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Awad KG, Nahmias J, Aryan N, Lucas AN, Fierro N, Dhillon NK, Ley EJ, Smith J, Burruss S, Dahan A, Johnson A, Ganske W, Biffl WL, Bayat D, Castelo M, Wintz D, Schaffer KB, Zheng DJ, Tillou A, Coimbra R, Tuli R, Santorelli JE, Emigh B, Schellenberg M, Inaba K, Duncan TK, Diaz G, Tay-Lasso E, Zezoff DC, Grigorian A. Outcomes of severely injured pregnant trauma patients: a multicenter analysis. Updates Surg 2024:10.1007/s13304-024-01817-3. [PMID: 38554224 DOI: 10.1007/s13304-024-01817-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/04/2024] [Indexed: 04/01/2024]
Abstract
Nearly 10% of pregnant women suffer traumatic injury. Clinical outcomes for pregnant trauma patients (PTPs) with severe injuries have not been well studied. We sought to describe outcomes for PTPs presenting with severe injuries, hypothesizing that PTPs with severe injuries will have higher rates of complications and mortality compared to less injured PTPs. A post-hoc analysis of a multi-institutional retrospective study at 12 Level-I/II trauma centers was performed. Patients were stratified into severely injured (injury severity score [ISS] > 15) and not severely injured (ISS < 15) and compared with bivariate analyses. From 950 patients, 32 (3.4%) had severe injuries. Compared to non-severely injured PTPs, severely injured PTPs were of similar maternal age but had younger gestational age (21 vs 26 weeks, p = 0.009). Penetrating trauma was more common in the severely injured cohort (15.6% vs 1.4%, p < 0.001). The severely injured cohort more often underwent an operation (68.8% vs 3.8%, p < 0.001), including a hysterectomy (6.3% vs 0.3%, p < 0.001). The severely injured group had higher rates of complications (34.4% vs 0.9%, p < 0.001), mortality (15.6% vs 0.1%, p < 0.001), a higher rate of fetal delivery (37.5% vs. 6.0%, p < 0.001) and resuscitative hysterotomy (9.4% vs. 0%, p < 0.001). Only approximately 3% of PTPs were severely injured. However, severely injured PTPs had a nearly 40% rate of fetal delivery as well as increased complications and mortality. This included a resuscitative hysterotomy rate of nearly 10%. Significant vigilance must remain when caring for this population.
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Affiliation(s)
- Kyrillos G Awad
- Department of Surgery, Desert Regional Medical Center, Palm Springs, CA, USA
| | - Jeffry Nahmias
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Negaar Aryan
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Alexa N Lucas
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Nicole Fierro
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Navpreet K Dhillon
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eric J Ley
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jennifer Smith
- Division of Trauma and Critical Care, Harbor-UCLA Hospital, Torrance, CA, USA
| | - Sigrid Burruss
- Division of Trauma and Critical Care, Harbor-UCLA Hospital, Torrance, CA, USA
| | - Alden Dahan
- Department of Trauma, Acute Care Surgery, Surgical Critical Care, Loma Linda Medical Center, Loma Linda, CA, USA
| | - Arianne Johnson
- Cottage Health Research Institute, Santa Barbara Cottage Hospital, Santa Barbara, CA, USA
| | - William Ganske
- Cottage Health Research Institute, Santa Barbara Cottage Hospital, Santa Barbara, CA, USA
| | - Walter L Biffl
- Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA, USA
| | - Dunya Bayat
- Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA, USA
| | - Matthew Castelo
- Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA, USA
| | - Diane Wintz
- Department of Surgery, Sharp Memorial Hospital, San Diego, CA, USA
| | | | - Dennis J Zheng
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Areti Tillou
- Riverside University Health System Medical Center, Comparative Effectiveness and Clinical Outcomes Research Center - CECORC, Moreno Valley, CA, USA
| | - Raul Coimbra
- Riverside University Health System Medical Center, Comparative Effectiveness and Clinical Outcomes Research Center - CECORC, Moreno Valley, CA, USA
| | - Rahul Tuli
- Riverside University Health System Medical Center, Comparative Effectiveness and Clinical Outcomes Research Center - CECORC, Moreno Valley, CA, USA
| | - Jarrett E Santorelli
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, San Diego School of Medicine, University of California, San Diego, CA, USA
| | - Brent Emigh
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Morgan Schellenberg
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Kenji Inaba
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Thomas K Duncan
- Department of Trauma, Ventura County Medical Center, Ventura, CA, USA
| | - Graal Diaz
- Department of Trauma, Ventura County Medical Center, Ventura, CA, USA
| | - Erika Tay-Lasso
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Danielle C Zezoff
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Areg Grigorian
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA.
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2
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Lucas AN, Tay-Lasso E, Zezoff DC, Fierro N, Dhillon NK, Ley EJ, Smith J, Burruss S, Dahan A, Johnson A, Ganske W, Biffl WL, Bayat D, Castelo M, Wintz D, Schaffer KB, Zheng DJ, Tillou A, Coimbra R, Tuli R, Santorelli JE, Emigh B, Schellenberg M, Inaba K, Duncan TK, Diaz G, Kirby KA, Nahmias J. Significant variation in computed tomography imaging of pregnant trauma patients: a retrospective multicenter study. Emerg Radiol 2024; 31:53-61. [PMID: 38150084 PMCID: PMC10830714 DOI: 10.1007/s10140-023-02195-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 12/08/2023] [Indexed: 12/28/2023]
Abstract
PURPOSE Following motor vehicle collisions (MVCs), patients often undergo extensive computed tomography (CT) imaging. However, pregnant trauma patients (PTPs) represent a unique population where the risk of fetal radiation may supersede the benefits of liberal CT imaging. This study sought to evaluate imaging practices for PTPs, hypothesizing variability in CT imaging among trauma centers. If demonstrated, this might suggest the need to develop specific guidelines to standardize practice. METHODS A multicenter retrospective study (2016-2021) was performed at 12 Level-I/II trauma centers. Adult (≥18 years old) PTPs involved in MVCs were included, with no patients excluded. The primary outcome was the frequency of CT. Chi-square tests were used to compare categorical variables, and ANOVA was used to compare the means of normally distributed continuous variables. RESULTS A total of 729 PTPs sustained MVCs (73% at high speed of ≥ 25 miles per hour). Most patients were mildly injured but a small variation of injury severity score (range 1.1-4.6, p < 0.001) among centers was observed. There was a variation of imaging rates for CT head (range 11.8-62.5%, p < 0.001), cervical spine (11.8-75%, p < 0.001), chest (4.4-50.2%, p < 0.001), and abdomen/pelvis (0-57.3%, p < 0.001). In high-speed MVCs, there was variation for CT head (12.5-64.3%, p < 0.001), cervical spine (16.7-75%, p < 0.001), chest (5.9-83.3%, p < 0.001), and abdomen/pelvis (0-60%, p < 0.001). There was no difference in mortality (0-2.9%, p =0.19). CONCLUSION Significant variability of CT imaging in PTPs after MVCs was demonstrated across 12 trauma centers, supporting the need for standardization of CT imaging for PTPs to reduce unnecessary radiation exposure while ensuring optimal injury identification is achieved.
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Affiliation(s)
- Alexa N Lucas
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Erika Tay-Lasso
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, 3800 W. Chapman Ave., Suite 6200, Orange, CA, 92868, USA
| | - Danielle C Zezoff
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA
| | - Nicole Fierro
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Navpreet K Dhillon
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eric J Ley
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jennifer Smith
- Division of Trauma and Critical Care, Harbor-UCLA Hospital, Torrance, CA, USA
| | - Sigrid Burruss
- Department of Trauma, Acute Care Surgery, Surgical Critical Care, Loma Linda Medical Center, Loma Linda, CA, USA
| | - Alden Dahan
- Riverside School of Medicine, University of California, Riverside, CA, USA
| | - Arianne Johnson
- Cottage Health Research Institute, Santa Barbara Cottage Hospital, Santa Barbara, CA, USA
| | - William Ganske
- Cottage Health Research Institute, Santa Barbara Cottage Hospital, Santa Barbara, CA, USA
| | - Walter L Biffl
- Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, CA, USA
| | - Dunya Bayat
- Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, CA, USA
| | - Matthew Castelo
- Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, CA, USA
| | - Diane Wintz
- Department of Surgery, Sharp Memorial Hospital, San Diego, CA, USA
| | | | - Dennis J Zheng
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Areti Tillou
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Raul Coimbra
- Comparative Effectiveness and Clinical Outcomes Research Center (CECORC), Riverside University Health System Medical Center, Riverside, CA, USA
| | - Rahul Tuli
- Comparative Effectiveness and Clinical Outcomes Research Center (CECORC), Riverside University Health System Medical Center, Riverside, CA, USA
| | - Jarrett E Santorelli
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego School of Medicine, San Diego, CA, USA
| | - Brent Emigh
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Morgan Schellenberg
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Kenji Inaba
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Thomas K Duncan
- Department of Trauma, Ventura County Medical Center, Ventura, CA, USA
| | - Graal Diaz
- Department of Trauma, Ventura County Medical Center, Ventura, CA, USA
| | - Katharine A Kirby
- Center for Statistical Consulting, Department of Statistics, University of California Irvine, Irvine, CA, USA
| | - Jeffry Nahmias
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, 3800 W. Chapman Ave., Suite 6200, Orange, CA, 92868, USA.
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Gallagher SP, Capacio BA, Rooney AS, Schaffer KB, Calvo RY, Sise CB, Krzyzaniak A, Sise MJ, Bansal V, Biffl WL, Martin MJ. Modified Brain Injury Guidelines for preinjury anticoagulation in traumatic brain injury: An opportunity to reduce health care resource utilization. J Trauma Acute Care Surg 2024; 96:240-246. [PMID: 37872672 DOI: 10.1097/ta.0000000000004171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
INTRODUCTION The Brain Injury Guidelines (BIG) stratify patients by traumatic brain injury (TBI) severity to provide management recommendations to reduce health care resource burden but mandates that patients on anticoagulation (AC) are allocated to the most severe tertile (BIG 3). We sought to analyze TBI patients on AC therapy using a modified BIG model to determine if this population can offer further opportunity for safe reductions in health care resource utilization. METHODS Patients 55 years or older on AC with traumatic intracranial hemorrhage (ICH) from two centers were retrospectively stratified into BIG 1 to 3 risk groups using modified BIG criteria excluding AC as a criterion. Intracranial hemorrhage progression, neurosurgical intervention (NSI), death, and worsened discharge status were compared. RESULTS A total of 221 patients were included, with 23%, 29%, and 48% classified as BIG 1, BIG 2, and BIG 3, respectively. The BIG 3 cohort had a higher rate of AC reversal agents administered (66%) compared with the BIG 1 (40%) and BIG 2 (54%) cohorts ( p < 0.01), as well as ICH progression discovered on repeat head computed tomography (56% vs. 38% vs. 26%, respectively; p < 0.001). No patients in the BIG 1 and 2 cohorts required NSI. No patients in BIG 1 and 3% of patients in BIG 2 died secondary to the ICH. In the BIG 3 cohort, 16% of patients required NSI and 26% died. Brain Injury Guidelines 3 patients had 15 times the odds of mortality compared with BIG 1 patients ( p < 0.01). CONCLUSION The AC population had higher rates of ICH progression than the BIG literature, but this did not lead to more NSI or mortality in the lower tertiles of our modified BIG protocol. If the modified BIG used the original tertile management on our population, then NS consultation may have been reduced by up to 52%. These modified criteria may be a safe opportunity for further health care resource and cost savings in the TBI population. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Shea P Gallagher
- From the Division of Trauma and Acute Care Surgery, Department of Surgery (S.P.G., B.A.C., A.S.R., R.Y.C., C.B.S., A.K., M.J.S., V.B., M.J.M.), Scripps Mercy Hospital, San Diego, California; Division of Trauma and Acute Care Surgery, Department of Surgery (S.P.G., M.J.M.), Los Angeles General Medical Center, Los Angeles, California; and Division of Trauma and Acute Care Surgery, Department of Surgery (K.B.S., W.L.B.), Scripps Memorial Hospital La Jolla, La Jolla, California
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Harrell KN, Grimes AD, Gill H, Reynolds JK, Ueland WR, Sciarretta JD, Todd SR, Trust MD, Ngoue M, Thomas BW, Ayuso SA, LaRiccia A, Spalding MC, Collins MJ, Collier BR, Karam BS, de Moya MA, Lieser MJ, Chipko JM, Haan JM, Lightwine KL, Cullinane DC, Falank CR, Phillips RC, Kemp MT, Alam HB, Udekwu PO, Sanin GD, Hildreth AN, Biffl WL, Schaffer KB, Marshall G, Muttalib O, Nahmias J, Shahi N, Moulton SL, Maxwell RA. A western trauma association multicenter comparison of mesh versus non-mesh repair of blunt traumatic abdominal wall hernias. Injury 2024; 55:111204. [PMID: 38039636 DOI: 10.1016/j.injury.2023.111204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 11/01/2023] [Accepted: 11/12/2023] [Indexed: 12/03/2023]
Abstract
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.
