Retrospective analysis of small intracranial hemorrhage in trauma: Is acute care surgery team management alone safe?

Background: The Brain Injury Guidelines (BIG) provide a validated framework for categorizing patients with small intracranial haemorrhages (ICH) who could be managed by acute care surgery without neurosurgical consultation or repeat head computed tomography in the absence of neurological deterioration. This replication study retrospectively applied BIG criteria to ICH subjects and only included BIG1 and BIG2 subjects.Methods: The trauma registry was queried from 2014 to 2019 for subjects with a traumatic ICH <1 cm, Glasgow Coma Scale score of 14/15 and not on anticoagulation therapy. Patients were then categorized under BIG 1 or BIG2 and outcomes were evaluated.Results: Two hundred fourteen subjects were reviewed (88 BIG1 and 126 BIG2). Twenty-three subjects had worse repeat imaging, but only one had worsening exam that resolved spontaneously. None required neurosurgical intervention. One died of non-neurological causes.Conclusions: Retrospective analysis supported our hypothesis that patients categorized as BIG1 or BIG2 could have been safely managed by acute care surgeons without neurosurgical consultation or repeat head imaging. A review of minor worsening on repeat imaging without changes in neurological exams and no need for neurosurgical interventions supports this evidence-based approach to the management of small intracranial haemorrhages.

The impact of clinical crisis management on trauma team outcomes following a prolonged strike by nursing, technical, and support staff.

There is a paucity of literature describing the preparation of hospital institutions prior to a nursing strike and the quality outcomes during and after a prolonged nursing strike. No published study was found describing the effects of a prolonged strike on quality outcomes specific to trauma patients. The American College of Surgeons (ACS) suggests specific critiques and complications data that each trauma program may choose to track as quality indicators, and those metrics are submitted to regional, state and national databanks and closely examined during site accreditations. This research study analyzed data from three equal time periods following a multiservices strike involving both nurses and service/technical staff lasting 63 days. The purposes of this study were to (1) evaluate the effects of prestrike organizational leadership and crisis management planning on organizational staffing and emergency management to reduce health care risk during the strike, (2) describe outcomes data from three equal time periods: prestrike, strike, and poststrike, and (3) specifically compare the trauma program's selected ACS trauma metrics for critiques and complication rates for our high-risk/high-volume population as a level 1 trauma center.

The combined effects of alcohol and marijuana use prior to traumatic brain injury on mortality.

BACKGROUND: Alcohol (ETOH) intoxication is a common comorbidity in traumatic brain injury (TBI), and marijuana (THC) has been implicated as a major risk factor for trauma. The objective this study was to investigate the combined effects of ETOH and THC on mortality after TBI. MATERIALS AND METHODS: A retrospective review of patient data was performed to assess adult (>18 years) patients with brain injuries between January 2012 and December 2018. Included patients sustained TBI (Abbreviated Injury Scale (AIS 1-6)) and were divided into two groups: No Substances and THC + ETOH. RESULTS: 1085 (median age 52 years [range: 18-97 years]; 33.5% female (364/1085)) patients met the inclusion criteria. Significant differences for mortality at discharge were found between groups (p = 0.0025) with higher mortality in the No Substances group. On multiple logistic regression, a positive test for both ETOH + THC was found not to independently predict mortality at discharge, while age, Glasgow Coma Scale, intensive care unit stay, Injury Severity Score, length of hospital stay, and days on ventilator were independent predictors. CONCLUSIONS: After controlling for confounding variables, positive ETOH + THC screens were not found to be independent predictors of mortality at discharge. Therefore, our results indicated no survival benefit for TBI patients with concomitant ETOH and THC use prior to injury.

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.

The effects of alcohol and marijuana on survival after severe traumatic brain injury: A retrospective cohort study.

BACKGROUND: Alcohol (ETOH) and marijuana (THC) use have previously shown to improve outcomes after Traumatic Brain Injury (TBI). However, whether TBI severity impacts outcomes among patients tested positive for both ETOH and THC remains unclear. MATERIALS AND METHODS: A retrospective review from the Northern Ohio Regional Trauma Registry, which includes deidentified data from six regional hospitals, including three Level 1 and three Level 3 trauma centers, was performed to assess adult (>18 years) patients with severe TBI (head Abbreviated Injury Score ≥ 3) between January 2012 and December 2018 having an alcohol and drug toxicology screen and data regarding outcome at discharge. Patients were divided into two groups: 1) patients with a negative ETOH and drug test, and 2) patients positive for ETOH + THC. Mortality at discharge was the primary outcome measure and multiple logistic regression was used to assess predictors of mortality at discharge. RESULTS: A total of 854 (median age: 51 years [range: 18-72]; 34.4% female [294/854]) patients were included. On multiple logistic regression, age (p = 0.003), days in intensive care unit (ICU) (p < 0.001), Glasgow Coma Scale (GCS) (p < 0.001), Injury Severity Score (ISS) (p < 0.001), length of stay (LOS) (p < 0.001), and days on ventilator support (p = 0.032) were significant predictors of mortality at discharge. Blood alcohol content (BAC), cause of TBI, drug class, and sex were not significant predictors of mortality at discharge. CONCLUSIONS: After severe TBI, positive THC and BAC screening did not predict mortality at discharge after controlling for confounding variables, indicating no survival benefit for patients with severe TBI.

Surgical Management of a Giant Pheochromocytoma.

Pheochromocytomas are rare tumors arising from chromaffin cells of the adrenal medulla and extramedullary sympathetic ganglia. The incidence of asymptomatic disease is rising due to increased detection rates from widespread use of computed tomography. We describe a case of one of the largest documented pheochromocytomas resected in the United States, an 18-cm tumor in a patient who presented with exertional dyspnea, abdominal pain, constipation, weight loss, and intermittent hypertension. After biochemical and appropriate imaging workup, the patient underwent an open resection of the mass.

Head injury on Warfarin: likelihood of delayed intracranial bleeding in patients with negative initial head CT.

OBJECTIVE: To determine the likelihood that head injured patients on Warfarin with a negative initial head CT will have a positive repeat head CT. A retrospective chart review of our institution's trauma registry was performed for all patients admitted for blunt head trauma and on Warfarin anti-coagulation from January 2009 to April 2014. Inclusion criteria included patients over 18 years of age with initial GCS ≥ 13, INR greater than 1.5 and negative initial head CT. Initial CT findings, repeat CT findings and INR were recorded. Interventions performed on patients with a delayed bleed were also investigated. RESULTS: 394 patients met the study inclusion criteria. 121 (31%) of these patients did not receive a second CT while 273 patients (69%) underwent a second CT. The mean INR was 2.74. Six patients developed a delayed bleed, of which two were clinically significant. No patients had any neurosurgical intervention. Our results demonstrate a low rate of delayed bleeding. The utility of repeat head CT in the neurologically stable patient is thus questioned. Patients who have an abnormal baseline neurological status and those with INR >3 may represent a subgroup of patients in whom repeat head CT should be performed.