Pneumopericardium following severe thoracic trauma

BACKGROUND

Traumatic pneumopericardium (PPC) is a rare clinical entity associated with chest trauma, resulting from a pleuropericardial connection in the presence of a pneumothorax, interstitial air tracking along the pulmonary perivascular sheaths from ruptured alveoli to the pericardium, or direct trachea-bronchial-pericardial communication.  Our objectives were to describe the modern management approach to PPC and to identify variables that could improve survival with severe thoracic injury.

METHODS

We conducted a retrospective study of the trauma registry between 2015 and 2022 at a Level I verified adult trauma center for all patients with PPC. Demographics, injury patterns, and treatment characteristics were compared between blunt and penetrating trauma. This study focused on the management strategies and the physiologic status regarding PPC and the development of tension physiology. The main outcome measure was operative versus nonoperative management.

RESULTS

Over a seven-year period, there were 46,389 trauma admissions, of which 488 patients had pneumomediastinum. Eighteen patients were identified with PPC at admission. Median age was 39.5 years (range, 18-77 years), predominantly male (n = 16, 89 %), Black (n = 12, 67 %), and the majority from blunt trauma (78 %). Half had subcutaneous emphysema on presentation while 39 % had recognizable pneumomediastinum on chest x-ray. Tube thoracostomy was the most common intervention in this cohort (89 %). Despite tube thoracostomy, tension PPC was observed in three patients, two mandating emergent pericardial windows for progression to tension physiology, and the remaining requiring reconstruction of a blunt tracheal disruption. The majority of PPC patients recovered with expectant management (83 %), and no deaths were directly related to PPC.

CONCLUSIONS

Traumatic PPC is a rare radiographic finding with the majority successfully managed conservatively in a monitored ICU setting. These patients often have severe thoracic injury with concomitant injuries requiring thoracostomy alone; however, emergent surgical intervention may be required when PPC progresses to tension physiology to improve overall survival.

Is Traumatic Anterior Stove-In Chest Truly so Rare? A Single Institution Experience

INTRODUCTION

The anterior stove-in chest (ASIC) is a rare form of flail chest involving bilateral rib or sternal fractures resulting in an unstable chest wall that caves into the thoracic cavity. Given ASIC has only been described in a handful of case reports, this study sought to review our institution's experience in the surgical management of ASIC injuries.

METHODS

A retrospective review of patients with ASIC was conducted at our level I trauma center from 1//2021 to 3//2023. Information pertaining to patient demographics, fracture pattern, operative management, and outcomes was obtained and compared across patients in the case series.

RESULTS

6 patients met inclusion criteria, all males aged 37-78 years. 5 suffered motor vehicle collisions, and 1 was a pedestrian struck by an automobile. The median injury severity score was 28. All received ORIF within 5 days of admission, most commonly for ongoing respiratory distress. Patients 2 and 4 underwent bilateral ORIF of the ribs and sternum while patients 1, 5, and 6 underwent left-sided repair. Patient 3 required ORIF of left ribs and the sternum to stabilize their injuries. 5 of 6 patients were liberated from the ventilator and survived to discharge.

CONCLUSIONS

This study demonstrates successful operative management of 6 patients with ASIC and suggests that early operative intervention with ORIF for affected segments may improve respiratory mechanics, ability to wean from the ventilator, and overall survival. Further research is needed to generate standardized guidelines for the management of this uncommon and complex thoracic injury.

Rigid Plate Fixation for Closure of Emergent Sternotomies for Trauma

BACKGROUND

No studies to date have evaluated the use of rigid plate fixation for emergent sternotomy in trauma patients. We evaluated our use of rigid plate fixation vs wire cerclage in patients requiring emergent sternotomy. We hypothesized there would be no difference in complications related to sternal closure between the two groups.

METHODS

We performed a retrospective cohort study to include all patients who underwent emergent sternotomy from 1/1/2018 to 1/31/2021 and survived to have their sternum closed. Outcomes in patients closed with wire cerclage group (WC) were compared to patients who underwent rigid plate fixation (RPF).

RESULTS

Twenty-two patients underwent emergent sternotomy. There were 11 patients in each group. There was no significant difference in admission demographics, ISS, or admission characteristics between the two groups. Complication rates related to closure (wound infection and hardware removal) were not significantly different (WC 27% vs RPF 9%, P = .58). Neither hospital length of stay (WC: 29 days vs RPF: 13 days, P = .13), ICU length of stay (WC: 6 days vs RPF: 7 days, P = .62), nor the number of ventilator days (WC: 3 days vs RPF: 1 day, P .11) were statistically different. All patients survived to discharge.

DISCUSSION

This is the first study comparing RPF and WC for sternotomy closure in the setting of trauma. We found no difference in the rate of wound related complications. This study demonstrates the feasibility of rigid plate fixation for trauma sternotomy closure and lays the foundation for future prospective studies.

