In for a Penny, in for a Pound: Obesity weighs heavily on both cost and outcome in trauma.

BACKGROUND: The current literature offers mixed conclusions regarding the effect of increased body mass index (BMI) on outcomes after trauma laparotomy. This study evaluated the impact of obesity on outcomes and cost for patients undergoing trauma laparotomy at a level 1 trauma center. STUDY DESIGN: Data on patients requiring trauma laparotomy in 2016 were prospectively collected and patients were stratified by BMI. Statistical analyses were used to determine variables significantly associated with patient morbidity and length of stay. RESULTS: 313 patients underwent trauma laparotomy: 225 non-obese, 69 obese, and 19 morbidly obese. Obese and morbidly obese patients had longer ICU and hospital lengths of stay (LOS), more ventilator days, larger hospital costs, and higher morbidity compared to non-obese patients. Obesity was an independent predictor for patient morbidity, ICU, and hospital LOS. CONCLUSIONS: Morbidity and length of stay increased with worsening obesity after trauma laparotomy, contributing to rising hospital costs.

Impact of Chemoprophylaxis on Thromboembolism Following Operative Fixation of Pelvic Fractures.

BACKGROUND: Venous thromboembolism (VTE) is a common cause of serious morbidity and mortality. While chemoprophylaxis decreases VTE, there is the theoretical risk of increased hemorrhagic complications. The purpose of this study was to evaluate the impact of preoperative anticoagulation on VTE and bleeding complications in patients with blunt pelvic fractures requiring operative fixation. METHODS: Patients with blunt pelvic fractures requiring operative fixation over 10.5 years were identified. Patients were stratified by age, severity of shock, operative management, and timing and duration of anticoagulation. Outcomes were evaluated to determine risk factors for bleeding complications and VTE. RESULTS: 310 patients were identified: 212 patients received at least one dose of preoperative anticoagulation and 98 received no preoperative anticoagulation. 68% were male with a mean injury severity score and Glasgow Coma Scale of 26 and 13, respectively. Bleeding complications occurred in 24 patients and 21 patients suffered VTE. Patients with VTE had a greater initial severity of shock (resuscitation transfusions, 4 vs. 2 units, P = .02). Despite longer time to mobilization (4 vs. 3 days, P = .001), patients who received their scheduled preoperative doses within 48 hours of arrival had no significant differences in the number of deep vein thrombosis events (5.2% vs. 5.7%, P = .99), but fewer episodes of pulmonary embolism (PE) (1.5% vs. 6.8%, P = .03) with no difference in bleeding complications (7.5% vs. 8%, P = .87) compared to either patients who had their doses held until after 48 hours of arrival or received no preoperative anticoagulation. DISCUSSION: Preoperative anticoagulation prior to pelvic fixation reduced the risk of PE without increasing bleeding complications. Preoperative anticoagulation is safe and beneficial in this group of patients.

Radiographic predictors of therapeutic operative intervention after blunt abdominal trauma: the RAPTOR score.

PURPOSE: Bowel and mesenteric injuries are rare in patients following blunt abdominal trauma. Computed tomography (CT) imaging has become a mainstay in the work-up of the stable trauma patient. The purpose of this study was to identify radiographic predictors of therapeutic operative intervention for mesenteric and/or bowel injuries in patients after blunt abdominal trauma. METHODS: All patients with a discharge diagnosis of bowel and/or mesenteric injury after blunt trauma were identified over a 5-year period. Admission CT scans were reviewed to identify potential predictors of bowel and/or mesenteric injury. Patients were then stratified by operative intervention [therapeutic laparotomy (TL) vs. non-therapeutic laparotomy (NTL)] and compared. All potential predictors included in the initial regression model were assigned one point and a score based on the number of predictors was calculated: the radiographic predictors of therapeutic operative intervention (RAPTOR) score. RESULTS: 151 patients were identified. 114 (76%) patients underwent operative intervention. Of these, 75 patients (66%) underwent TL. Multifocal hematoma, acute arterial extravasation, bowel wall hematoma, bowel devascularization, fecalization, pneumoperitoneum and fat pad injury, identified as potential predictors on univariable analysis, were included in the initial regression model and comprised the RAPTOR score. The optimal RAPTOR score was identified as ≥ 3, with a sensitivity, specificity and positive predictive value of 67%, 85% and 86%, respectively. Acute arterial extravasation (OR 3.8; 95% CI 1.2-4.3), bowel devascularization (OR 14.5; 95% CI 11.8-18.4) and fat pad injury (OR 4.5 95% CI 1.6-6.2) were identified as independent predictors of TL (AUC 0.91). CONCLUSIONS: CT imaging remains vital in assessing for potential bowel and/or mesenteric injuries following blunt abdominal trauma. The RAPTOR score provides a simplified approach to predict the need for early therapeutic operative intervention.

