Failure rates of nonoperative management of low-grade splenic injuries with active extravasation: an Eastern Association for the Surgery of Trauma multicenter study.

Objectives: There is little evidence guiding the management of grade I-II traumatic splenic injuries with contrast blush (CB). We aimed to analyze the failure rate of nonoperative management (NOM) of grade I-II splenic injuries with CB in hemodynamically stable patients. Methods: A multicenter, retrospective cohort study examining all grade I-II splenic injuries with CB was performed at 21 institutions from January 1, 2014, to October 31, 2019. Patients >18 years old with grade I or II splenic injury due to blunt trauma with CB on CT were included. The primary outcome was the failure of NOM requiring angioembolization/operation. We determined the failure rate of NOM for grade I versus grade II splenic injuries. We then performed bivariate comparisons of patients who failed NOM with those who did not. Results: A total of 145 patients were included. Median Injury Severity Score was 17. The combined rate of failure for grade I-II injuries was 20.0%. There was no statistical difference in failure of NOM between grade I and II injuries with CB (18.2% vs 21.1%, p>0.05). Patients who failed NOM had an increased median hospital length of stay (p=0.024) and increased need for blood transfusion (p=0.004) and massive transfusion (p=0.030). Five patients (3.4%) died and 96 (66.2%) were discharged home, with no differences between those who failed and those who did not fail NOM (both p>0.05). Conclusion: NOM of grade I-II splenic injuries with CB fails in 20% of patients. Level of evidence: IV.

Use of a Modified ABTHERA ADVANCE™ Open Abdomen Dressing with Intrathoracic Negative-Pressure Therapy for Temporary Chest Closure After Damage Control Thoracotomy.

BACKGROUND Damage control surgery (DCS) is an established emergency operative concept, initially described and most often utilized in abdominal trauma. DCS prioritizes managing acute hemorrhage and contamination, leaving the abdominal wall fascia open and covering the existing wound with a temporary abdominal wall closure, most commonly negative-pressure wound therapy (NPWT). The patient undergoes aggressive resuscitation to optimize physiology. Once achieved, the patient is returned to the operating room for definitive surgical intervention. There is limited evidence suggesting that using damage control thoracotomy within the chest cavity improves mortality and morbidity rates. Our review failed to find a case in which NPWT using ABTHERA ADVANCE™ Open Abdomen Dressing has been successfully used in the setting of thoracic trauma. CASE REPORT This case series describes 2 examples of NPWT as a form of temporary chest closure in penetrating and blunt thoracic injury. The first case was a penetrating self-inflicted stab wound to the chest. The NPWT was applied as a form of temporary thoracotomy, closure at the index surgery. The second case was a blunt injury to the chest of a polytrauma patient following a motor vehicle accident. The patient sustained rib fractures on his left side and had a bilateral pneumothorax. An emergent thoracotomy was performed due to delayed intrathoracic bleeding noted on hospital day 11, and NPWT was applied as described above, in the first case. CONCLUSIONS These cases suggest that damage control thoracotomy with intrathoracic placement of a modified ABTHERA ADVANCE™ Open Abdomen Dressing negative-pressure system may be an effective and life-saving technique with the potential for positive outcomes in these high-risk patients.

An analysis of police transport in an Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients.

BACKGROUND: Police transport (PT) of penetrating trauma patients in urban locations has become routine in certain metropolitan areas; however, whether it results in improved outcomes over prehospital Advanced life support (ALS) transport has not been determined in a multicenter study. We hypothesized that PT would not result in improved outcomes. METHODS: This was a multicenter, prospective, observational study of adults (18+ years) with penetrating trauma to the torso and/or proximal extremity presenting at 25 urban trauma centers. Police transport and ALS patients were allocated via nearest neighbor, propensity matching. Transport mode also examined by Cox regression. RESULTS: Of 1,618 total patients, 294 (18.2%) had PT and 1,324 (81.8%) were by ALS. After matching, 588 (294/cohort) remained. The patients were primarily Black (n = 497, 84.5%), males (n = 525, 89.3%, injured by gunshot wound (n = 494, 84.0%) with 34.5% (n = 203) having Injury Severity Score of 16 or higher. Overall mortality by propensity matching was not different between cohorts (15.6% ALS vs. 15.0% PT, p = 0.82). In severely injured patients (Injury Severity Score ≥16), mortality did not differ between PT and ALS transport (38.8% vs. 36.0%, respectively; p = 0.68). Cox regression analysis controlled for relevant factors revealed no association with a mortality benefit in patients transported by ALS. CONCLUSION: Police transport of penetrating trauma patients in urban locations results in similar outcomes compared with ALS. Immediate transport to definitive trauma care should be emphasized in this patient population. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level III.

An Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients.

BACKGROUND: Prehospital procedures (PHP) by emergency medical services (EMS) are performed regularly in penetrating trauma patients despite previous studies demonstrating no benefit. We sought to examine the influence of PHPs on outcomes in penetrating trauma patients in urban locations where transport to trauma center is not prolonged. We hypothesized that patients without PHPs would have better outcomes than those undergoing PHP. METHODS: This was an Eastern Association for the Surgery of Trauma-sponsored, multicenter, prospective, observational trial of adults (18+ years) with penetrating trauma to the torso and/or proximal extremity presenting at 25 urban trauma centers. The impact of PHPs and transport mechanism on in-hospital mortality were examined. RESULTS: Of 2,284 patients included, 1,386 (60.7%) underwent PHP. The patients were primarily Black (n = 1,527, 66.9%) males (n = 1,986, 87.5%) injured by gunshot wound (n = 1,510, 66.0%) with 34.1% (n = 726) having New Injury Severity Score of ≥16. A total of 1,427 patients (62.5%) were transported by Advanced Life Support EMS, 17.2% (n = 392) by private vehicle, 13.7% (n = 312) by police, and 6.7% (n = 153) by Basic Life Support EMS. Of the PHP patients, 69.1% received PHP on scene, 59.9% received PHP in route, and 29.0% received PHP both on scene and in route. Initial scene vitals differed between groups, but initial emergency department vitals did not. Receipt of ≥1 PHP increased mortality odds (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.01-1.83; p = 0.04). Logistic regression showed increased mortality with each PHP, whether on scene or during transport. Subset analysis of specific PHP revealed that intubation (OR, 10.76; 95% CI, 4.02-28.78; p < 0.001), C-spine immobilization (OR, 5.80; 95% CI, 1.85-18.26; p < 0.01), and pleural decompression (OR, 3.70; 95% CI, 1.33-10.28; p = 0.01) had the highest odds of mortality after adjusting for multiple variables. CONCLUSION: Prehospital procedures in penetrating trauma patients impart no survival advantage and may be harmful in urban settings, even when performed during transport. Therefore, PHP should be forgone in lieu of immediate transport to improve patient outcomes. LEVEL OF EVIDENCE: Prognostic, level III.

Is low-molecular-weight heparin safe for venous thromboembolism prophylaxis in patients with traumatic brain injury? A Western Trauma Association multicenter study.

BACKGROUND: Venous thromboembolism (VTE) is a significant risk in trauma patients. Although low-molecular weight heparin (LMWH) is effective in VTE prophylaxis, its use for patients with traumatic intracranial hemorrhage remains controversial. The purpose of this study was to evaluate the safety of LMWH for VTE prophylaxis in blunt intracranial injury. METHODS: We conducted a retrospective multicenter study of LMWH chemoprophylaxis on patients with intracranial hemorrhage caused by blunt trauma. Patients with brain Abbreviated Injury Scale score of 3 or higher, age 18 years or older, and at least one repeated head computed tomographic scan were included. Patients with previous VTE; on preinjury anticoagulation; hospitalized for less than 48 hours; on heparin for VTE prophylaxis; or required emergent thoracic, abdominal, or vascular surgery at admission were excluded. Patients were divided into two groups: those who received LMWH and those who did not. The primary outcome was progression of intracranial hemorrhage on repeated head computed tomographic scan. RESULTS: The study included 1,215 patients, of which 220 patients (18.1%) received LMWH and 995 (81.9%) did not. Hemorrhage progression occurred in 239 of 995 control subjects and 93 of 220 LMWH patients (24% vs. 42%, p < 0.001). Hemorrhage progression occurred in 32 patients after initiating LMWH (14.5%). Nine of these patients (4.1%) required neurosurgical intervention for hemorrhage progression. CONCLUSION: Patients receiving LMWH were at higher risk for hemorrhage progression. We were unable to demonstrate safety of LMWH for VTE prophylaxis in patients with brain injury. The risk of using LMWH may exceed its benefit. LEVEL OF EVIDENCE: Therapeutic study, level IV.

