Covered endovascular reconstruction of the aortic bifurcation with inferior mesenteric artery chimney for management of bilateral lower extremity tissue loss with concomitant mesenteric stenosis.

Aortoiliac occlusive disease involving mesenteric branches poses an interesting challenge. Although an open surgical approach is considered the gold standard, endovascular techniques such as covered endovascular reconstruction of the aortic bifurcation with inferior mesenteric artery chimney have been presented as alternatives for patients unfit for major surgical repair. A 64-year-old man with bilateral chronic limb-threatening ischemia and severe chronic malnutrition underwent covered endovascular reconstruction of the aortic bifurcation with inferior mesenteric artery chimney due to significant intraoperative risk. We have presented the operative technique used. The intraoperative course was successful, and, postoperatively, the patient underwent successful, planned, left below-the-knee amputation and his right lower extremity wounds healed.

Use of Direct Peritoneal Resuscitation for Intra-Abdominal Catastrophes: A Technical Note.

Direct peritoneal resuscitation (DPR) involves instilling 2.5% dextrose peritoneal dialysate into the abdomen in an attempt to both resuscitate the patient and decrease systemic inflammation; 800cc are instilled in the first hour and 400cc/h are instilled each subsequent hour. DPR has been shown to decrease systemic inflammation, increase the rate of primary abdominal closure, lower the rate of intra-abdominal infections, and lower the rate of complications. It also increases blood flow to the intestines, helping to prevent ischemia and re-perfusion injury. We present the technique used for DPR in a patient with an intra-abdominal catastrophe, as well as the use of Kerecis® Omega3 Wound graft (Kerecis, Arlington, VA) and wound vacuum-assisted closure (VAC) for creation of a floating stoma.

Developing a Simple Clinical Score for Predicting Mortality and Need for ICU in Trauma Patients.

Several models exist to predict trauma center need in the prehospital setting; however, there is lack of simple clinical tools to predict the need for ICU admission and mortality in trauma patients. The aim of our study was to develop a simple clinical tool that can be used with ease in the prehospital or emergency setting and can reliably predict the need for ICU admission and mortality in trauma patients. We abstracted one year of National Trauma Data Bank for all patients aged ≥ 18 years. Transferred patients and those dead on arrival were excluded. Patient demographics, injury parameters, vital signs, and Glasgow Coma Scale (GCS) were recorded. Our primary outcome measures were mortality and ICU admission. Logistic regression analysis was performed using three variables (age > 55 years, shock index (SI) > 1, and GCS score) to determine the appropriate weights for predicting mortality. Appropriate weights derived from regression analysis were used to construct a simple SI, age, and GCS (SAG) score, and associated mortality and ICU admissions were calculated for three different risk groups (low, intermediate, and high). A total of 281,522 patients were included. The mean age was 47 ± 20 years, and 65 per cent were male. The overall mortality rate was 2.9 per cent, and the rate of ICU admission was 28.7 per cent. The SAG score was constructed using weights derived from regression analysis for age ≤ 55 years (4 points), SI < 1 (3 points), and GCS (3-15 points). The median [IQR] SAG score was 21 [18-22]. The area under the receiver operating curve [95% Confidence Interval (CI)] of the SAG score for predicting mortality and ICU admission was 0.873 [0.870-0.877] and 0.644 [0.642-0.647], respectively. Each 1-point increase in the SAG score was associated with 18 per cent lower odds of mortality (odds ratio [95% CI]: 0.822 [0.820-0.825]) and 10 per cent lower odds of ICU admission (odds ratio [95% CI]: 0.901 [0.899-0.902]). The SAG score is a simple clinical tool derived from variables that can be assessed with ease during the initial evaluation of trauma patients. It provides a rapid assessment and can reliably predict mortality and need for ICU admission in trauma patients. This simple tool may allow early resource mobilization possibly even before the arrival of the patient.

Risk-adjusted adverse outcomes in complex abdominal wall hernia repair with biologic mesh: A case series of 140 patients.

