Robotic repair of traumatic bronchial disruption: A minimally invasive and multi-disciplinary approach to a complex constellation of injuries.

Bronchial disruption is a catastrophic consequence of blunt thoracic trauma with high pre-hospital lethality. This injury is classically managed through a large thoracotomy incision to facilitate adequate exposure for open repair. Here, we describe a case of complete bronchus intermedius disruption following a motor vehicle accident that was repaired via robotic thoracoscopy. The patient sustained multi-system trauma, including a grade III liver laceration, an innominate artery pseudoaneurysm, and femoral condyle fracture, all of which required systematic intervention and multi-disciplinary coordination to best facilitate this patient's care. This patient recovered well from his multiple injuries and was discharged after an uneventful post-operative course.

Youth violence prevention can be enhanced by geospatial analysis of trauma registry data.

BACKGROUND: Geographic information systems (GIS) have been used to understand relationships between trauma mechanisms, locations, and social determinants for injury prevention. We hypothesized that GIS analysis of trauma center registry data for assault patients aged 14 years to 29 years with census tract data would identify geospatial and structural determinants of youth violence. METHODS: Admissions to a Level I trauma center from 2010 to 2019 were retrospectively reviewed to identify assaults in those 14 years to 29 years. Prisoners were excluded. Home and injury scene addresses were geocoded. Cluster analysis was performed with the Moran I test for spatial autocorrelation. Census tract comparisons were done using American Communities Survey (ACS) data by t-test and linear regression. RESULTS: There were 1,608 admissions, 1,517 (92.4%) had complete addresses and were included in the analysis. Mean age was 23 ± 3.8 years, mean ISS was 7.5 ± 6.2, there were 11 (0.7%) in-hospital deaths. Clusters in six areas of the trauma catchment were identified with a Moran I value of 0.24 ( Z score = 17.4, p < 0.001). Linear regression of American Communities Survey demographics showed predictors of assault were unemployment (odds ratio, 4.5; 95% confidence interval, 2.7-6.4; p < 0.001), Spanish spoken at home (odds ratio, 6.6; 95% confidence interval, 3.4-9.8; p < 0.001) and poverty level (odds ratio, 1.9; 95% confidence interval, 1.1-2.7; p < 0.001). Education level of less than high school diploma, single parent households and race were not significant predictors. CONCLUSION: GIS analysis of registry data can identify high-risk areas for youth violence and correlated social and structural determinants. Violence prevention efforts can be better targeted geographically and socioeconomically with better understanding of these risk factors. LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level III.

The e-merging e-pidemic of e-scooters.

INTRODUCTION: Since their release in 2017, standing electric motorized scooters (eScooters) have risen in popularity as an alternative mode of transportation. We sought to examine the incidence of injury, injury patterns, prevalence of helmet and drug and alcohol use in eScooter trauma. METHODS: This was a multi-institutional retrospective case series of patients admitted for injuries related to operation of an eScooter following the widespread release of these devices in September 2017 (September 1, 2017 to October 31, 2018). Demographics, drug and alcohol use, helmet use, admission vitals, injuries, procedures, hospital and intensive care unit length of stay (LOS), death, and disposition were analyzed. RESULTS: 103 patients were admitted during the study period, and monthly admissions increased significantly over time. Patients were young men (mean age 37.1 years; 65% male), 98% were not wearing a helmet. Median LOS was 1 day (IQR 1-3). 79% of patients were tested for alcohol and 48% had a blood alcohol level >80 mg/dL. 60% of patients had a urine toxicology screen, of which 52% were positive. Extremity fractures were the most frequent injury (42%), followed by facial fractures (26%) and intracranial hemorrhage (18%). Median Injury Severity Score was 5.5 (IQR 5-9). One-third of patients (n=34) required an operative intervention, the majority of which were open fixations of extremity and facial fractures. No patients died during the study. The majority of patients were discharged home (86%). CONCLUSION: eScooter-related trauma has significantly increased over time. Alcohol and illicit substance use among these patients was common, and helmet use was extremely rare. Significant injuries including intracranial hemorrhage and fractures requiring operative intervention were present in over half (51%) of patients. Interventions aimed at increasing helmet use and discouraging eScooter operation while intoxicated are necessary to reduce the burden of eScooter-related trauma. LEVEL OF EVIDENCE: Level IV.

Laboratory measures of coagulation among trauma patients on NOAs: results of the AAST-MIT.