TBI risk stratification at presentation: a prospective study of the incidence and timing of radiographic worsening in the Parkland Protocol.

BACKGROUND: We have created a theoretical algorithm for venous thromboembolism prophylaxis after traumatic brain injury (TBI) known as the Parkland Protocol, which stratifies patients into low-, medium-, and high-risk categories for spontaneous progression of hemorrhage. This prospective study characterizes the incidence and timing of radiographic progression of the TBI patterns in these categories. METHODS: Inclusion criterion was presentation with intracranial blood between February 2010 and March 2011; exclusion was receipt of only one computed tomographic scan of the head during the inpatient stay or preinjury warfarin. At admission, all patients were preliminarily categorized per the Parkland Protocol as follows: low risk (LR), patients meeting the modified Berne-Norwood criteria; moderate risk (MR), injuries larger than the modified Berne-Norwood criteria without requiring a neurosurgical procedure; high risk (HR), any patient with a craniotomy/monitor. RESULTS: A total of 245 patients with intracranial hemorrhage were enrolled during the 13-month study period. Of patients preliminarily classified as LR at admission (n = 136), progression was seen in 25.0%. Spontaneous worsening was seen in 7.4% of LR patients at 24 hours after injury, and no LR patients progressed at 72 hours after injury. In patients initially classified as MR at admission (n = 42), progression was seen in 42.9%, with 91.5% of patients demonstrating stable computed tomographic head scans at 72 hours after injury. In patients initially classified as HR (n = 67), 64.2% demonstrated spontaneous progression of their TBI patterns, with 10.5% continuing to progress at 72 hours after injury. Most repeat scans were performed as routinely scheduled studies (81-91%). CONCLUSION: Increases in the incidence of spontaneous worsening were seen as severities of injury progressed from the Parkland Protocol's LR to MR to HR arms. The time frames for these spontaneous worsenings seem to be such that the protocol's theoretical recommendations for venous thromboembolism prophylaxis are worth pursuing as future points of investigation.

A randomized, double-blinded, placebo-controlled pilot trial of anticoagulation in low-risk traumatic brain injury: The Delayed Versus Early Enoxaparin Prophylaxis I (DEEP I) study.

BACKGROUND: Our group has created an algorithm for venous thromboembolism prophylaxis after traumatic brain injury (TBI), which stratifies patients into low, moderate, and high risk for spontaneous injury progression and tailors a prophylaxis regimen to each arm. We present the results of the Delayed Versus Early Enoxaparin Prophylaxis I study, a double-blind, placebo-controlled, randomized pilot trial on the low-risk arm. METHODS: In this two-institution study, patients presenting within 6 hours of injury with prespecified small TBI patterns and stable scans at 24 hours after injury were randomized to receive enoxaparin 30 mg bid or placebo from 24 to 96 hours after injury in a double-blind fashion. An additional computed tomography scan was obtained on all subjects 24 hours after starting treatment (and therefore 48 hours after injury). The primary end point was the radiographic worsening of TBI; secondary end points were venous thromboembolism occurrence and extracranial hemorrhagic complications. RESULTS: A total of 683 consecutive patients with TBI were screened during the 28 center months. The most common exclusions were for injuries larger than the prespecified criteria (n = 199) and preinjury anticoagulant use (n = 138). Sixty-two patients were randomized to enoxaparin (n = 34) or placebo (n = 28). Subclinical, radiographic TBI progression rates on the scans performed 48 hours after injury and 24 hours after start of treatment were 5.9% (95% confidence interval [CI], 0.7-19.7%) for enoxaparin and 3.6% (95% CI, 0.1-18.3%) for placebo, a treatment effect difference of 2.3% (95% CI, -14.42-16.5%). No clinical TBI progressions occurred. One deep vein thrombosis occurred in the placebo arm. CONCLUSION: TBI progression rates after starting enoxaparin in small, stable injuries 24 hours after injury are similar to those of placebo and are subclinical. The next Delayed Versus Early Enoxaparin Prophylaxis studies will assess efficacy of this practice in a powered study on the low-risk arm and a pilot trial of safety of a 72-hour time point in the moderate-risk arm. LEVEL OF EVIDENCE: Therapeutic study, level II.

Management of pediatric occult pneumothorax in blunt trauma: a subgroup analysis of the American Association for the Surgery of Trauma multicenter prospective observational study.

