Weight-based enoxaparin thromboprophylaxis in young trauma patients: analysis of the CLOTT-1 registry.

Introduction: Optimal venous thromboembolism (VTE) enoxaparin prophylaxis dosing remains elusive. Weight-based (WB) dosing safely increases anti-factor Xa levels without the need for routine monitoring but it is unclear if it leads to lower VTE risk. We hypothesized that WB dosing would decrease VTE risk compared with standard fixed dosing (SFD). Methods: Patients from the prospective, observational CLOTT-1 registry receiving prophylactic enoxaparin (n=5539) were categorized as WB (0.45-0.55 mg/kg two times per day) or SFD (30 mg two times per day, 40 mg once a day). Multivariate logistic regression was used to generate a predicted probability of VTE for WB and SFD patients. Results: Of 4360 patients analyzed, 1065 (24.4%) were WB and 3295 (75.6%) were SFD. WB patients were younger, female, more severely injured, and underwent major operation or major venous repair at a higher rate than individuals in the SFD group. Obesity was more common among the SFD group. Unadjusted VTE rates were comparable (WB 3.1% vs. SFD 3.9%; p=0.221). Early prophylaxis was associated with lower VTE rate (1.4% vs. 5.0%; p=0.001) and deep vein thrombosis (0.9% vs. 4.4%; p<0.001), but not pulmonary embolism (0.7% vs. 1.4%; p=0.259). After adjustment, VTE incidence did not differ by dosing strategy (adjusted OR (aOR) 0.75, 95% CI 0.38 to 1.48); however, early administration was associated with a significant reduction in VTE (aOR 0.47, 95% CI 0.30 to 0.74). Conclusion: In young trauma patients, WB prophylaxis is not associated with reduced VTE rate when compared with SFD. The timing of the initiation of chemoprophylaxis may be more important than the dosing strategy. Further studies need to evaluate these findings across a wider age and comorbidity spectrum. Level of evidence: Level IV, therapeutic/care management.

Challenging Traditional Paradigms in Posttraumatic Pulmonary Thromboembolism.

Importance: Pulmonary clots are seen frequently on chest computed tomography performed after trauma, but recent studies suggest that pulmonary thrombosis (PT) and pulmonary embolism (PE) after trauma are independent clinical events. Objective: To assess whether posttraumatic PT represents a distinct clinical entity associated with the nature of the injury, different from the traditional venous thromboembolic paradigm of deep venous thrombosis (DVT) and PE. Design, Setting, and Participants: This prospective, observational, multicenter cohort study was conducted by the Consortium of Leaders in the Study of Traumatic Thromboembolism (CLOTT) study group. The study was conducted at 17 US level I trauma centers during a 2-year period (January 1, 2018, to December 31, 2020). Consecutive patients 18 to 40 years of age admitted for a minimum of 48 hours with at least 1 previously defined trauma-associated venous thromboembolism (VTE) risk factor were followed up until discharge or 30 days. Exposures: Investigational imaging, prophylactic measures used, and treatment of clots. Main Outcomes and Measures: The main outcomes of interest were the presence, timing, location, and treatment of any pulmonary clots, as well as the associated injury-related risk factors. Secondary outcomes included DVT. We regarded pulmonary clots with DVT as PE and those without DVT as de novo PT. Results: A total of 7880 patients (mean [SD] age, 29.1 [6.4] years; 5859 [74.4%] male) were studied, 277 with DVT (3.5%), 40 with PE (0.5%), and 117 with PT (1.5%). Shock on admission was present in only 460 patients (6.2%) who had no DVT, PT, or PE but was documented in 11 (27.5%) of those with PE and 30 (25.6%) in those with PT. Risk factors independently associated with PT but not DVT or PE included shock on admission (systolic blood pressure <90 mm Hg) (odds ratio, 2.74; 95% CI, 1.72-4.39; P < .001) and major chest injury with Abbreviated Injury Score of 3 or higher (odds ratio, 1.72; 95% CI, 1.16-2.56; P = .007). Factors associated with the presence of PT on admission included major chest injury (14 patients [50.0%] with or without major chest injury with an Abbreviated Injury Score >3; P = .04) and major venous injury (23 [82.1%] without major venous injury and 5 [17.9%] with major venous injury; P = .02). No deaths were attributed to PT or PE. Conclusions and Relevance: To our knowledge, this CLOTT study is the largest prospective investigation in the world that focuses on posttraumatic PT. The study suggests that most pulmonary clots are not embolic but rather result from inflammation, endothelial injury, and the hypercoagulable state caused by the injury itself.

