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The Association Between the Timing of Initiation of Pharmacologic Venous Thromboembolism Prophylaxis with Outcomes in Burns Patients. J Burn Care Res 2023; 44:1311-1315. [PMID: 37351845 DOI: 10.1093/jbcr/irad074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
Hospitalized burn patients are at increased risk for venous thromboembolism (VTE). Guidelines regarding thromboprophylaxis in burn patients are unclear. This study aims to compare the outcomes of early versus late thromboprophylaxis initiation in burn patients. In this 3-year analysis of 2017-2019 ACS-TQIP, adult(18-64years) burn patients were identified after applying inclusion/exclusion criteria and stratified based on timing of initiation of VTE prophylaxis: Early(<24 hours of admission); Late(>24 hours). Outcomes were deep venous thrombosis(DVT), pulmonary embolism(PE), unplanned return to operating room (OR), unplanned intensive care unit (ICU) admission, post-prophylaxis packed red blood cells (PRBC) transfusion, and mortality. Nine thousand two hundred and seventy-two patients were identified. Overall, median age was 41years, 71.5% were male, and median[IQR] injury severity score was 3[1-8]. 53% had second-degree burns, and 80% had less than 40% of total body surface area affected. Median time to thromboprophylaxis initiation was 11[6-20.6]hours. Overall VTE rate was 0.9% (DVT-0.7%, PE-0.2%). On univariable analysis, early prophylaxis group had lower rates of DVT(0.6% vs 1.1%, P = .025), and PE(0.1% vs 0.6%, P < .001). On multivariable regression, late prophylaxis was associated with 1.8 times higher odds of DVT (aOR = 1.8, 95% CI = 1.04-3.11, P = .03), 4.8 times higher odds of PE(aOR = 4.8, 95% CI = 1.9-11.9, P < .001), and 2 times higher odds of unplanned ICU admission(aOR = 2.1, 95% CI = 1.4-3.1, P < .001). Furthermore, early thromboprophylaxis was not associated with increased odds of post-prophylaxis PRBC transfusion(aOR = 1.1, 95% CI = 0.8-1.4, P = .4), and mortality(aOR = 0.68, 95% CI = 0.4-1.1, P = .13). Early VTE prophylaxis in burn patients is associated with decreased rates of DVT and PE, without increasing the risk of bleeding and mortality. VTE prophylaxis may be initiated within 24 hours of admission to reduce VTE in this high-risk patient population.
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Dealing with the elder abuse epidemic: Disparities in interventions against elder abuse in trauma centers. J Am Geriatr Soc 2023; 71:1735-1748. [PMID: 36876983 DOI: 10.1111/jgs.18286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 01/17/2023] [Accepted: 01/24/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Elder abuse is a major cause of injury, morbidity, and death. We aimed to identify the factors associated with interventions against suspected physical abuse in older adults. METHODS Analysis of the 2017-2018 ACS TQIP. All trauma patients ≥60 years with an abuse report for suspected physical abuse were included. Patients with missing information on abuse interventions were excluded. Outcomes were rates of abuse investigation initiation following an abuse report and change of caregiver at discharge among survivors with an abuse investigation initiated. Multivariable regression analyses were performed. RESULTS Of 727,975 patients, 1405 (0.2%) had an abuse report. Patients with an abuse report were younger (mean, 72 vs 75, p < 0.001), and more likely to be females (57% vs 53%, p = 0.007), Hispanic (11% vs 6%, p < 0.001), Black (15% vs 7%, p < 0.001), suffer from dementia (18% vs 11%, p < 0.001), functional disability (19% vs 15%, p < 0.001), have a positive admission drug screen (9% vs 5%, p < 0.001) and had a higher ISS (median [IQR], 9 [4-16] vs 6 [3-10], p < 0.001). Perpetrators were members of the immediate/step/extended family in 91% of cases. Among patients with an abuse report, 1060 (75%) had abuse investigations initiated. Of these, 227 (23%) resulted in a change of caregiver at discharge. On multivariate analysis for abuse investigation initiation, male gender, private insurance, and management at non-level I trauma centers were associated with lower adjusted odds (p < 0.05), while Hispanic ethnicity, positive admission drug screen, and penetrating injury were associated with higher adjusted odds (p < 0.05). On multivariate analysis for change of caregiver, male gender, and private insurance were associated with lower adjusted odds (p < 0.05), while functional disability and dementia were associated with higher adjusted odds (p < 0.05). CONCLUSIONS Significant gender, ethnic, and socioeconomic disparities exist in the management of physical abuse of older adults. Further studies are warranted to expand on and address the contributing factors underlying these disparities. LEVEL OF EVIDENCE III. STUDY TYPE Therapeutic/Care Management.
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Minimally Invasive Surgery for Genitourinary Trauma: A Nationwide Outcomes-Based Analysis. J Surg Res 2023; 282:129-136. [PMID: 36272231 DOI: 10.1016/j.jss.2022.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 08/04/2022] [Accepted: 09/17/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Bladder and ureteral injuries are uncommon in trauma patients but are associated with increased morbidity and mortality. Patients presenting with such injuries may undergo either open surgical repair or laparoscopic repair. We aimed to compare outcomes of open surgical approach and laparoscopy in trauma patients with isolated bladder and ureteral injury. We hypothesized that laparoscopy is associated with improved outcomes. METHODS We performed a 2017 review of American College of Surgeons Trauma Quality Improvement Program and identified trauma patients with bladder and ureteral injury who underwent open surgical repair or laparoscopy. A 1:1 propensity score matching was performed adjusting for demographics, emergency department vitals (systolic blood pressure, heart rate, Glasgow Coma Scale), mechanism of injury, Injury Severity Score, each body region Abbreviated Injury Scale score, and transfusion units. Outcomes were rates of in-hospital major complications and mortality. RESULTS Of the 1,004,440 trauma patients, 384 patients (open: 192 and laparoscopy: 192) were matched and included. The mean age was 36 ± 15 y, Injury Severity Score was 27 [27-48], 77% were males, and 56% of patients had a blunt mechanism of injury, and 44% had penetrating injuries. Overall mortality was 7.3%. On univariate analysis, mortality was lower in the open group as compared to the laparoscopy group (10.4% versus 4.2%, P = 0.019) and survivor-only hospital length of stay was longer in the open group (8 [8-9] versus 7 [5-11], P = 0.008). There was no difference in overall major complications (23% versus 21%, P = 0.621). On multivariate analysis, open surgical repair was independently associated with lower odds of mortality (adjusted odds ratio: 0.405, 95% confidence interval: [0.17-0.95], P-value = 0.038) CONCLUSIONS: In our analysis open surgical repair of bladder and ureteral injuries was associated with lower mortality with other outcomes being similar when compared to laparoscopy. Laparoscopic surgical repair may not have an advantage over the open surgical repair for bladder and ureteral injuries. Further prospective studies are needed to delineate the ideal surgical approach for these injuries.
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Association Between Hemorrhage Control Interventions and Mortality in US Trauma Patients With Hemodynamically Unstable Pelvic Fractures. JAMA Surg 2023; 158:63-71. [PMID: 36449300 PMCID: PMC9713682 DOI: 10.1001/jamasurg.2022.5772] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/09/2022] [Indexed: 12/02/2022]
Abstract
Importance Management of hemodynamically unstable pelvic fractures remains a challenge. Hemostatic interventions are used alone or in combination. There is a paucity of data on the association between the pattern of hemorrhage control interventions and outcomes after a severe pelvic fracture. Objective To characterize clinical outcomes and study the patterns of hemorrhage control interventions in hemodynamically unstable pelvic fractures. Design, Setting, and Participants In this cohort study, a retrospective review was performed of data from the 2017 American College of Surgeons Trauma Quality Improvement Program database, a national multi-institutional database of trauma patients in the United States. Adult patients (aged ≥18 years) with pelvic fractures who received early transfusions (≥4 units of packed red blood cells in 4 hours) and underwent intervention for pelvic hemorrhage control were identified. Use and order of preperitoneal pelvic packing (PP), pelvic angioembolization (AE), and resuscitative endovascular balloon occlusion of the aorta (REBOA) in zone 3 were examined and compared against the primary outcome of mortality. The associations between intervention patterns and mortality, complications, and 24-hour transfusions were further examined by backward stepwise regression analyses. Data analyses were performed in September 2021. Main Outcomes and Measures Primary outcomes were rates of 24-hour, emergency department, and in-hospital mortality. Secondary outcomes were major in-hospital complications. Results A total of 1396 patients were identified. Mean (SD) age was 47 (19) years, 975 (70%) were male, and the mean (SD) lowest systolic blood pressure was 71 (25) mm Hg. The median (IQR) Injury Severity Score was 24 (14-34), with a 24-hour mortality of 217 patients (15.5%), ED mortality of 10 patients (0.7%), in-hospital mortality of 501 patients (36%), and complication rate of 574 patients (41%). Pelvic AE was the most used intervention (774 [55%]), followed by preperitoneal PP (659 [47%]) and REBOA zone 3 (126 [9%]). Among the cohort, 1236 patients (89%) had 1 intervention, 157 (11%) had 2 interventions, and 3 (0.2%) had 3 interventions. On regression analyses, only pelvic AE was associated with a mortality reduction (odds ratio [OR], 0.62; 95% CI, 0.47 to 0.82; P < .001). Preperitoneal PP was associated with increased odds of complications (OR, 1.39; 95% CI, 1.07 to 1.80; P = .01). Increasing number of interventions was associated with increased 24-hour transfusions (β = +5.4; 95% CI, +3.5 to +7.5; P < .001) and mortality (OR, 1.57; 95% CI, 1.05 to 2.37; P = .03), but not with complications. Conclusions and Relevance This study found that among patients with pelvic fracture who received early transfusions and at least 1 invasive pelvic hemorrhage control intervention, more than 1 in 3 died, despite the availability of advanced hemorrhage control interventions. Only pelvic AE was associated with a reduction in mortality.
