Traumatic Abdominal Wall Hernia: Management Using a Standardized Approach.

Traumatic abdominal wall hernias are a rare complication of high energy blunt trauma. There exist several studies evaluating and outlining potential management options but still no generalized consensus on management. This series was meant to evaluate the diagnosis and management of traumatic abdominal wall hernias. A prospectively maintained database was used to identify patients with TAWH from 2021 to 2022. The primary outcome was operative management. Secondary outcomes included: time to diagnosis and post-operative outcomes. Of the 19 patients in this case series, 100% (n = 19/19) were secondary to blunt trauma with a mean ISS of 21. Exploratory laparotomy was performed in 17 cases. 14 cases had concomitant traumatic injuries to visceral structures. Complications were found in nearly half of the patients with 3 experiencing wound dehiscence. Future studies should be aimed at standardizing management approach taking into account nature of the mechanism and concomitant injuries.

Risk Factors for Empyema Following Penetrating Diaphragmatic Injuries.

Empyema resulting as a complication of penetrating diaphragmatic injuries is a subject that requires further investigation, and the aim of this study was to determine the risk factors associated with empyema in patients with penetrating trauma. Consecutive adult trauma patients from a level 1 trauma center were searched for penetrating diaphragm injuries. Data were collected on patient demographics, pre-existing conditions, injury type and severity, hospital interventions, in-hospital complications, and outcomes. Patients were stratified by empyema formation and univariant analyses were performed. 164 patients were identified, and 17 patients (10.4%) developed empyema. Empyema was associated with visible abdominal contamination (35.3% vs 15%, P = .04), thoracotomy (35.5% vs 13.6%, P = .03), pneumonia (41.2% vs 14.3%, P = .01), sepsis (35.3% vs 8.8%, P = .006), increased hospital length of stay (25.5 vs 10.1 days, p =<.001), increased intensive care unit length of stay (9.6 vs 4.3 days, P = .01), and decreased in-hospital mortality (0% vs 20.4%, P = .04).

Chest Tube Size Selection: Evaluating Provider Practices, Treatment Efficacy, and Complications in Management of Thoracic Trauma.

BACKGROUND: The standard for managing traumatic pneumothorax (PTX), hemothorax (HTX), and hemopneumothorax (HPTX) has historically been large-bore (LB) chest tubes (>20-Fr). Previous studies have shown equal efficacy of small-bore (SB) chest tubes (≤19-Fr) in draining PTX and HTX/HPTX. This study aimed to evaluate provider practice patterns, treatment efficacy, and complications related to the selection of chest tube sizes for patients with thoracic trauma. METHODS: A retrospective chart review was performed on adult patients who underwent tube thoracostomy for traumatic PTX, HTX, or HPTX at a Level 1 Trauma Center from January 2016 to December 2021. Comparison was made between SB and LB thoracostomy tubes. The primary outcome was indication for chest tube placement based on injury pattern. Secondary outcomes included retained hemothorax, insertion-related complications, and duration of chest tube placement. Univariate and multivariate analyses were performed. RESULTS: Three hundred and forty-one patients were included and 297 (87.1%) received LB tubes. No significant differences were found between the groups concerning tube failure and insertion-related complications. LB tubes were more frequently placed in patients with penetrating MOI, higher average ISS, and higher average thoracic AIS. Patients who received LB chest tubes experienced a higher incidence of retained HTX. DISCUSSION: In patients with thoracic trauma, both SB and LB chest tubes may be used for treatment. SB tubes are typically placed in nonemergent situations, and there is apparent provider bias for LB tubes. A future randomized clinical trial is needed to provide additional data on the usage of SB tubes in emergent situations.

The Burden of Burns: An Analysis of Public Health Measures.

Accurate analysis of injuries is paramount when allocating resources for prevention, research, education, and legislation. As burn mortality has improved over recent decades, the societal burden of burn injuries has grown ambiguous to the public while a scarcity of investigational funding for survivors has led to a gap in understanding lifelong sequela. We aim to compare national references reporting the incidence of burn injuries in the United States. The American Burn Association Burn Injury Summary Report (ABA-BISR), American Burn Association Fact Sheet, Centers for Disease Control and Prevention (CDC) Web-based Injury Statistics Query and Reporting (WISQARS) database, the CDC National Center for Health Statistics' National Hospital Ambulatory Medical Care Survey (NHAMCS), National Inpatient Sample (NIS), National Emergency Department Sample (NEDS), and commercially available claims databases were queried for 2020 or the most recent data available. The BISR estimated 30,135 burn admissions in 2022. The 2016 ABA Fact Sheet reported 486,000 burns presented to US emergency departments (ED). In 2020, CDC's WISQARS database reported 3,529 fatal, and 287,926 non-fatal, burn injuries. The 2020 NEDS reported 438,185 ED visits while the 2020 NIS estimated 103,235 inpatients. The NHAMCS reported 359,000 ED visits for burn injuries in the same period, and an analysis of ICD-10 burn codes demonstrated over 698,555 claims. Our study demonstrates a large variability in the reported incidence of burn injury by the ABA, CDC, national samples, and claims databases. Per our analyses, we estimate that 600,000 individuals annually suffer a burn injury which merits emergent care in the United States.

