management, and timing and duration of anticoagulation. Outcomes were evaluated to determine risk factors for bleeding complications and VTE. RESULTS: 310 patients were identified: 212 patients received at least one dose of preoperative anticoagulation and 98 received no preoperative anticoagulation. 68% were male with a mean injury severity score and Glasgow Coma Scale of 26 and 13, respectively. Bleeding complications occurred in 24 patients and 21 patients suffered VTE. Patients with VTE had a greater initial severity of shock (resuscitation transfusions, 4 vs. 2 units, P = .02). Despite longer time to mobilization (4 vs. 3 days, P = .001), patients who received their scheduled preoperative doses within 48 hours of arrival had no significant differences in the number of deep vein thrombosis events (5.2% vs. 5.7%, P = .99), but fewer episodes of pulmonary embolism (PE) (1.5% vs. 6.8%, P = .03) with no difference in bleeding complications (7.5% vs. 8%, P = .87) compared to either patients who had their doses held until after 48 hours of arrival or received no preoperative anticoagulation. DISCUSSION: Preoperative anticoagulation prior to pelvic fixation reduced the risk of PE without increasing bleeding complications. Preoperative anticoagulation is safe and beneficial in this group of patients.
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Anticoagulantes/uso terapêutico , Fraturas Ósseas/cirurgia , Ossos Pélvicos/lesões , Complicações Pós-Operatórias/prevenção & controle , Tromboembolia Venosa/prevenção & controle , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Feminino , Escala de Coma de Glasgow , Heparina/efeitos adversos , Heparina/uso terapêutico , Heparina de Baixo Peso Molecular/efeitos adversos , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/induzido quimicamente , Complicações Pós-Operatórias/epidemiologia , Hemorragia Pós-Operatória/induzido quimicamente , Hemorragia Pós-Operatória/epidemiologia , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/prevenção & controle , Fatores de Risco , Tromboembolia Venosa/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Traumatic subclavian artery injury (SAI) remains uncommon but can lead to significant morbidity and mortality. Although open and endovascular repair offer excellent limb salvage rates, their role in blunt and penetrating injuries is not well defined. The goal of this study was to examine the effect of mechanism of injury and type of repair on outcomes in patients with traumatic SAI. STUDY DESIGN: Patients undergoing procedures for traumatic SAI were identified from the Trauma Quality Improvement Program database between 2015 and 2018. Demographics, severity of injury and shock, type of subclavian repair (open vs endovascular), morbidity, and mortality were recorded. Patients with SAI were stratified by mechanism and type of repair and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of mortality. RESULTS: Seven hundred thirty-seven patients undergoing procedures for SAI were identified. Of these, 39% were penetrating. The majority were male (80%) with a median age and Injury Severity Score (ISS) of 37 and 21, respectively. 58% of patients were managed endovascularly. For patients with blunt injury, the type of repair affected neither morbidity (25% vs 19%, p = 0.116) nor mortality (11% vs 10%, p = 0.70). For patients with penetrating injuries, endovascular repair had significantly lower morbidity (12% vs 22%, p = 0.028) and mortality (6% vs 21%, p = 0.001). MLR identified endovascular repair as the only modifiable risk factor associated with reduced mortality (odds ratio, 0.35; 95% confidence interval, 0.14 to 0.87, p = 0.02). CONCLUSIONS: SAI results in significant morbidity and mortality regardless of mechanism. Although the type of repair did not affect mortality in patients with blunt injury, endovascular repair was identified as the only modifiable predictor of reduced mortality in patients with penetrating injuries.
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Procedimentos Endovasculares , Traumatismos Torácicos , Lesões do Sistema Vascular , Ferimentos não Penetrantes , Ferimentos Penetrantes , Procedimentos Endovasculares/métodos , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Estudos Retrospectivos , Fatores de Risco , Artéria Subclávia/lesões , Artéria Subclávia/cirurgia , Fatores de Tempo , Resultado do Tratamento , Lesões do Sistema Vascular/cirurgia , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/cirurgia , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/cirurgiaRESUMO
INTRODUCTION: Cryoprecipitate is frequently administered as an adjunct to balanced transfusion in the setting of traumatic hemorrhage. However, civilian studies have not demonstrated a clear survival advantage, and prior observational studies noted selection bias when analyzing cryoprecipitate use. Additionally, due to the logistics involved in cryoprecipitate administration, it is inconsistently implemented alongside standardized massive transfusion protocols. This study aims to evaluate the effects of early cryoprecipitate administration on inpatient mortality in the setting of massive transfusion for exsanguinating trauma and to use propensity score analysis to minimize selection bias. METHODS: The registry of an urban level 1 trauma center was queried for adult patients who received at least 6 units of packed red blood cells within 4 h of presentation. Univariate analysis, multiple logistic regression, and propensity score matching were performed. RESULTS: 562 patients were identified. Patients with lower median RTS (6.86 (IQR 4.09-7.84) vs 7.6 (IQR 5.97-7.84), P<0.01), decreased Glasgow coma scale (12 (IQR 4-15) vs 15 (IQR 10-15), P<0.01), and increased lactate (7.5 (IQR 4.3-10.2) vs 4.9 (IQR 3.1-7.2), P<0.01) were more commonly administered cryoprecipitate. Mortality was greater among those who received cryoprecipitate (40.2% vs 23.7%, p<0.01) on univariate analysis. Neither multiple logistic regression (OR 0.917; 95% confidence interval 0.462-1.822; p = 0.805) nor propensity score matching (average treatment effect on the treated 2.3%, p = 0.77) revealed that cryoprecipitate administration was associated with a difference in inpatient mortality. CONCLUSIONS: Patients receiving cryoprecipitate within 4 h of presentation were more severely injured at presentation and had increased inpatient mortality. Multivariable logistic regression and propensity score analysis failed to show that early administration of cryoprecipitate was associated with survival benefit for exsanguinating trauma patients. The prospect of definitively assessing the utility of cryoprecipitate in exsanguinating hemorrhage warrants prospective investigation.
