Survey of American College of Surgeons Committee on trauma members on firearm injury: Consensus and opportunities.

BACKGROUND: In the United States, there is a perceived divide regarding the benefits and risks of firearm ownership. The American College of Surgeons Committee on Trauma Injury Prevention and Control Committee designed a survey to evaluate Committee on Trauma (COT) member attitudes about firearm ownership, freedom, responsibility, physician-patient freedom and policy, with the objective of using survey results to inform firearm injury prevention policy development. METHODS: A 32-question survey was sent to 254 current U.S. COT members by email using Qualtrics. SPSS was used for χ exact tests and nonparametric tests, with statistical significance being less than 0.05. RESULTS: Our response rate was 93%, 43% of COT members have firearm(s) in their home, 88% believe that the American College of Surgeons should give the highest or a high priority to reducing firearm-related injuries, 86% believe health care professionals should be allowed to counsel patients on firearms safety, 94% support federal funding for firearms injury prevention research. The COT participants were asked to provide their opinion on the American College of Surgeons initiating advocacy efforts and there was 90% or greater agreement on 7 of 15 and 80% or greater on 10 of 15 initiatives. CONCLUSION: The COT surgeons agree on: (1) the importance of formally addressing firearm injury prevention, (2) allowing federal funds to support research on firearms injury prevention, (3) retaining the ability of health care professionals to counsel patients on firearms-related injury prevention, and (4) the majority of policy initiatives targeted to reduce interpersonal violence and firearm injury. It is incumbent on trauma and injury prevention organizations to leverage these consensus-based results to initiate prevention, advocacy, and other efforts to decrease firearms injury and death. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level I; therapeutic care, level II.

Seasonal Variation of Trauma in Western Massachusetts: Fact or Folklore?

BACKGROUND: Previous studies have demonstrated a significant relationship between weather or seasons and total trauma admissions. We hypothesized that specific mechanisms such as penetrating trauma, motor vehicle crashes, and motorcycle crashes (MCCs) occur more commonly during the summer, while more falls and suicide attempts during winter. METHODS: A retrospective review of trauma admissions to a single Level I trauma center in Springfield, Massachusetts from 01/2010 through 12/2015 was performed. Basic demographics including age, Injury Severity Score (ISS), and length of stay were collected. Linear regression analysis was used to test the association between monthly admission rates and season, year, injury class, and mechanism of injury, and whether seasonal variation trends were different according to injury class or mechanism. RESULTS: A total of 8886 admissions had a mean age of 44.6 and mean ISS of 11.9. Regression analysis showed significant seasonal variation in blunt compared with penetrating trauma (p<0.001), MCC (p<0.001), and falls (p=0.002). In addition, seasonal variation differed according to injury class or mechanism. There were significantly lower rates of MCCs in winter compared with all other seasons and conversely higher rates of total falls in winter compared with other seasons. DISCUSSION: A significant seasonal variation in blunt trauma, MCC, and falls was observed. This has potential ramifications for resource allocation, including trauma prevention programs geared toward mechanisms of injury with significant seasonal variation. LEVEL OF EVIDENCE: Retrospective Review, Level IV.

Blunt traumatic celiac artery avulsion managed with celiac artery ligation and open aorto-celiac bypass.

Traumatic celiac artery injuries are rare and highly lethal with reported mortality rates of 38-62%. The vast majority are caused by penetrating trauma with only 11 reported cases due to blunt trauma (Graham et al., 1978; Asensio et al., 2000, 2002). Only 3 of these cases were complete celiac artery avulsions. Management options described depend upon the type of injury and have included medical therapy with anti-platelet agents or anti-coagulants, endovascular stenting, and open ligation. We report a case of a survivor of complete celiac artery avulsion from blunt trauma managed by open bypass.

Cervical spine MRI in patients with negative CT: A prospective, multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT).

BACKGROUND: Although cervical spine CT (CSCT) accurately detects bony injuries, it may not identify all soft tissue injuries. Although some clinicians rely exclusively on a negative CT to remove spine precautions in unevaluable patients or patients with cervicalgia, others use MRI for that purpose. The objective of this study was to determine the rates of abnormal MRI after a negative CSCT. METHODS: Blunt trauma patients who either were unevaluable or had persistent midline cervicalgia and underwent an MRI of the C-spine after a negative CSCT were enrolled prospectively in eight Level I and II New England trauma centers. Demographics, injury patterns, CT and MRI results, and any changes in cervical spine management as a result of MRI imaging were recorded. RESULTS: A total of 767 patients had MRI because of cervicalgia (43.0%), inability to evaluate (44.1%), or both (9.4%). MRI was abnormal in 23.6% of all patients, including ligamentous injury (16.6%), soft tissue swelling (4.3%), vertebral disc injury (1.4%), and dural hematomas (1.3%). Rates of abnormal neurological signs or symptoms were not different among patients with normal versus abnormal MRI. (15.2 vs. 18.8%, p = 0.25). The c-collar was removed in 88.1% of patients with normal MRI and 13.3% of patients with an abnormal MRI. No patient required halo placement, but 11 patients underwent cervical spine surgery after the MRI results. Six of the eleven had neurological signs or symptoms. CONCLUSIONS: In a select population of patients, MRI identified additional injuries in 23.6% of patients despite a normal CSCT. It is uncertain if this is a true limitation of CT technology or represents subtle injuries missed in the interpretation of the scan. The clinical significance of these abnormal MRI findings cannot be determined from this study group. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Operative vs Nonoperative Management of Pediatric Blunt Pancreatic Trauma: Evaluation of the National Trauma Data Bank.