The impact of COVID-19 infection on outcomes after injury in a state trauma system.

BACKGROUND: The COVID-19 pandemic reshaped the health care system in 2020. COVID-19 infection has been associated with poor outcomes after orthopedic surgery and elective, general surgery, but the impact of COVID-19 on outcomes after trauma is unknown. METHODS: We conducted a retrospective cohort study of patients admitted to Pennsylvania trauma centers from March 21 to July 31, 2020. The exposure of interest was COVID-19 (COV+) and the primary outcome was inpatient mortality. Secondary outcomes were length of stay and complications. We compared demographic and injury characteristics between positive, negative, and not-tested patients. We used multivariable regression with coarsened exact matching to estimate the impact of COV+ on outcomes. RESULTS: Of 15,550 included patients, 8,170 (52.5%) were tested for COVID-19 and 219 (2.7%) were positive (COV+). Compared with COVID-19-negative (COV-) patients, COV+ patients were similar in terms of age and sex, but were less often white (53.5% vs. 74.7%, p < 0.0001), and more often uninsured (10.1 vs. 5.6%, p = 0.002). Injury severity was similar, but firearm injuries accounted for 11.9% of COV+ patients versus 5.1% of COV- patients (p < 0.001). Unadjusted mortality for COV+ was double that of COV- patients (9.1% vs. 4.7%, p < 0.0001) and length of stay was longer (median, 5 vs. 4 days; p < 0.001). Using coarsened exact matching, COV+ patients had an increased risk of death (odds ratio [OR], 6.05; 95% confidence interval [CI], 2.29-15.99), any complication (OR, 1.85; 95% CI, 1.08-3.16), and pulmonary complications (OR, 5.79; 95% CI, 2.02-16.54) compared with COV- patients. CONCLUSION: Patients with concomitant traumatic injury and COVID-19 infection have elevated risks of morbidity and mortality. Trauma centers must incorporate an understanding of these risks into patient and family counseling and resource allocation during this pandemic. LEVEL OF EVIDENCE: Level II, Prognostic Study.

Point of care ultrasound facilitated diagnosis of right ventricular mass as the etiology of syncope; A case report of intravenous leiomyomatosis.

Syncope is a common emergency department (ED) chief complaint. Rarely, syncope can be the result of right ventricular outflow obstruction from an intracardiac tumor, such as an intracardiac extension of intravenous leiomyomatosis (IVL). Typically, this type of tumor is confined to the pelvic veins, but in very rare cases, it can extend through the inferior vena cava into the right atrium. Point-of-care ultrasound (POCUS) can be a crucial tool in the ED for identifying intracardiac tumors presenting as syncope and expediting clinical management. We present the case of a 39-year-old female with no prior medical history that presented to the ED having experienced dyspnea on exertion and two syncopal episodes prior to ED admission. POCUS use in the ED elucidated the presence of a right atrial mass and further imaging showed a mass on the patient's uterus. After surgical removal of a portion of the atrial mass, a subsequent biopsy revealed it had leiomyoma-like features; as such, the patient was diagnosed with IVL. This case illustrates the importance of using POCUS in the ED to help determine the etiology of syncope. Although intracardiac extensions of IVL are rare, it is important for emergency physicians to keep this diagnosis in the differential in patients with symptoms or risk factors suggestive of IVL with intracardiac extension.

Right Patient, Right Place, Right Time : Field Triage and Transfer to Level I Trauma Centers.

