Emergent colectomy for colorectal cancer: A comparative analysis of open vs. minimally invasive approach.

INTRODUCTION: Emergent surgery for colorectal cancer (CRC) is associated with higher rates of morbidity and mortality and outcomes differ by surgical approach. METHODS: Our study compares short-term surgical outcomes of patients undergoing emergent colectomy for CRC using the open vs minimally invasive (MIS) approach. We performed a four-year review (2012-2015) of the ACS-NSQIP Colectomy dataset and included all adult patients with CRC who underwent emergent surgical intervention. Patients were stratified into groups based on surgical approach: Open and MIS (including laparoscopic and robotic). RESULTS: A total of 1855 (MIS: 279, Open: 1576) patients were included. Outcome measures were operative time, 30-day complications, 30-day readmission, and 30-day mortality. Multivariate Regression analysis was performed. Patients in the open group were more likely to be older (70y vs. 61y, p < 0.01), have higher ASA class, and were less likely to have received mechanical bowel preparation. On univariate analysis, patients in the MIS group had longer operative time (189 ± 41 min vs. 161 ± 69 min, p < 0.01). Patients in the open group had higher rates of mortality (6.7% vs. 3.8%, p < 0.01) and 30-day complications (28.1% vs. 16.7%, p < 0.01). On regression analysis, the open approach was independently associated with higher odds of 30-day mortality and 30-day complications. CONCLUSION: Given the lower overall mortality and complications, MIS colectomy may be a safer approach in the emergent treatment of patients with colorectal cancer.

Pre-Hospital Administration of Opioids in Trauma Patients: Is Dose Associated With Outcomes?

BACKGROUND: Opioids are commonly used as an analgesic agent in the prehospital setting. Current efforts to prevent and control prescription opioid overuse are focused on the in-hospital and post-discharge phases. The aim of our study was to assess the associations between pre-hospital opioids use and in-hospital outcomes among trauma patients. METHODS: We performed a 2 year (2016-2017) retrospective analysis of our Level-I trauma center database. We included all adult trauma patients (age > 18y) who received pre-hospital opioids (Fentanyl (F) or Morphine-Sulfate (MS)). Outcome measures were emergency-department (ED) hypotension (SPB < 90 mmHg), ED intubation, prescription opioid medication upon discharge, and mortality. Multivariate logistic regression was performed. RESULTS: In total, 709 patients were included in the analysis. Cutoff values of 200 mcg F and 15 mg MS were significantly associated with adverse outcomes. Overall, the ED hypotension rate was 14.4%, ED intubation rate was 6%, and ED mortality rate was 3.1%. On regression analysis, higher dosages of both pre-hospital F and pre-hospital MS were independently associated with increased odds of ED hypotension, ED intubation, and discharge on opioid medications, but not with ED mortality. CONCLUSION: Pre-hospital administration of high dose opioids is associated with increased odds of adverse outcomes. Collaborative efforts to standardize and control the overuse of opioids should target the pre-hospital setting to limit opioid associated adverse effects.

Trends in Geriatric Ground-Level Falls: Report from the National Trauma Data Bank.

INTRODUCTION: Ground-level falls (GLF) are typically reported as a minor mechanism of injury; however, they represent a significant portion of hospitalized geriatric trauma patients as they can result in multisystem injury in this subset of the population. Our study aimed to analyze trends in geriatric trauma falls on the national level. METHODS: We performed a 5-y (2011-2015) analysis of the American College of Surgeons National Trauma Data Bank (ACS-NTDB) and included all geriatric trauma patients (age ≥ 65 y) who presented with GLF. GLF was identified using ICD-9 E CODES. Our outcome measures were national incidence of GLF, and overall discharge disposition and trauma center level discharge disposition following GLF. We used Cochran Armitage test and multivariate regression analysis. RESULTS: We analyzed a total of 1,017,326 geriatric trauma patients, of which 39% had had a fall as a mechanism of injury. Among those who fell, mean age was 78 ± 7, 63% were females, and 85% were whites. The incidence of falls significantly increased over the study period, and was noted to be proportional to age, with a plateau beyond age 85 y old. The rate of discharge to SNF and/or Rehab significantly increased over the study period; however, discharge to home and mortality rates trended downwards over the study period. Discharge to SNF and/or Rehab was significantly lower among level I trauma centers compared to other level trauma centers. Conversely, discharge to home was higher in level I trauma centers compared to other level trauma centers. CONCLUSION: Around one in three elderly trauma patients were admitted following a GLF with an overall increased incidence of falls over time. Although overall mortality rates decreased, there was an increase in adverse discharge disposition and loss of functional independence over the study period, mostly among those admitted to non-level I trauma centers.

