Stroke Prevention in Blunt Cerebrovascular Injury: Role of Aspirin 81 mg.

BACKGROUND: The stroke rate in blunt cerebrovascular injury (BCVI) varies from 25% without treatment to less than 8% with antithrombotic therapy. There is no consensus on the optimal management to prevent stroke BCVI. We investigated the efficacy and safety of oral Aspirin (ASA) 81 mg to prevent BCVI-related stroke compared to historically reported stroke rates with ASA 325 mg and heparin. METHODS: A single-center retrospective study included adult trauma patients who received oral ASA 81 mg for BCVI management between 2013 and 2022. Medical records were reviewed for demographic and injury characteristics, imaging findings, treatment-related complications, and outcomes. RESULTS: Eighty-four patients treated with ASA 81 mg for BCVI were identified. The mean age was 41.50 years, and 61.9% were male. The mean Injury Severity Score and Glasgow Coma Scale were 19.82 and 12.12, respectively. A total of 101 vessel injuries were identified, including vertebral artery injuries in 56.4% and carotid artery injuries in 44.6%. Traumatic brain injury was found in 42.9%, and 16.7% of patients had a solid organ injur. Biffl grade I (52.4%) injury was the most common, followed by grade II (37.6%) and grade III (4.9%). ASA 81 mg was started in the first 24 hours in 67.9% of patients, including 20 patients with traumatic brain injury and 8 with solid organ injuries. BCVI-related stroke occurred in 3 (3.5%) patients with Biffl grade II (n = 2) and III (n = 1). ASA-related complications were not identified in any patient. The mean length of stay in the hospital was 10.94 days, and 8 patients died during hospitalization due to complications of polytrauma. Follow-up with computed tomography angiography was performed in 8 (9.5%) patients, which showed improvement in 5 and a stable lesion in 3 at a mean time of 58 days after discharge. CONCLUSIONS: In the absence of clear guidelines regarding appropriate medication, BCVI management should be individualized case-by-case through a multidisciplinary approach. ASA 81 mg is a viable option for BCVI-related stroke prevention compared to the reported stroke rates (2%-8%) with commonly used antithrombotics like heparin and ASA 325 mg. Future prospective studies are needed to provide insight into the safety and efficacy of the current commonly used agent in managing BCVI.

Colorectal Malignancy Complicated by Arterioenteric Fistula.

Arterioenteric fistulas (AEF) are rare and devastating complications of colorectal/pelvic malignancies. These fistulas can be seen following neoadjuvant or adjuvant therapy but are exceptionally rare de novo. The reported incidence of AEF is less than 1% and iliac artery-enteric fistulas make up less than .1% of all AEF. Here we present a patient in hemorrhagic shock secondary to an advanced colorectal malignancy without adjuvant therapies with local invasion of the right external iliac artery. Following initial resuscitation and hemorrhage control with coil embolization, definitive control with ligation and excision of the involved artery, end colostomy, and ureteral stent placement was achieved. It is important to consider malignancy as the source of lower gastrointestinal bleeds, especially in elderly patients without current colonoscopy studies. The management of this unfortunate diagnosis often involves a multidisciplinary approach with early and frequent goals of care discussions.

Trauma of abortion restrictions and forced pregnancy: urgent implications for acute care surgeons.

In the aftermath of the Supreme Court's Dobbs vs. Jackson Women's Health decision, acute care surgeons face an increased likelihood of seeing patients with complications from both self-managed abortions and forced pregnancy in underserved areas of reproductive and maternity care throughout the USA. Acute care surgeons have an ethical and legal duty to provide care to these patients, especially in obstetrics and gynecology deserts, which already exist in much of the country and are likely to be exacerbated by legislation banning abortion. Structural inequities lead to an over-representation of poor individuals and people of color among patients seeking abortion care, and it is imperative to make central the fact that people of color who can become pregnant will be disproportionately affected by this legislation in every respect. Acute care surgeons must take action to become aware of and trained to treat both the direct clinical complications and the extragestational consequences of reproductive injustice, while also using their collective voices to reaffirm the right to abortion as essential healthcare in the USA.