Lower Extremity Vascular Injury in the Pediatric Trauma Patient: Management and Outcomes at an Adult Level I Trauma Center

BACKGROUND

Traumatic vascular injuries of the lower extremity in the pediatric population are uncommon but can result in significant morbidity. The objective of this study is to demonstrate our experience with these injuries by describing patterns of traumatic vascular injury, the initial management, and data regarding early outcomes.

METHODS

In total, 506 patients presented with lower extremity vascular injury between January 1, 2009 and January 1, 2021 to Grady Memorial Hospital, an urban, adult Level I trauma center in Atlanta, Georgia. Thirty-two of the 506 patients were aged less than 18 years and were evaluated for a total of 47 lower extremity vascular injuries. To fully elucidate the injury patterns and clinical course in this population, we examined patient demographics, mechanism of injury, type of vessel injured, surgical repair performed, and early outcomes and complications.

RESULTS

The median (interquartile range) age was 16 (2) years (range, 3-17 years), and the majority were male (n = 29, 90.6%). Of the vascular injuries identified, 28 were arterial and 19 were venous. Of these injuries, 14 patients had combined arterial-venous injuries. The majority of injuries were the result of a penetrating injury (n = 28, 87.5%), and of these, all but 2 were attributed to gunshot wounds. Twenty-seven vascular interventions were performed by nonpediatric surgeons: 11 by trauma surgeons, 13 by vascular surgeons, 2 by orthopedic surgeons, and 1 by an interventional radiologist. Two patients required amputation: 1 during the index admission and 1 delayed at 3 months. Overall survival was 96.9%.

CONCLUSIONS

Vascular injuries as the result of trauma at any age often require early intervention, and we believe that these injuries in the pediatric population can be safely managed in adult trauma centers with a multidisciplinary team composed of trauma, vascular, and orthopedic surgeons with the potential to decrease associated morbidity and mortality from these injuries.

TiME OUT: Time-specific machine-learning evaluation to optimize ultramassive transfusion

BACKGROUND

Ultramassive transfusion (UMT) is a resource-demanding intervention for trauma patients in hemorrhagic shock, and associated mortality rates remains high. Current research has been unable to identify a transfusion ceiling or point where UMT transitions from lifesaving to futility. Furthermore, little consideration has been given to how time-specific patient data points impact decisions with ongoing high-volume resuscitation. Therefore, this study sought to use time-specific machine learning modeling to predict mortality and identify parameters associated with survivability in trauma patients undergoing UMT.

METHODS

A retrospective review was conducted at a Level I trauma (2018-2021) and included trauma patients meeting criteria for UMT, defined as ≥20 red blood cell products within 24 hours of admission. Cross-sectional data were obtained from the blood bank and trauma registries, and time-specific data were obtained from the electronic medical record. Time-specific decision-tree models predicating mortality were generated and evaluated using area under the curve.

RESULTS

In the 180 patients included, mortality rate was 40.5% at 48 hours and 52.2% overall. The deceased received significantly more blood products with a median of 71.5 total units compared with 55.5 in the survivors ( p < 0.001) and significantly greater rates of packed red blood cells and fresh frozen plasma at each time interval. Time-specific decision-tree models predicted mortality with an accuracy as high as 81%. In the early time intervals, hemodynamic stability, undergoing an emergency department thoracotomy, and injury severity were most predictive of survival, while, in the later intervals, markers of adequate resuscitation such as arterial pH and lactate level became more prominent.

CONCLUSION

This study supports that the decision of "when to stop" in UMT resuscitation is not based exclusively on the number of units transfused but rather the complex integration of patient and time-specific data. Machine learning is an effective tool to investigate this concept, and further research is needed to refine and validate these time-specific decision-tree models.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Management of lower extremity vascular injuries in pediatric trauma patients: 20-year experience at a level 1 trauma center

Introduction

Pediatric lower extremity vascular injuries (LEVI) are rare but can result in significant morbidity. We aimed to describe our experience with these injuries, including associated injury patterns, diagnostic and therapeutic challenges, and outcomes.

Methods

This was a retrospective review at a single level 1 trauma center from January 2000 to December 2019. Patients less than 18 years of age with LEVI were included. Demographics, injury patterns, clinical status at presentation, and intensive care unit (ICU) and hospital length of stay (LOS) were collected. Surgical data were extracted from patient charts.

Results

4,929 pediatric trauma patients presented during the 20-year period, of which 53 patients (1.1%) sustained LEVI. The mean age of patients was 15 years (range 1-17 years), the majority were Black (68%), male (96%), and most injuries were from a gunshot wound (62%). The median Glasgow Coma Scale score was 15, and the median Injury Severity Score was 12. The most commonly injured arteries were the superficial femoral artery (28%) and popliteal artery (28%). Hard signs of vascular injury were observed in 72% of patients and 87% required operative exploration. There were 36 arterial injuries, 36% of which were repaired with a reverse saphenous vein graft and 36% were repaired with polytetrafluoroethylene graft. One patient required amputation. Median ICU LOS was three days and median hospital LOS was 15 days. There were four mortalities.