INTRODUCTION: Biologic mesh is preferred for repair of complex abdominal wall hernias (CAWHs) in patients at high risk of wound infection. We aimed to identify predictors of adverse outcomes after complex abdominal wall hernia repair (CAWR) using biologic mesh with different placement techniques and under different surgical settings. METHODS: A retrospective case series study was conducted on all patients who underwent CAWR with biologic mesh between 2010 and 2015 at a tertiary medical center. RESULTS: the study population included 140 patients with a mean age of 54 ± 14 years and a median follow up period 8.8 months. Mesh size ranged from 50 to 1225 cm2. Ninety percent of patients had undergone previous surgery. Type of surgery was classified as elective in 50.7%, urgent in 24.3% and emergent in 25.0% and a porcine mesh was implanted in 82.9%. The most common mesh placement technique was underlay (70.7%), followed by onlay (16.4%) and bridge (12.9%). Complications included wound complications (30.7%), reoperation (25.9%), hernia recurrence (20.7%), and mesh removal (10.0%). Thirty-two patients (23.0%) were admitted to the ICU and the mean hospital length of stay was 10.8 ± 17.5 days. Age-sex adjusted predictors of recurrence were COPD (OR 4.2; 95%CI 1.003-17.867) and urgent surgery (OR 10.5; 95%CI 1.856-59.469), whereas for reoperation, mesh size (OR 6.8; 95%CI 1.344-34.495) and urgent surgery (OR 5.2; 95%CI 1.353-19.723) were the predictors. CONCLUSIONS: Using biologic mesh, one-quarter and one-fifth of CAWR patients are complicated with reoperation or recurrence, respectively. The operation settings and comorbidity may play a role in these outcomes regardless of the mesh placement techniques.

Bicycle helmets work when it matters the most.

BACKGROUND: Helmets are known to reduce the incidence of traumatic brain injury (TBI) after bicycle-related accidents. The aim of this study was to assess the association of helmets with severity of TBI and facial fractures after bicycle-related accidents. METHODS: We performed an analysis of the 2012 National Trauma Data Bank abstracted information of all patients with an intracranial hemorrhage after bicycle-related accidents. Regression analysis was also performed. RESULTS: A total of 6,267 patients were included. About 25.1% (n = 1,573) of bicycle riders were helmeted. Overall, 52.4% (n = 3,284) of the patients had severe TBI, and the mortality rate was 2.8% (n = 176). Helmeted bicycle riders had 51% reduced odds of severe TBI (odds ratio [OR] .49, 95% confidence interval [CI] .43 to .55, P < .001) and 44% reduced odds of mortality (OR .56, 95% CI .34 to .78, P = .010). Helmet use also reduced the odds of facial fractures by 31% (OR .69, 95% CI .58 to .81, P < .001). CONCLUSION: Bicycle helmet use provides protection against severe TBI, reduces facial fractures, and saves lives even after sustaining an intracranial hemorrhage.

Obesity and trauma mortality: Sizing up the risks in motor vehicle crashes.

BACKGROUND: Protective effects of safety devices in obese motorists in motor vehicle collisions (MVC) remain unclear. Aim of our study is to assess the association between morbid obesity and mortality in MVC, and to determine the efficacy of protective devices. We hypothesised that patients with morbid obesity will be at greater risk of death after MVC. METHODS: A retrospective analysis of MVC patients (age ≥16 y.o.) was performed using the National Trauma Data Bank from 2007 to 2010. Patients with recorded comorbidity of morbid obesity (BMI≥40) were identified. Patients dead on arrival, with isolated traumatic brain injury, or incomplete data were excluded. The primary outcome was in-hospital mortality. Multivariate logistic regression was performed. RESULTS: Our sample of 214,306 MVC occupants included 10,260 (4.8%) morbidly obese patients. Mortality risk was greatest among occupants with morbid obesity (ORcrude 1.74 [1.54-1.98]). After adjusting for patient demographics, safety device and physiological severity, odds of death was 1.52 [1.33-1.74] times greater in motorists with morbid obesity. Motorists with morbid obesity were at greater risk of death if no restraint (OR 1.84 [1.47-2.31]), seatbelt only (OR 1.48 [1.17-1.86]), or both seatbelt and airbag were present (OR 1.49 [1.13-1.97]). No significant differences in the odds of death exist between drivers with morbid obesity and non-morbidly obese drivers with only airbag deployment (OR 0.99 [0.65-1.51]). CONCLUSIONS: Motorists with morbid obesity are at greater risk of MVC. Regardless of safety device use, occupants with morbid obesity remained at greater risk of death. Further research examining the effectiveness of vehicle restraints in drivers with morbid obesity is warranted.

Assessing the Efficacy of Prothrombin Complex Concentrate in Multiply Injured Patients With High-Energy Pelvic and Extremity Fractures.