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The Known Risk of Thromboembolism in Pregnant Trauma Patients, or So We Thought? J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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The small (14 Fr) percutaneous catheter (P-CAT) versus large (28-32 Fr) open chest tube for traumatic hemothorax: A multicenter randomized clinical trial. J Trauma Acute Care Surg 2021; 91:809-813. [PMID: 33843831 DOI: 10.1097/ta.0000000000003180] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The traditional treatment of traumatic hemothorax (HTX) has been an insertion of a large-bore 36- to 40-Fr chest tube. Our previous single-center randomized controlled trial (RCT) had shown that 14-Fr percutaneous catheters (PCs) (pigtail) were equally as effective as chest tube. We performed a multicenter RCT, hypothesizing that PCs are as equally effective as chest tubes in the management of patients with traumatic HTX (NCT03546764). METHODS We performed a multi-institution prospective RCT comparing 14-Fr PCs with 28- to 32-Fr chest tubes in the management of patients with traumatic HTX from July 2015 to September 2020. We excluded patients who were in extremis and required emergent tube placement and those who refused to participate. The primary outcome was failure rate, defined as a retained HTX requiring a second intervention. Secondary outcomes included daily drainage output, tube days, intensive care unit and hospital length of stay, and insertion perception experience (IPE) score on a scale of 1 to 5 (1, tolerable experience; 5, worst experience). Unpaired Student's t test, χ2, and Wilcoxon rank sum test were used with significance set at p < 0.05. RESULTS After exclusion, 119 patients participated in the trial, 56 randomized to PCs and 63 to chest tubes. Baseline characteristics between the two groups were similar. The primary outcome, failure rate, was similar between the two groups (11% PCs vs. 13% chest tubes, p = 0.74). All other secondary outcomes were also similar, except PC patients reported lower IPE scores (median, 1: "I can tolerate it"; interquartile range, 1-2) than chest tube patients (median, 3: "It was a bad experience"; interquartile range, 2-5; p < 0.001). CONCLUSION Small caliber 14-Fr PCs are equally as effective as 28- to 32-Fr chest tubes in their ability to drain traumatic HTX with no difference in complications. Patients reported better IPE scores with PCs over chest tubes, suggesting that PCs are better tolerated. LEVEL OF EVIDENCE Therapeutic, level II.
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Abstract
Background Frailty in geriatric trauma patients is commonly associated with adverse outcomes. Racial disparities in geriatric trauma patients are previously described in the literature. We aimed to assess whether race and ethnicity influence outcomes in frail geriatric trauma patients. Methods We performed a 1-year (2017) analysis of TQIP including all geriatric (age ≥ 65 years) trauma patients. The frailty index was calculated using 11-variables and a cutoff limit of 0.27 was defined for frail status. Multivariate regression analysis was performed to control for demographics, insurance status, injury parameters, vital signs, and ICU and hospital length of stay. Results We included 41,111 frail geriatric trauma patients. In terms of race, among frail geriatric trauma patients, 35,376 were Whites and 2916 were African Americans; in terms of ethnicity, 37,122 were Non-Hispanics and 2184 were Hispanics. On regression analysis, the White race was associated with higher odds of mortality (OR, 1.5; 95% CI, 1.2–2.0; p < 0.01) and in-hospital complications (OR, 1.4; 95% CI, 1.1–1.9; p < 0.01). White patients were more likely to be discharged to SNF (OR, 1.2; 95% CI, 1.1–1.4; p = 0.03) and less likely to be discharged home (p = 0.04) compared to African Americans. Non-Hispanics were more likely to be discharged to SNF (OR, 1.3; 95% CI, 1.1–1.5; p < 0.01) and less likely to be discharged home (p < 0.01) as compared to Hispanics. No significant difference in in-hospital mortality was seen between Hispanics and Non-Hispanics. Conclusion Race and ethnicity influence outcomes in frail geriatric trauma patients. These disparities exist regardless of age, gender, injury severity, and insurance status. Further studies are needed to highlight disparities by race and ethnicity and to identify potentially modifiable risk factors in the geriatric trauma population.
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The survival benefit of low molecular weight heparin over unfractionated heparin in pediatric trauma patients. J Pediatr Surg 2021; 56:494-499. [PMID: 32883505 DOI: 10.1016/j.jpedsurg.2020.07.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/09/2020] [Accepted: 07/18/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE) prophylaxis in pediatric patients is controversial and is mainly dependent on protocols derived from adult practices. Our study aimed to compare outcomes among pediatric trauma patients who received low molecular weight heparin (LMWH) compared to those who received unfractionated heparin (UFH). METHODS We performed 2 years (2015-2016) retrospective analysis of the Pediatrics ACS-TQIP database. Pediatric trauma patients (age ≤17) who received thromboprophylaxis with either LMWH or UFH were included. Patients were stratified into three age groups. Analysis of each subgroup and the entire cohort was performed. Outcome measures included VTE events (deep vein thrombosis [DVT] and pulmonary embolism [PE]), hospital and ICU length of stay (LOS) among survivors, and mortality. Propensity score matching was used to match the two cohorts LMWH vs UFH. RESULTS A matched cohort of 1,678 pediatric trauma patients was analyzed. A significant difference in survival, DVT events, and in-hospital LOS was seen in the age groups above 9 years. Overall, the patients who received LMWH had lower mortality (1.4% vs 3.6%, p<0.01), DVT (1.7% vs 3.7%, p<0.01), and hospital LOS among survivors (7 days vs 9 days, p<0.01) compared to those who received UFH. There was no significant difference in the ICU LOS among survivors and the incidence of PE between the two groups. CONCLUSION LMWH is associated with increased survival, lower rates of DVT, and decreased hospital LOS compared to UFH among pediatric trauma patients age 10-17 years. LEVEL OF EVIDENCE Level III Prophylactic. STUDY TYPE Prophylactic.
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Managing acute uncomplicated appendicitis in frail geriatric patients: A second hit may be too much. J Trauma Acute Care Surg 2021; 90:501-506. [PMID: 33617197 DOI: 10.1097/ta.0000000000003028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Studies have proposed the use of antibiotics only in cases of acute uncomplicated appendicitis (AUA). However, there remains a paucity of data evaluating this nonoperative approach in the vulnerable frail geriatric population. The aim of this study was to examine long-term outcomes of frail geriatric patients with AUA treated with appendectomy compared with initial nonoperative management (NOP). METHODS We conducted a 1-year (2017) analysis of the Nationwide Readmissions Database and included all frail geriatric patients(age, ≥65 years) with a diagnosis of AUA. Frailty was assessed using the five-factor modified frailty index. Patients were stratified into those undergoing appendectomy at index admission (operative management) versus those receiving antibiotics only without operative intervention (NOP). Propensity score matching in a 1:1 ratio was performed adjusting for patient- and hospital-related factors. RESULTS A total of 5,562 frail geriatric patients with AUA were identified from which a matched cohort of 1,320 patients in each group was obtained. Patients in the NOP and operative management were comparable in terms of age (75.5 ± 7.7 vs. 75.5 ± 7.4 years; p = 0.882) and modified frailty index (0.4 [0.4-0.6] vs. 0.4 [0.4-0.6]; p = 0.526). Failure of NOP management was reported in 18% of patients, 95% of which eventually underwent appendectomy. Over the 6-month follow-up period, patients in the NOP group had significantly higher rates of Clostridium difficile enterocolitis (3% vs. 1%; p < 0.001), greater number of overall hospitalized days (5 [3-9] vs. 4 [2-7] days; p < 0.001), and higher overall costs (US $16,000 [12,000-25,000] vs. US $11,000 [8,000-19,000]; p < 0.001). Patients undergoing appendectomy after failed NOP had significantly higher rates of complications (20% vs. 11%; p < 0.001), mortality (4% vs. 2%; p = 0.019), and appendiceal neoplasm (3% vs. 1%; p = 0.027). CONCLUSION One in six patients failed NOP within 6 months and required appendectomy with subsequent more complications and higher mortality. Appendectomy may offer better outcomes in managing AUA in the frail geriatric population. LEVEL OF EVIDENCE Therapeutic, level IV.
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Randomized Clinical Trial of 14-French (14F) Pigtail Catheters versus 28-32F Chest Tubes in the Management of Patients with Traumatic Hemothorax and Hemopneumothorax. World J Surg 2021; 45:880-886. [PMID: 33415448 PMCID: PMC7790482 DOI: 10.1007/s00268-020-05852-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2020] [Indexed: 12/01/2022]
Abstract
Introduction Traditional management of traumatic hemothorax/hemopneumothorax (HTX/HPTX) has been insertion of large-bore 32–40 French (Fr) chest tubes (CTs). Retrospective studies have shown 14Fr percutaneous pigtail catheters (PCs) are equally effective as CTs. Our aim was to compare effectiveness between PCs and CTs by performing the first randomized controlled trial (RCT). We hypothesize PCs work equally as well as CTs in management of traumatic HTX/HPTX. Methods Prospective RCT comparing 14Fr PCs to 28–32Fr CTs for management of traumatic HTX/HPTX from 07/2015 to 01/2018. We excluded patients requiring emergency tube placement or who refused. Primary outcome was failure rate defined as retained HTX or recurrent PTX requiring additional intervention. Secondary outcomes included initial output (IO), tube days and insertion perception experience (IPE) score on a scale of 1–5 (1 = tolerable experience, 5 = worst experience). Unpaired Student’s t-test, chi-square and Wilcoxon rank-sum test were utilized with significance set at P < 0.05. Results Forty-three patients were enrolled. Baseline characteristics between PC patients (N = 20) and CT patients (N = 23) were similar. Failure rates (10% PCs vs. 17% CTs, P = 0.49) between cohorts were similar. IO (median, 650 milliliters[ml]; interquartile range[IR], 375–1087; for PCs vs. 400 ml; IR, 240–700; for CTs, P = 0.06), and tube duration was similar, but PC patients reported lower IPE scores (median, 1, “I can tolerate it”; IR, 1–2) than CT patients (median, 3, “It was a bad experience”; IR, 3–4, P = 0.001). Conclusion In patients with traumatic HTX/HPTX, 14Fr PCs were equally as effective as 28–32Fr CTs with no significant difference in failure rates. PC patients, however, reported a better insertion experience. www.ClinicalTrials.gov Registration ID: NCT02553434
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The Impact of FASTPASS: A Collaboration With Emergency Department to Improve Management of Patients With Gallbladder Disease and Acute Appendicitis. J Surg Res 2020; 260:293-299. [PMID: 33360754 DOI: 10.1016/j.jss.2020.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 10/05/2020] [Accepted: 11/01/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Efficient Emergency Department (ED) throughput depends on several factors, including collaboration and consultation with surgical services. The acute care surgery service (ACS) collaborated with ED to implement a new process termed "FASTPASS" (FP), which might improve patient-care for those with acute appendicitis and gallbladder disease. The aim of this study was to evaluate the 1-year outcome of FP. METHODS FASTPASS is a joint collaboration between ACS and ED. ED physicians were provided with a simple check-list for diagnosing young males (<50-year old) with acute appendicitis (AA) and young males or females (<50-year old) with gallbladder disease (GBD). Once ED deemed patients fit our FP check-list, patients were directly admitted (FASTPASSed) to the observation unit. The ACS then came to evaluate the patients for possible surgical intervention. We performed outcome analysis before and after the institution of the FP. Outcomes of interest were ED length of stay (LOS), time from ED to the operating room (OR) (door-to-knife), hospital LOS (HLOS), and cost. RESULTS During our 1-year study period, for those patients who underwent GBD/AA surgery, 56 (26%) GBD and 27 (26%) AA patients met FP criteria. Compared to the non-FP patients during FP period, FP halved ED LOS for GBD (7.4 ± 3.0 versus 3.5 ± 1.7 h, P < 0.001) and AA (6.7 ± 3.3 versus. 1.8 ± 1.6 h, P < 0.001). Similar outcome benefits were observed for door-to-knife time, HLOS, and costs. CONCLUSIONS In this study, the FP process improved ED throughput in a single, highly-trained ER leading to an overall improved patient care process. A future study involving multiple EDs and different disease processes may help decrease ED overcrowding and improve healthcare system efficiency.