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Affiliation(s)
- Kevin N Harrell
- University of Tennessee College of Medicine Chattanooga, Chattanooga, TN, United States.
| | | | - Harkanwar Gill
- University of Oklahoma, Oklahoma City, OK, United States
| | | | - Walker R Ueland
- University of Kentucky School of Medicine, Lexington, KY, United States
| | | | | | - Marc D Trust
- University of Texas at Austin, Austin, TX, United States
| | - Marielle Ngoue
- University of Texas at Austin, Austin, TX, United States
| | - Bradley W Thomas
- Atrium Health Carolinas Medical Center, Charlotte, NC, United States
| | - Sullivan A Ayuso
- Atrium Health Carolinas Medical Center, Charlotte, NC, United States
| | | | | | | | | | - Basil S Karam
- Medical College of Wisconsin, Milwaukee, WI, United States
| | - Marc A de Moya
- Medical College of Wisconsin, Milwaukee, WI, United States
| | - Mark J Lieser
- Research Medical Center, Kansas City, MO, United States
| | - John M Chipko
- Research Medical Center, Kansas City, MO, United States
| | - James M Haan
- Ascension Via Christi on St. Francis Hospital, Wichita, KS, United States
| | - Kelly L Lightwine
- Ascension Via Christi on St. Francis Hospital, Wichita, KS, United States
| | | | | | | | | | - Hasan B Alam
- University of Michigan, Ann Arbor, MI, United States
| | | | - Gloria D Sanin
- Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Amy N Hildreth
- Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Walter L Biffl
- Scripps Memorial Hospital La Jolla, La Jolla, CA, United States
| | | | - Gary Marshall
- Medical City Plano Hospital, Plano, TX, United States
| | - Omaer Muttalib
- University of California, Irvine, Orange, CA, United States
| | - Jeffry Nahmias
- University of California, Irvine, Orange, CA, United States
| | - Niti Shahi
- Children's Hospital Colorado, Denver, CO, United States
| | | | - Robert A Maxwell
- University of Tennessee College of Medicine Chattanooga, Chattanooga, TN, United States
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Santos JW, Grigorian A, Lucas AN, Fierro N, Dhillon NK, Ley EJ, Smith J, Burruss S, Dahan A, Johnson A, Ganske W, Biffl WL, Bayat D, Castelo M, Wintz D, Schaffer KB, Zheng DJ, Tillou A, Coimbra R, Tuli R, Santorelli JE, Emigh B, Schellenberg M, Inaba K, Duncan TK, Diaz G, Tay-Lasso E, Zezoff DC, Nahmias J. Predictors of fetal delivery in pregnant trauma patients: A multicenter study. J Trauma Acute Care Surg 2024; 96:109-115. [PMID: 37580875 DOI: 10.1097/ta.0000000000003964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
BACKGROUND Pregnant trauma patients (PTPs) undergo observation and fetal monitoring following trauma due to possible fetal delivery (FD) or adverse outcome. There is a paucity of data on PTP outcomes, especially related to risk factors for FD. We aimed to identify predictors of posttraumatic FD in potentially viable pregnancies. METHODS All PTPs (≥18 years) with ≥24-weeks gestational age were included in this multicenter retrospective study at 12 Level-I and II trauma centers between 2016 and 2021. Pregnant trauma patients who underwent FD ((+) FD) were compared to those who did not deliver ((-) FD) during the index hospitalization. Univariate analyses and multivariable logistic regression were performed to identify predictors of FD. RESULTS Of 591 PTPs, 63 (10.7%) underwent FD, with 4 (6.3%) maternal deaths. The (+) FD group was similar in maternal age (27 vs. 28 years, p = 0.310) but had older gestational age (37 vs. 30 weeks, p < 0.001) and higher mean injury severity score (7.0 vs. 1.5, p < 0.001) compared with the (-) FD group. The (+) FD group had higher rates of vaginal bleeding (6.3% vs. 1.1%, p = 0.002), uterine contractions (46% vs. 23.5%, p < 0.001), and abnormal fetal heart tracing (54.7% vs. 14.6%, p < 0.001). On multivariate analysis, independent predictors for (+) FD included abdominal injury (odds ratio [OR], 4.07; confidence interval [CI], 1.11-15.02; p = 0.035), gestational age (OR, 1.68 per week ≥24 weeks; CI, 1.44-1.95; p < 0.001), abnormal FHT (OR, 12.72; CI, 5.19-31.17; p < 0.001), and premature rupture of membranes (OR, 35.97; CI, 7.28-177.74; p < 0.001). CONCLUSION The FD rate was approximately 10% for PTPs with viable fetal gestational age. Independent risk factors for (+) FD included maternal and fetal factors, many of which are available on initial trauma bay evaluation. These risk factors may help predict FD in the trauma setting and shape future guidelines regarding the recommended observation of PTPs. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Jeffrey W Santos
- From the Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, (J.W.S., A.G., A.N.L., E.T.-L., D.C.Z., J.N.), University of California, Irvine, Orange; Department of Surgery (N.F., N.K.D., E.J.L.), Cedars-Sinai Medical Center, Los Angeles; Division of Trauma and Critical Care (J.S.), Harbor-UCLA Hospital, Torrance; Department of Trauma, Acute Care Surgery, Surgical Critical Care (S.B.), Loma Linda Medical Center, Loma Linda; Riverside School of Medicine (A.D.), University of California, Riverside; Cottage Health Research Institute (A.J., W.G.), Santa Barbara Cottage Hospital, Santa Barbara; Trauma and Acute Care Surgery, Scripps Memorial Hospital (W.L.B., D.B., M.C.), La Jolla; Department of Surgery (D.W., K.B.S.), Sharp Memorial Hospital, San Diego; Department of Surgery (D.J.Z., A.T.), UCLA David Geffen School of Medicine, Los Angeles; Department of Surgery, Comparative Effectiveness and Clinical Outcomes Research Center-CECORC (R.C., R.T.), Riverside University Health System Medical Center, Moreno Valley; Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery (J.E.S.), University of California San Diego School of Medicine, San Diego; Division of Acute Care Surgery (B.E., M.S., K.I.), LAC+USC Medical Center, University of Southern California, Los Angeles; and Department of Trauma (T.K.D., G.D.), Ventura County Medical Center, Ventura, California
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Wintz D, Schaffer KB, Hites JJ, Wybourn C, Bui EH, Langness S, Hamel M, Wright K, Frey JR. GIFTS: Geriatric Intensive Functional Therapy Sessions - For the older trauma patient. J Trauma Acute Care Surg 2023:01586154-990000000-00579. [PMID: 38051122 DOI: 10.1097/ta.0000000000004224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
BACKGROUND Considering resources for comprehensive geriatric (GERI) care, it would be beneficial for geriatric trauma (GTP) and medical patients to be co-managed in one program focusing on ancillary therapeutics (AT): physical (PT), occupational (OT), speech (SLP), respiratory (RT) and sleep wake hygiene (SWH). This pilot describes outcomes of GTP in a hospital-wide program focused on GERI-specific AT. METHODS GTP and GERI patients were screened by program coordinator (PC) for enrollment at one Level II trauma center from Aug 2021-Dec 2022. Enrolled patients (EP) were admitted to trauma or medicine floors and received repetitive AT with attention to SWH throughout hospitalization and compared to similar non-enrolled patients (NEP). Excluded patients had any of the following: indication of geriatric syndrome with FRAIL 5, no frailty with FRAIL 0, comfort focused plans, or arrived from skilled care. Retrospective chart review of demographics and outcomes was completed for both EP and NEP. RESULTS 224 EP (28 trauma (TR)) were compared to 574 NEP (148 TR). EP showed shorter LOS (mean 3.8 vs 6.1, p = 0.0001), less delirium (3.1% vs 9.6%, p = 0.00222), less time to ambulate (13 h vs 39 h, p = 0.0005), and higher likelihood to discharge home (56% vs 27%, p < 0.0001) as compared to NEP. Median FRAIL was 3 for both groups. Medical enrolled (M-EP) ambulated the soonest at 11 average hours, compared to 23 hours for TR-EP, compared to 39 hours for NEP. Zero delirium events among TR-EP; 25% among TR-NEP, p = 0.00288. CONCLUSION Despite a small trauma cohort, results support feasibility to include GTP in hospital-wide programs with GERI specific AT. Mobility and cognitive strategies may improve opportunities to avoid delirium, decrease LOS and influence more frequent disposition to home. TYPE OF STUDY Original observational retrospective review. LEVEL OF EVIDENCE Level IV- Therapeutic / Care Management.
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Affiliation(s)
- Diane Wintz
- All authors affiliated with Sharp HealthCare, Sharp Memorial Hospital Trauma and Acute Care Surgery: San Diego, CA
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7
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Santos J, Delaplain PT, Tay-Lasso E, Biffl WL, Schaffer KB, Sundel M, Ghneim M, Costantini TW, Santorelli JE, Switzer E, Schellenberg M, Keeley JA, Kim DY, Wang A, Dhillon NK, Patel D, Campion EM, Robinson CK, Kartiko S, Quintana MT, Estroff JM, Kirby KA, Grigorian A, Nahmias J. Development and Validation of a Novel Hollow Viscus Injury Prediction Score for Abdominal Seatbelt Sign: A Pacific Coast Surgical Association Multicenter Study. J Am Coll Surg 2023; 237:826-833. [PMID: 37703489 DOI: 10.1097/xcs.0000000000000863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
BACKGROUND High-quality CT can exclude hollow viscus injury (HVI) in patients with abdominal seatbelt sign (SBS) but performs poorly at identifying HVI. Delay in diagnosis of HVI has significant consequences necessitating timely identification. STUDY DESIGN This multicenter, prospective observational study conducted at 9 trauma centers between August 2020 and October 2021 included adult trauma patients with abdominal SBS who underwent abdominal CT before surgery. HVI was determined intraoperatively and physiologic, examination, laboratory, and imaging findings were collected. Least absolute shrinkage and selection operator- and probit regression-selected predictor variables and coefficients were used to assign integer points for the HVI score. Validation was performed by comparing the area under receiver operating curves (AUROC). RESULTS Analysis included 473 in the development set and 203 in the validation set. The HVI score includes initial systolic blood pressure <110 mmHg, abdominal tenderness, guarding, and select abdominal CT findings. The derivation set has an AUROC of 0.96, and the validation set has an AUROC of 0.91. The HVI score ranges from 0 to 17 with score 0 to 5 having an HVI risk of 0.03% to 5.36%, 6 to 9 having a risk of 10.65% to 44.1%, and 10 to 17 having a risk of 58.59% to 99.72%. CONCLUSIONS This multicenter study developed and validated a novel HVI score incorporating readily available physiologic, examination, and CT findings to risk stratify patients with an abdominal SBS. The HVI score can be used to guide decisions regarding management of a patient with an abdominal SBS and suspected HVI.
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Affiliation(s)
- Jeffrey Santos
- From the Division of Trauma, Burns, Critical Care & Acute Care Surgery, Department of Surgery, University of California, Irvine, Orange, CA (Santos, Delaplain, Tay-Lasso, Grigorian, Nahmias)
| | - Patrick T Delaplain
- From the Division of Trauma, Burns, Critical Care & Acute Care Surgery, Department of Surgery, University of California, Irvine, Orange, CA (Santos, Delaplain, Tay-Lasso, Grigorian, Nahmias)
- Department of Surgery, Boston Children's Hospital/Harvard Medical System, Boston, MA (Delaplain)
| | - Erika Tay-Lasso
- From the Division of Trauma, Burns, Critical Care & Acute Care Surgery, Department of Surgery, University of California, Irvine, Orange, CA (Santos, Delaplain, Tay-Lasso, Grigorian, Nahmias)
| | - Walter L Biffl
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, CA (Biffl, Schaffer)
| | - Kathryn B Schaffer
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, CA (Biffl, Schaffer)
| | - Margaret Sundel
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD (Sundel, Ghneim)
| | - Mira Ghneim
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD (Sundel, Ghneim)
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego School of Medicine, San Diego, CA (Costantini, Santorelli)
| | - Jarrett E Santorelli
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego School of Medicine, San Diego, CA (Costantini, Santorelli)
| | - Emily Switzer
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA (Switzer, Schellenberg)
| | - Morgan Schellenberg
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA (Switzer, Schellenberg)
| | - Jessica A Keeley
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, CA (Keeley, Kim)
| | - Dennis Y Kim
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, CA (Keeley, Kim)
| | - Andrew Wang
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (Want, Dhillon, Patel)
| | - Navpreet K Dhillon
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (Want, Dhillon, Patel)
| | - Deven Patel
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (Want, Dhillon, Patel)
| | - Eric M Campion
- Department of Surgery, Denver Health Medical Center, Denver, CO (Campion, Robinson)
| | - Caitlin K Robinson
- Department of Surgery, Denver Health Medical Center, Denver, CO (Campion, Robinson)
| | - Susan Kartiko
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC (Kartiko, Quintana, Estroff)
| | - Megan T Quintana
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC (Kartiko, Quintana, Estroff)
| | - Jordan M Estroff
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC (Kartiko, Quintana, Estroff)
| | - Katharine A Kirby
- Center for Statistical Consulting, Department of Statistics, University of California Irvine, Irvine, CA (Kirby)
| | - Areg Grigorian
- From the Division of Trauma, Burns, Critical Care & Acute Care Surgery, Department of Surgery, University of California, Irvine, Orange, CA (Santos, Delaplain, Tay-Lasso, Grigorian, Nahmias)
| | - Jeffry Nahmias
- From the Division of Trauma, Burns, Critical Care & Acute Care Surgery, Department of Surgery, University of California, Irvine, Orange, CA (Santos, Delaplain, Tay-Lasso, Grigorian, Nahmias)
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8
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Manasa M, Yeates EO, Grigorian A, Barrios C, Schellenberg M, Owattanapanich N, Barmparas G, Margulies D, Juillard C, Garber K, Cryer H, Tillou A, Burruss S, Penaloza-Villalobos L, Lin A, Figueras RA, Coimbra R, Brenner M, Costantini T, Santorelli J, Curry T, Wintz D, Biffl WL, Schaffer KB, Duncan TK, Barbaro C, Diaz G, Johnson A, Tay-Lasso E, Chinn J, Naaseh A, Leung A, Grabar C, Nahmias J. The Effect of 2019 Coronavirus Stay-at-Home Order on Geriatric Trauma Patients in Southern California. Am Surg 2023; 89:6053-6059. [PMID: 37347234 DOI: 10.1177/00031348221124329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
BACKGROUND California issued stay-at-home (SAH) orders to mitigate COVID-19 spread. Previous studies demonstrated a shift in mechanisms of injuries (MOIs) and decreased length of stay (LOS) for the general trauma population after SAH orders. This study aimed to evaluate the effects of SAH orders on geriatric trauma patients (GTPs), hypothesizing decreased motor vehicle collisions (MVCs) and LOS. METHODS A post-hoc analysis of GTPs (≥65 years old) from 11 level-I/II trauma centers was performed, stratifying patients into 3 groups: before SAH (1/1/2020-3/18/2020) (PRE), after SAH (3/19/2020-6/30/2020) (POST), and a historical control (3/19/2019-6/30/2019) (CONTROL). Bivariate comparisons were performed. RESULTS 5486 GTPs were included (PRE-1756; POST-1706; CONTROL-2024). POST had a decreased rate of MVCs (7.6% vs 10.6%, P = .001; vs 11.9%, P < .001) and pedestrian struck (3.4% vs 5.8%, P = .001; vs 5.2%, P = .006) compared with PRE and CONTROL. Other mechanisms of injury, LOS, mortality, and operations performed were similar between cohorts. However, POST had a lower rate of discharge to skilled nursing facility (SNF) (20% vs 24.5%, P = .001; and 20% vs 24.4%, P = .001). CONCLUSION This retrospective multicenter study demonstrated lower rates of MVCs and pedestrian struck for GTPs, which may be explained by decreased population movement as a result of SAH orders. Contrary to previous studies on the generalized adult population, no differences in other MOIs and LOS were observed after SAH orders. However, there was a lower rate of discharge to SNF, which may be related to a lack of resources due to the COVID-19 pandemic, and thus potentially negatively impacted recovery of GTPs.Keywords.