Is NBATS-2 up to the Task? Actual vs. Predicted Patient Volume Shifts With the Addition of Another Trauma Center.

INTRODUCTION: Version 2 of the Needs-Based Assessment of Trauma Systems (NBATS) tool quantifies the impact of an additional trauma center on a region. This study applies NBATS-2 to a system where an additional trauma center was added to compare the tool's predictions to actual patient volumes. METHODS: Injury data were collected from the trauma registry of the initial (legacy) center and analyzed geographically using ArcGIS. From 2012 to 2014 ("pre-"period), one Level 1 trauma center existed. From 2016 to 2018 ("post-"period), an additional Level 2 center existed. Emergency medical service (EMS) destination guidelines did not change and favored the legacy center for severely injured patients (Injury Severity Score (ISS) >15). NBATS-2 predicted volume was compared to the actual volume received at the legacy center in the post-period. RESULTS: 4068 patients were identified across 14 counties. In the pre-period, 72% of the population and 90% of injuries were within a 45-minute drive of the legacy trauma center. In the post-period, 75% of the total population and 90% of injuries were within 45 minutes of either trauma center. The post-predicted volume of severely injured patients at the legacy center was 434, but the actual number was 809. For minor injuries (ISS £15), NBATS-2 predicted 581 vs. 1677 actual. CONCLUSION: NBATS-2 failed to predict the post-period volume changes. Without a change in EMS destination guidelines, this finding was not surprising for severely injured patients. However, the 288% increase in volume of minor injuries was unexpected. NBATS-2 must be refined to assess the impact of local factors on patient volume.

They only come out at night: Impact of time of day on outcomes after penetrating abdominal trauma.

BACKGROUND: Patients who present at night following penetrating abdominal trauma are thought to have more severe injuries and increased risk for morbidity and mortality. The current literature is at odds regarding this belief. The purpose of this study was to evaluate time of day on outcomes following laparotomy for penetrating abdominal trauma. METHODS: Patients undergoing laparotomy following penetrating abdominal trauma over a 12-month period at a level I trauma center were stratified by age, sex, severity of shock, injury, operative complexity, and time of day (DAY = 0700-1900, NIGHT = 1901-0659). Outcomes of damage control laparotomy, ventilator days, intensive care unit length of stay, hospital length of stay, morbidity, and mortality were compared between DAY and NIGHT. RESULTS: A total of 210 patients were identified: 145 (69%) comprised NIGHT, and 65 (31%) comprised DAY. Overall mortality was 2.9%. Both injury severity and intraoperative transfusions were increased with NIGHT with no difference in morbidity (37% vs 40%, P = 0.63) or mortality (2.1% vs 4.6%, P = 0.31). Adjusting for sex, time of day, injury severity, and operative complexity, only abdominal abbreviated injury severity (odds ratio 1.46; 95% confidence interval 1.07-1.99, P = .019) and operative transfusions (odds ratio 1.18; 95% confidence interval 1.09-1.28, P < .0001) were identified as independent predictors of damage control laparotomy using multivariable logistic regression (area under the curve 0.96). CONCLUSION: The majority of operative penetrating abdominal trauma occurs at night with increased injury burden, more operative transfusions, and increased use of damage control laparotomy with no difference in morbidity and mortality. Outcomes at a fully staffed and operational trauma center should not be impacted by time of day.

Long-Term Analysis of Functional Outcomes in Traumatic Brain Injury Patients.