BACKGROUND: Warfarin is associated with poor outcomes after trauma, an effect correlated with elevations in the international normalized ratio (INR). In contrast, the novel oral anticoagulants (NOAs) have no validated laboratory measure to quantify coagulopathy. We sought to determine if use of NOAs was associated with elevated activated partial thromboplastin time (aPTT) or INR levels among trauma patients or increased clotting times on thromboelastography (TEG). METHODS: This was a post-hoc analysis of a prospective observational study across 16 trauma centers. Patients on dabigatran, rivaroxaban, or apixaban were included. Laboratory data were collected at admission and after reversal. Admission labs were compared between medication groups. Traditional measures of coagulopathy were compared with TEG results using Spearman's rank coefficient for correlation. Labs before and after reversal were also analyzed between medication groups. RESULTS: 182 patients were enrolled between June 2013 and July 2015: 50 on dabigatran, 123 on rivaroxaban, and 34 apixaban. INR values were mildly elevated among patients on dabigatran (median 1.3, IQR 1.1-1.4) and rivaroxaban (median 1.3, IQR 1.1-1.6) compared with apixaban (median 1.1, IQR 1.0-1.2). Patients on dabigatran had slightly higher than normal aPTT values (median 35, IQR 29.8-46.3), whereas those on rivaroxaban and apixaban did not. Fifty patients had TEG results. The median values for R, alpha, MA and lysis were normal for all groups. Prothrombin time (PT) and aPTT had a high correlation in all groups (dabigatran p=0.0005, rivaroxaban p<0.0001, and apixaban p<0.0001). aPTT correlated with the R value on TEG in patients on dabigatran (p=0.0094) and rivaroxaban (p=0.0028) but not apixaban (p=0.2532). Reversal occurred in 14%, 25%, and 18% of dabigatran, rivaroxaban, and apixaban patients, respectively. Both traditional measures of coagulopathy and TEG remained within normal limits after reversal. DISCUSSION: Neither traditional measures of coagulation nor TEG were able to detect coagulopathy in patients on NOAs. LEVEL OF EVIDENCE: Level IV.

Improving life expectancy: A 'broken neck' doesn't have to be a terminal diagnosis for the elderly.

BACKGROUND: Elderly patients with cervical spine fractures require optimal care. Treatment with a cervical collar or halo instead of surgical fixation may increase mortality. This investigation intends to describe the life expectancy after injury and evaluate the impact of surgical intervention on mortality. METHODS: Patients ≥65 years, with traumatic cervical spine fractures without cord injury were identified in the 1995-2009 California Office of Statewide Health and Planning database. Those with halo placement or surgical spine fixation were identified. Primary outcome was death, studied at the initial admission, 30 days, 1 year, and the entire study period. Univariate and multivariate regressions were performed to identify predictors of death. Kaplan-Meier survival curves were used to describe life expectancy after injury. RESULTS: 10 938 patients were identified. Mortality rate was 10% during the initial admission, 28% at 1 year and 50% during the entire study period. A halo was placed in 14% of patients and 12% underwent surgical fixation. Mortality rates during the initial admission were 11% for patients without an intervention, 7% with halo placement and 6% with surgical fixation; at 1 year, these increased to 30%, 26% and 19%, respectively. At 1 year, more than one in four patients above 75 years of age will die.At 1 year spine fixation, female gender and admission to a trauma center predicted a lower risk of death at 1 year (OR 0.59, 0.68; p<0.001 and OR 0.89; p=0.02, respectively). Having a complication, fall mechanism, and traumatic brain injury (OR 1.84, 1.33, 1.37; p<0.001, respectively) were predictors of a higher risk of death. Halo use had no impact on death at 1 year (OR 0.98; p=0.77). DISCUSSION: Mortality rates after cervical spine fracture in the elderly is high. Surgical fixation is associated with improved survival; remaining true after adjusting for age and comorbidities; suggesting that surgical fixation may improve outcomes in the elderly. LEVEL OF EVIDENCE: Level IV.

Abdominal vascular trauma.

Abdominal vascular trauma, primarily due to penetrating mechanisms, is uncommon. However, when it does occur, it can be quite lethal, with mortality ranging from 20% to 60%. Increased early mortality has been associated with shock, acidosis, hypothermia, coagulopathy, free intraperitoneal bleeding and advanced American Association for the Surgery of Trauma Organ Injury Scale grade. These patients often arrive at medical centers in extremis and require rapid surgical control of bleeding and aggressive resuscitation including massive transfusion protocols. The most important factor in survival is surgical control of hemorrhage and restoration of appropriate perfusion to the abdominal contents and lower extremities. These surgical approaches and the techniques of definitive vascular repair can be quite challenging, particularly to the inexperienced surgeon. This review hopes to describe the most common abdominal vascular injuries, their presentation, outcomes, and surgical techniques to control and repair such injuries.