Trends of Trauma Admissions in a Rural Trauma Center During Coronavirus Disease 2019 Pandemic.

INTRODUCTION: The spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) led to implementing strict social distancing mandates nationwide. This study evaluates the trauma trends during the pandemic at a rural level II trauma center in Pennsylvania. METHODS: A retrospective review of all trauma registries between 2018 and 2021 was performed overall and on a 6-month basis. Injury severity score, injury types-blunt versus penetrating, and mechanisms of injury were compared across the years. RESULTS: A total of 3056 patients in 2018-2019 and 2506 patients in 2020-2021 were evaluated as the historic control and study group, respectively. The median age of the patients was 63 and 62 years in the control and the study group, respectively (P = 0.616). There was an overall significant decline in blunt injuries and an increase in penetrating injuries (Blunt: 2945 versus 2329, Penetrating: 89 versus 159, P < 0.001). Injury severity score was not different across the eras. Falls, motorcycle accidents, motor vehicle accidents, and all-terrain vehicles comprised most of the blunt traumas. Penetrating injuries secondary to assault with firearms and sharp weapons had an increasing trend. CONCLUSIONS: There was no association between trauma numbers and the beginning of the pandemic. Overall, there was a decline in trauma numbers during the second 6 mo of the pandemic. There was an increase in injuries involving firearms and stabbing. Rural trauma centers have a unique demographic and admission trend that should be considered while advising regulatory changes during pandemics.

Possible Predictive Factor of Acute Respiratory Distress Syndrome Development After Mild Traumatic Brain Injury: A Single Rural Trauma Center Preliminary Study.

Introduction Acute respiratory distress syndrome (ARDS) after mild traumatic brain injury (TBI) can be associated with significant morbidity and mortality. This study aimed to evaluate the potential predictive factors of ARDS development following mild TBI in trauma patients. Methods A retrospective chart review was done for adult trauma patients with mild TBI (GCS 13-15) requiring admission at our center from 2012 to 2020. Linear regression analysis and chi-square test were utilized to identify independent predictors of the association with ARDS in adults with mild TBI.  Results A total of 784 mild TBI patients were admitted during the time of interest; 34 patients developed ARDS during their index hospitalization. Patients who had ARDS were more likely to have acute kidney injury (AKI; p < 0.0001), sepsis (p < 0.01), rib fractures (p < 0.05), use of anticoagulants (p < 0.001), deep vein thrombosis (p < 0.001), transfusion during the first 4four hours upon admission (p = 0.01), intravenous fluid (IVF) resuscitation during the first four hours (p <0.05), the first eight hours (p = 0.01), the first 12 hours (p = 0.03), and intubation upon the admission (p < 0.0001). ARDS associated with mild TBI demonstrated a statistically significant increase in mortality during the index hospitalization (p < 0.0001). Conclusion ARDS after mild TBI can be associated with significant morbidity and mortality. Key risk factors identified include AKI, sepsis, anticoagulant use, deep vein thrombosis (DVT), transfusion in the first four hours, IVF resuscitation in the first four, eight, and 12 hours, and intubation upon admission.

Proper use of noncontact infrared thermometry for temperature screening during COVID-19.

