Management of complex pediatric and adolescent liver trauma: adult vs pediatric level 1 trauma centers

PURPOSE

Management of high-grade pediatric and adolescent liver trauma can be complex. Studies suggest that variation exists at adult (ATC) vs pediatric trauma centers (PTC); however, there is limited granular comparative data. We sought to describe and compare the management and outcomes of complex pediatric and adolescent liver trauma between a level 1 ATC and two PTCs in a large metropolitan city.

METHODS

A retrospective review of pediatric and adolescent (age < 21 years) patients with American Association for the Surgery of Trauma (AAST) Grade 4 and 5 liver injuries managed at an ATC and PTCs between 2016 and 2022 was performed. Demographic, clinical, and outcome data were obtained at the ATC and PTCs. Primary outcomes included rates of operative management and use of interventional radiology (IR). Secondary outcomes included packed red blood cell (pRBC) utilization, intensive care unit (ICU) length of stay (LOS), and hospital LOS.

RESULTS

One hundred forty-four patients were identified, seventy-five at the ATC and sixty-nine at the PTC. The cohort was predominantly black (65.5%) males (63.5%). Six injuries (8.7%) at the PTC and forty-five (60%) injuries at the ATC were penetrating trauma. Comparing only blunt trauma, ATC patients had higher Injury Severity Score (median 37 vs 26) and ages (20 years vs 9 years). ATC patients were more likely to undergo operative management (26.7% vs 11.0%, p = 0.016) and utilized IR more (51.9% vs 4.8%, p < 0.001) compared to the PTC. The patients managed at the ATC required higher rates of pRBC transfusions though not statistically significant (p = 0.06). There were no differences in mortality, ICU, or hospital LOS.

CONCLUSION

Our retrospective review of high-grade pediatric and adolescent liver trauma demonstrated higher rates of IR and operating room use at the ATC compared to the PTC in the setting of higher Injury Severity Score and age. While the PTC successfully managed > 95% of Grade 4/5 liver injuries non-operatively, prospective data are needed to determine the optimal algorithm for management in the older adolescent population.

LEVEL OF EVIDENCE

Level IV.

Understanding Chest CT Scan Usage Among Adolescent Blunt Trauma Patients at Adult Trauma Centers

PURPOSE

The utility of chest computed tomography (CCT) is not well established in the diagnostic algorithm of adolescent blunt trauma patients. Our study's aim was to review CCT usage in the initial evaluation of adolescent blunt trauma.

METHODS

We retrospectively reviewed adolescent blunt trauma patients treated at our urban level 1 adult trauma center from 2015 to 2019. Our primary outcome was the rate of positive CCT findings. Univariate and multivariate logistic regression analyses were performed.

RESULTS

There were 288 patients that met our inclusion criteria and 153 positive CCT and 135 negative CCT. There was no statistically significant difference between both groups in terms of age, gender, and race. Those with a positive CCT were found to have a statistically significant higher ISS than the negative CCT group (20.6 ± 12.3 vs 12.3 ± 7.6; P < .01). Those with a positive CCT were more likely to have a GCS <15 (40% vs 25%), have a positive CXR (38% vs 2%), have chest pain (16% vs 7%), and have an abnormal chest exam (27% vs 7%) than those with a negative CCT (P < .01). On multivariate analysis, positive CXR (P < .05, OR = 13.96) and ISS (P < .05, OR = 3.10) were independently associated with a positive CCT.

CONCLUSION

While CCT may provide valuable information, clinical exam coupled with low-ionizing radiographic imaging (i.e., CXR) may sufficiently identify chest trauma after blunt mechanisms. This shift in management can potentially reduce the risk of radiation without compromising the care of adolescent trauma patients at adult trauma centers.

Utilization of Angiography in Pediatric Blunt Abdominal Injury at Adult versus Pediatric Trauma Centers

INTRODUCTION

Angiography has been widely accepted as an adjunct in the management of blunt abdominal trauma in adults. However, the role of angiography with or without angioembolization (AE) is still being defined in pediatric solid organ injury. We sought to compare the use of angiography in solid organ injury (SOI) at pediatric trauma centers (PTCs) versus an adult trauma center (ATC) in a large metropolitan city.

METHODS

Data were drawn from a collaborative effort of three Trauma centers (one adult and two pediatric) in Atlanta, GA. All pediatric patients (ages 1-18) treated for SOI between January 1, 2016 and December 31, 2021 were included (n = 350). Registry data obtained included demographics, mechanism of injury, injury grade, injury severity score (ISS), procedures performed, and transfusions. Multivariate regression analysis was used to identify factors associated with angiography.