Venovenous Extracorporeal Membrane Oxygenation Usage Following Bullet Embolism to the Pulmonary Artery.

Background: Pulmonary artery embolus is a rare complication following gunshot wounds that creates a unique and serious challenge for trauma surgeons. While the majority of bullets that embolize through the vascular system end in the peripheral circulation, approximately one-third enter the central venous circulation. Case Report: We present the case of a bullet embolus to the left pulmonary artery following gunshot wounds to the right chest and the abdomen, with the abdominal ballistic traversing the liver before entering the vena cava and embolizing. The patient's course was complicated by the development of severe acute respiratory distress syndrome that was successfully managed by venovenous extracorporeal membrane oxygenation. Conclusion: Venovenous extracorporeal membrane oxygenation support for severe acute respiratory distress syndrome after bullet embolization to the pulmonary tree and surgical embolectomy is a viable option in appropriately selected patients.

Discrepancies in Mass Shootings and Access to Trauma Care Across the United States, 2014-2018.

INTRODUCTION: The United States has one of the highest rates of gun violence and mass shootings. Timely medical attention in such events is critical. The objective of this study was to assess geographic disparities in mass shootings and access to trauma centers. METHODS: Data for all Level I and II trauma centers were extracted from the American College of Surgeons and the Trauma Center Association of America registries. Mass shooting event data (4+ individuals shot at a single event) were taken from the Gun Violence Archive between 2014 and 2018. RESULTS: A total of 564 trauma centers and 1672 mass shootings were included. Ratios of the number of mass shootings vs trauma centers per state ranged from 0 to 11.0 mass shootings per trauma center. States with the greatest disparity (highest ratio) included Louisiana and New Mexico. CONCLUSION: States in the southern regions of the US experience the greatest disparity due to a high burden of mass shootings with less access to trauma centers. Interventions are needed to increase access to trauma care and reduce mass shootings in these medically underserved areas.

Comparison of rampage and non-rampage mass shootings in the U.S.: A 5-year demographic analysis.

BACKGROUND: Rampage mass shootings (RMS) are a subset of mass shootings occurring in public involving random victims. Due to rarity, RMS are not well-characterized. We aimed to compare RMS and NRMS. We hypothesized that RMS and NRMS would be significantly different with respect to time/season, location, demographics, victim number/fatality rate, victims being law enforcement, and firearm characteristics. STUDY DESIGN: Mass shootings (4 or more victims shot at a single event) from 2014-2018 were identified in the Gun Violence Archive (GVA). Data were collected from the public domain (e.g. news). Crude comparisons between NRMS and RMS were performed using Chi-squared or Fisher's exact tests. Parametric models of victim and perpetrator characteristics were conducted at the event level using negative binomial regression and logistic regression. RESULTS: There were 46 RMS and 1626 NRMS. RMS occurred most in businesses (43.5%), whereas NRMS occurred most in streets (41.1%), homes (28.6%), and bars (17.9%). RMS were more likely to occur between 6AM-6PM (OR=9.0 (4.8-16.8)). RMS had more victims per incident (23.6 vs. 4.9, RR: 4.8 (4.3,5.4)). Casualties of RMS were more likely to die (29.7% vs. 19.9%, OR: 1.7 (1.5,2.0)). RMS were more likely to have at least one police casualty (30.4% versus 1.8%, OR: 24.1 (11.6,49.9)) or police death (10.9% versus 0.6%, OR: 19.7 (6.4,60.3)). RMS had significantly greater odds that casualties were adult (OR: 1.3 (1.0,1.6)) and female (OR: 1.7 (1.4,2.1)). Deaths in RMS were more likely to be female (OR: 2.0 (1.5,2.5)) and White (OR: 8.6 (6.2,12.0) and less likely to be children (OR: 0.4 (0.2,0.8)). Perpetrators of RMS were more likely to die by suicide (34.8%), be killed by police (28.3%), or be arrested at the scene (26.1%), while more than half of perpetrators from NRMS escaped without death or apprehension (55.8%). Parametric models of perpetrator demographics indicated significant increases in the odds that a RMS shooter was White (OR: 13.9 (7.3,26.6)) or Asian (OR: 16.9 (3.7,78.4)). There was no significant difference in weapon type used (p=0.35). CONCLUSION: The demographics, temporality, and location differ between RMS and NRMS, suggesting that they are dissimilar and require different preventive approaches.

