Does splenic embolization and grade of splenic injury impact nonoperative management in patients sustaining blunt splenic trauma?

Nonoperative management (NOM) for blunt splenic trauma (BST) is an established practice. The impact of splenic embolization (SE) in the algorithm for NOM has not been well studied. This study evaluates the role of SE and spleen injury grade on failure of NOM. Retrospective cohort of trauma registry over a 7-year period (2000-2006) for patients who suffered BST was studied. Data including demographics, splenic injury grade, and SE were recorded. Characteristics were compared between the successful and failed NOM groups. Kaplan-Meier, life table, and Cox-proportional hazard regression analyses were performed. Of the 499 patients who suffered BST, 407 (81.6%) patients had successful NOM and 92 (18.4%) patients failed NOM (including splenectomies performed within 1 hour of admission). Failed NOM group had a higher splenic injury grade compared with the successful NOM group (P < 0.0001). Seventy-five per cent underwent a splenectomy within 7.7 hours of admission. Nearly all grade I and II splenic injuries that failed NOM occurred by 24 hours. Grade 3 and 4 injuries that failed NOM occurred by 150 hours. SE was protective against splenectomy (Hazard Ratio (HR) 0.18, 95% confidence interval: 0.06-0.55, P = 0.004), whereas splenic injury grades III or higher was associated with increased risk of splenectomy (grade III: HR 5.26, P = 0.003; grade IV: HR 6.84, P = 0.002; grade V: HR 9.81, P = 0.002) compared with those with splenic injury grade I. Splenic embolization is a protective measure to reduce the failure of NOM. Spleen injury grade III and higher was significantly associated with NOM failure and would require a 5-day inpatient observation.

Fall prevention initiative: A fall screening and intervention pilot study on the ambulatory setting.

BACKGROUND: Falling is the most common cause of trauma in the geriatric population. To identify patients that were at-risk for falling, we implemented a provider-directed fall prevention screening initiative in the ambulatory setting of a large tertiary care referral center. We used three clinician-directed questions from the Stopping Elderly Accidents, Death and Injuries toolkit. Our goal was to intervene on patients who were screened as at-risk for falling by referring them to our physical therapy program and evaluating its effects to these patients. METHODS: Patients 55 years or older who live in the community were screened from June 2017 to June 2018. Patients who answered yes to any of the three questions were identified as at-risk for falling, and referred to the Fall Prevention Initiative Physical Therapy Program (FPIPTP). The FPIPTP is a program that establishes a quantifiable fall risk using the Time Up and Go (TUG) test, which then initiates PT treatments, designed to prevent future falls by improving, gait, balance, and fitness. The Wilcoxon signed rank test was used to determine significance (p < 0.05). RESULTS: We identified 112 patients with a median age of 76.5 years (IQR, 68-82 years) to be at-risk for falling. The initial median TUG score in this group of patients is 15.85 seconds (12-20.33 seconds), which is consistent with a high fall-risk (time >12 seconds). After completing the FPIPTP, the median TUG score significantly improved to 12 seconds (9-15 seconds, p < 0.0001). CONCLUSION: We conclude that a provider can use the three specific questions from the Stopping Elderly Accidents, Death and Injuries toolkit to identify patients (≥55 years) that are at-risk for falling. Additionally, the FPIPTP is able to significantly improve the TUG score in this group. We will need to confirm this conclusion with a larger population study. LEVEL OF EVIDENCE: Therapeutic, Level IV.

Characteristics and outcomes of trauma patients with ICU lengths of stay 30 days and greater: a seven-year retrospective study.

