The Alvarado score should be used to reduce emergency department length of stay and radiation exposure in select patients with abdominal pain.

BACKGROUND: Abdominal pain is the common reason patients seek treatment in emergency departments (ED), and computed tomography (CT) is frequently used for diagnosis; however, length of stay (LOS) in the ED and risks of radiation remain a concern. The hypothesis of this study was the Alvarado score (AS) could be used to reduce CT scans and decrease ED LOS for patients with suspected acute appendicitis (AA). METHODS: A retrospective review of patients who underwent CT to rule out AA from January 1, 2015, to December 31, 2015, was performed. Patient demographics, medical history, ED documentation, operative interventions, complications, and LOS were all collected. Alvarado score was calculated from the medical record. Time to CT completion was calculated from times the patient was seen by ED staff, CT order, and CT report. RESULTS: Four hundred ninety-two patients (68.1% female; median age, 33 years) met the inclusion criteria. Most CT scans (70%) did not have findings consistent with AA. Median AS for AA on CT scan was 7, compared with 3 for negative CT (p < 0.001). One hundred percent of female patients with AS of 10 and males with AS of 9 or greater had AA confirmed by surgical pathology. Conversely, 5% or less of female patients with AS of 2 or less and 0% of male patients with AS of 1 or less were diagnosed with AA. One hundred six (21.5%) patients had an AS within these ranges and collectively spent 10,239 minutes in the ED from the time of the CT order until the radiologist's report. CONCLUSION: Males with an AS of 9 or greater and females with AS of 10 should be considered for treatment of AA without imaging. Males with AS of 1 or less and females with AS of 2 or less can be safely discharged with follow-up. Using AS, a significant proportion of patients can avoid the radiation risk, the increased cost, and increased ED LOS associated with CT. LEVEL OF EVIDENCE: Diagnostic IV, therapeutic IV.

Clot dynamics and mortality: The MA-R ratio.

INTRODUCTION: The coagulopathy of trauma, illustrated by a short R-time, is common and well understood. The physiology behind this may be early thrombin burst with rapid clot formation. Rapid consumption of fibrinogen, however, may result in weak clot and substrate depletion, resulting in low MA. While these characteristics are interesting, utilizing thromboelastography (TEG) to identify those at risk of subsequent bleeding diathesis, especially in those who do not demonstrate early signs of physiologic derangement, is challenging. We have developed a novel ratio utilizing TEG values to describe patients at specific risk of traumatic coagulopathy. The purpose of this study was to create a single TEG value, which would reflect both the hypercoagulability and hypocoagulability of TIC. We hypothesized that this ratio, at admission, would be indicative of TIC and predictive of both blood product transfusion volumes and subsequent mortality. METHODS: Patients admitted via the highest activation criteria at one of two Level I trauma centers were included if they received at least 1 unit of packed red blood cells in the first 24 hours of admission. The admission TEG was collected, and a ratio was calculated by dividing the MA by the R-time (MA-R). MA-R quartiles were developed, and multivariable logistic regression was utilized to determine odds of mortality. RESULTS: Three hundred thirty patients with admission TEG were included. In all patients, median age was 35 years (interquartile range, 25-54 years), Injury Severity Score (ISS) was 20 (interquartile range, 13-29), 76% were male, and 43% had penetrating trauma. The MA-R groups were based on quartiles. Multivariable analysis, controlling for mechanism of injury, ISS, and admission pH, showed that increasing ratios were associated with decreased odds of death. The lowest MA-R ratios were also significantly associated with higher ISS, higher rates of blunt injury, and higher plasma utilization without a significant difference in packed red blood cell administration. CONCLUSIONS: Patients with the lowest MA-R ratios demonstrated the highest mortality rates. This novel ratio may prove highly useful to predict at-risk patients early, when other physiologic indicators are absent. The mechanism driving this finding may rest in fibrinogen depletion, resulting in weak clot. Patients with low MA-R ratios may benefit from earlier resuscitation with cryoprecipitate, rather than the traditional use of plasma found in current massive transfusion protocols. LEVELS OF EVIDENCE: Prognostic study, Level I.

1: 1 Transfusion strategies are right for the wrong reasons.

