The Silent Majority of Emergency General Surgery: An Assessment of Consult and Operative Volumes.

BACKGROUND: Defining the work performed by emergency general surgery (EGS) surgeons has relied on quantifying surgical interventions, failing to include nonsurgical management performed. The purpose of this study was to identify the extent of operative and nonoperative patient management provided by an EGS service line in response to consults from other hospital providers. METHODS: This is a retrospective descriptive study of all adult patients with an EGS consult request placed from July 1, 2014 to June 30, 2016 at a 1000-bed tertiary referral center. Consult requests were classified by suspected diagnosis and linked to patient demographic and clinical information. Operative and nonoperative cases were compared. RESULTS: About 4998 EGS consults were requested during the 2-y period, of which 69.6% were placed on the first day of the patient encounter. Disposition outcomes after consultation included admission to the EGS service (27.6%) and discharge from the emergency department (25.3%). Small bowel obstruction, appendicitis, and cholecystitis decisively comprised the top three diagnoses for overall consults and those requiring admission to the EGS service. For every consult requiring an operation (n = 1400), 2.6 consults were managed without an operation (n = 3598). CONCLUSIONS: EGS surgeons are asked to evaluate and manage a variety of potentially surgical diagnoses. As most consults do not require surgical intervention, operative volume is a poor surrogate for quantifying EGS productivity. The role of this service is vital to patient triage and disposition, particularly in the emergency department setting. Institutions should consider the volume of their nonoperative consultations when evaluating EGS service line workload and in guiding staffing needs.

Impact of a New Helicopter Base on Transport Time and Survival in a Rural Adult Trauma Population.

BACKGROUND: Significant disparities in access to prompt helicopter transport exist among rural trauma populations. We evaluated the impact of an additional helicopter base on transport time and mortality in a rural adult trauma population. MATERIALS AND METHODS: We performed a retrospective cohort study of adult patients with trauma transported by helicopter from scene to a level one trauma center between 2014 and 2018. A new rural helicopter base added to the trauma center's catchment area in 2016 served as the transition time for an interrupted time series analysis. Patients injured in this base's county and adjoining counties were analyzed. Baseline characteristics were compared with a Student's t-test and Pearson's chi-squared test. Cox and linear regression models evaluated the new base's effect on mortality and transport time, respectively. RESULTS: A total of 332 patients were analyzed: 120 (36.1%) transported before the addition of the new helicopter base and 212 (63.9%) transported after. Patients transported after the addition of the base had higher injury severity score (13.7 versus 10.1, P < 0.001) and were more likely to receive blood en route (19.3% versus 6.7%, P = 0.005). After the addition of the base, there was a decreased hazard ratio for mortality (hazard ratio 0.26, 95% confidence interval: 0.11-0.65, P = 0.004) with no significant change in transport time (-36.7 min, P = 0.071) for the area. CONCLUSIONS: Local helicopter transport units may confer improved survival for the injured patient. This study demonstrates the important role of helicopter transport within a regional trauma system and the impact that expanded access to rapid air transport can have on mortality.

Musculoskeletal Trauma in Critically Injured Patients: Factors Leading to Delayed Operative Fixation and Multiple Organ Failure.

BACKGROUND: Musculoskeletal injuries are common following trauma and variables that are associated with late femur fracture fixation are important to perioperative management. Furthermore, the association of late fracture fixation and multiple organ failure (MOF) is not well defined. METHODS: We performed a retrospective cohort investigation from 2 academic trauma centers. INCLUSION CRITERIA: age 18-89 years, injury severity score (ISS) >15, femoral shaft fracture requiring operative fixation, and admission to the intensive care unit >2 days. Admission physiology variables and abbreviated injury scale (AIS) scores were obtained. Lactate was collected as a marker of shock and was described as admission lactate (LacAdm) and as 24-hour time-weighted lactate (LacTW24h), which reflects an area under the curve and is considered a marker for the overall depth of shock. The primary aim was to evaluate clinical variables associated with late femur fracture fixation (defined as ≥24 hours after admission). A multivariable logistic regression model tested variables associated with late fixation and is reported by odds ratio (OR) with 95% confidence interval (CI). The secondary aim evaluated the association between late fixation and MOF, defined by the Denver MOF score. The summation of scores (on a scale from 0 to 3) from the cardiac, pulmonary, hepatic, and renal systems was calculated and MOF was confirmed if the total daily sum of the worst scores from each organ system was >3. We assessed the association between late fixation and MOF using a Cox proportional hazards model adjusted for confounding variables by inverse probability weighting (a propensity score method). A P value <.05 was considered statistically significant. RESULTS: One hundred sixty of 279 (57.3%) patients received early fixation and 119 of 279 (42.7%) received late fixation. LacTW24h (OR = 1.66 per 1 mmol/L increase, 95% CI, 1.24-2.21; P < .001) and ISS (OR = 1.07 per 1-point increase, 95% CI, 1.03-1.10; P < .001) were associated with higher odds of late fixation. Late fixation was associated with a 3-fold increase in the odds of MOF (hazard ratio [HR] = 3.21, 95% CI, 1.48-7.00; P < .01). CONCLUSIONS: In a cohort of multisystem trauma patients with femur fractures, greater injury severity and depth of shock, as measured by LacTW24h, were associated with late operative fixation. Late fixation was also associated with MOF. Strategies to reduce the burden of MOF in this population require further investigation.

