Recent changes in practice patterns and outcomes in patients with severe traumatic brain injury.

BACKGROUND: Despite recent advances in the management of severe traumatic brain injury, the role of decompressive craniectomy remains unclear. The purpose of this study was to compare practice patterns and patient outcomes between 2 study periods over the past decade. METHODS: This is a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Project database. We included patients (age ≥18 years) with isolated severe traumatic brain injury. The patients were divided into the early (2013-2014) and late (2017-2018) groups. The primary outcome was the rate of craniectomy, and secondary outcomes included in-hospital mortality and discharge disposition. A subgroup analysis of patients undergoing intracranial pressure monitoring was also performed. A multivariable logistic regression analysis assessed the association between the early/late period and study outcomes. RESULTS: A total of 29,942 patients were included. In the logistic regression analysis, the late period was associated with decreased use of craniectomy (odds ratio: 0.58, P < .001). Although the late period was associated with higher in-hospital mortality (odds ratio: 1.10, P = .013), it was also associated with a higher likelihood of discharge to home/rehab (odds ratio: 1.61, P < .001). Similarly, the subgroup analysis of patients with intracranial pressure monitoring showed that the late period was associated with a lower craniectomy rate (odds ratio: 0.26, P < .001) and a higher likelihood of discharge to home/rehab (odds ratio:1.98, P < .001). CONCLUSION: The use of craniectomy for severe traumatic brain injury has decreased over the study period. Although further studies are warranted, these trends may reflect recent changes in the management of patients with severe traumatic brain injury.

Disparities in Care Among Gunshot Victims: A Nationwide Analysis.

INTRODUCTION: Given the well-known healthcare disparities most pronounced in racial and ethnic minorities, trauma healthcare in underrepresented patients should be examined, as in-hospital bias may influence the care rendered to patients. This study seeks to examine racial differences in outcomes and resource utilization among victims of gunshot wounds in the United States. METHODS: This is a retrospective review of the National Trauma Data Bank (NTDB) conducted from 2007 to 2017. The NTDB was queried for patients who suffered a gunshot wound not related to accidental injury or suicide. Patients were stratified according to race. The primary outcome for this study was mortality. Secondary outcomes included racial differences in resource utilization including air transport and discharge to rehabilitation centers. Univariate and multivariate analyses were used to compare differences in outcomes between the groups. RESULTS: A total of 250,675 patients were included in the analysis. After regression analysis, Black patients were noted to have greater odds of death compared to White patients (odds ratio [OR] 1.14, confidence interval [CI] 1.037-1.244; P = 0.006) and decreased odds of admission to the intensive care unit (ICU) (OR 0.76, CI 0.732-0.794; P < 0.001). Hispanic patients were significantly less likely to be discharged to rehabilitation centers (Hispanic: 0.78, CI 0.715-0.856; P < 0.001). Black patients had the shortest time to death (median time in minutes: White 49 interquartile range [IQR] [9-437] versus Black 24 IQR [7-205] versus Hispanic 39 IQR [8-379] versus Asian 60 [9-753], P < 0.001). CONCLUSIONS: As society carefully examines major institutions for implicit bias, healthcare should not be exempt. Greater mortality among Black patients, along with differences in other important outcome measures, demonstrate disparities that encourage further analysis of causes and solutions to these issues.

Hodgkin lymphoma masquerading as perforated gallbladder adenocarcinoma: A case report.

