Early surgical stabilization of rib fractures for flail chest is associated with improved patient outcomes: An ACS-TQIP review.

BACKGROUND: Rib fractures are a common in thoracic trauma. Increasingly, patients with flail chest are being treated with surgical stabilization of rib fractures (SSRF). We performed a retrospective review of the Trauma Quality Improvement Program database to determine if there was a difference in outcomes between patients undergoing early SSRF (≤3 days) versus late SSRF (>3 days). METHODS: Patients with flail chest in Trauma Quality Improvement Program were identified by CPT code, assessing those who underwent SSRF between 2017 and 2019. We excluded those younger than 18 years and Abbreviated Injury Scale head severity scores greater than 3. Patients were grouped based on SSRF before and after hospital Day 3. These patients were case matched based on age, Injury Severity Score, Abbreviated Injury Scale head and chest, body mass index, Glasgow Coma Scale, and five modified frailty index. All data were examined using χ2, one-way analysis of variance, and Fisher's exact test within SPSS version 28.0. RESULTS: For 3 years, 20,324 patients were noted to have flail chest, and 3,345 (16.46%) of these patients underwent SSRF. After case matching, 209 patients were found in each group. There were no significant differences between reported major comorbidities. Patients with early SSRF had fewer unplanned intubations (6.2% vs. 12.0%; p = 0.04), fewer median ventilator days (6 days Q1: 3 to Q3: 10.5 vs. 9 Q1: 4.25 to Q3: 14; p = 0.01), shorter intensive care unit length of stay (6 days Q1: 4 to Q3: 11 vs. 11 Q1: 6 to Q3: 17; p < 0.01), and hospital length of stay (15 days Q1: 11.75 to Q3: 22.25 vs. 20 Q1: 15.25 - Q3: 27, p < 0.01. Early plating was associated with lower rates of deep vein thrombosis and ventilator-acquired pneumonia. CONCLUSION: In trauma-accredited centers, patients with flail chest who underwent early SSRF (<3 days) had better outcomes, including fewer unplanned intubations, decreased ventilator days, shorter intensive care unit LOS and HLOS, and fewer DVTs, and ventilator-associated pneumonia. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Detecting direct oral anticoagulants in trauma patients using liquid chromatography-mass spectrometry: A novel approach to medication reconciliation.

BACKGROUND: Accurate medication reconciliation in trauma patients is essential but difficult. Currently, there is no established clinical method of detecting direct oral anticoagulants (DOACs) in trauma patients. We hypothesized that a liquid chromatography-mass spectrometry (LCMS)-based assay can be used to accurately detect DOACs in trauma patients upon hospital arrival. METHODS: Plasma samples were collected from 356 patients who provided informed consent including 10 healthy controls, 19 known positive or negative controls, and 327 trauma patients older than 65 years who were evaluated at our large, urban level 1 trauma center. The assay methodology was developed in healthy and known controls to detect apixaban, rivaroxaban, and dabigatran using LCMS and then applied to 327 samples from trauma patients. Standard medication reconciliation processes in the electronic medical record documenting DOAC usage were compared with LCMS results to determine overall accuracy, sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of the assay. RESULTS: Of 356 patients, 39 (10.96%) were on DOACs: 21 were on apixaban, 14 on rivaroxaban, and 4 on dabigatran. The overall accuracy of the assay for detecting any DOAC was 98.60%, with a sensitivity of 94.87% and specificity of 99.05% (PPV, 92.50%; NPV, 99.37%). The assay detected apixaban with a sensitivity of 90.48% and specificity of 99.10% (PPV, 86.36%; NPV 99.40%). There were three false-positive results and two false-negative LCMS results for apixaban. Dabigatran and rivaroxaban were detected with 100% sensitivity and specificity. CONCLUSION: This LCMS-based assay was highly accurate in detecting DOACs in trauma patients. Further studies need to confirm the clinical efficacy of this LCMS assay and its value for medication reconciliation in trauma patients. LEVEL OF EVIDENCE: Diagnostic Test, level III.