OBJECTIVES: Prothrombin complex concentrate (PCC) is being increasingly used for reversing induced coagulopathy of trauma. However, the use of PCC for reversing coagulopathy in multiply injured patients with pelvic and/or lower extremity fractures remains unclear. The aim of our study was to assess the efficacy of PCC for reversing coagulopathy in this group of patients. DESIGN: Two-year retrospective analysis. SETTING: Our level I trauma center. PATIENTS/PARTICIPANTS: All coagulopathic [International normalized ratio (INR) ≥1.5] trauma patients. Patients with femur, tibia, or pelvic fracture were included. Patients were divided into 2 groups: PCC (single dose) and fresh frozen plasma (FFP). Patients in the 2 groups were matched using propensity score matching. MAIN OUTCOME MEASUREMENTS: Time to correction of INR, time to intervention, development of thromboembolic complications, mortality, and cost of therapy. RESULTS: A total of 81 patients (PCC: 27, FFP: 54) were included. Patients who received PCC had faster correction of INR and shorter time to surgical intervention in comparison to patients who received FFP. PCC therapy was also associated with lower overall blood product requirement (P = 0.02) and lower transfusion costs (P = 0.0001). CONCLUSIONS: In a matched cohort of multiply injured patients with pelvic and/or lower extremity fractures, administration of a single dose of PCC significantly reduced the time to correction of INR and time to intervention compared with patients who received FFP therapy. This may allow orthopaedic surgeons to more safely proceed with early, definitive fixation strategies. LEVEL OF EVIDENCE: Therapeutic level III. See Instructions for Authors for a complete description of levels of evidence.

Substituting systolic blood pressure with shock index in the National Trauma Triage Protocol.

INTRODUCTION: The National Trauma Triage Protocol (NTTP) is an algorithm that guides emergency medical services providers through four decision steps to identify the patients that would benefit from trauma center care. The NTTP defines a systolic blood pressure (SBP) of less than 90 mm Hg as one of the criteria for trauma center need. The aim of our study was to determine the impact of substituting SBP of less than 90 mm Hg with shock index (SI) on triage performance. METHODS: A 2-year (2011-2012) retrospective analysis of all trauma patients 18 years or older in the National Trauma Databank was performed. Transferred patients, patients dead on arrival, and those with missing data were excluded. Our outcome measure was trauma center need defined by Injury Severity Score greater than 15, need for emergent operation, death in the emergency department, and intensive care unit stay of more than 1 day. Area under the characteristic curve and triage characteristics were compared between SBP of less than 90 mm Hg and SI of more than 1.0. Logistic regression analysis was performed to compare the mortality between patients triaged under current protocol of SBP of less than 90 mm Hg and patients triaged using the new defined protocol (SI >1.0). RESULTS: A total of 505,296 patients were included. Compared with SBP of less than 90 mm Hg, SI of more than 1.0 had a higher sensitivity (44.4% vs. 41.7%) but lower specificity (80.2% vs. 82.4%). The area under the curve was significantly higher for SI of more than 1.0 (0.623 [95% confidence interval, 0.622-.625] vs. 0.620 [95% confidence interval, 0.619-0.622]). Substituting SBP of less than 90 mm Hg with SI of more than 1.0 resulted in a decrease in undertriage rate of 30,233 patients (5.9%) but an increase in overtriage of only 6,386 patients (1.3%). CONCLUSION: Substituting the current criterion of SBP of less than 90 mm Hg in the NTTP with an SI of more than 1.0 results in significant reduction in undertriage rate without causing large increase in overtriage. Because of simplicity of use, better discrimination power, and minimal effect on overtriage rates, future studies should consider exploring the possibility of replacing the current SBP of less than 90 mm Hg criterion with SI of more than 1.0 in the NTTP. LEVEL OF EVIDENCE: Prognostic study, level III; therapeutic study, level IV.

Identifying potential utility of resuscitative endovascular balloon occlusion of the aorta: An autopsy study.