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Number and Type of Complications Associated With Failure to Rescue in Trauma Patients. J Surg Res 2020; 254:41-48. [PMID: 32408029 DOI: 10.1016/j.jss.2020.04.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 03/28/2020] [Accepted: 04/15/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Failure to rescue (FTR) is becoming a ubiquitous metric of quality care. The aim of our study is to determine the type and number of complications associated with FTR after trauma. METHODS We reviewed the Trauma Quality Improvement Program including patients who developed complications after admission. Patients were divided as the following: "FTR" if the patient died or "rescued" if the patient did not die. Logistic regression was used to ascertain the effect of the type and number of complications on FTR. RESULTS A total of 25,754 patients were included with 972 identified as FTR. Logistic regression identified sepsis (odds ratio [OR] = 6.61 [4.72-9.27]), pneumonia (OR = 2.79 [2.15-3.64]), acute respiratory distress syndrome (OR = 4.6 [3.17-6.69]), and cardiovascular complications (OR = 24.22 [19.39-30.26]) as predictors of FTR. The odds ratio of FTR increased by 8.8 for every single increase in the number of complications. CONCLUSIONS Specific types of complications increase the odds of FTR. The overall complication burden will also increase the odds of FTR linearly. LEVEL OF EVIDENCE Level III Prognostic.
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Prospective Evaluation of Delirium in Geriatric Patients Undergoing Emergency General Surgery. J Am Coll Surg 2020; 230:758-765. [PMID: 32088308 DOI: 10.1016/j.jamcollsurg.2020.01.029] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/22/2020] [Accepted: 01/22/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND The prevalence of delirium and its impact on outcomes after emergency general surgery (EGS) remain unexplored. The aims of our study were to assess the impact of frailty on delirium and the impact of delirium on outcomes in geriatric EGS patients. STUDY DESIGN We performed a 1-year (2017) prospective cohort analysis of all geriatric (age ≥ 65 years) patients who underwent EGS. Frailty was calculated using the Emergency General Surgery-Specific Frailty Index (ESFI). Delirium was assessed using the Confusion Assessment Method (CAM). Patients were dichotomized as delirious or non-delirious. We performed regression analysis controlling for demographics, admission vitals, American Society of Anesthesiologists (ASA) score, comorbidity, and the diagnosis and type of surgery. RESULTS A total of 163 patients underwent emergency general surgery and were included. Mean age was 71 ± 7 years, and 59% were male. Overall, the incidence of postoperative delirium was 26%. Patients who developed postoperative delirium were more likely to be frail (40% vs 14%, p < 0.01), on more than 3 medications (29% vs 18%, p < 0.01), and were more likely to have 3 or more comorbidities (32% vs 21%, p < 0.01). On regression analysis, frail status (odds ratio [OR] 3.7 [2.4-4.2], p < 0.01) and receiving more than 3 medications (OR 1.3 [range 1.1-1.4], p < 0.01) were independent predictors of developing postoperative delirium. An episode of delirium was associated with longer hospital length of stay (LOS) (6 days vs 3 days, p < 0.01), higher odds of ICU admission (OR 2 [1.3-4.5], p < 0.01), longer ICU LOS (2 days vs 1 day, p < 0.01), and higher odds of unplanned intubation (OR 1.8 [1.2-3.4], p < 0.01). CONCLUSIONS The incidence of delirium after EGS was 26%. Frailty and polypharmacy were associated with increased risk of delirium. Delirium appears to be associated with higher rates of in-hospital adverse events.
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Preinjury Statins Are Associated With Improved Survival in Patients With Traumatic Brain Injury. J Surg Res 2019; 245:367-372. [PMID: 31425877 DOI: 10.1016/j.jss.2019.07.081] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 07/08/2019] [Accepted: 07/19/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND Statins have been shown to improve outcomes in traumatic brain injury (TBI) in animal models. The aim of our study was to determine the effect of preinjury statins on outcomes in TBI patients. METHODS We performed a 4-y (2014-2017) review of our TBI database and included all patients aged ≥18 y with severe isolated TBI. Patients were stratified into those who were on statins and those who were not and were matched (1:2 ratio) using propensity score matching. The primary outcome was in-hospital mortality. The secondary outcomes were skilled nursing facility disposition, Glasgow Outcome Scale-extended score, and hospital and intensive care unit length of stay (LOS). RESULTS We identified 1359 patients, of which 270 were matched (statin: 90, no-statin: 180). Mean age was 55 ± 8y, median Glasgow Coma Scale was 10 (8-12), and median head-abbreviated injury scale was 3 (3-5). Matched groups were similar in age, mechanism of injury, Glasgow Coma Scale, Injury Severity Score, neurosurgical intervention, type and size of intracranial hemorrhage, and preinjury anticoagulant or antiplatelet use. The overall in-hospital mortality rate was 18%. Patients who received statins had lower rates of in-hospital mortality (11% versus 21%, P = 0.01), skilled nursing facility disposition (19% versus 28%; P = 0.04), and a higher median Glasgow Outcome Scale-extended (11 [9-13] versus 9 [8-10]; P = 0.04). No differences were found between the two groups in terms of hospital LOS (6 [4-9] versus 5 [3-8]; P = 0.34) and intensive care unit LOS (3 [3-6] versus 4 [3-5]; P = 0.09). CONCLUSIONS Preinjury statin use in isolated traumatic brain injury patients is associated with improved outcomes. This finding warrants further investigations to evaluate the potential beneficial role of statins as a therapeutic drug in a TBI. LEVEL OF EVIDENCE Level III Therapeutic.
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Chronic Alcohol Consumption and Risk of Deep Venous Thrombosis: A Propensity-Matched Analysis. J Surg Res 2019; 244:251-256. [PMID: 31301481 DOI: 10.1016/j.jss.2019.06.067] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 04/30/2019] [Accepted: 06/14/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Alcoholism is associated with variable effects on the coagulation system. Therefore, the aim of our study was to analyze the currently unknown association between chronic alcohol consumption and the risk of venous thromboembolism, which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). METHODS We performed a 2-y (2013-2014) analysis of the American College of Surgeons Trauma Quality Improvement Program database. All trauma patients with an Injury Severity Score (ISS) > 16 were included. We excluded patients with acute alcohol intoxication, hematologic disorders, and cancer. Patients were divided into two groups (alcoholic and nonalcoholic) and were matched using propensity score matching (1:1) for demographics, ISS, injury location, and admission vitals. Outcomes measures were the prevalence of venous thromboembolism in each group. RESULTS Of the 91,066 trauma patients included in our analysis, 35,460 patients were matched (alcoholics: 17,730; nonalcoholics: 17,730). The mean was age 45 ± 18 y, and 81% were males. Matched groups were similar in age (P = 0.32), heart rate (P = 0.31), systolic blood pressure (P = 0.46), location of injury (P = 0.85), ISS (P = 0.76), and Glasgow Coma Scale (P = 0.38). Prevalence of DVT was lower in alcoholics compared with nonalcoholics (2.34% versus 5.12%, P = 0.01). The overall incidence of PE was 1.2%, and there was no difference between the two groups (1.1% versus 1.3%, P = 0.22). Similarly, there was no difference in mortality (14.8% versus 15.4%, P = 0.32) between the groups. CONCLUSIONS Chronic alcohol consumption is associated with a low risk of DVT in trauma patients. This association warrants further investigation of the possible physiological effects of alcohol in trauma patients. LEVEL OF EVIDENCE Level III Prognostic.
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Racial and Ethnic Differences in Limiting Life-Sustaining Treatment in Trauma Patients. Am J Hosp Palliat Care 2019; 36:974-979. [DOI: 10.1177/1049909119847970] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: Differences in health care between racial and ethnic groups exist. The literature suggests that African Americans and Hispanics prefer more aggressive treatment at the end of life. The aim of this study is to assess racial and ethnic differences in limiting life-sustaining treatment (LLST) after trauma. Study Design: We performed a 2-year (2013-2014) retrospective analysis of Trauma Quality Improvement Program database. Patients with age ≥16 and Injury Severity Score (ISS) ≥ 16 were included. Outcome measures were the incidence and the predictors of LLST. Multivariable logistic regression was performed to control for confounding variables. Results: A total of 97 024 patients were identified. Mean age was 49 (21) years, 68% were male, 68% were white, and 14% were Hispanic. The overall incidence of LLST was 7.2%. Based on race, LLST was selected as consistent with goals of care more often in white when compared to African American individuals who experience serious traumatic injury (8.0% vs 4.5%; P < .001). Based on ethnicity, LLST was more often selected in non-Hispanics (7.5% vs 5.2%, P < .001) when compared to Hispanics. On regression analysis, the independent predictors of LLST were white race (odds ratio [OR]: 2.7 [1.6–4.4], P = .02), non-Hispanic ethnicity (OR: 1.9 [1.4-4.6]; P = .03), severe head injury (OR: 1.7 [1.1-3.2]; P = .04), and ISS (OR: 3.1 [2.4-5.1]; P < .01). Conclusions: Differences exist in selecting LLST between different racial and ethnic groups in severe trauma. African Americans and Hispanics are less likely to select LLST when compared to whites and non-Hispanics. Further studies are required to analyze the factors associated with selecting LLST in African Americans and Hispanics.