BACKGROUND: Occult pneumothorax (OPTX) represents air within the pleural space not visible on conventional chest radiographs. Increased use of computed tomography has led to a rise in the detection of OPTX. Optimal management remains undefined. METHODS: A pediatric subgroup analysis (age <18 years) from a multicenter, observational study evaluating OPTX management. Data analyzed were pneumothorax size, management outcome, and associated risk factors to characterize those that may be safely observed. RESULTS: Fifty-two OPTX (7.3 ± 6.2 mm) in 51 patients were identified. None were greater than 27 mm; all those under 16.5 mm (n = 48) were successfully managed without intervention. Two patients underwent initial tube thoracostomy (one [21 mm] and the other with bilateral OPTX [24 mm, 27 mm]). Among patients under observation (n = 49), OPTX size progressed in 2; one (6.4mm) required no treatment, while one (16.5 mm) received elective intervention. Respiratory distress occurred in one patient (10.7 mm) who did not require tube thoracostomy. Nine received positive pressure ventilation; 8 did not have a tube thoracostomy. Twenty-four patients (51%) had one or more rib fractures; 3 required tube thoracostomy. CONCLUSION: No pediatric OPTX initially observed developed a tension pneumothorax or adverse event related to observation. Pediatric patients with OPTX less than 16 mm may be safely observed. Neither the presence of rib fractures nor need for PPV alone necessitates intervention.

Blunt traumatic occult pneumothorax: is observation safe?--results of a prospective, AAST multicenter study.

BACKGROUND: An occult pneumothorax (OPTX) is found incidentally in 2% to 10% of all blunt trauma patients. Indications for intervention remain controversial. We sought to determine which factors predicted failed observation in blunt trauma patients. METHODS: A prospective, observational, multicenter study was undertaken to identify patients with OPTX. Successfully observed patients and patients who failed observation were compared. Multivariate logistic regression was used to identify predictors of failure of observation. OPTX size was calculated by measuring the largest air collection along a line perpendicular from the chest wall to the lung or mediastinum. RESULTS: Sixteen trauma centers identified 588 OPTXs in 569 blunt trauma patients. One hundred twenty-one patients (21%) underwent immediate tube thoracostomy and 448 (79%) were observed. Twenty-seven patients (6%) failed observation and required tube thoracostomy for OPTX progression, respiratory distress, or subsequent hemothorax. Fourteen percent (10 of 73) failed observation during positive pressure ventilation. Hospital and intensive care unit lengths of stay, and ventilator days were longer in the failed observation group. OPTX progression and respiratory distress were significant predictors of failed observation. Most patient deaths were from traumatic brain injury. Fifteen percentage of patients in the failed observation group developed complications. No patient who failed observation developed a tension PTX, or experienced adverse events by delaying tube thoracostomy. CONCLUSION: Most blunt trauma patients with OPTX can be carefully monitored without tube thoracostomy; however, OPTX progression and respiratory distress are independently associated with observation failure.

A multivariate logistic regression analysis of risk factors for blunt cerebrovascular injury.

INTRODUCTION: The diagnosis of blunt cerebrovascular injuries (BCVI) has improved with widespread adaptation of screening protocols and more accurate multi-detector computed tomography (MDCT-A) angiography. The population at risk and for whom screening is indicated is still controversial. To help determine which blunt trauma patients would best benefit from screening we performed a comprehensive analysis of risk factors associated with BCVI. METHODS: All patients with BCVI from June 12, 2000 (the date at which our institution began screening for these injuries) to June 30, 2009 were identified by the primary author (JDB) and recorded in a prospective database. Associated injuries were identified retrospectively by International Classification of Diseases, Ninth Revision (ICD-9) code and compared with similar patients without BCVI. Demographic information was also compared from data obtained from the trauma registry. Univariate analyses exploring associations between individual risk factors and BCVI were performed using Fisher's exact test for dichotomous variables and Student's t test for continuous variables. Additionally, relative risk (RR) was calculated for dichotomous variables to describe the strength of the relationship between the categorical risk factors and BCVI. Multivariate logistic regression models for BCVI, BCAI (blunt internal carotid artery injury), and BVAI (blunt vertebral artery injury) were developed to explore the relative contributions of the various risk factors. RESULTS: One hundred two patients with BCVI were identified out of 9935 blunt trauma patients admitted during this time period (1.03% incidence). Fifty-nine patients (0.59% incidence) had a BVAI and 43 patients (0.43% incidence) had a BCAI. Univariate analysis found cervical spine fracture (CSI) (RR = 10.4), basilar skull fracture (RR = 3.60), and mandible fracture (RR = 2.51) to be most predictive of the presence of BCVI (P < .005). Independent predictors of BCVI on multivariate logistic regression were CSI (OR = 7.46), mandible fracture (OR = 2.59), basilar skull fracture (OR = 1.76), injury severity score (ISS) (OR = 1.05), and emergency department Glasgow Coma Scale (ED-GCS) (OR = 0.93): all P < .05. CONCLUSIONS: Blunt trauma patients with a high risk mechanism and a low GCS, high injury severity score, mandible fracture, basilar skull fracture, or cervical spine injury are at high risk for BCVI should be screened with MDCT-A.

Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: a multi-center study of the american association for the surgery of trauma.

BACKGROUND: Cervical spine clearance in the very young child is challenging. Radiographic imaging to diagnose cervical spine injuries (CSI) even in the absence of clinical findings is common, raising concerns about radiation exposure and imaging-related complications. We examined whether simple clinical criteria can be used to safely rule out CSI in patients younger than 3 years. METHODS: The trauma registries from 22 level I or II trauma centers were reviewed for the 10-year period (January 1995 to January 2005). Blunt trauma patients younger than 3 years were identified. The measured outcome was CSI. Independent predictors of CSI were identified by univariate and multivariate analysis. A weighted score was calculated by assigning 1, 2, or 3 points to each independent predictor according to its magnitude of effect. The score was established on two thirds of the population and validated using the remaining one third. RESULTS: Of 12,537 patients younger than 3 years, CSI was identified in 83 patients (0.66%), eight had spinal cord injury. Four independent predictors of CSI were identified: Glasgow Coma Score <14, GCSEYE = 1, motor vehicle crash, and age 2 years or older. A score of <2 had a negative predictive value of 99.93% in ruling out CSI. A total of 8,707 patients (69.5% of all patients) had a score of <2 and were eligible for cervical spine clearance without imaging. There were no missed CSI in this study. CONCLUSIONS: CSI in patients younger than 3 years is uncommon. Four simple clinical predictors can be used in conjunction to the physical examination to substantially reduce the use of radiographic imaging in this patient population.

Blunt vertebral artery injuries in the era of computed tomographic angiographic screening: incidence and outcomes from 8,292 patients.

INTRODUCTION: Blunt injuries to the vertebral artery (BVI) are rare. Recent improvements in the multidetector computer tomography (MDCT) technology and increased use of screening protocols have led to a greater number of these injuries identified. Well-defined treatment recommendations are still lacking, and it is unclear whether screening and treatment lead to improved outcome. METHODS: All patients who met predefined screening criteria were screened for BVI with a MDCT angiogram (MDCT-A). All patients identified with BVI were treated based on injury grade and associated injuries. Hospital course, morbidity, mortality, and follow-up were recorded and analyzed. RESULTS: A total of 8,292 patients were admitted for blunt injuries during this time period. Forty-four patients were found to have 47 BVI (three bilateral). Pharmacologic treatment with anticoagulants (AC)-heparin and warfarin-or an antiplatelet agent-clopidogrel and aspirin-was initiated in 37 patients (84%). Angiographic coiling was performed in eight patients (18%), and two (5%) had endovascular stents placed. Four patients developed signs of cerebral ischemia (9%), of whom three died and one recovered completely. Overall mortality rate was 16% (7/44). BVI-related mortality occurred in three patients (7%). Of these, two patients had bilateral vertebral artery occlusion or transaction, and death was considered nonpreventable. One death occurred in a patient with a unilateral vertebral dissection developed a posterior circulation infarct. Anticoagulation was felt to be contraindicated in this patient initially due to intracranial hemorrhage. This was deemed the only potentially preventable BVI-related mortality. Annual BVI-related mortality rate in the 4 years before initiating the screening protocol was 0.75 cases per year. During this study period, it was 0.57 cases per year. CONCLUSION: Under an aggressive screening and individualized treatment protocol for BVI, we had very few potentially preventable BVI-related strokes and deaths. We are unable to conclude; however, based on historical controls that either screening or treatment improved overall outcome.

An evaluation of multidetector computed tomography in detecting pancreatic injury: results of a multicenter AAST study.