INTRODUCTION: Prolonged intensive care unit lengths of stay (ICU LOS) for critical illness can have acceptable mortality rates and quality of life despite significant costs. Only a few studies have specifically addressed prolonged ICU LOS after trauma. Our goals were to examine characteristics and outcomes of trauma patients with LOS >or= 30 days, predictors of prolonged stay and mortality. METHODS: All trauma ICU admissions over a seven-year period in a level 1 trauma center were analyzed. Admission characteristics, pre-existing conditions and acquired complications in the ICU were recorded. Logistic regression was used to identify independent predictors of prolonged LOS and predictors of mortality among those with prolonged LOS after univariate analyses. RESULTS: Of 4920 ICU admissions, 205 (4%) had ICU LOS >30 days. These patients were older and more severely injured. Age and injury severity score (ISS) were associated with prolonged LOS. After logistic regression analysis, sepsis, acute respiratory distress syndrome, and several infectious complications were important independent predictors of prolonged LOS. Within the group with ICU LOS >30 days, predictors of mortality were age, pre-existing renal disease as well as the development of renal failure requiring dialysis. Overall mortality was 12%. CONCLUSIONS: The majority of patients with ICU LOS >or= 30 days will survive their hospitalization. Infectious and pulmonary complications were predictors of prolonged stay. Further efforts targeting prevention of these complications are warranted.

Surgical Stabilization of Rib Fractures: A Single Institution Experience.

BACKGROUND: Use of surgical stabilization of rib fractures (SSRF) has increased. Despite compelling small studies, many centers still struggle with determining criteria for intervention. We investigated the benefit of SSRF in our patients compared with nonoperative (NonOp) National Trauma Databank (NTDB) controls, specifically in the older population. STUDY DESIGN: We performed a retrospective comparison of trauma patients with ≥3 and >5 rib fractures, who underwent SSRF at a tertiary care level I trauma center, with nonoperatively managed NTDB controls from equivalent level I centers between 2007 and 2014. The main outcomes measures included mortality, pneumonia, length of stay (LOS), ICU LOS, ventilator use, and tracheostomy rates. RESULTS: Overall, SSRF patients were older, had a higher percentage of respiratory disease, and higher Injury Severity Scores (ISS). Despite more respiratory disease in SSRF patients vs NonOp (p < 0.0001), there was no difference in ventilator usage. Results of SSRF included decreases in mortality (12%, p = 0.008) and pneumonia (13%, p < 0.001) compared with NonOp on propensity score matching. On subgroup analysis of patients 65 years of age or older, ISS was higher in the SSRF group. Mortality was significantly lower for SSRF vs NonOp, even with higher frequency of respiratory disease within the group (p < 0.001). CONCLUSIONS: Patients who underwent SSRF at our institution had improved outcomes despite a higher percentage of respiratory disease, compared with patients who were managed nonoperatively nationwide. Mortality rates improved for patients aged 65 and older, suggesting that this patient population may benefit more from SSRF.

A multicenter evaluation of the optimal timing of surgical stabilization of rib fractures.

BACKGROUND: The optimal timing of surgical stabilization of rib fractures (SSRF) remains debated. We hypothesized that (1) demographic, radiologic, and clinical variables are associated with time to surgery and (2) shorter time to SSRF improves acute outcomes. METHODS: Prospectively collected SSRF databases from four trauma centers were merged and analyzed (2006-2016). The independent variable was days from hospital admission to SSRF (early [<1 day], mid [1-2 days], and late [3-10 days]). Outcomes included length of operation, number of ribs repaired, prolonged (>24 hours) mechanical ventilation, pneumonia, tracheostomy, length of stay, and mortality. Multivariable logistic regression was used to control for significant differences in covariates between groups. RESULTS: Five hundred fifty-one patients were analyzed. The median time to SSRF was 1 day (range, 0-10); 207 (37.6%) patients were in the early group, 168 (30.5%) in the midgroup, and 186 (31.9%) in the late group. There was a significant shift toward earlier SSRF over the study period. Time to SSRF was significantly associated with study center (p < 0.01), year of surgery (p < 0.01), age (p = 0.02), mechanism of injury (p = 0.04), and body mass index (p = 0.02). Injury severity was not associated with time to surgery. Despite repairing the same median number of ribs (4; range, 1-13), median length of surgery was 68 minutes longer for the late as compared to the early group (p < 0.01). After controlling for the aforementioned significant covariates, each additional hospital day before SSRF was independently associated with a 31% increased likelihood of pneumonia (p < 0.01), a 27% increased likelihood of prolonged mechanical ventilation (p < 0.01), and a 26% increased likelihood of tracheostomy (p < 0.01). CONCLUSION: Surgical stabilization of rib fractures within 1 day of admission is associated with certain demographic and physiologic variables. After controlling for confounding factors, early SSRF was accomplished using less operative time, and was associated with favorable outcomes. When indicated and feasible, SSRF should occur as early as possible. LEVEL OF EVIDENCE: Therapy, level III.