Conclusion

Pediatric LEVIs are rare and can result in significant morbidity. Surgical principles for pediatric vascular injuries are similar to those applied to adults, and this subset of patients can be safely managed in a tertiary specialized center.

Level of evidence

Level IV, retrospective study.

Management of Pediatric Lower Extremity Vascular Trauma: Adult vs Pediatric Level I Trauma Centers

BACKGROUND

Pediatric lower extremity vascular injury (PLEVI) is uncommon. Though epidemiologic studies exist, the availability of granular data is sparse. Additionally, few studies compare the management between adult (ATC) and pediatric (PTC) trauma centers. The objective of this study was to analyze the surgical management of PLEVIs between a Level I ATC and a Level 1 PTCs in our metropolitan area.

METHODS

We performed a retrospective review of all PLEVIs (age < 18 years) managed surgically between 01/2009-12/2022. Demographics, clinical and outcome data were obtained and compared between centers. Primary outcomes included amputation and fasciotomy rates. Secondary outcomes included type of vessel repair, mortality, and intensive care unit (ICU) and hospital length of stay.

RESULTS

Seventy-nine patients were identified, 41 at the ATC and 38 at the PTC totaling 111 vessels injured. Overall, 84.8% were male. ATC patients were older (median 16.0 vs 12.5) and almost exclusively (97.6% vs 29.0%) gunshot wounds. There was no difference in ISS. The popliteal artery was the most injured vessel, ATC (50%) and PTC (40%). Vascular surgeons managed 50% of injuries at ATC vs 60.5% of injuries at the PTC (p = 0.35). Rates of arterial or venous repair, ligation, or grafting were not significantly different. Amputations were uncommon at both centers and not significantly different. Seventeen patients (44.7%) required fasciotomies at the PTC vs 21 (51.2%) at the ATC (p = 0.56). There was no significant difference in mortality, ICU, or hospital length of stay.

CONCLUSIONS

PLEVI have acceptable outcomes (low amputation and/or fasciotomy rates, low mortality) and are managed uniformly between ATCs and PTCs. This data adds important context to the management of PLEVI.

LEVEL OF EVIDENCE

Retrospective Chart Review, Level IV.

A western trauma association multicenter comparison of mesh versus non-mesh repair of blunt traumatic abdominal wall hernias

BACKGROUND

Blunt traumatic abdominal wall hernias (TAWH) occur in <1 % of trauma patients. Optimal repair techniques, such as mesh reinforcement, have not been studied in detail. We hypothesize that mesh use will be associated with increased surgical site infections (SSI) and not improve hernia recurrence.

MATERIALS AND METHODS

A secondary analysis of the Western Trauma Association blunt TAWH multicenter study was performed. Patients who underwent TAWH repair during initial hospitalization (1/2012-12/2018) were included. Mesh repair patients were compared to primary repair patients (non-mesh). A logistic regression was conducted to assess risk factors for SSI.

RESULTS

157 patients underwent TAWH repair during index hospitalization with 51 (32.5 %) having mesh repair: 24 (45.3 %) synthetic and 29 (54.7 %) biologic. Mesh patients were more commonly smokers (43.1 % vs. 22.9 %, p = 0.016) and had a larger defect size (10 vs. 6 cm, p = 0.003). Mesh patients had a higher rate of SSI (25.5 % vs. 9.5 %, p = 0.016) compared to non-mesh patients, but a similar rate of recurrence (13.7 % vs. 10.5%, p = 0.742), hospital length of stay (LOS), and mortality. Mesh use (OR 3.66) and higher ISS (OR 1.06) were significant risk factors for SSI in a multivariable model.

CONCLUSION

Mesh was used more frequently in flank TAWH and those with a larger defect size. Mesh use was associated with a higher incidence and risk of SSI but did not reduce the risk of hernia recurrence. When repairing TAWH mesh should be employed judiciously, and prospective randomized studies are needed to identify clear indications for mesh use in TAWH.

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.

Blunt Traumatic Abdominal Wall Hernias: An Indicator for Emergent Laparotomy?

BACKGROUND

Traumatic abdominal wall hernias (TAWH) are relatively uncommon; however, the shearing force that results in fascial disruption could indicate an increased risk of visceral injury. The aim of our study was to evaluate whether the presence of a TAWH was associated with intra-abdominal injury requiring emergent laparotomy.