BACKGROUND: Efforts to determine the suitability of low-grade pancreatic injuries for nonoperative management have been hindered by the inaccuracy of older computed tomography (CT) technology for detecting pancreatic injury (PI). This retrospective, multicenter American Association for the Surgery of Trauma-sponsored trial examined the sensitivity of newer 16- and 64-multidetector CT (MDCT) for detecting PI, and sensitivity/specificity for the identification of pancreatic ductal injury (PDI). METHODS: Patients who received a preoperative 16- or 64-MDCT followed by laparotomy with a documented PI were enrolled. Preoperative MDCT scans were classified as indicating the presence (+) or absence (-) of PI and PDI. Operative notes were reviewed and all patients were confirmed as PI (+), and then classified as PDI (+) or (-). As all patients had PI, an analysis of PI specificity was not possible. PI patients formed the pool for further PDI analysis. As sensitivity and specificity data were available for PDI, multivariate logistic regression was performed for PDI patients using the presence or absence of agreement between CT and operative note findings as an independent variable. Covariates were age, gender, Injury Severity Score, mechanism of injury, presence of oral contrast, presence of other abdominal injuries, performance of the scan as part of a dedicated pancreas protocol, and image thickness < or =3 mm or > or =5 mm. RESULTS: Twenty centers enrolled 206 PI patients, including 71 PDI (+) patients. Intravenous contrast was used in 203 studies; 69 studies used presence of oral contrast. Eight-nine percent were blunt mechanisms, and 96% were able to have their duct status operatively classified as PDI (+) or (-). The sensitivity of 16-MDCT for all PI was 60.1%, whereas 64-MDCT was 47.2%. For PDI, the sensitivities of 16- and 64-MDCT were 54.0% and 52.4%, respectively, with specificities of 94.8% for 16-MDCT scanners and 90.3% for 64-MDCT scanners. Logistic regression showed that no covariates were associated with an increased likelihood of detecting PDI for either 16- or 64-MDCT scanners. The area under the curve was 0.66 for the 16-MDCT PDI analysis and 0.77 for the 64-MDCT PDI analysis. CONCLUSION: Sixteen and 64-MDCT have low sensitivity for detecting PI and PDI, while exhibiting a high specificity for PDI. Their use as decision-making tools for the nonoperative management of PI are, therefore, limited.

Early venous thromboembolism prophylaxis with enoxaparin in patients with blunt traumatic brain injury.

OBJECTIVE: To determine the safety of early enoxaparin for venous thromboembolism (VTE) prophylaxis in patients with blunt traumatic brain injury (TBI). METHODS: Prospective observational study of patients with TBI who received enoxaparin within 48 hours after admission. Brain computed tomography (CT) scans were obtained at the time of admission, at 24 hours, and at variable intervals thereafter based on clinical course. Patients were excluded from the study for intracerebral contusions >/=2 cm, multiple contusions within one brain region, subdural or epidural hematomas >/=8 mm, increased size or number of lesions on follow-up CT, persistent intracranial pressure >20 mm Hg, or neurosurgeon or trauma surgeon reluctance to initiate early pharmacologic VTE prophylaxis. Bleeding complications were defined as CT progression of hemorrhage by Marshall CT Classification or radiologists' report, regardless of any neurologic deterioration. Main outcomes measured were intracranial bleeding complications, discharge Glasgow Outcome Score, and hospital mortality. RESULTS: Five hundred twenty-five patients were studied. Eighteen patients (3.4%) had progressive hemorrhagic CT changes after receiving enoxaparin, 12 of whom had no change in treatment, neurologic status, or outcome. Six patients (1.1%) had a change in treatment or potential outcome, including three who required subsequent craniotomy. Twenty-one patients (4.0%) died, and pharmacologic prophylaxis may have contributed to one death (0.2%). Discharge Glasgow Outcome Scores were 445 (84.8%) good recovery, 19 (3.6%) moderate disability, 36 (6.8%) severe disability, 4 (0.8%) persistent vegetative state, and 21 (4.0%) dead. CONCLUSION: Enoxaparin should be considered as an option for early VTE prophylaxis in selected patients with blunt TBI. Early enoxaparin should be strongly considered in those patients with TBI with additional high risk traumatic injuries.

Internal carotid artery stenting for blunt carotid artery injuries with an associated pseudoaneurysm.

