Overutilization of Helicopter Emergency Medical Services in Central Gulf Coast Region Results in Unnecessary Expenditure.

INTRODUCTION: When appropriately used, helicopter emergency medical services (HEMSs) allow for timely delivery of severely injured patients to definitive care. Inappropriate utilization of HEMSs results in increased cost to the patient and trauma system. The purpose of this study was to review current HEMS criteria in the central Gulf Coast region and evaluate for potential areas of triage refinement and cost savings. We hypothesized that a significant number of patients received potentially unwarranted HEMS transport. METHODS: A retrospective cohort study of all patients with trauma arriving to a level I trauma center by helicopter over 28 mo was performed; 381 patients with trauma and with HEMS transport from the scene were included. Data were collected from prehospital sources, as well as hospital chart review for each patient. The primary outcome was the rate of unwarranted HEMS transport. RESULTS: A total of 381 adult patients with trauma transported by the HEMS were analyzed, of which 34% were deemed potentially nonwarranted transports. The significant factors correlating with warranted HEMS transport included age, multiple long bone fractures, penetrating mechanism, and vehicle ejection. Insurance demographics did not correlate to transport modality. Many of these patients were transported from a location within the same county or the county adjacent to the trauma center. When comparing patients transported by ground and HEMSs from the same scene, no time savings were identified. Unwarranted transports at the trauma center represented an estimated health care expenditure of over $3 million. CONCLUSIONS: HEMSs may be overused in the central Gulf Coast region, creating the risk for a substantial resource and financial burden to the trauma system. Further collaboration is needed to establish HEMS triage criteria, that is, more appropriate use of resources.

The Treatment of Rib Fractures : A Single-Center Comparison.

BACKGROUND: Rib fractures are a major problem characterized by pain, increased length of stay, and respiratory complications. Treatments include fixation, management with opiates, paraspinous local anesthetic pumps, and intercostal nerve blocks. The aim of this study was to evaluate the use of treatment options and compare clinically relevant outcomes. METHODS: Patients admitted to a Level 1 trauma center with multiple rib fractures between 2015 and 2019 were screened. We included all participants treated with surgical fixation and/or intercostal nerve block or local anesthetic pump. Patients were case-matched 1:2 by Injury Severity Score (ISS), Abbreviated Injury Scale (AIS) Chest and Head, age, and number of rib fractures. Outcomes assessed were hospital length of stay (LOS), intensive care unit (ICU) LOS, ventilator days, pneumonia, and tracheostomy rates. RESULTS: We identified 25 patients who received rib fixation and intercostal analgesia. Of these, 14 cases were treated with liposomal bupivaicaine nerve block and 11 by paraspinous catheter block. Fifty control cases treated with opiates were identified. All patients survived to discharge. Cases and controls were approximately equivalent in age, ISS, number of fractured ribs, chest AIS, and head AIS. Rib-plated patients had a lower rate of pneumonia (OR 0.2029, 95% CI 0.0242, 0.09718), decreased average ICU LOS (10.62 vs 6.64, P = .018), and decreased average ventilator days (5.44 vs 1.68, P = .003). DISCUSSION: Findings suggest more aggressive treatment of rib fractures may decrease ICU LOS, ventilator days, and pneumonia in patients with multiple rib fractures. These findings are in line with current literature; however, more research is needed in this area.

Potential contribution of mitochondrial DNA damage associated molecular patterns in transfusion products to the development of acute respiratory distress syndrome after multiple transfusions.