Quantifying and exploring the recent national increase in surgical stabilization of rib fractures.

BACKGROUND: Surgical stabilization of rib fractures (SSRF) has become pivotal in the management of severe chest injuries. Recent literature supports improved outcomes and mortality in severe fracture and flail chest patients who undergo SSRF compared with nonoperative management (NOM). A 2014 National Trauma Data Bank review provided a point prevalence of 0.7% SSRF in flail patients. We hypothesize that this prevalence is increasing and that temporal, regional, and American College of Surgeons (ACS) trauma designation vary in SSRF utilization. METHODS: Retrospective National Trauma Data Bank data were extracted for years 2007 to 2014 for patients with rib fractures. Cases were divided into SSRF versus NOM. SSRF frequencies were analyzed across year, region, and ACS level. Patient demographics, injury severity score, number of fractured ribs, and hospital characteristics were identified for multivariable analysis. RESULTS: Between 2007 and 2014, 687,137 rib fracture patients were identified; 29,981 (4.36%) underwent SSRF. SSRF increased by 76% nationally during the review period (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.50-1.67; p < 0.001). Compared with the north, SSRF was used more in the west (OR, 1.6; 95% CI, 1.57-1.71), south (OR, 1.48; 95% CI, 1.43-1.54), then midwest (OR, 1.4; 95% CI, 1.34-1.46; p < 0.001). Although likelihood of SSRF is higher at ACS Level I (LI) centers compared with Level II (LII) centers (OR, 0.67; 95% CI, 0.65-0.69) or Level III (LIII) (OR, 0.24; 95% CI, 0.22-0.26); p < 0.001), frequency of SSRF increased dramatically at lower-level centers from 2007 to 2014 (LI, 41.4%; LII, 53.6%; LIII, 60.0%).Overall SSRF mortality was 1.58% (NOM, 5.3%; p < 0.001), decreasing significantly between 2007 and 2014 (p < 0.0001). ACS LII had higher mortality than LI (OR, 1.82; 95% CI, 1.39-2.39; p < 0.0001), controlled by Injury Severity Score. CONCLUSION: Utilization of SSRF has risen considerably nationwide. Prevalence varies by region and ACS level. Although greatest growth is occurring at LII hospitals, mortality is also the highest at these centers. Further research is needed to determine the need for regionalization of care and center of excellence designation. LEVEL OF EVIDENCE: Epidemiological study, level III.

Trauma centers with higher rates of angiography have a lesser incidence of splenectomy in the management of blunt splenic injury.

BACKGROUND: Nonoperative management (NOM) for blunt splenic injury (BSI) is well-established. Angiography (ANGIO) has been shown to improve success rates with NOM. Protocols for NOM are not standardized and vary widely between centers. We hypothesized that trauma centers that performed ANGIO at a greater rate would demonstrate decreased rates of splenectomy compared with trauma centers that used ANGIO less frequently. METHODS: A large, multicenter, statewide database (Pennsylvania Trauma Systems Foundation) from 2007 to 2011 was used to generate the study cohort of patients with BSI (age ≥ 13). The cohort was divided into 2 populations based on admission to centers with high (≥13%) or low (<13%) rates of ANGIO. Patient demographics, grade of BSI, Injury Severity Score, level of trauma center designation, and patient volume were analyzed. Splenectomy rates were then compared between the 2 groups, and multivariable logistic regression for predictors of splenectomy (failed NOM) were also performed. RESULTS: The overall rate of splenectomy in the entire cohort was 21.0% (1,120 of 5,333 BSI patients). The high ANGIO group had a lesser rate of splenectoy compared with the low ANGIO group (19% vs 24%; P < .001). Treatment at high ANGIO centers was negatively associated with splenectomy compared with low ANGIO centers (odds ratio, 0.68; 95% CI 0.58-0.80; P < .001); this association was independent of the number of BSI admissions or level of trauma center designation. CONCLUSION: Treatment of BSI at trauma centers that performed ANGIO more frequently resulted in lesser splenectomy rates compared with centers with lesser rate of ANGIO. Inclusion of angiographic protocols for NOM of BSI should be considered strongly.