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Fibrinogênio , Ferimentos e Lesões , Adulto , Transfusão de Sangue , Exsanguinação , Fibrinogênio/uso terapêutico , Humanos , Escala de Gravidade do Ferimento , Pontuação de Propensão , Estudos Prospectivos , Estudos Retrospectivos , Ferimentos e Lesões/terapiaRESUMO
ABSTRACT: The associate membership of the American Association for the Surgery of Trauma (AAST) was established in 2019 to create a defined but incorporated entity within the larger AAST for the next generation of acute care surgeons. The Associate Member Council (AMC) was subsequently established in 2020 to provide the new AM with an elected group of leaders who would represent them within the AAST. In its inaugural year, this cohort of junior faculty and surgical trainees had developed for the AM a set of bylaws, a mission statement, a strategic vision, and a succession plan. The experience of the AAST AMC is exemplary of what can be accomplished with collaboration, mentorship, innovation, and tenacity. It has the potential to serve as a template for the creation and vitalization of future professional groups. In this piece, the AMC proposes a blueprint for the successful conception of a new organization.
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Cirurgiões , Cuidados Críticos , Humanos , Estudos Retrospectivos , Índice de Gravidade de Doença , Estados UnidosRESUMO
OBJECTIVE: We sought to determine the diagnostic accuracy of computed tomographic angiography (CTA) using 32-channel multidetector computed tomography for blunt cerebrovascular injuries (BCVIs). BACKGROUND: Unrecognized BCVI is a cause of stroke in young trauma patients. Digital subtraction angiography (DSA), the reference standard, is invasive, expensive, and time-consuming. Computed tomographic angiography has been rapidly adopted by many institutions because of its availability, less resource intensive, and noninvasive nature. However, conflicting results comparing CTA and DSA have been reported. Studies with 16-channel CTA report a wide range of sensitivities for BCVI diagnosis. METHODS: From January 2007 through May 2009, patients with risk factors for BCVI underwent both CTA and DSA. All CTAs were performed using a 32-channel multidetector CT scanner. Using DSA as the reference standard, the diagnostic accuracy of CTA for determination of BCVI was calculated. RESULTS: There were 684 patients who met the inclusion criteria. Ninety patients (13%) had 109 injuries identified; 52 carotid and 57 vertebral injuries were diagnosed. CTA failed to detect 53 confirmed BCVI, yielding a sensitivity of 51%. CONCLUSION: Given the devastation of stroke, and high mortality from missed injuries, this study demonstrates that even with more advanced technology (32 vs 16 channel), CTA is inadequate for BCVI screening. Digital subtraction angiography remains the gold standard for the diagnosis of BCVI.
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Angiografia Cerebral , Traumatismos Cranianos Fechados/diagnóstico por imagem , Processamento de Imagem Assistida por Computador , Hemorragia Intracraniana Traumática/diagnóstico por imagem , Tomografia Computadorizada Espiral , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiografia Digital/efeitos adversos , Angiografia Digital/normas , Morte Encefálica , Feminino , Traumatismos Cranianos Fechados/terapia , Humanos , Hemorragia Intracraniana Traumática/terapia , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Padrões de Referência , Estudos Retrospectivos , Sensibilidade e Especificidade , Adulto JovemRESUMO
OBJECTIVE: Recent reports indicate that mortality after trauma center admission may be directly related to the rate of operative intervention after blunt solid organ injury. These findings bring into question the role of urgent splenectomy after blunt splenic injury (BSI). The purpose of this study was to determine the role of urgent splenectomy (defined as splenectomy within 6 hours of admission) in the management of BSI as well as the relationship between urgent splenectomy and in-hospital mortality. METHODS: The National Trauma Data Bank for 2007 was queried for adults (18-81) who suffered BSI. Patients who died in or were transferred from the emergency department were excluded. Hierarchical multivariate models were used to account for clustering of patients within hospitals and to identify hospital and patient factors associated with urgent splenectomy. Propensity score matching was used to analyze the relationship between urgent splenectomy and mortality. RESULTS: There were 507,202 total incidents identified. Of those, 11,793 met inclusion criteria. Urgent splenectomy was performed on 1,104 (9.4%). Hierarchical models revealed that age ≥55 years, arrival systolic blood pressure ≤90 mm Hg, no or mild head injury, increasing injury severity, and massive disruption of the spleen were associated with urgent splenectomy. Hospitals level factors associated with urgent splenectomy included hospital region, hospital type, and trauma center level. The propensity-matched cohorts revealed no association between urgent splenectomy and in-hospital mortality (odds ratio, 1.08; 95% confidence interval, 0.82-1.42). CONCLUSION: Despite ongoing variation in the use of urgent splenectomy after BSI in adults, urgent splenectomy was not associated with in-hospital mortality.