BACKGROUND: Massive transfusions are accompanied by an increased incidence of a particularly aggressive and lethal form of acute lung injury (delayed transfusion-related acute lung injury) which occurs longer than 24 hours after transfusions. In light of recent reports showing that mitochondrial (mt)DNA damage-associated molecular patterns (DAMPs) are potent proinflammatory mediators, and that their abundance in the sera of severely injured or septic patients is predictive of clinical outcomes, we explored the idea that mtDNA DAMPs are present in transfusion products and are associated with the occurrence of delayed transfusion-related acute lung injury. METHODS: We prospectively enrolled fourteen consecutive severely injured patients that received greater than three units of blood transfusion products and determined if the total amount of mtDNA DAMPs delivered during transfusion correlated with serum mtDNA DAMPs measured after the last transfusion, and whether the quantity of mtDNA DAMPs in the serum-predicted development of acute respiratory distress syndrome (ARDS). RESULTS: We found detectable levels of mtDNA DAMPs in packed red blood cells (3 ± 0.4 ng/mL), fresh frozen plasma (213.7 ± 65 ng/mL), and platelets (94.8 ± 69.2), with the latter two transfusion products containing significant amounts of mtDNA fragments. There was a linear relationship between the mtDNA DAMPs given during transfusion and the serum concentration of mtDNA fragments (R = 0.0.74, p < 0.01). The quantity of mtDNA DAMPs in serum measured at 24 hours after transfusion predicted the occurrence of ARDS (9.9 ± 1.4 vs. 3.3 ± 0.9, p < 0.01). CONCLUSION: These data show that fresh frozen plasma and platelets contain large amounts of extracellular mtDNA, that the amount of mtDNA DAMPs administered during transfusion may be a determinant of serum mtDNA DAMP levels, and that serum levels of mtDNA DAMPs after multiple transfusions may predict the development of ARDS. Collectively, these findings support the idea that mtDNA DAMPs in transfusion products significantly contribute to the incidence of ARDS after massive transfusions. LEVEL OF EVIDENCE: Prognostic study, level II; therapeutic study, level II.

Rib fractures and their association With solid organ injury: higher rib fractures have greater significance for solid organ injury screening.

BACKGROUND: The purpose of this study was to identify patients with rib injuries who were at risk for solid organ injury. METHODS: A retrospective chart review was performed of all blunt trauma patients with rib fractures during the period from July 2007 to July 2012. Data were analyzed for association of rib fractures and solid organ injury. RESULTS: In all, 1,103 rib fracture patients were identified; 142 patients had liver injuries with 109 (77%) associated right rib fractures. Right-sided rib fractures with highest sensitivity for liver injury were middle rib segment (5 to 8) and lower segment (9 to 12) with liver injury sensitivities of 68% and 43%, respectively (P < .001); 151 patients had spleen injuries with 119 (79%) associated left rib fractures. Left middle segment rib fractures and lower segment rib fractures had sensitivities of 80% and 63% for splenic injury, respectively (P < .003). CONCLUSIONS: Rib fractures higher in the thoracic cage have significant association with solid organ injury. Using rib fractures from middle plus lower segments as indication for abdominal screening will significantly improve rib fracture sensitivity for identification of solid organ injury.

A Novel Classification System for Injuries After Electronic Cigarette Explosions.

Electronic cigarettes (e-cigarettes) contain lithium batteries that have been known to explode and/or cause fires that have resulted in burn injury. The purpose of this article is to present a case study, review injuries caused by e-cigarettes, and present a novel classification system from the newly emerging patterns of burns. A case study was presented and online media reports for e-cigarette burns were queried with search terms "e-cigarette burns" and "electronic cigarette burns." The reports and injury patterns were tabulated. Analysis was then performed to create a novel classification system based on the distinct injury patterns seen in the study. Two patients were seen at our regional burn center after e-cigarette burns. One had an injury to his thigh and penis that required operative intervention after ignition of this device in his pocket. The second had a facial burn and corneal abrasions when the device exploded while he was inhaling vapor. The Internet search and case studies resulted in 26 cases for evaluation. The burn patterns were divided in direct injury from the device igniting and indirect injury when the device caused a house or car fire. A numerical classification was created: direct injury: type 1 (hand injury) 7 cases, type 2 (face injury) 8 cases, type 3 (waist/groin injury) 11 cases, and type 5a (inhalation injury from using device) 2 cases; indirect injury: type 4 (house fire injury) 7 cases and type 5b (inhalation injury from fire started by the device) 4 cases. Multiple e-cigarette injuries are occurring in the United States and distinct patterns of burns are emerging. The classification system developed in this article will aid in further study and future regulation of these dangerous devices.

The Combination of SAT and SBT Protocols May Help Reduce the Incidence of Ventilator-Associated Pneumonia in the Burn Intensive Care Unit.