Four-factor prothrombin complex concentrate in adjunct to whole blood in trauma-related hemorrhage: Does whole blood replace the need for factors?

BACKGROUND: The use of whole blood (WB) for the treatment of hemorrhagic shock and coagulopathy is increasing in civilian trauma patients. Four-factor prothrombin complex concentrate (4-PCC) in adjunct to component therapy showed improved outcomes in trauma patients. Our study aims to evaluate the outcomes of trauma patients who received 4-PCC and WB (4-PCC-WB) compared with WB alone. METHODS: We performed a 3-year (2015-2017) analysis of the American College of Surgeons-Trauma Quality Improvement Program database. All adult (age, ≥18 years) trauma patients who received WB were included. We excluded patients who were on preinjury anticoagulants. Patients were stratified into two groups, 4-PCC-WB versus WB alone, and matched in a 1:2 ratio using propensity score matching. Outcome measures were packed red blood cells, plasma, platelets, and cryoprecipitate transfused, in-hospital complications, hospital and intensive care unit (ICU) length of stay (LOS) among survivors, and mortality. RESULTS: A total of 252 patients (4-PCC-WB, 84; WB alone, 168) were matched. The mean ± SD age was 47 ± 21 years, 63% were males, median Injury Severity Score was 30 (21-40), and 87% had blunt injuries. Patients who received 4-PCC-WB had decreased requirement for packed red blood cell (8 U vs. 10 U, p = 0.04) and fresh frozen plasma (6 U vs. 8 U, p = 0.01) transfusion, lower rates of acute kidney injury (p = 0.03), and ICU LOS (5 days vs. 8 days, p = 0.01) compared with WB alone. There was no difference in the platelet transfusion (p = 0.19), cryoprecipitate transfusion (p = 0.37), hospital LOS (p = 0.72), and in-hospital mortality (p = 0.72) between the two groups. CONCLUSION: Our study demonstrates that the use of 4-PCC as an adjunct to WB is associated with a reduction in transfusion requirements and ICU LOS compared with WB alone in the resuscitation of trauma patients. Further studies are required to evaluate the role of PCC with WB in the resuscitation of trauma patients. LEVEL OF EVIDENCE: Therapeutic, level III.

Open vs Endovascular Treatment of Traumatic Peripheral Arterial Injury: Propensity Matched Analysis.

BACKGROUND: Arterial injuries occur in the setting of blunt and penetrating trauma. Despite increasing use, there remains a paucity of data comparing long-term outcomes of endovascular vs open repair management of these injuries. The aim of our study was to compare outcomes and readmission rates of open vs endovascular repair of traumatic arterial injuries. STUDY DESIGN: The National Readmission Database (2011-2014) was queried for all adult (age ≥ 18 y) patients presenting with peripheral arterial (axillary, brachial, femoral, and popliteal) injuries. Patients were stratified into 2 groups based on intervention: open vs endovascular approach. Propensity score matching (1:2 ratio) was performed. Outcomes measures were complications, length of stay (LOS), 30-day readmission, and cost of readmission. RESULTS: A matched cohort of 786 patients was obtained (endovascular: 262, open: 524). Mean age was 45 ± 17 years, and 79% were males. Median LOS was 4 (range 2-6) days for the endovascular group vs 3 (range 2-5) days for the open group (p < 0.01). The endovascular group had higher rates of seroma (4% vs 2%; p = 0.04) and arterial thrombosis (13% vs 7%; p < 0.01) during index hospitalization. Patients who underwent endovascular repair had higher 30-day readmission (11% vs 7%; p = 0.03) and a higher 30-day open-reoperation rate (6% vs 2%; p < 0.01). On subanalysis of the patients who were readmitted, the median cost of each readmission was higher in the endovascular group $47,000 ($27,202-$56,763) compared with $21,000 ($11,889-$43,503) in the open group. CONCLUSIONS: Endovascular repair for peripheral arterial injuries was associated with higher rates of in-hospital complications, readmissions, and costs. As this new technology continues to undergo refinement, a thorough re-evaluation of its indications, risks, and benefits is warranted.