Antibiotic prophylaxis for tube thoracostomy placement in trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma.

Background: Antibiotic prophylaxis is routinely administered for most operative procedures, but their utility for certain bedside procedures remains controversial. We performed a systematic review and meta-analysis and developed evidence-based recommendations on whether trauma patients receiving tube thoracostomy (TT) for traumatic hemothorax or pneumothorax should receive antibiotic prophylaxis. Methods: Published literature was searched through MEDLINE (via PubMed), Embase (via Elsevier), Cochrane Central Register of Controlled Trials (via Wiley), Web of Science and ClinicalTrials.gov databases by a professional librarian. The date ranges for our literature search were January 1900 to March 2020. A systematic review and meta-analysis of currently available evidence were performed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Results: Fourteen relevant studies were identified and analyzed. All but one were prospective, with eight being prospective randomized control studies. Antibiotic prophylaxis protocols ranged from a single dose at insertion to 48 hours post-TT removal. The pooled data showed that patients who received antibiotic prophylaxis were significantly less likely to develop empyema (OR 0.47, 95% CI 0.25 to 0.86, p=0.01). The benefit was greater in patients with penetrating injuries (penetrating OR 0.25, 95% CI 0.10 to 0.59, p=0.002, vs blunt OR 0.25, 95% CI 0.06 to 1.12, p=0.07). Administration of antibiotic prophylaxis did not significantly affect pneumonia incidence or mortality. Discussion: In adult trauma patients who require TT insertion, we conditionally recommend antibiotic prophylaxis be given at the time of insertion to reduce incidence of empyema. PROSPERO registration number: CRD42018088759.

Full-face motorcycle helmets to reduce injury and death: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: While motorcycle helmets reduce mortality and morbidity, no guidelines specify which is safest. We sought to determine if full-face helmets reduce injury and death. METHODS: We searched for studies without exclusion based on: age, language, date, or randomization. Case reports, professional riders, and studies without original data were excluded. Pooled results were reported as OR (95% CI). Risk of bias and certainty was assessed. (PROSPERO #CRD42021226929). RESULTS: Of 4431 studies identified, 3074 were duplicates, leaving 1357 that were screened. Eighty-one full texts were assessed for eligibility, with 37 studies (n = 37,233) eventually included. Full-face helmets reduced traumatic brain injury (OR 0.40 [0.23-0.70]); injury severity for the head and neck (Abbreviated Injury Scale [AIS] mean difference -0.64 [-1.10 to -0.18]) and face (AIS mean difference -0.49 [-0.71 to -0.27]); and facial fracture (OR 0.26 [0.15-0.46]). CONCLUSION: Full-face motorcycle helmets are conditionally recommended to reduce traumatic brain injury, facial fractures, and injury severity.

Outcomes after emergency general surgery and trauma care in incarcerated individuals: An EAST multicenter study.

BACKGROUND: The US incarcerates more individuals than any other country. Prisoners are the only population guaranteed health care by the US constitution, but little is known about their surgical needs. This multicenter study aimed to describe the acute care surgery (ACS) needs of incarcerated individuals. METHODS: Twelve centers prospectively identified incarcerated patients evaluated in their emergency department by the ACS service. Centers collected diagnosis, treatment, and complications from chart review. Patients were classified as either emergency general surgery (EGS) patients or trauma patients and their characteristics and outcomes were investigated. Poisson regression accounting for clustering by center was used to calculate the relative risk (RR) of readmission, representation within 90 days, and failure to follow-up as an outpatient within 90 days for each cohort. RESULTS: More than 12 months, ACS services evaluated 943 patients, 726 (80.3%) from jail, 156 (17.3%) from prison, and 22 (2.4%) from other facilities. Most were men (89.7%) with a median age of 35 years (interquartile range, 27-47). Trauma patients comprised 54.4% (n = 513) of the cohort. Admission rates were similar for trauma (61.5%) and EGS patients (60.2%). Head injuries and facial fractures were the most common injuries, while infections were the most common EGS diagnosis. Self-harm resulted in 102 trauma evaluations (19.9%). Self-inflicted injuries were associated with increased risk of readmission (RR, 4.3; 95% confidence interval, 3.02-6.13) and reevaluation within 90 days (RR, 4.96; 95% confidence interval, 3.07-8.01). CONCLUSION: Incarcerated patients who present with a range of trauma and EGS conditions frequently require admission, and follow-up after hospitalization was low at the treating center. Poor follow-up coupled with high rates of assault, self-harm, mental health, and substance use disorders highlight the vulnerability of this population. Hospital and correctional facility interventions are needed to decrease self-inflicted injuries and assaults while incarcerated. LEVEL OF EVIDENCE: Prognostic and epidemiological, Level III.

