Andexanet alfa therapy showed No increased rate of thromboembolic events in spontaneous intracranial hemorrhage patients: A multicenter electronic health record study.

•Intracranial hemorrhage accounts for two out of every three major intracranial hemorrhages.•Systemic anticoagulation is routinely prescribed for prevention of cerebrovascular accidents.•The FDA approved Andexanet alfa to treat life-threatening bleeding.•Andexanet alfa relationship to outcomes requires further investigation.

Database Integration Correlates Street Crossing Design Strategies With Pedestrian Injury.

INTRODUCTION: Transportation databases have limited data regarding injury severity of pedestrian versus automobile patients. To identify opportunities to reduce injury severity, transportation and trauma databases were integrated to examine the differences in pedestrian injury severity at street crossings that were signalized crossings (SCs) versus nonsignalized crossings (NSCs). It was hypothesized that trauma database integration would enhance safety analysis and pedestrians struck at NSC would have greater injury severity. METHODS: Single-center retrospective review of all pedestrian versus automobile patients treated at a level 1 trauma center from 2014 to 2018 was performed. Patients were matched to the transportation database by name, gender, and crash date. Google Earth Pro satellite imagery was used to identify SC versus NSC. Injury severity of pedestrians struck at SC was compared to NSC. RESULTS: A total of 512 patients were matched (median age = 41 y [Q1 = 26, Q3 = 55], 74% male). Pedestrians struck at SC (n = 206) had a lower injury severity score (ISS) (median = 9 [4, 14] versus 17 [9, 26], P < 0.001), hospital length of stay (median = 3 [0, 7] versus 6 [1, 15] days, P < 0.001), and mortality (21 [10%] versus 52 [17%], P = 0.04), as compared to those struck at NSC (n = 306). The transportation database had a sensitivity of 63.4% (55.8%-70.4%) and specificity of 63.4% (57.7%-68.9%) for classifying severe injuries (ISS >15). CONCLUSIONS: Pedestrians struck at SC were correlated with a lower ISS and mortality compared to those at NSC. Linkage with the trauma database could increase the transportation database's accuracy of injury severity assessment for nonfatal injuries. Database integration can be used for evidence-based action plans to reduce pedestrian morbidity, such as increasing the number of SC.

Vascular Surgery Role in Vascular Trauma: 11-Year Analysis of Peripheral Vascular Trauma Management at a Level-1 Trauma Center.

BACKGROUND: Vascular surgeons are increasingly relied upon in the management of complex peripheral vascular trauma. The degree however that vascular surgery (VS) is involved in vascular trauma care is not well established. We hypothesize that VS consultation is required in a high portion of complex lower extremity vascular trauma. METHODS: A single-center retrospective review of all consecutive patients who sustained traumatic arterial injury of the lower extremity requiring open operative repair at a level-1 trauma center (from February 2009 to May 2020) was performed. Patients who underwent surgical repair were stratified by the service that performed the operation (VS versus trauma surgery [TS]). Secondary outcomes assessed included location of arterial injury, type of repair, and clinical outcomes. RESULTS: A total of 111 patients underwent operative repair of lower extremity arterial injury (mean age 34.5 ± 15.5 years, 89% male). The most common vessels requiring intervention were the superficial femoral artery (n = 42, 38%), popliteal artery (n = 35, 31.5%), and tibial vessels (n = 19, 17.1%). The most common intervention required in patients was an autologous bypass (n = 85, 76.5%), followed by ligation (n = 9, 8.1%) and primary repair (n = 6, 5.4%). Most interventions overall required VS involvement (n = 95, 86%). VS performed a higher proportion of autologous graft procedures compared to TS (n = 79, 92.9% vs. n = 6, 7.1%). VS case load overall was likewise predominantly autologous grafts (n = 79/95, 83.2%). TS operated on a higher proportion of injuries to the tibial vessels (44% vs. 13%, P = 0.01), whereas VS intervened more frequently on popliteal injuries (36% vs. 6%, P = 0.02). With regard to the method of arterial repair, TS was more likely to perform ligation (38% vs. 3 %, P < 0.001) or primary repair (13% vs. 3%, P = 0.04) compared to VS. However, VS was more likely to perform repair with autologous graft (83% vs. 38%, P < 0.001). There were no significant differences in rates of mortality, limb loss, transfusions requirement, fasciotomy, deep venous thrombosis, hematoma formation, or length of stay between groups. Although, surgical site infections were more common in the TS group (38% vs. 15%, P = 0.04). CONCLUSIONS: Vascular surgeons play a large role in managing complex lower extremity vascular trauma. In particular, VS remains integral for the management of more difficult injuries (e.g., popliteal injuries) and is more likely to provide more complex repairs (e.g., autologous grafts).