INTRODUCTION: This study sought to compare outcomes of trauma patients taken directly from the field to a Level I trauma center (direct) versus patients that were first brought to a Level III trauma center prior to being transferred to a Level I (transfer) within our inclusive Delaware trauma system. METHODS: A retrospective review of the Level I center's trauma registry was performed using data from 2013 to 2017 for patients brought to a single Level I trauma center from 2 surrounding counties. The direct cohort consisted of 362 patients, while the transfer cohort contained 204 patients. Linear regression analysis was performed to investigate hospital length of stay (LOS), while logistic regression was used for mortality, complications, and craniotomy. Covariates included age, gender, county, and injury severity score (ISS). Propensity score weighting was also performed between the direct and transfer cohorts. RESULTS: When adjusting for age, gender, ISS, and county, transferred patients demonstrated worse outcomes compared with direct patients in both the regression and propensity score analyses. Transferred patients were at increased risk of mortality (odds ratio [OR] 2.17, CI 1.10-4.37, P = .027) and craniotomy (OR 3.92, CI 1.87-8.72, P < .001). Age was predictive of mortality (P < .001). ISS was predictive of increased risk of mortality (P < .001), increased LOS (P < .001), and craniotomy (P < .001). Older age, Sussex County, and higher ISS were predictive of patients being transferred (P < .001). DISCUSSION: Delays in the presentation to our Level I trauma center resulted in worse outcomes. Patients that meet criteria should be considered for transport directly to the highest level trauma center in the system to avoid delays in care.

Right Patient, Right Place, Right Time: Field Triage and Transfer to Level I Trauma Centers.

INTRODUCTION: This study sought to compare the outcomes of trauma patients taken directly from the field to a level I trauma center (direct) versus patients that were first brought to a level III trauma center prior to being transferred to a level I (transfer) within our inclusive Delaware trauma system. METHODS: A retrospective review of the level I center's trauma registry was performed using data from 2013 to 2017 for patients brought to a single level I trauma center from two surrounding counties. The direct cohort consisted of 362 patients, while the transfer cohort contained 204 patients. Linear regression analysis was performed to investigate hospital length of stay (LOS), while logistic regression was used for mortality, complications, and craniotomy. Covariates included age, gender, county, and injury severity score (ISS). Propensity score weighting was also performed between the direct and transfer cohorts. RESULTS: When adjusting for age, gender, ISS, and county, transferred patients demonstrated worse outcomes compared to direct patients in both the regression and propensity score analyses. Transferred patients were at increased risk of mortality (OR 2.17, CI 1.10-4.37, P = .027) and craniotomy (OR 3.92, CI 1.87-8.72, P < .001). Age was predictive of mortality (P < .001). ISS was predictive of increased risk of mortality (P < .001), increased LOS (P < .001), and craniotomy (P < .001). Older age, Sussex County, and higher ISS were predictive of patients being transferred (P < .001). DISCUSSION: Delays in presentation to our level I trauma center resulted in worse outcomes. Patients that meet criteria should be considered for transport directly to the highest level trauma center in the system to avoid delays in care.

Improving Tracheostomy Decannulation Rate In Trauma Patients.

OBJECTIVE: Identify the effect of a multidisciplinary tracheostomy decannulation protocol (TDP) in the trauma population. DESIGN: Single center retrospective review. SETTING: American College of Surgeons Level 1 Trauma Center; large academic associated community hospital. PATIENTS: Adult trauma patients who required a tracheostomy. INTERVENTIONS: A TDP empowering respiratory therapists to move patients towards tracheostomy decannulation (TD). MEASUREMENTS: TD rate, time to TD, length of stay, reintubation and recannulation rates. MAIN RESULTS: A total of 252 patients met inclusion criteria during the study period with 134 presenting after the TDP was available. Since the TDP was implemented, patients managed by the TDP had a 50% higher chance of TD during the hospital stay (p<0.001). The time to TD was 1 day shorter with the TDP (p=0.54). There was no difference in time to discharge after ventilator liberation (p=0.91) or in discharge disposition (p=0.66). When comparing all patients, the development of a TDP, regardless if a patient was managed by the TDP, resulted in an 18% higher chance of TD (p=0.003). Time to TD was 5 days shorter in the post intervention period (p=0.07). There was no difference in discharge disposition (p=0.88) but the time to discharge after ventilator liberation was shorter post protocol initiation (p=0.04). CONCLUSIONS: In a trauma population, implementation of a TDP significantly improves TD rates during the same hospital stay. A larger population will be required to identify patient predictive factors for earlier successful TD.