BACKGROUND: There are several case reports of acute cholecystitis as the initial presentation of lymphoma of the gallbladder; all reports describe non-Hodgkin lymphoma or its subtypes on histopathology of the gallbladder tissue itself. Interestingly, there is no description in the literature of Hodgkin lymphoma causing hilar lymphadenopathy, inevitably presenting as ruptured cholecystitis with imaging mimicking gallbladder adenocarcinoma. CASE SUMMARY: A 48-year-old man with a past medical history of diabetes mellitus presented with progressive abdominal pain, jaundice, night sweats, weakness, and unintended weight loss for one month. Work-up revealed a mass in the region of the porta hepatis causing obstructions of the cystic and common hepatic ducts, gallbladder rupture, as well as retroperitoneal lymphadenopathy. The clinical picture and imaging findings were suspicious for locally advanced gallbladder adenocarcinoma causing ruptured cholecystitis and cholangitis, with metastases to retroperitoneal lymph nodes. Minimally invasive techniques, including endoscopic duct brushings and percutaneous lymph node biopsy, were inadequate for tissue diagnosis. Therefore, this case required exploratory laparotomy, open cholecystectomy, and periaortic lymph node dissection for histopathological assessment and definitive diagnosis. Hodgkin lymphoma was present in the lymph nodes while the gallbladder specimen had no evidence of malignancy. CONCLUSION: This clinical scenario highlights the importance of histopathological assessment in diagnosing gallbladder malignancy in a patient with gallbladder perforation and a grossly positive positron emission tomography/computed tomography scan. For both gallbladder adenocarcinoma and Hodgkin lymphoma, medical and surgical therapies must be tailored to the specific disease entity in order to achieve optimal long-term survival rates.

Gluteal Necrotizing Soft Tissue Infection and Hip Osteomyelitis due to Candida Glabrata.

BACKGROUND: Necrotizing soft tissue infection (NSTI) is a rapidly progressive and often fatal infection of the soft tissue. Classically, it is attributed to bacterial infection and immunocompromised patients are particularly vulnerable. However, NSTI due to fungal infection rarely does occur, including from Candida species, and can pose a diagnostic challenge for unfamiliar providers. Expedient clinical recognition, surgical debridement, fungal tissue culture, and initiation of antifungal therapy are key. CASE PRESENTATION: We report a 39-year-old obese male with long-standing history of poorly controlled diabetes who presented to a community hospital, noted to have NSTI of the sacrum, bilateral buttocks, and left hip, and was treated only with antibiotics. After transfer to an academic center, the patient underwent aggressive debridement and tissue diagnosis of Candida glabrata NSTI was made. He received broad-spectrum antibiotic and antifungal therapy for several months. Over the course of 4 months, his infection was cleared, and his large tissue defects were reconstructed with rotation flaps and the patient was discharged home. CONCLUSIONS: Fungal NSTI is a rare entity, especially when due to Candida species. It can be exceedingly difficult to diagnose and manage, as these patients may suffer higher mortality than those with NSTI due to bacteria. A high index of suspicion for the entity, rapid debridement, intraoperative tissue culture, and treatment with appropriate antifungal therapy offers the greatest chance of survival.

Extracorporeal Membrane Oxygenation May Improve Outcomes After Resuscitative Thoracotomy: A National Trauma Data Bank Analysis.

BACKGROUND: Albeit low survival rates, resuscitative thoracotomy (RT) is considered standard for selected trauma patients. Because it has potential for rapid cardiopulmonary rescue, extracorporeal membrane oxygenation (ECMO) may augment RT. The aim of this study was to identify the impact of ECMO on trauma patients that recently underwent RT after injury. STUDY DESIGN: All patients who underwent RT were identified from the National Trauma Data Bank (2007-2017). Patients were excluded if they died within 60 minutes, underwent delayed ECMO, and/or had missing data. Delayed ECMO group was defined as those patients undergoing ECMO after 1 hour following RT. RESULTS: Out of 8 694 272 injured patients, 10 106 (.1%) underwent RT. Median age was 31 years [23-45], 86% male. Penetrating injury was the dominant mechanism (62%). Of these, .6% (23) underwent immediate ECMO. Extracorporeal membrane oxygenation patients were significantly younger (23[17-33] vs. 31[23-46], p .003) and had significantly higher chest abbreviated injury scale scores (5[4-5] vs. 3[3-4], P < .001). Extracorporeal membrane oxygenation patients achieved significantly higher rate of return of spontaneous circulation (96% vs. 70%, p .007) and had nonsignificant trend of improved mortality (52% vs. 63%, p .260). CONCLUSION: Immediate ECMO may be a useful therapeutic modality after RT. It achieves higher ROSC rates with opportunity for improved survival. Future prospective study is warranted.

