Angioembolization May Improve Survival in Patients With Severe Hepatic Injuries.

INTRODUCTION: Although reports on angioembolization (AE) show favorable results for severe hepatic trauma, information is lacking on its benefit in the management and mechanisms of injury (MOI). This study examined patient outcomes with severe hepatic injuries to determine the association of in-hospital mortality with AE. The hypothesis is that AE is associated with increased survival in severe hepatic injuries. METHODS: Demographics, age, sex, MOI, shock index (SI), ≥6 units packed red blood cells (PRBCs) per hospital length of stay (LOS), intensive care unit LOS, injury severity score (ISS), and AE were collected. The primary outcome was in-hospital mortality. Patients were stratified into groups according to MOI, AE, and operative vs non-operative management. Multivariable logistic regression determined the independent association of mortality with AE vs no AE and operative vs nonoperative management and modeled the odds of mortality controlling for MOI, AE vs no AE, age and ISS groups, SI >.9, and ≥6 units PRBCs/LOS. RESULTS: From 2013 to 2018, 2462 patients (1744 blunt; 718 penetrating) were treated for severe hepatic injuries. AE was used in only 21% of patients. Mortality rates increased with higher ISS and age. AE was associated with mortality when compared to patients who did not undergo AE. The strongest associations with mortality were ISS ≥25, transfusion ≥ 6 units PRBCs/LOS, and age ≥65 years. CONCLUSIONS: AE is underutilized in severe hepatic trauma. AE may be a valuable adjunct in the treatment of severe hepatic injuries especially in older patients and those needing exploratory laparotomy.

Blood utilization and mortality in victims of gun violence.

BACKGROUND: Blood transfusion can be lifesaving for patients with hemorrhage; however, transfusion requirements for victims of gun violence are poorly understood. STUDY DESIGN AND METHODS: In an urban, Level 1 trauma center, 23,422 trauma patients were analyzed in a retrospective cohort study. Patients with gunshot wounds (GSWs) (n = 2,672; 11.4% of trauma patients) were compared to those with non-GSW traumatic injuries from 2005 to 2017, to assess blood utilization. RESULTS: The GSW cohort was approximately five times more likely to require transfusion (538 of 2672 [20.1%] vs. 798 of 20,750 [3.9%]; p < 0.0001), and the number of blood component units transfused per patient was approximately 10 times greater (3.3 ± 13.5 vs. 0.31 ± 3.8 units/patient; p < 0.0001), compared to the non-GSW cohort. The risk-adjusted likelihood of requiring high-dose transfusion was greater in the GSW cohort (odds ratio, 2.38; 95% confidence interval, 1.14-5.80), and requirements were increased for all four blood components (red blood cells, platelets, plasma, and cryoprecipitate). Patients with GSWs had approximately 14 times greater overall mortality (653 of 2672 [24.4%] vs. 352 of 20,750 [1.7%]; p < 0.0001]. Compared to non-GSW penetrating injuries (e.g., stab wounds), those with GSWs had approximately four times higher transfusion requirements (3.3 ± 13.5 vs. 0.80 ± 3.8 units/patient; p < 0.0001), and approximately eight times greater overall mortality (653 of 2672 [24.4%] vs. 28 of 956 [2.9%]; p < 0.0001). CONCLUSIONS: Compared to other traumatic injuries, GSW injuries are associated with substantially greater blood utilization and mortality. Trauma centers treating GSW injuries should have ready access to all blood components and ability to implement massive transfusions.

Aggression after traumatic brain injury: prevalence and correlates.

Aggression after traumatic brain injury (TBI) is common but not well defined. Sixty-seven participants with first-time TBI were evaluated for aggression within 3 months of injury. The prevalence of aggression was found to be 28.4%, predominantly verbal aggression. Post-TBI aggression was associated with new-onset major depression (p=0.02), poorer social functioning (p=0.04), and increased dependency in activities of daily living (p=0.03), but not with a history of substance abuse or adult/childhood behavioral problems. Implications of the study include early screening for aggression, evaluation for depression, and consideration of psychosocial support in aggressive patients.

Prevalence and types of sleep disturbances acutely after traumatic brain injury.