Embedding a trauma hospitalist in the trauma service reduces mortality and 30-day trauma-related readmissions.

BACKGROUND: Recognizing the increasing age and comorbid conditions of patients admitted to our trauma service, we embedded a hospitalist on the trauma service at our Level I trauma center.This program was initiated in January 2013. This study was designed to investigate differences in outcomes between trauma patients who received care from the trauma hospitalist (THOSP) program and similarly medically complex trauma patients who did not receive THOSP care. METHODS: There were 566 patients comanaged with THOSP between December 2013 and November 2014. These patients were matched (1:2) with propensity scores to a contemporaneous control group based on age, Injury Severity Score (ISS), and comorbid conditions. Outcomes examined included mortality, trauma-related readmissions, upgrades to the intensive care unit, hospital length of stay, the development of in-hospital complications, and the frequency of obtaining medical subspecialist consultation. Differences in outcomes were compared with Mann-Whitney U-test or χ test as appropriate. RESULTS: High-quality matching resulted in the loss of 97 THOSP patients for the final analysis. Table 1 shows the balance between the two groups after matching. While there was a 1-day increase in hospital length of stay and an increase in upgrades to the intensive care unit, there was a reduction in mortality, trauma-related readmissions, and the development of renal failure after implementation of the THOSP program (Table 2). Implementation of this program made no significant difference in the frequency of cardiology, nephrology, neurology, or endocrinology consultations. There was also no difference in the development of the complications of venous thromboembolism, pneumonia, stroke, urinary tract infection, bacteremia, or alcohol withdrawal. CONCLUSION: Our study provides evidence that embedding a hospitalist on the trauma service reduces mortality and trauma-related readmissions. A reason for these improved outcomes may be related to THOSP "vigilance." LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.

Determining the magnitude of surveillance bias in the assessment of lower extremity deep venous thrombosis: A prospective observational study of two centers.

BACKGROUND: Venous thromboembolism (VTE) remains a significant cause of morbidity and mortality in trauma. Controversy exists regarding the use of lower extremity duplex ultrasound screening and surveillance (LEDUS). Advocates cite earlier diagnosis and treatment of deep venous thrombosis (DVT) to prevent clot propagation and pulmonary embolism (PE). Opponents argue that LEDUS identifies more DVT (surveillance bias) but does not reduce the incidence of PE. We sought to determine the magnitude of surveillance bias associated with LEDUS and test the hypothesis that LEDUS does not decrease the incidence of PE after injury. METHODS: We compared data from two Level 1 trauma centers: Scripps Mercy Hospital, which used serial LEDUS, and Christiana Care Health System, which used LEDUS only for symptomatic patients. Beginning in 2013, both centers prospectively collected data on demographics, injury severity, and VTE risk for patients admitted for more than 48 hours. Both centers used mechanical and pharmacologic prophylaxis based on VTE risk assessment. RESULTS: Scripps Mercy treated 772 patients and Christiana Care treated 454 patients with similar injury severity and VTE risk. The incidence of PE was 0.4% at both centers. The odds of a DVT diagnosis were 5.3 times higher (odds ratio, 5.3; 95% confidence interval, 2.5-12.9; p < 0.0001) for patients admitted to Scripps Mercy than for patients admitted to Christiana Care. Of the 80 patients who developed DVT, PE, or both, 99% received prophylaxis before the event. Among those who received pharmacologic prophylaxis, the VTE rates between the two centers were not statistically significantly different (Scripps Mercy, 11% vs. Christiana Care, 3%; p = 0.06). CONCLUSION: The odds of a diagnosis of DVT are increased significantly when a program of LEDUS is used in trauma patients. Neither pharmacologic prophylaxis nor mechanical prophylaxis is completely effective in preventing VTE in trauma patients. VTE should not be considered a "never event" in this cohort. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III; therapeutic study, level III.