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Four-factor prothrombin complex concentrate is associated with improved survival in trauma-related hemorrhage: A nationwide propensity-matched analysis. J Trauma Acute Care Surg 2019; 87:274-281. [DOI: 10.1097/ta.0000000000002262] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Risk Factors for Perforated Appendicitis in the Acute Care Surgery Era-Minimizing the Patient's Delayed Presentation Factor. J Surg Res 2019; 238:113-118. [PMID: 30769247 DOI: 10.1016/j.jss.2019.01.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 12/26/2018] [Accepted: 01/10/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND Numerous factors contribute to advanced disease or increased complications in patients with acute appendicitis (AA). This study aimed to identify risk factors associated with AA perforation, including the effect of system time (ST) delay, after controlling for patient time (PT) delay. In this study, PT was controlled (to less than or equal to 24 h) to better understand the effect of ST delay on AA perforation. METHODS Medical records of patients who underwent surgery for AA at a tertiary referral hospital from October 2009 through September 2013 were reviewed. Data collected included demographics, body mass index, presence of fecalith, PT (i.e., duration of time from symptom onset to arrival in emergency department), and ST (i.e., duration of time from arrival in emergency department to operating room). AA was classified as simple (acute, nonperforated) versus advanced (gangrenous, perforated). RESULTS Seven hundred forty-seven patients underwent surgery for AA. After excluding patients with PT > 24 h, 445 patients fit the study criteria, of which 358 patients with simple AA and 87 patients with advanced disease. Advanced appendicitis patients were older and had higher body mass index, longer PT, higher WBC, and higher incidence of fecaliths. Both groups had similar ST. Risk factors for advanced appendicitis after multiple regression analysis are age >50 y old, WBC >15,000, the presence of fecaliths, and PT delay >12 h. CONCLUSIONS Once PT delay was limited to ≤24 h, the ST delay of >12 h did not adversely affect the incidence of advanced AA. Age >50 y, WBC >15,000, PT delay >12 h, and the presence of fecaliths were identified as risk factors associated with advanced AA.
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Is There a Need for Platelet Transfusion After Traumatic Brain Injury in Patients on P2Y12 Inhibitors? J Surg Res 2018; 236:224-229. [PMID: 30694760 DOI: 10.1016/j.jss.2018.11.050] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 10/04/2018] [Accepted: 11/26/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND A significant portion of patients sustaining traumatic brain injury (TBI) are on antiplatelet medications. The reversal of P2Y12 agents after intracranial hemorrhage (ICH) remains unclear. The aim of our study is to evaluate outcomes after TBI in patients who are on preinjury P2Y12 inhibitors and received a platelet transfusion. METHODS We analyzed our prospectively maintained TBI database from 2013 to 2016 and included all patients with isolated ICH who were on P2Y12 inhibitors (Clopidogrel, Prasugrel, Ticagrelor). Regression analysis was performed adjusting for demographics and injury parameters. Outcome measures included progression of ICH, adverse discharge disposition (skilled nursing facility), and mortality. RESULTS A total 243 patients with ICH on preinjury P2Y12 inhibitor met our inclusion criteria and were analyzed. Mean age was 55 ± 18 y, 58% were males and 60% were white and median injury severity score was 13 [9-18]. 73.6% received platelet transfusion after admission. The median packs of platelet transfusion were 1 [1-2] units. After controlling for confounders, patients who received platelet transfusion had a lower rate of progression (OR: 0.68, P = 0.01) and decreased rate of neurosurgical intervention (OR: 0.80, P = 0.03). Overall mortality was 12.3%. Patients on P2Y12 inhibitors who received platelet transfusion had lower odds of discharge to a skilled nursing facility (OR: 0.75, P = 0.02) and mortality (OR: 0.85, P = 0.04). CONCLUSIONS Platelet transfusion after isolated traumatic ICH in patients on P2Y12 inhibitors is associated with improved outcomes. Platelet transfusion was associated with decreased risk of progression of ICH, neurosurgical intervention, and mortality. Further randomized studies to validate the use of platelet transfusion and define the optimal dose in patients on P2Y12 inhibitors are warranted.
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Outcomes After Massive Transfusion in Trauma Patients: Variability Among Trauma Centers. J Surg Res 2018; 234:110-115. [PMID: 30527461 DOI: 10.1016/j.jss.2018.09.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 08/13/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Exsanguinating trauma patients often require massive blood transfusion (defined as transfusion of 10 or more pRBC units within first 24 h). The aim of our study is to assess the outcomes of trauma patients receiving massive transfusion at different levels of trauma centers. METHODS Two-y (2013-2014) retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program. We included all adult trauma patients who received massive transfusion (MT) of blood. Outcome measures were mortality, hospital length of stay, intensive care unit-free and ventilator-free days, blood products received, and complications. RESULTS We analyzed a total of 416,957 patients, of which 2776 met the inclusion criteria and included in the study. Mean age was 40.6 ± 20 y, 78.3% were males and 33.1% of the injuries were penetrating. Median injury severity score [IQR] was 29 [18-40], median [IQR] Glasgow Coma Scale 10[4-15]. Mean packed red blood cells transfusion in the first 24 h was 20 ± 13 units and mean plasma transfusion was 13 ± 11 units. Overall in-hospital mortality was 43.5%. Receiving MT in level I trauma center was independently associated with lower rates of mortality (odds ratio [OR]: 0.75 [0.46-0.96], P < 0.001). Higher injury severity score (OR: 1.020 [1.010-1.030], P < 0.001) and increased units of packed red blood cells transfused (OR: 1.067 [1.041-1.093], P < 0.001) were independently associated with increased mortality. However, there was no association between teaching status, age, gender, emergency department vitals, and units of plasma transfused. CONCLUSIONS Hemorrhage continues to remain one of the most common cause of death after trauma. Almost half of the patients who received massive transfusion died. Patients who receive massive blood transfusion in a level I trauma centers have improved survival compared with level II trauma centers.
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Day of Hospital Admission and Effect on Outcomes: The Weekend Effect in Acute Gallstone Pancreatitis. J Surg Res 2018; 233:192-198. [PMID: 30502247 DOI: 10.1016/j.jss.2018.07.070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 07/12/2018] [Accepted: 07/19/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The aim of our study was to evaluate outcomes in patients who are admitted on weekend compared with those admitted on a weekday for acute gallstone pancreatitis. METHODS We performed a 3-y (2010-2012) analysis of the Nationwide Inpatient Sample database. Patients with acute gallstone pancreatitis who underwent endoscopic retrograde cholangiopancreatography (ERCP) were included and were divided into two groups: admission on the weekend versus the weekday. Primary outcome measures were time to ERCP, adverse events, and mortality. Secondary outcome measures were hospital length of stay and total cost. RESULTS A total of 5803 patients with acute gallstone pancreatitis who underwent ERCP were included in our study; of which 22.6% were admitted on the weekend, whereas 77.4% were admitted on a weekday. Mean age was 57 ± 18 y and 57.1% were female. Within 24 h, the rate of ERCP was higher in patients admitted on the weekday compared with those admitted on the weekend (40% versus 24%; P < 0.001). Similarly, by 48 h, the rate of ERCP was higher in the weekday group (69% versus 49%, P < 0.001). Patients admitted over the weekends had higher complications rate (P = 0.03), hospital length of stay (P < 0.001), and the total cost of hospitalization (P < 0.001) compared with the weekday group with no difference in in-hospital mortality. CONCLUSIONS Patients admitted on weekends for acute gallstone pancreatitis experience a delay in getting ERCP and have higher complications, prolonged hospital stay, and increased hospital costs compared with those admitted on weekdays.
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A Prospective Study of 7-Year Experience Using Percutaneous 14-French Pigtail Catheters for Traumatic Hemothorax/Hemopneumothorax at a Level-1 Trauma Center: Size Still Does Not Matter. World J Surg 2018; 42:107-113. [PMID: 28795207 DOI: 10.1007/s00268-017-4168-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The effectiveness of 14-French (14F) pigtail catheters (PCs) compared to 32-40F chest tubes (CTs) in patients with traumatic hemothorax (HTX) and hemopneumothorax (HPTX) is becoming more well known but still lacking. The aim of our study was to analyze our cumulative experience and outcomes with PCs in patients with traumatic HTX/HPTX. We hypothesized that PCs would be as effective as CTs. METHODS Using our PC database, we analyzed all trauma patients who required chest drainage for HTX/HPTX from 2008 to 2014. Primary outcomes of interest, comparing PCs to CTs, included initial drainage output in milliliters (mL), tube insertion-related complications, and failure rate. For our statistical analysis, we used the unpaired Student's t test, Chi-square test, and Wilcoxon rank-sum test. We defined statistical significance as P < 0.05. RESULTS During the 7-year period, 496 trauma patients required chest drainage for traumatic HTX/HPTX: 307 by CTs and 189 by PCs. PC patients were older (52 ± 21 vs. 42 ± 19, P < 0.001), demonstrated a significantly higher occurrence of blunt trauma (86 vs. 55%, P ≤ 0.001), and had tubes placed in a non-emergent fashion (Day 1 [interquartile range (IQR) 1-3 days] for PC placement vs. Day 0 [IQR 0-1 days] for CT placement, P < 0.001). All primary outcomes of interest were similar, except that the initial drainage output for PCs was higher (425 mL [IQR 200-800 mL] vs. 300 mL [IQR 150-500], P < 0.001). Findings for subgroup analysis among emergent and non-emergent PC placement were also similar to CT placement. CONCLUSION PCs had similar outcomes to CTs in terms of failure rate and tube insertion-related complications, and the initial drainage output from PCs was not inferior to that of CTs. The usage of PCs was, however, selective. A future multi-center study is needed to provide additional support and information for PC usage in traumatic HTX/HPTX.
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Evaluating the Relevance of the 2013 Tokyo Guidelines for the Diagnosis and Management of Cholecystitis. J Am Coll Surg 2018; 227:38-43.e1. [PMID: 29580879 DOI: 10.1016/j.jamcollsurg.2018.02.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 02/05/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND The 2013 Tokyo Guidelines (TG13) are used to diagnose, grade severity, and guide management of acute cholecystitis (AC). The aim of our study was to verify the diagnostic criteria, severity assessment, and management protocols based on the TG13. STUDY DESIGN Our prospectively maintained emergency general surgery registry was used to review patients who had a surgical consultation for right upper quadrant pain (from 2013 to 2015). Diagnosis and severity were graded based on TG13 and compared with pathology reports. Our institutional management protocols were compared with TG13. RESULTS Nine hundred and fifty-two patients were analyzed, of which 857 had biliary diseases. Mean age was 42 ± 18 years and 67% were female. Seven hundred and seventy-nine had a cholecystectomy, 15 underwent cholecystostomy tube placement, and 63 patients were managed conservatively. Only 4% were febrile on presentation and 51% of patients had leukocytosis. Fifty-nine percent of patients did not have any signs of AC on ultrasonography. The TG13 criteria had a sensitivity of 53% for diagnosing AC (definitive 27%, suspected 26%, and undiagnosed 47%) when compared with the final pathology report; 92.5% of patients with grade I, 93% with grade II, and even 64% with grade III, underwent cholecystectomy safely at our institute. There were no differences in complication rates (3.7% vs 4.7%; p = 0.81), return to operating room rates (0.6% vs 0.7%; p = 0.95), or mortality rates (0.3% vs 0%; p = 0.96) between grade I and grade II patients who underwent early cholecystectomy. CONCLUSIONS The TG13 diagnostic criteria lack sensitivity and missed more than half of the patients with AC, as many patients lack clinical signs (fever and leukocytosis). The TG13 recommendations for conservative management and delayed cholecystectomy in grade II and grade III disease are not warranted.