BACKGROUND: Resuscitative thoracotomy (RT) has been the standard therapy in patients with acute arrest due to hemorrhagic shock. However, with the development of resuscitative endovascular balloon occlusion of the aorta (REBOA), its role as a potential adjunct to a highly morbid intervention such as RT is being discussed. The aim of this study was to identify patients who most likely would have potentially benefited from REBOA use based on autopsy findings. METHODS: We performed a 4-year retrospective review of all RTs performed at our Level I trauma center. Patients with in-hospital mortality and who underwent subsequent autopsies were included. Patients were divided into blunt and penetrating trauma with and without thoracic injuries. Autopsy reports were reviewed to identify vascular and solid organ injuries. Outcome measure was potential benefit with REBOA. Potential benefit with REBOA was defined based on the ability to safely deploy REBOA. In patients without cardiac, aortic, and major pulmonary vasculature injuries, REBOA was considered potentially beneficial. In all other patients, it was considered as nonbeneficial. RESULTS: A total of 98 patients underwent an RT, of whom 87 had subsequent autopsies and were reviewed. The mean age was 35.25 (SD, 17.85) years, mean admission systolic blood pressure was 51.38 (SD, 70.11) mm Hg, median Injury Severity Score was 29 (interquartile range [IQR], 25-42), and 44 had penetrating injury. Resuscitative endovascular balloon occlusion of the aorta would have been potentially beneficial in 51.2% of patients (22 of 43 patients) with blunt mechanism of trauma, whereas REBOA would have been potentially beneficial in 38.6% of patients (17 of 44 patients) with penetrating mechanism of trauma. A subgroup analysis showed that REBOA use would have been potentially beneficial in 50.0% of blunt thoracic and 33.3% of penetrating thoracic trauma patients. CONCLUSIONS: There are a great enthusiasm and premature efforts to introduce REBOA as an alternative to RT. While there exists a great potential for benefit with REBOA use in the management of noncompressible torso hemorrhage, the current indications for REBOA need to be defined better. Patients with penetrating chest trauma in extremis should be considered an absolute contraindication for REBOA use. The majority of patients with blunt trauma in extremis may potentially benefit from REBOA. However, better criteria will help increase these patients who may potentially benefit from REBOA placement. LEVEL OF EVIDENCE: Therapeutic study, level V.

Stress among surgical attending physicians and trainees: A quantitative assessment during trauma activation and emergency surgeries.

BACKGROUND: The adverse effects of stress on the wellness of trauma team members are well established; however, the level of stress has never been quantitatively assessed. The aim of our study was to assess the level of stress using subjective data and objective heart rate variability (HRV) among attending surgeons (ASs), junior residents (JRs) (PGY2/PGY3), and senior residents (SRs) (PGY5/PGY6) during trauma activation and emergency surgery. METHODS: We preformed a prospective study enrolling participants over eight 24-hour calls in our Level I trauma center. Stress was assessed based on decrease in HRV, which was recorded using body worn sensors. Stress was defined as HRV of less than 85% of baseline HRV. We collected subjective data on stress for each participant during calls. Three groups (ASs, JRs, SRs) were compared for duration of different stress levels through trauma activation and emergency surgery. RESULTS: A total of 22 participants (ASs: n = 8, JRs: n = 7, SRs: n = 7) were evaluated over 192 hours, which included 33 trauma activations and 50 emergency surgeries. Stress level increased during trauma activations and operations regardless of level of training. The ASs had significantly lower stress when compared with SRs and JRs during trauma activation (21.9 ± 10.7 vs. 51.9 ± 17.2 vs. 64.5 ± 11.6; p < 0.001) and emergency surgery (30.8 ± 7.0 vs. 53.33 ± 6.9 vs. 56.1 ± 3.8; p < 0.001). The level of stress was similar between JRs and SRs during trauma activation (p = 0.37) and emergency surgery (p = 0.19). There was no correlation between objectively measured stress level and subjectively measured stress using State-Trait Anxiety Inventory (R = 0.16; p = 0.01) among surgeons or residents. CONCLUSIONS: Surgeon wellness is a significant concern, and this study provides empirical evidence that trauma and acute care surgeons encounter mental strain and fail to recognize it. Stress management and burnout are very important in this high-intensity field, and this research may provide some insight in finding those practitioners who are at risk. LEVEL OF EVIDENCE: Epidemiologic study, level II.

Emergency general surgery specific frailty index: A validation study.