Heparin Decreases in Tumor Necrosis Factor α (TNFα)-induced Endothelial Stress Responses Require Transmembrane Protein 184A and Induction of Dual Specificity Phosphatase 1.

Despite the large number of heparin and heparan sulfate binding proteins, the molecular mechanism(s) by which heparin alters vascular cell physiology is not well understood. Studies with vascular smooth muscle cells (VSMCs) indicate a role for induction of dual specificity phosphatase 1 (DUSP1) that decreases ERK activity and results in decreased cell proliferation, which depends on specific heparin binding. The hypothesis that unfractionated heparin functions to decrease inflammatory signal transduction in endothelial cells (ECs) through heparin-induced expression of DUSP1 was tested. In addition, the expectation that the heparin response includes a decrease in cytokine-induced cytoskeletal changes was examined. Heparin pretreatment of ECs resulted in decreased TNFα-induced JNK and p38 activity and downstream target phosphorylation, as identified through Western blotting and immunofluorescence microscopy. Through knockdown strategies, the importance of heparin-induced DUSP1 expression in these effects was confirmed. Quantitative fluorescence microscopy indicated that heparin treatment of ECs reduced TNFα-induced increases in stress fibers. Monoclonal antibodies that mimic heparin-induced changes in VSMCs were employed to support the hypothesis that heparin was functioning through interactions with a receptor. Knockdown of transmembrane protein 184A (TMEM184A) confirmed its involvement in heparin-induced signaling as seen in VSMCs. Therefore, TMEM184A functions as a heparin receptor and mediates anti-inflammatory responses of ECs involving decreased JNK and p38 activity.

The pediatric trauma center and the inclusive trauma system: Impact on splenectomy rates.

BACKGROUND: Before 2006, the Delaware Trauma System (DTS) did not include a designated pediatric trauma center (PTC). In 2006, the Delaware Trauma System designated and the American College of Surgeons Committee on Trauma verification/consultation program verified Nemours AI DuPont Hospital for Children, a freestanding children's hospital, as a PTC. We evaluated the impact of the addition of the PTC to the state trauma system on pediatric traumatic splenectomy rates. METHODS: The study cohort comprised DTS trauma registry recorded children younger than 16 years with spleen injury (ICD-9 codes 865.0-865.9) from January 1998 through December 2012. This cohort was categorized into pre-PTC (1998-2005) and post-PTC (2006-2012) groups. Penetrating injuries were excluded. Comparisons between groups included age, gender, length of stay, organ-specific injury grade, Injury Severity Score, incidence of polytrauma, splenectomy rate, and admitting hospital. Management, operative versus nonoperative, of low grade (Organ Injury Scale [OIS] score, 1-3) and high grade (OIS score, 4-5) were also compared. Pearson's χ analysis was performed for categorical variables. Continuous variables were reported as mean (standard deviation) and compared by Student's t test for independent normally distributed samples. Mann-Whitney U-test was used for non-normally distributed variables. A value of p < 0.05 was considered significant. RESULTS: Of the 231 pediatric spleen injuries, 118 occurred pre-PTC and 113 occurred post-PTC. There were no significant differences in age, gender, length of stay, Injury Severity Score, OIS grade, or incidence of polytrauma. Splenectomy rates decreased from 11% (13 of 118) pre-PTC to 2.7% (3 of 113) post-PTC (p = 0.012). CONCLUSION: The addition of an American College of Surgeons-verified PTC within an inclusive trauma system that was previously without one was associated with a significant reduction in the rate of blunt trauma-related splenectomy. Integration of a verified PTC is an influential factor in achieving spleen preservation rates equivalent to published American Pediatric Surgery Association benchmarks within a trauma system. LEVEL OF EVIDENCE: Therapeutic study, level IV; epidemiologic study, level III.

Platelet transfusion: a clinical practice guideline from the AABB.