RAMPED-UP: The Development and Testing of an Interprofessional Collaboration Model.

Interprofessional collaboration (IPC) is an essential component of care delivery needed to achieve optimal patient- and system-level outcomes. The purpose of this project was to measure the impact of a structured IPC model, RAMPED-UP, on hospital length of stay (LOS) in a surgical trauma population. The study design was a prospective cohort with a historical comparison group. The project was conducted at a Level 1 trauma center. The RAMPED-UP group constituted trauma patients admitted from October to December 2017 (n = 96). Trauma patients admitted from October to December 2016 constituted the pre-RAMPED-UP group (n = 98). The 2 groups were similar in demographics. Hospital LOS was not statistically significant between groups. Median RAMPED-UP LOS, defined as the number of days the patient received RAMPED-UP rounds, was 3 days. Patients in the RAMPED-UP group were more likely to be discharged home, with higher discharge-by-noon (DBN) rates of 18.2% (p = .005). A statistically significant correlation was found between incentive spirometry (I/S) values and hospital LOS and RAMPED-UP LOS in the RAMPED-UP group (95% CI: rs -0.301, p = .008; 95% CI: rs -0.270, p = .018, respectively). Although the RAMPED-UP model did not decrease hospital LOS, the model did significantly improve DBN and RAMPED-UP LOS. Further exploration of I/S values as a predictor of LOS is warranted. The use of a structured IPC model that includes essential members of the IPC team can aid in improving patient outcomes such as DBN.

Medications and patient safety in the trauma setting: a systematic review.

Background: Medication errors account for the most common adverse events and a significant cause of mortality in the USA. The Joint Commission has required medication reconciliation since 2006. We aimed to survey the literature and determine the challenges and effectiveness of medication reconciliation in the trauma patient population. Materials and methods: We conducted a systematic review of the literature to determine the effectiveness of medication reconciliation in trauma patients. English language articles were retrieved from PubMed/Medline, CINAHL, and Cochrane Review databases with search terms "trauma OR injury, AND medication reconciliation OR med rec OR med rek, AND effectiveness OR errors OR intervention OR improvements." Results: The search resulted in 82 articles. After screening for relevance and duplicates, the 43 remaining were further reviewed, and only four articles, which presented results on medication reconciliation in 3041 trauma patients, were included. Two were retrospective and two were prospective. Two showed only 4% accuracy at time of admission with 48% of medication reconciliations having at least one medication discrepancy. There were major differences across the studies prohibiting comparative statistical analysis. Conclusions: Trauma medication reconciliation is important because of the potential for adverse outcomes given the emergent nature of the illness. The few articles published at this time on medication reconciliation in trauma suggest poor accuracy. Numerous strategies have been implemented in general medicine to improve its accuracy, but these have not yet been studied in trauma. This topic is an important but unrecognized area of research in this field.

Defining the cervical spine clearance algorithm: A single-institution prospective study of more than 9,000 patients.

BACKGROUND: Variability exists in the approach to cervical spine (c-spine) clearance after significant trauma. Using concurrently gathered data on more than 9,000 such patients, the current study develops an evidence-based and readily adoptable algorithm for c-spine clearance aimed at timely removal of collar, optimal use of imaging, and appropriate spine consultations. METHODS: Prospective study of adult blunt trauma team alert (TTA) patients presenting at a Level I trauma center who underwent screening computed tomography (CT) to diagnose/rule out c-spine injury (January 2008 to May 2014). Regression analysis comparing patients with and without c-spine injury-fracture and/or ligament-was used to identify significant predictors of injury. The predictors with the highest odds ratio were used to develop the algorithm. RESULTS: Among 9,227 patients meeting inclusion criteria, c-spine injury was identified in 553 patients (5.99%). All 553 patients had a c-spine fracture, and of these, 57 patients (0.6% of entire population and 10.31% of patients with injury) also had a ligamentous injury. No patient with a normal CT result was found to have an injury. The five greatest predictors of ligament injury that follow were used to develop the algorithm: (1) CT evidence of ligament injury; (2) fracture pattern "not" isolated transverse/spinous process; (3) neurologic symptoms; (4) midline tenderness; and (5) Glasgow Coma Scale score <15. CONCLUSION: TTA patients should undergo screening c-spine CT to rule out injury. Most patients will have a negative CT and can have their collars removed. A select group of patients will require collars and spine consultation and a smaller subset of magnetic resonance imaging to rule out ligament injury. LEVEL OF EVEDINCE: Therapeutic study, level III.