BACKGROUND: Early assessment of clot function identifies coagulopathies after injury. Abnormalities include a hypercoagulable state from excess thrombin generation, as well as an acquired coagulopathy. Efforts to address coagulopathy have resulted in earlier, aggressive use of plasma emphasizing 1:1 resuscitation. The purpose of this study was to describe coagulopathies in varying hemorrhagic profiles from a cohort of injured patients. METHODS: All injured patients who received at least one unit of packed red blood cells (PRBC) in the first 24 hours of admission from September 2013 to May 2015 were eligible for inclusion. Group-Based Trajectory Modeling, using volume of transfusion over time, was used to identify specific hemorrhagic phenotypes. The thromboelastography profile of each subgroup was characterized and group features were compared. RESULTS: Four hemorrhagic profiles were identified among 330 patients-minimal (MIN, group 1); patients with large PRBC requirements later in the hospital course (LH, group 2); massive PRBC usage (MH, group 3), and PRBC transfusion limited to shortly after injury (EH, group 4). All groups had an R-time shorter than the normal range (3.2-3.5, p = NS). Patients in group 3 had longer K-times (1.8 vs. 1.2-1.3, p < 0.05), significantly flatter α-angles (66.7 vs. 70.4-72.8, p < 0.05), and significantly weaker clot strength (MA 54.6 vs. 62.3-63.6, p < 0.05). Group 3 had greater physiologic derangements at admission and worse overall outcomes. CONCLUSION: Hemorrhagic profiles suggest a rapid onset of clot formation in all subgroups but significantly suppressed thrombin burst and diminished clot strength in the most injured. Patients are both hypercoagulable, with early and precipitous clot formation, and also have a demonstrable hypocoagulability. The exact cause of traumatic hypocoagulability is likely multifactorial. Goal-directed resuscitation, as early as institution of the massive transfusion protocol, may be more effective in resuscitating the most coagulopathic patients. LEVEL OF EVIDENCE: Prognostic study, level III.

Arterial Injuries Associated with Blunt Fractures in the Lower Extremity.

Problems related to the combination of an arterial injury and a blunt fracture in the lower extremity are well known-delayed diagnosis, damaged soft tissue, and high amputation rate. The actual incidence of this injury pattern is, however, unknown. The purposes of this study were to determine the current incidence of named arterial injuries in patients with blunt fractures in the lower extremities and assess potential associated risk factors. This was a 7-year (2007-2013) retrospective review of patients ≥18 years with blunt lower extremity fractures at a Level I trauma center. Fracture location and concomitant arterial injury were determined and patients stratified by age, gender, and injury velocity. Low injury velocity was defined as falls or assaults, whereas an injury secondary to a motorized vehicle was defined as high velocity. A total of 4413 patients (mean age 52.2 years, 54.3% male, mean Injury Severity Score 13.1) were identified. Forty-six patients (1.04%) had arterial injuries (20.4% common femoral, 8.2% superficial femoral, 44.9% popliteal, and 26.5% shank). After stratifying by age and injury velocity, younger age was associated with a significantly higher rate of vascular injury. For high-velocity injuries, there was no difference based on age. In conclusion, the prevalence of arterial injury after blunt lower extremity fractures is 1.04 per cent in our study. A significant paradoxical relationship exists between age and associated arterial injuries in patients with low-velocity injuries. If these data are confirmed in future studies, a low index of suspicion in patients >55 years after falls is appropriate.

Diagnostic Yield and Clinical Utility of Abdominopelvic CT Following Emergent Laparotomy for Trauma.

Purpose To determine the incidence of unexpected injuries that are diagnosed with computed tomography (CT) after emergent exploratory laparotomy for trauma and whether identification of such injuries results in additional surgery or angiography. Materials and Methods This HIPAA-compliant retrospective study was approved by the institutional review board, and the requirement for informed consent was waived. The trauma databases of two urban level 1 trauma centers were queried over a period of more than 5 years for patients who underwent abdominopelvic CT within 48 hours of emergent exploratory laparotomy for trauma. Comparisons were made between CT findings and those described in the surgical notes. Descriptive statistics were generated, and 95% confidence intervals (CIs) were determined by using an exact method based on a binomial distribution. Results The study cohort consisted of 90 patients, including both blunt and penetrating trauma victims with a median injury severity score of 17.5 (interquartile range, 9.25-34). Seventy-three percent (66 of 90) of patients sustained penetrating trauma, 82% (74 of 90) of whom were male. A total of 19 patients (21.1%; 95% CI: 13.2, 31.0) had additional injuries within the surgical field that were not identified during laparotomy. There were 17 unidentified solid organ injuries, and eight patients had active bleeding within the surgical field. Eight patients (8.9%; 95% CI: 3.9, 16.8) had unexpected injuries at CT that were substantial enough to warrant additional surgery or angiography. In addition, previously undiagnosed fractures were found in 45 patients (50%; 95% CI: 39.3, 60.7). Conclusion Performing CT after emergent exploratory laparotomy for trauma is useful in identifying unexpected injuries and confirming suspected injuries that were not fully explored at initial surgery. (©) RSNA, 2016.

Traumatic abdominal wall hernias: Location matters.