INTRODUCTION: Traumatic brain injury (TBI) remains a significant cause of morbidity and mortality. The purpose of this study is to examine outcomes after discharge and identify factors from the index admission that may contribute to long-term mortality. METHODS: The study population is composed of patients who survived to discharge from a previously published study examining TBI. Demographics, injury severity, and length of stay were abstracted from the index study. Phone surveys of surviving patients were performed to evaluate each patient's Glasgow Outcome Scale-Extended (GOSE). Patients who were deceased at the time of the survey were compared with those who were alive. RESULTS: 1615 patients were alive at the end of the first study period and 211 (13%) comprised the study population. Overall, the median age was 54 years, and the majority were male (74%). The median time to follow-up was 80 months. The population was severely injured, with a median injury severity score (ISS) of 25 and a median head abbreviated injury score (AIS) of 4. Overall mortality was 57%. The group that survived at the time of the survey was younger, more injured, less likely to have received beta-blockers (BB) during the index admission, and had a longer time to follow-up. After adjusting for ISS, age, base deficit, and BB, age was the only variable predictive of mortality (HR 1.03; HL 1.02-1.04). CONCLUSION: Despite being more severely injured, younger patients were more likely to survive to follow-up. Further investigation is needed to determine if aggressive care in older TBI patients in the acute phase leads to good long-term outcomes.

How soon is too soon?: Optimal timing of split-thickness skin graft following polyglactin 910 mesh closure of the open abdomen.

BACKGROUND: Various management strategies exist for the abdomen that will not close. At our institution, these patients are managed with polyglactin 910 mesh followed 14 days later (LATE) by split-thickness skin graft (STSG) or, in some cases, earlier (EARLY, <14 days), if the wound is judged to be adequately granulated. The purpose of this study was to evaluate the impact of STSG timing for wounds felt ready for grafting on STSG failure. METHODS: Consecutive patients over a 3-year period managed with polyglactin 910 mesh followed by STSG were identified. Patient characteristics, severity of injury and shock, time to STSG, and outcomes, including STSG failure, were recorded and compared. Multivariable logistic regression analysis was performed to identify predictors of graft failure. RESULTS: Sixty-one patients were identified: 31 EARLY and 30 LATE. There was no difference in severity of injury or shock between the groups. Split-thickness skin graft failure occurred in 11 patients (9 EARLY vs. 2 LATE, p < 0.0001). Time to STSG was significantly less in patients with graft failure (11 days vs. 15 days, p = 0.012). In fact, after adjusting for age, injury severity, severity of shock, and time to STSG, multivariable logistic regression identified EARLY STSG (odds ratio, 1.4; 95% confidence interval, 1.1-1.8, p = 0.020) as the only independent predictor of graft failure. CONCLUSION: Appearance of the open abdomen can be misleading during the first 2 weeks following polyglactin 910 mesh placement. EARLY STSG was the only modifiable risk factor associated with graft failure. Thus, for optimal results, STSG should be delayed at least 14 days after polyglactin 910 mesh placement. LEVEL OF EVIDENCE: Prognostic study, level IV.

Separating Truth from Alternative Facts: 37 Years of Guns, Murder, and Violence Across the US.

BACKGROUND: Gun violence remains a significant public health problem that is both understudied and underfunded, and plagued by inadequate or inaccessible data sources. Over the years, numerous trauma centers have attempted to use local registries to study single-institutional trends, however, this approach limits generalizability to our national epidemic. In fact, even easily accessible, health-centered data from the CDC lack national relevance because they are limited to those enrolled states only. We sought to examine how publicly available law enforcement data from all 50 states might complement our understanding of circumstances and demographics surrounding national firearm death and help forge the first step in partnering law enforcement with trauma centers. METHODS: All homicide that occurred in the US during a 37-year period ending in 2016 was analyzed. Primary data files were obtained from the Federal Bureau of Investigation and comprised the database. Data analyzed included homicide type, situation, circumstance, firearm type, and demographic characteristics of victims and offenders. The proportion of firearm-related homicide was stratified by year and compared over time using simple linear regression. RESULTS: There were 485,288 incidents of firearm homicide analyzed (64% of 752,935 total homicides). Most victims were male (85%), black (53%), and a mean age of 33 years; offenders were predominantly male (67%), black (39%), and a mean age of 30 years. Fifty-four percent of all homicide involved a single victim and single offender, followed by a single victim and unknown offender(s) (31%); 4% of firearm homicide had multiple victims. Overall, handguns, shotguns, and rifles accounted for 76%, 7%, and 5% of all firearm homicide, respectively; 11% had no firearm type listed and <1% were other gun or unknown. Linear regression analysis identified a significant increase in the proportion of firearm-related homicide from 61% in 1980 to 71% in 2016 (ß = 0.25; p < 0.0001). CONCLUSIONS: Gun violence represents an ongoing public health concern, with the proportion of firearm homicide steadily and significantly increasing from 1980 to 2016. Homicide data from the Federal Bureau of Investigation can serve to supplement trauma registry data by helping to define gun violence patterns. However, stronger partnerships between local law enforcement agencies and trauma centers are necessary to better characterize firearm type and resultant injury patterns, direct prevention efforts and firearm policy, and reduce gun-related deaths.