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The burden of firearm violence in the United States: stricter laws result in safer states. J Inj Violence Res 2018; 10:11-16. [PMID: 29127770 PMCID: PMC5801608 DOI: 10.5249/jivr.v10i1.951] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 10/11/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Increasing firearm violence has resulted in a strong drive for stricter firearm legislations. Aim of this study was to determine the relationship between firearm legislations and firearm-related injuries across states in the United States. METHODS We performed a retrospective analysis of all patients with trauma related hospitalization using the 2011 Nationwide Inpatient Sample database. Patients with firearm-related injury were identified using E-codes. States were dichotomized into strict firearm laws [SFL] or non-strict firearm laws [Non-SFL] states based on Brady Center score. Outcome measures were the rate of firearm injury and firearm mortality. Linear Regression and correlation analysis were used to assess outcomes among states. RESULTS 1,277,250 patients with trauma related hospitalization across 44 states were included of which, 2,583 patients had firearm-related injuries. Ten states were categorized as SFL and 34 states as Non-SFL. Mean rate of firearm related injury per 1000 trauma patients was lower in SFL states (1.3±0.5 vs. 2.1±1.4; p=0.006) and negatively correlated with Brady score (R2 linear=-0.07; p=0.04). SFL states had a 28% lower incidence of firearm related injuries compared to Non-SFL states (Beta coefficient, -0.28; 95% CI, -1.7- -0.06; p=0.04). Firearm related mortalities resulted in overall 9,722 potential life years lost and more so in the non-SFL states (p=0.001). CONCLUSIONS States without SFL have higher firearm related injury rates, higher firearm related mortality rate, and significant potential years of life lost compared to SFL states. Further analysis of differences in the legislation between SFL and non-SFL states may help reduce firearm related injury rate.
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Geriatric rescue after surgery (GRAS) score to predict failure-to-rescue in geriatric emergency general surgery patients. Am J Surg 2017; 215:53-57. [PMID: 28851486 DOI: 10.1016/j.amjsurg.2017.08.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/26/2017] [Accepted: 08/07/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Geriatric-patients(GP) undergoing emergency-general-surgery(EGS) are vulnerable to develop adverse-outcomes. Impact of patient-level-factors on Failure-to-Rescue(FTR) in EGS-GP remains unclear. Aim of our study was to determine factors associated with FTR(death from major-complication) and devise simple-bedside-score that predicts FTR in EGS-GP. METHODS 3-year(2013-15) analysis of patients, age≥65y on acute-care-surgery-service and underwent EGS. Regression analysis used to analyze factors associated with FTR and natural-logarithm of significant odds-ratio used to calculate estimated-weights for each factor. Geriatric-Rescue-After-Surgery(GRAS)-score calculated for each-patient. AUROC used to assess model discrimination. RESULTS 725 EGS-patients analyzed. 44.6%(n = 324) had major-complications. The FTR-rate was 11.5%. Overall-mortality rate was 15.3%. On regression, significant-factors with their estimated-weights were:Age≥80y(2), Chronic-Obstructive-Pulmonary-Disease(COPD)(1), Chronic-renal-failure(CRF)(2), Congestive-heart-failure(CHF)(1), Albumin<3.5(1) and ASA score>3(2). AUROC of score was 0.787. CONCLUSION GRAS-score is first score based on preoperative assessment that can reliably predict FTR in EGS-GP. Preoperative identification of patients at increased-risk of FTR can help in risk-stratification and timely-mobilization of resources for successful rescue of these patients.
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Primary repair for pediatric colonic injury: Are there differences among adult and pediatric trauma centers? J Surg Res 2017; 220:176-181. [PMID: 29180180 DOI: 10.1016/j.jss.2017.06.092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 06/21/2017] [Accepted: 06/29/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Management of colonic injuries (colostomy [CO] versus primary anastomosis [PA]) among pediatric patients remains controversial. The aim of this study was to assess outcomes in pediatric trauma patient with colonic injury undergoing operative intervention. METHODS The National Trauma Data Bank (2011-2012) was queried including patients with isolated colonic injury undergoing exploratory laparotomy with PA or CO with age ≤18 y. Missing value analysis was performed. Patients were stratified into two groups: PA and CO. Outcome measures were mortality, in-hospital complications, and hospital length of stay. Multivariate regression analysis was performed. RESULTS A total of 1151 patients included. Mean ± standard deviation age was 11.61 ± 2.8 y, and median [IQR] Injury Severity Score was 12 [8-16]; 39% (n = 449) of the patients had CO, and 35.6% (n = 410) were managed in pediatric trauma centers (PC). Patients with CO had a higher Injury Severity Score (P < 0.001), a trend toward lower blood pressure (P = 0.40), and an older age (P < 0.001). There was no difference in mortality between the PA and CO groups. However, patients who underwent PA had a shorter length of stay (P < 0.001) and lower in-hospital complications (P < 0.001). A subanalysis shows that, after controlling for all confounding factors, patients managed in PC were 1.2 times (1.2 [1.1-2.1], P = 0.04) more likely to receive a CO than those patients managed in adult trauma centers (AC). Moreover, there was no difference in mortality between the AC and the PC (P = 0.79). CONCLUSIONS Our data demonstrate no difference in mortality in pediatric trauma patients with colonic injury who undergo primary repair or CO. However, adult trauma centers had lower rates of CO performed as compared to a similar cohort of patients managed in pediatric trauma centers. Further assessment of the reasons underlying such differences will help improve patient outcomes.
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Early thromboprophylaxis with low-molecular-weight heparin is safe in patients with pelvic fracture managed nonoperatively. J Surg Res 2017; 219:360-365. [PMID: 29078906 DOI: 10.1016/j.jss.2017.06.049] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 05/22/2017] [Accepted: 06/16/2017] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Early initiation of thromboprophylaxis is highly desired in pelvic fracture patients, but it is often delayed due to the fear of hemorrhage. Aim of our study was to assess the safety of early initiation of venous thromboprophylaxis in patients with pelvic trauma managed nonoperatively. METHODS Three-year (2010-2012) retrospective study of trauma patients with pelvic fractures who were managed nonoperatively and received thromboprophylaxis with low-molecular-weight heparin (LMWH). Patients were stratified in two groups based on the timing of initiation of prophylaxis; early (initiation within first 24 h) and late (after 24 h). Primary outcome measures included decrease in hemoglobin (Hb) levels, number of packed red blood cell (pRBC) units transfused, and the need for hemorrhage control (operative or angioembolization) after initiation of prophylaxis. Regression analysis was performed. RESULTS 255 patients were included (158 in early and 97 in late group). Mean ± standard deviation age was 48.2 ± 23.3 y, and 50.6% were male. After adjusting for confounders, there was no difference between the two groups in the decrease in Hb levels (b = 0.087, 95% confidence interval [CI] = -0.253 to 1.025; P = 0.23) or pRBC units transfused (b = -0.005, 95% CI = -0.366 to 0.364; P = 0.75).One patient required hemorrhage control postprophylaxis and belonged to the late group. Subanalysis of patients with signs of bleeding (n = 52) showed no difference between the two groups in the decrease in Hb levels or pRBC units transfused. Patients who received LMWH after 24 h had a higher incidence of symptomatic deep venous thrombosis and a longer hospital length of stay. CONCLUSIONS Early initiation of thromboprophylaxis with LMWH in patients with pelvic fractures managed nonoperatively is safe and decreases the risk of symptomatic deep venous thrombosis.
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More Helmets Fewer Deaths: Motorcycle Helmet Legislation Impacts Traumatic Brain Injury-Related Mortality in Young Adults. Am Surg 2017. [DOI: 10.1177/000313481708300616] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of our study was to assess the impact of helmet legislations on the incidence and the mortality rate of motorcycle collision (MCC)-related traumatic brain injury (TBI) in young adult trauma patients. A 1-year (2011) retrospective analysis was performed of all patients under 21 years old with trauma-related hospitalization using the Nationwide Inpatient Sample database (representing 20% of all in-patient admissions). Patients with MCC were identified using E-codes. States were classified into three groups based on helmet legislations: universal age helmet legislation, <18 years helmet legislation, and <21 years helmet legislation. Outcome measures were the rates of TBI and mortality. Linear regression analysis was used to assess outcomes among the states. A total of 1,165,150 patients with trauma-related hospitalizations across 29 states were reviewed of which, 587 patients with MCC were included. Ten states had universal age legislation; 13 states had age <18 years legislation, and 6 states had age <21 years legislation. There was a lower incidence in the rate of TBI (P = 0.03) in states with universal helmet legislations compared with states with age-restricted helmet legislation. Universal helmet legislations lowered the rate of MCC-related TBI injures by a factor of 2.15 (β coefficient: 2.15; 95% confidence interval: 0.91–10.18; P = 0.04). States with age-restricted helmet legislations have a higher rate of traumatic brain injury and mortality compared with states with universal helmet legislations. Establishing universal helmet legislations across the states may provide a potential preventive strategy against traumatic brain injury.
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The impact of Glasgow Coma Scale-age prognosis score on geriatric traumatic brain injury outcomes. J Surg Res 2017; 216:109-114. [PMID: 28807194 DOI: 10.1016/j.jss.2017.04.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/10/2017] [Accepted: 04/27/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND As the population ages, increasing number of geriatric patients sustain traumatic brain injury (TBI). Communication of accurate prognostic information is crucial for making informed decisions on behalf of such patients. Therefore, the aim of our study was to develop a simple and clinically applicable tool that accurately predicts the prognosis in geriatric TBI patients. METHODS We performed a 1-y (2011) retrospective analysis of isolated geriatric TBI patients (age ≥65 y, head abbreviated injury score [AIS] ≥ 3, and other body AIS < 3) in the National Trauma Data Bank. We calculated a Glasgow Coma Scale (GCS)-age prognosis (GAP) score (age/GCS score) for all patients. Outcome measures were in-hospital adverse outcomes (mortality and Rehab/skilled nursing facility discharge disposition). Regression analysis and receiver operator characteristic curve analysis were performed to determine the discriminatory power of GAP score. RESULTS A total of 8750 geriatric patients with TBI were included. Mean age was 77.8 ± 7.1 y, the median (interquartile range) GCS was 15 (13-15), and the median (interquartile range) head AIS was 4 (3-4). The overall in-hospital mortality rate was 12.7%, and 34.2% of the patients were discharged home. As the GAP score increased, the mortality rate increased and discharge to-home decreased. Receiver operator characteristic curve analysis revealed excellent discriminatory power for mortality (area under the curve: 0.826). Above a GAP score of 12, the mortality rate was >50% and more than 45% of the patients were discharged to Rehab/skilled nursing facility. CONCLUSIONS For geriatric patients with TBI, a simple GAP score reliably predicts outcomes. A score above 12 results in a drastic increase in mortality and an adverse discharge disposition. This simple tool may help clinicians provide accurate prognostic information to patients' families.