There are few published reports on the unique nature of burn patients using a paired spontaneous awakening and spontaneous breathing protocol. A combined protocol was implemented in our burn intensive care unit (ICU) on January 1, 2012. This study evaluates the impact of this protocol on patient outcomes in a burn ICU. We performed a retrospective review of our burn registry over 4 years, including all patients placed on mechanical ventilation. In the latter 2 years, patients meeting criteria underwent daily spontaneous awakening trial; if successful, spontaneous breathing trial was performed. Patient data included age, burn size, percent full-thickness burn, tracheostomy, and inhalation injury. Outcome measures included ventilator days, ICU and hospital lengths of stay, pneumonia, and disposition. Data were analyzed using Graphpad Prism and IBM SPSS software, with statistical significance defined as P < .05. There were 171 admissions in the preprotocol period and 136 after protocol implementation. Protocol patients had greater percent full-thickness burns, but did not differ in other characteristics. The protocol group had significantly shorter ICU length of stay, fewer ventilator days, and lower pneumonia incidence. Hospital length of stay, disposition, and mortality were not significantly different. Among patients with inhalation injuries, the protocol group exhibited fewer ventilator and ICU days. Protocol implementation in a burn ICU was accompanied by decreased ventilator days and a reduced incidence of pneumonia. A combined spontaneous awakening and breathing protocol is safe and may improve clinical practice in the burn ICU.

Mitochondrial DNA damage associated molecular patterns in ventilator-associated pneumonia: Prevention and reversal by intratracheal DNase I.

BACKGROUND: Previous studies in isolated perfused rat lungs have revealed that endothelial barrier disruption after intratracheal administration of Pseudomonas aeruginosa (strain 103; PA103) only occurs after accumulation of extracellular mitochondrial DNA (mtDNA) damage-associated molecular patterns (DAMPs) in the perfusate and is suppressed by addition of DNase to the perfusion medium. Herein, we tested the hypothesis that intratracheal DNase-a route of administration readily translatable to patient with ventilator-associated pneumonia (VAP)-also enhances degradation of mtDNA and prevents bacteria-induced lung injury. METHODS: Intratracheal DNase was administered to isolated rat lungs either before or after intratracheal challenge with PA103 to determine if bacteria-induced mtDNA DAMP-dependent lung injury could be prevented or reversed by enhanced mtDNA degradation. To explore whether this concept is translatable to patients with VAP, consecutive patients suspected of VAP were prospectively enrolled. All patients suspected of VAP received a bronchoalveolar lavage (BAL) with quantitative culture for the diagnosis of VAP. Mitochondrial and nuclear DNAs were measured from the BAL. MtDNA DAMPs (i.e., ND6) were measured from serum at time of suspected diagnosis and at 24 to 48 hours afterward. RESULTS: Intratracheal PA103 caused significantly increased the vascular filtration coefficient (Kf) and perfusate mtDNA DAMPs. In contrast, lungs pretreated or posttreated with intratracheal DNase were protected from increases in Kf and mtDNA DAMPs. Patients with the diagnosis of VAP had significantly higher mtDNA DAMPs in the BAL (248.70 ± 109.7 vs. 43.91 ± 16.61, p < 0.05, respectively) and in the serum at 24 hours (159.60 ± 77.37 vs. 10.43 ± 4.36, p < 0.05; respectively) when compared with patients that did not have VAP. CONCLUSION: These findings in isolated perfused rat lungs and a cohort of severely injured patients reveal an association between bacterial pneumonia and accumulation of mtDNA DAMPs in the lung and serum. Furthermore, administration of intratracheal DNase I prevented and reversed pulmonary endothelial dysfunction evoked by PA103.

Intraoperative management of renal gunshot injuries: is mandatory exploration of Gerota's fascia necessary?

BACKGROUND: Many trauma surgeons and trauma centers use routine exploration of Gerota's fascia (GE) for renal gunshot wounds (RGSW). The purpose of this study was to assess whether RGSW can be selectively explored for patients who undergo exploratory laparotomy. METHODS: Retrospective 10-year review of all patients who underwent exploratory laparotomy for abdominal gunshot wounds and had RGSW selectively explored. RESULTS: Sixty-three patients with RGSW underwent exploratory laparotomy. Twenty-eight (44%) underwent GE vs 35 (56%) who did not. Eight (29%) mortalities occurred with GE and 5 (14%) without GE (P < .05). Of GE patients, 14 (50%) had nephrectomy and 14 (50%) had renorrhaphy. Average hospital length of stay with GE was 16.7 days vs 17.9 without GE. Three (9%) renal-associated complications occurred without GE and 1 (4%) with GE. CONCLUSIONS: Most patients who suffer RGSW do not require exploration of GE during abdominal exploration. Complication rates due to nonexploration of RGSW are very low with infrequent need for surgical intervention due to renal-associated complications. High nephrectomy rates may be avoided when GE is averted.

