Trauma resource pit stop: increasing efficiency in the evaluation of lower severity trauma patients.

BACKGROUND: Overtriage of trauma patients is unavoidable and requires effective use of hospital resources. A 'pit stop' (PS) was added to our lowest tier trauma resource (TR) triage protocol where the patient stops in the trauma bay for immediate evaluation by the emergency department (ED) physician and trauma nursing. We hypothesized this would allow for faster diagnostic testing and disposition while decreasing cost. METHODS: We performed a before/after retrospective comparison after PS implementation. Patients not meeting trauma activation (TA) criteria but requiring trauma center evaluation were assigned as a TR for an expedited PS evaluation. A board-certified ED physician and trauma/ED nurse performed an immediate assessment in the trauma bay followed by performance of diagnostic studies. Trauma surgeons were readily available in case of upgrade to TA. We compared patient demographics, Injury Severity Score, time to physician evaluation, time to CT scan, hospital length of stay, and in-hospital mortality. Comparisons were made using 95% CI for variance and SD and unpaired t-tests for two-tailed p values, with statistical difference, p<0.05. RESULTS: There were 994 TAs and 474 TRs in the first 9 months after implementation. TR's preanalysis versus postanalysis of the TR group shows similar mean door to physician evaluation times (6.9 vs. 8.6 minutes, p=0.1084). Mean door to CT time significantly decreased (67.7 vs. 50 minutes, p<0.001). 346 (73%) TR patients were discharged from ED; 2 (0.4%) were upgraded on arrival. When admitted, TR patients were older (61.4 vs. 47.2 years, p<0.0001) and more often involved in a same-level fall (59.5% vs. 20.1%, p<0.0001). Undertriage was calculated using the Cribari matrix at 3.2%. DISCUSSION: PS implementation allowed for faster door to CT time for trauma patients not meeting activation criteria without mobilizing trauma team resources. This approach is safe, feasible, and simultaneously decreases hospital cost while improving allocation of trauma team resources. LEVEL OF EVIDENCE: Level II, economic/decision therapeutic/care management study.

A multicenter trial of current trends in the diagnosis and management of high-grade pancreatic injuries.

BACKGROUND: Outcomes following pancreatic trauma have not improved significantly over the past two decades. A 2013 Western Trauma Association algorithm highlighted emerging data that might improve the diagnosis and management of high-grade pancreatic injuries (HGPIs; grades III-V). We hypothesized that the use of magnetic resonance cholangiopancreatography, pancreatic duct stenting, operative drainage versus resection, and nonoperative management of HGPIs increased over time. METHODS: Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018 was performed. Data were analyzed by grade and time period (PRE, 2010-2013; POST, 2014-2018) using various statistical tests where appropriate. RESULTS: Thirty-two centers reported data on 515 HGPI patients. A total of 270 (53%) had penetrating trauma, and 58% went directly to the operating room without imaging. Eighty-nine (17%) died within 24 hours. Management and outcomes of 426 24-hour survivors were evaluated. Agreement between computed tomography and operating room grading was 38%. Magnetic resonance cholangiopancreatography use doubled in grade IV/V injuries over time but was still low.Overall HGPI treatment and outcomes did not change over time. Resection was performed in 78% of grade III injuries and remained stable over time, while resection of grade IV/V injuries trended downward (56% to 39%, p = 0.11). Pancreas-related complications (PRCs) occurred more frequently in grade IV/V injuries managed with drainage versus resection (61% vs. 32%, p = 0.0051), but there was no difference in PRCs for grade III injuries between resection and drainage.Pancreatectomy closure had no impact on PRCs. Pancreatic duct stenting increased over time in grade IV/V injuries, with 76% used to treat PRCs. CONCLUSION: Intraoperative and computed tomography grading are different in the majority of HGPI cases. Resection is still used for most patients with grade III injuries; however, drainage may be a noninferior alternative. Drainage trended upward for grade IV/V injuries, but the higher rate of PRCs calls for caution in this practice. LEVEL OF EVIDENCE: Retrospective diagnostic/therapeutic study, level III.

Intercostal nerve cryoablation for control of traumatic rib fracture pain: A case report.

Pain from traumatic rib fractures presents a source of major morbidity and mortality. Prior studies have reported 59% of patients continue to have persistent pain at 2 months post injury. Most modern analgesia modalities have short duration of effect (<72 h) and require repeated doses to achieve adequate effect. There are few studies that address long-term analgesia treatment for these injuries. Intercostal cryoneurolysis (IC) is a technique of long-term chest wall analgesia previously studied in thoracic surgery and pediatric chest wall reconstruction. This technique may also be an effective treatment for rib fracture pain. Presented is a case of successful control of rib fracture pain with IC used as an adjunct to surgical stabilization of rib fractures (SSRF). This is followed by a discussion of IC's role in the treatment of traumatic rib fracture pain.

Effect of Pneumatic Tubing System Transport on Platelet Apheresis Units.