RESULTS

A total of 350 patients were identified during the study period with 101 treated at ATC and 249 treated at the two PTCs. The median age at the ATC was 17 y (IQR 16, 18) compared to nine (6, 13) at the PTCs. ISS was significantly higher at the ATC 22 (14, 34) compared to 16 (9, 22) at PTCs (P < 0.001). At the ATC, 11 (10.9%) patients underwent angiography, 4 (4.9%) of which underwent AE compared to seven (2.8%) patients who underwent angiography and AE at PTCs. In the multivariate analysis, factors associated with angiography use included age (OR 1.44, 95% CI 1.09-1.90, P = 0.010) and ISS (OR 1.05, 95% CI 1.02-1.09, P = 0.004). Through setting, ATC versus PTC was significant on univariable analysis, it did not remain a significant predictor of angiography on multivariable regression.

CONCLUSIONS

Our study demonstrated increased utilization of angiography for the management of SOI in pediatric patients treated at ATCs versus PTCs. On regression analysis, age and ISS remained significant predictors for angiography utilization, while setting (ATC versus PTC) was notably not a significant predictor. This data would suggest that differences in angiography utilization for pediatric SOI at PTCs and ATCs are influenced by differing patient populations (older and higher ISS), with otherwise uniform use. These findings provide a basis for future treatment algorithm revisions for pediatric blunt abdominal trauma that include angiography and provide support for the development of formal guidelines.

Optimizing Transitions of Care and Enhancing Surgical Education on Acute Care Surgery: A Multi-Institutional Survey Study

OBJECTIVE

Critically ill and injured patients are routinely managed on the Trauma and Acute Care Surgery (ACS) service and receive care from numerous residents during hospital admission. The Clinical Learning Environment Review (CLER) program established by the ACGME identified variability in resident transitions of care (TC) while observing quality care and patient safety concerns. The aim of our multi-institutional study was to review surgical trainees' impressions of a specialty-specific handoff format in order to optimize patient care and enhance surgical education on the ACS service.

DESIGN

A survey study was conducted with a voluntary electronic 20-item questionnaire that utilized a 5 point Likert scale regarding TC among resident peers, supervised handoffs by trauma attendings, and surgical education. It also allowed for open-ended responses regarding perceived advantages and disadvantages of handoffs.

SETTING

Ten American College of Surgeons-verified Level 1 adult trauma centers.

PARTICIPANTS

All general surgery residents and trauma/acute/surgical critical care fellows were surveyed.

RESULTS

The study task was completed by 147 postgraduate trainees (125 residents, 14 ACS fellows, and 8 surgical critical care fellows) with a response rate of 61%. Institutional responses included: university hospital (67%), community hospital-university affiliate (16%), and private hospital-university affiliate (17%). A majority of respondents were satisfied with morning TC (62.6%) while approximately half were satisfied with evening TC (52.4%). Respondees believe supervised handoffs improved TC and prevented patient care delays (80.9% and 74.8%, respectively). A total of 35% of trainees utilized the open-ended response field to highlight specific best practices of their home institutions.

CONCLUSIONS

Surgical trainees view ACS morning handoff as an effective standard to provide the highest level of clinical care and an opportunity to enhance surgical knowledge. As TC continue to be a focus of certifying bodies, identifying best practices and opportunities for improvement are critical to optimizing quality patient care and surgical education.

Hepatic Arterioportal Fistula Following Liver Trauma: Case Series and Review of the Literature

PURPOSE

Hepatic arterioportal fistula (HAPF) is an uncommon complication of hepatic trauma, which can manifest with abdominal pain and the sequelae of portal hypertension months to years after injury. The purpose of this study is to present cases of HAPF from our busy urban trauma center and make recommendations for management.

METHODS

One hundred and twenty-seven patients with high-grade penetrating liver injuries (American Association for the Surgery of Trauma [AAST] - Grades IV-V) between January 2019 and October 2022 were retrospectively reviewed. Five patients were identified with an acute hepatic arterioportal fistula following abdominal trauma from our ACS-verified adult Level 1 trauma center. Institutional experience with overall surgical management is described and reviewed with the current literature.

RESULTS

Four of our patients presented in hemorrhagic shock requiring emergent operative intervention. The first patient had postoperative angiography and coil embolization of the HAPF. Patients 2 through 4 underwent damage control laparotomy with temporary abdominal closure followed by postoperative transarterial embolization with gelatin sponge particles (Gelfoam) or combined Gelfoam/n-butyl cyanoacrylate. The final patient went directly for angiography and Gelfoam embolization after identification of the HAPF. All 5 patients had resolution of HAPF on follow-up imaging with continued post management for traumatic injuries.