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Affiliation(s)
- Morgan Manasa
- Department of Surgery, University of California, Irvine (UCI), Orange, CA, USA
| | - Eric O Yeates
- Department of Surgery, University of California, Irvine (UCI), Orange, CA, USA
| | - Areg Grigorian
- Department of Surgery, University of Southern California (USC), Los Angeles, CA, USA
| | - Cristobal Barrios
- Department of Surgery, University of California, Irvine (UCI), Orange, CA, USA
| | - Morgan Schellenberg
- Department of Surgery, University of Southern California (USC), Los Angeles, CA, USA
| | | | - Galinos Barmparas
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel Margulies
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Catherine Juillard
- Department of Surgery, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Kent Garber
- Department of Surgery, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Henry Cryer
- Department of Surgery, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Areti Tillou
- Department of Surgery, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Sigrid Burruss
- Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | | | - Ann Lin
- Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | | | - Raul Coimbra
- Riverside University Health System, Moreno Valley, CA, USA
| | - Megan Brenner
- Riverside University Health System, Moreno Valley, CA, USA
| | - Todd Costantini
- Department of Surgery, University of California, San Diego (UCSD), San Diego, CA, USA
| | - Jarrett Santorelli
- Department of Surgery, University of California, San Diego (UCSD), San Diego, CA, USA
| | - Terry Curry
- Department of Surgery, University of California, San Diego (UCSD), San Diego, CA, USA
| | - Diane Wintz
- Department of Surgery, Sharp Memorial Hospital, San Diego, CA, USA
| | - Walter L Biffl
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, CA, USA
| | - Kathryn B Schaffer
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, CA, USA
| | - Thomas K Duncan
- Department of Surgery, Ventura County Medical Center, Ventura, CA, USA
| | - Casey Barbaro
- Department of Surgery, Ventura County Medical Center, Ventura, CA, USA
| | - Graal Diaz
- Department of Surgery, Ventura County Medical Center, Ventura, CA, USA
| | | | - Erika Tay-Lasso
- Department of Surgery, University of California, Irvine (UCI), Orange, CA, USA
| | - Justine Chinn
- Department of Surgery, University of California, Irvine (UCI), Orange, CA, USA
| | - Ariana Naaseh
- Department of Surgery, University of California, Irvine (UCI), Orange, CA, USA
| | - Amanda Leung
- Department of Surgery, University of California, Irvine (UCI), Orange, CA, USA
| | - Christina Grabar
- Department of Surgery, University of California, Irvine (UCI), Orange, CA, USA
| | - Jeffry Nahmias
- Department of Surgery, University of California, Irvine (UCI), Orange, CA, USA
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9
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Aryan N, Grigorian A, Lucas AN, Tay-Lasso E, Zezoff DC, Fierro N, Dhillon NK, Ley EJ, Smith J, Dahan A, Johnson A, Ganske W, Biffl WL, Bayat D, Castelo M, Wintz D, Schaffer KB, Zheng DJ, Tillou A, Coimbra R, Santorelli JE, Schellenberg M, Inaba K, Emigh B, Duncan TK, Diaz G, Burruss S, Tuli R, Nahmias J. Outcomes for advanced aged (35 and older) versus younger aged pregnant trauma patients: A multicenter study. Am J Surg 2023; 226:798-802. [PMID: 37355376 DOI: 10.1016/j.amjsurg.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 05/25/2023] [Accepted: 06/01/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Effects of advanced maternal age (AMA) pregnancies (defined as ≥35 years) on pregnant trauma patients (PTPs) are unknown. This study compared AMA versus younger PTPs, hypothesizing AMA PTPs have increased risk of fetal delivery (FD). METHODS A retrospective (2016-2021) multicenter study included all PTPs. Multivariable logistic regression was used to evaluate risk of FD after trauma. RESULTS A total of 950 PTPs were included. Both cohorts had similar gestational age and injury severity scores. The AMA group had increased injuries to the pancreas, bladder, and stomach (p < 0.05). There was no difference in rate or associated risk of FD between cohorts (5.3% vs. 11.4%; OR 0.59, CI 0.19-1.88, p > 0.05). CONCLUSION Compared to their younger counterparts, some intra-abdominal injuries (pancreas, bladder, and stomach) were more common among AMA PTPs. However, there was no difference in rate or associated risk of FD in AMA PTPs, thus they do not require increased observation.
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Affiliation(s)
- Negaar Aryan
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, California, USA.
| | - Areg Grigorian
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, California, USA.
| | - Alexa N Lucas
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, California, USA.
| | - Erika Tay-Lasso
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, California, USA.
| | - Danielle C Zezoff
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, California, USA.
| | - Nicole Fierro
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Navpreet K Dhillon
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Eric J Ley
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Jennifer Smith
- Division of Trauma and Critical Care, Harbor-UCLA Hospital, Torrance, CA, USA.
| | - Alden Dahan
- University of California, Riverside School of Medicine, Riverside, CA, USA.
| | - Arianne Johnson
- Cottage Health Research Institute, Santa Barbara Cottage Hospital, Santa Barbara, CA, USA.
| | - William Ganske
- Cottage Health Research Institute, Santa Barbara Cottage Hospital, Santa Barbara, CA, USA.
| | - Walter L Biffl
- Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, CA, USA.
| | - Dunya Bayat
- Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, CA, USA.
| | - Matthew Castelo
- Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, CA, USA.
| | - Diane Wintz
- Department of Surgery, Sharp Memorial Hospital, San Diego, CA, USA.
| | | | - Dennis J Zheng
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.
| | - Areti Tillou
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.
| | - Raul Coimbra
- Riverside University Health System Medical Center, Comparative Effectiveness and Clinical Outcomes Research Center - CECORC, CA, USA.
| | - Jarrett E Santorelli
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego School of Medicine, San Diego, CA, USA.
| | - Morgan Schellenberg
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA.
| | - Kenji Inaba
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA.
| | - Brent Emigh
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA; Warren Alpert Medical School at Brown University, Department of Surgery, Division of Trauma, USA.
| | - Thomas K Duncan
- Department of Trauma, Ventura County Medical Center, Ventura, CA, USA.
| | - Graal Diaz
- Department of Trauma, Ventura County Medical Center, Ventura, CA, USA.
| | - Sigrid Burruss
- Department of Trauma, Acute Care Surgery, Surgical Critical Care, Loma Linda Medical Center, Loma Linda, CA, USA.
| | - Rahul Tuli
- Comparative Effectiveness and Clinical Outcomes Research Center - CECORC, University of California Riverside School of Medicine, CA, USA.
| | - Jeffry Nahmias
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, California, USA.
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10
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Zeineddin A, Tominaga GT, Crandall M, Almeida M, Schuster KM, Jawad G, Maqbool B, Sheffield AC, Dhillon NK, Radow BS, Moorman ML, Martin ND, Jacovides CL, Lowry D, Kaups K, Horwood CR, Werner NL, Proaño-Zamudio JA, Kaafarani HMA, Marshall WA, Haines LN, Schaffer KB, Staudenmayer KL, Kozar RA. Contemporary management and outcomes of penetrating colon injuries: Validation of the 2020 AAST Colon Organ Injury Scale. J Trauma Acute Care Surg 2023; 95:213-219. [PMID: 37072893 DOI: 10.1097/ta.0000000000003969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
INTRODUCTION The American Association for the Surgery of Trauma Colon Organ Injury Scale (OIS) was updated in 2020 to include a separate OIS for penetrating colon injuries and included imaging criteria. In this multicenter study, we describe the contemporary management and outcomes of penetrating colon injuries and hypothesize that the 2020 OIS system correlates with operative management, complications, and outcomes. METHODS This was a retrospective study of patients presenting to 12 Level 1 trauma centers between 2016 and 2020 with penetrating colon injuries and Abbreviated Injury Scale score of <3 in other body regions. We assessed the association of the new OIS with surgical management and clinical outcomes and the association of OIS imaging criteria with operative criteria. Bivariate analysis was done with χ 2 , analysis of variance, and Kruskal-Wallis, where appropriate. Multivariable models were constructed in a stepwise selection fashion. RESULTS We identified 573 patients with penetrating colon injuries. Patients were young and predominantly male; 79% suffered a gunshot injury, 11% had a grade V destructive injury, 19% required ≥6 U of transfusion, 24% had an Injury Severity Score of >15, and 42% had moderate-to-large contamination. Higher OIS was independently associated with a lower likelihood of primary repair, higher likelihood of resection with anastomosis and/or diversion, need for damage-control laparotomy, and higher incidence of abscess, wound infection, extra-abdominal infections, acute kidney injury, and lung injury. Damage control was independently associated with diversion and intra-abdominal and extra-abdominal infections. Preoperative imaging in 152 (27%) cases had a low correlation with operative findings ( κ coefficient, 0.13). CONCLUSION This is the largest study to date of penetrating colon injuries and the first multicenter validation of the new OIS specific to these injuries. While imaging criteria alone lacked strong predictive value, operative American Association for the Surgery of Trauma OIS colon grade strongly predicted type of interventions and outcomes, supporting use of this grading scale for research and clinical practice. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Ahmad Zeineddin
- From the Department of Surgery (A.Z.), Howard University Hospital, Washington, DC; Department of Surgery (A.Z., N.K.D., R.A.K.), Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery (M.A., K.M.S.), Yale University, New Haven, Connecticut; Department of Surgery (G.J., B.M.), University of New Mexico Health Science Center, Albuquerque, New Mexico; Department of Surgery (M.C., A.C.S.), College of Medicine, University of Florida, Jacksonville, Florida; Department of Surgery (B.S.R., M.L.M.), University Hospitals Cleveland Medical Center, Cleveland, Ohio; Department of Surgery (N.D.M., C.L.J.), University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.L., K.K.), Community Regional Medical Center, UCSF Fresno, Fresno, California; Department of Surgery (C.R.H., N.L.W.), Denver Health, Denver, Colorado; Department of Surgery (J.A.P.-Z., H.M.A.K.), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Surgery (W.A.M., L.N.H.), University of California San Diego Health, San Diego; Department of Surgery (G.T.T., K.B.S.), Scripps Memorial Hospital, La Jolla; and Department of Surgery (K.L.S.), Stanford University, Stanford, California
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11
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Harrell KN, Grimes AD, Gill H, Reynolds JK, Ueland WR, Sciarretta JD, Todd SR, Trust MD, Ngoue M, Thomas BW, Ayuso SA, LaRiccia A, Spalding MC, Collins MJ, Collier BR, Karam BS, de Moya MA, Lieser MJ, Chipko JM, Haan JM, Lightwine KL, Cullinane DC, Falank CR, Phillips RC, Kemp MT, Alam HB, Udekwu PO, Sanin GD, Hildreth AN, Biffl WL, Schaffer KB, Marshall G, Muttalib O, Nahmias J, Shahi N, Moulton SL, Maxwell RA. Risk factors for recurrence in blunt traumatic abdominal wall hernias: A secondary analysis of a Western Trauma association multicenter study. Am J Surg 2022; 225:1069-1073. [PMID: 36509587 DOI: 10.1016/j.amjsurg.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/30/2022] [Accepted: 12/06/2022] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Kevin N Harrell
- University of Tennessee College of Medicine Chattanooga, 979 E 3rd Street Suite B 401, Chattanooga, TN, 37403, USA.
| | - Arthur D Grimes
- University of Oklahoma, 800 Stanton L. Young Blvd #9000, Oklahoma City, OK, 73104, USA.
| | - Harkanwar Gill
- University of Oklahoma, 800 Stanton L. Young Blvd #9000, Oklahoma City, OK, 73104, USA.
| | - Jessica K Reynolds
- University of Kentucky School of Medicine, 800 Rose St, MN268A, Lexington, KY, 40536, USA.
| | - Walker R Ueland
- University of Kentucky School of Medicine, 800 Rose St, MN268A, Lexington, KY, 40536, USA.
| | - Jason D Sciarretta
- Grady Health System, 80 Jesse Hill Jr Drive SE, Atlanta, GA, 30303, USA.
| | - Samual R Todd
- Grady Health System, 80 Jesse Hill Jr Drive SE, Atlanta, GA, 30303, USA.
| | - Marc D Trust
- University of Texas at Austin, 1501 Red River St, Austin, TX, 78712, USA.
| | - Marielle Ngoue
- University of Texas at Austin, 1501 Red River St, Austin, TX, 78712, USA.
| | - Bradley W Thomas
- Atrium Health Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA.
| | - Sullivan A Ayuso
- Atrium Health Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA.
| | - Aimee LaRiccia
- Grant Medical Center, 111 S Grant Ave, Columbus, OH, 43215, USA.
| | | | | | - Bryan R Collier
- Carilion Clinic, 1906 Belleview Ave SE, Roanoke, VA, 24014, USA.
| | - Basil S Karam
- Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI, 53226, USA.
| | - Marc A de Moya
- Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI, 53226, USA.
| | - Mark J Lieser
- Research Medical Center, 2316 E Meyer Blvd, Kansas City, MO, 64132, USA.
| | - John M Chipko
- Research Medical Center, 2316 E Meyer Blvd, Kansas City, MO, 64132, USA.
| | - James M Haan
- Ascension Via Christi on St. Francis Hospital, 929 St Francis, Wichita, KS, 67214, USA.
| | - Kelly L Lightwine
- Ascension Via Christi on St. Francis Hospital, 929 St Francis, Wichita, KS, 67214, USA.
| | | | | | - Ryan C Phillips
- Denver Health Medical Center, 777 Bannock St, Denver, CO, 80204, USA.
| | - Michael T Kemp
- University of Michigan, 1500 E Medical Center Dr Ann Arbor, MI, 48109, USA.
| | - Hasan B Alam
- University of Michigan, 1500 E Medical Center Dr Ann Arbor, MI, 48109, USA.
| | | | - Gloria D Sanin
- Wake Forest School of Medicine, 1 Medical Center Blvd Winston-Salem, NC, 27157, USA.
| | - Amy N Hildreth
- Wake Forest School of Medicine, 1 Medical Center Blvd Winston-Salem, NC, 27157, USA.
| | - Walter L Biffl
- Scripps Memorial Hospital La Jolla, 9888 Genesee Ave, La Jolla, CA, 92037, USA.
| | - Kathryn B Schaffer
- Scripps Memorial Hospital La Jolla, 9888 Genesee Ave, La Jolla, CA, 92037, USA.
| | - Gary Marshall
- Medical City Plano Hospital, 3901 W 15th St, Plano, TX, 75075, USA.
| | - Omaer Muttalib
- University of California, Irvine, 101 The City Dr S Orange, CA, 92868, USA.
| | - Jeffry Nahmias
- University of California, Irvine, 101 The City Dr S Orange, CA, 92868, USA.
| | - Niti Shahi
- Children's Hospital Colorado, 13123 E 16th Ave, Aurora, CO, 80045, USA.
| | - Steven L Moulton
- Children's Hospital Colorado, 13123 E 16th Ave, Aurora, CO, 80045, USA.
| | - Robert A Maxwell
- University of Tennessee College of Medicine Chattanooga, 979 E 3rd Street Suite B 401, Chattanooga, TN, 37403, USA.