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Bicycle helmets work when it matters the most. Am J Surg 2016; 213:413-417. [PMID: 27596799 DOI: 10.1016/j.amjsurg.2016.05.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 05/23/2016] [Accepted: 05/31/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Helmets are known to reduce the incidence of traumatic brain injury (TBI) after bicycle-related accidents. The aim of this study was to assess the association of helmets with severity of TBI and facial fractures after bicycle-related accidents. METHODS We performed an analysis of the 2012 National Trauma Data Bank abstracted information of all patients with an intracranial hemorrhage after bicycle-related accidents. Regression analysis was also performed. RESULTS A total of 6,267 patients were included. About 25.1% (n = 1,573) of bicycle riders were helmeted. Overall, 52.4% (n = 3,284) of the patients had severe TBI, and the mortality rate was 2.8% (n = 176). Helmeted bicycle riders had 51% reduced odds of severe TBI (odds ratio [OR] .49, 95% confidence interval [CI] .43 to .55, P < .001) and 44% reduced odds of mortality (OR .56, 95% CI .34 to .78, P = .010). Helmet use also reduced the odds of facial fractures by 31% (OR .69, 95% CI .58 to .81, P < .001). CONCLUSION Bicycle helmet use provides protection against severe TBI, reduces facial fractures, and saves lives even after sustaining an intracranial hemorrhage.
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Accuracy of Unenhanced MR Imaging in the Detection of Acute Appendicitis: Single-Institution Clinical Performance Review. Radiology 2016; 279:451-60. [DOI: 10.1148/radiol.2015150468] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Abstract
IMPORTANCE Domestic violence is an extremely underreported crime and a growing social problem in the United States. However, the true burden of the problem remains unknown. OBJECTIVE To assess the reported prevalence of domestic violence among trauma patients. DESIGN, SETTING, AND PARTICIPANTS A 6-year (2007-2012) retrospective analysis of the prospectively maintained National Trauma Data Bank. Trauma patients who experienced domestic violence and who presented to trauma centers participating in the National Trauma Data Bank were identified using International Classification of Diseases, Ninth Revision diagnosis codes (995.80-995.85, 995.50, 995.52-995.55, and 995.59) and E codes (E967.0-E967.9). Patients were stratified by age into 3 groups: children (≤18 years), adults (19-54 years), and elderly patients (≥55 years). Trend analysis was performed on April 10, 2014, to assess the reported prevalence of domestic violence over the years. PARTICIPANTS Trauma patients presenting to trauma centers participating in the National Trauma Data Bank. MAIN OUTCOMES AND MEASURES To assess the reported prevalence of domestic violence among trauma patients. RESULTS A total of 16 575 trauma patients who experienced domestic violence were included. Of these trauma patients, 10 224 (61.7%) were children, 5503 (33.2%) were adults, and 848 (5.1%) were elderly patients. The mean (SD) age was 15.9 (20.6), the mean (SD) Injury Severity Score was 10.9 (9.6), and 8397 (50.7%) were male patients. Head injuries (46.8% of patients) and extremity fractures (31.2% of patients) were the most common injuries. A total of 12 515 patients (75.1%) were discharged home, and the overall mortality rate was 5.9% (n = 980). The overall reported prevalence of domestic violence among trauma patients was 5.7 cases per 1000 trauma center discharges. The prevalence of domestic violence increased among children (14.0 cases per 1000 trauma center discharges in 2007 to 18.5 case per 1000 trauma center discharges in 2012; P = .001) and adults (3.2 cases per 1000 discharges in 2007 to 4.5 cases per 1000 discharges in 2012; P = .001) over the 6-year period and remained unchanged for elderly patients (0.8 cases per 1000 discharges in 2007 to 0.96 cases per 1000 discharges in 2012; P = .09). On subanalysis of adults and elderly patients, the prevalence of domestic violence increased among both female (4.6 cases per 1000 discharges in 2007 to 5.3 cases per 1000 discharges in 2012; P = .001) and male patients (1.5 cases per 1000 discharges in 2007 to 2.8 cases per 1000 discharges in 2012; P = .001). CONCLUSIONS AND RELEVANCE Domestic violence is prevalent among trauma patients. Over the years, the reported prevalence of domestic violence has been increasing among children and adults, and continues to remain high among female trauma patients. A robust mandatory screening for evaluating domestic violence among trauma patients, along with a focused national intervention, is warranted.
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Blunt bilateral diaphragmatic rupture-A right side can be easily missed. Trauma Case Rep 2015; 1:84-87. [PMID: 30101182 PMCID: PMC6082499 DOI: 10.1016/j.tcr.2015.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2015] [Indexed: 11/19/2022] Open
Abstract
Blunt diaphragmatic rupture (BDR) is uncommon with a reported incidence range of 1%–2%. The true incidence is not known. Bilateral BDR is particularly rare. We presented a case of bilateral BDR and we think that the incidence is under-recognised thanks to an easily missed and difficult to diagnose right sided injury.
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The protective effect of remote ischemic conditioning in a septic mice model. J Crit Care 2015. [DOI: 10.1016/j.jcrc.2015.04.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Clinical outcomes in patients on preinjury ibuprofen with traumatic brain injury. Am J Surg 2015; 209:921-6. [DOI: 10.1016/j.amjsurg.2014.05.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 05/11/2014] [Accepted: 05/28/2014] [Indexed: 11/15/2022]
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Use of Prothrombin Complex Concentrate as an Adjunct to Fresh Frozen Plasma Shortens Time to Craniotomy in Traumatic Brain Injury Patients. Neurosurgery 2015; 76:601-7; discussion 607. [DOI: 10.1227/neu.0000000000000685] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
AbstractBACKGROUND:The use of prothrombin complex concentrate (PCC) to reverse acquired (coagulopathy of trauma) and induced coagulopathy (preinjury warfarin use) is well defined.OBJECTIVE:To compare outcomes in patients with traumatic brain injury without warfarin therapy receiving PCC as an adjunct to fresh frozen plasma (FFP) therapy compared with patients receiving FFP therapy alone.METHODS:All patients with traumatic brain injury coagulopathy without warfarin therapy who received PCC (25 IU/kg) in conjunction with FFP or FFP alone at our Level I trauma center were reviewed. Coagulopathy was defined as an international normalized ratio >1.5. The groups (PCC + FFP vs FFP alone) were matched using propensity score matching on a 1:2 ratio for age, sex, Glasgow Coma Scale score, Injury Severity Score, head Abbreviated Injury Scale score, and international normalized ratio (INR) on presentation. The primary outcome measure was time to craniotomy. Secondary outcome measures were blood product requirements, cost of therapy, and mortality.RESULTS:A total of 1641 patients were reviewed, 222 of whom were included (PCC + FFP, 74; FFP, 148). The mean ± standard deviation age was 46.4 ± 21.7 years, the median (range) Glasgow Coma Scale score was 8 (3-12), and the mean ± standard deviation INR on presentation was 1.92 ± 0.6. PCC + FFP therapy was associated with an accelerated correction of INR (P = .001) and decrease in overall pack red blood cell (P = .035) and FFP (P = .041) administration requirement. Craniotomy was performed in 26.1% of patients (n = 58). Patients who received PCC + FFP therapy had faster time to craniotomy (P = .028) compared with patients who received FFP therapy alone.CONCLUSION:PCC as an adjunct to FFP decreases the time to craniotomy with faster correction of INR and concomitant decrease in the need for blood product requirement in patients with traumatic brain injury exclusive of prehospital warfarin therapy.
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Management of acute mild gallstone pancreatitis under acute care surgery: should patients be admitted to the surgery or medicine service? Am J Surg 2014; 208:981-7; discussion 986-7. [PMID: 25312841 DOI: 10.1016/j.amjsurg.2014.09.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Revised: 09/08/2014] [Accepted: 09/09/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND We hypothesized that patients with acute mild gallstone pancreatitis (GSP) admitted to surgery (SUR; vs medicine [MED]) had a shorter time to surgery, shorter hospital length of stay (HLOS), and lower costs. METHODS We performed chart reviews of patients who underwent a cholecystectomy for acute mild GSP from October 1, 2009 to May 31, 2013. We excluded patients with moderate to severe and non-gallstone pancreatitis. We compared outcomes for time to surgery, HLOS, costs, and complications between the 2 groups. RESULTS Fifty acute mild GSP patients were admitted to MED and 52 to SUR. MED patients were older and had more comorbidity. SUR patients had a shorter time to surgery (44 vs 80 hours; P < .001), a shorter HLOS (3 vs 5 days; P < .001), and lower hospital costs ($11,492 ± 6,480 vs $16,183 ± 12,145; P = .03). In our subgroup analysis on patients with an American Society of Anesthesiologists score between 1 and 2, the subgroups were well matched; all outcomes still favored SUR patients. CONCLUSIONS Admitting acute mild GSP patients directly to SUR shortened the time to surgery, shortened HLOS, and lowered hospital costs.