Impact of Referring Hospital Imaging on Mortality at a Level I Trauma Center.

BACKGROUND: Computed tomography (CT) has become a standard adjunct in the evaluation of patients with trauma. However, utility of imaging at the referring hospital remains controversial. We study the effect of CT scans at referring hospitals on in-hospital mortality at a receiving trauma center. MATERIALS AND METHODS: A retrospective cohort study was performed with adult patients with severe trauma transferred to a level I trauma center from regional nontrauma hospitals between 2012 and 2017. Baseline characteristics were compared with Student's t-test and Pearson's chi-squared testing. The primary endpoint was in-hospital mortality. Cox regression, controlling for transfer time, was used to evaluate the effect of imaging on mortality. RESULTS: Three thousand four hundred and fifteen adult patients with trauma were included: 1135 (33.2%) received a pretransfer CT scan, whereas 2280 (66.8%) did not. Patients who received a pretransfer CT scan were more likely to be older, female, white, have a higher Charlson Comorbidity Index, less severely injured, have a blunt mechanism, and be transferred by ground. There was no difference in distance (58.3 miles versus 57.0 miles, P = 0.34), but transfer times were significantly increased for those who received pretransfer scans (288 versus 213 min, P < 0.005). The adjusted model controlling for multiple variables has a hazard ratio of 0.533 (95% confidence interval 0.42-0.68, P < 0.005). CONCLUSIONS: There is a survival advantage for patients who receive pretransfer CT scans despite having significantly longer transport times. We suggest that this decreased mortality associated with pretransfer imaging may reflect improving trends in referring physician transfer decisions.

The Cost of Poverty: The Relationship Between Insurance Status, Length of Stay, and Discharge Disposition in Trauma Patients.

INTRODUCTION: Insurance status (IS) is known to be associated with length of stay (LOS). The impact of IS on excess LOS (ELOS), days between medical readiness and discharge date, has not been explored. METHODS: We conducted a retrospective study of patients with pelvic fractures at a level I trauma center. Outcomes included ELOS (primary), discharge disposition (secondary), and ELOS-associated complications (secondary). RESULTS: 185 patients were included. Uninsured patients were the youngest and had the least baseline comorbidities (31.3 years (median), Charlson Comorbidity Index (CCI) .1) while publicly insured patients were the oldest and had the most baseline comorbidities (58.4 years (median), CCI 2.32). Excess LOS and associated complications did not differ among groups. After regression analysis, UIPs had longer LOS than PRPs (2.07 days, 95% CI .28-3.85). UIPs were recommended to go to inpatient rehabilitation 51.6% of the time but were discharged home 93.6% of the time; 81.0% of these changes were attributed to insufficient financial resources. CONCLUSIONS: Excess LOS and complications associated with ELOS were not associated with IS. Although UIPs were younger and had fewer baseline comorbidities, they had longer LOS after regression analysis. While discharge recommendations differed based on insurance status, UIPs had limited access to rehabilitation due to financial disparities. Despite initial treatment team recommendations, UIPs had to be sent home as their lack of insurance precluded inpatient rehabilitation placement.

Computed tomography scanning is feasible in select patients with REBOA catheter deployment.