CONCLUSION

Hepatic arterioportal fistula can present as a complication of hepatic injury and manifest with significant hemodynamic aberrations. Although surgical intervention was required to achieve hemorrhage control in almost all cases, management of HAPF in the setting of high-grade liver injuries was achieved successfully with modern endovascular techniques. A multidisciplinary approach to such injuries is necessary to optimize care in the acute setting following traumatic injury.

Increases in adolescent firearm injuries were associated with school closures during COVID-19

BACKGROUND

Mitigation measures, including school closures, were enacted to protect the public during the COVID-19 pandemic. However, the negative effects of mitigation measures are not fully known. Adolescents are uniquely vulnerable to policy changes since many depend on schools for physical, mental, and/or nutritional support.  This study explores the statistical relationships between school closures and adolescent firearm injuries (AFI) during the pandemic.

METHODS

Data were drawn from a collaborative registry of 4 trauma centers in Atlanta, GA (2 adult and 2 pediatric). Firearm injuries affecting adolescents aged 11-21 years from 1/1/2016 to 6/30/2021 were evaluated. Local economic and COVID data were obtained from the Bureau of Labor Statistics and the Georgia Department of Health. Linear models of AFI were created based on COVID cases, school closure, unemployment, and wage changes.

RESULTS

There were 1,330 AFI at Atlanta trauma centers during the study period, 1,130 of whom resided in the 10 metro counties. A significant spike in injuries was observed during Spring 2020. A season-adjusted time series of AFI was found to be non- stationary (p = 0.60). After adjustment for unemployment, seasonal variation, wage changes, county baseline injury rate, and county-level COVID incidence, each additional day of unplanned school closure in Atlanta was associated with 0.69 (95% CI 0.34- 1.04, p < 0.001) additional AFIs across the city.

CONCLUSION

AFI increased during the COVID pandemic. This rise in violence is statistically attributable in part to school closures after adjustment for COVID cases, unemployment, and seasonal variation. These findings reinforce the need to consider the direct implications on public health and adolescent safety when implementing public policy.

Trends in Adolescent Firearm-Related Injury: A Time Series Analysis

BACKGROUND

Firearm-related injury (FRI) became the leading cause of death among children/adolescents in 2019.

PURPOSE

This study sought to determine changes over time in the population of adolescents affected by FRI in Atlanta, Georgia, such that high risk cohorts could be identified.

RESEARCH DESIGN

City-wide retrospective cohort review.

STUDY SAMPLE

Adolescent victims (age 11-21 years of age) of FRI, defined by ICD9/10 codes, in Atlanta, Georgia.

DATA ANALYSIS

Descriptive, multivariate and time series analysis.

RESULTS

There were 1,453 adolescent FRI victims in this time period, predominantly Black (86%) and male (86.6%). Unintentional injury was higher among ages 11-14 years (43.1%) compared to 15-17 years (10.2%) and 18-21 years (9.3%) (P < .01). FRI affecting females increased at a rate of 8.1 injuries/year (P < .01), and unintentional injuries increased at by 7.6/year (P < .01). Mortality declined from 16% in 2016 to 7.7% in 2021.

CONCLUSION

Our data provides evidence for firearm policy reform. Interventions should target prevention of intentional injury among AQ4 females and seek to reverse the trend in unintentional injuries.

Missing Bullets: Bullet Embolization Case Series and Review of the Literature

PURPOSE

Bullet embolization is a rare but dangerous phenomenon. Based on the location of embolization, migration of bullets can cause limb or intra-abdominal ischemia, pulmonary infarction, cardiac valve injury, or cerebrovascular accident. Bullet emboli can present a diagnostic challenge given the varied nature of complications based on location of embolization, which may not coincide with the site of initial injury. The purpose of this study is to present several cases of bullet embolization from our busy urban trauma center and make recommendations for management.

METHODS

We present 3 cases of bullet embolization seen in injured patients at our Level 1 trauma center. We describe our management of these injuries and make recommendations for management in the context of our institutional experience and comment on the available literature regarding bullet embolization.

RESULTS

Two of our patients presented in extremis and required operative intervention to achieve stability. The intravascular missile was discovered intraoperatively in one patient and removed in the operating room, while the missile was discovered on postoperative imaging in another patient and again removed operatively after an unsuccessful attempt at minimally invasive retrieval. Our third patient remained hemodynamically stable throughout his hospitalization and had endovascular management of his bullet embolus.

CONCLUSION

Bullet emboli present a challenging complication of penetrating trauma. We recommend removal of all arterial bullet emboli and those within the pulmonary venous system. In hemodynamically stable patients, we recommend initial attempts of endovascular retrieval followed by open surgical removal. We recommend open removal in cases of hemodynamic instability.