BACKGROUND: The AABB (formerly, the American Association of Blood Banks) developed this guideline on appropriate use of platelet transfusion in adult patients. METHODS: These guidelines are based on a systematic review of randomized, clinical trials and observational studies (1900 to September 2014) that reported clinical outcomes on patients receiving prophylactic or therapeutic platelet transfusions. An expert panel reviewed the data and developed recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. RECOMMENDATION 1: The AABB recommends that platelets should be transfused prophylactically to reduce the risk for spontaneous bleeding in hospitalized adult patients with therapy-induced hypoproliferative thrombocytopenia. The AABB recommends transfusing hospitalized adult patients with a platelet count of 10 × 109 cells/L or less to reduce the risk for spontaneous bleeding. The AABB recommends transfusing up to a single apheresis unit or equivalent. Greater doses are not more effective, and lower doses equal to one half of a standard apheresis unit are equally effective. (Grade: strong recommendation; moderate-quality evidence). RECOMMENDATION 2: The AABB suggests prophylactic platelet transfusion for patients having elective central venous catheter placement with a platelet count less than 20 × 109 cells/L. (Grade: weak recommendation; low-quality evidence). RECOMMENDATION 3: The AABB suggests prophylactic platelet transfusion for patients having elective diagnostic lumbar puncture with a platelet count less than 50 × 109 cells/L. (Grade: weak recommendation; very-low-quality evidence). RECOMMENDATION 4: The AABB suggests prophylactic platelet transfusion for patients having major elective nonneuraxial surgery with a platelet count less than 50 × 109 cells/L. (Grade: weak recommendation; very-low-quality evidence). RECOMMENDATION 5: The AABB recommends against routine prophylactic platelet transfusion for patients who are nonthrombocytopenic and have cardiac surgery with cardiopulmonary bypass. The AABB suggests platelet transfusion for patients having bypass who exhibit perioperative bleeding with thrombocytopenia and/or evidence of platelet dysfunction. (Grade: weak recommendation; very-low-quality evidence). RECOMMENDATION 6: The AABB cannot recommend for or against platelet transfusion for patients receiving antiplatelet therapy who have intracranial hemorrhage (traumatic or spontaneous). (Grade: uncertain recommendation; very-low-quality evidence).

Long-term outcome in elderly patients after operation for traumatic intracranial hemorrhage.

OBJECTIVE: This study examined outcomes in elderly TBI patients who underwent a cranial operation. METHODS: We identified TBI patients > or = 65 who underwent a cranial operation from January 1, 2004 to December 31, 2008. Data collected included: age, admission GCS, mechanism of injury, ISS, Head AIS, type of operation, hemorrhage acuity, time to operation, pre-hospital warfarin or clopidogrel, and in-hospital death. Survivors were contacted by phone to determine an Extended Glasgow Outcome Score (GOSE). A favorable outcome was defined as having a GOSE of > or = 5 at follow-up, an unfavorable outcome was defined as: in-hospital death, death within one year of injury, and a GOSE < 5 at follow-up. Chi-square and student's t-test were used. RESULTS: One hundred sixty-four elderly TBI patients underwent cranial surgery. Mean age was 79.2 +/- 7.6 years. Most patients: had a ground level fall (86.0%), suffered a subdural hematoma (95.1%), and underwent craniotomy (89.0%). Twenty-eight percent died in the hospital and another 20.1% died within one year. Fifty-six patients were eligible for a GOSE interview of these: 17 were lost to follow-up, seven refused the GOSE interview, 22 had a GOSE > or = 5, and ten had a GOSE < 5. Mean follow-up was 42.6 +/- 14.9 months. Of all the factors analyzed, only older age was associated with an unfavorable outcome. CONCLUSIONS: While age was associated with outcome, we were unable to demonstrate any other early factors that were associated with long-term functional outcome in elderly patients that underwent a cranial operation for TBI.

Management of bleeding and reversal strategies for oral anticoagulants: clinical practice considerations.