INTRODUCTION: Assessment of operative risk in geriatric patients undergoing emergency general surgery (EGS) is challenging. Frailty is an established measure for risk assessment in surgical cases. The aim of our study was to validate a modified 15-variable EGS-specific frailty index (EGSFI). METHODS: We prospectively collected geriatric (age older than 65 years) EGS patients for 2 years. Postoperative complications were collected. Frailty index was calculated for 200 patients based on their preadmission condition using 50-variable modified Rockwood frailty index. Emergency general surgery-specific frailty index was developed based on the regression model for complications and the most significant factors in the frailty index. Receiver operating characteristic curve analysis was performed to determine cutoff for frail status. We validated our results using 60 patients for predicting complications. RESULTS: A total of 260 patients (developing, 200; validation, 60) were enrolled in this study. Mean age was 71 ± 11 years, and 33% developed complications. Most common complications were pneumonia (12%), urinary tract infection (9%), and wound infection (7%). Univariate analysis identified 15 variables significantly associated with complications that were used to develop the EGSFI. A cutoff frailty score of 0.325 was identified using receiver operating characteristic curve analysis for frail status. Sixty patients (frail, 18; nonfrail, 42) were enrolled in the validation cohort. Frail patients were more likely to have postoperative complications (47% vs. 20%; p < 0.001) compared to nonfrail patients. Frail status based on EGSFI was a significant predictor of postoperative complications (odds ratio, 7.3; 95% confidence interval, 1.7-19.8; p = 0.006). Age was not associated with postoperative complications (odds ratio, 0.99; 95% confidence interval, 0.92-1.06; p = 0.86). CONCLUSION: The 15-variable validated EGSFI is a simple and reliable bedside tool to determine the frailty status of patients undergoing EGS. Frail status as determined by the EGSFI is an independent predictor of postoperative complications and mortality in geriatric EGS patients. LEVEL OF EVIDENCE: Prognostic study, level II.

The impact of patient protection and Affordable Care Act on trauma care: A step in the right direction.

INTRODUCTION: The Patient Protection and Affordable Care Act (ACA) was implemented to guarantee financial coverage for health care for all Americans. The implementation of ACA is likely to influence the insurance status of Americans and reimbursement rates of trauma centers. The aim of this study was to assess the impact of ACA on the patient insurance status, hospital reimbursements, and clinical outcomes at a Level I trauma center. We hypothesized that there would be a significant decrease in the proportion of uninsured trauma patients visiting our Level I trauma center following the ACA, and this is associated with improved reimbursement. METHODS: We performed a retrospective analysis of the trauma registry and financial database at our Level I trauma center for a 27-month (July 2012 to September 2014) period by quarters. Our outcome measures were change in insurance status, hospital reimbursement rates (total payments/expected payments), and clinical outcomes before and after ACA (March 31, 2014). Trend analysis was performed to assess trends in outcomes over each quarter (3 months). RESULTS: A total of 9,892 patients were included in the study. The overall uninsured rate during the study period was 20.3%. Post-ACA period was associated with significantly lower uninsured rate (p < 0.001). During the same time, there was as a significant increase in the Medicaid patients (p = 0.009). This was associated with significantly improved hospital reimbursements (p < 0.001).On assessing clinical outcomes, there was no change in hospitalization (p = 0.07), operating room procedures (p = 0.99), mortality (p = 0.88), or complications (p = 0.20). Post-ACA period was also not associated with any change in the hospital (p = 0.28) or length of stay at intensive care unit (p = 0.66). CONCLUSION: The implementation of ACA has led to a decrease in the number of uninsured trauma patients. There was a significant increase in Medicaid trauma patients. This was associated with an increase in hospital reimbursements that substantially improved the financial revenues. Despite the controversies, implementation of ACA has the potential to substantially improve the financial outcomes of trauma centers through Medicaid expansion. LEVEL OF EVIDENCE: Economic and value-based evaluation, level III.

Early feeds not force feeds: Enteral nutrition in traumatic brain injury.

BACKGROUND: Brain Trauma Foundation guidelines recommend the early use of enteral nutrition to optimize recovery following traumatic brain injury (TBI). Our aim was to examine the effect of early feeds (≤24 hours) on clinical outcomes after TBI. METHODS: We performed a 3-year retrospective study of patients with severe TBI (Glasgow Coma Scale score <8) who were intubated, admitted to the intensive care unit (ICU), and received tube feeds. Early tube feeds (early TF) were defined as initiation of tube feeds within 24 hours, whereas late tube feeds (late TF) were defined as initiation of tube feeds after 24 hours. Outcome measures included pneumonia rates, days on ventilator, hospital and ICU stay, and mortality rates. RESULTS: A total of 90 patients (early TF: 58, late TF: 32) were included, of which 73.3% were male, mean age was 42 (SD, 20) years, and median head Abbreviated Injury Scale score was 4 (range, 3-5). There was no difference in age (p = 0.1), head Abbreviated Injury Scale score (p = 0.5), or admission Glasgow Coma Scale score (p = 0.9) between the two groups. Patients with early TF were associated with higher number of ICU days (p = 0.03) and higher pneumonia rates (p = 0.04), but there was no significant difference in mortality (p = 0.44) as compared with those who underwent late TF. CONCLUSIONS: Although early tube feeds are known to improve outcomes in TBI patients, our data suggest that early feeds in TBI patients are associated with higher rates of pneumonia and greater hospital resource utilization. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Revitalizing Vital Signs: The Role of Delta Shock Index.

