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

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

Management of Extraperitoneal Bladder Injuries in Patients With Pelvic Fractures.

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

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

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

Keeping it Simple: Impact of a Restrictive Antibiotic Policy for Ventilator-Associated Pneumonia in Trauma Patients on Incidence and Sensitivities of Causative Pathogens.

BACKGROUND: An integral part of ventilator-associated pneumonia (VAP) therapy is the appropriate choice of empiric antibiotics. Our previous experience demonstrated adherence to an empiric therapy pathway was associated with only modest changes in organisms causing VAP. The purpose of the current study was to evaluate the impact of a restrictive antibiotic policy for VAP in trauma patients on the incidence and sensitivities of causative pathogens since the previous study. PATIENTS AND METHODS: Patients with VAP diagnosed on bronchoalveolar lavage since the previous study were stratified by age, gender, mechanism of injury, and injury severity. All patients received empiric antibiotics based on duration of intensive care unit (ICU) stay using a unit-specific pathway. The incidence and sensitivities of causative pathogens in the current study were documented. The adequacy of the VAP pathway was evaluated for all VAP episodes. The current study was then compared with the previous study. RESULTS: Over a 10-year period, 1,474 episodes of VAP were diagnosed with 2,387 causative pathogens isolated. Overall incidence of gram-positive and gram-negative VAP pathogens was unchanged between the study periods. The current study experienced an increase in the incidence of Staphylococcus aureus (23% vs. 17%, p = 0.001) and methicillin-resistant Staphylococcus aureus (10% vs. 6%, p = 0.002) compared with the previous study. The pathway for empiric antibiotics resulted in adequate empiric coverage in 85% of VAP episodes, which was improved compared with the previous study (76%, p = 0.024). Furthermore, despite the increased incidence of early methicillin-resistant Staphylococcus aureus (MRSA) VAP, adequacy of the pathway improved for both the early period (91% vs. 86%, p = 0.001) as well as the late period (86% vs. 63%, p < 0.001) in the current study compared with the previous study. CONCLUSIONS: A comprehensive protocol for the diagnosis and management of VAP, along with antibiotic stewardship, can prevent the development of bacterial resistance to empiric therapy.

Airway management following repair of cervical tracheal injuries: A retrospective, multicenter study.

BACKGROUND: Optimal airway management following repair of cervical tracheal injuries is unknown. This study aimed to determine the optimal airway strategy following cervical tracheal injury repair. METHODS: Patients with cervical tracheal injuries admitted from January 2000 to January 2014 at seven US Level I trauma centers were identified. Patients were grouped depending on postoperative airway management: immediate or early extubation (≤24 hours, EXT), prolonged intubation (>24 hours, INT), and immediate tracheostomy (TRACH). Following univariate analysis, a multivariate model was then developed to evaluate for surgical site infection (SSI) and intensive care unit-free and ventilator-free days, comparing INT and TRACH with EXT as the reference. RESULTS: A total of 120 cervical tracheal injuries were treated at seven Level I trauma centers. Ten patients were excluded for incomplete data, and seven died within 24 hours of admission, leaving 103 patients included in the study. Patients were grouped based on airway management: 40 (39%) in the EXT, 30 (29%) in the INT, and 33 (32%) in the TRACH group. There were no differences in demographics or injury mechanism. The INT and TRACH groups were more severely injured than the EXT group (median Injury Severity Score [ISS]: INT, 25; TRACH, 17 vs. EXT, 16; p < 0.01). Despite a higher SSI rate (TRACH, 21% vs. INT, 13% vs. EXT, 2%; p = 0.11), the TRACH group had a lower mortality rate (TRACH, 0% vs. INT, 13% vs. EXT, 0%, p < 0.01) and more ventilator-free days compared with the INT cohort. On multivariate analysis, tracheostomy was associated with an increased risk in the odds of SSI (odds ratio, 9.56; 95% confidence interval, 1.35-67.95) compared with both EXT and INT, while INT was associated with fewer ventilator-free days (correlation coefficient, -9.24; 95% confidence interval, -12.30 to -6.18) compared with both EXT and TRACH. CONCLUSION: In patients with a cervical tracheal injury, immediate or early extubation was common and safe. However, among those with more severe injuries, immediate tracheostomy versus prolonged intubation presents a risk-benefit decision. Immediate tracheostomy is associated with increased risk of SSI, while prolonged intubation is associated with higher risk of mortality and fewer ventilator-free days. LEVEL OF EVIDENCE: Therapeutic study, level IV.