PURPOSE: Currently available clinical data and optimal strategies for reversing oral anticoagulants in patients who are bleeding or need an urgent invasive procedure or operation are reviewed. SUMMARY: Bleeding from oral anticoagulants, including new target-specific oral agents (TSOAs), is a common cause of morbidity and mortality, especially in elderly patients. Limited clinical data are available to guide the reversal of warfarin or TSOAs in patients who are bleeding or need an urgent invasive procedure or operation. A panel of five experts with diverse backgrounds in anticoagulation therapy, cardiology, critical care, and emergency medicine and with experience in managing complications of anticoagulation therapy was convened to develop practical strategies for managing patients receiving oral anticoagulants who are bleeding or have an urgent need for an invasive procedure. The strategies were designed to guide clinicians in the acute care setting by providing efficient and potentially effective management concepts to avoid delays in initiating treatment that could adversely affect patient outcomes. The consensus of this expert panel is summarized herein. Recommendations are based on currently available evidence from a comprehensive review of the literature and other pertinent data, along with the experience and expert opinion of the panelists. CONCLUSION: Bleeding is a serious complication of the use of oral anticoagulants, and limited information is available to guide the reversal of warfarin or TSOAs in patients who are bleeding or are in need of an urgent invasive procedure. Use of a systematic approach to assessing and treating these patients based on available evidence and expert opinion can help avoid delays that could adversely affect patient outcomes.

Fracture of the humeral neck with intrathoracic dislocation of the humeral head.

Intrathoracic fracture-dislocation of the humeral neck is a rare and easily overlooked clinical entity. We present a case and review of the literature. The objective of this study was to summarize the clinical presentation of this injury and to provide recommendations for initial diagnostic imaging and management. A 68-year-old man presented to the Emergency Department after a fall onto an abducted arm with moderate respiratory distress, mild left shoulder pain, and palpable crepitus over the shoulder and chest wall. Radiographic examination demonstrated the humeral head to be lying within the left hemithorax, devoid of any attachments to the remaining proximal humerus. After initial stabilization, the patient underwent surgical excision of the humeral head and delayed hemiarthroplasty. Careful attention to radiographic studies is required to recognize this injury. Initial management centers on airway management, adjunctive imaging, and treatment of any associated injuries followed by surgical excision and proximal humeral reconstruction.

Odontoid fractures in the elderly: should we operate?

BACKGROUND: : Treatment of odontoid fractures remains controversial. There are conflicting data in the literature with regard to timing of operative fixation (OP), as well as whether OP should be performed. Within our own institution, treatment is variable depending largely on surgeon preference. This study was undertaken in an attempt to develop management consensus by examining outcomes in elderly patients with odontoid fractures and comparing OP to a nonoperative (non-OP) approach. METHODS: : The trauma registry of our level I trauma center was queried for elderly (age > or = 60) patients with odontoid fractures from January 2000 to May 2006. Patients were then grouped according to treatment, early-OP (< or =3 days posttrauma), late-OP (>3 days), or non-OP treatment. Patient characteristics that were evaluated and compared among the three groups included age, Injury Severity Score, preexisting conditions, and the type of odontoid fracture. Outcomes evaluated included in-hospital mortality, ventilator days, hospital length of stay (HLOS), need for tracheostomy and percutaneous endoscopic gastrostomy (PEG), and the complications of urinary tract infection (UTI), deep vein thrombosis (DVT), and pneumonia. Differences among groups were tested using analysis of variance, Students t test, chi, and Fishers exact test. RESULTS: : The non-OP patients were significantly older than either operative group (mean, 82.4 for non-OP; 77.4 for early-OP; and 76.4 for late-OP; p = 0.006 non-OP compared with either operative group). Injury Severity Score, number of preexisting conditions, mechanism of injury, and distribution of type of odontoid fractures were similar among all three groups. There was no statistically significant difference in mortality among the three groups (11.7% early-OP, 8.7% late-OP, and 17.6% non-OP). There was also no difference among all three groups with respect for the need for tracheostomy and PEG and the development of UTI or pneumonia. However, there were significantly less DVTs in the non-OP group compared with the early-OP group (2.9% vs. 17.6%, p = 0.02). The percentage of patients discharged to a skilled nursing facility was similar among all three groups. The non-OP group had a significant decrease in both ventilator days and HLOS when compared with the operative groups. Only 2.9% of non-OP patients returned for OP for nonunion of the odontoid fracture. CONCLUSIONS: : Despite being an older population, elderly patients with odontoid fracture who were managed non-OP had similar mortality, UTI, and pneumonia rates compared with their younger counterparts who underwent OP. The need for tracheostomy and PEG and discharge disposition was similar among all three groups. Elderly patients with odontoid fracture managed non-OP had a reduction in HLOS and ventilator days compared with either operative group and less DVT compared with the early operative group. Based on these results, non-OP management should be given strong consideration in elderly patients with traumatic odontoid fractures.