BACKGROUND: Traumatic pancreatic injury is associated with significant morbidity and mortality. We evaluated the differences in outcomes among children with blunt pancreatic injuries managed operatively and nonoperatively. STUDY DESIGN: The National Trauma Data Bank was evaluated from 2002 to 2011. Patients less than18 years of age with blunt pancreatic injuries and Abbreviated Injury Scale (AIS) scores ≥ 3 were identified. Patients were divided into nonoperative (NO), operative (O), and delayed operative (DO; operation performed 48 hours or more after admission) groups. Outcomes evaluated were total length of stay (LOS), ICU use/LOS, complications, and death. Univariate comparisons were performed using Fisher's exact and Kruskal-Wallis rank tests. Multivariable analyses were performed using robust regression and logistic regression. RESULTS: There were 424 cases analyzed. Mean (± SD) age was 10.6 ± 5.3 years, and mean Injury Severity Score (ISS) was 23.4 ± 13.4. Operative groups differed by age (p = 0.002), AIS severity (p = 0.04), and concomitant head injury (p = 0.01), but were similar with regard to sex, race, and ISS. Length of stay was significantly higher in the DO group compared with the NO or O groups; the NO group had the lowest LOS (covariate-adjusted: 18.7 days vs 11.8 days, p < 0.001 and 12.6 days, p < 0.001, respectively) and infection rates (10.2% vs 1.6% and 6.2%, respectively, p = 0.04). The ICU LOS was greatest in the DO group (vs NO, p = 0.03; O, p = 0.29), as was the likelihood of ICU use (vs NO, p = 0.02; O, p = 0.75). Groups did not differ with respect to outcomes including death (p = 0.94) and overall complication rate (p = 0.63). CONCLUSIONS: Overall, children managed nonoperatively have equivalent or better outcomes when compared with operative and delayed operative management in regard to death, overall complications, LOS, ICU LOS, and ICU use.

Management of the most severely injured spleen: a multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT).

OBJECTIVE: To determine the rate and predictors of failure of nonoperative management (NOM) in grade IV and V blunt splenic injuries (BSI). DESIGN: Retrospective case series. SETTING: Fourteen trauma centers in New England. PATIENTS: A total of 388 adult patients with a grade IV or V BSI who were admitted between January 1, 2001, and August 31, 2008. MAIN OUTCOME MEASURES: Failure of NOM (f-NOM). RESULTS: A total of 164 patients (42%) were operated on immediately. Of the remaining 224 who were offered a trial of NOM, the treatment failed in 85 patients (38%). At the end, 64% of patients required surgery. Multivariate analysis identified 2 independent predictors of f-NOM: grade V BSI and the presence of a brain injury. The likelihood of f-NOM was 32% if no predictor was present, 56% if 1 was present, and 100% if both were present. The mortality of patients for whom NOM failed was almost 7-fold higher than those with successful NOM (4.7% vs 0.7%; P = .07). CONCLUSIONS: Nearly two-thirds of patients with grade IV or V BSI require surgery. A grade V BSI and brain injury predict failure of NOM. This data must be taken into account when generalizations are made about the overall high success rates of NOM, which do not represent severe BSI.

Management of blunt hepatic trauma at a Connecticut Level I trauma center.

This study examined the management of patients with hepatic trauma treated at a Level I trauma center in Connecticut from January 1, 2003 to December 31, 2003. Forty-four patients over the age of 16 years sustained blunt liver injury and were brought to Hartford Hospital during the study period. Eight of these patients died; three of these deaths occurred in the emergency department (ED) shortly after arrival. Thirty-four patients (82.9%) with blunt liver injuries were managed nonoperatively. Only one of these patients died, not as a direct result of hepatic injury. The average Injury Severity Score (ISS) for these patients decreased as the injury grade increased but this was not statistically significant (P=0.684). A moderate positive and statistically significant relationship was noted between the length of hospital stay and the ISS (r=0.597, P=0.000). Our findings suggest that the current standard of care for most patients with blunt hepatic injuries is nonoperative management. It is the rare and most severely injured patient that will require operative management. As reported in the literature, mortality for these patients remains unchanged.

An update on the surgeons scope and depth of practice to all hazards emergency response.

This article outlines the position of The Eastern Association of the Surgery of Trauma (EAST) in defining the role of surgeons, and specifically trauma/critical care surgeons, in the development of public health initiatives that are designed to react to and deal effectively with acts of terrorism. All aspects of the surgeon's role in response to mass casualty incidents are considered, from prehospital response teams to the postevent debriefing. The role of the surgeon in response to mass casualty incidents (MCIs) is substantial in response to threats and injury from natural, unintentional, and intentional disasters. The surgeon must take an active role in pre-event community preparation in training, planning, and executing the response to MCI. The marriage of initiatives among Departments of Public Health, the Department of Homeland Security, and existing trauma systems will provide a template for successful responses to terrorist acts.