Platelet apheresis units are transfused into patients to mitigate or prevent bleeding. In a hospital, platelet apheresis units are transported from the transfusion service to the healthcare teams via two methods: a pneumatic tubing system (PTS) or ambulatory transport. Whether PTS transport affects the activity and utility of platelet apheresis units is unclear. We quantified the gravitational forces and transport time associated with PTS and ambulatory transport within our hospital. Washed platelets and supernatants were prepared from platelet apheresis units prior to transport as well as following ambulatory or PTS transport. For each group, we compared resting and agonist-induced platelet activity and platelet aggregate formation on collagen or von Willebrand factor (VWF) under shear, platelet VWF-receptor expression and VWF multimer levels. Subjection of platelet apheresis units to rapid acceleration/deceleration forces during PTS transport did not pre-activate platelets or their ability to activate in response to platelet agonists as compared to ambulatory transport. Platelets within platelet apheresis units transported via PTS retained their ability to adhere to surfaces of VWF and collagen under shear, although platelet aggregation on collagen and VWF was diminished as compared to ambulatory transport. VWF multimer levels and platelet GPIb receptor expression was unaffected by PTS transport as compared to ambulatory transport. Subjection of platelet apheresis units to PTS transport did not significantly affect the baseline or agonist-induced levels of platelet activation as compared to ambulatory transport. Our case study suggests that PTS transport may not significantly affect the hemostatic potential of platelets within platelet apheresis units.

Estimating Geriatric Mortality after Injury Using Age, Injury Severity, and Performance of a Transfusion: The Geriatric Trauma Outcome Score.

BACKGROUND: A tool to determine the probability of mortality for severely injured geriatric patients is needed. OBJECTIVE: We sought to create an easily calculated geriatric trauma prognostic score based on parameters available at the bedside to aid in mortality probability determination. METHODS: All patients ≥ 65 years of age were identified from our Level I trauma center's registry between January 1, 2000 and December 31, 2013. Measurements included age, Injury Severity score (ISS), units of packed red blood cells (PRBCs) transfused in the first 24 hours, and patients' mortality status at the end of their index hospitalization. As a first step, a logistic regression model with maximum likelihood estimation and robust standard errors was used to estimate the odds of mortality from age, ISS, and PRBCs after dichotomizing PRBCs as yes/no. We then constructed a Geriatric Trauma Outcome (GTO) score that became the sole predictor in the re-specified logistic regression model. RESULTS: The sample (n = 3841) mean age was 76.5 ± 8.1 years and the mean ISS was 12.4 ± 9.8. In-hospital mortality was 10.8%, and 11.9% received a transfusion by 24 hours. Based on the logistic regression model, the equation with the highest discriminatory ability to estimate probability of mortality was GTO Score = age + (2.5 × ISS) + 22 (if given PRBCs). The area under the receiver operating characteristic curve (AUC) for this model was 0.82. Selected GTO scores and their related probability of dying were: 205 = 75%, 233 = 90%, 252 = 95%, 310 = 99%. The range of GTO scores was 67.5 (survivor) to 275.1 (died). CONCLUSION: The GTO model accurately estimates the probability of dying, and can be calculated at bedside by those possessing a working knowledge of ISS calculation.

Contemporary management and outcomes of blunt thoracic aortic injury: a multicenter retrospective study.

BACKGROUND: Blunt thoracic aortic injuries (BTAIs) are composed of a spectrum of lesions ranging from intimal tear to rupture, yet optimal management and ultimate outcome have not been clearly established. METHODS: This is a retrospective multicenter study of BTAIs from January 2008 to December 2013. Demographics, diagnosis, treatment, and in-hospital outcomes were analyzed. RESULTS: Nine American College of Surgeons-verified Level I trauma centers contributed data from 453 patients with BTAIs. After exclusion of patients expiring before imaging (58) and transfers (13), 382 patients with imaging diagnosis were available for analysis (Grade 1, 94; Grade 2, 68; Grade 3, 192; Grade 4, 28). Hypotension was present on admission in 56 (14.7%). Computed tomographic angiography was used for diagnosis in 94.5%. Nonoperative management (NOM) was selected in 32%, with two in-hospital failures (Grade 1, Grade 4) requiring endovascular salvage (thoracic endovascular aortic repair [TEVAR]). Open repair (OR) was completed in 61 (16%). TEVAR was conducted in 198 (52%), with 41% of these requiring left subclavian artery coverage. Complications of TEVAR included endograft malposition (6, 3.0%), endoleak (5, 2.5%), paralysis (1, 0.5%), and stroke (2, 1.0%). Six TEVAR failures were treated by repeat TEVAR (2) or OR (4). Overall in-hospital mortality was 18.8%, and aortic-related mortality was 6.5% (NOM, 9.8%; OR, 13.1%; TEVAR, 2.5%) (Grade 1, 0%; Grade 2, 2.9%; Grade 3, 5.2%; Grade 4, 46.4%). The majority of aortic-related deaths (18 of 25) occurred before the opportunity for repair. Independent predictors of aortic-related mortality among BTAI patients were higher chest Abbreviated Injury Scale (AIS) score, grade, and Injury Severity Score (ISS); TEVAR was protective (p = 0.03; odds ratio, 0.21; confidence interval, 0.05-0.88). CONCLUSION: Failures and aortic-related mortality of NOM following BTAI Society of Vascular Surgery Grade 1 to 3 injuries are rare. TEVAR seems independently protective against aortic-related mortality. Early complications of TEVAR have decreased relative to previous reports. Prospective long-term follow-up data are required to better refine indications for intervention. LEVEL OF EVIDENCE: Level IV.