Racial and Ethnic Disparities in Frail Geriatric Trauma Patients.

BACKGROUND: Frailty in geriatric trauma patients is commonly associated with adverse outcomes. Racial disparities in geriatric trauma patients are previously described in the literature. We aimed to assess whether race and ethnicity influence outcomes in frail geriatric trauma patients. METHODS: We performed a 1-year (2017) analysis of TQIP including all geriatric (age ≥ 65 years) trauma patients. The frailty index was calculated using 11-variables and a cutoff limit of 0.27 was defined for frail status. Multivariate regression analysis was performed to control for demographics, insurance status, injury parameters, vital signs, and ICU and hospital length of stay. RESULTS: We included 41,111 frail geriatric trauma patients. In terms of race, among frail geriatric trauma patients, 35,376 were Whites and 2916 were African Americans; in terms of ethnicity, 37,122 were Non-Hispanics and 2184 were Hispanics. On regression analysis, the White race was associated with higher odds of mortality (OR, 1.5; 95% CI, 1.2-2.0; p < 0.01) and in-hospital complications (OR, 1.4; 95% CI, 1.1-1.9; p < 0.01). White patients were more likely to be discharged to SNF (OR, 1.2; 95% CI, 1.1-1.4; p = 0.03) and less likely to be discharged home (p = 0.04) compared to African Americans. Non-Hispanics were more likely to be discharged to SNF (OR, 1.3; 95% CI, 1.1-1.5; p < 0.01) and less likely to be discharged home (p < 0.01) as compared to Hispanics. No significant difference in in-hospital mortality was seen between Hispanics and Non-Hispanics. CONCLUSION: Race and ethnicity influence outcomes in frail geriatric trauma patients. These disparities exist regardless of age, gender, injury severity, and insurance status. Further studies are needed to highlight disparities by race and ethnicity and to identify potentially modifiable risk factors in the geriatric trauma population.

Managing acute uncomplicated appendicitis in frail geriatric patients: A second hit may be too much.

INTRODUCTION: Studies have proposed the use of antibiotics only in cases of acute uncomplicated appendicitis (AUA). However, there remains a paucity of data evaluating this nonoperative approach in the vulnerable frail geriatric population. The aim of this study was to examine long-term outcomes of frail geriatric patients with AUA treated with appendectomy compared with initial nonoperative management (NOP). METHODS: We conducted a 1-year (2017) analysis of the Nationwide Readmissions Database and included all frail geriatric patients(age, ≥65 years) with a diagnosis of AUA. Frailty was assessed using the five-factor modified frailty index. Patients were stratified into those undergoing appendectomy at index admission (operative management) versus those receiving antibiotics only without operative intervention (NOP). Propensity score matching in a 1:1 ratio was performed adjusting for patient- and hospital-related factors. RESULTS: A total of 5,562 frail geriatric patients with AUA were identified from which a matched cohort of 1,320 patients in each group was obtained. Patients in the NOP and operative management were comparable in terms of age (75.5 ± 7.7 vs. 75.5 ± 7.4 years; p = 0.882) and modified frailty index (0.4 [0.4-0.6] vs. 0.4 [0.4-0.6]; p = 0.526). Failure of NOP management was reported in 18% of patients, 95% of which eventually underwent appendectomy. Over the 6-month follow-up period, patients in the NOP group had significantly higher rates of Clostridium difficile enterocolitis (3% vs. 1%; p < 0.001), greater number of overall hospitalized days (5 [3-9] vs. 4 [2-7] days; p < 0.001), and higher overall costs (US $16,000 [12,000-25,000] vs. US $11,000 [8,000-19,000]; p < 0.001). Patients undergoing appendectomy after failed NOP had significantly higher rates of complications (20% vs. 11%; p < 0.001), mortality (4% vs. 2%; p = 0.019), and appendiceal neoplasm (3% vs. 1%; p = 0.027). CONCLUSION: One in six patients failed NOP within 6 months and required appendectomy with subsequent more complications and higher mortality. Appendectomy may offer better outcomes in managing AUA in the frail geriatric population. LEVEL OF EVIDENCE: Therapeutic, level IV.