Among the myriad of challenges healthcare institutions face in dealing with coronavirus disease 2019 (COVID-19), screening for the detection of febrile persons entering facilities remains problematic, particularly when paired with CDC and WHO spatial distancing guidance. Aggressive source control measures during the outbreak of COVID-19 has led to re-purposed use of noncontact infrared thermometry (NCIT) for temperature screening. This study was commissioned to establish the efficacy of this technology for temperature screening by healthcare facilities. We conducted a prospective, observational, single-center study in a level II trauma center at the onset of the COVID-19 outbreak to assess (i) method agreement between NCIT and temporal artery reference temperature, (ii) diagnostic accuracy of NCIT in detecting referent temperature [Formula: see text] and ensuing test sensitivity and specificity and (iii) technical limitations of this technology. Of 51 healthy, non-febrile, healthcare workers surveyed, the mean temporal artery temperature was [Formula: see text] ([Formula: see text] confidence interval (CI) = [Formula: see text]). Mean NCIT temperatures measured from [Formula: see text], [Formula: see text], and [Formula: see text] distances were [Formula: see text] [Formula: see text], [Formula: see text] [Formula: see text], and [Formula: see text] [Formula: see text], respectively. From statistical analysis, the only method in sufficient agreement with the reference standard was NCIT at [Formula: see text]. This demonstrated that the device offset (mean temperature difference) between these methods was [Formula: see text] ([Formula: see text]) with 95% of measurement differences within [Formula: see text] ([Formula: see text]) and [Formula: see text] ([Formula: see text]). By setting the NCIT screening threshold to [Formula: see text] at [Formula: see text], we achieve diagnostic accuracy with [Formula: see text] test sensitivity and specificity for temperature detection [Formula: see text] by reference standard. In comparison, reducing this screening criterion to the lower limit of the device-specific offset, such as [Formula: see text], produces a highly sensitive screening test at [Formula: see text], which may be favorable in high-risk pandemic disease. For future consideration, an infrared device with a higher distance-to-spot size ratio approaching 50:1 would theoretically produce similar results at [Formula: see text], in accordance with CDC and WHO spatial distancing guidelines.

Impact of Protocol Utilizing Water-Soluble Contrast for Adhesive Small Bowel Obstruction.

INTRODUCTION: Adhesive small bowel obstruction (ASBO) has classically been managed with nasogastric tube decompression and watchful waiting. Our group developed an evidence-based protocol to manage ASBO utilizing a water-soluble contrast (WSC) agent. We hypothesized the protocol would decrease the length of stay (LOS) for patients admitted with ASBO along with the time interval from admission to surgery. METHOD: From 2010 to 2018, a retrospective review was performed, including all patients admitted with a diagnosis of ASBO. These patients were divided into two groups: the preprotocol group included years 2010-2013 and the postprotocol group included years 2015-2018. A Student t-test and a two-proportion z-test were used for statistical analysis. RESULT: We captured 767 patients; 296 in the preprotocol group and 471 in the postprotocol group. We found a significant decrease in overall LOS between the preprotocol and postprotocol groups (6.56 d versus 4.08 d; P < 0.001) along with decreases in LOS for patients managed nonoperatively (5.36 d versus 3.42 d; P < 0.001) and operatively (16.09 d versus 9.47 d; P < 0.001). Time interval from admission to the operation was significantly decreased in the postprotocol group (3.79 d versus 2.10 d; P < 0.050). We identified a trend toward decreased rates of bowel ischemia and resections with our protocol. CONCLUSIONS: These results reaffirm previous reports of WSC's impact on overall LOS in ASBO while showing a similar impact on both operative and nonoperative groups. The decreased time interval between admission and operation may impact the incidence of bowel ischemia and resections.

Closing Contaminated Fascial Defects With Synthetic Mesh and a Vacuum-Assisted Closure Device.

BACKGROUND: The use of synthetic mesh is considered too high risk, and therefore, not an option when closing a contaminated abdominal fascial defect. This study evaluated the clinical outcomes when using synthetic mesh combined with vacuum-assisted closure (VAC) dressing to close these facial defects. MATERIALS AND METHODS: From 2010 to 2016, a retrospective review was performed, including 34 patients in a single rural trauma center who underwent a damage control laparotomy in the presence of a contaminated or infected field. Definitive abdominal closure with a bridging polypropylene mesh along with the application of a VAC dressing was done in all cases. Data collection included baseline demographics, operative indication, postoperative complications, mortality and length of follow up. RESULTS: Median age of the patients was 67 y (IQR 40-87 y), with 22 (65%) being male at the time of operation. The median duration of clinical follow-up was 15.15 mo. The observed complications included three fistulas, two hernias, nine draining sinus tracts, and three mesh explanations with an overall complication rate of 41.1%. Although the absolute observed fistula rate was 8.8% (3 cases), the adjusted mesh-related fistulas formation rate after chart review was 0.0%. No mortalities were attributed directly to mesh-related complication. CONCLUSIONS: This study found no mesh-related fistulas when using a synthetic mesh along with a VAC dressing for abdominal closure in a contaminated field. These results may provide a platform for further study regarding the safety of this technique.