INTRODUCTION: Although variability in vital parameters has been shown to predict outcomes, the role of change in shock index (delta SI) as a predictive tool remains unknown. METHODS: The National Trauma Data Bank (2011-2012) was abstracted for all patients aged 18 to 85 years and Injury Severity Score more than 15 with complete data. Transferred patients and patients dead on arrival were excluded. Patient demographics and injury parameters were recorded, and SI in the field, SI in the emergency department (ED), and change in SI (delta SI = ED SI-field SI) were calculated. Our outcome measure was mortality. Cox regression and Kaplan-Meier analysis was performed. RESULTS: A total of 95,088 patients were included, and the overall mortality rate was 11.9%. Patients with a positive delta SI had a mortality rate of 13.3% compared with 9.6% mortality rate in patients who had an unchanged or negative delta SI. After controlling for confounders, a delta SI more than 0.1 was found to be associated with an increased hazard of death (hazard ratio [95% CI] = 1.36 [1.29-1.45]) and mortality (16.6% vs. 9.5%, P < 0.001). Even in hemodynamically stable patients, a delta SI more than 0.1 was associated with increased hazard of death (hazard ratio [95% CI] = 1.29 [1.20-1.39]). CONCLUSIONS: Delta SI from field to hospital independently predicts higher mortality. It predicts higher mortality even in apparently hemodynamically stable patients with normal traditional vital signs and normal SI. Delta SI may serve as an adjunct to existing traditional vital signs for the identification of occult hypovolemic shock and higher risk of death in trauma patients.

Injury prevention programs against distracted driving among students.

BACKGROUND: Motor vehicle crashes are the leading cause of death and nonfatal injury among young adults. The aims of this study were to assess the magnitude of distracted driving (DD) among students and to examine the effectiveness of awareness campaign against DD. We hypothesized that DD is prevalent among students and educational efforts such as DD awareness campaign can effectively reduce it. METHODS: This study was conducted within the University of Arizona that has a student enrollment of 42,000 students. We conducted our prospective interventional study in four phases at the university campus. Phase 1 involved 1-week preintervention observation, Phase 2 involved 1-week intervention, Phase 3 involved 1-week postintervention observation, and Phase 4 involved 1-week 6-month postintervention observation. We used a combination of e-mails, pamphlets, interactive sessions, and banners as intervention tools in student union. Our primary outcome was the prevalence of DD before, after, and 6 months after intervention. RESULTS: A total of 47,764 observations (before, 14,844; after, 17,939; 6 months after, 14,981) were performed. During the study period, overall rate of DD rate among the students was 8.8 (5.4) per 100 drivers (texting, 4.8 [3.7] per 100 drivers; talking, 3.9 [2.0] per 100 drivers).The baseline rate of DD among students during the phase one was 9.0 (1.2) per 100 drivers (texting, 4.8 [1.7] per 100 drivers; talking, 4.1 [1.1] per 100 drivers). Following intervention, there was a 32% significant reduction in overall DD (9.0 [1.2] vs. 6.1 [1.7], p < 0.001) in the immediate postintervention phase; however, the rate of DD returned to baseline at 6 months after intervention and trended toward increase (9.0 [1.2] vs. 11.1 [8.4], p = 0.34). CONCLUSION: DD is prevalent among university students. Following a comprehensive preventive campaign against DD, there was a 32% reduction in the rate of DD in the immediate postintervention period. However, a single episode of intervention did not have a sustainable preventive effect on the DD, and the rate increased to the baseline at 6-month follow-up. Targeting DD with a successful injury prevention campaign with repeated boosters may decrease its prevalence among the students.

Contemporary outcomes of lower extremity vascular repairs extending below the knee: A multicenter retrospective study.