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12
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Delaplain PT, Tay-Lasso E, Biffl WL, Schaffer KB, Sundel M, Behdin S, Ghneim M, Costantini TW, Santorelli JE, Switzer E, Schellenberg M, Keeley JA, Kim DY, Wang A, Dhillon NK, Patel D, Campion EM, Robinson CK, Kartiko S, Quintana MT, Estroff JM, Kirby KA, Nahmias J. Excluding Hollow Viscus Injury for Abdominal Seat Belt Sign Using Computed Tomography. JAMA Surg 2022; 157:771-778. [PMID: 35830194 DOI: 10.1001/jamasurg.2022.2770] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Importance Abdominal seat belt sign (SBS) has historically entailed admission and observation because of the diagnostic limitations of computed tomography (CT) imaging and high rates of hollow viscus injury (HVI). Recent single-institution, observational studies have questioned the utility of this practice. Objective To evaluate whether a negative CT scan can safely predict the absence of HVI in the setting of an abdominal SBS. Design, Setting, and Participants This prospective, observational cohort study was conducted in 9 level I trauma centers between August 2020 and October 2021 and included adult trauma patients with abdominal SBS. Exposures Inclusion in the study required abdominal CT as part of the initial trauma evaluation and before any surgical intervention, if performed. Results of CT scans were considered positive if they revealed any of the following: abdominal wall soft tissue contusion, free fluid, bowel wall thickening, mesenteric stranding, mesenteric hematoma, bowel dilation, pneumatosis, or pneumoperitoneum. Main Outcomes and Measures Presence of HVI diagnosed at the time of operative intervention. Results A total of 754 patients with abdominal SBS had an HVI prevalence of 9.2% (n = 69), with only 1 patient with HVI (0.1%) having a negative CT (ie, none of the 8 a priori CT findings). On bivariate analysis comparing patients with and without HVI, there were significant associations between each of the individual CT scan findings and the presence of HVI. The strongest association was found with the presence of free fluid, with a more than 40-fold increase in the likelihood of HVI (odds ratio [OR], 42.68; 95% CI, 20.48-88.94; P < .001). The presence of free fluid also served as the most effective binary classifier for presence of HVI (area under the receiver operator characteristic curve [AUC], 0.87; 95% CI, 0.83-0.91). There was also an association between a negative CT scan and the absence of HVI (OR, 41.09; 95% CI, 9.01-727.69; P < .001; AUC, 0.68; 95% CI, 0.66-0.70). Conclusions and Relevance The prevalence of HVI among patients with an abdominal SBS and negative findings on CT is extremely low, if not zero. The practice of admitting and observing all patients with abdominal SBS should be reconsidered when a high-quality CT scan is negative, which may lead to significant resource and cost savings.
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Affiliation(s)
- Patrick T Delaplain
- Division of Trauma, Burns, & Surgical Critical Care, University of California, Irvine
| | - Erika Tay-Lasso
- Division of Trauma, Burns, & Surgical Critical Care, University of California, Irvine
| | - Walter L Biffl
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California
| | - Kathryn B Schaffer
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California
| | - Margaret Sundel
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Samar Behdin
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Mira Ghneim
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego School of Medicine, San Diego
| | - Jarrett E Santorelli
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego School of Medicine, San Diego
| | - Emily Switzer
- Los Angeles County + USC Medical Center, Division of Acute Care Surgery, University of Southern California, Los Angeles
| | - Morgan Schellenberg
- Los Angeles County + USC Medical Center, Division of Acute Care Surgery, University of Southern California, Los Angeles
| | - Jessica A Keeley
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, California
| | - Dennis Y Kim
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, California
| | - Andrew Wang
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Navpreet K Dhillon
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Deven Patel
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric M Campion
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | | | - Susan Kartiko
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC
| | - Megan T Quintana
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC
| | - Jordan M Estroff
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC
| | - Katharine A Kirby
- Center for Statistical Consulting, Department of Statistics, University of California, Irvine
| | - Jeffry Nahmias
- Division of Trauma, Burns, & Surgical Critical Care, University of California, Irvine
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Ruhi-Williams P, Yeates EO, Grigorian A, Schellenberg M, Owattanapanich N, Barmparas G, Margulies D, Juillard C, Garber K, Cryer H, Tillou A, Burruss S, Penaloza-Villalobos L, Lin A, Figueras RA, Coimbra R, Brenner M, Costantini T, Santorelli J, Curry T, Wintz D, Biffl WL, Schaffer KB, Duncan TK, Barbaro C, Diaz G, Johnson A, Chinn J, Naaseh A, Leung A, Grabar C, Nahmias J. Adolescent Trauma During the COVID Pandemic: Just Like Adults, Children, or Someone Else? Am Surg 2022; 88:2429-2435. [PMID: 35583103 PMCID: PMC9127450 DOI: 10.1177/00031348221101475] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
COVID-19 stay-at-home (SAH) orders were impactful on adolescence, when social
interactions affect development. This has the potential to change adolescent
trauma. A post-hoc multicenter retrospective analysis of adolescent
(13-17 years-old) trauma patients (ATPs) at 11 trauma centers was performed.
Patients were divided into 3 groups based on injury date: historical control
(CONTROL:3/19/2019-6/30/2019, before SAH (PRE:1/1/2020-3/18/2020), and after SAH
(POST:3/19/2020-6/30/2020). The POST group was compared to both PRE and CONTROL
groups in separate analyses. 726 ATPs were identified across the 3
time periods. POST had a similar penetrating trauma rate compared to both PRE
(15.8% vs 13.8%, P = .56) and CONTROL (15.8% vs 14.5%,
P = .69). POST also had a similar rate of suicide attempts
compared to both PRE (1.2% vs 1.5%, P = .83) and CONTROL (1.2%
vs 2.1%, P = .43). However, POST had a higher rate of drug
positivity compared to CONTROL (28.6% vs 20.6%, P = .032), but
was similar in all other comparisons of alcohol and drugs to PRE and POST
periods (all P > .05). Hence ATPs were affected differently
than adults and children, as they had a similar rate of penetrating trauma,
suicide attempts, and alcohol positivity after SAH orders. However, they had
increased drug positivity compared to the CONTROL, but not PRE group.
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Affiliation(s)
- Perisa Ruhi-Williams
- Department of Surgery, 21769University of California, Irvine (UCI), Orange, CA, USA
| | - Eric O Yeates
- Department of Surgery, 21769University of California, Irvine (UCI), Orange, CA, USA
| | - Areg Grigorian
- Department of Surgery, 21769University of California, Irvine (UCI), Orange, CA, USA.,Department of Surgery, University of Southern California (USC), Los Angeles, CA, USA
| | - Morgan Schellenberg
- Department of Surgery, University of Southern California (USC), Los Angeles, CA, USA
| | | | - Galinos Barmparas
- Department of Surgery, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel Margulies
- Department of Surgery, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Catherine Juillard
- Department of Surgery, 8783University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Kent Garber
- Department of Surgery, 8783University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Henry Cryer
- Department of Surgery, 8783University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Areti Tillou
- Department of Surgery, 8783University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Sigrid Burruss
- Department of Surgery, 4608Loma Linda University, Loma Linda, CA, USA
| | | | - Ann Lin
- Department of Surgery, 4608Loma Linda University, Loma Linda, CA, USA
| | | | - Raul Coimbra
- Department of Surgery, 4608Loma Linda University, Loma Linda, CA, USA.,472028Riverside University Health System Medical CenterUniversity, Moreno Valley, CA, USA
| | - Megan Brenner
- University of California, Riverside/Riverside University Health System Department of Surgery, Moreno Valley, CA, USA
| | - Todd Costantini
- Department of Surgery, 8784University of California, San Diego (UCSD), San Diego, CA, USA
| | - Jarrett Santorelli
- Department of Surgery, 8784University of California, San Diego (UCSD), San Diego, CA, USA
| | - Terry Curry
- Department of Surgery, 8784University of California, San Diego (UCSD), San Diego, CA, USA
| | - Diane Wintz
- Department of Surgery, 21380Sharp Memorial Hospital, San Diego, CA, USA
| | - Walter L Biffl
- Trauma Department, 24146Scripps Memorial Hospital La Jolla, La Jolla, CA, USA
| | - Kathryn B Schaffer
- Trauma Department, 24146Scripps Memorial Hospital La Jolla, La Jolla, CA, USA
| | - Thomas K Duncan
- Department of Surgery, 25352Ventura County Medical Center, Ventura, CA, USA
| | - Casey Barbaro
- Department of Surgery, 25352Ventura County Medical Center, Ventura, CA, USA
| | - Graal Diaz
- Department of Surgery, 25352Ventura County Medical Center, Ventura, CA, USA
| | - Arianne Johnson
- Cottage Health Research Institute, 22854Santa Barbara Cottage Hospital, Santa Barbara, CA, USA
| | - Justine Chinn
- Department of Surgery, 21769University of California, Irvine (UCI), Orange, CA, USA
| | - Ariana Naaseh
- Department of Surgery, 21769University of California, Irvine (UCI), Orange, CA, USA
| | - Amanda Leung
- Department of Surgery, 21769University of California, Irvine (UCI), Orange, CA, USA
| | - Christina Grabar
- Department of Surgery, 21769University of California, Irvine (UCI), Orange, CA, USA
| | - Jeffry Nahmias
- Department of Surgery, 21769University of California, Irvine (UCI), Orange, CA, USA
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14
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Schaffer S, Bayat D, Biffl WL, Smith J, Schaffer KB, Dandan TH, Wang J, Snyder D, Nalick C, Dandan IS, Tominaga GT, Castelo MR. Pain management on a trauma service: a crisis reveals opportunities. Trauma Surg Acute Care Open 2022; 7:e000862. [PMID: 35402732 PMCID: PMC8948384 DOI: 10.1136/tsaco-2021-000862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 03/08/2022] [Indexed: 11/07/2022] Open
Abstract
Objectives The opioid crisis has forced an examination of opioid prescribing and usage patterns. Multimodal pain management and limited, procedure-specific prescribing guidelines have been proposed in general surgery but are less well studied in trauma, where multisystem injuries and multispecialty caregivers are the norm. We hypothesized that opioid requirements would differ by primary type of injury and by age, and we sought to identify factors affecting opioid prescribing at discharge (DC). Methods Retrospective analysis of pain management at a level II trauma center for January–November 2018. Consecutive patients with exploratory laparotomy (LAP); 3 or more rib fractures (fxs) (RIB); or pelvic (PEL), femoral (FEM), or tibial (TIB) fxs were included, and assigned to cohorts based on the predominant injury. Patients who died or had head Abbreviated Injury Scale >2 and Glasgow Coma Scale <15 were excluded. All pain medications were recorded daily; doses were converted to oral morphine equivalents (OMEs). The primary outcomes of interest were OMEs administered over the final 72 hours of hospitalization (OME72) and prescribed at DC (OMEDC). Multimodal pain therapy defined as 3 or more drugs used. Categorical variables and continuous variables were analyzed with appropriate statistical analyses. Results 208 patients were included: 17 LAP, 106 RIB, 31 PEL, 26 FEM, and 28 TIB. 74% were male and 8% were using opiates prior to admission. Injury cohorts varied by age but not Injury Severity Score (ISS) or length of stay (LOS). 64% of patients received multimodal pain therapy. There was an overall difference in OME72 between the five injury groups (p<0.0001) and OME72 was lower for RIB compared with all other cohorts. Compared with younger (age <65) patients, older (≥65 years) patients had similar ISS and LOS, but lower OME72 (45 vs 135*) and OMEDC. Median OME72 differed significantly between older and younger patients with PEL (p=0.02) and RIB (p=0.01) injuries. No relationship existed between OMEDC across injury groups, by sex or injury severity. Patients were discharged almost exclusively by trauma service advanced practice clinicians (APCs). There was no difference among APCs in number of pills or OMEs prescribed. 81% of patients received opioids at DC, of whom 69% were prescribed an opioid/acetaminophen combination drug; and only 13% were prescribed non-steroidal anti-inflammatory drugs, 19% acetaminophen, and 31% gabapentin. Conclusions Opioid usage varied among patients with different injury types. Opioid DC prescribing appears rote and does not correlate with actual opioid usage during the 72 hours prior to DC. Paradoxically, OMEDC tends to be higher among females, patients with ISS <16, and those with rib fxs, despite a tendency toward lower OME72 usage among these groups. There was apparent underutilization of non-opioid agents. These findings highlight opportunities for improvement and further study. Level of evidence IV.
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Affiliation(s)
- Sabina Schaffer
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Dunya Bayat
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Walter L Biffl
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Jeffrey Smith
- Orthopedic Trauma, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Kathryn B Schaffer
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Tala H Dandan
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Jiayan Wang
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Deb Snyder
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Chris Nalick
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Imad S Dandan
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Gail T Tominaga
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Matthew R Castelo
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
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15
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Yeates EO, Grigorian A, Schellenberg M, Owattanapanich N, Barmparas G, Margulies D, Juillard C, Garber K, Cryer H, Tillou A, Burruss S, Penaloza-Villalobos L, Lin A, Figueras RA, Coimbra R, Brenner M, Costantini T, Santorelli J, Curry T, Wintz D, Biffl WL, Schaffer KB, Duncan TK, Barbaro C, Diaz G, Johnson A, Chinn J, Naaseh A, Leung A, Grabar C, Nahmias J. Decreased hospital length of stay and intensive care unit admissions for non-COVID blunt trauma patients during the COVID-19 pandemic. Am J Surg 2022; 224:90-95. [PMID: 35219493 PMCID: PMC8863305 DOI: 10.1016/j.amjsurg.2022.02.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 02/16/2022] [Accepted: 02/20/2022] [Indexed: 01/08/2023]
Abstract
Background The COVID-19 pandemic overwhelmed hospitals, forcing adjustments including discharging patients earlier and limiting intensive care unit (ICU) utilization. This study aimed to evaluate ICU admissions and length of stay (LOS) for blunt trauma patients (BTPs). Methods A retrospective review of COVID (3/19/20-6/30/20) versus pre-COVID (3/19/19-6/30/19) BTPs at eleven trauma centers was performed. Multivariable analysis was used to identify risk factors for ICU admission. Results 12,744 BTPs were included (6942 pre-COVID vs. 5802 COVID). The COVID cohort had decreased mean LOS (3.9 vs. 4.4 days, p = 0.029), ICU LOS (0.9 vs. 1.1 days, p < 0.001), and rate of ICU admission (22.3% vs. 24.9%, p = 0.001) with no increase in complications or mortality compared to the pre-COVID cohort (all p > 0.05). On multivariable analysis, the COVID period was associated with decreased risk of ICU admission (OR = 0.82, CI 0.75–0.90, p < 0.001). Conclusions BTPs had decreased LOS and associated risk of ICU admission during COVID, with no corresponding increase in complications or mortality.