National Surgical Quality Improvement Program Adverse Events Combined With Clavien-Dindo Scores Can Direct Quality Improvement Processes in Surgical Patients.

OBJECTIVE: The burden of postoperative adverse events (AE) weighs immediately on the patient as unanticipated stress and on the healthcare system as unreimbursed cost. Applying the Clavien-Dindo (C-D) system of AE gradation as a surrogate of cost, we analyzed 4 years' data from a single-state National Surgical Quality Improvement Program (NSQIP) collaboration, hypothesizing that trends of AE were consistent over time and that more frequently performed cases would be associated with less and more minor AE. METHODS: The NSQIP defined AEs, consisting of 21 listed postoperative occurrences, which were analyzed using deidentified 30-day postoperative data for 2015 to 2018. Each AE was graded using (C-D) severity (1, lowest; 4, highest with survival). The C-D severity weight, as defined in previous multi-institutional studies, was used as a surrogate for cost and unplanned patient burden. Adverse event incidence was calculated as sum AE/case volume, and population burden as total AE burden/case volume. RESULTS: There were 12,567 surgical cases recorded by members of the state collaborative. The overall data demonstrated no significant difference in AE incidence; however, the burden of AE increased by 18.8%. The 8 most common Current Procedural Terminology codes had approximately 50% lower AE incidence compared with overall cases; however, the incidence increased by 56.0% and the AE burden/case increased by 48.0%. CONCLUSIONS: Although the 8 most common Current Procedural Terminology codes showed a 50% lower AE incidence compared with overall cases, the incidence increased over the study period. Surgical quality initiatives should be patient centered and focus on high burden AE.

PICC versus midlines: Comparison of peripherally inserted central catheters and midline catheters with respect to incidence of thromboembolic and infectious complications.

INTRODUCTION: To decrease the complications related to central catheters there has been an increasing utilization of peripherally inserted central catheters (PICC) and ultrasound-guided long peripheral intravenous catheters (i.e. midlines). While the complications of PICC lines are well described there is less reported data on complications related to midline catheters. Our study aims are to compare the incidences of infectious and deep venous thrombosis (DVT) and sepsis related to PICCs and Midlines. METHODS: We performed a single-center retrospective review at an academic hospital. Data were collected on patients admitted between 1/1/2014-5/31/2016. Patient demographics, hospital length of stay (LOS), and ventilator days were collected. Outcomes of interest were line-related infections and thromboembolic events after the placement of these catheters. Endpoints were compared between three groups (PICC group, midline group and PICC placement followed by midline placement group). Univariate and multivariable analyses were used to compare across the three groups. RESULTS: The study included 3560 unique patients with 5058 catheters. There was an increase in use of midlines over the observed study period (245% increase from the end of 2015 to the middle of 2016). We found no significant differences in the rates of DVT among the three groups (PICC 4%, midline 3% and PICC-midline 4%; p = 0.12). There were no differences across the groups for sepsis (PICC 29%, midline 27%, and PICC-midline 32%; p = 0.14) or septic shock (PICC 7%, midline 8%, and PICC-midline 6%; p = 0.39). Adjusted means LOS were higher for patients with PICC lines compared to midlines, in both females and males. PICC group stayed longer, on average, on the ventilator compared to the midline group. No other significant differences were seen among groups. CONCLUSION: Increased utilization of midline catheters were not associated with decreased risk of DVT or sepsis when compared to peripherally inserted central catheters.

Prevention of Firearm Violence Through Specific Types of Community-based Programming: An Eastern Association for the Surgery of Trauma Evidence-based Review.