Cultural and Linguistic Adaptations of Stop the Bleed in Multi-Ethnic Refugee Communities

INTRODUCTION

Stop the Bleed (STB), and other trainings that promote health education in basic trauma management techniques, is offered mostly in English and Spanish in the United States. Limited access to injury prevention training may contribute to inequities in health outcomes for individuals with limited English proficiency (LEP). Our study aims to determine the feasibility and effectiveness of STB training in 4 languages spoken in a super diverse refugee settlement community, Clarkston, GA.

METHODS

Written STB educational materials were culturally adapted, translated, and back translated into 4 languages: Arabic, Burmese, Somali, and Swahili. Four 90-minute in-person STB trainings were conducted by medical personnel with community-based interpreters at a central and familiar location in the Clarkston community. Pre- and post-tests were administered in participant's preferred language to evaluate change in knowledge and beliefs as well as the effectiveness of the training method.

RESULTS

A total of 46 community members were trained in STB, the majority of which were women (63%). Participants demonstrated improvement in their knowledge, confidence, and comfort using STB techniques. Participants reported that 2 aspects of the training were particularly beneficial: the presence of language concordant interpreters from the community and small group hands on sessions that allowed for practicing STB techniques.

CONCLUSION

Cultural and linguistic adaptation of STB training is a feasible, cost-effective, and effective method for disseminating life-saving information and trauma education to immigrant populations who have LEP. Expansion of community training and partnerships to support the needs of diverse communities is both necessary and urgent.

Understanding Head CT Scan Usage Amongst Adolescent Blunt Trauma Patients Treated at a Level 1 Adult Trauma Center

BACKGROUND

Guidelines developed by the Pediatric Emergency Care Applied Research Network (PECARN) exist to reserve the use of head CT for pediatric patients with a high risk of head injury. However, CTs are still being overutilized especially at adult trauma centers. The aim of our study was to review our use of head CTs in adolescent blunt trauma patients.

MATERIALS AND METHODS

Patients aged 11-18 who underwent head CT scans from 2016 to 2019 at our urban level 1 adult trauma center were included. Data was collected via electronic medical record and analyzed through retrospective chart review.

RESULTS

Of the 285 patients requiring a head CT, 205 had a negative head CT (NHCT) and 80 patients had a positive head CT (PHCT). There was no difference in age, gender, race, and trauma mechanism between the groups. The PHCT group was found to be with a statistically significant higher likelihood of the Glasgow Coma Scale (GCS) < 15 (65% vs 23%; P < .01), abnormal head exam (70% vs 25%; P < .01), and loss of consciousness (85% vs 54%; P < .01) compared to the NHCT group. There were 44 patients who had low risk of head injury, based on the PECARN guidelines, and received a head CT. None of the patients had a positive head CT.

CONCLUSION

Our study suggests that reinforcement of the PECARN guidelines should occur for ordering head CTs in adolescent blunt trauma patients. Future prospective studies are needed to validate the use of PECARN head CT guidelines in this patient population.

Cervical Spine Computed Tomography in Adolescent Blunt Trauma Patients: Are They Being Overutilized?

INTRODUCTION

Cervical spine computed tomography (CSCT) scans are used to evaluate cervical spine traumatic injuries; however, recent evidence demonstrates that adult trauma centers (ATCs) overutilize CSCT when evaluating adolescent patients. This leads to unnecessary radiation exposure. The aim of this study is to review a level 1 ATC's use of CSCT in the adolescent blunt trauma population.

METHODS

A retrospective chart review was conducted of a level 1 ATC's trauma database. Blunt trauma patients between the ages of 11 and 18 who receive a CSCT between January 2015 to December 2019 were included. The primary outcome was the prevalence of positive findings on CSCT scans. Data were analyzed using Fischer-Exact analysis and multivariate logistic regression where appropriate.

RESULTS

Three-hundred thirty-seven of 546 (61.7%) adolescent blunt trauma patients received CSCT. Of those, 68.2% (230) were male; the mean age was 16.6 ± 1.0 y old. Twenty-eight patients (8.3%) had a positive finding on CSCT. All patients with a positive CSCT failed the National Emergency X-Radiography Utilization study (NEXUS) criteria while 123 patients (36.5%) with a negative CSCT met NEXUS criteria.

CONCLUSIONS

CSCT was overutilized in our trauma center. There is a low positive CSCT scan rate among adolescent patients, which aligns with the current literature. All patients with positive CSCT passed NEXUS criteria suggesting that a quality improvement project focusing on the use of the NEXUS criteria to assess the risk of cervical spine injury could potentially reduce the use of CSCT scans by nearly 40%.