Time to first take-back operation predicts successful primary fascial closure in patients undergoing damage control laparotomy.

BACKGROUND: Failure to achieve primary fascial closure (PFC) after damage control laparotomy is costly and carries great morbidity. We hypothesized that time from the initial laparotomy to the first take-back operation would be predictive of successful PFC. METHODS: Trauma patients managed with open abdominal techniques after damage control laparotomy were prospectively followed at 14 Level 1 trauma centers during a 2-year period. Time to the first take-back was evaluated as a predictor of PFC using hierarchical multivariate logistic regression analysis. RESULTS: A total of 499 patients underwent damage control laparotomy and were included in this analysis. PFC was achieved in 327 (65.5%) patients. Median time to the first take-back operation was 36 hours (interquartile range 24-48). After we adjusted for patient demographics, resuscitation volumes, and operative characteristics, increasing time to the first take-back was associated with a decreased likelihood of PFC. Specifically, each hour delay in return to the operating room (24 hours after initial laparotomy) was associated with a 1.1% decrease in the odds of PFC (odds ratio 0.989; 95% confidence interval 0.978-0.999; P = .045). In addition, there was a trend towards increased intra-abdominal complications in patients returning after 48 hours (odds ratio 1.80; 95% confidence interval 1.00-3.25; P = .05). CONCLUSION: Data from this prospective, multicenter study demonstrate that delays in returning to the operating room after damage control laparotomy are associated with reductions in PFC. These findings suggest that emphasis should be placed on returning to the operating room within 24 hours after the initial laparotomy if possible (and no later than 48 hours).

Complicated intra-abdominal infections worldwide: the definitive data of the CIAOW Study.

The CIAOW study (Complicated intra-abdominal infections worldwide observational study) is a multicenter observational study underwent in 68 medical institutions worldwide during a six-month study period (October 2012-March 2013). The study included patients older than 18 years undergoing surgery or interventional drainage to address complicated intra-abdominal infections (IAIs). 1898 patients with a mean age of 51.6 years (range 18-99) were enrolled in the study. 777 patients (41%) were women and 1,121 (59%) were men. Among these patients, 1,645 (86.7%) were affected by community-acquired IAIs while the remaining 253 (13.3%) suffered from healthcare-associated infections. Intraperitoneal specimens were collected from 1,190 (62.7%) of the enrolled patients. 827 patients (43.6%) were affected by generalized peritonitis while 1071 (56.4%) suffered from localized peritonitis or abscesses. The overall mortality rate was 10.5% (199/1898). According to stepwise multivariate analysis (PR = 0.005 and PE = 0.001), several criteria were found to be independent variables predictive of mortality, including patient age (OR = 1.1; 95%CI = 1.0-1.1; p < 0.0001), the presence of small bowel perforation (OR = 2.8; 95%CI = 1.5-5.3; p < 0.0001), a delayed initial intervention (a delay exceeding 24 hours) (OR = 1.8; 95%CI = 1.5-3.7; p < 0.0001), ICU admission (OR = 5.9; 95%CI = 3.6-9.5; p < 0.0001) and patient immunosuppression (OR = 3.8; 95%CI = 2.1-6.7; p < 0.0001).

Independent predictors of enteric fistula and abdominal sepsis after damage control laparotomy: results from the prospective AAST Open Abdomen registry.