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Affiliation(s)
- Eric O Yeates
- University of California, Irvine (UCI), Department of Surgery, Orange, CA, USA.
| | - Areg Grigorian
- University of California, Irvine (UCI), Department of Surgery, Orange, CA, USA; University of Southern California (USC), Department of Surgery, Los Angeles, CA, USA.
| | - Morgan Schellenberg
- University of Southern California (USC), Department of Surgery, Los Angeles, CA, USA.
| | | | - Galinos Barmparas
- Cedars-Sinai Medical Center, Department of Surgery, Los Angeles, CA, USA.
| | - Daniel Margulies
- Cedars-Sinai Medical Center, Department of Surgery, Los Angeles, CA, USA.
| | - Catherine Juillard
- University of California, Los Angeles (UCLA), Department of Surgery, Los Angeles, CA, USA.
| | - Kent Garber
- University of California, Los Angeles (UCLA), Department of Surgery, Los Angeles, CA, USA.
| | - Henry Cryer
- University of California, Los Angeles (UCLA), Department of Surgery, Los Angeles, CA, USA.
| | - Areti Tillou
- University of California, Los Angeles (UCLA), Department of Surgery, Los Angeles, CA, USA.
| | - Sigrid Burruss
- Loma Linda University, Department of Surgery, Loma Linda, CA, USA.
| | | | - Ann Lin
- Loma Linda University, Department of Surgery, Loma Linda, CA, USA.
| | | | - Raul Coimbra
- Loma Linda University, Department of Surgery, Loma Linda, CA, USA; Riverside University Health System Medical Center, Moreno Valley, CA, USA.
| | - Megan Brenner
- University of California, Riverside/Riverside University Health System Department of Surgery, Moreno Valley, CA, USA.
| | - Todd Costantini
- University of California, San Diego (UCSD), Department of Surgery, San Diego, CA, USA.
| | - Jarrett Santorelli
- University of California, San Diego (UCSD), Department of Surgery, San Diego, CA, USA.
| | - Terry Curry
- University of California, San Diego (UCSD), Department of Surgery, San Diego, CA, USA.
| | - Diane Wintz
- Sharp Memorial Hospital, Department of Surgery, San Diego, CA, USA.
| | - Walter L Biffl
- Scripps Memorial Hospital La Jolla, Trauma Department, La Jolla, CA, USA.
| | - Kathryn B Schaffer
- Scripps Memorial Hospital La Jolla, Trauma Department, La Jolla, CA, USA.
| | - Thomas K Duncan
- Ventura County Medical Center, Department of Surgery, Ventura, CA, USA.
| | - Casey Barbaro
- Ventura County Medical Center, Department of Surgery, Ventura, CA, USA.
| | - Graal Diaz
- Ventura County Medical Center, Department of Surgery, Ventura, CA, USA.
| | - Arianne Johnson
- Santa Barbara Cottage Hospital, Cottage Health Research Institute, Santa Barbara, CA, USA.
| | - Justine Chinn
- University of California, Irvine (UCI), Department of Surgery, Orange, CA, USA.
| | - Ariana Naaseh
- University of California, Irvine (UCI), Department of Surgery, Orange, CA, USA.
| | - Amanda Leung
- University of California, Irvine (UCI), Department of Surgery, Orange, CA, USA.
| | - Christina Grabar
- University of California, Irvine (UCI), Department of Surgery, Orange, CA, USA.
| | - Jeffry Nahmias
- University of California, Irvine (UCI), Department of Surgery, Orange, CA, USA.
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16
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Harrell KN, Grimes AD, Albrecht RM, Reynolds JK, Ueland WR, Sciarretta JD, Todd SR, Trust MD, Ngoue M, Thomas BW, Ayuso SA, LaRiccia A, Spalding MC, Collins MJ, Collier BR, Karam BS, de Moya MA, Lieser MJ, Chipko JM, Haan JM, Lightwine KL, Cullinane DC, Falank CR, Phillips RC, Kemp MT, Alam HB, Udekwu PO, Sanin GD, Hildreth AN, Biffl WL, Schaffer KB, Marshall G, Muttalib O, Nahmias J, Shahi N, Moulton SL, Maxwell RA. Management of blunt traumatic abdominal wall hernias: A Western Trauma Association multicenter study. J Trauma Acute Care Surg 2021; 91:834-840. [PMID: 34695060 DOI: 10.1097/ta.0000000000003250] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Kevin N Harrell
- From the Department of Surgery (K.N.H., R.A.M.), University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee; Department of Surgery (A.D.G., R.M.A.), University of Oklahoma, School of Medicine, Oklahoma City, Oklahoma; Department of Surgery (J.K.R., W.R.U.), University of Kentucky College of Medicine, Lexington, Kentucky; Department of Surgery (J.D.S., S.R.T.), Grady Health System, Emory University School of Medicine, Atlanta, Georgia; University of Texas at Austin (M.D.T., M.N.), Austin, Texas; Atrium Health Carolinas Medical Center (B.W.T., S.A.A.), Charlotte, North Carolina; Grant Medical Center (A.LR., M.C.S.), Columbus, Ohio; Department of Surgery (M.J.C., B.R.C.), Virginia Tech Carilion School of Medicine, Roanoke, Virginia; Department of Surgery (B.S.K., M.A.dM.), Medical College of Wisconsin Milwaukee, Wisconsin; Research Medical Center (M.J.L., J.M.C.), Kansas City, Missouri; Ascension Via Christi on St. Francis Hospital (J.M.H., K.L.L.), Wichita, Kansas; Department of Surgery (D.C.C., C.R.F.), Maine Medical Center, Portland, Maine; Department of Surgery (R.C.P.), Denver Health Medical Center, Denver, Colorado; Department of Surgery (M.T.K., H.B.A.), University of Michigan, Ann Arbor, Michigan; Department of Surgery (P.O.U.), WakeMed Health Raleigh; Department of General Surgery (G.D.S., A.N.H.), Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Trauma/Acute Care Surgery (W.L.B., K.B.S.), Scripps Memorial Hospital La Jolla, La Jolla, California; Medical City Plano Hospital (G.M.) Plano, Texas; Department of Surgery (O.M., J.N.), University of California, School of Medicine, Irvine, Orange, California; Department of Pediatric Surgery (N.S., S.L.M.), Children's Hospital Colorado, Denver, Colorado
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17
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Biffl WL, Ball CG, Moore EE, Lees J, Todd SR, Wydo S, Privette A, Weaver JL, Koenig SM, Meagher A, Dultz L, Udekwu PO, Harrell K, Chen AK, Callcut R, Kornblith L, Jurkovich GJ, Castelo M, Schaffer KB. Don't mess with the pancreas! A multicenter analysis of the management of low-grade pancreatic injuries. J Trauma Acute Care Surg 2021; 91:820-828. [PMID: 34039927 DOI: 10.1097/ta.0000000000003293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Current guidelines recommend nonoperative management (NOM) of low-grade (American Association for the Surgery of Trauma-Organ Injury Scale Grade I-II) pancreatic injuries (LGPIs), and drainage rather than resection for those undergoing operative management, but they are based on low-quality evidence. The purpose of this study was to review the contemporary management and outcomes of LGPIs and identify risk factors for morbidity. METHODS Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018. The primary outcome was pancreas-related complications (PRCs). Predictors of PRCs were analyzed using multivariate logistic regression. RESULTS Twenty-nine centers submitted data on 728 patients with LGPI (76% men; mean age, 38 years; 37% penetrating; 51% Grade I; median Injury Severity Score, 24). Among 24-hour survivors, definitive management was NOM in 31%, surgical drainage alone in 54%, resection in 10%, and pancreatic debridement or suturing in 5%. The incidence of PRCs was 21% overall and was 42% after resection, 26% after drainage, and 4% after NOM. On multivariate analysis, independent risk factors for PRC were other intra-abdominal injury (odds ratio [OR], 2.30; 95% confidence interval [95% CI], 1.16-15.28), low volume (OR, 2.88; 1.65, 5.06), and penetrating injury (OR, 3.42; 95% CI, 1.80-6.58). Resection was very close to significance (OR, 2.06; 95% CI, 0.97-4.34) (p = 0.0584). CONCLUSION The incidence of PRCs is significant after LGPIs. Patients who undergo pancreatic resection have PRC rates equivalent to patients resected for high-grade pancreatic injuries. Those who underwent surgical drainage had slightly lower PRC rate, but only 4% of those who underwent NOM had PRCs. In patients with LGPIs, resection should be avoided. The NOM strategy should be used whenever possible and studied prospectively, particularly in penetrating trauma. LEVEL OF EVIDENCE Therapeutic Study, level IV.
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Affiliation(s)
- Walter L Biffl
- From the Scripps Memorial Hospital (W.L.B., M.C., K.B.S.), La Jolla, La Jolla, CA; University of Calgary, Calgary (C.G.B.), Alberta, Canada; Ernest E. Moore Shock Trauma Center at Denver Health (E.E.M.), Denver, CO; University of Oklahoma (J.L.), Oklahoma City, OK; Grady Memorial Hospital (S.R.T.), Atlanta, GA; Cooper University Hospital (SW), Camden, NJ; Medical University of South Carolina (A.P.), Charleston, SC; University of California-San Diego (J.L.W.), San Diego, CA; Virginia Tech Carilion School of Medicine (S.M.K.), Carilion Clinic, Roanoke VA; Indiana University School of Medicine- Methodist (A.M.), Indianapolis, IN; Parkland- UT Southwestern Medical Center (L.D.), Dallas, TX; WakeMed Health (P.O.U.), Raleigh, NC; University of Tennessee College of Medicine (K.H.), Chattanooga, TN; UCSF Fresno (A.K.C.), Fresno, CA; and San Francisco General Hospital (R.C., L.K.), San Francisco, CA; University of California-Davis (G.J.J.), Sacramento, CA
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18
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Schaffer KB, Dandan T, Bayat D, Castelo MR, Reames SH, Hutkin-Slade L, Biffl WL. Self-inflicted injury and the older trauma patient: a 20 year review of suicide attempts and outcomes. Eur Geriatr Med 2021; 13:119-125. [PMID: 34542844 PMCID: PMC8450697 DOI: 10.1007/s41999-021-00561-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 09/08/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Older patients (Older) have complex health management needs often requiring additional resources. Mental health disorders are common among trauma patients, yet minimal information on older suicidal related injury and outcomes exists. A review of trauma patients with intentional self-inflicted injury at one trauma center was done to describe and identify unique elements of this cohort of patients. METHODS Trauma registry data from 2000 to 2019 were reviewed for intentional injury and data abstracted included demographics, injury severity, diagnoses, comorbidities and outcomes. Cohorts by age were compared: Older (65 +) vs Younger (< 65). Values considered significant at p ≤ 0.05. RESULTS 557 suicide attempts were identified with 9% among Older patients. Most patients were male with median age of 75 years for Older and 35 years for Younger cohort, with similar length of stay (LOS) and injury severity scores (ISS). Penetrating injury was more common among Older patients with firearm used most often, 34% vs 14% for Younger. Differences were evident between male and female Older patients with ISS 16.7 vs 5, p < 0.01 and mortality, p = 0.03. The outcome of discharge to home was significantly different between Older and Younger, 6% vs 20% (p < 0.05). A difference in mortality was evident, Older 38% vs Younger 18% (p < 0.05). CONCLUSION With the growing aging population, it is important to acknowledge the resultant increase in concomitant mental health issues and suicidality among older patients, where depression may be undiagnosed and untreated. Providing care within this cohort may reduce future attempts and lessen the burden on the health care system.
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Affiliation(s)
- Kathryn B Schaffer
- Scripps Memorial Hospital Trauma Service, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA.
| | - Tala Dandan
- Scripps Memorial Hospital Trauma Service, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
| | - Dunya Bayat
- Scripps Memorial Hospital Trauma Service, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
| | - Matthew R Castelo
- Scripps Memorial Hospital Trauma Service, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
| | - Summer H Reames
- Scripps Memorial Hospital Trauma Service, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
| | - Linda Hutkin-Slade
- Scripps Memorial Hospital Trauma Service, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
| | - Walter L Biffl
- Scripps Memorial Hospital Trauma Service, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
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19
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Biffl WL, Lu N, Schultz PR, Wang J, Castelo MR, Schaffer KB. Improving length of stay on a trauma service. Trauma Surg Acute Care Open 2021; 6:e000744. [PMID: 34527812 PMCID: PMC8395366 DOI: 10.1136/tsaco-2021-000744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 08/02/2021] [Indexed: 11/04/2022] Open
Abstract
Background Reducing length of stay (LOS) is a major healthcare initiative. While LOS is closely linked to the diagnosis and procedure in elective surgery, many additional factors influence LOS on a trauma service. We hypothesized that more standardized patient management would lead to decreased LOS. Methods Retrospective analysis of Trauma Registry data compared LOS before (PRE) and after (POST) implementation of standardized processes on a trauma service. Patients were subdivided by age (over and under 65 years). Data were compared using unpaired t-test, χ2 test and analysis of variance tests, where appropriate. Results 1613 PRE and 1590 POST patients were compared. Although age and Injury Severity Score were similar, median LOS decreased by 1 day for the group overall (p<0.0001), and for subgroups over and under the age of 65 years (p<0.0001). Older patients were discharged home 13% more often in POST, compared with 4% more for younger patients. Conclusions Improved standardization of processes on a trauma service reduced LOS in patients of all ages. A prospective study may identify specific factors associated with prolonged LOS, to allow further improvement. Level of evidence III. Study type Therapeutic/Care management.
