A Descriptive Analysis of Patients With Attempted Suicide at a Rural Level I Trauma Center.

Objectives: For patients with self-harm, suicide attempt, or suicide completion, the trauma bay is often the single point of contact. Regional differences and patterns exist for suicide that should be studied to enhance preventive strategies. Our goal was to critically evaluate the suicidal population of Southeast Georgia over a 9-year period. Methods: A retrospective review of our trauma database from January 2010 through December 2019 was conducted at a Level I Trauma Center. All ages were included. All patients arriving with attempted suicide or death due to a suicidal complication were included. Patients with deaths highly suspicious for suicide were also included. Exclusion criteria included accidental motor vehicle death, accidental generalized deaths, and accidental drowning. Age, gender, race, ethnicity, mechanism of injury (MOI), death rates, length of stay (LOS), injury severity score (ISS), home zip code, day of the week, transfer vs. from scene, location of injury, alcohol levels, and urine drug screening results were analyzed. Results: From 2010 to 2019, there were 381 total suicides with 260 survivals and 121 completions (mortality: 31.7%) at our Level I Trauma Center. The majority of suicides were performed by middle-aged White men with an average age of 40 years (SD: 17.2). This was true even if the White race was not the majority race in the patient's zip code. The majority of the time, these patients presented directly from the scene and, if the patient's suicide location was known, it usually took place at their home. Other common areas included secluded areas, such as wooded areas, and personal vehicles. Of the suicides, 11.6% were performed within the criminal justice system including jail and solitary confinement. The average LOS following admission was 7.51 days (SD: 22.1). The majority of suicides came from the metro Savannah district, which has higher unemployment and poverty rates than other parts of our study area. Gun violence was the most common MOI for suicide (75%). If suicide was attempted via a penetrating mechanism including glass, knife, or gun, there was an increased rate of death when compared to our general data (38% vs. 31%). When the gun mechanisms were analyzed as a group, there was a 57% rate of death after arrival at the hospital. Acute alcohol intoxication was present in 56.6% of patients and 80 (21%) had drugs in their system. Conclusion: Our data demonstrate epidemiologic and socioeconomic trends in Southeast Georgia. This included increased alcohol intoxication, deaths related to gun use, and in a higher incidence of suicide among White males, including geographic locations where the White race is not the majority. Suicides and suicide attempts were also more common in areas with higher unemployment rates.

Education Empowers Emergency Department Nurses During Pediatric Traumas.

In January 2017, the Emergency Trauma Advocate (ETA) program was piloted at our Level 1 trauma center to promote patient advocacy, particularly in pediatric patients. The goal was to empower emergency department nurses by improving their knowledge base through interactive didactic sessions. This study reviews the preliminary findings of the program. Surveys were administered after each teaching session to participating ETA nurses to determine their personal academic interests and how to improve the program. We then performed a retrospective review of pediatric trauma admissions from January 2017 through April 2017 to delineate the most common injury patterns. Survey responses demonstrated the greatest nursing interest in learning critical care (n = 11), orthopedic management (n = 11), and neurosurgical trauma education (n = 9). During this study period, 113 pediatric patients arrived and had a mean age of 7.8 ± 5.2 years. The most common injury patterns were orthopedic (n = 38) and neurosurgical (n = 28), and 35 patients required critical care management. Bivariate analysis revealed a significant and positive relationship between injury frequency and educational interests (R = 98.8%, p = .0057). A nurse's interest in educational topics directly correlates with recent pediatric trauma injury patterns. Future work should focus on determining what impact the ETA program has had on pediatric outcomes.

What's in the Box? The Effectiveness of a Low-Volume Massive Transfusion Protocol.