Prospective Evaluation of Health Literacy and Its Impact on Outcomes in Emergency General Surgery.

BACKGROUND: Health literacy (HL) is an important component of national health policy. The aim of our study was to assess the prevalence of low HL (LHL) and determine its impact on outcomes after emergency general surgery (EGS). METHODS: We performed a (2016-2017) prospective cohort analysis of adult EGS patients. HL was assessed using the Short Assessment of HL score. LHL was defined as Short Assessment of HL score <14. Outcomes were the prevalence of LHL, compliance with medications, wound/drain care, 30-d complications, 30-d readmission, and time to resuming activities of daily living. RESULTS: We enrolled 900 patients. The mean age was 43 ± 11 y. Overall, 22% of the patients had LHL. LHL patients were more likely to be Hispanics (59% versus 15%, P < 0.01), uninsured (50% versus 20%, P < 0.01), have lower socioeconomic status (80% versus 40%, P < 0.02), and are less likely to have completed college (5% versus 60%, P < 0.01) compared with HL patients. On regression analysis, LHL was associated with lower medication compliance (OR: 0.81, [0.4-0.9], P = 0.02), inadequate wound/drain care (OR: 0.75, [0.5-0.8], P = 0.01), 30-d complications (OR: 1.95, [1.3-2.5], P < 0.01), and 30-d readmission (OR: 1.51, [1.2-2.6], P = 0.02). The median time of resuming activities of daily living was longer in patients with LHL than HL patients (4 d versus 7 d, P < 0.01). CONCLUSIONS: One in five patients undergoing EGS has LHL. LHL is associated with decreased compliance with discharge instructions, medications, and wound/drain care. Health literacy must be taken into account when discussing the postoperative plan and better instruction is needed for patients with LHL. LEVEL OF EVIDENCE: Level III. STUDY TYPE: Prognostic.

Traumatic brain injury induced temperature dysregulation: What is the role of ß blockers?

BACKGROUND: Traumatic brain injury (TBI) is associated with sympathetic discharge that leads to posttraumatic hyperthermia (PTH). Beta blockers (ßß) are known to counteract overactive sympathetic discharge. The aim of our study was to evaluate the effect of ßß on PTH in critically-ill TBI patients. METHODS: We performed retrospective cohort analysis of the Medical Information Mart for Intensive Care database. We included all critically ill TBI patients with head Abbreviated Injury Scale (AIS) score of 3 or greater and other body region AIS score less than 2 who developed PTH (at least one febrile episode [T > 38.3°C] with negative microbiological cultures (blood, urine, and bronchoalveolar lavage). Patients on preinjury ßß were excluded. Patients were stratified into (ßß+) and (ßß-) groups. Propensity score matching was performed (1:1 ratio) controlling for patient demographics, injury parameters and other medications that influence temperature. Outcomes were the number of febrile episodes, maximum temperature, and the time interval between febrile episodes. Multivariate linear regression was performed. RESULTS: We analyzed 4,286 critically ill TBI patients. A matched cohort of 1,544 patients was obtained: 772 ßß + (metoprolol, 60%; propranolol, 25%; and atenolol, 15%) and 772 ßß-. Mean age was 63.4 ± 15.4 years, median head AIS score of 3 (3-4), and median Injury Severity Score of 10 (9-16). Patients in the ßß+ group had a lower number of febrile episodes (8 episodes vs. 12 episodes; p = 0.003), lower median maximum temperature (38.0°C vs. 38.5°C; p = 0.025), and a longer median time between febrile episodes (3 hours vs. 1 hour; p = 0.013). On linear regression, propranolol was found to be superior in terms of reducing the number of febrile episodes and the maximum temperature. However, there was no significant difference between the three ßß in terms of reducing the time interval between febrile episodes (p = 0.582). CONCLUSION: Beta blockers attenuate PTH by decreasing the frequency of febrile episodes, increasing the time interval between febrile episodes, and reducing the maximum rise in temperature. ßß may be a potential therapeutic modality in PTH. LEVEL OF EVIDENCE: Therapeutic, level IV.