METHODS

The trauma registry was queried over an 8-year period (7/2012-7/2020) for adult patients with blunt thoracoabdominal trauma diagnosed with a TAWH. Those patients who were identified with a TAWH and greater than 15 years of age were included in the study. Demographics, mechanism of injury, ISS, BMI, length of stay, TAWH size, type of TAWH repair, and outcomes were analyzed.

RESULTS

Overall, 38,749 trauma patients were admitted over the study period, of which 64 (.17%) had a TAWH. Patients were commonly male (n = 42, 65.6%); the median age was 39 years (range 16-79 years) and a mean ISS of 21. Twenty-eight percent had a clinical seatbelt sign. Twenty-seven (42.2%) went emergently to the operating room, the majority for perforated viscus requiring bowel resection (n = 16, 25.0%), and 6 patients (9.4%) who were initially managed nonoperatively underwent delayed laparotomy. Average ventilator days was 14 days, with a mean ICU LOS of 14 days and mean hospital LOS of 18 days. About half of the hernias were repaired at the index operation, 6 of which were repaired primarily and 10 with mesh.

CONCLUSION

The presence of a TAWH alone was an indication for immediate laparotomy to evaluate for intra-abdominal injury. In the absence of other indications for exploration, nonoperative management may be safe.

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.

Outcomes Among Trauma Patients with Duodenal Leak Following Primary vs Complex Repair of Duodenal Injuries: An EAST Multicenter Trial

BACKGROUND

Duodenal leak is a feared complication of repair and innovative, complex repairs with adjunctive measures(CRAM) were developed to decrease both leak occurrence and severity when leaks occur. Data on the association of CRAM and duodenal leak is sparse and its impact on duodenal leak outcomes nonexistent. We hypothesized primary repair alone (PRA) would be associated with decreased duodenal leak rates, however CRAM would be associated with improved recovery and outcomes when leaks do occur.

METHODS

A retrospective, multicenter analysis from 35 Level-1 trauma centers included patients older than 14 with operative, traumatic duodenal injuries(1/2010-12/2020). The study sample compared duodenal operative repair strategy: primary repair alone(PRA) vs CRAM(any repair plus pyloric exclusion, gastrojejunostomy, triple tube drainage, duodenectomy).

RESULTS

The sample(n = 861) was primarily young(33 years) male(84%) with penetrating injuries(77%); 523 underwent PRA and 338 underwent CRAM. CRAM were more critically injured than PRA and had higher leak rates(CRAM 21% vs PRA 8%, p < 0.001). Adverse outcomes were more common after CRAM with more IR drains, prolonged NPO and LOS, greater mortality, and more readmissions than PRA(all p < 0.05). Importantly, CRAM had no positive impact on leak recovery; there was no difference in number of operations, drain duration, NPO duration, need for IR drainage, HLOS, or mortality between PRA leak vs CRAM leak patients(all p > 0.05). CRAM leaks had longer antibiotic duration, more GI complications, and longer duration until leak resolution(all p < 0.05). PRA was associated with 60% lower odds of leak, whereas injury grade II-IV, damage control, and BMI had higher odds of leak(all p < 0.05). There were no leaks among patients with grade IV-V injuries repaired by PRA.

CONCLUSIONS

CRAM did not prevent duodenal leaks and moreover, did not reduce adverse sequelae when leaks did occur. Our results suggest CRAM is not a protective operative duodenal repair strategy and PRA should be pursued for all injury grades when feasible.

LEVEL OF EVIDENCE

IV, Multicenter retrospective comparative study.

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.

Abdominal Wall Evisceration Coupled With Iliac Vascular Injury After Blunt Trauma

Abdominal evisceration after blunt trauma is uncommon and rarely survivable when coupled with a concomitant iliac vascular injury. Blunt abdominal injury is rarely a cause of abdominal evisceration but may, on occasion, present in patients affected by a unique or high-energy traumatic injury. In these instances, major vascular injury is exceedingly rare but is associated with a high mortality rate. Damage to important vessels that may present more subtly, such as iliac arterial injury, can still be lethal and are important to evaluate in the trauma workup for blunt evisceration. We report the case of a 20-year-old woman who survived an abdominal wall and vascular injury in a motor vehicle accident. Management of this unusual association is discussed.

Risk factors for recurrence in blunt traumatic abdominal wall hernias: A secondary analysis of a Western Trauma association multicenter study

BACKGROUND

Few studies have investigated risk factors for recurrence of blunt traumatic abdominal wall hernias (TAWH).

METHODS

Twenty trauma centers identified repaired TAWH from January 2012 to December 2018. Logistic regression was used to investigate risk factors for recurrence.

RESULTS

TAWH were repaired in 175 patients with 21 (12.0%) known recurrences. No difference was found in location, defect size, or median time to repair between the recurrence and non-recurrence groups. Mesh use was not protective of recurrence. Female sex, injury severity score (ISS), emergency laparotomy (EL), and bowel resection were associated with hernia recurrence. Bowel resection remained significant in a multivariable model.