BACKGROUND: Rapidly localizing and controlling bleeding is central to treating hemorrhagic shock. While REBOA allows temporary control, identifying the source of bleeding remains challenging. CT imaging with REBOA in place may provide information to direct hemorrhage control. The purpose of this study is to provide a descriptive summary of data comparing patients who did and did not undergo CT scan following REBOA deployment. Our hypothesis was that performing CT scan after REBOA placement in select patients is safe and can guide management of hemorrhagic shock. METHODS: We queried the AAST AORTA registry for patients receiving REBOA at our level 1 trauma center from May 2017 to December 2021. Clinical data was obtained through the Trauma Registry of the American College of Surgeons (TRACS). Comparison groups were those who underwent CT scan after REBOA deployment versus those who did not undergo CT scan after REBOA deployment. The primary outcome was inhospital mortality, and secondary outcomes included hospital-, ICU-, and ventilator-free days. RESULTS: 61 patients underwent CT scan with REBOA in place; 25 patients proceeded directly to hemorrhage control. Patients with REBOA prior to CT were more likely to have blunt mechanism, higher ISS, pelvic bleeding, and zone 3 REBOA placement. Mortality was not significantly different (51 % vs. 64 %). Patients who underwent CT with REBOA were more likely to undergo hemorrhage control in interventional radiology (43 % vs. 0 %). There was no difference in hospital-, ICU-, and ventilator-free days. DISCUSSION: We demonstrate the feasibility of performing CT in select trauma patients who undergo REBOA. We describe a pathway to enable expeditious workup and management of these patients. Optimal hemorrhage control management is impacted by CT scans when it can be performed. It is important to note that this is a severely injured patient population, and mortality is high even when hemorrhage is controlled. LEVEL OF EVIDENCE: III.

Opioid and non-opioid analgesic regimens after fracture and risk of serious opioid-related events.

Background: Non-opioid analgesics are prescribed in combination with opioids among patients with long bone fracture to reduce opioid prescribing needs, yet evidence is limited on whether they reduce the risk of serious opioid-related events (SOREs). We compared the risk of SOREs among hospitalized patients with long bone fracture discharged with filled opioid prescriptions, with and without non-opioid analgesics. Design: We identified a retrospective cohort of analgesic-naïve adult patients with a long bone fracture hospitalization using the Merative MarketScan Commercial Database (2013-2020). The exposure was opioid and non-opioid analgesic (gabapentinoids, muscle relaxants, non-steroidal anti-inflammatory drugs, acetaminophen) prescriptions filled in the 3 days before through 42 days after discharge. The outcome was the development of new persistent opioid use or opioid use disorder during follow-up (day 43 through day 408 after discharge). We used Cox proportional hazards regression with inverse probability of treatment weighting with overlap trimming to compare outcomes among those that filled an opioid and a non-opioid analgesic to those that filled only an opioid analgesic. In secondary analyses, we used separate models to compare those that filled a prescription for each specific non-opioid analgesic type with opioids to those that filled only opioids. Results: Of 29 489 patients, most filled an opioid prescription alone (58.4%) or an opioid and non-opioid (22.0%). In the weighted proportional hazards regression model accounting for relevant covariates and total MME, filling both a non-opioid analgesic and an opioid analgesic was associated with 1.63 times increased risk of SOREs compared with filling an opioid analgesic only (95% CI 1.41 to 1.89). Filling a gabapentin prescription in combination with an opioid was associated with an increased risk of SOREs compared with those that filled an opioid only (adjusted HR: 1.84 (95% CI1.48 to 2.27)). Conclusions: Filling a non-opioid analgesic in combination with an opioid was associated with an increased risk of SOREs after long bone fracture. Level of evidence: Level III, prognostic/epidemiological. Study type: Retrospective cohort study.

Comparison of phenobarbital monotherapy to a benzodiazepine-based regimen for management of alcohol withdrawal syndrome in trauma patients.