Selective Computed Tomography (CT) Imaging is Superior to Liberal CT Imaging in the Hemodynamically Normal Pediatric Blunt Trauma Patient.

BACKGROUND: The optimal imaging strategy in hemodynamically stable pediatric blunt trauma remains to be defined. The purpose of this study was to determine the differences between selective and liberal computed tomography (CT) strategy in a pediatric trauma population with respect to radiation exposure and outcomes. METHODS: We performed a retrospective analysis of hemodynamically stable blunt pediatric trauma patients (≤16 y) who were admitted to a Level I trauma center between 2013-2016. Patients were stratified into selective and liberal imaging cohorts. Univariate and multivariate regression analyses were used to compare outcomes between the groups. Outcomes included radiation dose, hospital and ICU length of stay, complications and mortality. RESULTS: Of the 485 patients included, 176 underwent liberal and 309 selective CT imaging. The liberal cohort were more likely to be severely injured (ISS>15: 34.1 versus 8.4%, P< 0.001). The odds of exposure to a radiation dose of >15 mSv were higher with liberal scanning in patients with both ISS > 15 (OR 2.78, 95% CI 1.76-5.19, P< 0.001) and ISS ≤ 15 (OR 3.41, 95% CI 2.19-8.44, P < 0.001). Adjusted outcomes regarding mortality, ICU length of stay, and complications were similar between the cohorts. CONCLUSION: Selective CT imaging in hemodynamically stable blunt pediatric trauma patients was associated with reduced radiation exposure and similar outcomes when compared to a liberal CT strategy.

Extracorporeal support for trauma: A trauma quality improvement project (TQIP) analysis in patients with acute respiratory distress syndrome.

INTRODUCTION: The use of extracorporeal membrane oxygenation (ECMO) in trauma patients with severe acute respiratory distress syndrome (ARDS) continues to evolve. The objective of this study was to perform a comparative analysis of trauma patients with ARDS who received ECMO to a propensity matched cohort of patients who underwent conventional management. METHODS: The Trauma Quality Improvement Program (TQIP) database was queried from 2013 to 2016 for all patients with ARDS and those who received ECMO. Demographics, as well as clinical, injury, intervention, and outcome data were collected and analyzed. Patients with ARDS were divided into two groups, those who received ECMO and those who did not. A propensity score analysis was performed using the following criteria: age, gender, vital signs (HR, SBP) and GCS on admission, Injury Severity Score (ISS), and Abbreviated Injury Scale (AIS) score in several body regions. Outcomes between the groups were subsequently compared using univariate as well as Cox regression analyses. Secondary outcomes such as hospitalization (HLOS), ICU length-of-stay (LOS) and ventilation days stratified for patient demographics, timing of ECMO and anticoagulation status were compared. RESULTS: Over the 3-year study period, 8990 patients with ARDS were identified from the TQIP registry. Following exclusion, 3680 were included in the final analysis, of which 97 (2.6%) received ECMO. On univariate analysis following matching, patients who underwent ECMO had lower overall hospital mortality (23 vs 50%, p < 0.001) with higher rates of complications (p < 0.005), including longer HLOS. In those undergoing ECMO, early initiation (<7 days) was associated with shorter HLOS, ICU LOS, and fewer ventilator days. No difference was observed between the two groups with regard to anticoagulation. CONCLUSION: Extracorporeal membrane oxygenation use in trauma patients with ARDS may be associated with improved survival, especially for young patients with thoracic injuries, early in the course of ARDS. Anticoagulation while on circuit was not associated with increased risk of hemorrhage or mortality, even in the setting of head injuries. The mortality benefit suggested with ECMO comes at the expense of a potential increase in complication rate and prolonged hospitalization.

Increased Incidence of COVID-19 Infections Amongst Interpersonal Violence Patients.