Telemedicine in the ICU: Innovation in the Critical Care Process.

Tele-ICU is a technology-based model designed to deliver effective critical care in the intensive care unit (ICU). The tele-ICU system has been developed to address the increasing demand for intensive care services and the shortage of intensivists. A finite number of intensivists from remote locations provide real-time services to multiple ICUs and assist in the treatment of critically ill patients. Risk prediction algorithms, smart alarm systems, and machine learning tools augment conventional coverage and can potentially improve the quality of care. Tele-ICU is associated with substantial improvements in mortality, reduced hospital and ICU length of stay, and decreased health care costs. Although multiple studies show improved outcomes following the implementation of tele-ICU, results are not consistent. Several factors, including the heterogeneity of tele-ICU infrastructure deployed in different facilities and the reluctance of health care workers to accept tele-ICU, could be associated with these varied results. Considerably high installation and ongoing operational costs might also be limiting the widespread utilization of this innovative service. While we believe that the implementation of tele-ICU offers potential advantages and makes critical care delivery more efficient, further research on the impact of this technology in critical care settings is warranted.

The Emergency Department Systolic Blood Pressure Relationship After Traumatic Brain Injury.

BACKGROUND: Blood pressure alterations in patients with traumatic brain injury (TBI) have been shown to be associated with increased mortality. However, there is paucity of data describing the optimal emergency department (ED) systolic blood pressure (SBP) target during the initial evaluation. The aim of our study was to assess the association between SBP on presentation and mortality in patients with TBI. METHODS: We performed a retrospective (2015-2016) review of the American College of Surgeons Trauma Quality Improvement Program database and included all adult (age ≥18y) trauma patients who had TBI on presentation. The outcome measure was in-hospital mortality at different ED-SBP values. A subanalysis by age and TBI severity in accordance with the Glasgow Coma Scale (GCS) was performed (mild (GCS ≥13), moderate (GCS 9-12), and severe (≤8)). Multivariate logistic regression analysis was performed. RESULTS: A total of 94,411 adult trauma patients with TBI were included. Mean age was 59 ± 21y, 62% were male, and median GCS was 15 [14-15]. Mean SBP was 147 ± 28 mmHg, and overall mortality was 8.6%. The lowest rate of mortality was noticed at ED SBP between 110 and 149 mmHg, whereas the highest mortality was at admission SBP <90 mmHg and SBP >190 mmHg. On regression analysis, SBP between 130 and 149 mmHg (odds ratio = 0.92; P = 0.68) was not associated with increased odds of mortality relative to SBP between 110 and 129 mmHg. On subanalysis based on severity of TBI (mild 80.9%, moderate 5.3%, and severe 13.8%), patients with SBP between 110 and 149 mmHg were less likely to die across all TBI groups. CONCLUSIONS: The optimal ED-SBP range for patients with TBI seems to be age and severity dependent. The optimum range might guide clinicians in developing resuscitation protocols for managing patients with TBI. LEVEL OF EVIDENCE: Level III Prognostic.

Regionalization of trauma care by operative experience: Does the volume of emergent laparotomy matter?

INTRODUCTION: The volume-outcome relationship led to the regionalization of trauma care. The relationship between trauma centers' injury-specific laparotomy volume and outcomes has not been explored. The aim of our study was to examine the relationship between a trauma center's injury-specific laparotomy volume and outcomes in blunt and penetrating trauma patients. METHODS: We performed a (2017) analysis of the Trauma Quality Improvement Program database. We included adult (age, ≥18 years) blunt and penetrating trauma patients who required emergent laparotomies for hemorrhage control. Trauma centers were stratified based on their blunt and penetrating laparotomy volumes: high volume (HV), ≥25 cases per year; medium volume (MV), 13 to 24 cases per year; and low volume (LV), ≤12 cases per year. Multivariate regression analysis was performed to explore predictors of in-hospital mortality. RESULTS: A total of 8,588 patients underwent emergent laparotomy for either blunt (4,936; 57.5%) or penetrating injuries (3,652; 42.5%). Overall, mean ± SD age was 40 ± 17 years, abdomen Abbreviated Injury Scale was 3 (2-4), and Injury Severity Score was 26 (17-35). For American College of Surgeons (ACS) level I centers, 50% were HV; 29%, MV; and 21%, LV. For ACS level II centers, 7% were HV; 23%, MV; and 70%, LV. For ACS level III centers, 100% were LV. On multivariate regression analysis, admission of blunt and penetrating trauma patients to HV blunt and HV penetrating centers, respectively, was independently associated with improved in-hospital mortality. High-volume blunt centers had a significantly lower time to laparotomy (72 [41-144] minutes) versus MV (81 [49-145] minutes) and LV (94 [56-158] minutes) centers (p < 0.001). The same trend was observed for HV penetrating trauma centers (35 [24-52] minutes) versus MV (46 [33-63] minutes) and LV (51 [38-69] minutes) centers (p < 0.001). CONCLUSION: Blunt and penetrating injury patients requiring emergent laparotomy had higher survival when admitted to trauma centers with HV operative experience for their particular mechanism of injury. The regionalization of trauma care should be based on a thorough evaluation of trauma centers' injury-specific operative experience. LEVEL OF EVIDENCE: Prognostic, Level III; Therapeutic/Care management, Level IV.