Endoluminal wound VAC therapy for the management of esophageal trauma: A case series.

Esophageal trauma is rare and associated with high morbidity and mortality. Management can be challenging. Operative intervention involves exposure of the esophageal injury followed by primary two-layer repair with or without a buttressing muscle flap and wide local drainage. Repair can be complicated by post-operative leak and esophagocutaneous fistula. Endoluminal wound VAC therapy in the management of non-traumatic and iatrogenic esophageal perforations has shown efficacy. Presented here is a case series of four patients who sustained penetrating trauma to the esophagus and were managed successfully with endoluminal wound VAC therapy following primary repair. Therefore, endoscopic placement of an endoluminal wound VAC over the site of esophageal injury can serve as a safe and effective adjunct to primary repair of penetrating esophageal trauma. This procedure allows for frequent direct visualization of the injury as it heals, controls leakage of luminal contents, and promotes granulation for local wound healing.

Tracheotomy in ventilator-dependent patients with COVID-19: a cross-sectional study of analgesia and sedative requirements.

OBJECTIVE: During March 2020 in the United States, demand for sedatives increased by 91%, that for analgesics rose by 79%, and demand for neuromuscular blockers increased by 105%, all owing to the number of COVID-19 cases requiring invasive mechanical ventilation (MV). We hypothesize that analgesic and sedative requirements decrease following tracheotomy in this patient population. METHODS: In this cross-sectional study, we conducted a retrospective chart review to identify patients with COVID-19 who underwent tracheotomy (T) at an academic medical center between March 2020 and January 2021. We used a paired Student t-test to compare total oral morphine equivalents (OMEs), total lorazepam equivalents, 24-hour average dexmedetomidine dosage in µg/kg/hour, and 24-hour average propofol dosage in µg/kg/minute on days T-1 and T+2 for each patient. RESULTS: Of 50 patients, 46 required opioids before and after tracheotomy (mean decrease of 49.4 mg OMEs). Eight patients required benzodiazepine infusion (mean decrease of 45.1 mg lorazepam equivalents. Fifteen patients required dexmedetomidine infusion (mean decrease 0.34 µg/kg/hour). Seventeen patients required propofol (mean decrease 20.5 µg/kg/minute). CONCLUSIONS: When appropriate personal protective equipment is available, use of tracheotomy in patients with COVID-19 who require MV may help to conserve medication supplies in times of extreme shortages.

Preoperative frailty measured by risk analysis index predicts complications and poor discharge outcomes after Brain Tumor Resection in a large multi-center analysis.

PURPOSE: To evaluate the independent effect of frailty, as measured by the Risk Analysis Index-Administrative (RAI-A) for postoperative complications and discharge outcomes following brain tumor resection (BTR) in a large multi-center analysis. METHODS: Patients undergoing BTR were queried from the National Surgical Quality Improvement Program (NSIQP) for the years 2015 to 2019. Multivariable logistic regression was performed to evaluate the independent associations between frailty tools (age, 5-factor modified frailty score [mFI-5], and RAI-A) on postoperative complications and discharge outcomes. RESULTS: We identified 30,951 patients who underwent craniotomy for BTR; the median age of our study sample was 59 (IQR 47-68) years old and 47.8% of patients were male. Overall, increasing RAI-A score, in an overall stepwise fashion, was associated with increasing risk of adverse outcomes including in-hospital mortality, non-routine discharge, major complications, Clavien-Dindo Grade IV complication, and extended length of stay. Multivariable regression analysis (adjusting for age, sex, BMI, non-elective surgery status, race, and ethnicity) demonstrated that RAI-A was an independent predictor for worse BTR outcomes. The RAI-A tiers 41-45 (1.2% cohort) and > 45 (0.3% cohort) were ~ 4 (Odds Ratio [OR]: 4.3, 95% CI: 2.1-8.9) and ~ 9 (OR: 9.5, 95% CI: 3.9-22.9) times more likely to have in-hospital mortality compared to RAI-A 0-20 (34% cohort). CONCLUSIONS AND RELEVANCE: Increasing preoperative frailty as measured by the RAI-A score is independently associated with increased risk of complications and adverse discharge outcomes after BTR. The RAI-A may help providers present better preoperative risk assessment for patients and families weighing the risks and benefits of potential BTR.