OBJECTIVE: The purpose of this review was to provide an evidence-based recommendation for community-based programs to mitigate gun violence, from the Eastern Association for the Surgery of Trauma (EAST). SUMMARY BACKGROUND DATA: Firearm Injury leads to >40,000 annual deaths and >115,000 injuries annually in the United States. Communities have adopted culturally relevant strategies to mitigate gun related injury and death. Two such strategies are gun buyback programs and community-based violence prevention programs. METHODS: The Injury Control and Violence Prevention Committee of EAST developed Population, Intervention, Comparator, Outcomes (PICO) questions and performed a comprehensive literature and gray web literature search. Using GRADE methodology, they reviewed and graded the literature and provided consensus recommendations informed by the literature. RESULTS: A total of 19 studies were included for analysis of gun buyback programs. Twenty-six studies were reviewed for analysis for community-based violence prevention programs. Gray literature was added to the discussion of PICO questions from selected websites. A conditional recommendation is made for the implementation of community-based gun buyback programs and a conditional recommendation for community-based violence prevention programs, with special emphasis on cultural appropriateness and community input. CONCLUSIONS: Gun violence may be mitigated by community-based efforts, such as gun buybacks or violence prevention programs. These programs come with caveats, notably community cultural relevance and proper support and funding from local leadership.Level of Evidence: Review, Decision, level III.

Level of Comfort With Pediatric Trauma Transports: Survey of Prehospital Providers.

BACKGROUND: Unintentional injury is the leading cause of death in pediatric patients. Despite a heavy burden of pediatric trauma, prehospital transport and triage of pediatric trauma patients are not standardized. Prehospital providers report anxiety and a lack of confidence in transport, triage, and care of pediatric trauma patients. MATERIALS AND METHODS: Prehospital transport providers with 3 organizations across southeast Georgia and northeast Florida were contacted via email (n = 146) and asked to complete 2 Web-based surveys to evaluate their comfort level with performing tasks in the transport of pediatric and adult trauma patients. Bivariate statistics and qualitative thematic analyses were performed to assess comfort with pediatric trauma transports. RESULTS: Survey 1 (N = 35) showed that mean comfort levels of prehospital providers were significantly lower for pediatric patients than adult trauma patients in 7 out of 9 tasks queried, including airway management and interpreting children's physiology. The following themes emerged from survey 2 (N = 14) responses: additional clinical knowledge resources would be beneficial when caring for pediatric trauma patients, pediatric medication administration is a source of uncertainty, prehospital transport teams would benefit from additional pediatric trauma training, infrequent transport of pediatric trauma patients affects provider comfort level, and pediatric trauma generates higher levels of anxiety among providers. DISCUSSION: Prehospital transport of pediatric trauma patients is infrequent and a source of anxiety for prehospital providers. Rigs should be equipped with a reference tool addressing crucial tasks and deficiencies in training.

Diaphragm pacing decreases hospital charges for patients with acute cervical spinal cord injury.

BACKGROUND: Cervical spinal cord injury (CSCI) is devastating and costly. Previous research has demonstrated that diaphragm pacing (DPS) is safe and improves respiratory mechanics. This may decrease hospital stays, vent days, and costs. We hypothesized DPS implantation would facilitate liberation from ventilation and would impact hospital charges. METHODS: We performed a retrospective review of patients with acute CSCI between January 2005 and May 2017. Routine demographics were collected. Patients underwent propensity matching based on age, injury severity score, ventilator days, hospital length of stay, and need for tracheostomy. We then adjusted total hospital charges by year using US Bureau of Labor Statistics annual adjusted Medical Care Prices. Bivariate and multivariate linear regression statistics were performed using STATA V.15. RESULTS: Between July 2011 and May 2017, all patients with acute CSCI were evaluated for DPS implantation. 40 patients who had laparoscopic DPS implantation (DPS) were matched to 61 who did not (NO DPS). Following DPS implantation, there was a statistically significant increase in spontaneous Vt compared with NO DPS (+88 mL vs -13 mL; 95% CI 46 to 131 vs -78 to 51 mL, respectively; p=0.004). Median time to liberation after DPS was significantly shorter (10 vs 29 days; 95% CI 6.5 to 13.6 vs 23.1 to 35.3 days; p<0.001). Adjusted hospital charges were significantly lower for DPS on multivariate linear regression models controlling for year of injury, sex, race, injury severity, and age (p=0.003). DISCUSSION: DPS implantation in patients with acute CSCI produces significant improvements in spontaneous Vt and reduces time to liberation, which translated into reduced hospital charges on a risk-adjusted, inflation-adjusted model. DPS implantation for patients with acute CSCI should be considered. LEVEL OF EVIDENCE: Level III.