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Affiliation(s)
- Walter L Biffl
- Trauma, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Ning Lu
- Trauma, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Peter R Schultz
- Trauma, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Jiayan Wang
- Trauma, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Matthew R Castelo
- Trauma, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
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20
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Ghneim M, Albrecht J, Brasel K, Knight A, Liveris A, Watras J, Michetti CP, Haan J, Lightwine K, Winfield RD, Adams SD, Podbielski J, Armen S, Zacko JC, Nasrallah FS, Schaffer KB, Dunn JA, Smoot B, Schroeppel TJ, Stillman Z, Cooper Z, Stein DM. Factors associated with receipt of intracranial pressure monitoring in older adults with traumatic brain injury. Trauma Surg Acute Care Open 2021; 6:e000733. [PMID: 34395918 PMCID: PMC8311332 DOI: 10.1136/tsaco-2021-000733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 06/05/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Traumatic Brain Injury (TBI) include intracranial pressure monitoring (ICPM), yet very little is known about ICPM in older adults. Our objectives were to characterize the utilization of ICPM in older adults and identify factors associated with ICPM in those who met the BTF guidelines. METHODS We analyzed data from the American Association for the Surgery of Trauma Geriatric TBI Study, a registry study conducted among individuals with isolated, CT-confirmed TBI across 45 trauma centers. The analysis was restricted to those aged ≥60. Independent factors associated with ICPM for those who did and did not meet the BTF guidelines were identified using logistic regression. RESULTS Our sample was composed of 2303 patients, of whom 66 (2.9%) underwent ICPM. Relative to Glasgow Coma Scale (GCS) score of 13 to 15, GCS score of 9 to 12 (OR 10.2; 95% CI 4.3 to 24.4) and GCS score of <9 (OR 15.0; 95% CI 7.2 to 31.1), intraventricular hemorrhage (OR 2.4; 95% CI 1.2 to 4.83), skull fractures (OR 3.6; 95% CI 2.0 to 6.6), CT worsening (OR 3.3; 95% CI 1.8 to 5.9), and neurosurgical interventions (OR 3.8; 95% CI 2.1 to 7.0) were significantly associated with ICPM. Restricting to those who met the BTF guidelines, only 43 of 240 (18%) underwent ICPM. Factors independently associated with ICPM included intraparenchymal hemorrhage (OR 2.2; 95% CI 1.0 to 4.7), skull fractures (OR 3.9; 95% CI 1.9 to 8.2), and neurosurgical interventions (OR 3.5; 95% CI 1.7 to 7.2). DISCUSSION Worsening GCS, intraparenchymal/intraventricular hemorrhage, and skull fractures were associated with ICPM among older adults with TBI, yet utilization of ICPM remains low, especially among those meeting the BTF guidelines, and potential benefits remain unclear. This study highlights the need for better understanding of factors that influence compliance with BTF guidelines and the risks versus benefits of ICPM in this population. LEVEL OF EVIDENCE Prognostic and epidemiological, level III.
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Affiliation(s)
- Mira Ghneim
- Department of Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Jennifer Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Karen Brasel
- Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Ariel Knight
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Anna Liveris
- Department of Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
- Department of Surgery, Albert Einstein School, Bronx, New York, USA
| | - Jill Watras
- Department of Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| | | | - James Haan
- Department of Trauma Services, Ascension Via Christi, Wichita, Kansas, USA
| | - Kelly Lightwine
- Department of Trauma Services, Ascension Via Christi, Wichita, Kansas, USA
| | | | - Sasha D Adams
- Department of Surgery, McGovern Medical School, Houston, Texas, USA
| | | | - Scott Armen
- Departments of Surgery and Neurosurgery, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - J Christopher Zacko
- Departments of Surgery and Neurosurgery, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Fady S Nasrallah
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Kathryn B Schaffer
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Julie A Dunn
- Trauma and Acute Care Surgery, Medical Center of the Rockies, Loveland, Colorado, USA
| | - Brittany Smoot
- Trauma and Acute Care Surgery, Medical Center of the Rockies, Loveland, Colorado, USA
| | - Thomas J Schroeppel
- Trauma and Acute Care Surgery, University of Colorado Health - South, Colorado Springs, Colorado, USA
| | - Zachery Stillman
- UCHealth Memorial Hospital Central, Colorado Springs, Colorado, USA
| | - Zara Cooper
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Deborah M Stein
- Department of Surgery, University of California, San Francisco, CA, USA
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21
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Young KN, Yeates EO, Grigorian A, Schellenberg M, Owattanapanich N, Barmparas G, Margulies D, Juillard C, Garber K, Cryer H, Tillou A, Burruss S, Penaloza-Villalobos L, Lin A, Figueras RA, Brenner M, Firek C, Costantini T, Santorelli J, Curry T, Wintz D, Biffl WL, Schaffer KB, Duncan TK, Barbaro C, Diaz G, Johnson A, Chinn J, Naaseh A, Leung A, Grabar C, Nahmias J. Drug and alcohol positivity of traumatically injured patients related to COVID-19 stay-at-home orders. Am J Drug Alcohol Abuse 2021; 47:605-611. [PMID: 34087086 DOI: 10.1080/00952990.2021.1904967] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background: COVID-19 related stay-at-home (SAH) orders created many economic and social stressors, possibly increasing the risk of drug/alcohol abuse in the community and trauma population.Objectives: Describe changes in alcohol/drug use in traumatically injured patients after SAH orders in California and evaluate demographic or injury pattern changes in alcohol or drug-positive patients.Methods: A retrospective analysis of 11 trauma centers in Southern California (1/1/2020-6/30/2020) was performed. Blood alcohol concentration, urine toxicology results, demographics, and injury characteristics were collected. Patients were grouped based on injury date - before SAH (PRE-SAH), immediately after SAH (POST-SAH), and a historical comparison (3/19/2019-6/30/2019) (CONTROL) - and compared in separate analyses. Groups were compared using chi-square tests for categorical variables and Mann-Whitney U tests for continuous variables.Results: 20,448 trauma patients (13,634 male, 6,814 female) were identified across three time-periods. The POST-SAH group had higher rates of any drug (26.2% vs. 21.6% and 24.7%, OR = 1.26 and 1.08, p < .001 and p = .035), amphetamine (10.4% vs. 7.5% and 9.3%, OR = 1.43 and 1.14, p < .001 and p = .023), tetrahydrocannabinol (THC) (13.8% vs. 11.0% and 11.4%, OR = 1.30 and 1.25, p < .001 and p < .001), and 3,4-methylenedioxy methamphetamine (MDMA) (0.8% vs. 0.4% and 0.2%, OR = 2.02 and 4.97, p = .003 and p < .001) positivity compared to PRE-SAH and CONTROL groups. Alcohol concentration and positivity were similar between groups (p > .05).Conclusion: This Southern California multicenter study demonstrated increased amphetamine, MDMA, and THC positivity in trauma patients after SAH, but no difference in alcohol positivity or blood concentration. Drug prevention strategies should continue to be adapted within and outside of hospitals during a pandemic.
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Affiliation(s)
- Kirsten N Young
- Department of Surgery, University of California, Irvine, CA, USA
| | - Eric O Yeates
- Department of Surgery, University of California, Irvine, CA, USA
| | - Areg Grigorian
- Department of Surgery, University of California, Irvine, CA, USA.,Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Morgan Schellenberg
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | | | - Galinos Barmparas
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel Margulies
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Kent Garber
- Department of Surgery, University of California, Los Angeles, CA, USA
| | - Henry Cryer
- Department of Surgery, University of California, Los Angeles, CA, USA
| | - Areti Tillou
- Department of Surgery, University of California, Los Angeles, CA, USA
| | - Sigrid Burruss
- Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | | | - Ann Lin
- Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | | | - Megan Brenner
- Riverside/Riverside University Health System Department of Surgery, University of California, Moreno Valley, CA, USA
| | - Christopher Firek
- Riverside University Health System, Comparative Effectiveness and Clinical Outcomes Research Center (CECORC), Moreno Valley, CA, USA
| | - Todd Costantini
- Department of Surgery, University of California, San Diego, CA, USA
| | | | - Terry Curry
- Department of Surgery, University of California, San Diego, CA, USA
| | - Diane Wintz
- Department of Surgery, Sharp Memorial Hospital, San Diego, CA, USA
| | - Walter L Biffl
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, CA, USA
| | - Kathryn B Schaffer
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, CA, USA
| | - Thomas K Duncan
- Department of Surgery, Ventura County Medical Center, Ventura, CA, USA
| | - Casey Barbaro
- Department of Surgery, Ventura County Medical Center, Ventura, CA, USA
| | - Graal Diaz
- Department of Surgery, Ventura County Medical Center, Ventura, CA, USA
| | - Arianne Johnson
- Department of Trauma, Santa Barbara Cottage Hospital, Cottage Health Research Institute, Santa Barbara, CA, USA
| | - Justine Chinn
- Department of Surgery, University of California, Irvine, CA, USA
| | - Ariana Naaseh
- Department of Surgery, University of California, Irvine, CA, USA
| | - Amanda Leung
- Department of Surgery, University of California, Irvine, CA, USA
| | - Christina Grabar
- Department of Surgery, University of California, Irvine, CA, USA
| | - Jeffry Nahmias
- Department of Surgery, University of California, Irvine, CA, USA
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22
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Yeates EO, Grigorian A, Schellenberg M, Owattanapanich N, Barmparas G, Margulies D, Juillard C, Garber K, Cryer H, Tillou A, Burruss S, Figueras RA, Mladenov G, Brenner M, Firek C, Costantini T, Santorelli J, Curry T, Wintz D, Biffl WL, Schaffer KB, Duncan TK, Barbaro C, Diaz G, Johnson A, Chinn J, Naaseh A, Leung A, Grabar C, Nahmias J. COVID-19 in trauma: a propensity-matched analysis of COVID and non-COVID trauma patients. Eur J Trauma Emerg Surg 2021; 47:1335-1342. [PMID: 34031703 PMCID: PMC8143988 DOI: 10.1007/s00068-021-01699-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/13/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE There is mounting evidence that surgical patients with COVID-19 have higher morbidity and mortality than patients without COVID-19. Infection is prevalent amongst the trauma population, but any effect of COVID-19 on trauma patients is unknown. We aimed to evaluate the effect of COVID-19 on a trauma population, hypothesizing increased mortality and pulmonary complications for COVID-19-positive (COVID) trauma patients compared to propensity-matched COVID-19-negative (non-COVID) patients. METHODS A retrospective analysis of trauma patients presenting to 11 Level-I and II trauma centers in California between 1/1/2019-6/30/2019 and 1/1/2020-6/30/2020 was performed. A 1:2 propensity score model was used to match COVID to non-COVID trauma patients using age, blunt/penetrating mechanism, injury severity score, Glasgow Coma Scale score, systolic blood pressure, respiratory rate, and heart rate. Outcomes were compared between the two groups. RESULTS A total of 20,448 trauma patients were identified during the study period. 53 COVID trauma patients were matched with 106 non-COVID trauma patients. COVID patients had higher rates of mortality (9.4% vs 1.9%, p = 0.029) and pneumonia (7.5% vs. 0.0%, p = 0.011), as well as a longer mean length of stay (LOS) (7.47 vs 3.28 days, p < 0.001) and intensive care unit LOS (1.40 vs 0.80 days, p = 0.008), compared to non-COVID patients. CONCLUSION This multicenter retrospective study found increased rates of mortality and pneumonia, as well as a longer LOS, for COVID trauma patients compared to a propensity-matched cohort of non-COVID patients. Further studies are warranted to validate these findings and to elucidate the underlying pathways responsible for higher mortality in COVID trauma patients.
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Affiliation(s)
- Eric O. Yeates
- Department of Surgery, University of California, Irvine (UCI), 333 The City Blvd West, Suite 1600, Orange, CA 92868-3298 USA
| | - Areg Grigorian
- Department of Surgery, University of California, Irvine (UCI), 333 The City Blvd West, Suite 1600, Orange, CA 92868-3298 USA
- Department of Surgery, University of Southern California (USC), Los Angeles, CA USA
| | - Morgan Schellenberg
- Department of Surgery, University of Southern California (USC), Los Angeles, CA USA
| | | | - Galinos Barmparas
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Daniel Margulies
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Catherine Juillard
- Department of Surgery, University of California, Los Angeles (UCLA), Los Angeles, CA USA
| | - Kent Garber
- Department of Surgery, University of California, Los Angeles (UCLA), Los Angeles, CA USA
| | - Henry Cryer
- Department of Surgery, University of California, Los Angeles (UCLA), Los Angeles, CA USA
| | - Areti Tillou
- Department of Surgery, University of California, Los Angeles (UCLA), Los Angeles, CA USA
| | - Sigrid Burruss
- Department of Surgery, Loma Linda University, Loma Linda, CA USA
| | | | - Georgi Mladenov
- Department of Surgery, Loma Linda University, Loma Linda, CA USA
| | - Megan Brenner
- Department of Surgery, University of California, Riverside/Riverside University Health System, Moreno Valley, CA USA
| | - Christopher Firek
- Comparative Effectiveness and Clinical Outcomes Research Center (CECORC), Riverside University Health System, Moreno Valley, CA USA
| | - Todd Costantini
- Department of Surgery, University of California, San Diego (UCSD), San Diego, CA USA
| | - Jarrett Santorelli
- Department of Surgery, University of California, San Diego (UCSD), San Diego, CA USA
| | - Terry Curry
- Department of Surgery, University of California, San Diego (UCSD), San Diego, CA USA
| | - Diane Wintz
- Department of Surgery, Sharp Memorial Hospital, San Diego, CA USA
| | - Walter L. Biffl
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, San Diego, CA USA
| | - Kathryn B. Schaffer
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, San Diego, CA USA
| | - Thomas K. Duncan
- Department of Surgery, Ventura County Medical Center, Ventura, CA USA
| | - Casey Barbaro
- Department of Surgery, Ventura County Medical Center, Ventura, CA USA
| | - Graal Diaz
- Department of Surgery, Ventura County Medical Center, Ventura, CA USA
| | - Arianne Johnson
- Santa Barbara Cottage Hospital, Cottage Health Research Institute, Santa Barbara, CA USA
| | - Justine Chinn
- Department of Surgery, University of California, Irvine (UCI), 333 The City Blvd West, Suite 1600, Orange, CA 92868-3298 USA
| | - Ariana Naaseh
- Department of Surgery, University of California, Irvine (UCI), 333 The City Blvd West, Suite 1600, Orange, CA 92868-3298 USA
| | - Amanda Leung
- Department of Surgery, University of California, Irvine (UCI), 333 The City Blvd West, Suite 1600, Orange, CA 92868-3298 USA
| | - Christina Grabar
- Department of Surgery, University of California, Irvine (UCI), 333 The City Blvd West, Suite 1600, Orange, CA 92868-3298 USA
| | - Jeffry Nahmias
- Department of Surgery, University of California, Irvine (UCI), 333 The City Blvd West, Suite 1600, Orange, CA 92868-3298 USA
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Dandan IS, Tominaga GT, Zhao FZ, Schaffer KB, Nasrallah FS, Gawlik M, Bayat D, Dandan TH, Biffl WL. Trauma resource pit stop: increasing efficiency in the evaluation of lower severity trauma patients. Trauma Surg Acute Care Open 2021; 6:e000670. [PMID: 34013050 PMCID: PMC8094379 DOI: 10.1136/tsaco-2020-000670] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 04/08/2021] [Accepted: 04/15/2021] [Indexed: 11/04/2022] Open
Abstract
Background Overtriage of trauma patients is unavoidable and requires effective use of hospital resources. A 'pit stop' (PS) was added to our lowest tier trauma resource (TR) triage protocol where the patient stops in the trauma bay for immediate evaluation by the emergency department (ED) physician and trauma nursing. We hypothesized this would allow for faster diagnostic testing and disposition while decreasing cost. Methods We performed a before/after retrospective comparison after PS implementation. Patients not meeting trauma activation (TA) criteria but requiring trauma center evaluation were assigned as a TR for an expedited PS evaluation. A board-certified ED physician and trauma/ED nurse performed an immediate assessment in the trauma bay followed by performance of diagnostic studies. Trauma surgeons were readily available in case of upgrade to TA. We compared patient demographics, Injury Severity Score, time to physician evaluation, time to CT scan, hospital length of stay, and in-hospital mortality. Comparisons were made using 95% CI for variance and SD and unpaired t-tests for two-tailed p values, with statistical difference, p<0.05. Results There were 994 TAs and 474 TRs in the first 9 months after implementation. TR's preanalysis versus postanalysis of the TR group shows similar mean door to physician evaluation times (6.9 vs. 8.6 minutes, p=0.1084). Mean door to CT time significantly decreased (67.7 vs. 50 minutes, p<0.001). 346 (73%) TR patients were discharged from ED; 2 (0.4%) were upgraded on arrival. When admitted, TR patients were older (61.4 vs. 47.2 years, p<0.0001) and more often involved in a same-level fall (59.5% vs. 20.1%, p<0.0001). Undertriage was calculated using the Cribari matrix at 3.2%. Discussion PS implementation allowed for faster door to CT time for trauma patients not meeting activation criteria without mobilizing trauma team resources. This approach is safe, feasible, and simultaneously decreases hospital cost while improving allocation of trauma team resources. Level of evidence Level II, economic/decision therapeutic/care management study.