IMPORTANCE: Enterocutaneous fistula (ECF), enteroatmospheric fistula (EAF), and intra-abdominal sepsis/abscess (IAS) are major challenges for surgeons caring for patients undergoing damage control laparotomy after trauma. OBJECTIVE: To determine independent predictors of ECF, EAF, or IAS in patients undergoing damage control laparotomy after trauma, using the AAST Open Abdomen Registry. DESIGN: The AAST Open Abdomen registry of patients with an open abdomen following damage control laparotomy was used to identify patients who developed ECF, EAF, or IAS and to compare these patients with those without these complications. Univariate analyses were performed to compare these groups of patients. Variables from univariate analyses differing at P < .20 were entered into a stepwise logistic regression model to identify independent risk factors for ECF, EAF, or IAS. SETTING: Fourteen level I trauma centers. PARTICIPANTS: A total of 517 patients with an open abdomen following damage control laparotomy. MAIN OUTCOMES AND MEASURES: Complication of ECF, EAF, or IAS. RESULTS: More patients in the ECF/EAF/IAS group than in the group without these complications underwent bowel resection (63 of 111 patients [57%] vs 133 of 406 patients [33%]; P < .001). Within the first 48 hours after surgery, the ECF/EAF/IAS group received more colloids (P < .03) and total fluids (P < .03) than did the group without these complications. The ECF/EAF/IAS group underwent almost twice as many abdominal reexplorations as did the group without these complications (mean [SD] number, 4.1 [4.1] vs 2.2 [3.4]; P < .001). After multivariate analysis, the independent predictors of ECF/EAF/IAS were a large bowel resection (adjusted odds ratio [AOR], 3.56 [95% CI, 1.88-6.76]; P < .001), a total fluid intake at 48 hours of between 5 and 10 L (AOR, 2.11 [95% CI, 1.15-3.88]; P = .02) or more than 10 L (AOR, 1.93 [95% CI, 1.04-3.57]; P = .04), and an increasing number of reexplorations (AOR, 1.14 [95% CI, 1.06-1.21]; P < .001). CONCLUSIONS AND RELEVANCE: Large bowel resection, large-volume fluid resuscitation, and an increasing number of abdominal reexplorations were statistically significant predictors of ECF, EAF, or IAS in patients with an open abdomen after damage control laparotomy.

Thin chest wall is an independent risk factor for the development of pneumothorax after chest tube removal.

The factors contributing to the development of pneumothorax after removal of chest tube thoracostomy are not fully understood. We hypothesized that development of post pull pneumothorax (PPP) after chest tube removal would be significantly lower in those patients with thicker chest walls, due to the "protective" layer of adipose tissue. All patients on our trauma service who underwent chest tube thoracostomy from July 2010 to February 2011 were retrospectively reviewed. Patient age, mechanism of trauma, and chest Abbreviated Injury Scale score were analyzed. Thoracic CTs were reviewed to ascertain chest wall thickness (CW). Thickness was measured at the level of the nipple at the midaxillary line, as perpendicular distance between skin and pleural cavity. Chest X-ray reports from immediately prior and after chest tube removal were reviewed for interval development of PPP. Data are presented as average ± standard deviation. Ninety-one chest tubes were inserted into 81 patients. Patients who died before chest tube removal (n = 11), or those without thoracic CT scans (n = 13) were excluded. PPP occurred in 29.9 per cent of chest tube removals (20/67). When PPP was encountered, repeat chest tube was necessary in 20 per cent of cases (4/20). After univariate analysis, younger age, penetrating mechanism, and thin chest wall were found to be significant risk factors for development of PPP. Chest Abbreviated Injury Scale score was similar in both groups. Logistic regression showed only chest wall thickness to be an independent risk factor for development of PPP.

Bladder pressure measurements and urinary tract infection in trauma patients.