Does lack of thoracic trauma attenuate the severity of pulmonary failure? An 8-year analysis of critically injured patients.

PURPOSE: Patients with thoracic trauma are presumed to be at higher risk for pulmonary dysfunction, but adult respiratory distress syndrome (ARDS) may develop in any patient, regardless of associated chest injury. This study evaluated the impact of thoracic trauma and pulmonary failure on outcomes in trauma patients admitted to the intensive-care unit (ICU). METHODS: All trauma patients admitted to the ICU over an 8-year period were identified. Patients that died within 48 h of arrival were excluded. Patients were stratified by baseline characteristics, injury severity, development of ARDS, and infectious complications. Multiple logistic regression was used to determine variables significantly associated with the development of ARDS. RESULTS: 10,362 patients were identified. After exclusions, 4898 (50%) patients had chest injury and 4975 (50%) did not. 200 (2%) patients developed ARDS (3.6% of patients with chest injury and 0.5% of patients without chest injury). Patients with ARDS were more likely to have chest injury than those without ARDS (87% vs 49%, p < 0.001). However, of the patients without chest injury, the development of ARDS still led to a significant increase in mortality compared to those patients without ARDS (58% vs 5%, p < 0.001). Multiple logistic regression found ventilator-associated pneumonia (VAP) to be the only independent predictor for the development of ARDS in ICU patients without chest injury. CONCLUSIONS: ARDS development was more common in patients with thoracic trauma. Nevertheless, the development of ARDS in patients without chest injury was associated with a tenfold higher risk of death. The presence of VAP was found to be the only potentially preventable and treatable risk factor for the development of ARDS in ICU patients without chest injury.

Concomitant bladder and rectal injuries: Results from the American Association for the Surgery of Trauma Multicenter Rectal Injury Study Group.

BACKGROUND: Combined traumatic injuries to the rectum and bladder are rare. We hypothesized that the combination of bladder and rectal injures would have worse outcomes than rectal injury alone. METHODS: This is an American Association for the Surgery of Trauma multi-institutional retrospective study from 2004 to 2015 traumatic rectal injury patients who were admitted to one of 22 participating centers. Demographics, mechanism, and management of rectal injury were collected. Patients who sustained a rectal injury alone were compared with patients who sustained a combined injury to the bladder and rectum. Multivariable logistic regression was used to determine if abdominal complications, mortality, and length of stay were impacted by a concomitant bladder injury after adjusting for cofounders. RESULTS: There were 424 patients who sustained a traumatic rectal injury, of which 117 (28%) had a combined injury to the bladder. When comparing the patients with a combined bladder/rectal injury to the rectal alone group, there was no difference in admission demographics admission physiology, or Injury Severity Score. There were also no differences in management of the rectal injury and no difference in abdominal complications (13% vs. 16%, p = 0.38), mortality (3% vs. 2%, p = 0.68), or length of stay (17 days vs. 21 days, p = 0.10). When looking at only the 117 patients with a combined injury, the addition of a colostomy did not significantly decrease the rate of abdominal complications (14% vs. 8%, p = 0.42), mortality (3% vs. 0%, p = 0.99), or length of stay (17 days vs. 17 days, p = 0.94). After adjusting for cofounders (AAST rectal injury grade, sex, damage-control surgery, diverting colostomy, and length of stay) the presence of a bladder injury did not impact outcomes. CONCLUSION: For patients with traumatic rectal injury, a concomitant bladder injury does not increase the rates of abdominal complications, mortality, or length of stay. Furthermore, the addition of a diverting colostomy for management of traumatic bladder and rectal injury does not change outcomes. LEVEL OF EVIDENCE: Level IV; prognostic/therapeutic.

Long-term functional outcomes after traumatic popliteal artery injury: A 20-year experience.