The survival benefit of low molecular weight heparin over unfractionated heparin in pediatric trauma patients.

INTRODUCTION: Venous thromboembolism (VTE) prophylaxis in pediatric patients is controversial and is mainly dependent on protocols derived from adult practices. Our study aimed to compare outcomes among pediatric trauma patients who received low molecular weight heparin (LMWH) compared to those who received unfractionated heparin (UFH). METHODS: We performed 2 years (2015-2016) retrospective analysis of the Pediatrics ACS-TQIP database. Pediatric trauma patients (age ≤17) who received thromboprophylaxis with either LMWH or UFH were included. Patients were stratified into three age groups. Analysis of each subgroup and the entire cohort was performed. Outcome measures included VTE events (deep vein thrombosis [DVT] and pulmonary embolism [PE]), hospital and ICU length of stay (LOS) among survivors, and mortality. Propensity score matching was used to match the two cohorts LMWH vs UFH. RESULTS: A matched cohort of 1,678 pediatric trauma patients was analyzed. A significant difference in survival, DVT events, and in-hospital LOS was seen in the age groups above 9 years. Overall, the patients who received LMWH had lower mortality (1.4% vs 3.6%, p<0.01), DVT (1.7% vs 3.7%, p<0.01), and hospital LOS among survivors (7 days vs 9 days, p<0.01) compared to those who received UFH. There was no significant difference in the ICU LOS among survivors and the incidence of PE between the two groups. CONCLUSION: LMWH is associated with increased survival, lower rates of DVT, and decreased hospital LOS compared to UFH among pediatric trauma patients age 10-17 years. LEVEL OF EVIDENCE: Level III Prophylactic. STUDY TYPE: Prophylactic.

Platelet Transfusion After Traumatic Intracranial Hemorrhage in Patients on Antiplatelet Agents.

BACKGROUND: With an aging population, the number of patients on antiplatelet medications and traumatic brain injury (TBI) is increasing. Our study aimed to evaluate the role of platelet transfusion on outcomes after traumatic intracranial bleeding (IB) in these patients. METHODS: We analyzed our prospectively maintained TBI database from 2014 to 2016. We included all isolated TBI patients with an IB, who were on preinjury antiplatelet agents and excluded patients taking anticoagulants. Outcome measures included the progression of IB, neurosurgical intervention, and mortality. Regression analysis was performed. RESULTS: A total of 343 patients met the inclusion criteria. Mean age was 58 ± 11 y, 58% were men, and median injury severity score was 15 (10-24). Distribution of antiplatelet agents was as follows: aspirin (60%) and clopidogrel (35%). Overall, 74% patients received platelet transfusion after admission with a median number of two platelet units. After controlling for confounders, patients who received one unit of pooled platelets had no difference in progression of IB (odds ratio [OR]: 0.98, [0.6-1.9], P = 0.41), need for neurosurgical intervention (OR: 1.09, [0.7-2.5], P = 0.53), and mortality (OR: 0.84, [0.6-1.8], P = 0.51). However, patients who received two units of pooled platelets had lower rate of progression of IB (OR: 0.69, [0.4-0.8], P = 0.02), the need for neurosurgical intervention (OR: 0.81, [0.3-0.9], P = 0.03), and mortality (OR: 0.84, [0.5-0.9], P = 0.04). Both groups were compared with those who did not receive platelet transfusion. CONCLUSIONS: The use of two units of platelet may decrease the risk of IB progression, neurosurgical intervention, and mortality in patients on preinjury antiplatelet agents and TBI. Further studies should focus on developing protocols for platelet transfusion to improve outcomes in these patients. LEVEL OF EVIDENCE: Level III prognostic.