BACKGROUND: Alcohol withdrawal syndrome (AWS) is associated with increased morbidity and mortality in the trauma population. Benzodiazepines (BZDs) are standard of care for AWS; however, given the risk of delirium with BZDs and reports of BZD-refractory withdrawal, phenobarbital (PHB) has emerged as an alternative therapy for AWS. Safety and efficacy studies of PHB for AWS in trauma patients are lacking. Our aim was to compare a BZD versus PHB protocol in the management of AWS in trauma patients. METHODS: We performed a retrospective cohort study at a level 1 trauma center of patients at risk for AWS managed with either a BZD or a low-dose oral PHB regimen. Patients were excluded if they were taking BZDs or barbiturates before admission, received propofol or dexmedetomidine before initiation of the study drug, presented with delirium tremens or seizures, or died or discharged within 24 hours of presentation. The primary outcome was complicated AWS (seizures or alcohol withdrawal delirium/delirium tremens). Secondary outcomes included uncomplicated AWS; therapy escalation; oversedation; delirium-, intensive care unit-, and ventilator-free days; and length of stay. RESULTS: A total of 411 patients were identified; 118 received BZD, and 293 received PHB. The odds of developing complicated AWS with PHB versus BZD-based therapy were not statistically significant (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.21-1.39); however, patients receiving PHB were less likely to develop uncomplicated AWS (OR, 0.08; 95% CI, 0.04-0.14) and less likely to require escalation of therapy (OR, 0.45; 95% CI, 0.24-0.84). The PHB group had a length of stay 3.1 days shorter than the BZD group ( p = 0.002). There was no difference in intensive care unit-, ventilator-, or delirium-free days. CONCLUSION: A PHB-based protocol for the management of AWS is a safe and effective alternative to BZD-based regimens in trauma patients. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Does scene physiology predict helicopter transport trauma admission?

BACKGROUND: Helicopter transport (HT) is necessary in the management of civilian trauma; however, its significant expense underscores the need to minimize overuse and inefficiency. Our objective was to determine whether on-scene physiologic criteria predict appropriate triage in HT trauma patients. METHODS: We performed a retrospective review of patients flown from the injury scene to the emergency department of a level 1 trauma center by a university HT service from January 2006 to December 2010. Demographics, mechanism of injury, scene revised trauma score (RTS), travel distance, trauma alert level, payer status, emergency department and hospital disposition, and injury severity scores were queried from the electronic medical record and Trauma Registry of the American College of Surgeons with similar data on patients admitted because of trauma by ground transport for comparison. Proper triage criteria were defined through by the American College of Surgeons Committee on Trauma. RESULTS: We identified 2522 HT patients. Of these, 1491 (59%) were properly triaged and 1031 (41%) were overtriaged. Univariate analysis revealed that the mean scene RTS was significantly higher for over- versus proper triage (7.68 ± 0.67 and 6.97 ± 1.57 respectively, P < 0.001). Neither the scene RTS nor travel distance predicted the triage criteria in a regression model (odds ratio 0.37, 95% confidence interval 0.16-0.85, and odds ratio 0.67, 95% confidence interval 0.60-0.74, respectively). Compared with ground transport, admitted HT patients had significantly more blunt trauma, lower scene RTSs, higher injury severity scores, more intensive care unit and ventilator days, a longer length of stay, and a greater travel distance and were more likely to be intubated (P < 0.001). CONCLUSIONS: The physiological criteria did not predict the triage status in HT trauma patients. Although >40% of HT patients were overtriaged, they were more severely injured and required greater institutional resources than did the ground transport patients. Overtriage by a helicopter transport program might be appropriate.

Analysis of Need for Intervention in Low-Grade Traumatic Splenic Injury.

BACKGROUND: Blunt splenic injuries are common traumatic injuries. Severe injuries may require blood transfusion, procedural, or operative intervention. Conversely, patients with low-grade injuries and normal vital signs frequently do not require intervention. The level and duration of monitoring required to safely manage these patients are unclear. We hypothesize that low-grade splenic trauma has a low rate of intervention and may not require acute hospitalization. METHODS: This retrospective descriptive analysis included patients admitted to a level I trauma center with low injury burden (injury severity score <15) and The American Association for the Surgery of Trauma (AAST) grade 1 (G1) and 2 (G2) splenic injuries between January 2017 and December 2019 using the Trauma Registry of the American College of Surgeons (TRACS). The primary outcome was the need for any intervention. Secondary outcomes included time to intervention and length of stay. RESULTS: 107 patients met inclusion criteria. 87.9% required no intervention . 9.4% required blood products, with a median time to transfusion of 7.4 hours from arrival. All patients receiving blood products had extenuating circumstances such as bleeding from other injuries, anticoagulant use, or medical comorbidities. 2 patients required splenic artery embolization, one presenting with return precautions 9 days post-injury and 1 with significant comorbidities. One patient with concomitant bowel injury required splenectomy. CONCLUSIONS: Low-grade blunt splenic trauma has a low rate of intervention, which typically occurs within the first 12 hours of presentation. This suggests that outpatient management with return precautions may be appropriate for select patients after a short interval of observation.