Surgical Infection Society: Chest Wall Injury Society Recommendations for Antibiotic Use during Surgical Stabilization of Traumatic Rib or Sternal Fractures to Reduce Risk of Implant Infection.

Background: Surgical stabilization of rib fractures is recommended in patients with flail chest or multiple displaced rib fractures with physiologic compromise. Surgical stabilization of rib fractures (SSRF) and surgical stabilization of sternal fractures (SSSF) involve open reduction and internal fixation of fractures with a plate construct to restore anatomic alignment. Most plate constructs are composed of titanium and presence of this foreign, non-absorbable material presents opportunity for implant infection. Although implant infection rates after SSRF and SSSF are low, they present a challenging clinical entity often requiring prolonged antibiotic therapy, debridement, and potentially implant removal. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee and Chest Wall Injury Society's Publication Committee convened to develop recommendations for antibiotic use during and after surgical stabilization of traumatic rib and sternal fractures. Clinical scenarios included patients with concomitant infectious processes (sepsis, pneumonia, empyema, cellulitis) or sources of contamination (open chest, gross contamination) incurred as a result of their trauma and present at the time of their surgical stabilization. PubMed, Embase, and Cochrane databases were searched for pertinent studies. Using a process of iterative consensus, all committee members voted to accept or reject each recommendation. Results: For patients undergoing SSRF or SSSF in the absence of pre-existing infectious process, there is insufficient evidence to suggest existing peri-operative guidelines or recommendations are inadequate. For patients undergoing SSRF or SSSF in the presence of sepsis, pneumonia, or an empyema, there is insufficient evidence to provide recommendations on duration and choice of antibiotic. This decision may be informed by existing guidelines for the concomitant infection. For patients undergoing SSRF or SSSF with an open or contaminated chest there is insufficient evidence to provide specific antibiotic recommendations. Conclusions: This guideline document summarizes the current Surgical Infection Society and Chest Wall Injury Society recommendations regarding antibiotic use during and after surgical stabilization of traumatic rib or sternal fractures. Limited evidence exists in the chest wall surgical stabilization literature and further studies should be performed to delineate risk of implant infection among patients undergoing SSSRF or SSSF with concomitant infectious processes.

Should we resuscitate elderly patients with blunt traumatic cardiac arrest? Analysis of National Trauma Registry Data in Japan.

OBJECTIVES: Recent studies suggest that survival after traumatic cardiac arrest (TCA) has been improving. Many elderly adults enjoy active lifestyles, which occasionally result in TCA. The epidemiology and efficacy of resuscitative procedures on blunt TCA in elderly patients are largely unknown. Our primary aim was to compare the survival to discharge following blunt TCA between non-elderly adult (ages 18-59 years) and elderly patients (age ≥60 years). METHODS: We analysed 2004-2015 observational cohort data from a nationwide trauma registry in Japan. We included all adult patients (18 years and older) who experienced blunt TCA. We excluded patients missing data for age, survival, mechanism of injury or initial vital signs. Resuscitative procedures included thoracotomy and resuscitative endovascular balloon occlusion of the aorta. We compared survival for elderly patients (age ≥60 years old) to younger adults. RESULTS: Of 8347 patients with blunt TCA, 3547 (42.5%) were elderly. Survival differed significantly by age: 164/4800 (3.4%) of younger adults survived whereas 188/3547 (5.3%) of elderly patients survived (p<0.001). Survival increased but Injury Severity Scores (ISSs) declined with increasing patient age. The efficacy of resuscitative procedures did not vary by age. In logistic regression models, increasing age was independently associated with better survival. CONCLUSION: In a cohort of patients with blunt TCA, survival increased with increasing patient age. A number of patients with low ISS in the elderly group raises the possibility that this improved survival is due to preceding or concomitant medical cardiac arrest in the older cohort. Clinicians should be cautious about applying TCA algorithms to elderly patients and should not be discouraged from resuscitating TCA because of patient age.