Hepatic angioembolization in trauma patients: indications and complications.

BACKGROUND: Hepatic angiography (HA) and hepatic angioembolization (HAE) are increasingly used to diagnose and treat intrahepatic arterial injuries. This study was performed to review indications, outcomes, and complications of HA/HAE in blunt trauma patients who underwent HAE as adjunct management of hepatic injury. METHODS: A retrospective review of consecutive cases of HA/HAE at a Level I trauma center during an 8-year period. Data include demographics, physiologic condition, liver injury grade, HA/HAE indications, outcomes, morbidity, and mortality. RESULTS: Seventy-nine patients underwent diagnostic HA; 31 (39%) had subsequent HAE. Fifty-eight hemodynamically stable patients had computerized axial tomographic (CT) scan followed by HA. HA was performed for contrast blush on CT in 30 (52%) of 58 patients, high-grade liver injury in 4 (7%), subsequent hemodynamic instability in 15 (27%), and angiography planned for other purpose in 9 (17%). HA confirmed arterial injury and led to HAE in 50% of patients with contrast blush on CT or high-grade liver injury. HA was negative when performed for hemodynamic instability or for other primary purposes. Twenty-one hemodynamically unstable patients underwent emergent laparotomy followed by postoperative HA with 11 (50%) requiring HAE. Overall mortality in HAE group was 16%, and liver-related morbidity was 29% usually presenting as gallbladder or liver necrosis. CONCLUSION: HA/HAE should be used when CT scan suggests associated intrahepatic arterial or high-grade injury in the management of hepatic injuries and should also be considered after laparotomy and perihepatic packing to control inaccessible intrahepatic hemorrhage. Mortality related to HAE is uncommon, but morbidity occurs frequently.

Clinical practice guideline: red blood cell transfusion in adult trauma and critical care.

OBJECTIVE: To develop a clinical practice guideline for red blood cell transfusion in adult trauma and critical care. DESIGN: Meetings, teleconferences and electronic-based communication to achieve grading of the published evidence, discussion and consensus among the entire committee members. METHODS: This practice management guideline was developed by a joint taskforce of EAST (Eastern Association for Surgery of Trauma) and the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM). We performed a comprehensive literature review of the topic and graded the evidence using scientific assessment methods employed by the Canadian and U.S. Preventive Task Force (Grading of Evidence, Class I, II, III; Grading of Recommendations, Level I, II, III). A list of guideline recommendations was compiled by the members of the guidelines committees for the two societies. Following an extensive review process by external reviewers, the final guideline manuscript was reviewed and approved by the EAST Board of Directors, the Board of Regents of the ACCM and the Council of SCCM. RESULTS: Key recommendations are listed by category, including (A) Indications for RBC transfusion in the general critically ill patient; (B) RBC transfusion in sepsis; (C) RBC transfusion in patients at risk for or with acute lung injury and acute respiratory distress syndrome; (D) RBC transfusion in patients with neurologic injury and diseases; (E) RBC transfusion risks; (F) Alternatives to RBC transfusion; and (G) Strategies to reduce RBC transfusion. CONCLUSIONS: Evidence-based recommendations regarding the use of RBC transfusion in adult trauma and critical care will provide important information to critical care practitioners.