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Affiliation(s)
- Imad S Dandan
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Gail T Tominaga
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Frank Z Zhao
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Kathryn B Schaffer
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Fady S Nasrallah
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Melanie Gawlik
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Dunya Bayat
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Tala H Dandan
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Walter L Biffl
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
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Biffl WL, Zhao FZ, Morse B, McNutt M, Lees J, Byerly S, Weaver J, Callcut R, Ball CG, Nahmias J, West M, Jurkovich GJ, Todd SR, Bala M, Spalding C, Kornblith L, Castelo M, Schaffer KB, Moore EE. A multicenter trial of current trends in the diagnosis and management of high-grade pancreatic injuries. J Trauma Acute Care Surg 2021; 90:776-786. [PMID: 33797499 DOI: 10.1097/ta.0000000000003080] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Outcomes following pancreatic trauma have not improved significantly over the past two decades. A 2013 Western Trauma Association algorithm highlighted emerging data that might improve the diagnosis and management of high-grade pancreatic injuries (HGPIs; grades III-V). We hypothesized that the use of magnetic resonance cholangiopancreatography, pancreatic duct stenting, operative drainage versus resection, and nonoperative management of HGPIs increased over time. METHODS Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018 was performed. Data were analyzed by grade and time period (PRE, 2010-2013; POST, 2014-2018) using various statistical tests where appropriate. RESULTS Thirty-two centers reported data on 515 HGPI patients. A total of 270 (53%) had penetrating trauma, and 58% went directly to the operating room without imaging. Eighty-nine (17%) died within 24 hours. Management and outcomes of 426 24-hour survivors were evaluated. Agreement between computed tomography and operating room grading was 38%. Magnetic resonance cholangiopancreatography use doubled in grade IV/V injuries over time but was still low.Overall HGPI treatment and outcomes did not change over time. Resection was performed in 78% of grade III injuries and remained stable over time, while resection of grade IV/V injuries trended downward (56% to 39%, p = 0.11). Pancreas-related complications (PRCs) occurred more frequently in grade IV/V injuries managed with drainage versus resection (61% vs. 32%, p = 0.0051), but there was no difference in PRCs for grade III injuries between resection and drainage.Pancreatectomy closure had no impact on PRCs. Pancreatic duct stenting increased over time in grade IV/V injuries, with 76% used to treat PRCs. CONCLUSION Intraoperative and computed tomography grading are different in the majority of HGPI cases. Resection is still used for most patients with grade III injuries; however, drainage may be a noninferior alternative. Drainage trended upward for grade IV/V injuries, but the higher rate of PRCs calls for caution in this practice. LEVEL OF EVIDENCE Retrospective diagnostic/therapeutic study, level III.
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Affiliation(s)
- Walter L Biffl
- From the Scripps Memorial Hospital La Jolla (WLB, FZZ, MC, KBS), La Jolla, CA; Maine Medical Center (BM), Portland, ME; Memorial Hermann Hospital (MM), Houston, TX; University of Oklahoma (JL), Oklahoma City, OK; Ryder Trauma Center (SB), Miami, FL; University of California-San Diego (JW), San Diego, CA; San Francisco General Hospital (RC, LK), San Francisco, CA; University of Calgary (CCGB), Calgary, Alberta, Canada; University of California-Irvine (JN), Irvine, CA; North Memorial Health Hospital (MW), Robbinsdale, MN; University of California-Davis (GJJ), Sacramento, CA; Grady Memorial Hospital (SRT), Atlanta, GA; Hadassah- Hebrew University Medical Center (MB), Jerusalem, Israel; Grant Medical Center (CS), Columbus, OH; Ernest E. Moore Shock Trauma Center at Denver Health (EEM), Denver, CO
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Yeates EO, Grigorian A, Barrios C, Schellenberg M, Owattanapanich N, Barmparas G, Margulies D, Juillard C, Garber K, Cryer H, Tillou A, Burruss S, Penaloza-Villalobos L, Lin A, Figueras RA, Brenner M, Firek C, Costantini T, Santorelli J, Curry T, Wintz D, Biffl WL, Schaffer KB, Duncan TK, Barbaro C, Diaz G, Johnson A, Chinn J, Naaseh A, Leung A, Grabar C, Nahmias J. Changes in traumatic mechanisms of injury in Southern California related to COVID-19: Penetrating trauma as a second pandemic. J Trauma Acute Care Surg 2021; 90:714-721. [PMID: 33395031 PMCID: PMC7996056 DOI: 10.1097/ta.0000000000003068] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/04/2020] [Accepted: 12/18/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND The COVID-19 pandemic resulted in a statewide stay-at-home (SAH) order in California beginning March 19, 2020, forcing large-scale behavioral changes and taking an emotional and economic toll. The effects of SAH orders on the trauma population remain unknown. We hypothesized an increase in rates of penetrating trauma, gunshot wounds, suicide attempts, and domestic violence in the Southern California trauma population after the SAH order. METHODS A multicenter retrospective analysis of all trauma patients presenting to 11 American College of Surgeons levels I and II trauma centers spanning seven counties in California was performed. Demographic data, injury characteristics, clinical data, and outcomes were collected. Patients were divided into three groups based on injury date: before SAH from January 1, 2020, to March 18, 2020 (PRE), after SAH from March 19, 2020, to June 30, 2020 (POST), and a historical control from March 19, 2019, to June 30, 2019 (CONTROL). POST was compared with both PRE and CONTROL in two separate analyses. RESULTS Across all periods, 20,448 trauma patients were identified (CONTROL, 7,707; PRE, 6,022; POST, 6,719). POST had a significantly increased rate of penetrating trauma (13.0% vs. 10.3%, p < 0.001 and 13.0% vs. 9.9%, p < 0.001) and gunshot wounds (4.5% vs. 2.4%, p = 0.002 and 4.5% vs. 3.7%, p = 0.025) compared with PRE and CONTROL, respectively. POST had a suicide attempt rate of 1.9% and a domestic violence rate of 0.7%, which were similar to PRE (p = 0.478, p = 0.514) and CONTROL (p = 0.160, p = 0.618). CONCLUSION This multicenter Southern California study demonstrated an increased rate of penetrating trauma and gunshot wounds after the COVID-19 SAH orders but no difference in attempted suicide or domestic violence rates. These findings may provide useful information regarding resource utilization and a target for societal intervention during the current or future pandemic(s). LEVEL OF EVIDENCE Epidemiological, level IV.
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Yeates EO, Juillard C, Grigorian A, Schellenberg M, Owattanapanich N, Barmparas G, Margulies D, Garber K, Cryer H, Tillou A, Burruss S, Penaloza-Villalobos L, Lin A, Figueras RA, Brenner M, Firek C, Costantini T, Santorelli J, Curry T, Wintz D, Biffl WL, Schaffer KB, Duncan TK, Barbaro C, Diaz G, Johnson A, Chinn J, Naaseh A, Leung A, Grabar C, Yeates TO, Nahmias J. The coronavirus disease 2019 (COVID-19) stay-at-home order's unequal effects on trauma volume by insurance status in Southern California. Surgery 2021; 170:962-968. [PMID: 33849732 DOI: 10.1016/j.surg.2021.02.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/02/2021] [Accepted: 02/22/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND The rapid spread of coronavirus disease 2019 in the United States led to a variety of mandates intended to decrease population movement and "flatten the curve." However, there is evidence some are not able to stay-at-home due to certain disadvantages, thus remaining exposed to both coronavirus disease 2019 and trauma. We therefore sought to identify any unequal effects of the California stay-at-home orders between races and insurance statuses in a multicenter study utilizing trauma volume data. METHODS A posthoc multicenter retrospective analysis of trauma patients presenting to 11 centers in Southern California between the dates of January 1, 2020, and June 30, 2020, and January 1, 2019, and June 30, 2019, was performed. The number of trauma patients of each race/insurance status was tabulated per day. We then calculated the changes in trauma volume related to stay-at-home orders for each race/insurance status and compared the magnitude of these changes using statistical resampling. RESULTS Compared to baseline, there was a 40.1% drop in total trauma volume, which occurred 20 days after stay-at-home orders. During stay-at-home orders, the average daily trauma volume of patients with Medicaid increased by 13.7 ± 5.3%, whereas the volume of those with Medicare, private insurance, and no insurance decreased. The average daily trauma volume decreased for White, Black, Asian, and Latino patients with the volume of Black and Latino patients dropping to a similar degree compared to White patients. CONCLUSION This retrospective multicenter study demonstrated that patients with Medicaid had a paradoxical increase in trauma volume during stay-at-home orders, suggesting that the most impoverished groups remain disproportionately exposed to trauma during a pandemic, further exacerbating existing health disparities.
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Affiliation(s)
- Eric O Yeates
- University of California, Irvine (UCI), Department of Surgery, Orange, CA
| | - Catherine Juillard
- University of California, Los Angeles (UCLA), Department of Surgery, Los Angeles, CA
| | - Areg Grigorian
- University of California, Irvine (UCI), Department of Surgery, Orange, CA; University of Southern California (USC), Department of Surgery, Los Angeles, CA
| | - Morgan Schellenberg
- University of Southern California (USC), Department of Surgery, Los Angeles, CA
| | | | | | - Daniel Margulies
- Cedars-Sinai Medical Center, Department of Surgery, Los Angeles, CA
| | - Kent Garber
- University of California, Los Angeles (UCLA), Department of Surgery, Los Angeles, CA
| | - Henry Cryer
- University of California, Los Angeles (UCLA), Department of Surgery, Los Angeles, CA
| | - Areti Tillou
- University of California, Los Angeles (UCLA), Department of Surgery, Los Angeles, CA
| | - Sigrid Burruss
- Loma Linda University, Department of Surgery, Loma Linda, CA
| | | | - Ann Lin
- Loma Linda University, Department of Surgery, Loma Linda, CA
| | | | - Megan Brenner
- University of California, Riverside/Riverside University Health System Department of Surgery, Moreno Valley, CA
| | - Christopher Firek
- Comparative Effectiveness and Clinical Outcomes Research Center (CECORC), Riverside University Health System, Moreno Valley, CA
| | - Todd Costantini
- University of California, San Diego (UCSD), Department of Surgery, San Diego, CA
| | - Jarrett Santorelli
- University of California, San Diego (UCSD), Department of Surgery, San Diego, CA
| | - Terry Curry
- University of California, San Diego (UCSD), Department of Surgery, San Diego, CA
| | - Diane Wintz
- Sharp Memorial Hospital, Department of Surgery, San Diego, CA
| | - Walter L Biffl
- Scripps Memorial Hospital La Jolla, Trauma Department, La Jolla, CA
| | | | - Thomas K Duncan
- Ventura County Medical Center, Department of Surgery, Ventura, CA
| | - Casey Barbaro
- Ventura County Medical Center, Department of Surgery, Ventura, CA
| | - Graal Diaz
- Ventura County Medical Center, Department of Surgery, Ventura, CA
| | - Arianne Johnson
- Santa Barbara Cottage Hospital, Cottage Health Research Institute, Santa Barbara, CA
| | - Justine Chinn
- University of California, Irvine (UCI), Department of Surgery, Orange, CA
| | - Ariana Naaseh
- University of California, Irvine (UCI), Department of Surgery, Orange, CA
| | - Amanda Leung
- University of California, Irvine (UCI), Department of Surgery, Orange, CA
| | - Christina Grabar
- University of California, Irvine (UCI), Department of Surgery, Orange, CA
| | - Todd O Yeates
- University of California, Los Angeles (UCLA), Department of Chemistry and Biochemistry, Los Angeles, CA
| | - Jeffry Nahmias
- University of California, Irvine (UCI), Department of Surgery, Orange, CA.
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Schaffer KB, Wang J, Nasrallah FS, Bayat D, Dandan T, Ferkich A, Biffl WL. Disparities in triage and management of the homeless and the elderly trauma patient. Inj Epidemiol 2020; 7:39. [PMID: 32654664 PMCID: PMC7358191 DOI: 10.1186/s40621-020-00262-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 05/22/2020] [Indexed: 11/10/2022] Open
Abstract
Background Trauma systems are designed to provide specialized treatment for the most severely injured. As populations change, it is imperative for trauma centers to remain dynamic to provide the best care to all members of the community. Methods A retrospective review of all trauma patients treated at one Level II trauma center in Southern CA over 5 years. Three cohorts of patients were studied: geriatric (> 65 years), the homeless, and all other trauma patients. Triage, hospitalization, and outcomes were collected and analyzed. Results Of 8431 patients treated, 30% were geriatric, 3% homeless and 67% comprised all other patients. Trauma activation criteria was met for 84% of all other trauma patients, yet only 61% of homeless and geriatric patients combined. Injury mechanism for homeless included falls (38%), pedestrian/bicycle related (27%) and assaults (24%), often while under the influence of alcohol and drugs. Average length of hospital stay (LOS) was greater for homeless and geriatric patients and frequently attributed to discharge planning challenges. Both the homeless and geriatric groups demonstrated increased complications, comorbidities, and death rates. Conclusions Homeless trauma patients reflect similar challenges in care as with the elderly, requiring additional resources and more complex case management. It is prudent to identify and understand the issues surrounding patients transported to our trauma center requiring a higher level of care yet are under-triaged upon arrival to the Emergency Department. Although a monthly review is done for all under-triaged patients, and geriatric patients are acknowledged to be a cohort continually having delays, the homeless cohort continues to be under-triaged. The admitted homeless trauma patient has similar complex case management issues as the elderly related to pre-existing health issues and challenges with discharge planning, both which can add to longer lengths of hospital stay as compared to other trauma patients. Given the lack of social support that is endemic to both populations, these cohorts represent a unique challenge to trauma centers. Further research into specialized care is required to determine best practices to address disparities evident in the homeless and elderly, and to promote health equity in marginalized populations.