Acquired Tracheomalacia Requiring Urgent Tracheostomy Exchange in Patients With COVID-19.

Tracheostomy for prolonged ventilation of patients with COVID-19 was often delayed due to high viral loads and persistent high ventilatory requirements. With prolonged intubation and significant dose corticosteroid use, patients with COVID-19 are at risk for tracheomalacia, and urgent tube exchange may be required to address persistent cuff leak and to maintain adequate mechanical ventilation. We sought to describe our single center experience with COVID-19 patients requiring tracheostomy and the tracheal complications that followed. We performed a review of patients with COVID-19 who underwent tracheostomy from June 2020 to October 2021. 45 patients were identified; 82.2% survived their index hospitalization. Tracheostomy was performed after 16.4 days of mechanical ventilation. 22.2% required urgent exchange to an extended length tracheostomy tube after 7.2 days from initial tracheostomy. Placement of an extended length tracheostomy tube can reduce cuff leak in ventilated COVID-19 patients and may be considered during initial tracheostomy placement.

Prior Antibiotic Exposure Is Associated With Reoperation After Elective Non-colorectal Surgery.

BACKGROUND: Recent antibiotic exposure has previously been associated with poor outcomes following elective surgery. The purpose of this study is to evaluate the impact of prior recent antibiotic exposure in a multicenter cohort of Veterans Affairs patients undergoing elective non-colorectal surgery. METHODS: This is a retrospective cohort study of the Veterans Affairs Surgical Quality Improvement Program, including elective, non-cardiovascular, non-colorectal surgery from 2013 to 2017. Outpatient antibiotic exposure within 90 days prior to surgery was identified from the Veterans Affairs outpatient pharmacy database and matched with each case. Primary outcomes included serious complication, any complication, any infection, or surgical site infection. Secondary outcomes included 30-day mortality, length of stay, and Clostridioides difficile infection. RESULTS: Of 21,112 eligible patients, 2885 (13.7%) were exposed to antibiotics within 90 days prior to surgery with a duration of 7 (IQR: 5-10) days and prescribed 42 (IQR: 21-64) days prior to surgical intervention. Compared to non-exposed patients, exposed patients had higher unadjusted complication rates, increased length of stay, and rates of return to the operating. Exposure was independently associated with return to the operating room (OR: 1.39; 99% CI: 1.05-1.84). CONCLUSIONS: Among Veterans, recent antibiotic exposure within 90 days of elective surgery was associated with a 39% increase in the odds of return to the operating room. Further work is needed to evaluate the effects of antibiotic exposure and dysbiosis on surgical outcomes.

The Cost of Not Training a Surgical Resident.

OBJECTIVE: To quantify surgical trainees' direct financial impact on an academic medical center (AMC) by modeling the cost of replacing them. DESIGN: The authors developed a model that estimates the financial costs to an AMC if surgical residents were replaced with surgical first assistants (SFAs) and physician assistants (PAs). SETTING: One AMC providing tertiary level clinical care. PARTICIPANTS: The model accounts for the training, work hours, and salary differential of residents, as well as other factors that are specific to education and support of residents, SFAs, and PAs. RESULTS: After accounting for the expenses of surgical residents and the replacement providers in our model, the authors determined that the net cost of replacing 30 surgical residents with PAs and SFAs at one institution is $1,728,628 or $57,621 annually per resident. CONCLUSIONS: Without considering other larger and arguably more important issues of educational value or population needs, we provide a reproducible model of financial considerations regarding residents in an AMC. The costs (and foregone benefits) of not training residents may provide additional support for the funding of graduate medical education and finding the optimal balance of graduate medical education and other providers.

Redox-active tripodal aminetris(aryloxide) complexes of titanium(IV).