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The Burden of Firearm Violence in the United States: Stricter Laws Result in Safer States. J Am Coll Surg 2014. [DOI: 10.1016/j.jamcollsurg.2014.07.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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The Bimodal Effect: Impact of Admission Systolic Blood Pressure on Mortality in Isolated Traumatic Brain Injury. J Am Coll Surg 2014. [DOI: 10.1016/j.jamcollsurg.2014.07.156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
INTRODUCTION Conventionally, a Glasgow Coma Scale (GCS) score of 13-15 defines mild traumatic brain injury (mTBI). The aim of this study was to identify the factors that predict progression on repeat head computed tomography (RHCT) and neurosurgical intervention (NSI) in patients categorized as mild TBI with intracranial injury (intracranial haemorrhage and/or skull fracture). METHODS This study performed a retrospective chart review of all patients with traumatic brain injury who presented to a level 1 trauma centre. Patients with blunt TBI, an intracranial injury and admission GCS of 13-15 without anti-platelet and anti-coagulation therapy were included. The outcome measures were: progression on RHCT and need for neurosurgical intervention (craniotomy and/or craniectomy). RESULTS A total of 1800 patients were reviewed, of which 876 patients were included. One hundred and fifteen (13.1%) patients had progression on RHCT scan. Progression on RHCT was 8-times more likely in patients with subdural haemorrhage ≥10 mm, 5-times more likely with epidural haemorrhage ≥10 mm and 3-times more likely with base deficit ≥4. Forty-seven patients underwent a neurosurgical intervention. Patients with displaced skull fracture were 10-times more likely and patients with base deficit >4 were 21-times more likely to have a neurosurgical intervention. CONCLUSION In patients with intracranial injury, a mild GCS score (GCS 13-15) in patients with an intracranial injury does not preclude progression on repeat head CT and the need for a neurosurgical intervention. Base deficit greater than four and displaced skull fracture are the greatest predictors for neurosurgical intervention in patients with mild TBI and an intracranial injury.
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Early thromboembolic prophylaxis in patients with blunt solid abdominal organ injuries undergoing nonoperative management: is it safe? Am J Surg 2014; 209:194-8. [PMID: 24928334 DOI: 10.1016/j.amjsurg.2014.03.007] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 03/27/2014] [Accepted: 03/29/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND The aim of this study was to compare the safety of early (≤48 hours), intermediate (48 to 72 hours), and late (≥72 hours) venous thromboembolism prophylaxis in patients with blunt abdominal solid organ injury managed nonoperatively. METHODS We performed a 6-year (2006 to 2011) retrospective review of all trauma patients with blunt abdominal solid organ injuries. Patients were matched using propensity score matching in a 2:1:1 (early:intermediate:late) for age, gender, systolic blood pressure, Glasgow Coma Scale, Injury Severity Score, and type and grade of organs injured. Our primary outcome measures were: hemorrhage complications and need for intervention (operative intervention and/or angioembolization). RESULTS A total of 116 patients (58 early, 29 intermediate, and 29 late) were included. There were no differences in age (P = .5), Injury Severity Score (P = .6), type (P = .1), and grade of injury of the organ (P = .6) between the 3 groups. There were 67 liver (43.2%), 63 spleen (40.6%), 49 kidney (31.6%), and 24 multiple solid organ (15.4%) injuries. There was no difference in operative intervention (P = .8) and postprophylaxis blood transfusion (P = .3) between the 3 groups. CONCLUSIONS Early enoxaparin-based anticoagulation may be a safe option in trauma patients with blunt solid organ injury. This study showed no significant correlation between early anticoagulation and development of bleeding complications.
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Effect of alcohol in traumatic brain injury: is it really protective? J Surg Res 2014; 190:634-9. [PMID: 24857283 DOI: 10.1016/j.jss.2014.04.039] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 04/17/2014] [Accepted: 04/24/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Studies have proposed a neuroprotective role for alcohol (ETOH) in traumatic brain injury (TBI). We hypothesized that ETOH intoxication is associated with mortality in patients with severe TBI. METHODS Version 7.2 of the National Trauma Data Bank (2007-2010) was queried for all patients with isolated blunt severe TBI (Head Abbreviated Injury Score ≥4) and blood ETOH levels recorded on admission. Primary outcome measure was mortality. Multivariate logistic regression analysis was performed to assess factors predicting mortality and in-hospital complications. RESULTS A total of 23,983 patients with severe TBI were evaluated of which 22.8% (n = 5461) patients tested positive for ETOH intoxication. ETOH-positive patients were more likely to have in-hospital complications (P = 0.001) and have a higher mortality rate (P = 0.01). ETOH intoxication was an independent predictor for mortality (odds ratio: 1.2, 95% confidence interval: 1.1-2.1, P = 0.01) and development of in-hospital complications (odds ratio: 1.3, 95% confidence interval: 1.1-2.8, P = 0.009) in patients with isolated severe TBI. CONCLUSIONS ETOH intoxication is an independent predictor for mortality in patients with severe TBI patients and is associated with higher complication rates. Our results from the National Trauma Data Standards differ from those previously reported. The proposed neuroprotective role of ETOH needs further clarification.
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Randomized clinical trial of pigtail catheter versus chest tube in injured patients with uncomplicated traumatic pneumothorax. Br J Surg 2014; 101:17-22. [PMID: 24375295 DOI: 10.1002/bjs.9377] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2013] [Indexed: 01/28/2023]
Abstract
BACKGROUND Small pigtail catheters appear to work as well as the traditional large-bore chest tubes in patients with traumatic pneumothorax, but it is not known whether the smaller pigtail catheters are associated with less tube-site pain. This study was conducted to compare tube-site pain following pigtail catheter or chest tube insertion in patients with uncomplicated traumatic pneumothorax. METHODS This prospective randomized trial compared 14-Fr pigtail catheters and 28-Fr chest tubes in patients with traumatic pneumothorax presenting to a level I trauma centre from July 2010 to February 2012. Patients who required emergency tube placement, those who refused and those who could not respond to pain assessment were excluded. Primary outcomes were tube-site pain, as assessed by a numerical rating scale, and total pain medication use. Secondary outcomes included the success rate of pneumothorax resolution and insertion-related complications. RESULTS Forty patients were enrolled. Baseline characteristics of 20 patients in the pigtail catheter group were similar to those of 20 patients in the chest tube group. No patient had a flail chest or haemothorax. Pain scores related to chest wall trauma were similar in the two groups. Patients with a pigtail catheter had significantly lower mean(s.d.) tube-site pain scores than those with a chest tube, at baseline after tube insertion (3.2(0.6) versus 7.7(0.6); P < 0.001), on day 1 (1.9(0.5) versus 6.2(0.7); P < 0.001) and day 2 (2.1(1.1) versus 5.5(1.0); P = 0.040). The decreased use of pain medication associated with pigtail catheter was not significantly different. The duration of tube insertion, success rate and insertion-related complications were all similar in the two groups. CONCLUSION For patients with a simple, uncomplicated traumatic pneumothorax, use of a 14-Fr pigtail catheter is associated with reduced pain at the site of insertion, with no other clinically important differences noted compared with chest tubes. REGISTRATION NUMBER NCT01537289 (http://clinicaltrials.gov).
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Shock Index Predicts Mortality in Geriatric Trauma Patients: An Analysis of The National Trauma Data Bank. J Surg Res 2014. [DOI: 10.1016/j.jss.2013.11.998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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The Effect of Age on Mortality In Patients With Traumatic Brain Injury. J Surg Res 2014. [DOI: 10.1016/j.jss.2013.11.844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Mortality after trauma laparotomy in geriatric patients. J Surg Res 2014; 190:662-6. [PMID: 24582068 DOI: 10.1016/j.jss.2014.01.029] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 01/13/2014] [Accepted: 01/16/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Geriatric patients are at higher risk for adverse outcomes after injury because of their altered physiological reserve. Mortality after trauma laparotomy remains high; however, outcomes in geriatric patients after trauma laparotomy have not been well established. The aim of our study was to identify factors predicting mortality in geriatric trauma patients undergoing laparotomy. METHODS A retrospective study was performed of all trauma patients undergoing a laparotomy at our level 1 trauma center over a 6-y period (2006-2012). Patients with age ≥55 y who underwent a trauma laparotomy were included. Patients with head abbreviated injury scale (AIS) score ≥ 3 or thorax AIS ≥ 3 were excluded. Our primary outcome measure was mortality. Significant factors in univariate regression model were used in multivariate regression analysis to evaluate the factors predicting mortality. RESULTS A total of 1150 patients underwent a trauma laparotomy. Of which 90 patients met inclusion criteria. The mean age was 67 ± 10 y, 63% were male, and median abdominal AIS was 3 (2-4). Overall mortality rate was 23.3% (21/90) and progressively increased with age (P = 0.013). Age (P = 0.02) and lactate (P = 0.02) were the independent predictors of mortality in geriatric patients undergoing laparotomy. CONCLUSIONS Mortality rate after trauma laparotomy increases with increasing age. Age and admission lactate were the predictors of mortality in geriatric population undergoing trauma laparotomies.
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Incidence and pattern of cervical spine injury in patients who fall: don't worry about how high, worry about how old. J Am Coll Surg 2013. [DOI: 10.1016/j.jamcollsurg.2013.07.259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Time and cost analysis of gallbladder surgery under acute care surgery model. J Am Coll Surg 2013. [DOI: 10.1016/j.jamcollsurg.2013.07.263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Rehabilitation after trauma; does age matter? J Surg Res 2013; 184:541-5. [PMID: 23664534 DOI: 10.1016/j.jss.2013.03.069] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 03/14/2013] [Accepted: 03/20/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Variability exits in the ability to predict overall recovery after trauma and inpatient rehabilitation. The aim of this study was to identify factors predicting functional improvement in trauma patients undergoing inpatient rehabilitation. METHODS We performed a 3-y retrospective cohort analysis on a prospectively collected database of all trauma patients discharged from a level I trauma center to a single inpatient rehabilitation center. Patient's Functional Independence Measures (FIM) scores on hospital discharge and on discharge from the rehabilitation center were collected. Delta FIM was defined as the difference in FIM between rehabilitation center discharge and hospital discharge. Multiple linear regressions were performed to identify hospital admission factors associated with delta FIM. RESULTS We included 160 patients, 69% were male, mean age 54.6 ± 22 y, and median Injury Severity Score 14 [10-50]. Based on rehabilitation admission FIM scores, 29 were totally dependent and 131 were partially dependent. The mean change in FIM was 39.4 ± 13. Age, gender, Glasgow Coma Scale on presentation, Injury Severity Score, systolic blood pressure on presentation, and intensive care unit length of stay were not predictive of delta FIM. Hospital length of stay and head Abbreviated Injury Score on hospital admission were negative predictors of delta FIM. CONCLUSIONS In our study, age as an independent factor was not predictive of functional outcome after injury. The extent of head injury continues to negatively affect the overall functional improvement based on FIM.