Understanding abdominal pelvic computerized tomography scan usage amongst adolescent blunt trauma patients treated at adult trauma centers

INTRODUCTION

The algorithm for evaluating adolescent patients with blunt trauma includes abdominal pelvic CT (APCT). The aim of this study is to evaluate the utility of APCT in this context.

METHODS

We performed a retrospective review of adolescent (11 to 18 years of age) blunt trauma patients at an urban adult level 1 trauma center from January 2015 to December 2019. The primary outcome was the prevalence of positive findings on APCT scan.  Additionally, clinical risk factors concerning for intra-abdominal injury were analyzed.

RESULTS

There were 546 patients evaluated for blunt trauma and the prevalence of APCT within the population was 59.3% (95% CI 54.2%-64.9%). Of the patients who received APCT, 123 (37.9%) had positive findings on APCT. Only 25 patients (7.7% of those who underwent APCT) required abdominal surgery while 40 patients (12.3%) had intraabdominal injury that did not require surgery. Risk factors were present in 100% of patients with intraabdominal injury and absent in 28.7% of patients without intraabdominal injury. Abnormal abdominal exam, abnormal FAST, positive chest x-ray and elevated transaminases were independently associated with intraabdominal injury.

CONCLUSIONS

Our study found that adolescent blunt trauma patients treated at our trauma center had a higher rate of APCT usage, but a comparable rate of positive findings when compared with the most recent literature. Future studies should focus on reducing the number of patients who undergo APCT despite an absence of clinical risk factors.

Vaccination after spleen embolization: A practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND

Angioembolization is an important adjunct in the non-operative management of adult trauma patients with splenic injury. Multiple studies have shown that angioembolization may increase the non-operative splenic salvage rate for patients with high-grade splenic injuries. We performed a systematic review and developed evidence-based recommendations regarding the need for post-splenectomy vaccinations after splenic embolization in trauma patients.

METHODS

A systematic review and meta-analysis of currently available evidence were performed utilizing the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

RESULTS

Nine studies were identified and analyzed. A total of 240 embolization patients were compared to 443 control patients who neither underwent splenectomy nor were embolized. There was no statistical difference between the splenic immune function of embolized and control patients. In addition, a total of 3974 splenectomy patients was compared with 686 embolization patients. Embolization patients had fewer infectious complications and a greater degree of preserved splenic immune function.

CONCLUSION

In adult trauma patients who have undergone splenic angioembolization, we conditionally recommend against routine post-splenectomy vaccinations.

STUDY TYPE

systematic review/meta-analysis Level of evidence: level III.

Second Victim Syndrome in Trauma Practitioners and Other Ancillary Staff

In health care, second victims are traumatized clinicians involved in unanticipated or untoward patient events. Programs that address second victim syndrome are sparse and its diagnosis often goes unrecognized. Consistently, literature has identified gaps in support resources, leading to compromised patient care and provider health. This project evaluates the need for second victim resources in trauma care providers at a tertiary public level 1 trauma hospital by electronically implementing a validated second victim survey over 5 weeks. Our results illustrate that second victim syndrome is prevalent among 57.1% of trauma care providers, of which 22.9% agree that second victim syndrome results in some form of undesirable work intentions.

Presentation, clinical course and complications in trauma patients with concomitant COVID-19 infection

BACKGROUND

This study investigated the impact of COVID-19 infection on hospitalized trauma patients.

METHODS

A retrospective review of hospitalized trauma patients at a level I trauma center was performed from March-December 2020. Data pertaining to patient demographics, presentation and hospital course was compared between COVID positive and negative trauma patients.

RESULTS

There were 4,912 patients and 179 (3.64%) were COVID-19 positive. Demographics and clinical presentation did not differ significantly between those with and without concomitant COVID-19. However, COVID positive trauma patients had higher rates of acute kidney injury (p = 0.016), sepsis (p = 0.016), unplanned intubation (p = 0.002) and unplanned return to the ICU (p = 0.01). The COVID positive cohort also had longer hospital stays (p < 0.01) with no significant difference in mortality.

CONCLUSIONS

In the setting of an ongoing pandemic, awareness of the complications COVID positive trauma patients are predisposed to is important for providers.

Screening, Brief Intervention, and Referral to Treatment to Prevent Post-Traumatic Stress Disorder After Gunshot Wounds

Screening, brief intervention, and referral to treatment (SBIRT) is an intervention originally developed to prevent and deter substance abuse. Adaptation of the SBIRT model to prevent post-traumatic stress disorder (PTSD) may potentially reduce acute stress symptoms after traumatic injury. We conducted a prospective randomized control study of adult patients admitted for gunshot wounds. Patients were randomized to intervention (INT) vs. treatment as usual (TAU) groups. INT received the newly developed SBIRT Intervention for Trauma Patients (SITP)-a 15-minute session with elements of cognitive behavioral therapy techniques. SITP took place during the index hospitalization; both groups had followup at 30 and 90 days at which time a validated PTSD screening tool, PCL-5, was administered. Most of the 46 participants were young (mean age = 30.5y), male (91.3%), and black (86.9%). At three-month follow-up, SBIRT and TAU patients had similar physical healing scores but the SBIRT arm showed reductions in PTSD symptoms.