Acute Care Surgery Billing, Coding and Documentation Series Part 3: Coding of Additional Select Procedures; Modifiers; Telemedicine Coding; Robotic Surgery.

This series of reviews has been produced to assist both the experienced surgeon and coder, as well as those just starting practice that may have little formal training in this area. Understanding this complex system will allow the provider to work "smarter, not harder" and garner the maximum compensation for their work. We hope we have been successful in achieving and that goal that this series will provide useful information and be worth the time invested in reading it by bringing tangible benefits to the efficiency of practice and its reimbursement. This third section deals with coding of additional select procedures, modifiers, telemedicine coding, and robotic surgery.

Acute Care Surgery Billing, Coding and Documentation Series Part 2: Postoperative Documentation and Coding; Documentation and Coding in Conjunction with Trainees and Advanced Practitioners; Coding Select Procedures.

This series of reviews has been produced to assist both the experienced surgeon and coder, as well as those just starting practice that may have little formal training in this area. Understanding this complex system will allow the provider to work "smarter, not harder" and garner the maximum compensation for their work. We hope we have been successful in achieving that goal and that this series will provide useful information and be worth the time invested in reading it by bringing tangible benefits to the efficiency of practice and its reimbursement. This second section deals with postoperative documentation and coding, documentation and coding in conjunction with trainees and advanced practitioners, and coding of select procedures.

Acute Care Surgery Billing, Coding and Documentation Series Part 1: Basic Evaluation and Management (E/M), Emergency Department E/M, Prolonged Services, Adult Critical Care Documentation and Coding.

This series of reviews has been produced to assist both the experienced surgeon and coder, as well as those just starting practice that may have little formal training in this area. Understanding this complex system will allow the provider to work 'smarter, not harder' and garner the maximum compensation for their work. We hope we have been successful in achieving that goal and that this series will provide useful information and be worth the time invested in reading it by bringing tangible benefits to the efficiency of practice and its reimbursement.

Describing the density of high-level trauma centers in the 15 largest US cities.

BACKGROUND: There has been a proliferation of urban high-level trauma centers. The aim of this study was to describe the density of high-level adult trauma centers in the 15 largest cities in the USA and determine whether density was correlated with urban social determinants of health and violence rates. METHODS: The largest 15 US cities by population were identified. The American College of Surgeons' (ACS) and states' department of health websites were cross-referenced for designated high-level (levels 1 and 2) trauma centers in each city. Trauma centers and associated 20 min drive radius were mapped. High-level trauma centers per square mile and per population were calculated. The distance between high-level trauma centers was calculated. Publicly reported social determinants of health and violence data were tested for correlation with trauma center density. RESULTS: Among the 15 largest cities, 14 cities had multiple high-level adult trauma centers. There was a median of one high-level trauma center per every 150 square kilometers with a range of one center per every 39 square kilometers in Philadelphia to one center per596 square kilometers in San Antonio. There was a median of one high-level trauma center per 285 034 people with a range of one center per 175 058 people in Columbus to one center per 870 044 people in San Francisco. The median minimum distance between high-level trauma centers in the 14 cities with multiple centers was 8 kilometers and ranged from 1 kilometer in Houston to 43 kilometers in San Antonio. Social determinants of health, specifically poverty rate and unemployment rate, were highly correlated with violence rates. However, there was no correlation between trauma center density and social determinants of health or violence rates. DISCUSSION: High-level trauma centers density is not correlated with social determinants of health or violence rates. LEVEL OF EVIDENCE: VI. STUDY TYPE: Economic/decision.