BACKGROUND: Traumatic popliteal arterial injury (TPAI) is associated with a risk of both limb loss and long-term morbidity due to prolonged ischemia and the often-associated musculoskeletal injuries. Long-term functional outcome following this injury has not been adequately studied. We evaluated patients with TPAI to determine if there was an improvement in functional outcome over time. We hypothesized that both the initial severity of ischemia and the associated injuries limited the ability of patients to improve functional outcome. METHODS: Patients with TPAI for 20 years were identified. All patients had at least a 2-year follow-up. Functional outcomes were measured using the Boston University Activity Measure for Post-Acute Care to assess basic mobility (BM) and daily activity (DA). Multiple linear regression, adjusted for age, severity of injury and shock, operative complexity, associated injuries, ischemic time, and length of follow-up were used to identify predictors of functional outcome after TPAI. RESULTS: A total of 214 patients were identified: 123 penetrating (57%) and 91 blunt (43%). Overall mortality was 1.9% (all in-hospital), and amputation occurred in 10%. Of the 210 survivors, follow-up was obtained in 145 patients (69%). Median follow-up was 9.2 years (interquartile range, 5.7-15.7 years). Mean Activity Measure for Post-Acute Care scores for BM and DA were 78 and 75, respectively, both signifying mild impairment (normal, >84). Multiple linear regression failed to identify increasing length of follow-up as a predictor of improved functional outcomes. Only age, lower extremity fracture, and ischemic time were identified as predictors of decreased BM and DA. CONCLUSION: Increasing age, lower extremity fracture, and prolonged ischemic time worsened long-term functional outcomes. Functional outcome did not improve over time, suggesting that maximal recovery may be achieved within the first 2 years postinjury. Thus, early and effective revascularization remains the only potentially modifiable risk factor for improving functional outcomes following TPAI. LEVEL OF EVIDENCE: Prognostic, level III.

Location, location, location: Utilizing Needs-Based Assessment of Trauma Systems-2 in trauma system planning.

BACKGROUND: In 2015, the American College of Surgeons Committee on Trauma introduced the Needs-Based Assessment of Trauma Systems (NBATS) tool to quantify the optimal number of trauma centers for a region. While useful, more focus was required on injury population, distribution, and transportation systems. Therefore, NBATS-2 was developed utilizing advanced geographical modeling. The purpose of this study was to evaluate NBATS-2 in a large regional trauma system. METHODS: Data from all injured patients from 2016 to 2017 with an Injury Severity Score greater than 15 was collected from the trauma registry of the existing (legacy) center. Injury location and demographics were analyzed by zip code. A regional map was built using US census data to include hospital and population demographic data by zip code. Spatial modeling was conducted using ArcGIS to estimate an area within a 45-minute drive to a trauma center. RESULTS: A total of 1,795 severely injured patients were identified across 54 counties in the tri-state region. Forty-eight percent of the population and 58% of the injuries were within a 45-minute drive of the legacy trauma center. With the addition of another urban center, injured and total population coverage increased by only 1% while decreasing the volume to the existing center by 40%. However, the addition of two rural trauma centers increased coverage significantly to 62% of the population and 71% of the injured (p < 0.001). The volume of the legacy center was decreased by 25%, but the self-pay rate increased by 16%. CONCLUSION: The geospatial modeling of NBATS-2 adds a new dimension to trauma system planning. This study demonstrates how geospatial modeling applied in a practical tool can be incorporated into trauma system planning at the local level and used to assess changes in population and injury coverage within a region, as well as potential volume and financial implications to a current system. LEVEL OF EVIDENCE: Care management/economic, level V.

Rectal Injury After Foreign Body Insertion: Secondary Analysis From the AAST Contemporary Management of Rectal Injuries Study Group.