Transfusion ratios approaching 1:1:1 of packed red blood cells (PRBCs) to fresh frozen plasma (FFP) to platelet have been shown to improve outcomes in trauma. There is little data available to describe in what quantity that ratio should be delivered. We hypothesized that lowering the total volume of products delivered in each protocol round would not adversely affect outcomes in the bleeding trauma patient. A retrospective review of 9732 trauma patients admitted to a rural Level I trauma center over a 3-year period was performed. Patients who received a massive transfusion (greater than 10 units of blood product transfused in the first 24 hours), between January 2012 and April 2015 were identified as the study cohort. In May of 2014, our institution switched from a massive transfusion protocol (MTP) that included 6 PRBCs:6 FFP:1 platelet to a lower volume massive transfusion protocol (LVMTP) that included 4 PRBC:4 FFP:1 platelet. Data collected included patient demographics, vital signs, and outcomes. A total of 131 patients met study criteria. MTP was activated on 65 per cent of patients (57/88), receiving a massive transfusion during the 28 months before implementation of the new protocol. In contrast, LVMTP was activated in 100 per cent of patients (43/43) receiving a massive transfusion in the 12 months after implementation of the new protocol. There was no significant difference in age (36.6 vs 37.2, P = 0.87), injury severity score (29.8 vs 32.3, P = 0.45), or per cent penetrating mechanism (43.9 vs 37.2%, P = 0.503) when comparing MTP to LVMTP. In addition, there was no significant difference in mortality (47.4 vs 41.9%, P = 0.584), lengths of stay (13.5 vs 17.1, P = 0.258), or vent days (6.4 vs 8.2, P = 0.236) when comparing MTP to LVMTP. A LVMTP is safe and effective for the resuscitation of the trauma patient.

The first 72 hours of brain tissue oxygenation predicts patient survival with traumatic brain injury.

BACKGROUND: Utilization of brain tissue oxygenation (pBtO(2)) is an important but controversial variable in the treatment of traumatic brain injury. We hypothesize that pBtO(2) values over the first 72 hours of monitoring are predictive of mortality. METHODS: Consecutive, adult patients with severe traumatic brain injury and pBtO(2) monitors were retrospectively identified. Time-indexed measurements of pBtO(2), cerebral perfusion pressure (CPP), and intracranial pressure (ICP) were collected, and average values over 4-hour blocks were determined. Patients were stratified according to survival, and repeated measures analysis of variance was used to compare pBtO(2), CPP, and ICP. The pBtO(2) threshold most predictive for survival was determined. RESULTS: There were 8,759 time-indexed data points in 32 patients. The mean age was 39 years ± 16.5 years, injury severity score was 27.7 ± 10.7, and Glasgow Coma Scale score was 6.6 ± 3.4. Survival was 68%. Survivors consistently demonstrated higher pBtO(2) values compared with nonsurvivors including age as a covariate (F = 12.898, p < 0.001). Individual pBtO(2) was higher at the time points 8 hours, 12 hours, 20 hours to 44 hours, 52 hours to 60 hours, and 72 hours of monitoring (p < 0.05). There was no difference in ICP (F = 1.690, p = 0.204) and CPP (F = 0.764, p = 0.389) values between survivors and nonsurvivors including age as a covariate. Classification and regression tree analysis identified 29 mm Hg as the threshold at which pBtO(2) was most predictive for mortality. CONCLUSION: The first 72 hours of pBtO(2) neurologic monitoring predicts mortality. When the pBtO(2) monitor remains below 29 mm Hg in the first 72 hours of monitoring, mortality is increased. This study challenges the brain oxygenation threshold of 20 mm Hg that has been used conventionally and delineates a time for monitoring pBtO(2) that is predictive of outcome. LEVEL OF EVIDENCE: III, prognostic study.

O' surgery case log data, where art thou?

BACKGROUND: The American College of Surgeons (ACS) Case Log represents a data system that satisfies the American Board of Surgery (ABS) Maintenance of Certification (MOC) program, yet has broad data fields for surgical subspecialties. Using the ACS Case Log, we have developed a method of data capture, categorization, and reporting of acute care surgery fellows' experiences. STUDY DESIGN: In July 2010, our acute care surgery fellowship required our fellows to log their clinical experiences into the ACS Case Log. Cases were entered similar to billable documentation rules. Keywords were entered that specified institutional services and/or resuscitation types. These data were exported in comma separated value format, deidentified, structured by Current Procedural Terminology (CPT) codes relevant to acute care surgery, and substratified by fellow and/or fellow year. RESULTS: Fifteen report types were created consisting of operative experience by service, procedure by major category (cardiothoracic, vascular, solid organ, abdominal wall, hollow viscus, and soft tissue), total resuscitations, ultrasound, airway, ICU services, basic neurosurgery, and basic orthopaedics. Results are viewable via a secure Web application, accessible nationally, and exportable to many formats. CONCLUSIONS: Using the ACS Case Log satisfies the ABS MOC program requirements and provides a method for monitoring and reporting acute care surgery fellow experiences. This system is flexible to accommodate the needs of surgical subspecialties and their training programs. As documentation requirements expand, efficient clinical documentation is a must for the busy surgeon. Although, our data entry and processing method has the immediate capacity for acute care surgery fellowships nationwide, multiple larger decisions regarding national case log systems should be encouraged.