A chest trauma scoring system to predict outcomes.

BACKGROUND: Rib fractures (RIBFX) are a common injury and are associated with substantial morbidity and mortality. Using a previously published RIBFX scoring system, we sought to validate the system by applying it to a larger patient population. We hypothesized that the RIBFX scoring system reliably predicts morbidity and mortality in patients with chest wall injury at the time of initial evaluation. METHODS: A 3-year, registry-based, retrospective study involving 1,361 trauma patients was performed. Patients were divided into two groups with a Chest Trauma Score (CTS) < 5 and ≥5 (n = 724 and 637, respectively). Each cohort was analyzed for specific outcomes (mortality, pneumonia, acute respiratory failure). CTS was defined by age, severity of pulmonary contusion, number of RIBFX, and the presence of bilateral RIBFX with a maximum score of 12. Receiver operating characteristics were used to determine the use of CTS ≥5 cut point. RESULTS: Patients with a CTS of 5 or more were (P ≤ .05) older (61 vs 50 years), had greater Injury Severity Scores (21.6 vs 16.2), and had a greater prevalence of pneumonia (10.1 vs 3.5%), tracheostomy (7.4 vs 2.9%), and mortality (9.0 vs 2.2%). Patients with CTS ≥ 5 had nearly 4-fold increased odds of mortality (odds ratio 3.99, 95% confidence interval 1.92-8.31, P = .001) compared with those who had CTS < 5. CONCLUSION: A CTS of at least 5 is associated with worse patient outcomes. Increased vigilance is needed with trauma patients who present with RIBFX and a CTS ≥ 5 at initial presentation. This simple RIBFX scoring system may improve early identification of vulnerable patients and expedite therapeutic interventions.

Starting the clock: defining nonoperative management of blunt splenic injury by time.

BACKGROUND: There is no consensus when the designation of nonoperative management (NOM) for splenic injury (BSI) should start. We evaluated NOM success rates based on different time points after admission. METHODS: The National Trauma Data Bank was evaluated for BSI for the year 2008. Observations were evaluated by facility, the time to splenectomy, and the volume of BSI admissions. RESULTS: Of 15,732 BSIs identified, the overall splenectomy salvage rate was 81%. After the 5th hour, the NOM success rate was 95%. Multivariable analysis revealed that higher BSI grades, level 2 centers and community hospitals, and age ≥55 were associated with failed NOM. CONCLUSIONS: The grade of injury is an important predictor for failure of NOM. If a 5% failure rate is to be considered a benchmark, then the 5-hour time point after admission should be used for the calculation of NOM success rates.

Risk of pulmonary embolism in trauma patients: Not all created equal.

INTRODUCTION: Patients with traumatic brain injury (TBI) are assumed to be at an increased risk for pulmonary embolism (PE). Delay in the initiation of chemoprophylaxis and prophylactic placement of inferior vena cava filters have been advocated by some because of concerns for increased intracranial hemorrhage in the presence of prophylactic anticoagulation. We hypothesized that patients with isolated TBI would not be at increased risk for the development of PE compared with the general trauma population. METHODS: Patients from the National Trauma Data Bank from the year 2008 were analyzed. Patient demographics, Injury Severity Score, and the prevalence of deep-vein thrombosis and PE were extracted. Studied injuries were assigned to six categories: thorax, abdominal solid organs, pelvic fracture, lower extremity fracture, spine fracture, and TBI. RESULTS: Of a total of 627,775 injured patients, 2,182 (0.35%) had a documented PE. The prevalence of PE in patients with isolated TBI, lower extremity, pelvic fracture, liver and/or spleen, thorax, spine, multiple injuries, and none of the studied injuries were 0.25%, 0.36%, 0.35%, 0.37%, 0.52%, 0.37%, 1.1%, and 0.12%, respectively. Using an age-, sex- and race-adjusted multivariable logistic regression model and controlling for interaction between inferior vena cava filters and injury types, we found that isolated TBI was not associated with PE. CONCLUSION: Isolated TBI does not appear to be associated with an increased incidence of PE compared with other injuries. Patients with isolated TBI may not require early aggressive prophylaxis as is the standard for other high-risk groups.