Delta Shock Index Predicts Outcomes in Pediatric Trauma Patients Regardless of Age.

INTRODUCTION: Changes in the shock index (ΔSI) can be a predictive tool but is not established among pediatric trauma patients. The aim of our study was to assess the impact of ΔSI on mortality in pediatric trauma patients. METHODS: We performed a 2017 analysis of all pediatric trauma patients (age 0-16 y) from the ACS-TQIP. SI was defined as heart rate(HR)/systolic blood pressure(SBP). We abstracted the SI in the field (EMS), SI in the emergency department (ED) and calculated the change in SI (ΔSI = ED SI-EMS SI). Patients were divided into four age groups: 0-3 y, 4-6 y, 7-12 y, and 13-16 y and substratified into two groups based on the value of the age-group-specific ΔSI cutoff obtained with receiver operating characteristic ROC analysis; +ΔSI and -ΔSI. Our outcome measure was mortality. Multivariable logistic and Cox regression analyses were performed. RESULTS: We included 31,490 patients. Mean age was 10.6 ± 4.6 y, and 65.8% were male. The overall mortality rate was 1.4%. In the age group 0-3 y the cutoff point for ΔSI was 0.29 with an area under the curve (AUC) 0.70 [0.62-0.79], ΔSI cutoff 4-6 y was 0.41 AUC 0.81 [0.70-0.92], ΔSI cutoff 7-12 y was 0.05 AUC 0.83 [0.76-0.90], and ΔSI cutoff 13-16 y was 0.13 AUC 0.75 [0.69-0.81]. On the Cox regression analysis, +ΔSI was independently associated with increased in-hospital mortality and 24-h mortality (P ≤ 0.01). CONCLUSIONS: Vital signs vary by age group in children, but ΔSI inherently accounts for this variation. ΔSI predicts mortality and may be utilized as a predictor to help guide triage of pediatric trauma patients. LEVEL OF EVIDENCE: Level III Prognostic.

Resuscitative Endovascular Balloon Occlusion of the Aorta vs Pre-Peritoneal Packing in Patients with Pelvic Fracture.

BACKGROUND: Pelvic hemorrhage is potentially lethal despite homeostatic interventions such as pre-peritoneal packing (PP), resuscitative endovascular balloon occlusion of the aorta (REBOA), surgery, and/or angioembolization. REBOA may be used as an alternative/adjunct to PP for temporizing bleeding in patients with pelvic fractures. Our study aimed to compare the outcomes of REBOA and/or PP, as temporizing measures, in blunt pelvic fracture patients. We hypothesized that REBOA is associated with worsened outcomes. STUDY DESIGN: We performed a 2017 review of the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) and identified trauma patients with blunt pelvic fractures who underwent REBOA placement and/or PP before laparotomy and/or angioembolization. Propensity score matching was performed, adjusting for demographics, vitals, mechanism of injury, ISS, each body region-AIS, and pelvic fracture type. Outcomes were complication rates and mortality. RESULTS: A total of 156 patients (PP: 52; REBOA: 52; REBOA+PP: 52) were matched and included. Mean age was 43 ± 18 years, Injury Severity Score (ISS) was 28 (range 17-32), and 74% were males. Overall mortality was 42%. The 24-hour mortality (25% vs 14% vs 35%; p = 0.042), in-hospital mortality (44% vs 29% vs 54%; p = 0.034), and 4-hour pRBC units transfused (15 [9-23] vs 10 [4-19] vs 16 [9-27]; p = 0.017) were lower in the REBOA group. The REBOA group had faster times to both laparotomy (p = 0.040) and/or angioembolization (p = 0.012). There was no difference between the groups in acute kidney injury, lower limb amputations, or hospital and ICU length of stay among survivors. CONCLUSIONS: REBOA is a less invasive procedure compared with PP and is associated with improved outcomes. Further clinical trials are needed to define the optimal patient who will benefit from REBOA.