New sterically encumbered tripodal aminetris(aryloxide) ligands N(CH(2)C(6)H(2)-3-(t)Bu-5-X-2-OH)(3) ((tBu,X)LH(3)) with relatively electron-rich phenols are prepared by Mannich condensation (X = OCH(3)) or by a reductive amination/Hartwig-Buchwald amination sequence on the benzyl-protected bromosalicylaldehyde (X = N[C(6)H(4)-p-OCH(3)](2)), followed by debenzylation using Pearlman's catalyst (Pd(OH)(2)/C). The analogous dianisylamino-substituted compound lacking the tert-butyl group ortho to the phenol ((H,An(2)N)LH(3)) is also readily prepared. The ligands are metalated by titanium(IV) tert-butoxide to form the five-coordinate alkoxides LTi(O(t)Bu). Treatment of the tert-butoxides with aqueous HCl yields the five-coordinate chlorides LTiCl, and with acetylacetone gives the six-coordinate diketonates LTi(acac). The diketonate complexes (tBu,X)LTi(acac) show reversible ligand-based oxidations with first oxidation potentials of +0.57, +0.33, and -0.09 V (vs ferrocene/ferrocenium) for X = (t)Bu, MeO, and An(2)N, respectively. Both dianisylamine-substituted complexes (R,An(2)N)LTi(acac) (R = (t)Bu, H) show similar electrochemistry, with three one-electron oxidations closely spaced at approximately 0 V and three oxidations due to removal of a second electron from each diarylaminoaryloxide arm at approximately + 0.75 V. The new electron-rich tripodal ligands therefore have the capacity to release multiple electrons at unusually low potentials for aryloxide groups.

Impact of Operative Management on Recurrence of Adhesive Small Bowel Obstruction: A Longitudinal Analysis of a Statewide Database.

BACKGROUND: Recurrence of adhesive small bowel obstruction (ASBO) can lead to multiple admissions. There is limited knowledge of the role of operative and nonoperative treatment in the long-term recurrence risk for ASBO. We sought to determine the effect of operative and nonoperative management on future ASBO recurrences. METHODS: This is a retrospective study of administrative discharge data from the Tennessee Hospital Association. Adult discharges from 2007 to 2009 with ASBO and all subsequent readmission within any hospital in the state were included; patients with earlier ASBO from 2003 to 2007 and out-of-state residents were excluded. ASBO recurrence was compared between operative and nonoperative approaches using the Andersen-Gill approach for modeling recurrent time-to-event data. Secondary outcomes included mortality, complication, and time to recurrence. RESULTS: We analyzed 6,191 records; 30.0% were initially treated operatively. Patients initially managed surgically had lower overall recurrence rates (19.0% vs 25.6%; p < 0.005). The hazard for recurrence was lower if the most recent ASBO management was operative (hazard ratio 0.27; 95% CI, 0.23 to 0.31). The risk of ASBO recurrence increased with more cumulative operative or nonoperative ASBO admissions relative to patients with fewer earlier admissions (operative: hazard ratio 2.30; 95% CI, 2.04 to 2.60 and nonoperative: hazard ratio 1.18; 95% CI, 1.16 to 1.20). In-hospital mortality rate (3.7% vs 2.6%; p = 0.025) and time to recurrence (729 vs 550 days; p = 0.009) were greater in the operative group. CONCLUSIONS: Operative management for the most recent ASBO is associated with fewer recurrences. Subsequent cumulative recurrences of ASBO predispose to recurrence regardless of operative or nonoperative management. When considering ASBO management, subsequent recurrence should be considered.

Comparison of American Association for the Surgery of Trauma grading scale with modified Hinchey classification in acute colonic diverticulitis: A pilot study.

BACKGROUND: The American Association for the Surgery of Trauma (AAST) developed a severity scale for surgical conditions, including diverticulitis. The Hinchey classification requires operative intervention yet remains the established scoring system for acute diverticulitis. This is a pilot study to compare the AAST grading scale for acute colonic diverticulitis with the traditional Hinchey classification. We hypothesize that the AAST classification scale is equivalent to the Hinchey in predicting outcomes. METHODS: This is a retrospective cohort study at an academic medical center. A consecutive sample of patients with acute diverticulitis and computed tomography imaging was reviewed. Chart review identified demographic and physiologic data with interventional and clinical outcomes. Each computed tomography scan was assigned AAST and modified Hinchey classification scores by a radiologist. Multivariate regression and receiver operating characteristic curve analysis compared six outcomes: need for procedure, complication, intensive care unit (ICU) admission, length of stay, 30-day readmission, and mortality. RESULTS: One hundred twenty-nine patients were included. Of the total patients, 42.6% required procedural intervention, 21.7% required ICU admission, 18.6% were readmitted, and 6.2% died. Both AAST and Hinchey predicted the need for operation (AAST odds ratios, 1.55, 12.7, 18.09, and 77.24 for stages 2-5; Hinchey odds ratios, 8.85, 11.49, and 22.9 for stages 1b-3, stage 4 predicted perfectly). The need for operation c-statistics (area under the curve) for AAST and Hinchey was 0.80 and 0.83 for Hinchey and AAST, respectively (p = 0.35). The complication c-statistics curve for AAST and Hinchey was 0.83 and 0.80, respectively (p = 0.33). The AAST and Hinchey scores were less predictive for ICU admission, readmission, and mortality with c-statistics of less than 0.80. CONCLUSION: The AAST grading of acute diverticulitis is equivalent to the modified Hinchey classification in predicting procedural intervention and complications. The AAST system may be preferable to Hinchey because it can be applied preoperatively. Although this pilot study demonstrated that the AAST score predicts surgical need, a larger study is required to evaluate the AAST score for other outcomes. LEVEL OF EVIDENCE: Prognostic and epidemiological study, level III.