PRIMARY OBJECTIVE: To assess the prevalence of and risk factors for sleep disturbances in the acute post-traumatic brain injury (TBI) period. RESEARCH DESIGN: Longitudinal, observational study. METHODS AND PROCEDURES: Fifty-four first time closed-head injury patients were recruited and evaluated within 3 months after injury. Pre-injury and post-injury sleep disturbances were compared on the Medical Outcome Scale for Sleep. The subjects were also assessed on anxiety, depression, medical comorbidity and severity of TBI. MAIN OUTCOMES AND RESULTS: Subjects were worse on most sleep measures after TBI compared to before TBI. Anxiety disorder secondary to TBI was the most consistent significant risk factor to be associated with worsening sleep status. CONCLUSIONS: Anxiety is associated with sleep disturbances after TBI. Further studies need to be done to evaluate if this is a causal relationship.

Can increased incidence of deep vein thrombosis (DVT) be used as a marker of quality of care in the absence of standardized screening? The potential effect of surveillance bias on reported DVT rates after trauma.

BACKGROUND: Deep vein thrombosis (DVT) is a significant cause of morbidity and mortality in trauma patients, even with appropriate prophylaxis. Many national agencies (Agency for Healthcare Research and Quality, Joint Commission, National Quality Forum) have suggested DVT incidence as a measurement of health care quality, but none has recommended a standardized screening approach. Duplex ultrasound serves an important role as a noninvasive diagnostic tool for detection of DVT. However, screening of asymptomatic patients for DVT is somewhat controversial and these practices vary widely among trauma centers. We hypothesized that as the number of screening duplex examinations in trauma patients increases, the rate of DVT identification will also increase. METHODS: Retrospective cohort study of 21,961 patients from an urban, university-based Level I trauma center for more than 11 years (1995-2005). We grouped patients according to admission at the trauma service either before or after implementation of a written practice management guideline for DVT prophylaxis and duplex ultrasound surveillance in 1998. We compared duplex, DVT, and pulmonary embolism rates per 1,000 trauma admissions using Fisher's exact test. RESULTS: The proportion of trauma patients having a duplex ultrasound increased significantly (20.9-81.5 per 1,000 trauma admissions, p < 0.0001). The rate of DVT reported increased 10-fold (0.7-7.0 per 1,000 admissions, p = 0.0024), significantly, between the two periods. The pulmonary embolism rate increased almost fivefold (0.7-3.2 per 1,000 admissions, p = 0.15), although this difference was not statistically significant. CONCLUSIONS: Increasing the number of duplex screening exams resulted in an increased rate of DVT identification. In the absence of standardized surveillance, DVT rates may be more influenced by how often caregivers look for these events rather than the quality of care provided.

Laterality of deep venous thrombosis among trauma patients: are we screening our patients adequately?

OBJECTIVES: Major trauma represents a significant risk for development of deep venous thrombosis (DVT). Duplex ultrasonography is a noninvasive test to identify DVT and has been suggested for screening asymptomatic high-risk trauma patients. While some risk factors for DVT are well described, it remains unclear whether site of DVT development is associated with anatomical location of injury. An association between anatomical locations of injury would serve to highlight the importance of directed screening of those extremities at highest risk. Therefore, we hypothesize that location of DVT correlates with side of lower extremity injury. METHODS: We performed an 11-year (1995-2005) retrospective review from the prospectively collected trauma registry at an urban, university-based, level I trauma center. All trauma patients with lower extremity DVT were included. Lateralizing lower extremity injuries were defined as penetrating or blunt injuries affecting only one lower extremity. Fisher's exact test compared concordance between side of injury and side of DVT. RESULTS: A total of 6674 trauma patients were admitted, of whom 40 (0.6%) were diagnosed with lower extremity or pelvic DVT. Mean age of patients with DVT was 39 y, with 80% male, 80% African American, and 55% penetrating trauma. Fourteen patients (35%) with DVT sustained lateralizing lower extremity injuries (6 gunshot wounds, 5 tibia/fibula fractures, 2 femur fractures, and 1 calcaneus fracture). Twelve of these 14 patients (86%) developed DVT on the same side as their injury; (7/7 on right side and 5/7 on left side, P = 0.02). The 26 patients without lateralizing injuries had equal distribution of DVT (39% right, 42% left, and 19% bilateral). CONCLUSION: Patients who sustained lateralizing lower extremity injury and developed lower extremity DVT had a high likelihood of developing their DVT on the same side as their injury. A larger multi-institutional analysis is needed to assess the correlation between injury site and anatomical location of DVT before suggesting any changes in recommendations for duplex screening.