BACKGROUND: The purpose of this trial was to determine if using a closed technique for bladder pressure measurements (BPMs) would eliminate them as a risk factor for urinary tract infection (UTI) in trauma patients, as was shown previously using an open technique. METHODS: Data were collected prospectively from January 2006 until December 2009 by a dedicated epidemiology nurse and combined with trauma registry data at our Level 1 trauma center. All trauma patients admitted to the surgical trauma intensive care unit (STICU) with and without UTIs were compared for demographic and epidemiologic data. A closed system was used in which the urinary drainage catheter (UDC) remained connected to the bag and 45 mL of saline was injected through a two-way valved sideport, with subsequent measurements through the sideport. RESULTS: There were 1,641 patients in the trial. The UTI group was sicker (Injury Severity Score [ISS] 18.7±11.9 no UTI vs. 28±10.7 UTI; p<0.0001), with longer stays (11.4±12.4 days no UTI vs. 37.9±20.3 days UTI; p<0.0001) and more UDC days (4.3±6.6 no UTI vs. 23.9±16.6 UTI; p<0.0001). The BPM group had more UDC days (15.6 days±16.0 BPM vs. 5.4 days±7.3 no BPM; p<0.0001), yet no difference in UTI rate/1,000 UDC days (5.7 no BPM vs. 8.0 BPM; p=0.5291). Logistic regression demonstrated only UDC days to be a predictor of UTI (1.125; 95% confidence interval [CI] 1.097-1.154; p<0.0001), whereas ISS (1.083, 95% CI 1.063-1.104; p<0.0001) and age (1.051, 95% CI 1.037-1.065; p<0.0001) were the only predictors of death. CONCLUSION: Although patients undergoing BPM have more UTIs than patients without BPM, the measurements are not an independent predictor of UTI when done by the closed technique. These findings emphasize the judicious use of BPM with a closed system and, more importantly, the need for early removal of catheters.

Canadian Cervical Spine rule compared with computed tomography: a prospective analysis.

BACKGROUND: The Canadian cervical spine rule (CCS) has been found to be an effective tool to determine the need for radiographic evaluation of the cervical spine (c-spine) incorporating both clinical findings and mechanism. Previously, it has been validated only through clinical follow-up or selective use of X-rays. The purpose of this study was to validate it using computed tomography (CT) as the gold standard to identify fractures. METHODS: Prospective evaluation was performed on 3,201 blunt trauma patients who were screened by CCS and were compared with a complete c-spine CT. CSS positive indicated at least one positive clinical or mechanism finding, whereas CT positive indicated presence of a fracture. RESULTS: There were 192 patients with c-spine fractures versus 3,009 without fracture on CT. The fracture group was older (42.7 ± 19.0 years vs. 37.8 ± 17.5 years, p = 0.0006), had a lower Glasgow Coma Scale score (13.8 ± 4.2 vs. 14.4 ± 4.3, p < 0.0001), and lower systolic blood pressure (133.3 ± 23.8 mm Hg vs. 139.5 ± 23.1 mm Hg, p = 0.0023). The sensitivity of CCS was 100% (192/192), specificity was 0.60% (18/3009), positive predictive value was 6.03% (192/3183), and negative predictive value was 100% (18/18). Logistic regression identified only 8 of the 19 factors included in the CCS to be independent predictors of c-spine fracture. CONCLUSIONS: CCS is very sensitive but not very specific to determine the need for radiographic evaluation after blunt trauma. Based on this study, the rule should be streamlined to improve specificity while maintaining sensitivity.

National Emergency X-Radiography Utilization Study criteria is inadequate to rule out fracture after significant blunt trauma compared with computed tomography.