CONCLUSION

Female sex, ISS, EL, and bowel resection were identified as risk factors for hernia recurrence. Mesh use and time to repair were not associated with recurrence. Surgeons should be mindful of these risk factors but could attempt acute repair in the setting of appropriate physiologic parameters.

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.

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.

Rectal Contrast CT Scans of Limited Utility in Diagnosing Colonic Injuries in Penetrating Trauma: A Meta-Analysis

OBJECTIVES

Using rectal contrast computed tomography (CT) to identify traumatic colorectal injuries has become commonplace; however, these injuries remain relatively infrequent findings on CTs obtained for penetrating back and flank trauma. We conducted a meta-analysis to ascertain the efficacy of rectal contrast CT in identifying such injuries in victims penetrating injuries.

METHODS

PubMed and Embase were queried for relevant articles between 1974 and 2022. Review articles, case studies, and non-English manuscripts were excluded. Studies without descriptive CT and operative findings were excluded. Positive scans refer to rectal contrast extravasation. Sensitivity and specificity of rectal contrast CT scans were calculated with aggregated CT findings that were cross-referenced with laparotomy findings.

RESULTS

Only 8 manuscripts representing 506 patients quantified colorectal injuries and specified patients with rectal contrast extravasation. Seven patients with true colorectal injuries had no contrast extravasation on CT. There was one true positive scan. Another scan identified contrast extravasation, but laparotomy revealed no colorectal injury. Rectal contrast had sensitivity of 12.5%, specificity 99.8%, positive predictive value (PPV) 50%, negative predictive value (NPV) 99%, and a false negative rate of 88% in identifying colonic injuries.

DISCUSSION

The summation of 8 manuscripts suggest that the addition of rectal contrast in identifying colonic and rectal injuries may be of limited utility given its poor sensitivity and may be unnecessary. In its absence, subtle clues such as hematomas, extraluminal air, IV-dye extravasation, and trajectory may be additional indicators of injury. Further investigations are required to demonstrate a true benefit for the addition of rectal contrast.

Management of blunt traumatic abdominal wall hernias: A Western Trauma Association multicenter study

BACKGROUND

Blunt traumatic abdominal wall hernias (TAWH) occur in approximately 15,000 patients per year. Limited data are available to guide the timing of surgical intervention or the feasibility of nonoperative management.

METHODS

A retrospective study of patients presenting with blunt TAWH from January 2012 through December 2018 was conducted. Patient demographic, surgical, and outcomes data were collected from 20 institutions through the Western Trauma Association Multicenter Trials Committee.

RESULTS

Two hundred and eighty-one patients with TAWH were identified. One hundred and seventy-six (62.6%) patients underwent operative hernia repair, and 105 (37.4%) patients underwent nonoperative management. Of those undergoing surgical intervention, 157 (89.3%) were repaired during the index hospitalization, and 19 (10.7%) underwent delayed repair. Bowel injury was identified in 95 (33.8%) patients with the majority occurring with rectus and flank hernias (82.1%) as compared with lumbar hernias (15.8%). Overall hernia recurrence rate was 12.0% (n = 21). Nonoperative patients had a higher Injury Severity Score (24.4 vs. 19.4, p = 0.010), head Abbreviated Injury Scale score (1.1 vs. 0.6, p = 0.006), and mortality rate (11.4% vs. 4.0%, p = 0.031). Patients who underwent late repair had lower rates of primary fascial repair (46.4% vs. 77.1%, p = 0.012) and higher rates of mesh use (78.9% vs. 32.5%, p < 0.001). Recurrence rate was not statistically different between the late and early repair groups (15.8% vs. 11.5%, p = 0.869).

CONCLUSION

This report is the largest series and first multicenter study to investigate TAWHs. Bowel injury was identified in over 30% of TAWH cases indicating a significant need for immediate laparotomy. In other cases, operative management may be deferred in specific patients with other life-threatening injuries, or in stable patients with concern for bowel injury. Hernia recurrence was not different between the late and early repair groups.

LEVEL OF EVIDENCE

Therapeutic/care management, Level IV.

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.

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.

Blunt Traumatic Injury to the Superficial Femoral Artery in a Morbidly Obese Female: Case Report Using Endovascular Covered Stent Repair

Lower extremity vascular injuries following trauma are rare events that require prompt identification and management in order to prevent ischemia and limb loss. Endovascular approaches, rather than traditional open procedures, are increasingly used to treat a wide range of vascular disease. The use of endovascular repair for revascularization in the trauma setting is not routine but may provide an appealing alternative in select trauma patients and injuries. We present a case of successful endovascular repair with stent grafting of a superficial femoral artery intimal injury following a femur fracture in a 35-year-old morbidly obese female and review the current literature regarding the use of endovascular therapy in the trauma setting.