The impact of hyperglycemia on patients with severe brain injury.

BACKGROUND: This study aimed to analyze the relation of hyperglycemia to outcome in cases of severe traumatic brain injury, and to examine factors that may be responsible for the hyperglycemic state. METHODS: A retrospective analysis in an intensive care unit of a level 1 trauma center investigated 77 patients with severe traumatic brain injury. Patients with a Glasgow Coma Scale (GCS) of 8 or lower who survived more than 5 days were reviewed. Serum glucose, base deficit, GCS, use of steroids, and amounts of insulin and carbohydrates were recorded for 5 days, along with age. The Injury Severity Score (ISS) and the Abbreviated Injury Score (AIS) for the head, chest, and abdomen also were recorded. A hyperglycemia score (HS) was calculated as follows. A value of 1 was assigned each day the glucose exceeded 170 mg/dL (range, 0-5). A hyperglycemia score for days 3, 4, and 5 (HS day 3-5) also was calculated (range, 0-3). Outcomes included mortality, day 5 GCS, intensive care unit length of stay, and hospital length of stay. RESULTS: Of the 77 patients, 24 (31.2%) died. Nonsurvivors had higher glucose levels each day. The HS was higher for those who died: 2.4 +/- 1.7 versus 1.5 +/- 1.4 (p = 0.02). Univariate analysis showed that only HS and ISS correlated with all four outcome variables studied. Cox's regression analysis showed that mortality was related to age and ISS. Head AIS and HS were independent predictors of lower day 5 GCS, whereas HS 3-5 and day 4 GCS were related to prolonged hospital length of stay. Older age, diabetes, and lower day 1 GCS were associated with higher HS, whereas carbohydrate infusion rate, ISS, head AIS, and steroid administration were not. CONCLUSIONS: Early hyperglycemia is associated with poor outcomes for patients with severe traumatic brain injury. Tighter control of serum glucose without reduction of nutritional support may improve the prognosis for these critically ill patients.

Harbingers of poor outcome the day after severe brain injury: hypothermia, hypoxia, and hypoperfusion.

BACKGROUND: Traumatic brain injury (TBI) can be compounded by physiologic derangements that produce secondary brain injury. The purpose of this study is to elucidate the frequency with which physiologic factors that are associated with secondary brain injury occur in patients with severe closed head injuries and to determine the impact of these factors on outcome. METHODS: The records of 81 adult blunt trauma patients with Glasgow Coma Scale scores < or = 8 and transport times < 2 hours to a Level I trauma center were retrospectively reviewed searching for the following 11 secondary brain injury factors (SBIFs) in the first 24 hours postinjury: hypotension, hypoxia, hypercapnia, hypocapnia, hypothermia, hyperthermia, metabolic acidosis, seizures, coagulopathy, hyperglycemia, and intracranial hypertension. We recorded the worst SBIF during six time periods: hours 1, 2, 3, 4, 5 to 14, and 16 to 24. Occurrence of each SBIF was then correlated with outcome. RESULTS: Hypocapnia, hypotension, and acidosis occurred more frequently than other SBIFs (60-80%). Hypotension, hyperglycemia, and hypothermia were associated with increased mortality rate. Patients with episodes of hypocapnia, acidosis, and hypoxia had significantly longer intensive care unit length of stay (LOS). These three SBIFs and hyperglycemia related to longer hospital LOS as well. Hypotension and acidosis were associated with discharge to a rehabilitation facility rather than home. Finally, multivariate regression analysis revealed that hypotension, hypothermia, and Abbreviated Injury Scale score of the head were independently related to mortality, whereas other SBIFs, age, Injury Severity Score, and Glasgow Coma Scale score were not. Metabolic acidosis and hypoxia were related to longer intensive care unit and hospital LOS. CONCLUSION: Our early management of head-injured patients stresses avoidance and correction of SBIFs at all costs. Nonetheless, SBIFs occur frequently in the first 24 hours after traumatic brain injury. Six of the 11 factors studied are associated with significantly worse outcomes. Hypotension and hypothermia are independently related to mortality. Because these SBIFs are potentially preventable, protocols could be developed to decrease their frequency.