Does Vehicle Intrusion Alone Still Predict Injury: A Retrospective Analysis of Mechanism as Trauma Activation Criteria.

Automobile collisions with driver side intrusion >12 inches or >18 elsewhere meet criteria for trauma activation. However, vehicle safety features have improved since this inception. We hypothesized vehicle intrusion (VI) alone as mechanism-of-injury (MOI) criteria inadequately predicts trauma center activation. A retrospective, single-center chart review of adult patients involved in motor vehicle collisions presenting to a level 1 trauma center from July 2016 to March 2022 was performed. Patients were divided by MOI criteria: VI vs. multiple MOI criteria. 2940 patients met inclusion criteria. The VI group reported lower injury severity scores (P = 0.004), higher incidence of ED discharge (P = 0.001), lower ICU admissions (P = 0.004), and fewer in-hospital procedures (P = 0.03). Vehicle intrusion was found to have a positive likelihood ratio of 0.889 for predicting trauma center need. According to current guidelines, these results suggest that VI criteria alone may not be an accurate predictor for trauma center transport and require further investigation.

Compression of the Right Atrium and Inferior Vena Cava from an Extrahepatic Biloma Following Liver Trauma.

A 26-year-old male presented to a Level 1 trauma center following a motorcycle crash. Workup of his injuries demonstrated a grade 5 liver laceration with active extravasation, grade 5 kidney laceration, right apical pneumothorax, and a sternal fracture. The patient underwent hepatic artery embolization with interventional radiology (IR) followed by an exploratory laparotomy, liver packing, and small bowel resection with primary anastomosis. Four days post-op, the patient developed dyspnea, tachycardia, and decreasing oxygen saturation. Computed tomography pulmonary angiography demonstrated perihepatic fluid compressing the right atrium and inferior vena cava. Percutaneous perihepatic drain placement with aspiration of 700 mL bilious fluid resulted in immediate resolution of the compression. He subsequently underwent endoscopic retrograde cholangiopancreatography (ERCP) with stenting of the ampulla nine days later. The patient was discharged ten days post-ERCP with oral amoxicillin/clavulanic acid for polymicrobial coverage and follow-up with gastroenterology and IR for stent removal and drain maintenance.

Maintaining trauma center operational readiness during a pandemic.

The coronavirus disease 2019 (COVID-19) pandemic is a slow-moving global disaster with unique challenges for maintaining trauma center operations. University Medical Center New Orleans is the only level 1 trauma center in New Orleans, LA, which became an early hotspot for COVID-19. Intensive care unit surge capacity, addressing components including space, staff, stuff, and structure, is important in maintaining trauma center operability during a high resource-strain event like a pandemic. We report management of the trauma center's surge capacity to maintain trauma center operations while assisting in the care of critically ill COVID-19 patients. Lessons learned and recommendations are provided to assist trauma centers in planning for the influx of COVID-19 patients at their centers.

Predictors of Inappropriate Helicopter Transport.

BACKGROUND: Helicopter transport (HT) is an efficient, but costly, means for injured patients to receive life-saving, definitive trauma care. Identifying the characteristics of inappropriate HT presents an opportunity to improve the utilization of this finite medical resource. METHODS: Trauma registry records of all HT for a 3-year period (2016-2018) to an urban Level I trauma center were reviewed. HT was defined as inappropriate for patients who were discharged home from the emergency department or had a hospital length of stay <1 day, and who were discharged alive. Chi-square analysis and Student's t-test were used for univariate analysis. Predictors with a P value of less than .15 were subject to binary logistic regression analysis. A P value ≤.05 was considered significant. RESULTS: There were 713 patients who received HT during the study period. One-hundred and forty-eight (20.8%) patients met the criteria as an inappropriate HT. In univariate analysis, Glasgow Coma Scale >8, Shock Index <0.9, and fall mechanism were found to be significantly associated with inappropriate HT. Age >55 was found to be associated with an appropriate HT. The average Injury Severity Score of the inappropriate HT group was 3.86 (±3.85) compared with 16.80 (±11.23) (P = .0001, Student's t-test). DISCUSSION: Our findings suggest that there are evidence-based predictors of patients receiving inappropriate HT. Triage of HT using these predictors has the potential to decrease unnecessary deployments and reduce health care costs.