Cerebral perfusion pressure and intracranial pressure are not surrogates for brain tissue oxygenation in traumatic brain injury.

OBJECTIVE: Utilization of brain tissue oxygenation (pBtO(2)) is an important but controversial variable in the treatment of traumatic brain injury (TBI). We evaluated the correlation between pBtO(2)/CPP and pBtO(2)/ICP and determined the parameter most closely related to survival. METHODS: Consecutive, adult patients with severe TBI and pBtO(2) monitors were retrospectively identified. Time-indexed measurements of pBtO(2), CPP and ICP were collected and correlation coefficients were determined. Patients were then stratified according to survival and pBtO(2), CPP and ICP values were compared between groups. RESULTS: There were 4169 time-indexed data points (i.e., pBtO(2) with respective CPP and ICP values) in 15 patients. The cohort consisted of a mean age of 37±17 years, ISS of 27±7 and GCS of 4.5±1.5. Survival was 53% (8/15). In a normal regression models, neither the ICP (p=0.58) nor the CPP (p=0.71) predict pBtO(2) significantly. There was a significant difference in pBtO(2) in survivors (31.5±3.1 vs. 25.2±4.8, p=0.010) but not in CPP or ICP. Survivors had a lower proportion of time with pBtO(2)<25 mmHg [20% (3.4-44.6) vs. 40% (16.2-89), p=0.049]. In contrast, survivors had a greater proportion of time with CPP<70 and no difference in the proportion of time with and ICP>20. CONCLUSIONS: CPP and ICP should not be used as surrogates for pBtO(2) since cerebral oxygenation varies independently of cerebral hemodynamics and pressures. Brain tissue oxygen monitoring in patients with TBI provides unique information regarding cerebral oxygenation the utility of which remains to be fully described. SIGNIFICANCE: CPP and ICP are not surrogates for pBtO(2). Brain tissue oxygenation monitoring provides unique information for the treatment of traumatically injured patients.

Tight blood glucose control in trauma patients: Who really benefits?

BACKGROUND: This study was designed to evaluate the effect of intensive insulin control (IIT) on outcomes for traumatically injured patients as a function of injury severity score (ISS) and age. PATIENTS AND METHODS: A retrospective review of 2028 adult trauma patients admitted to the surgical intensive care unit (SICU) in a Level I trauma center was performed. Data were collected from a 48-month period before (Pre-IIT) (goal blood glucose 80-200 mg/dL) and after (Post-IIT) (goal blood glucose level 80-110 mg/dL), an IIT protocol was initiated. Patients were stratified by age and ISS. The primary endpoint was mortality. RESULTS: There were 784 Pre-IIT and 1244 Post-IIT patients admitted. There was no significant difference between Pre-IIT vs. Post-IIT for the mechanism of injury or ISS. Values for the Pre-IIT group were significantly higher for mortality (21.5% vs. 14.7%, P<0.001) and hospital, but not ICU length of stay were decreased. A significant improvement in mortality was demonstrated between Pre-IIT vs. Post-IIT stratified within the age groups of 41-50, 51-60, and 61 but not the groups 18-30 and 31-40. Mean glucose levels (mg/dL) decreased significantly after the institution of IIT (144.7±1.4 vs. 130.9±0.9; P<0.001). In addition, the occurrence per patient of blood glucose levels <40 mg/dL increased (0.77% vs. 2.86%; P=0.001) and blood glucose levels greater than 200 mg/dL was similar (39.1% vs. 38.8%; P=0.892) in the Pre-IIT and Post-IIT groups, respectively. Glycemic variability, reflected by the standard deviation of each patient's mean glucose level during ICU stay, as well as mean glucose level were lower in survivors than in nonsurvivors. Finally, multivariable logistic regression analysis identified both mean glucose level and glycemic variability as independent contributors to the risk of mortality. CONCLUSIONS: The implementation of IIT has been associated with a decrease in both hospital length of stay as well as mortality. Average glucose value and glucose variability are independent predictors of survival. Trauma patients with moderate, severe, and very severe injuries benefit most from IIT. These observational data suggest that patients over 40 years of age benefited a great deal more than their younger counterparts from IIT. This study supports the need for a randomized controlled trial to investigate the role of IIT in traumatically injured patients.