BACKGROUND: Retained rectal foreign bodies are a common but incompletely studied problem. This study defined the epidemiology, injury severity, and outcomes after rectal injuries following foreign body insertion. METHODS: Twenty-two level I trauma centers retrospectively identified all patients sustaining a rectal injury in this AAST multi-institutional trial (2005-2014). Only patients injured by foreign body insertion were included in this secondary analysis. Exclusion criteria were death before rectal injury management or ≤48 h of admission. Demographics, clinical data, and outcomes were collected. Study groups were defined as partial thickness (AAST grade I) versus full thickness (AAST grades II-V) injuries. Subgroup analysis was performed by management strategy (nonoperative versus operative). RESULTS: After exclusions, 33 patients were identified. Mean age was 41 y (range 18-57), and 85% (n = 28) were male. Eleven (33%) had full thickness injuries and 22 (67%) had partial thickness injuries, of which 14 (64%) were managed nonoperatively and 8 (36%) operatively (proximal diversion alone [n = 3, 14%]; direct repair with proximal diversion [n = 2, 9%]; laparotomy without rectal intervention [n = 2, 9%]; and direct repair alone [n = 1, 5%]). Subgroup analysis of outcomes after partial thickness injury demonstrated significantly shorter hospital length of stay (2 ± 1; 2 [1-5] versus 5 ± 2; 4 [2-8] d, P = 0.0001) after nonoperative versus operative management. CONCLUSIONS: Although partial thickness rectal injuries do not require intervention, difficulty excluding full thickness injuries led some surgeons in this series to manage partial thickness injuries operatively. This was associated with significantly longer hospital length of stay. Therefore, we recommend nonoperative management after a retained rectal foreign body unless full thickness injury is conclusively identified.

Beta-adrenergic blockade for attenuation of catecholamine surge after traumatic brain injury: a randomized pilot trial.

BACKGROUND: Beta-blockers have been proven in multiple studies to be beneficial in patients with traumatic brain injury. Few prospective studies have verified this and no randomized controlled trials. Additionally, most studies do not titrate the dose of beta-blockers to therapeutic effect. We hypothesize that propranolol titrated to effect will confer a survival benefit in patients with traumatic brain injury. METHODS: A randomized controlled pilot trial was performed during a 24-month period. Patients with traumatic brain injury were randomized to propranolol or control group for a 14-day study period. Variables collected included demographics, injury severity, physiologic parameters, urinary catecholamines, and outcomes. Patients receiving propranolol were compared with the control group. RESULTS: Over the study period, 525 patients were screened, 26 were randomized, and 25 were analyzed. Overall, the mean age was 51.3 years and the majority were male with blunt mechanism. The mean Injury Severity Score was 21.8 and median head Abbreviated Injury Scale score was 4. Overall mortality was 20.0%. Mean arterial pressure was higher in the treatment arm as compared with control (p=0.021), but no other differences were found between the groups in demographics, severity of injury, severity of illness, physiologic parameters, or mortality (7.7% vs. 33%; p=0.109). No difference was detected over time in any variables with respect to treatment, urinary catecholamines, or physiologic parameters. Glasgow Coma Scale (GCS), Sequential Organ Failure Assessment, and Acute Physiology and Chronic Health Evaluation scores all improved over time. GCS at study end was significantly higher in the treatment arm (11.7 vs. 8.9; p=0.044). Finally, no difference was detected with survival analysis over time between groups. CONCLUSIONS: Despite not being powered to show statistical differences between groups, GCS at study end was significantly improved in the treatment arm and mortality was improved although not at a traditional level of significance. The study protocol was safe and feasible to apply to an appropriately powered larger multicenter study. LEVEL OF EVIDENCE: Level 2-therapeutic.

Better understanding the utilization of damage control laparotomy: A multi-institutional quality improvement project.

BACKGROUND: Rates of damage control laparotomy (DCL) vary widely and consensus on appropriate indications does not exist. The purposes of this multicenter quality improvement (QI) project were to decrease the use of DCL and to identify indications where consensus exists. METHODS: In 2016, six US Level I trauma centers performed a yearlong, QI project utilizing a single QI tool: audit and feedback. Each emergent trauma laparotomy was prospectively reviewed. Damage control laparotomy cases were adjudicated based on the majority vote of faculty members as being appropriate or potentially, in retrospect, safe for definitive laparotomy. The rate of DCL for 2 years prior (2014 and 2015) was retrospectively collected and used as a control. To account for secular trends of DCL, interrupted time series was used to effectiveness of the QI interventions. RESULTS: Eight hundred seventy-two emergent laparotomies were performed: 73% definitive laparotomies, 24% DCLs, and 3% intraoperative deaths. Of the 209 DCLs, 162 (78%) were voted appropriate, and 47 (22%) were voted to have been potentially safe for definitive laparotomy. Rates of DCL ranged from 16% to 34%. Common indications for DCL for which consensus existed were packing (103/115 [90%] appropriate) and hemodynamic instability (33/40 [83%] appropriate). The only common indication for which primary closure at the initial laparotomy could have been safely performed was avoiding a planned second look (16/32 [50%] appropriate). CONCLUSION: A single faceted QI intervention failed to decrease the rate of DCL at six US Level I trauma centers. However, opportunities for improvement in safely decreasing the rate of DCL were present. Second look laparotomy appears to lack consensus as an indication for DCL and may represent a target to decrease the rate of DCL after injury. LEVEL OF EVIDENCE: Epidemiological study with one negative criterion, level III.