BMI and VTE Risk in Emergency General Surgery, Does Size Matter? : An ACS-NSQIP Database Analysis

BACKGROUND

Venous thromboembolism (VTE) is a preventable cause of morbidity and mortality. Emergency general surgery (EGS) patients comprise 7% of hospital admissions in America with a reported rate of VTE of 2.5%. Of these, >69% required hospital readmission, making VTE the second most common cause for readmission after infection in EGS patients. We hypothesize a correlation between body mass index (BMI) and VTE in EGS patients.

METHODS

The American College of Surgeons National Surgery Quality Improvement Database (NSQIP) was queried from January 2015 to December 2016. 83 272 patients met inclusion criteria: age ≥18 and underwent an EGS procedure. Patients were stratified by BMI. Descriptive statistics were used for demographic and numerical data. Categorical comparisons between covariates were completed using the chi-square test. Continuous variables were compared using Student's t-test, Mann Whitney U-test, or Kruskal-Wallis H test.

RESULTS

83 272 patients met the inclusion criteria. 1358 patients developed VTE (903 deep vein thrombosis (DVT) only, 335 pulmonary embolism (PE) only, and 120 with DVT and PE). Morbidly obese patients were 1.7 times more likely to be diagnosed with a PE compared with normal BMI (P = .004). Increased BMI was associated with the co-diagnosis of PE and DVT (P = .027). Patients with BMI <18.5 were 1.4 times more likely to experience a VTE compared with normal BMI (P = .018). Patients with a VTE were 3.2 times more likely to die (P < .001) and less likely to be discharged home (P < .001).

DISCUSSION

Our study found that obese and underweight EGS patients had an increased incidence of VTE. Risk recognition and chemoprophylaxis may improve outcomes in this population.

Managing Craniomaxillofacial Injury Without Inpatient Consult: Outcomes and Patient Cost Savings

BACKGROUND

We hypothesized that trauma surgeons can safely selectively manage traumatic craniomaxillofacial injuries (CMF) without specialist consult, thereby decreasing the overall cost burden to patients.

METHODS

A 4-year retrospective analysis of all CMF fractures diagnosed on facial CT scans. CMF consultation was compared with no-CMF consultation. Demographics, injury severity, and specialty consultation charges were recorded. Penetrating injuries, skull fractures, or patients completing inpatient craniofacial surgery were excluded.

RESULTS

303 patients were studied (124 CMF consultation vs 179 no-CMF consultation), mean age was 47.8 years, with 70% males. Mean Glasgow Coma Scale and Injury Severity Score (ISS) was 14 ± 3.4 and 10 ± 9, respectively. Patients with CMF consults had higher ISS (P < .001) and needed surgery on admission (P < .001), while no-CMF consults had shorter length of stay (P < .002). No in-hospital mortality or 30-day readmission rates were related to no-CMF consult. Total patient charges saved with no-CMF consultation was $26 539.96.

DISCUSSION

Trauma surgeons can selectively manage acute CMF injuries without inpatient specialist consultation. Additional guidelines can be established to avoid tertiary transfers for specialty consultation and decrease patient charges.

The Understated Malignancy Potential of Nonoperative Acute Appendicitis

Cancer of the appendix is rare and is most commonly found incidentally on pathology after an appendectomy for uncomplicated appendicitis (UA). The medical management alternative with antibiotics and observation remains an ongoing debate. The purpose of our study was to develop modern epidemiological data for adult patients completing an appendectomy for UA secondary to an appendiceal neoplasm (AN). ACS-NSQIP database was queried (2005–2016) to identify patients completing an appendectomy. Cohorts of patients who were diagnosed with UA and an AN were included in the study. Relevant perioperative clinical and outcomes data were collected. Type of AN, surgical procedure, and mortality were analyzed. A total of 239,615 UA patients were identified, of whom 2,773 (1.2%) met the inclusion criteria of AN. Patients with AN were predominantly white (79.5%), with a mean age of 54.5 ± 15.9 years, and 54.6 per cent were females. AN pathology findings included malignant neoplasm (64.5%), malignant carcinoid (17.3%), benign carcinoid (9.3%), and benign neoplasm (8.8%). The overall reported incidence was 1.2 per cent and the mortality rate was 0.7 per cent. Our study emphasizes surgical intervention in adult UA maintains a 1 per cent incidence of AN, and treatment with antibiotics alone will presumably lead to a delay in surgical treatment and progression of disease.