Colon anastomosis after damage control laparotomy: recommendations from 174 trauma colectomies.

BACKGROUND: Primary colonic anastomosis in trauma patients has been demonstrated to be safe. However, few studies have investigated this in the setting of damage control laparotomy. We hypothesized that colonic anastomosis for trauma patients requiring an open abdomen (OA) would have a higher anastomotic leak (AL) rate when compared with patients having an immediate abdominal closure following trauma laparotomy. METHODS: We performed a cohort comparison study of all trauma patients who underwent colectomy, between the years 2004 and 2009. Exclusion criteria were mortality within 24 hours of admission or colectomy for indications unrelated to injury. Data collected included age, gender, injury severity score, mechanism, length of stay, and mortality. Multivariable logistic regression was performed to assess the relationship of OA to our primary outcome measure, AL. RESULTS: Totally, 174 patients met study criteria. Fecal diversion was performed in 58 patients, and colonic anastomosis was performed in the remaining 116 patients. Patients with OA had a clinically significant increase in AL rate compared with immediate abdominal closure (6% vs. 27%, p=0.002). Logistic regression demonstrated that OA was independently associated with AL, with OA patients having more than a sixfold increase in odds of AL compared with those who were closed (odds ratio=6.37, p=0.002, area under the receiver operator curve=0.72). Transfusion requirement and left-sided anastomosis were risk factors for leak. CONCLUSIONS: Patients with a colonic anastomosis and an OA have an unacceptably high leak rate compared with those who undergo reconstruction with immediate closure. Given the significant risk of AL, colonic anastomosis should not be routinely performed in patients with OA.

Once bitten, twice incised: recurrent gallstone ileus.

Uncommon causes of small bowel obstruction can provide interesting surgical decision-making challenges. This report describes a patient with recurrent gallstone ileus. According to most current reviews, erring on the side of enterolithotomy alone as the treatment of choice for gallstone ileus appears to be the most appropriate decision. Although a rare scenario, the situation of recurrent gallstone ileus presents an interesting learning opportunity. It is important to keep in mind the need for complete examination of the abdomen. Furthermore, evacuation of any remaining stones from the gallbladder is imperative if possible. Erring on the side of enterolithotomy alone as the treatment of choice for gallstone ileus has been shown to be a safe and effective treatment decision over a single-stage removal of the stone with closure of the cholecystoduodenostomy.

Antiplatelet and anticoagulation therapies do not increase mortality in the absence of traumatic brain injury.

BACKGROUND: : As the population continues to age, the number of patients undergoing traumatic injury while on antiplatelet or anticoagulation therapies is increasing. Mortality has been shown to increase in traumatic brain injury patients on warfarin therapy. Whether this increased mortality is seen in trauma patients without traumatic brain injury remains controversial. We investigated whether patients on antiplatelet and/or anticoagulation therapy were at increased risk of death from blunt traumatic injury in the absence of head injury. METHODS: : A retrospective review of our Level I trauma center database was performed from 2002 to 2007. Inclusion criteria included all patients older than 60 years admitted to the trauma service. Only patients with a computed tomography scan negative for intracranial injury were analyzed. RESULTS: : Two hundred twelve patients were found, of which 67 were found to be taking aspirin, warfarin, clopidogrel, or a combination of the three. Injury Severity Score (21 vs. 21), length of stay (11 days vs. 9 days), intensive care unit days (5 days vs. 4 days), and deaths (13% vs. 10%) were similar between those patients on antiplatelet/anticoagulation therapy and those who were not. CONCLUSION: : In the absence of traumatic brain injury, the use of preinjury antiplatelet and/or anticoagulation therapy does not significantly increase the risk of mortality in the trauma patient. As the number of active seniors rises, this patient population will continue to present to the trauma service. To the best of our knowledge, this study is one of the largest addressing this question, and the only study examining the addition of antiplatelet therapy.

Initial results of a thoracic aortic endovascular program: safer in high-risk patients.