BACKGROUND: EAST guidelines now recommend computed tomography (CT) to evaluate cervical spine (c-spine) fractures after blunt trauma in patients who do not meet National Emergency X-Radiography Utilization Study criteria (NC), yet no imaging is required in those patients who do meet these criteria. NC are based on patients with both minor and severe (trauma team activation [TTA]) trauma. The purpose of this study was to evaluate the NC using CT as the gold standard in TTA patients. METHODS: We prospectively evaluated 2,606 blunt TTA patients at our Level I trauma center. NC defined as alertness (Glasgow Coma Scale [GCS] score = 15), evidence of intoxication, clinically distracting injury, midline c-spine tenderness, or neurologic deficits were documented. CT was used to determine the accuracy of these criteria. RESULTS: There were 157 patients with c-spine fractures and 2,449 patients without c-spine fractures. The fracture group was older (age, 43.4 years ± 19.3 years fracture group vs. 37.7 years ± 17.5 years no fracture group, p = 0.0003) with a lower GCS score (fracture group 13.7 ± 4.5 vs. no fracture group 14.4 ± 3.6, p = 0.0001) and initial systolic blood pressure (132.5 mm Hg ± 23.4 mm Hg vs. 139.9 mm Hg vs. 23.5 mm Hg, p = 0.0009). The sensitivity and specificity of clinical examination for all patients were 82.8% (130 of 157) and 45.7% (1,118 of 2,449), respectively. The positive predictive value (PPV) and negative predictive value (NPV) were 8.9% (130 of 1,461) and 97.6% (1,118 of 1,145), respectively. Patients with a GCS score of 15 had a sensitivity of 77%, specificity of 52.3%, PPV of 8.5%, and NPV of 97.5% for clinical examination. In those patients with the GCS score of 15, no intoxication or distracting injury, clinical examination had a sensitivity of 59.4%, specificity of 79.5%, PPV of 12.5%, and NPV of 97.5%. Of 26 patients with missed injuries based on NC, 19 (73.1%) required further intervention (16 collars, 2 OR, 1 Halo). CONCLUSION: As in our previous trial, NC is inaccurate compared with CT to diagnose c-spine fractures in TTA patients. CT should be used in all blunt TTA patients regardless of whether they meet NC.

Flexion-extension cervical spine plain films compared with MRI in the diagnosis of ligamentous injury.

The purpose of this study was to compare flexion-extension (FE) plain films with MRI as the gold standard in the diagnosis of ligamentous injury (LI) of the cervical spine after trauma. A retrospective review of patients sustaining blunt trauma from January 2000 to December 2008 (n = 22929) who had both FE and MRI of the cervical spine was performed. Two hundred seventy-one patients had 303 FE films. Forty-nine also had MRI. The average Injury Severity Score was 15.6 +/- 10.2, Glasgow Coma Scale was 13.8 +/- 3.5, lactate 2.2 +/- 1.7 mmol/L, and hospital stay of 8 +/- 11.2 days. FE failed to identify all eight LIs seen on MRI. FE film sensitivity was 0 per cent (zero of eight), specificity 98 per cent (40 of 41), positive predictive value 0 per cent (zero of one), and negative predictive value 83 per cent (40 of 48). Although classified as negative for purposes of analysis, FE was incomplete 20.5 per cent (62 of 303) and ambiguous 9.2 per cent (28 of 303) of the time. The charge of FE is $535 so $48150 (90 incomplete/ambiguous films) could have been saved by eliminating these films. FE should no longer be used to diagnose LI. Given the rare incidence of these injuries, MRI should be used when there is high clinical suspicion of injury.

Do flexion extension plain films facilitate treatment after trauma?

We hypothesized that flexion extension (FE) films do not facilitate the diagnosis or treatment of ligamentous injury of the cervical spine after blunt trauma. From January 2000 to December 2008 we reviewed all patients who underwent FE films and compared five-view plain films (5 view) and cervical spine CTC with FE in the diagnosis of ligamentous injury. There were 22,929 patients with blunt trauma and of these, 271 patients underwent 303 FE films. Average age was 39.6 years, Injury Severity Score was 10.8, Glasgow Coma Score was 14.1, lactate was 2.6 mmol/L, and hospital length of stay was 6 days. Compared with FE, 5 view and CTC had a sensitivity of 80 per cent (8 of 10), positive predictive value of 47.1 per cent (8 of 17), specificity of 96.55 per cent (252 of 261), and negative predictive value of 99.21 per cent (252 of 254). For purposes of analysis, incomplete and ambiguous FE films were listed as negative; however, 20.5 per cent (62 of 303) were incomplete and 9.2 per cent (28 of 303) were ambiguous. Management did not change for the 2 patients with missed ligament injuries. The 303 studies cost $162,105.00 to obtain. FEs are often incomplete and unreliable making it difficult to use them to base management decisions. They do not facilitate treatment and may lead to increased cost and prolonged cervical collars.