Effect of damage control laparotomy on major abdominal complications and lengths of stay: A propensity score matching and Bayesian analysis.

BACKGROUND: In patients for whom surgical equipoise exists for damage control laparotomy (DCL) and definitive laparotomy (DEF), the effect of DCL and its associated resource utilization are unknown. We hypothesized that DEF would be associated with fewer abdominal complications and less resource utilization. METHODS: In 2016, six US Level I trauma centers performed a yearlong, prospective, quality improvement project with the primary aim to safely decrease the use of DCL. From this cohort of patients undergoing emergent trauma laparotomy, those who underwent DCL but were judged by majority faculty vote at each center to have been candidates for potential DEF (pDEF) were prospectively identified. These pDEF patients were matched 1:1 using propensity scoring to the DEF patients. The primary outcome was the incidence of major abdominal complications (MAC). Deaths within 5 days were excluded. Outcomes were assessed using both Bayesian generalized linear modeling and negative binomial regression. RESULTS: Eight hundred seventy-two total patients were enrolled, 639 (73%) DEF and 209 (24%) DCL. Of the 209 DCLs, 44 survived 5 days and were judged to be patients who could have safely been closed at the primary laparotomy. Thirty-nine pDEF patients were matched to 39 DEF patients. There were no differences in demographics, mechanism of injury, Injury Severity Score, prehospital/emergency department/operating room vital signs, laboratory values, resuscitation, or procedures performed during laparotomy. There was no difference in MAC between the two groups (31% DEF vs. 21% pDEF, relative risk 0.99, 95% credible interval 0.60-1.54, posterior probability 56%). Definitive laparotomy was associated with a 72%, 77%, and 72% posterior probability of more hospital-free, intensive care unit-free, and ventilator-free days, respectively. CONCLUSION: In patients for whom surgeons have equipoise for DCL versus definitive surgery, definitive abdominal closure was associated with a similar probability of MAC, but a high probability of fewer hospital-free, intensive care unit-free, and ventilator-free days. LEVEL OF EVIDENCE: Therapeutic/care management, level III.

Evolution of Firearm Violence over 20 Years: Integrating Law Enforcement and Clinical Data.

BACKGROUND: Data linking ballistics to injury are lacking. To address this data chasm, a partnership with law enforcement was developed to describe clinical outcomes from specific firearms. STUDY DESIGN: A random sample of patients with gunshot wounds over a 20-year period ending in 2015, was identified. Circumstances of incident, firearm type, and/or caliber were extracted from police reports. Data on demographics, mortality, injury severity, and clinical outcomes were collected from the trauma registry, and these datasets were linked. Firearms were stratified by velocity (high > 2,500 ft/sec; low < 1,200 ft/sec) and caliber (large = .40 and .45; small = .20 and .25) and compared over time. RESULTS: Police reports were obtained on 366 patients who had a gun type or caliber documented. The majority were male (82%) with a median age of 28 years. Twenty-one percent of patients had an Injury Severity Score > 25, 60% required immediate operative intervention, and overall mortality was 13%. The use of large caliber firearms increased from 4% (1996 to 2000) to 33% (2011 to 2015); small caliber guns decreased from 33% to 7% over the same time period (p < 0.0001). High velocity firearm usage significantly increased (p = 0.0320). Recovered shell casings doubled from the first decade to the second (2 vs 4; p = 0.0006). Both median New Injury Severity Score (p = 0.0488) and hospital days (p = 0.0321) increased from 1996 to 2015. CONCLUSIONS: Larger caliber and higher velocity firearms have significantly increased over the past 20 years in conjunction with injury severity, hospital days, and mean number of gun-related homicides per year (112 in 1996 to 2000 vs 143 in 2011 to 2015). Robust data sharing partnerships can be built between police and trauma centers to address the dearth of data on firearm crime and resulting injury.