Thoracolumbar spine clearance: Clinical examination for patients with distracting injuries.

BACKGROUND: The purpose of this study was to prospectively assess the sensitivity of clinical examination to screen for thoracolumbar spine (TLS) injury in awake and alert blunt trauma patients with distracting injuries. METHODS: From December 2012 to June 2014, all blunt trauma patients older than 13 years were prospectively evaluated as per standard TLS examination protocol at a Level 1 trauma center. Awake and alert patients with Glasgow Coma Scale (GCS) score of 14 or greater underwent clinical examination of the TLS. Clinical examination was performed regardless of distracting injuries. Patients with no complaints of pain or tenderness on examination of the TLS were considered clinically cleared of injury. Patients with distracting injuries, including those clinically cleared and those with complaints of TLS pain or tenderness, underwent computed tomographic scan of the entire TLS. Patients with minor distracting injuries were not considered to have a distracting injury. RESULTS: A total of 950 blunt trauma patients were entered, 530 (56%) of whom had at least one distracting injury. Two hundred nine patients (40%) with distracting injuries had a positive TLS clinical examination result, of whom 50 (25%) were diagnosed with TLS injury. Three hundred twenty-one patients (60%) with distracting injuries were initially clinically cleared, in whom 17 (5%) TLS injuries were diagnosed. There were no missed injuries that required surgical intervention, with only four injuries receiving TLS orthotic bracing. This yielded an overall clinical clearance sensitivity for injury of 75% and sensitivity for clinically significant injury of 89%. CONCLUSION: In awake and alert blunt trauma patients with distracting injuries, clinical examination is a sensitive screening method for significant TLS injury. Radiologic assessment may be unnecessary for safe clearance of the asymptomatic TLS in patients with distracting injuries. These findings suggest significant potential reduction of both health care cost and patient radiation exposure. LEVEL OF EVIDENCE: Diagnostic study, level IV; therapeutic/care management study, level IV.

Standard Dosing of Enoxaparin for Venous Thromboembolism Prophylaxis Is Not Sufficient for Most Patients Within a Trauma Intensive Care Unit.

Recent reports confirm that the standard dose of enoxaparin in obese patients is often subtherapeutic, leading to a higher incidence of venous thromboembolism. All patients receiving subcutaneous enoxaparin 30 mg twice a day (b.i.d.) for venous thromboembolism prophylaxis were prospectively enrolled in this study. Trough antiXa levels were obtained and any level less than 0.1 IU/mL was considered subtherapeutic and the final dosage requirement was recorded. Body mass index (BMI), abdominal wall thickness, and fluid balance were collected. Thirty-four patients were prospectively enrolled in the study, 14 (50%) of which had a BMI >30. Sixty-five per cent of obese patients were initially nontherapeutic, compared with 53 per cent of the nonobese (P = 0.73). However, elevated BMI (P < 0.05) and abdominal wall thickness (P < 0.05) correlated to an increased final dose required to attain an anti Xa ≥0.1 when not initially therapeutic, whereas fluid balance demonstrated no correlation (P = 0.232). Subcutaneous enoxaparin dosing of 30 mg b.i.d. is not sufficient for the majority adult trauma patients in the intensive care unit, regardless of BMI. When enoxaparin 30 mg b.i.d. is initially subtherapeutic, obese patients may require a larger dose necessary to achieve necessary anticoagulation.

The validity of abdominal examination in blunt trauma patients with distracting injuries.