Barriers to clinical research in trauma.

As with all areas of medicine, high-quality clinical research is essential to improving the care of trauma patients. This research is crucial in developing evidence-based treatments that decrease cost, decrease morbidity, and improve mortality. Trauma continues to extract a significant toll on society and is the single largest cause of years of life lost in the United States. The need to conduct high-quality clinical research in trauma is not disputed. However, significant challenges and barriers unique to the field of trauma make performing this research more difficult. It is critical to be aware of these challenges and barriers to performing clinical research involving trauma patients so these challenges can be accounted for and solutions implemented to minimize their impact on research. This review will focus on the barriers and challenges that are encountered while performing clinical research in trauma.

General surgeon management of complex hepatopancreatobiliary trauma at a level I trauma center.

BACKGROUND: The impact of general surgeons (GS) taking trauma call on patient outcomes has been debated. Complex hepatopancreatobiliary (HPB) injuries present a particular challenge and often require specialized care. We predicted no difference in the initial management or outcomes of complex HPB trauma between GS and trauma/critical care (TCC) specialists. MATERIALS AND METHODS: A retrospective review of patients who underwent operative intervention for complex HPB trauma from 2008 to 2015 at an ACS-verified level I trauma center was performed. Chart review was used to obtain variables pertaining to demographics, clinical presentation, operative management, and outcomes. Patients were grouped according to whether their index operation was performed by a GS or TCC provider and compared. RESULTS: 180 patients met inclusion criteria. The GS (n = 43) and TCC (n = 137) cohorts had comparable patient demographics and clinical presentations. Most injuries were hepatic (73.3% GS versus 72.6% TCC) and TCC treated more pancreas injuries (15.3% versus GS 13.3%; P = 0.914). No significant differences were found in HPB-directed interventions at the initial operation (41.9% GS versus 56.2% TCC; P = 0.100), damage control laparotomy with temporary abdominal closure (69.8% versus 69.3%; P = 0.861), LOS, septic complications or 30-day mortality (13.9% versus 10.2%; P = 0.497). TCC were more likely to place an intraabdominal drain than GS (52.6% versus 34.9%; P = 0.043). CONCLUSIONS: We found no significant differences between GS and TCC specialists in initial operative management or clinical outcomes of complex HPB trauma. The frequent and proper use of damage control laparotomy likely contribute to these findings.

Management of splenic ectopic pregnancy presenting with massive haemoperitoneum.

Abdominal ectopic pregnancy (EP) accounts for only 1.3% of EPs and occurs when a fertilised ovum implants in an extrapelvic peritoneal location. Primary splenic pregnancy is a rare type of abdominal EP, with only 16 cases previously reported in the literature. Early diagnosis is essential as delay in treatment carries significant potential for morbidity and mortality. We present the case of a 27-year-old woman presenting with left upper quadrant abdominal pain, elevated human chorionic gonadotropin levels, absence of intrauterine gestational sac and massive haemoperitoneum on transvaginal ultrasound. The patient underwent emergent surgical exploration for high suspicion of ruptured abdominal EP. An open splenectomy was performed when the source of bleeding was confirmed to originate from the left upper quadrant. Final pathology confirmed subcapsular gestational sac implantation within the spleen. While two cases of medical management have been reported, splenectomy remains the current definitive management of rare cases of primary splenic pregnancy.

Complications of pelvic ring fixation in patients requiring laparotomy.