Analysis of over 2 decades of colon injuries identifies optimal method of diversion: Does an end justify the means?

INTRODUCTION: Conflicting evidence exists regarding the definitive management of destructive colon injuries. Although diversion with an end ostomy can theoretically decrease initial complications, it mandates a more extensive reversal procedure. Conversely, anastomosis with proximal loop ostomy diversion, while simplifying the reversal, increases the number of suture lines and potential initial morbidity. Thus, the purpose of this study was to evaluate the impact of diversion technique on morbidity and mortality in patients with destructive colon injuries. METHODS: Consecutive patients with destructive colon injuries managed with diversion from 1996 to 2016 were stratified by demographics, severity of shock and injury, operative management, and timing of reversal. Outcomes, including ostomy complications (obstruction, ischemia, readmission) and reversal complications (obstruction, abscess, suture line failure, fascial dehiscence), were compared between patients managed with a loop versus end colostomy. Patients with rectal injuries and who died within 24 hours were excluded. RESULTS: A total of 115 patients were identified: 80 with end colostomy and 35 with loop ostomy. Ostomy complications occurred in 22 patients (19%), and 11 patients (10%) suffered reversal complications. There was no difference in ostomy-related (2.9% vs. 3.8%, p = 0.99) mortality. For patients without a planned ventral hernia (PVH), there was no difference in ostomy complications between patients managed with a loop versus end colostomy (12% vs. 18%, p = 0.72). However, patients managed with a loop ostomy had a shorter reversal operative time (95 vs. 245 minutes, p = 0.002) and reversal length of stay (6 vs. 10, p = 0.03) with fewer reversal complications (0% vs. 36%, p = 0.02). For patients with a PVH, there was no difference in outcomes between patients managed with a loop versus end colostomy. CONCLUSION: For patients without PVH, anastomosis with proximal loop ostomy reduced reversal-related complications, operative time, LOS, and hospital charges without compromising initial morbidity. Therefore, loop ostomy should be the preferred method of diversion, if required, following destructive colon injury. LEVEL OF EVIDENCE: Therapeutic, level IV.

Impact of a simplified management algorithm on outcome following exsanguinating pelvic fractures: A 10-year experience.

BACKGROUND: Optimal management of exsanguinating pelvic fractures remains controversial. Our previous experience suggested that management decisions based on a defined algorithm were associated with a significant reduction in transfusion requirements and mortality. Based on these outcomes, a clinical pathway (PW) for the management of exsanguinating pelvic fractures was developed. The purpose of this study was to evaluate the impact of this PW on outcomes. METHODS: Consecutive patients over 10 years with blunt pelvic fractures subsequent to the implementation of the clinical PW were identified. Patients with hemodynamically unstable pelvic fractures are managed initially with a pelvic orthotic device. For those with continued hemodynamic instability and no extrapelvic source of hemorrhage, pelvic angiography was performed followed by elective pelvic fixation. Patients managed according to the PW were compared with those patients whose management deviated (DEV) from the PW. RESULTS: There were 3,467 patients identified. Three hundred twelve (9%) met entry criteria: 246 (79%) comprised the PW group and 66 (21%) the DEV group. Injury severity, as measured by Injury Severity Score (35 vs. 36; p = 0.55), admission Glasgow Coma Scale (10 vs. 10; p = 0.58), admission BE (-7.4 vs. -6.4, p = 0.38), admission SBP (107 vs. 104, p = 0.53), and PRBC requirements during initial resuscitation (6.1 units vs. 6.6 units, p = 0.22) were similar between the groups. Pelvic orthotic device use was 48% in the DEV group (p < 0.001). Twenty-four percent of the PW group required angiography compared with 74% of the DEV group (p < 0.001). Forty-eight-hour transfusions (11 vs. 16, p = 0.01) and mortality (35% vs. 48%, p = 0.04) were reduced in the PW group compared with the DEV group. Pathway adherence was identified as an independent predictor of both decreased transfusions (ß = -5.8, p = 0.002) via multiple linear regression and decreased mortality (hazard ratio, 0.74; 95% confidence interval, 0.42-0.98) via multivariable cox proportional hazards analysis. CONCLUSION: Adherence to a defined clinical PW simplified the management of exsanguinating pelvic fractures and contributed to a reduction in both transfusion requirements and mortality. LEVEL OF EVIDENCE: Prognostic, level III.