Diaphragm pacing improves respiratory mechanics in acute cervical spinal cord injury.

BACKGROUND: Cervical spinal cord injury (CSCI) is devastating with ventilator-associated pneumonia being a main driver of morbidity and mortality. Laparoscopic diaphragm pacing implantation (DPS) has been used for earlier liberation from mechanical ventilation. We hypothesized that DPS would improve respiratory mechanics and facilitate liberation. METHODS: We performed a retrospective review of acute CSCI patients between January 2005 and May 2017. Routine demographics were collected. Patients underwent propensity score matching based on age, Injury Severity Score, ventilator days, hospital length of stay, and need for tracheostomy. Patients with complete respiratory mechanics data were analyzed and compared. Those who did not have DPS (NO DPS) had spontaneous tidal volume (Vt) recorded at time of intensive care unit admission, at day 7, and at day 14, and patients who had DPS had spontaneous Vt recorded before and after DPS. Time to ventilator liberation and changes in size of spontaneous Vt for patients while on the ventilator were analyzed. Bivariate and multivariate logistic and linear regression statistics were performed using STATA v10. RESULTS: Between July 2011 and May 2017, 37 patients that had DPS were matched to 34 who did not (NO DPS). Following DPS, there was a statistically significant increase in spontaneous Vt compared with NO DPS (+88 mL vs. -13 mL; 95% confidence interval, 46-131 mL vs. -78 to 51 mL, respectively; p = 0.004). Median time to liberation after DPS was significantly shorter (10 days vs. 29 days; 95% CI, 6.5-13.6 days vs. 23.1-35.3 days; p < 0.001). Liberation prior to hospital discharge was not different between the two groups. The DPS placement was found to be associated with a statistically significant decrease in days to liberation and an increase in spontaneous Vt in multivariate linear regression models. CONCLUSION: The DPS implantation in acute CSCI patients produces significant improvements in spontaneous Vt and reduces time to liberation from mechanical ventilation. Prospective comparative studies are needed to define the clinical benefits and potential cost savings of DPS implantation. LEVEL OF EVIDENCE: Therapeutic IV.

Elderly adults with isolated hip fractures- orthogeriatric care versus standard care: A practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Elderly patients commonly suffer isolated hip fractures, causing significant morbidity and mortality. The use of orthogeriatrics (OG) management services, in which geriatric specialists primarily manage or co-manage patients after admission, may improve outcomes. We sought to provide recommendations regarding the role of OG services. METHODS: Using GRADE methodology with meta-analyses, the Practice Management Guidelines Committee of the Eastern Association for the Surgery of Trauma conducted a systematic review of the literature from January 1, 1900, to August 31, 2017. A single Population, Intervention, Comparator and Outcome (PICO) question was generated with multiple outcomes: Should geriatric trauma patients 65 years or older with isolated hip fracture receive routine OG management, compared with no-routine OG management, to decrease mortality, improve discharge disposition, improve functional outcomes, decrease in-hospital medical complications, and decrease hospital length of stay? RESULTS: Forty-five articles were evaluated. Six randomized controlled trials and seven retrospective case-control studies met the criteria for quantitative analysis. For critical outcomes, retrospective case-control studies demonstrated a 30-day mortality benefit with OG (OR, 0.78 [0.67, 0.90]), but this was not demonstrated prospectively or at 1 year. Functional outcomes were superior with OG, specifically improved score on the Short Physical Performance Battery at 4 months (mean difference [MD], 0.78 [0.28, 1.29]), and improved score on the Mini Mental Status Examination with OG at 12 months (MD, 1.57 [0.40, 2.73]). Execution of activities of daily living was improved with OG as measured by two separate tests at 4 and 12 months. There was no difference in discharge disposition. Among important outcomes, the OG group had fewer hospital-acquired pressure ulcers (OR, 0.30 [0.15, 0.60]). There was no difference in other complications or length of stay. Overall quality of evidence was low. CONCLUSION: In geriatric patients with isolated hip fracture, we conditionally recommend an OG care model to improve patient outcomes. LEVEL OF EVIDENCE: Systematic review/meta-analysis, level III.