Stats and ladders: Injury risk and outcomes following falls from ladders

Fatal lower level falls commonly result from ladder fall injuries (LFIs), an often-avoidable injury. We hypothesized that older patients' injury severity differs from younger patients falling from the same mechanism with fall height determining overall morbidity. A retrospective review was completed of all traumatic LFIs during a 6-year period resulting in 178 patients. The mean LFI height was 10.9 ± 6.0 feet, the majority being male (87%), with a mean age of 50.7 ± 16.6 years. The mean ISS was 7.7 ± 7.0 (range, 1-38), 23.6% sustaining > 1 injury. Age inversely correlated with the mean LFI height with patients ≥66 years falling from significantly lower heights (12.3 ft For age group 18-45 y; 10.4 ft vs 9.0 ft (p = 0.003) and having longer LOS (7.3 vs 3.8 days, P = 0.011). No difference in ventilator requirement/days, blood product requirements, or mortality among age groups was observed. Geriatric patients sustain similar injury patterns at lower height levels compared to all ages. Injury prevention programs are necessary to reduce the incidence of a commonly preventable injury.

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.

The Understated Malignancy Potential of Nonoperative Acute Appendicitis

Cancer of the appendix is rare and is most commonly found incidentally on pathology after an appendectomy for uncomplicated appendicitis (UA). The medical management alternative with antibiotics and observation remains an ongoing debate. The purpose of our study was to develop modern epidemiological data for adult patients completing an appendectomy for UA secondary to an appendiceal neoplasm (AN). ACS-NSQIP database was queried (2005-2016) to identify patients completing an appendectomy. Cohorts of patients who were diagnosed with UA and an AN were included in the study. Relevant perioperative clinical and outcomes data were collected. Type of AN, surgical procedure, and mortality were analyzed. A total of 239,615 UA patients were identified, of whom 2,773 (1.2%) met the inclusion criteria of AN. Patients with AN were predominantly white (79.5%), with a mean age of 54.5 ± 15.9 years, and 54.6 per cent were females. AN pathology findings included malignant neoplasm (64.5%), malignant carcinoid (17.3%), benign carcinoid (9.3%), and benign neoplasm (8.8%). The overall reported incidence was 1.2 per cent and the mortality rate was 0.7 per cent. Our study emphasizes surgical intervention in adult UA maintains a 1 per cent incidence of AN, and treatment with antibiotics alone will presumably lead to a delay in surgical treatment and progression of disease.

Impact of Laparoscopy on Training: Are Open Appendectomy and Cholecystectomy on the Brink of Extinction?

The operative experience of present-day surgical residency training has evolved as a result of the contributions of laparoscopic surgery. Some traditional open procedures are now more descriptive and less of a familiarity to many general surgery residents (GSRs). The aim of this study was to investigate how open operative experience compares with laparoscopy for GSRs. A retrospective, multicenter, consecutive cohort study of all patients undergoing surgical intervention involving the appendix and gallbladder identified from the ACS-NSQIP database over a 2.5-year period. All GSR postgraduate year-level operative experience was recorded. Of 777 procedures, 13 laparoscopic appendectomy conversions to open (4.3%) by Rocky-Davis (15%) or lower midline (84.6%) incisions were performed versus 285 that remained laparoscopic (95.6%). Fifty (10.4%) open cholecystectomies (38 open + 10 conversions + 2 common bile duct (CBD) exploration), 27 (5.6%) laparoscopic cholecystectomies with cholangiogram, and 402 (83.9%) laparoscopic cholecystectomies were performed. Twenty-nine different GSRs participated in procedures. Eighty-five (10.9%) operations were performed with multi-postgraduate year levels. Surgical residents have an unequal operative experience for case-specific open procedures. A competency-based system to demonstrate a resident's hands-on surgical skills is fundamental to residency training and should be considered for specific types of low-volume open surgical cases.

Multidisciplinary team approach in the management of popliteal artery injury

Popliteal artery injuries (PAIs) remain a challenging entity and carry the greatest risk of limb loss among traumatic lower extremity vascular injuries. Operative management of traumatic popliteal vascular injuries continues to evolve. Improved diagnostic imaging and the introduction of endovascular techniques offered alternative modalities to traditional surgical management. Despite major efforts in establishing protocols and guidelines in the management of vascular trauma, optimal strategies of traumatic PAIs are still under investigation. Herein, we discussed the role of multidisciplinary team, involving trauma and endovascular surgeons, emergency department personnel, and interventional radiologists in the management of complex PAIs.

Gastroduodenal Surgery: A Persistent and Continuing Challenge

The number of patients being treated surgically for gastroduodenal disease has decreased over the past five decades as a result of focus on medical treatment. However, perforated and bleeding peptic ulcer disease (PUD) continues to represent a significant percentage of patients who require emergency surgery. The aim of this study was to characterize these critically ill surgical patients treated for gastroduodenal disease in our hospital. A retrospective, single-center, consecutive cohort study of all patients identified from the hospital National Surgical Quality Improvement Program database who were admitted to our institution requiring emergent surgical intervention over the past two years was conducted. Of 423 patients, 33 (7.8%) had operative procedures for complications of PUD, of which 19 patients (57.6%) had perforation; nine patients (27.3%) had hemorrhage; one patient (3.0%) had both perforation and hemorrhage; two patients (6.1%) had distal gastrectomies for ulcers refractory to medical management alone, and two patients (6.1%) had gastrectomies for malignant gastric neoplasms. There is a significant population of patients who present with life-threatening complications of PUD, despite the decline in PUD worldwide. These patients are critically ill and require careful and diligent management for good outcomes.