OBJECTIVE: To investigate whether any specific acute care surgery patient populations are associated with a higher incidence of COVID-19 infection. BACKGROUND: Acute care providers may be exposed to an increased risk of contracting the COVID-19 infection since many patients present to the emergency department without complete screening measures. However, it is not known which patients present with the highest incidence. METHODS: All acute care surgery (ACS) patients who presented to our level I trauma center between March 19, 2020, and September 20, 2020 and were tested for COVID-19 were included in the study. The patients were divided into two cohorts: COVID positive (+) and COVID negative (-). Patient demographics, type of consultation (emergency general surgery consults [EGS], interpersonal violence trauma consults [IPV], and non-interpersonal violence trauma consults [NIPV]), clinical data and outcomes were analyzed. Univariate and multivariate analyses were used to compare differences between the groups. RESULTS: In total, 2177 patients met inclusion criteria. Of these, 116 were COVID+ (5.3%) and 2061 were COVID- (94.7%). COVID+ patients were more frequently Latinos (64.7% versus 61.7%, P = 0.043) and African Americans (18.1% versus 11.2%, P < 0.001) and less frequently Caucasian (6.0% versus 14.1%, P < 0.001). Asian/Filipino/Pacific Islander (7.8% versus 7.2%, P = 0.059) and Native American/Other/Unknown (3.4% versus 5.8%, P = 0.078) groups showed no statistical difference in COVID incidence. Mortality, hospital and ICU lengths of stay were similar between the groups and across patient populations stratified by the type of consultation. Logistic regression demonstrated higher odds of COVID+ infection amongst IPV patients (OR 2.33, 95% CI 1.62-7.56, P < 0.001) compared to other ACS consultation types. CONCLUSION: Our findings demonstrate that victims of interpersonal violence were more likely positive for COVID-19, while in hospital outcomes were similar between COVID-19 positive and negative patients.

Increased Use of Prehospital Tourniquet and Patient Survival: Los Angeles Countywide Study.

BACKGROUND: Recent trends in prehospital tourniquet use remain underreported. In addition, the impact of prehospital tourniquet use on patient survival has not been evaluated in a population-level study. We hypothesized that prehospital tourniquets were used more frequently in Los Angeles County and their use was associated with improved patient survival. STUDY DESIGN: This is a retrospective cohort study using a database maintained by the Los Angeles County Emergency Medical Services Agency. We included patients who sustained extremity vascular injuries between October 2015 and July 2019. Patients were divided into the following study groups: prehospital tourniquet and no-tourniquet group. Our primary end point was in-hospital mortality. The secondary outcomes included 4- and 24-hour transfusion requirements and delayed amputation. RESULTS: A total of 944 patients met our inclusion criteria. Of those, 97 patients (10.3%) had prehospital tourniquets placed. The rate of tourniquet use increased linearly throughout our study period (goodness of fit, p = 0.014). In multivariable analysis, prehospital tourniquet use was significantly associated with improved mortality (adjusted odds ratio 0.32; 95% CI, 0.16 to 0.85; p = 0.032). Similarly, transfusion requirements were significantly lower within 4 hours (regression coefficient -547.76; 95% CI, -762.73 to -283.49; p < 0.001) and 24 hours (regression coefficient -1,389.82; 95% CI, -1,824.88 to -920.97; p < 0.001). There was no significant difference in delayed amputation rates (adjusted odds ratio 1.07; 95% CI, 0.21 to 10.88; p < 0.097). CONCLUSIONS: Prehospital tourniquet use has been on the rise in Los Angeles County. Our results suggest that the use of prehospital tourniquets for extremity vascular injuries is associated with improved patient survival and decreased blood transfusion requirements, without an increase in delayed amputations.

Prehospital Needle Decompression Improves Clinical Outcomes in Helicopter Evacuation Patients With Multisystem Trauma: A Multicenter Study.