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Trauma Association of Canada (TAC) Annual Scientific Meeting. The Westin Whistler Resort & Spa, Whistler, BC, Thursday, Apr. 11 to Saturday, Apr. 13, 2013Testing the reliability of tools for pediatric trauma teamwork evaluation in a North American high-resource simulation settingThe association of etomidate with mortality in trauma patientsDefinition of isolated hip fractures as an exclusion criterion in trauma centre performance evaluations: a systematic reviewEstimation of acute care hospitalization costs for trauma hospital performance evaluation: a systematic reviewHospital length of stay following admission for traumatic injury in Canada: a multicentre cohort studyPredictors of hospital length of stay following traumatic injury: a multicentre cohort studyInfluence of the heterogeneity in definitions of an isolated hip fracture used as an exclusion criterion in trauma centre performance evaluations: a multicentre cohort studyPediatric trauma, advocacy skills and medical studentsCompliance with the prescribed packed red blood cell, fresh frozen plasma and platelet ratio for the trauma transfusion pathway at a level 1 trauma centreEarly fixed-wing aircraft activation for major trauma in remote areasDevelopment of a national, multi-disciplinary trauma crisis resource management curriculum: results from the pilot courseThe management of blunt hepatic trauma in the age of angioembolization: a single centre experienceEarly predictors of in-hospital mortality in adult trauma patientsThe impact of open tibial fracture on health service utilization in the year preceding and following injuryA systematic review and meta-analysis of the efficacy of red blood cell transfusion in the trauma populationSources of support for paramedics managing work-related stress in a Canadian EMS service responding to multisystem trauma patientsAnalysis of prehospital treatment of pain in the multisystem trauma patient at a community level 2 trauma centreIncreased mortality associated with placement of central lines during trauma resuscitationChronic pain after serious injury — identifying high risk patientsEpidemiology of in-hospital trauma deaths in a Brazilian university teaching hospitalIncreased suicidality following major trauma: a population-based studyDevelopment of a population-wide record linkage system to support trauma researchInduction of hmgb1 by increased gut permeability mediates acute lung injury in a hemorrhagic shock and resuscitation mouse modelPatients who sustain gunshot pelvic fractures are at increased risk for deep abscess formation: aggravated by rectal injuryAre we transfusing more with conservative management of isolated blunt splenic injury? A retrospective studyMotorcycle clothesline injury prevention: Experimental test of a protective deviceA prospective analysis of compliance with a massive transfusion protocol - activation alone is not enoughAn evaluation of diagnostic modalities in penetrating injuries to the cardiac box: Is there a role for routine echocardiography in the setting of negative pericardial FAST?Achievement of pediatric national quality indicators — an institutional report cardProcess mapping trauma care in 2 regional health authorities in British Columbia: a tool to assist trauma sys tem design and evaluationPatient safety checklist for emergency intubation: a systematic reviewA standardized flow sheet improves pediatric trauma documentationMassive transfusion in pediatric trauma: a 5-year retrospective reviewIs more better: Does a more intensive physiotherapy program result in accelerated recovery for trauma patients?Trauma care: not just for surgeons. Initial impact of implementing a dedicated multidisciplinary trauma team on severely injured patientsThe role of postmortem autopsy in modern trauma care: Do we still need them?Prototype cervical spine traction device for reduction stabilization and transport of nondistraction type cervical spine injuriesGoing beyond organ preservation: a 12-year review of the beneficial effects of a nonoperative management algorithm for splenic traumaAssessing the construct validity of a global disability measure in adult trauma registry patientsThe mactrauma TTL assessment tool: developing a novel tool for assessing performance of trauma traineesA quality improvement approach to developing a standardized reporting format of ct findings in blunt splenic injuriesOutcomes in geriatric trauma: what really mattersFresh whole blood is not better than component therapy (FFP:RBC) in hemorrhagic shock: a thromboelastometric study in a small animal modelFactors affecting mortality of chest trauma patients: a prospective studyLong-term pain prevalence and health related quality of life outcomes for patients enrolled in a ketamine versus morphine for prehospital traumatic pain randomized controlled trialDescribing pain following trauma: predictors of persistent pain and pain prevalenceManagement strategies for hemorrhage due to pelvic trauma: a survey of Canadian general surgeonsMajor trauma follow-up clinic: Patient perception of recovery following severe traumaLost opportunities to enhance trauma practice: culture of interprofessional education and sharing among emergency staffPrehospital airway management in major trauma and traumatic brain injury by critical care paramedicsImproving patient selection for angiography and identifying risk of rebleeding after angioembolization in the nonoperative management of high grade splenic injuriesFactors predicting the need for angioembolization in solid organ injuryProthrombin complex concentrates use in traumatic brain injury patients on oral anticoagulants is effective despite underutilizationThe right treatment at the right time in the right place: early results and associations from the introduction of an all-inclusive provincial trauma care systemA multicentre study of patient experiences with acute and postacute injury carePopulation burden of major trauma: Has introduction of an organized trauma system made a difference?Long-term functional and return to work outcomes following blunt major trauma in Victoria, AustraliaSurgical dilemma in major burns victim: heterotopic ossification of the tempromandibular jointWhich radiological modality to choose in a unique penetrating neck injury: a differing opinionThe Advanced Trauma Life Support (ATLS) program in CanadaThe Rural Trauma Team Development Course (RTTDC) in Pakistan: Is there a role?Novel deployment of BC mobile medical unit for coverage of BMX world cup sporting eventIncidence and prevalence of intra-abdominal hypertension and abdominal compartment syndrome in critically ill adults: a systematic review and meta-analysisRisk factors for intra-abdominal hypertension and abdominal compartment syndrome in critically ill or injured adults: a systematic review and meta-analysisA comparison of quality improvement practices at adult and pediatric trauma centresInternational trauma centre survey to evaluate content validity, usability and feasibility of quality indicatorsLong-term functional recovery following decompressive craniectomy for severe traumatic brain injuryMorbidity and mortality associated with free falls from a height among teenage patients: a 5-year review from a level 1 trauma centreA comparison of adverse events between trauma patients and general surgery patients in a level 1 trauma centreProcoagulation, anticoagulation and fibrinolysis in severely bleeding trauma patients: a laboratorial characterization of the early trauma coagulopathyThe use of mobile technology to facilitate surveillance and improve injury outcome in sport and physical activityIntegrated knowledge translation for injury quality improvement: a partnership between researchers and knowledge usersThe impact of a prevention project in trauma with young and their learningIntraosseus vascular access in adult trauma patients: a systematic reviewThematic analysis of patient reported experiences with acute and post-acute injury careAn evaluation of a world health organization trauma care checklist quality improvement pilot programProspective validation of the modified pediatric trauma triage toolThe 16-year evolution of a Canadian level 1 trauma centre: growing up, growing out, and the impact of a booming economyA 20-year review of trauma related literature: What have we done and where are we going?Management of traumatic flail chest: a systematic review of the literatureOperative versus nonoperative management of flail chestEmergency department performance of a clinically indicated and technically successful emergency department thoracotomy and pericardiotomy with minimal equipment in a New Zealand institution without specialized surgical backupBritish Columbia’s mobile medical unit — an emergency health care support resourceRoutine versus ad hoc screening for acute stress: Who would benefit and what are the opportunities for trauma care?A geographical analysis of the Early Development Instrument (EDI) and childhood injuryDevelopment of a pediatric spinal cord injury nursing course“Kids die in driveways” — an injury prevention campaignEpidemiology of traumatic spine injuries in childrenA collaborative approach to reducing injuries in New Brunswick: acute care and injury preventionImpact of changes to a provincial field trauma triage tool in New BrunswickEnsuring quality of field trauma triage in New BrunswickBenefits of a provincial trauma transfer referral system: beyond the numbersThe field trauma triage landscape in New BrunswickImpact of the Rural Trauma Team Development Course (RTTDC) on trauma transfer intervals in a provincial, inclusive trauma systemTrauma and stress: a critical dynamics study of burnout in trauma centre healthcare professionalsUltrasound-guided pediatric forearm fracture reduction with sedation in the emergency departmentBlock first, opiates later? The use of the fascia iliaca block for patients with hip fractures in the emergency department: a systematic reviewRural trauma systems — demographic and survival analysis of remote traumas transferred from northern QuebecSimulation in trauma ultrasound trainingIncidence of clinically significant intra-abdominal injuries in stable blunt trauma patientsWake up: head injury management around the clockDamage control laparotomy for combat casualties in forward surgical facilitiesDetection of soft tissue foreign bodies by nurse practitioner performed ultrasoundAntihypertensive medications and walking devices are associated with falls from standingThe transfer process: perspectives of transferring physiciansDevelopment of a rodent model for the study of abdominal compartment syndromeClinical efficacy of routine repeat head computed tomography in pediatric traumatic brain injuryEarly warning scores (EWS) in trauma: assessing the “effectiveness” of interventions by a rural ground transport service in the interior of British ColumbiaAccuracy of trauma patient transfer documentation in BCPostoperative echocardiogram after penetrating cardiac injuries: a retrospective studyLoss to follow-up in trauma studies comparing operative methods: a systematic reviewWhat matters where and to whom: a survey of experts on the Canadian pediatric trauma systemA quality initiative to enhance pain management for trauma patients: baseline attitudes of practitionersComparison of rotational thromboelastometry (ROTEM) values in massive and nonmassive transfusion patientsMild traumatic brain injury defined by GCS: Is it really mild?The CMAC videolaryngosocpe is superior to the glidescope for the intubation of trauma patients: a prospective analysisInjury patterns and outcome of urban versus suburban major traumaA cost-effective, readily accessible technique for progressive abdominal closureEvolution and impact of the use of pan-CT scan in a tertiary urban trauma centre: a 4-year auditAdditional and repeated CT scan in interfacilities trauma transfers: room for standardizationPediatric trauma in situ simulation facilitates identification and resolution of system issuesHospital code orange plan: there’s an app for thatDiaphragmatic rupture from blunt trauma: an NTDB studyEarly closure of open abdomen using component separation techniqueSurgical fixation versus nonoperative management of flail chest: a meta-analysisIntegration of intraoperative angiography as part of damage control surgery in major traumaMass casualty preparedness of regional trauma systems: recommendations for an evaluative frameworkDiagnostic peritoneal aspirate: An obsolete diagnostic modality?Blunt hollow viscus injury: the frequency and consequences of delayed diagnosis in the era of selective nonoperative managementEnding “double jeopardy:” the diagnostic impact of cardiac ultrasound and chest radiography on operative sequencing in penetrating thoracoabdominal traumaAre trauma patients with hyperfibrinolysis diagnosed by rotem salvageable?The risk of cardiac injury after penetrating thoracic trauma: Which is the better predictor, hemodynamic status or pericardial window?The online Concussion Awareness Training Toolkit for health practitioners (CATT): a new resource for recognizing, treating, and managing concussionThe prevention of concussion and brain injury in child and youth team sportsRandomized controlled trial of an early rehabilitation intervention to improve return to work Rates following road traumaPhone call follow-upPericardiocentesis in trauma: a systematic review. Can J Surg 2013. [DOI: 10.1503/cjs.005813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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