Superior Mesenteric Artery and Vein Injuries: Operative Strategies and Outcomes

Traumatic injuries to the mesenteric vessels are rare and often lethal. Visceral vessels, such as the superior mesenteric artery (SMA) and vein (SMV), supply blood to the small and large bowel by a rich system of collaterals. Because fewer than 100 such injuries have been described in the literature, they pose challenges in both diagnosis and management and can unfortunately result in high mortality rates. Prompt diagnosis, surgical intervention, and resuscitation can lead to improved outcomes. Here, we review the literature surrounding traumatic injuries of the SMA/SMV and discuss management strategies.

Suicide Attempts and Adolescents: The Need for Specialized Resources at Adult Trauma Centers

Background:

Suicide is the second leading cause of adolescent death and suicide attempts outnumber deaths 50:1 for adolescents 15 to 19 years of age. This study examines differences in outcomes between adolescents and adults treated at an adult trauma center in an effort to guide recovery and prevention strategies following an adolescent suicide attempt.

Methods:

Retrospective review of patients aged ≥14 years treated at an urban, Level 1 trauma center for self-inflicted injuries between 2009 and 2018 was performed. The cohort was divided into adolescents (14-19 years) and adults (≥20 years) and into group A (economically distressed) and group B (non-distressed). Demographics, injury, outcomes, and geospatial analysis were compared.

Results:

Among 723 patients, 60 (8%) were adolescents of which 92% were male, 55% black, 47% blunt injuries, and 53% penetrating. In adults, 76% were male, 41% black, 28% blunt injuries, and 72% penetrating. Mortality estimates for adolescents and adults were 35% and 24%, respectively (p=0.09). Most adolescent deaths occurred within 3 days after admission, while adult deaths occurred further into hospitalization (p<0.01). Cox regression analysis found higher mortality with self-pay compared to private insurance (HR 2.6; p<0.001), and penetrating vs. blunt/other injuries (HR 2.4; p<0.001). Psychiatric care was administered in 64% of adolescents (n=39) and 84% of adults (p< 0.01).

Conclusions:

Inpatient psychiatric care for adolescents who attempted suicide was limited at an adult trauma center. The high incidence of suicide attempts and community-level distress in adolescents require immediate attention and resources.

Intra-abdominal Inferior Vena Cava Injuries: Operative Strategies and Outcomes

Visceral vascular injuries are relatively uncommon even in busy urban trauma centers. The inferior vena cava (IVC) is the most frequently injured visceral vein and can be a complex operative challenge. Despite advances in early volume resuscitation, improved transport times, prompt operative intervention, and hemorrhage control, mortality rates have remained largely unchanged. This article conducts an in-depth review of the literature surrounding IVC injuries and a detailed discussion of operative strategies and management as survivability is ultimately dependent on the grade of injury, location, and the presence of hemorrhagic shock.

Is Blush on CT Scan in Patients With Pelvic Fracture Associated With Embolization Rates and Outcomes?

INTRODUCTION

In trauma patients with pelvic fractures, computed tomography (CT) scans are a critical tool to evaluate life-threatening hemorrhage. Contrast extravasation, or "blush", on CT may be a sign of bleeding, prompting a consult for angiography and possible embolization. However, the utility of blush on CT is controversial. We sought to evaluate our experience with patients who sustained pelvic fractures and had blush on CT.

METHOD

A retrospective review was performed for all patients with blunt pelvic fractures between January 1, 2017 and December 31, 2018. Demographic, clinical, radiographic, and injury data were obtained. Comparison of mortality, hospital length of stay (LOS), and intensive care unit (ICU) LOS was performed for 3 subgroups: angio versus no angio; embo versus no embo; prophylactic embo versus therapeutic embo. We also calculated the sensitivity, specify, positive predictive value (PPV), and negative predictive value (NPV) of CT blush to predict the need for embolization.

RESULTS

889 patients were found to have a blunt pelvic fracture. 51 patients had blush on CT scan. 29 (56.9%) underwent angiography. 17 (58.6%) of these 29 patients were found to have extravasation and were embolized. 12 patients had an angio with no extravasation, and 6 of these patients (50%) underwent prophylactic embolization. No significant difference was found for hospital LOS, ICU LOS, or mortality in our 3 groups. Sensitivity, specificity, PPV, and NPV for CT blush were 74%, 96%, 33%, 99%, respectively.