Results are presented from our single-institutional experience with thoracic endovascular aortic repair to confirm that it is safe in patients with significant comorbidities. A retrospective review of all patients undergoing endovascular or open thoracic aortic repair at our institution since 2002 was performed. Main outcome measures included clinical presentation, demographics, preoperative risk factors, operative details, and clinical outcomes. The endovascular group included 37 patients (22 males), whereas the open group included 19 patients (eight males). Eight patients per group were treated emergently for trauma or rupture (22% and 42%, respectively; p=0.11). Endovascular patients were significantly older with more comorbid conditions (p<0.05). However, the overall perioperative complication rate was similar in the two groups (32.4% and 31.6%, respectively). Postoperative renal failure occurred only in four open patients (21.1% vs. 0%, p < 0.05). Operative time, ventilator days, and total length of stay were also greater for open patients (p<0.05). There was one death in the endovascular group and three in the open group (2.7% and 15.8%, respectively; p=0.07). Endovascular patients had shorter operative time and length of stay, fewer ventilator days and intensive care unit days, and fewer transfusions. Although the endovascular patients were significantly older with more comorbidities, the complication rate was similar to the open group. Also, there was a trend toward lower mortality in the endovascular group (p=0.07). Endovascular repair is the procedure of choice for treating the descending thoracic aorta in high-risk patients even in the emergent setting.

The protective effect of the blood brain barrier from systemic cytokines in an animal femur fracture model.

BACKGROUND: Previous studies of head trauma have shown profound release of cytokines in the brain. These changes were not expressed in peripheral tissues. The intent of this study was to take an animal model of femur fracture, monitor the expression of biochemical markers in the periphery, and compare this to their expression in the brain. METHODS: Rats were subjected to a weight-drop, femur fracture model, and then killed at various times. Samples of muscle, liver, serum, and brain were analyzed for concentrations of cytokines, and compared with controls. RESULTS: Statistically significant (p < 0.05) results from the study were found in the liver. Interleukin (IL)-2, IL-10, IL-11, and other acute phase reactants were elevated at 24 hours after injury, compared with in controls. Analysis of these cytokines in the brain showed no significant increase when compared with those of controls. Further analysis also demonstrated an increase in plasma C-reactive protein and leptin in the fracture group. These results differ from our previous brain trauma study, which demonstrated no increased expression of cytokines in liver or plasma. CONCLUSIONS: This animal model of peripheral injury demonstrates that there is a significant rise in acute phase reactants in liver tissue and plasma within 24 hours after injury, without a corresponding rise in cytokine concentration in the brain. These results suggest that although the brain is potentially exposed to the biochemical response to injury, the brain parenchyma itself is protected from up-regulation of proinflammatory cytokines. Interestingly, this is the opposite effect seen in our isolated brain injury study.

Radiation exposure in trauma patients.

BACKGROUND: Trauma patients are exposed to a large amount of ionizing radiation. Radiologic examinations may include a multitude of plain films, computed tomography scans, and/or fluoroscopic examination. Previous studies have assessed radiation exposure to staff members at trauma centers, and in pregnant trauma patients. The purpose of the current study is to evaluate the amount of radiation to which trauma patients are exposed in a Level I trauma center. METHODS: The study used a prospective cohort design. All patients for whom a trauma code was activated between the months of September 2004 and July of 2005 were eligible to be enrolled in the study. Upon arrival to the trauma bay, a dosimeter badge, that measures ionizing radiation, was attached to a Velcro bracelet on the wrist of the patient. The badges were removed at the time of discharge from the hospital and analyzed. RESULTS: Data were collected on 224 patients (167 adults, 57 pediatric). The median amount of radiation exposure to all patients equaled 68 MREM (Interquartile range 31-181). A significant increase in the median amount of radiation exposure was found in patients with orthopedic injuries (107 MREM vs. 45 MREM), an Injury Severity Score (ISS) >15 (107 MREM vs. 46 MREM), a length of stay >than 1 week (105 MREM vs. 65 MREM), age >18 (82 MREM vs. 44 MREM), and when >11 radiologic procedures were performed (127 MREM vs. 46 MREM). CONCLUSION: Trauma patients are being exposed to high amounts of radiation. Patients with orthopedic injuries, and those more severely injured, are at an increased risk. Further precautions to limit radiation exposure in this population are needed.