Terrorism: a public health threat with a trauma system response.

BACKGROUND: The threat of mass casualties and widespread infectious disease caused by terrorism is now a challenge for our government and public health system. Funds have been granted to the states by the Centers for Disease Control and Prevention and the Health Resources and Services Administration to establish bioterrorism preparedness and response capabilities. METHODS: Hartford Hospital has been designated as a Center of Excellence for Bioterrorism Preparedness by the Commissioner of the Connecticut Department of Public Health. The Center of Excellence has implemented strategies to prepare for a possible bioterrorist attack. A unique model that combines epidemiology and traumatology is being used to guide the preparedness activities. Although the focus of the grant from the Connecticut Department of Public Health is bioterrorism, the application of the model can apply to preparation for all terrorist events. RESULTS: Implementation of strategies indicates that bioterrorism preparedness is well underway. Similar initiatives should be achievable by other trauma systems throughout the country. CONCLUSION: A Center of Excellence for Bioterrorism Preparedness in Connecticut is successfully modifying a trauma system to meet the challenge of a new public health threat, terrorism.

Development and evaluation of the advanced trauma operative management course.

BACKGROUND: The Advanced Trauma Operative Management (ATOM) course was developed as a model for teaching operative trauma techniques to surgical residents, fellows, and attending surgeons as the number of these cases decreases. METHODS: The ATOM course consists of lectures and a porcine operative experience. Comprehensive evaluation of ATOM was designed to assess participant learning in the cognitive, affective, and psychomotor domains. Data on the first 50 participants were prospectively collected and analyzed. RESULTS: Participants included 20 expert traumatologists, 9 general surgeons, 9 trauma fellows, 8 general surgery fifth-year residents, and 4 general surgery fourth-year residents. All groups showed improvement in knowledge, with results in the expert and fellow groups reaching statistical significance. Self-efficacy (self-confidence) also improved, with all groups reaching statistical significance. CONCLUSION: This course creates life-like situations in a standardized fashion that, along with didactic instruction, improves knowledge and operative confidence for practicing surgeons and surgeons-in-training.

Experiencia inicial con 100 colecistectomías laparoscópicas / Initial experience 100 laparoscopic cholecystectomies

Este trabajo prospectivo presenta la experiencia obtenida con los 100 primeros casos de colecistectomía por vía laparoscópica en el Hospital de Norwalk desde mayo de 1990 hasta mayo de 1991. La edad media de los pacientes fue de 40,2 años con predominio femenino (76%). Las indicaciones fueron las mismas que para la cirugía convencional. El diagnóstico de litiasis biliar se confirmó con ecografía y/o tomografía comparada. No hubo mortalidad ni lesiones de la vía biliar. El 8%de los casos fueron convertidos y se registró una morbilidad de importancia relacionada con el procedimiento del 3%; complicaciones médicas ocurrieron en 8 enfermos. El tiempo operatorio medio fue de 97 minutos, la estadia media de internación 1,3 días, otorgándose alta hospitalaria al 64%de los enfermos en las primeras 24 horas. Se realizó colangiograma en el 7%. Hubo 3 casos de litiasis coledociana residual. No se registraron infecciones y en 2 casos fue necesario tranfundir, uno por hemorragia. La colecistectomía laparoscópica es tan eficaz y segura como la colecistectomía convencional. Cabe resaltar la necesidad de completar un curso de entrenamiento adecuado y poseer el instrumental apropiado antes de iniciar la experiencia clínica

Experiencia inicial con 100 colecistectomías laparoscópicas / Initial experience 100 laparoscopic cholecystectomies

Este trabajo prospectivo presenta la experiencia obtenida con los 100 primeros casos de colecistectomía por vía laparoscópica en el Hospital de Norwalk desde mayo de 1990 hasta mayo de 1991. La edad media de los pacientes fue de 40,2 años con predominio femenino (76%). Las indicaciones fueron las mismas que para la cirugía convencional. El diagnóstico de litiasis biliar se confirmó con ecografía y/o tomografía comparada. No hubo mortalidad ni lesiones de la vía biliar. El 8%de los casos fueron convertidos y se registró una morbilidad de importancia relacionada con el procedimiento del 3%; complicaciones médicas ocurrieron en 8 enfermos. El tiempo operatorio medio fue de 97 minutos, la estadia media de internación 1,3 días, otorgándose alta hospitalaria al 64%de los enfermos en las primeras 24 horas. Se realizó colangiograma en el 7%. Hubo 3 casos de litiasis coledociana residual. No se registraron infecciones y en 2 casos fue necesario tranfundir, uno por hemorragia. La colecistectomía laparoscópica es tan eficaz y segura como la colecistectomía convencional. Cabe resaltar la necesidad de completar un curso de entrenamiento adecuado y poseer el instrumental apropiado antes de iniciar la experiencia clínica