BACKGROUND: The utility of prehospital thoracic needle decompression (ND) for tension physiology in the civilian setting continues to be debated. We attempted to provide objective evidence for clinical improvement when ND is performed and determine whether technical success is associated with provider factors. We also attempted to determine whether certain clinical scenarios are more predictive than others of successful improvement in symptoms when ND is performed. METHODS: Prehospital ND data acquired from one air ambulance service serving 79 trauma centers consisted of 143 patients (n = 143; ND attempts = 172). Demographic and clinical outcome data were retrospectively reviewed. Patients were stratified by prehospital characteristics and indications. Objective outcomes were measured as improvement in vital signs, subjective patient assessment, and physical examination findings. Univariate analysis was performed using chi-square for variable proportions and unpaired Student's t-test for variable means; p < .05 was considered statistically significant. RESULTS: The success rate of ND performed for hypoxia (70.5%) was notably higher than ND performed for hemodynamic instability (20.3%; p < .01) or cardiac arrest (0%; p < .01). Compared to vital sign parameters, clinical examination findings as part of the indication for ND did not reliably predict technical success (p > .52 for all indications). No difference was observed comparing registered nurse versus paramedic (p = .23), diameter of catheter (p > .13 for all), or length of catheter (p = .12). CONCLUSION: Prehospital ND should be considered in the appropriate clinical setting. Outcomes are less reliable in cases of cardiopulmonary arrest or hypotension with respiratory symptoms; however, this should not deter prehospital providers from attempting ND when clinically indicated. Additionally, the success rate of prehospital ND does not appear to be related to catheter type or the role of the performing provider.

Trends in Trauma Admissions During the COVID-19 Pandemic in Los Angeles County, California.

Importance: Describing the changes in trauma volume and injury patterns during the course of the coronavirus disease 2019 (COVID-19) pandemic could help to inform policy development and hospital resource planning. Objective: To examine trends in trauma admissions throughout Los Angeles County (LAC) during the pandemic. Design, Setting, and Participants: In this cohort study, all trauma admissions to the 15 verified level 1 and level 2 trauma centers in LAC from January 1 to June 7, 2020 were reviewed. All trauma admissions from the same period in 2019 were used as historical control. For overall admissions, the study period was divided into 3 intervals based on daily admission trend analysis (January 1 through February 28, March 1 through April 9, April 10 through June 7). For the blunt trauma subgroup analysis, the study period was divided into 3 similar intervals (January 1 through February 27, February 28 through April 5, April 6 through June 7). Exposures: COVID-19 pandemic. Main Outcomes and Measures: Trends in trauma admission volume and injury patterns. Results: A total of 6777 patients in 2020 and 6937 in 2019 met inclusion criteria. Of those admitted in 2020, the median (interquartile range) age was 42 (28-61) years and 5100 (75.3%) were men. Mechanisms of injury were significantly different between the 2 years, with a higher incidence of penetrating trauma and fewer blunt injuries in 2020 compared with 2019 (penetrating: 1065 [15.7%] vs 1065 [15.4%]; blunt: 5309 [78.3%] vs 5528 [79.7%]). Overall admissions by interval in 2020 were 2681, 1684, and 2412, whereas in 2019 they were 2462, 1862, and 2613, respectively. There was a significant increase in overall admissions per week during the first interval (incidence rate ratio [IRR], 1.02; 95% CI, 1.002-1.04; P = .03) followed by a decrease in the second interval (IRR, 0.92; 95% CI, 0.90-0.94; P < .001) and, finally, an increase in the third interval (IRR, 1.05; CI, 1.03-1.07; P < .001). On subgroup analysis, blunt admissions followed a similar pattern to overall admissions, while penetrating admissions increased throughout the study period. Conclusions and Relevance: In this study, trauma centers throughout LAC experienced a significant change in injury patterns and admission trends during the COVID-19 pandemic. A transient decrease in volume was followed by a quick return to baseline levels. Trauma centers should prioritize maintaining access, capacity, and functionality during pandemics and other national emergencies.