CONCLUSION

Patients with active extravasation undergoing embolization had similar outcomes to patients without active extravasation. Blush on CT scan had low sensitivity and low PPV but high specificity and high NPV. Future studies need to include careful attention to the CT protocol utilized as well as patient selection.

Asymptomatic Trauma Patients Screened for Venous Thromboembolism Have a Higher Risk Profile with Lower Rate of Pulmonary Embolism: A Five-Year Single-Institution Experience

Deep vein thrombosis (DVT) is linked to reimbursements and publicly reported metrics. Some hospitals discourage venous duplex ultrasound (VDUS) screening in asymptomatic trauma patients because they often find higher rates of DVT. We aim to evaluate the association between lower extremity (LE) VDUS screening and pulmonary embolism (PE) in trauma patients. Trauma patients admitted to an urban Level-1 trauma center between 2010 and 2015 were retrospectively analyzed. We characterized the association of asymptomatic LE VDUSs with PE, upper extremity DVT, proximal LE DVT, and distal LE DVT by univariate and multivariable logistic regression controlling for confounders. Of the 3959 trauma patients included in our study—after adjusting for covariates related to patient demographics, injury, and procedures—there was a significantly lower likelihood of PE in screened patients (odds ratio (OR) = 0.02, P < 0.001) and a higher rate of distal LE DVT (OR 11.1, P = 0.004). Screening was not associated with higher rates of proximal LE DVTafter adjustment for covariates (OR = 1.8, P = 0.193). PE was associated with patient transfer status, pelvis fracture, and spinal procedures in unscreened patients. After adjusting for covariates, we have shown that LE VDUS asymptomatic screening is associated with lower rates of PE in trauma patients and not associated with higher rates of proximal LE DVT. Our detailed institutional review of a large cohort of trauma patients over five years provides support for ongoing asymptomatic screening and better characterizes venous thromboembolism outcomes than similarly sized purely administrative data reviews. As a retrospective cohort study with a large sample size, no loss to follow-up, and a population with low heterogeneity, this study should be considered as level III evidence for care management.

Successful Treatment of Dual Juxtahepatic Inferior Vena Cava Injuries Using Formal Atriocaval Shunt: A Case Report and Review of the Literature

Repair of penetrating retrohepatic inferior vena cava (IVC) injuries continues to challenge trauma surgeons due to difficulty in accessing the injury, hemorrhage prior to the repair, and associated high mortality rates. Complication by suprahepatic vena cava injuries portends an increased risk of an unfavorable outcome. Over time, overall survival has been relatively unchanged, and the morbidity and mortality associated with these injuries continue to be very high. First proposed by Shrock et al. in 1968, atriocaval shunt placement remains the gold standard approach for the temporary bypass of these lesions by controlling bleeding from the retrohepatic IVC to allow time for repair prior to exsanguination and death. Despite familiarity with this management strategy for decades, these injuries remain infrequent but continue to have poor survival due to their complexity. There are only rare examples of the use of this approach resulting in successful discharge from the hospital. We present a case report of survival after the successful deployment of an atriocaval shunt in a patient who sustained multiple gunshot wounds to his right thoraco-abdomen, left chest, and upper and lower extremities. He ultimately survived to discharge from the hospital. We provide a brief review of the current literature and propose future approaches to repairs of juxtahepatic IVC injuries.

Asymptomatic Trauma Patients Screened for Venous Thromboembolism Have a Higher Risk Profile with Lower Rate of Pulmonary Embolism: A Five-Year Single-Institution Experience

Deep vein thrombosis (DVT) is linked to reimbursements and publicly reported metrics. Some hospitals discourage venous duplex ultrasound (VDUS) screening in asymptomatic trauma patients because they often find higher rates of DVT. We aim to evaluate the association between lower extremity (LE) VDUS screening and pulmonary embolism (PE) in trauma patients. Trauma patients admitted to an urban Level-1 trauma center between 2010 and 2015 were retrospectively analyzed. We characterized the association of asymptomatic LE VDUSs with PE, upper extremity DVT, proximal LE DVT, and distal LE DVT by univariate and multivariable logistic regression controlling for confounders. Of the 3959 trauma patients included in our study-after adjusting for covariates related to patient demographics, injury, and procedures-there was a significantly lower likelihood of PE in screened patients (odds ratio (OR) = 0.02, P < 0.001) and a higher rate of distal LE DVT (OR 11.1, P = 0.004). Screening was not associated with higher rates of proximal LE DVT after adjustment for covariates (OR = 1.8, P = 0.193). PE was associated with patient transfer status, pelvis fracture, and spinal procedures in unscreened patients. After adjusting for covariates, we have shown that LE VDUS asymptomatic screening is associated with lower rates of PE in trauma patients and not associated with higher rates of proximal LE DVT. Our detailed institutional review of a large cohort of trauma patients over five years provides support for ongoing asymptomatic screening and better characterizes venous thromboembolism outcomes than similarly sized purely administrative data reviews. As a retrospective cohort study with a large sample size, no loss to follow-up, and a population with low heterogeneity, this study should be considered as level III evidence for care management.