Identifying temporal patterns in trauma admissions: Informing resource allocation.

BACKGROUND: Increased knowledge of the temporal patterns in the distribution of trauma admissions could be beneficial to staffing and resource allocation efforts. However, little work has been done to understand how this distribution varies based on patient acuity, trauma mechanism or need for intervention. We hypothesize that temporal patterns exist in the distribution of trauma admissions, and that deep patterns exist when traumas are analyzed by their type and severity. STUDY DESIGN: We conducted a cross-sectional observational study of adult patient flow at a level one trauma center over three years, 7/1/2013-6/30/2016. Primary thermal injuries were excluded. Frequency analysis was performed for patients grouped by ED disposition and mechanism against timing of admission; in subgroup analysis additional exclusion criteria were imposed. RESULTS: 10,684 trauma contacts were analyzed. Trauma contacts were more frequent on Saturdays and Sundays than on weekdays (p<0.001). Peak arrival time was centered around evening shift change (6-7pm), but differed based on ED disposition: OR and ICU or Step-Down admissions (p = 0.0007), OR and floor admissions (p<0.0001), and ICU or Step-Down and floor admissions (p<0.0001). Step-Down and ICU arrival times (p = 0.42) were not different. Penetrating injuries peaked later than blunt (p<0.0001). Trauma varies throughout the year; we establish a high incidence trauma season (April to late October). Different mechanisms have varying dependence upon season; Motorcycle crashes (MCCs) have the greatest dependence. CONCLUSION: We identify new patterns in the temporal and seasonal variation of trauma and of specific mechanisms of injury, including the novel findings that 1) penetrating trauma tends to present at later times than blunt, and 2) critically ill patients requiring an OR tend to present later than those who are less acute and require an ICU or Step-Down unit. These patients present later than those who are admitted to the floor. Penetrating trauma patients arriving later than blunt may be the underlying reason why operative patients arrive later than other patients.

Survey of trauma surgeon practice of emergency department thoracotomy.

BACKGROUND: There continues to be significant debate in the trauma community regarding the indications for emergency department thoracotomy (EDT). Numerous studies have focused on the duration of arrest in EDT, whereas few have examined other factors that influence surgeon decision-making. We hypothesize that there is continued variability among surgeons in the use of EDT. METHODS: A 13-question web-based survey was distributed to the membership of a large, national trauma association, examining demographics, trauma fellowship completion, trauma center designation, professional organization membership, and annual EDTs performed. Consideration of patient's age, comorbidities, total injury burden, and the use of technological adjuncts-such as ultrasound-was assessed. Respondents were asked when they would perform the procedure after loss of vital signs for blunt and penetrating trauma. Logistic regression determined factors influencing consideration of EDT. RESULTS: Overall 540 of 1,485 surveys were completed (36.4%). Patient age, total injury burden, and comorbidities are considered by 38.5%, 29.1%, and 55.7% of respondents, respectively. Technological adjuncts are used always or most of the time by 64% of respondents. A majority of respondents (51.9%) would perform an EDT for penetrating trauma with loss of vital signs 5 to 10 minutes before arrival. For blunt trauma, the largest group of respondents (47.0%) would perform an EDT only when loss of vital signs occurred in the ED. In addition, 20.6% would never perform EDT for blunt traumatic arrest. CONCLUSIONS: EDT decision-making is more nuanced than previously described. Variation continues in the use of thoracotomy after loss of vital signs, in both blunt and penetrating trauma. For both mechanisms, there remains little consensus on the appropriate duration of arrest before performing EDT after arrest despite published guidelines. A large proportion of surgeons consider other factors such as patient age, total injury burden, and comorbidities in addition to vital signs when deciding to perform an EDT. Technological adjuncts are frequently used by surgeons to determine the need for EDT.