Utility of the Laboratory Risk Indicator for Necrotizing Fasciitis Score: Comorbid Conditions Do Matter.

Background: The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) has been proposed as a diagnostic tool for necrotizing soft tissue infection (NSTI). However, its utility remains underreported, particularly in patients with comorbid conditions. The purpose of this study was to identify the test characteristics of LRINEC for patients with various comorbid conditions. Patients and Methods: We conducted a retrospective study including patients with suspected NSTI. Our study patients were then relegated into the subgroups; intravenous drug use (IVDU), end-stage liver disease (ESLD), and diabetes mellitus (DM). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a positive LRINEC score (≥ 6 or 8) were calculated in reference to intra-operative findings or results of the pathologic examination. Area under the curve (AUC) using receiver operating characteristic (ROC) plots were compared between each subgroup and the overall study population using DeLong test. Results: A total of 220 patients were included for the analysis. Overall, the sensitivity was 76%, specificity of 52%, PPV of 32%, and NPV of 88%. The subgroup analysis showed low PPVs in all subgroups. The DM and ESLD groups had a high NPV (90.5% and 88.0%, respectively), whereas NPV in the IVDU group was 70.6%. The AUC and DeLong test for the subgroups were 0.649 (p = 0.902) for ESLD, 0.699 (p = 0.683) for DM, and 0.565 (p = 0.034) for IVDU. Conclusions: The LRINEC can be a useful adjunct to rule out the diagnosis of NSTI with exception of IVDU. In contrast, further diagnostic workup might be still required in those patients with positive LRINEC.

Rapidly fatal necrotizing soft tissue infection due to Clostridium sordellii in an injection drug user.

Clostridium sordellii infections are known to be associated with high morbidity and mortality. To date, only a small number of cases with necrotizing soft tissue infection due to C. Sordellii have been reported. We report a case presented with necrotizing soft tissue infection of the right upper extremity caused by C. sordellii in a patient with known use of injected heroin. Despite broad spectrum antibiotics and surgical debridement, the patient's clinical course became rapidly fatal, within 24 h of admission. C. sordellii necrotizing soft tissue infections are particularly virulent. Even in the context of appropriate surgical debridement, these infections can be rapidly fatal. This case highlights the importance of high suspicion for C. sordellii as potential pathogen of necrotizing soft tissue infection in injection drug users.

A Novel Abdominal Decompression Technique to Treat Compartment Syndrome After Burn Injury.

BACKGROUND: Prevalence of abdominal compartment syndrome (ACS) is estimated to be 4%-17% in severely burned patients. Although decompressive laparotomy can be lifesaving for ACS patients, severe complications are associated with this technique, especially in burn populations. This study outlines a new technique of releasing intraabdominal pressure without resorting to decompressive laparotomy. MATERIALS AND METHODS: Ten fresh tissue cadavers were studied; none of whom had had prior abdominal surgery. Using Veress needles, abdomens were insufflated to 30 mm Hg and subsequently connected to arterial pressure transducers. Two techniques were then used to incise fascia. First, large skin flaps were raised from a midline incision (n = 5). Second, small 2 cm cutdowns at the proximal and distal extent of midaxillary, subcostal, and inguinal incisional sites were made, followed by tunneling a subfascial plane using an aortic clamp with fascial incisions made through the grooves of a tunneled vein stripper (n = 5). Pressures were recorded in the sequence of incisions mentioned previously. RESULTS: The open midline flap technique decreased abdominal pressure from a mean pressure of 30 ± 1.8 mm Hg to 6.9 ± 5.0 mm Hg (P < 0.01). The minimally invasive technique decreased intraabdominal pressure from 30 ± 0.9 to 5.8 ± 5.2 mm Hg (P < 0.01). This technique significantly reduced intraabdominal pressure via extraperitoneal component separation and fascial release at the midaxillary, subxiphoid, and inguinal regions. CONCLUSIONS: This technique offers the benefit of reducing the morbidity, mortality, and complications associated with an open abdomen, which may be beneficial in the burn injury population.