Readmission With Major Abdominal Complications After Penetrating Abdominal Trauma.

BACKGROUND: Despite improvements in operative techniques, major abdominal complications (MACs) continue to occur after penetrating abdominal trauma (PAT). This study aimed to evaluate the burden of MAC after PAT. METHODS: The (2012-2015) National Readmission Database was queried for all adult (age ≥18 y) trauma patients with penetrating injuries who underwent exploratory laparotomy and were readmitted within 6 mo of index hospitalization discharge. Patients were stratified by firearm injuries (FIs) and stab injuries (SIs). Primary outcomes were rates of MAC: intra-abdominal abscesses (IAAs), superficial surgical site infection (SSI), and fascial dehiscence within 6 mo after discharge. Secondary outcomes were both nonabdominal complications and mortality, postdischarge, and 6-mo readmission. Regression analysis was performed. RESULTS: A total of 4473 patients (FI, 2326; SI, 2147) were included in the study; the mean age was 32 ± 14 y, the Injury Severity Score was 19 (15-25), and 23% underwent damage control laparotomy (DCL). The rate of MAC within 6 mo was 22% (IAA 19%, SSI 7%, and fascial dehiscence 4%). Patients with FIs had a higher rate of IAA (27% versus 10%; P < 0.01), SSI (11% versus 3%; P < 0.01), fascial dehiscence (5% versus 3%; P = 0.03), nonabdominal complications (54% versus 24%; P < 0.01), and postdischarge mortality (8% versus 6%; P < 0.01) compared with patients with SIs . On regression analysis, DCL (P < 0.01), large bowel perforation (P < 0.01), biliary-pancreatic injury (P < 0.01), hepatic injury (P < 0.01), and blood transfusion (P = 0.02) were predictors of MAC. CONCLUSIONS: MAC developed in one in five patients after PAT. FIs have a higher potential for hollow viscus injury and peritoneal contamination, and are more predictive of MAC and nonabdominal complications, especially after DCL. LEVEL OF EVIDENCE: Level III Prognostic.

Angioembolization in intra-abdominal solid organ injury: Does delay in angioembolization affect outcomes?

INTRODUCTION: Angioembolization (AE) is an integral component in multidisciplinary algorithms for achieving hemostasis in patients with trauma. The American College of Surgeons Committee on Trauma recommends that interventional radiologists be available within 30 minutes to perform emergent AE. However, the impact of the timing of AE on patient outcomes is still not well known. We hypothesized that a delay in AE would be associated with increased mortality and higher blood transfusion requirements in patients with blunt intra-abdominal solid organ injury. METHODS: A 4-year (2013-2016) retrospective review of the ACS Trauma Quality Improvement Program database was performed. We included adult patients (age, ≥18 years) with blunt intra-abdominal solid organ injury who underwent AE within 4 hours of hospital admission. Patients who underwent operative intervention before AE were excluded. The primary outcome was 24-hour mortality. The secondary outcome was blood product transfusions. Patients were grouped into four 1-hour intervals according to their time from admission to AE. Multivariate regression analysis was performed to accommodate patient differences. RESULTS: We analyzed 1,009,922 trauma patients, of which 924 (1 hour, 76; 1-2 hours, 224; 2-3 hours, 350; 3-4 hours, 274) were deemed eligible. The mean ± SD age was 44 ± 19 years, and 66% were male. The mean ± SD time to AE was 144 ± 54 minutes, and 92% of patients underwent AE more than 1 hour after admission. Overall 24-hour mortality was 5.2%. On univariate analysis, patients receiving earlier AE had decreased 24-hour mortality (p = 0.016), but no decrease in blood products transfused. On regression analysis, every hour delay in AE was significantly associated with increased 24-hour mortality (p < 0.05). CONCLUSION: Delayed AE for hemorrhagic control in blunt trauma patients with an intra-abdominal solid organ injury is associated with increased 24-hour mortality. Trauma centers should ensure timeliness of interventional radiologist availability to prevent a delay in vital AE, and it should be a focus of quality improvement projects. LEVEL OF EVIDENCE: Prognostic, level III.