Gastroduodenal Surgery: A Persistent and Continuing Challenge

The number of patients being treated surgically for gastroduodenal disease has decreased over the past five decades as a result of focus on medical treatment. However, perforated and bleeding peptic ulcer disease (PUD) continues to represent a significant percentage of patients who require emergency surgery. The aim of this study was to characterize these critically ill surgical patients treated for gastroduodenal disease in our hospital. A retrospective, single-center, consecutive cohort study of all patients identified from the hospital National Surgical Quality Improvement Program database who were admitted to our institution requiring emergent surgical intervention over the past two years was conducted. Of 423 patients, 33 (7.8%) had operative procedures for complications of PUD, of which 19 patients (57.6%) had perforation; nine patients (27.3%) had hemorrhage; one patient (3.0%) had both perforation and hemorrhage; two patients (6.1%) had distal gastrectomies for ulcers refractory to medical management alone, and two patients (6.1%) had gastrectomies for malignant gastric neoplasms. There is a significant population of patients who present with life-threatening complications of PUD, despite the decline in PUD worldwide. These patients are critically ill and require careful and diligent management for good outcomes.

Bacteriology and Comorbidities in Patients Requiring Surgical Management of Empyema

Concern over the changing bacteriology of empyema has led to numerous attempts to characterize the most common locoregional bacterial isolates. The purpose of this study is to better characterize the bacteriology and demographics in patients with community-acquired pneumonia (CAP) and hospital-acquired pneumonia requiring surgery for empyema. All patients diagnosed with empyema preoperatively and had either a video-assisted thoracoscopic or open decortication surgery from January 2010 to September 2015 were reviewed. Forty-seven patients were identified with a mean age of 54.7 ± 16.8 years (X ± SD). Sixty per cent of patients had CAP. Anaerobes were the most common isolate at 21 per cent, followed by Streptococcus species and Staphylococcus aureus (50% Methicillin Resistant). Coagulase-negative Staphylococcus species were the next most frequent at 13 per cent. Hospital-acquired pneumonia patients had a higher incidence of S. aureus infections ( P = 0.047). Cancer history had higher rates of both fungal ( P = 0.004) and gram-negative infections ( P = 0.03). Older patients had increased incidence of gram-negative infections ( P = 0.05). The median length of stay for CAP patient who were intravenous drug abusers (n = 3) were 31 days (95% confidence interval (CI) [15, NA]), which was significantly longer than the others (median 12 days, 95% CI: [9, 18], P = 0.014). Streptococcus pneumoniae was not found in any of the isolates. Our data reveal that anaerobes and Staphylococcus species have replaced S. pneumoniae as the major regional pathogens in surgically treated empyema. In addition, anaerobic isolates were found in higher incidence in CAP than previously reported.

Bacteriology and Comorbidities in Patients Requiring Surgical Management of Empyema

Concern over the changing bacteriology of empyema has led to numerous attempts to characterize the most common locoregional bacterial isolates. The purpose of this study is to better characterize the bacteriology and demographics in patients with community-acquired pneumonia (CAP) and hospital-acquired pneumonia requiring surgery for empyema. All patients diagnosed with empyema preoperatively and had either a video-assisted thoracoscopic or open decortication surgery from January 2010 to September 2015 were reviewed. Forty-seven patients were identified with a mean age of 54.7 ± 16.8 years (X ± SD). Sixty per cent of patients had CAP. Anaerobes were the most common isolate at 21 per cent, followed by Streptococcus species and Staphylococcus aureus (50% Methicillin Resistant). Coagulase-negative Staphylococcus species were the next most frequent at 13 per cent. Hospital-acquired pneumonia patients had a higher incidence of S. aureus infections (P = 0.047). Cancer history had higher rates of both fungal (P = 0.004) and gram-negative infections (P = 0.03). Older patients had increased incidence of gram-negative infections (P = 0.05). The median length of stay for CAP patient who were intravenous drug abusers (n = 3) were 31 days (95% confidence interval (CI) [15, NA]), which was significantly longer than the others (median 12 days, 95% CI: [9, 18], P = 0.014). Streptococcus pneumoniae was not found in any of the isolates. Our data reveal that anaerobes and Staphylococcus species have replaced S. pneumoniae as the major regional pathogens in surgically treated empyema. In addition, anaerobic isolates were found in higher incidence in CAP than previously reported.