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Affiliation(s)
- Kathryn B Schaffer
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA.
| | - Jiayan Wang
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
| | - Fady S Nasrallah
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
| | - Dunya Bayat
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
| | - Tala Dandan
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
| | - Anthony Ferkich
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
| | - Walter L Biffl
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
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Schaffer KB, Schwendig G, Nasrallah F, Wang J, Kraus JF. Falls from a balcony while intoxicated: a new injury trend among young adults? Inj Epidemiol 2019; 6:4. [PMID: 31245253 PMCID: PMC6582677 DOI: 10.1186/s40621-019-0181-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 01/30/2019] [Indexed: 11/19/2022] Open
Abstract
Background Unintentional falls from heights, including balconies, result in life threatening traumatic injury. Alcohol, when combined with environmental factors and poor judgement, can potentially lead to fatal outcomes. One trauma center’s registry identified a group of young adults falling from balconies and we investigated the role of alcohol. Methods Hospital trauma service admissions from 2010 through 2017 were reviewed for unintentional falls from heights. Suicide attempts and unintentional falls off ladders or roofs were excluded. Data were obtained from trauma registry and medical record review, as well as social work service interviews. Results Falls from heights comprised 4.8% of injuries treated at our trauma center during the eight-year study period with 98.5% admitted. Of patients admitted because of falls, 10.3% (55/532) were from a balcony. The majority of this group of patients was male and 19–29 years old (67%). Of patients with a blood alcohol concentration (BAC) determination, 62% had a positive BAC upon hospital admission with an average of 0.20 g/dL among those 34 patients. No gender differences were evident for alcohol use. Seven of the eight patients under the legal drinking age of 21 years were a subgroup with high alcohol use as compared with patients 21 years and older (p = 0.099). Ninety-four percent of falls occurred at residential locations such as dormitories or apartment complexes, often during a social event. Backward falls off railings and attempts to jump to adjoining balconies were common. Head, thorax/abdomen, and extremity fractures were common, with an average injury severity score (ISS) of 16. Average length of hospital stay was 8 days. Most patients (67%) were discharged home after hospital stay, but 21% were transferred to inpatient rehabilitation or skilled nursing facilities. There were two deaths. Conclusions Falls from balconies among young adults occur in our area yet the true frequency of these events remain unknown. Occurrence was most common among underage drinkers. Generalization is difficult with this small sample, yet high risk behaviors and environmental factors were evident. It is imperative that educational programs focus on this population with collaborative prevention efforts focused on the dangers of, and increased risk of injury associated with the balcony environment.
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Affiliation(s)
- Kathryn B Schaffer
- 1Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA USA
| | - Gary Schwendig
- 1Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA USA
| | - Fady Nasrallah
- 1Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA USA
| | - Jiayan Wang
- 1Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA USA
| | - Jess F Kraus
- 2Department of Epidemiology, UCLA, Los Angeles, CA USA
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Tominaga GT, Dandan IS, Schaffer KB, Nasrallah F, Gawlik R N M, Kraus JF. Trauma resource designation: an innovative approach to improving trauma system overtriage. Trauma Surg Acute Care Open 2017; 2:e000102. [PMID: 29766100 PMCID: PMC5877913 DOI: 10.1136/tsaco-2017-000102] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 05/29/2017] [Accepted: 06/05/2017] [Indexed: 01/07/2023] Open
Abstract
Background Effective triage of injured patients is often a balancing act for trauma systems. As healthcare reimbursements continue to decline,1 innovative programs to effectively use hospital resources are essential in maintaining a viable trauma system. The objective of this pilot intervention was to evaluate a new triage model using 'trauma resource' (TR) as a new category in our existing Tiered Trauma Team Activation (TA) approach with hopes of decreasing charges without adversely affecting patient outcome. Methods Patients at one Level II Trauma Center (TC) over seven months were studied. Patients not meeting American College of Surgeons criteria for TA were assigned as TR and transported to a designated TC for expedited emergency department (ED) evaluation. Such patients were immediately assessed by a trauma nurse, ED nurse, and board-certified ED physician. Diagnostic studies were ordered, and the trauma surgeon (TS) was consulted as needed. Demographics, injury mechanism, time to physician evaluation, time to CT scan, time to disposition, hospital length of stay (LOS), and in-hospital mortality were analyzed. Results Fifty-two of the 318 TR patients were admitted by the TS and were similar to TA patients (N=684) with regard to gender, mean Injury Severity Score, mean LOS and in-hospital mortality, but were older (60.4 vs 47.2 years, p<0.0001) and often involved in a fall injury (52% vs 35%, p=0.0170). TR patients had increased door to physician evaluation times (11.5 vs 0.4 minutes, p<0.0001) and increased door to CT times (76.2 vs 25.9 minutes, p<0.0001). Of the 313 TR patients, 52 incurred charges totaling US$253 708 compared with US$1 041 612 if patients had been classified as TA. Conclusions Designating patients as TR prehospital with expedited evaluation by an ED physician and early TS consultation resulted in reduced use of resources and lower hospital charges without increase in LOS, time to disposition or in-hospital mortality. Level of evidence Level II.
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Affiliation(s)
- Gail T Tominaga
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Imad S Dandan
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Kathryn B Schaffer
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Fady Nasrallah
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Melanie Gawlik R N
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Jess F Kraus
- Department of Epidemiology, University of California Los Angeles, Carlsbad, California, USA
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Abstract
OBJECTIVE To provide new information on properties of skateboarders who were hospital admitted with head injuries with details of the injuries including region of head impact. METHODS Hospital records of patients aged 15 and older with a skateboard injury admitted to one Level II Trauma Centre during a 10-year period were reviewed. Data on demographic, exposure, severity, diagnostic and clinical factors for patients with head injury (HI) and without HI (N-HI) were compared analytically. RESULTS While there were no differences for patients with HI and N-HI by age, gender, mechanism of injury or alcohol use, patients with HI were more severely injured. Although significantly more head impacts occurred to the occipital region of the head, haematomas and/or contusions were much more likely to occur in the frontal region of the brain. Acute neurosurgical intervention was needed in 14% of HI skateboarders. CONCLUSION Skateboarding is not an innocuous recreational activity, with head injury present in 75% of patients who were hospital-admitted. Pre-hospital treatment protocols should be aware of this growing injured population. Falls while on a skateboard lead to impacts to the back of head with a contra-coup brain injury resulting in severe and sometimes fatal outcomes. The very low prevalence of helmet use among skateboarders with head injuries indicates that greater efforts should be directed toward incentives for their use.
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Affiliation(s)
- Gail T Tominaga
- Scripps Memorial Hospital La Jolla Trauma Service , La Jolla, CA , USA and
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Tominaga GT, Schaffer KB, Dandan IS, Kraus JF. Epidemiological and clinical features of an older high-risk population of skateboarders. Injury 2013; 44:645-9. [PMID: 22480946 DOI: 10.1016/j.injury.2012.01.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 01/19/2012] [Accepted: 01/23/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND Skateboard injuries have been described in the media and scientific journals as a problem prevalent among children and adolescents. Skateboarding popularity has continued to grow since the 1970s with ridership increasing to include all age groups. Recently, surgeons at one trauma centre at an urban hospital noted an increase in the number of older skateboarders with life-threatening injuries. We hypothesise that the clinical and epidemiological features of skateboard-related injuries from one trauma centre (TC) will be different from injured skateboarders identified in the U.S. National Trauma Data Bank (NTDB). We also sought to identify factors related to poor outcomes in the TC and NTDB patient groups. METHODS Two injured skateboarder patient groups were identified and compared using proportional morbidity odds ratios (PMORs) and multivariable methods to estimate differences among factors common to both groups of patients. Clinical and demographic features were evaluated for hospital admitted patients injured whilst riding a skateboard. Chi-square tests, PMORs and logistic regression were used to determine outcome differences between patients in both groups. RESULTS Patients in the TC group were on average older, with higher Injury Severity Scores (ISS), more head injuries requiring neurosurgical intervention, longer ICU and hospital stays, and injured more frequently on local streets than patients in the NTDB series. Poor outcomes in the TC group were related to moderate or severe head injuries and presence of a head/face injury. For NTDB patients, a GCS of <13, a head/face injury and an ISS of 25+ were related to poor outcomes. CONCLUSIONS From our Trauma Centre we describe an older injured skateboarding population, clinically and epidemiologically different from injured patients identified in the NTDB as well as those described in the literature. The greater severity of injury, including traumatic brain injury, has direct implications for preventive and educational measures and the planning of emergency surgical response.
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Affiliation(s)
- Gail T Tominaga
- Scripps Memorial Hospital, Trauma Service, La Jolla, CA 92037, USA.
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Karmy-Jones R, Jurkovich GJ, Velmahos GC, Burdick T, Spaniolas K, Todd SR, McNally M, Jacoby RC, Link D, Janczyk RJ, Ivascu FA, McCann M, Obeid F, Hoff WS, McQuay N, Tieu BH, Schreiber MA, Nirula R, Brasel K, Dunn JA, Gambrell D, Huckfeldt R, Harper J, Schaffer KB, Tominaga GT, Vinces FY, Sperling D, Hoyt D, Coimbra R, Rosengart MR, Forsythe R, Cothren C, Moore EE, Haut ER, Hayanga AJ, Hird L, White C, Grossman J, Nagy K, Livaudais W, Wood R, Zengerink I, Kortbeek JB. Practice Patterns and Outcomes of Retrievable Vena Cava Filters in Trauma Patients: An AAST Multicenter Study. ACTA ACUST UNITED AC 2007; 62:17-24; discussion 24-5. [PMID: 17215729 DOI: 10.1097/ta.0b013e31802dd72a] [Citation(s) in RCA: 177] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The purpose of this study is to describe practice patterns and outcomes of posttraumatic retrievable inferior vena caval filters (R-IVCF). METHODS A retrospective review of R-IVCFs placed during 2004 at 21 participating centers with follow up to July 1, 2005 was performed. Primary outcomes included major complications (migration, pulmonary embolism [PE], and symptomatic caval occlusion) and reasons for failure to retrieve. RESULTS Of 446 patients (69% male, 92% blunt trauma) receiving R-IVCFs, 76% for prophylactic indications and 79% were placed by interventional radiology. Excluding 33 deaths, 152 were Gunter-Tulip (G-T), 224 Recovery (R), and 37 Optease (Opt). Placement occurred 6 +/- 8 days after admission and retrieval at 50 +/- 61 days. Follow up after discharge (5.7 +/- 4.3 months) was reported in 51%. Only 22% of R-IVCFs were retrieved. Of 115 patients in whom retrieval was attempted, retrieval failed as a result of technical issues in 15 patients (10% of G-T, 14% of R, 27% of Opt) and because of significant residual thrombus within the filter in 10 patients (6% of G-T, 4% of R, 46% Opt). The primary reason R-IVCFs were not removed was because of loss to follow up (31%), which was sixfold higher (6% to 44%, p = 0.001) when the service placing the R-IVCF was not directly responsible for follow up. Complications did not correlate with mechanism, injury severity, service placing the R-IVCF, trauma volume, use of anticoagulation, age, or sex. Three cases of migration were recorded (all among R, 1.3%), two breakthrough PE (G-T 0.6% and R 0.4%) and six symptomatic caval occlusions (G-T 0, R 1%, Opt 11%) (p < 0.05 Opt versus both G-T and R). CONCLUSION Most R-IVCFs are not retrieved. The service placing the R-IVCF should be responsible for follow up. The Optease was associated with the greatest incidence of residual thrombus and symptomatic caval occlusion. The practice patterns of R-IVCF placement and retrieval should be re-examined.
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Abstract
Although the majority of work-related homicides are routinely reported in the United States, information on non-fatal events is less complete. Comprehensive surveillance of non-fatal events depends on understanding reporting trends to different agencies. This study characterizes workplace assaults reported to police and through employers in eight southern California cities. Employers' reports filed from October 1, 1994, through January 31, 1995, and police reports filed from June 1, 1994, through March 31, 1995, that involved a non-fatal workplace assault injury were included. Reports from police and employers were linked, and annualized rates combining non-duplicative reports were calculated and event characteristics compared. The combined annualized rate of workplace assault injury for the eight cities was 184.6 per 100,000 workers, which was almost twice the rate found in either reporting source individually. Police reports differed from employers' reports by industry and occupation of victim but not type of event or weapons used. Examination of multiple reporting sources for non-fatal workplace assault injuries is essential to identifying the magnitude of these events. Understanding trends in reporting is important for the effective design of prevention programs.
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Affiliation(s)
- C Peek-Asa
- Southern California Injury Prevention Research Center, UCLA School of Public Health, Los Angeles, Calif, USA
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34
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Abstract
Acute low back injuries are described in a cohort of about 31,000 material handlers employed in all Home Depot, Inc., retail stores in California from 1990 through 1994. With over 87 million work hours, incidence density rates, rate ratios, and confidence intervals are given by age, sex, length of employment, and job-lifting requirements. Injuries are further described by lost work days, activity at time of injury, work restrictions, and time frames. The unadjusted low back injury rate per million work hours was 1.6 times higher for men compared with women, and rates were highest for those less than 25 years of age, those with less than 2 years of current job experience, and employees with the greatest materials lifting and handling job requirements. These findings in unadjusted rates and rate ratios persisted when each was adjusted through a Poisson regression model, with the exception of sex. The adjusted risk ratio for males was reversed with significantly higher risk in females when the rate ratio was adjusted for age, lifting intensity, and length of job experience. Injuries were most commonly associated with lifting activities and, while injury occurrence was highest from 10 a.m. to 4 p.m., rates were greatest during those hours when the store was closed to retail activities. Merchandise stocking that requires heavy and frequent materials handling is done during these hours. Fewer injuries than expected were reported on weekends, days with considerably less materials handling activities.
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Affiliation(s)
- J F Kraus
- Department of Epidemiology, Southern California Injury Prevention Research Center, School of Public Health, University of California at Los Angeles 90095-1772, USA
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