BACKGROUND: Many trauma care providers often disregard the abdominal clinical examination in the presence of extra-abdominal distracting injuries and mandate abdominal computed tomographic scan in these patients. Ignoring the clinical examination may incur undue expense and radiation exposure. The purpose of this study was to assess the efficacy of abdominal clinical examination in patients with distracting injuries. METHODS: During a 1-year period, all awake and alert blunt trauma patients with Glasgow Coma Scale (GCS) score of 14 or 15 were entered into a prospective study. Abdominal clinical examination was performed and documented prospectively on all patients. Abdominal clinical examination included four-quadrant anterior abdominal palpation, flank palpation, lower thoracic palpation, pelvis examination, and palpation of the thoracolumbar spine. Following examination documentation, all patients underwent computed tomographic scan of the abdomen and pelvis with intravenous contrast. RESULTS: A total of 803 patients were enrolled: 451 patients had distracting injuries, and 352 patients did not. Of the 352 patients without distracting injuries, 19 (5.4%) had intra-abdominal injuries, of whom 2 (10.5%) had negative clinical examination result. Of the 451 patients with distracting injuries, 48 (10.6%) were diagnosed with intra-abdominal injury, of whom 5 (10.4%) had negative clinical examination result. All five missed injuries in patients with distracting injuries were solid organ injuries, none of which required surgical intervention or blood transfusion. The sensitivity and negative predictive value of abdominal examination for patients with distracting injuries were 90.0% and 97.0%, respectively. The sensitivity and negative predictive value of abdominal examination for surgically significant and transfusion-requiring injuries were both 100%. CONCLUSION: Distracting injuries do not seem to diminish the efficacy of clinical abdominal examination for the diagnosis of clinically significant abdominal injury. These data suggest that clinical examination of the abdomen is valid in awake and alert blunt trauma patients, regardless of the presence of other injuries. LEVEL OF EVIDENCE: Diagnostic study, level III.

Mesh wrapping for severe hepatic injury: a beneficial option in the trauma surgeon's armamentarium.

BACKGROUND: The purpose of this study was to assess the efficacy of absorbable mesh wrapping (MW) versus perihepatic packing (HP) for severe hepatic injury. METHODS: From January 2001 to December 2012, data were collected for MW patients with hepatic injury. Patients who underwent HP were matched with MW patients by injury mechanism, liver injury grade, Injury Severity Score, and age. RESULTS: Twenty-six MW and twenty-six HP patients were matched. Eighteen blunt and 8 penetrating injuries were present in each group. There were 9 (35%) mortalities in the MW group and 16 (62%) in the HP groups (P = .03). Average transfusions were 12.0 and 24.5 (P = .03) packed red blood cells in the MW and HP groups, respectively. Average laparotomies per survivors were 1.3 for the MW and 3.1 for the HP groups (P = .01). Average length of stay for survivors was 19 and 47 (P = .04) days in the MW and HP groups, respectively. CONCLUSION: MW for hepatic injuries can significantly decrease mortality, transfusions, laparotomies, and length of stay.

The safety of low molecular-weight heparin after blunt liver and spleen injuries.

BACKGROUND: Anticoagulation is routinely administered to all trauma patients owing to the high incidence of venous thromboembolism (VTE). However, the timing of administration of anticoagulation is not clearly defined when patients have blunt spleen or liver injuries because of the perceived risk of hemorrhage with early administration. METHODS: A retrospective chart review was performed of all blunt trauma patients who sustained blunt liver and/or spleen injuries during the 5-year period from 2007 to 2011. Data were collected for all patients managed with nonoperative therapy for these injuries while also receiving routine prophylactic anticoagulation with low molecular-weight heparin. Patients were categorized based on the initiation of enoxaparin therapy after injury: early (<48 hours), intermediate (48 to 72 hours), and late (>72 hours). Primary and secondary outcomes were designated as need for operative or radiologic intervention secondary to spleen or liver hemorrhage, number of transfusions, and incidence of VTE. RESULTS: Three hundred and twenty-eight patients were included. There were no enoxaparin-related hemorrhagic complications or hemorrhage necessitating operative intervention. Patients in the early, intermediate, and late groups received an average of .9, .93, and 1.55 units of blood, respectively. There was 1 pulmonary embolism in the early group, and there were 6 VTE complications in the late group (3 deep venous thromboses and 3 pulmonary embolisms). CONCLUSIONS: There are currently no standards for the initiation of prophylactic anticoagulation in trauma patients with blunt liver and spleen injuries. Early administration may be safe and reduce the incidence of thrombotic complications in patients with blunt spleen and liver injuries. Prospective studies in this area are warranted.