OBJECTIVES: To determine the outcomes of vascular injury interventions extending below the knee. METHODS: Vascular injury repairs extending below the knee from January 2008 to December 2014 were collected from six American College of Surgeons Level I trauma centers. Demographics, management, and outcomes were collected and analyzed. RESULTS: A total of 194 vascular injuries were identified. The mean age was 33.7 years, with 88.1% male, and 71.1% had blunt injury. Admission systolic blood pressure was less than 90 mm Hg in 10.8%; prehospital tourniquets were used in 5.6%. Median mangled extremity severity score (MESS) was 6.0 [interquartile range, 6]. Imaging used included computed tomography angiography (58.2%) and angiography (7.2%); with 66 (34.0%) proceeding directly to OR based on examination alone. Vascular interventions were conducted primarily by vascular (66.0%) and trauma (25.3%) surgeons at a median time from injury of 8 hours (interquartile range, 7 hours). Initial interventions included graft interposition (57.7%) with saphenous vein (111) or synthetic graft (1), primary repair (14.9%), endovascular stent-graft (1.5%), and patch angioplasty (2.1%). Fasciotomy was performed at initial operation in 41.8%, and for delayed compartment syndrome in 2.1%. Vascular reintervention was required in 20 patients (6.7%) for bleeding (seven patients) or thrombosis (13 patients). There was a higher reintervention rates for thrombosis among interposition grafts with distal anastomotic sites at the below-knee popliteal compared to those extending to the tibioperoneal trunk or distal trifurcation vessels, but this was not significant. (4/60, 6.7% vs. 6/49, 12.2%; p = 0.34). Postintervention amputation rates were significantly higher among interposition grafts extending distal to the popliteal (4/60 [6.7%] vs. 15/49 [30.6%]; p = 0.006). CONCLUSIONS: The management of vascular injuries extending below the knee remains a complex issue of extremity trauma care. The need for delayed amputation is significantly more common when revascularization below the distal popliteal artery is required. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III; therapeutic/care management study, level IV.

Identifying the broken heart: predictors of mortality and morbidity in suspected blunt cardiac injury.

BACKGROUND: Blunt cardiac injury (BCI) is an infrequent but potentially fatal finding in thoracic trauma. Its clinical presentation is highly variable and patient characteristics and injury pattern have never been described in trauma patients. The aim of this study was to identify predictors of mortality in BCI patients. METHODS: We performed an 8-year retrospective analysis of all trauma patients diagnosed with BCI at our Level 1 trauma center. Patients older than 18 years, blunt chest trauma, and a suspected diagnosis of BCI were included. BCI was diagnosed based on the presence of electrocardiography (EKG), echocardiography, biochemical cardiac markers, and/or radionuclide imaging studies. Elevated troponin I was defined as more than 2 recordings of greater than or equal to .2. Abnormal EKG findings were defined as the presence of bundle branch block, ST segment, and t-wave abnormalities. Univariate and multivariate regression analyses were performed. RESULTS: A total of 117 patients with BCI were identified. The mean age was 51 ± 22 years, 65% were male, mean systolic blood pressure was 93 ± 65, and overall mortality rate was 44%. Patients who died were more likely to have a lactate greater than 2.5 (68% vs 31%, P = .02), hypotension (systolic blood pressure < 90) (86% vs 14%, P = .001), and elevated troponin I (86% vs 11%, P = .01). There was no difference in the rib fracture (58% vs 56%, P = .8), sternal fracture (11% vs 21%, P = .2), and abnormal EKG (89% vs 90%, P = .6) findings. Hypotension and lactate greater than 2.5 were the strongest predictors of mortality in BCI. CONCLUSIONS: BCI remains an important diagnostic and management challenge. However, once diagnosed resuscitative therapy focused on correction of hypotension and lactate may prove beneficial. Although the role of troponin in diagnosing BCI remains controversial, elevated troponin may have prognostic significance.

The use of whole body computed tomography scans in pediatric trauma patients: Are there differences among adults and pediatric centers?

INTRODUCTION: Whole body CT (WBCT) scan is known to be associated with significant radiation risk especially in pediatric trauma patients. The aim of this study was to assess the use WBCT scan across trauma centers for the management of pediatric trauma patients. METHODS: We performed a two year (2011-2012) retrospective analysis of the National Trauma Data Bank. Pediatric (age≤18years) trauma patients managed in level I or II adult or pediatric trauma centers with a head, neck, thoracic, or abdominal CT scan were included. WBCT scan was defined as CT scan of the head, neck, thorax, and abdomen. Patients were stratified into two groups: patients managed in adult centers and patients managed in designated pediatric centers. Outcome measure was use of WBCT. Multivariate logistic regression analysis was performed. RESULTS: A total of 30,667 pediatric trauma patients were included of which; 38.3% (n=11,748) were managed in designated pediatric centers. 26.1% (n=8013) patients received a WBCT. The use of WBCT scan was significantly higher in adult trauma centers in comparison to pediatric centers (31.4% vs. 17.6%, p=0.001). There was no difference in mortality rate between the two groups (2.2% vs. 2.1%, p=0.37). After adjusting for all confounding factors, pediatric patients managed in adult centers were 1.8 times more likely to receive a WBCT compared to patients managed in pediatric centers (OR [95% CI]: 1.8 [1.3-2.1], p=0.001). CONCLUSIONS: Variability exists in the use of WBCT scan across trauma centers with no difference in patient outcomes. Pediatric patients managed in adult trauma centers were more likely to be managed with WBCT, increasing their risk for radiation without a difference in outcomes. Establishing guidelines for minimizing the use of WBCT across centers is warranted.