BACKGROUND: Because of its uncommon nature and a lack of comprehensive literature, abdominal wall hernias caused by blunt trauma continue to present a management dilemma. This study was performed to identify the incidence of associated injuries, the need for urgent operative intervention, and recurrence rates after hernia repair. METHODS: A retrospective review of patients diagnosed with a traumatic abdominal wall hernia from January 2002 to December 2014 was performed. Data were collected from the trauma registry and included patient demographics, location and type of hernia, associated injuries, operative interventions, complications, and length of stay. RESULTS: Eighty patients (64% male; median age, 36 years; mean Injury Severity Score [ISS], 22) were identified during the study period. A motor vehicle collision was the most frequent mechanism of injury (n = 58). Overall, 35 patients (44%) underwent urgent laparotomy or laparoscopy, and 10 of these (29%) were nontherapeutic excluding hernia repair. Of interest, 17 patients (49%) required bowel resection. Notably, the need for operative intervention and nontherapeutic rate differed depending on hernia location. Hernia repair was performed in 23 patients, the majority of whom (78.3%) underwent repair within 5 days of injury. There were six recurrences, four of which were repaired acutely (within 1 week of injury), with an overall first-time hernia recurrence rate of 26%. CONCLUSION: In the largest series to date, traumatic abdominal wall hernias were found to be associated with a high percentage of intra-abdominal injuries requiring urgent laparotomy or laparoscopy. Rates of therapeutic interventions varied by hernia location, with anterior abdominal hernias associated with the highest need for a therapeutic operation. Acute repair was associated with the majority of the recurrences. LEVEL OF EVIDENCE: Epidemiologic study, level III; therapeutic study, level IV.

Anatomic characteristics of aortic transection: centerline analysis to facilitate graft selection.

BACKGROUND: Traumatic transection of the thoracic aorta is a life-threatening complication that most commonly occurs after high-speed motor vehicle collisions. Although such injuries were previously treated with open surgical reconstruction, they are now more commonly being treated with endovascularly placed stent grafts. Unfortunately, most stent grafts are designed for treating aortic aneurysmal disease instead of traumatic injury. Further refinements in stent graft technology depend on a thorough anatomic understanding of the transection injury process. METHODS: All patients with computed tomography (CT) evidence of blunt aortic injury (BAI) between 2006 and 2012 at a Level 1 trauma center were queried. Their initial CT scans were imported into the Intuition (Terarecon, Inc.) viewing program, and off-line centerline reconstruction was performed. Standard demographic data were collected in addition to anatomic characteristics, including aortic diameters and the relationship of the injury to the arch vessels. RESULTS: Thirty-five patients were identified. Three patients were injured proximal to the left subclavian artery. The average length from the left subclavian artery to the proximal site of injury was 16.2 mm (range 2-31 mm). Most patients had >15 mm of landing zone beyond the left subclavian artery. The range of proximal diameters ranged from 17 to 32 mm, with an average aortic diameter of 23.9 mm. The average length of injured aortic segment was 27 mm. CONCLUSIONS: In this contemporary series from a large trauma center, 91% of patients are anatomically able to be treated with a stent graft that does not require coverage of the left common carotid artery. Most patients have an aortic diameter that falls between 21 and 26 mm in diameter, as well as a short segment of injured artery. Centers interested in emergently treating aortic transections are able to do so while maintaining a limited stock of stent grafts that can be used to treat the majority of the population.

Choice of motorcycle helmet makes a difference: a prospective observational study.

BACKGROUND: Although many states mandate that motorcyclists wear helmets, their laws do not indicate which type of helmet should be used. In addition, there are no prospective studies in the literature evaluating patterns of injuries as they relate to helmet type. The hypothesis in this study was that full-face helmets (FFHs) reduce craniofacial injuries associated with motorcycle collisions when compared with other helmet types. METHODS: A prospective observational study was conducted at a Level I trauma center to evaluate the efficacy of helmet types relative to craniofacial injuries. Data included patient demographics, helmet types, injuries, and outcomes. The incidences of facial fractures, skull fractures, and traumatic brain injuries (TBIs) were compared in patients wearing FFHs versus other helmet types (OH) during motorcycle crashes. RESULTS: From 2011 to 2012, 151 patients of motorcycle crashes (135 males, 16 female; mean age, 38.4 years; range, 19-74 years) whose helmet types were identified by health care providers were entered into the study. The distribution of helmets was 84 FFH and 67 OH (39 half and 28 modular). Facial fractures were present in 7% of the patients wearing FFH (95% confidence interval, 0.015-0.125) versus 27% (95% confidence interval, 0.164-0.376) of those wearing OH (p = 0.004). In addition skull fractures were present in 1% of the patients wearing FFH versus 8% in those wearing OH (p < 0.05). While there was a trend for patients wearing FFH to have a lower incidence of TBI (13% vs. 25% in those wearing OH), this was not statistically significant (p = 0.053). There were no differences in Injury Severity Score (ISS), length of stay, or mortality between the two groups. CONCLUSION: Victims of motorcycle crashes who are wearing FFH have a significant reduction in facial and skull fractures when compared with those wearing OH. Further studies will be needed to assess whether FFH will significantly decrease the incidence of TBI. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.