Mass Casualty Shootings and Emergency Preparedness: A Multidisciplinary Approach for an Unpredictable Event

Mass casualty events (MCE) are an infrequent occurrence to most daily healthcare systems however these incidents are the causation for new hospital preparedness and the development of coordinated emergency services. The broad support and operational plans outside the hospital include emergency medical services, local law enforcement, government agencies, and city officials. Modern-day hospital disaster preparedness goals include scheduled training for healthcare personnel to ensure effective and accurate triage for a high-volume of injured patients. This MDT collaboration strengthens the emergency response to optimize the delivery of life-saving care during MCEs. This review identifies the clinical importance of the interdisciplinary team interactions and the lessons learned from past MCE experiences, strengthening healthcare system readiness for such critical incidents.

Geriatric patients on antithrombotic therapy as a criterion for trauma team activation leads to over triage

BACKGROUND

Our institution amended its trauma activation criteria to require a Level II activation for patients ≥65 years old on antithrombotic medication presenting with suspected head trauma.

METHODS

Our institutional trauma registry was queried for geriatric patients on antithrombotic medication in the year before and after this criteria change. Demographics, presentation metrics, level of activation, and outcomes were compared between groups.

RESULTS

After policy change, a greater proportion of patients received a trauma activation (19.9 vs. 74.9%, P < 0.001) and a greater proportion of these patients were discharged directly home without injury (4.3 vs. 44%, P < 0.001). However, a smaller proportion of patients with a critical Emergency Department disposition or traumatic intracranial hemorrhage failed to receive a trauma activation (65.1 vs. 23.5%, P < 0.001; 70.7% vs. 27.3%, P < 0.001). There was no change in mortality (4.3 vs. 2.0%, P = 0.21).

CONCLUSIONS

Implementing new criteria increased overtriage, decreased undertriage, and had little effect on mortality.

Duodenal Adenocarcinoma in a Patient with Partial Intestinal Malrotation

Background: Small bowel cancers, specifically duodenal cancer, occur at very low rates but require aggressive surgical resection when diagnosed. An even rarer finding is the presence of intestinal malrotation. Case Presentation: We present the unique case of a patient with both duodenal cancer and partial intestinal malrotation undergoing pancreaticoduodenectomy. We discuss the challenges faced and techniques used to successfully perform a surgical resection in this circumstance. Conclusion: Understanding of intestinal malrotation and review of the imaging is crucial in preparing for a resection of a duodenal tumor in a patient with this condition.

Health status and behaviors among adults residing in rural Dominican Republic

INTRODUCTION

The rapidly increasing burden of chronic diseases linked to adequacy of healthcare services and individual health behaviors is a key determinant of global public health. Given demographic aging and the accompanying health transition, chronic diseases in low and middle income communities of the Dominican Republic are likely to increase significantly. The objective of this article was to report on efforts in surveillance of health conditions and behaviors in underserved rural Dominican communities.

METHODS

A modified 30 item, language-sensitive health survey was randomly administered to 117 adult participants (18 years and older) during a health fair held at three rural villages from March to April 2009 in the rural San Cristobál region of the Dominican Republic. Descriptive analyses of select health conditions and behavior variables from all completed surveys were tabulated.

RESULTS

Adult participant ages ranged from 18 to 79 years (mean ± standard deviation; 34.0 ± 2.1), height from 1.4 to 2.0 m (1.7 ± 0.1), weight from 41.8 to 100.0 kg (66.2 ± 1.7) and BMI from 15.2 to 46.2 (24.2 ± 0.7). Overall, 69.2% of the sample self-reported their general health status to be fair to poor. The top three chronic diseases included: high blood pressure (35.8%), diabetes (15.0%), and asthma (14.2%). In all, 33.4% reported current smoker status and 61.7% were classified as heavy alcohol drinkers.

CONCLUSION

Considerable variation was found in the self-report of health conditions and behavioral characteristics among those individuals that attended the health fair. Documenting these important health indicators in the rural communities has the potential to inform the development of surveillance activities and prevention efforts for future health education interventions.