Disparities in Mangement of Patients with Benign Colorectal Disease: Impact of Urbanization and Specialized Care.

Disparities in the management of patients with various medical conditions are well established. Colorectal diseases continue to remain one of the most common causes for surgical intervention. The aim of this study was to assess disparities (rural versus urban) in the surgical management of patients with noncancerous benign colorectal diseases. We hypothesized that there is no difference among rural versus urban centers (UC) in the surgical management for noncancerous benign colorectal diseases. The national estimates of surgical procedures for benign colorectal diseases from the National Inpatient Sample database 2011 representing 20 per cent of all in-patient admissions were abstracted. Patients undergoing procedures (abscess drainage, hemmoroidectomy, fistulectomy, and bowel resections) were included. Patients with colon cancer and those who underwent emergency surgery were excluded. The population was divided into two groups: urban and rural, based on the location of treatment. Outcome measures were in-hospital complications, mortality, and hospital costs. Subanalysis of UC was preformed: centers with colorectal surgeons and centers without colorectal surgeons. Regression analysis was performed. A total of 20,617 patients who underwent surgical intervention for benign colorectal diseases across 496 (urban: 342, rural: 154) centers, were included. Of the UC, 38.3 per cent centers had colorectal surgeons. Patients managed in UC had lower complication rate (7.6% vs 10.2%, P < 0.001), shorter hospital length of stay (4.7 ± 3.1 vs 5.9 ± 3.6 days, P < 0.001), and higher hospital costs ($56,820 ± $27,691 vs $49,341 ± $2,598, P < 0.001) compared with rural centers. On subanalysis, patients managed in UC with colorectal surgeons had 11 per cent lower incidence of in-hospital complications [odds ratio: 0.89 (95% confidence interval: 0.76-0.94)] and a shorter hospital length of stay [Beta: -0.72 (95% confidence interval: -0.81 to -0.65)] when compared with patients managed in UC without colorectal specialization. Disparities exit in outcomes of the patients with noncancerous benign colorectal diseases managed surgically in urban versus rural centers. Specialized care with colorectal surgeons at UC helps reduce adverse patient outcomes. Steps to provide effective and safe surgical care in a cost-effective manner across rural as well as UC are warranted. LEVEL OF EVIDENCE: Level III, retrospective cohort analysis.

Outcomes in Trauma Patients with Isolated Epidural Hemorrhage: A Single-Institution Retrospective Cohort Study.

The type, location, and size of intracranial hemorrhage are known to be associated with variable outcomes in patients with traumatic brain injury (TBI). The aim of our study was to assess the outcomes in patients with isolated epidural hemorrhage (EDH) based on the location of EDH. We performed a 3-year (2010-2012) retrospective chart review of the patients with TBI in our level 1 trauma center. Patients with an isolated EDH on initial head CT scan were included. Patients were divided into four groups based on the location of EDH: frontal, parietal, temporal, and occipital. Differences in demographics and outcomes between the four groups were assessed. Outcome measures were progression on repeat head CT and neurosurgical intervention (NI). A total of 76 patients were included in this study. The mean age was 20.6 ± 15.2 years, 68.4 per cent were male, median Glasgow Coma Scale (GCS) score 15 (13-15), and median head Abbreviated Injury Scale score was 3 (2-4). About 32.9 per cent patients (n = 25) had frontal EDH, 26.3 per cent (n = 20) had temporal EDH, 10.5 per cent (n = 8) had occipital EDH, while the remaining 30.3 per cent (n = 23) had parietal EDH. The overall progression rate was 21.1 per cent (n = 12) and NI rate was 29 per cent (n = 22). There was no difference in the outcome of patients based on location of EDH. Patients with NI had a longer hospital length of stay (P = 0.02) and longer intensive care unit length of stay (P = 0.05). The incidence of isolated EDH is low in patients with blunt TBI. Patients with isolated EDH undergoing NI have longer hospital stays compared to patients without NI. Further investigation is warranted to identify factors associated with need for NI and adverse outcomes in the cohort of patients with isolated EDH.