BACKGROUND: Pelvic ring disruptions in blunt trauma are rarely an isolated finding. Many individuals needing operative pelvic fixation also require laparotomy for other injuries. Pelvic fixation can be performed by open reduction and internal fixation (ORIF) or external fixation (Ex-fix). Often when a laparotomy incision is present, ORIF is performed by extending this incision. We hypothesized ORIF performed by extending the laparotomy incision would result in higher rates of ventral hernia and wound complications versus Ex-fix. METHODS: All patients admitted from 2004-June 2014 who underwent laparotomy and pelvic fixation either by ORIF through extension of a laparotomy incision (ORIF group) or definitive Ex-fix group were identified. Injury severity score, demographics, associated injuries, and complications were collected. RESULTS: A total of 35 patients were identified who underwent laparotomy and pelvic fixation, 21 underwent Ex-fix, whereas 14 underwent ORIF through an extended laparotomy incision. There were no differences in injury severity score, demographics, associated injuries, or rate of ventral hernia. The ORIF group had more laparotomy incision infections (50.0% versus 4.8%, P < 0.01) and pelvic abscesses (42.9% versus 9.5%, P < 0.05). They required more procedures to address their complications (13 versus 5, P < 0.05). CONCLUSIONS: Individuals who have undergone laparotomy and pelvic fixation are a complex group of patients with multiple injuries. These data suggest that when surgical repair of a pelvic ring disruption is indicated and the patient has undergone laparotomy, careful consideration to the method of fixation should be given.

Interhospital transfer of liver trauma in New Mexico: a state of austere resources.

BACKGROUND: There is debate in the trauma literature regarding the effect of prolonged prehospital transport on morbidity and mortality. This study analyzes the management of hepatic trauma patients requiring surgery and compares the outcomes of the group that was transferred to the University of New Mexico Hospital (UNMH) from outside institutions, to the directly admitted group. MATERIALS AND METHODS: The UNMH Trauma Database was queried from 2005-2012. Of 674 patients who sustained liver injuries, 163 required surgery: 46 patients (28.2%) underwent interhospital transfer, and 117 (71.8%) were directly admitted. Variables examined included transfer status, trauma mechanism, transport type, injury severity score (ISS), liver injury grade, and associated injuries. Outcome variables included length of stay (LOS) and 30-day mortality. Outcomes of the transfer group (TG) and direct admit group (DAG) were compared. RESULTS: Both TG and DAG had the same median age (31 y, P = 0.33). The blunt-to-penetrating ratio was the same for each group (48% blunt: 52% penetrating, P = 1.0). Median ISS was 25 for the TG and 26 for the DAG. Grade III or higher injury occurred in 29 (63%) of the TG and in 68 (58%) of the DAG (P = 0.56). Median hospital LOS was 14 d for TG and 9 d for DAG (P = 0.15). Median intensive care unit LOS was 4 d for both groups (P = 0.71). Thirty-day mortality was 20% in each group (P = 0.27). Using a multiple logistic regression model for the outcome of mortality, only age, ISS, and liver injury grade, not transfer status or transport type, had a significant effect on mortality. CONCLUSIONS: There was no significant difference in liver injury grade, ISS, LOS, and mortality between TG and DAG. In the patient population of our study, transfer status did not affect outcome.

Permanent suture used in uterosacral ligament suspension offers better anatomical support than delayed absorbable suture.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to compare the outcomes of uterosacral ligament suspension (USLS) procedures in relation to suture material used for apical suspension. METHODS: A retrospective chart review was performed for two senior surgeons who supervised and performed USLS with both suture types in 2008-2009. Permanent and delayed absorbable sutures were compared for failure of anatomical support. Failure, defined as recurrent prolapse beyond the hymen, was evaluated using survival analysis. RESULTS: Two hundred forty-eight procedures were performed. One percent in the permanent group had a loss of support beyond the hymen compared to 6% in the delayed absorbable group (p = 0.034). The preoperative prolapse stage and duration of follow-up did not differ between the two groups. The number of sutures used did not differ between patients who failed and those who did not fail. CONCLUSIONS: The use of permanent sutures for USLS of the vaginal apex was associated with a lower failure rate than delayed absorbable sutures in the short-term.