BACKGROUND: Blunt carotid artery injuries (BCI) are being recognized and treated with increasing frequency because of improved screening protocols. Recent advances in endovascular techniques using microcoils, angioplasty, and stenting offer a new treatment strategy for those patients with traumatic pseudoaneurysms (PA) (BCI and PA). Experience with these techniques is limited because of the rarity of these injuries. HYPOTHESIS: Early anticoagulation (AC) or antiplatelet (AP) therapy combined with carotid artery stenting is a safe alternative to AC alone for the treatment of grade III carotid artery injuries (BCI and PA). DESIGN: Prospective cohort study. SETTING: A rural, community Level I trauma center. PATIENTS AND METHODS: All patients with a nonocclusive BCI and PA during a 5.5 year period from June 23, 2000 to December 31, 2005 were included in the study. RESULTS: : Eleven patients with grade BCI and PA underwent endovascular repair. Nine patients (81%) had associated traumatic intracranial hemorrhage. AC (heparin drip) or AP therapy (clopidogrel or aspirin or both) was initiated in all patients within 48 hours of diagnosis of BCI. Time from admission to AC or AP was 21 +/- 9.5 hours (mean +/- SD). Mortality rate was 18% (2 of 11). One death was attributed to severe brain injury. The other was attributed to a stroke from the carotid injury. No patient had radiologic progression of traumatic intracranial hemorrhage on head computed tomography despite AP or AC. One patient sustained a mild embolic cerebrovascular ischemic event before stenting. No other survivors developed a stroke or any other evidence of cerebral ischemic symptoms. Two recurrent PAs developed during hospitalization and were successfully managed with an additional stent. All survivors were discharged with a good neurologic outcome. Seven patients had follow-up from 6 months to 4 years: one developed asymptomatic 50% stenosis at 6 months requiring successful angioplasty. All others showed complete healing without stenosis. CONCLUSIONS: Carotid artery stenting is safe and effective initial therapy for patients with nonocclusive BCI and PA. Initial intermediate-term follow-up also fails to demonstrate significant morbidity for up to 4 years.

Off-pump coronary artery bypass is an alternative to conventional cardiopulmonary bypass when repair of traumatic coronary artery injuries is indicated.

Coronary artery injuries after penetrating cardiac trauma are rare. The standard approach to these injuries has traditionally been coronary artery ligation. When cardiac perfusion is profoundly compromised, cardiopulmonary bypass has been used to facilitate revascularization, although with serious morbidity. We report a case of traumatic left anterior descending coronary artery transection repaired off-pump in a young stabbing victim. Penetrating traumatic cardiac injuries are highly lethal injuries. Cardiopulmonary bypass has been used for myocardial revascularization when cardiac perfusion is compromised, although with significant complications. Off-pump coronary artery bypass is a safe alternative in the traumatized patient.

Sixteen-slice multi-detector computed tomographic angiography improves the accuracy of screening for blunt cerebrovascular injury.

BACKGROUND: Blunt cerebrovascular injuries (BCVI) are rare but potentially devastating injuries, particularly if the diagnosis is delayed. Only four-vessel cerebral angiography (FVCA) has been shown to be adequately sensitive and specific as a screening tool for BCVI but is resource-intensive and invasive. Computed tomography (CT) angiography has emerged as a possible alternative, but its accuracy has been poor, particularly for low-grade injuries. Recent advances in CT technology, particularly the use of a multi-detector array for image acquisition should improve the accuracy of this technique. This study is the first reported experience of the role of the 16-slice multi- detector CT scanner in screening for BCVI. METHODS: From January 2, 2003 to October 31, 2004, all patients who met predefined screening criteria were screened for blunt injury to the carotid (BCI) and vertebral (BVI) arteries with a 16-slice multi-detector CT scanner with angiographic reconstruction (CTA). If CTA was positive or equivocal for BCVI, FVCA was performed as a confirmatory test. If CTA was negative, no further diagnostic studies were performed. RESULTS: There were 435 patients who met criteria and were screened with CTA. Of these, 25 injuries were identified in 24 patients for an incidence of BCVI of 1.2% (24/2023) among all blunt admissions (BTA) and 5.5% (24/435) among screened patients (SP). This was increased compared with the four-slice era (0.38% BTA, 2.4% SP, p<0.01). No patient with a negative CTA was subsequently identified as having, or developed neurologic symptoms attributable to a missed BCVI. CONCLUSION: Sixteen-slice multi-detector CT angiography is an excellent tool to screen for BCVI and detects all clinically significant injuries. The detected incidence of BCVI increased more than threefold with the 16-slice scanner when compared with the four-slice scanner. This demonstrates a clear technological improvement in our ability to screen for these injuries.