Rare aetiology of abdominal pain: contained abscess secondary to perforated jejunal diverticulitis.

A patient with a history of multiple jejunal diverticulosis (JD) presented with a non-peritonitic abdominal pain and leucocytosis. CT scan showed a thick-walled interloop collection within the left mid-abdomen with dilated bowels and mild diffuse air-fluid levels. Exploratory laparotomy revealed multiple diverticular outpouchings in the mid-jejunum, one of which was perforated, contained within the mesentery. Resection of the contained abscess and primary anastomosis were performed subsequently.

A novel protocol to maintain continuous access to thawed plasma at a rural trauma center.

BACKGROUND: Early administration of plasma improves mortality in massively transfused patients, but the thawing process causes delay. Small rural centers have been reluctant to maintain thawed plasma due to waste concerns. Our 254-bed rural Level II trauma center initiated a protocol allowing continuous access to thawed plasma, and we hypothesized its implementation would not increase waste or cost. METHODS: Two units of thawed plasma are continuously maintained in the trauma bay blood refrigerator. After 3 days, these units are replaced with freshly thawed plasma and returned to the blood bank for utilization prior to their 5-day expiration date. The blood bank monitors and rotates the plasma. Only trauma surgeons can use the plasma stored in the trauma bay. Wasted units and cost were measured over a 12-month period and compared with the previous 2 years. RESULTS: The blood bank thawed 1127 units of plasma during the study period assigning 274 to the trauma bay. When compared with previous years, we found a significant increase in waste (p < 0.001) and cost (p = 0.020) after implementing our protocol. It cost approximately US $125/month extra to maintain continuous access to thawed plasma during the study period. DISCUSSION: A protocol to maintain thawed plasma in the trauma bay at a rural Level II trauma center resulted in a miniscule increase in waste and cost when considering the scope of maintaining a trauma center. We think this cost is also minimal when compared with the value of having immediate access to thawed plasma. Constant availability of thawed plasma can be offered at smaller rural centers without a meaningful impact on cost. LEVEL OF EVIDENCE: Economic and Value-based Evaluations, Level III.

Rolling a trauma patient onto the right side increases sensitivity of FAST examination.

PURPOSE: Hemoperitoneum in the hypotensive trauma patient is an indication for emergent laparotomy. Focused assessment sonography in trauma (FAST) is a widely used tool for detecting hemoperitoneum. The usefulness of FAST is currently limited by low sensitivity. We hypothesize rolling patients onto their right side will pool small volumes of fluid into the right upper quadrant of the abdomen leading to increased sensitivity. METHODS: Peritoneal dialysis patients were recruited for voluntary participation in a small pilot prospective clinical trial. Each participant first underwent a supine FAST followed by a 30-second roll onto the right side. Once back in the supine position, the FAST was repeated (FASTeR or FAST examination after right-sided roll). About 50 mL aliquots of dialysate were sequentially infused into the abdomen and the imaging sequence repeated until a positive finding was obtained. RESULTS: Seven patients were consented for the study. One patient was found to have an equivocal examination secondary to renal cysts. All six remaining participants converted to a positive FASTeR at an intra-abdominal fluid volume at which standard FAST was negative. CONCLUSIONS: Rolling patients to the right side increased FAST sensitivity, converting false-negative to true positives examinations. A larger study is needed to validate our preliminary data.

Rethinking the Use of Routine Platelet Transfusions for Head Injured Patients on Antiplatelet Therapy.

Traumatic brain injury is responsible for over one million hospital visits, and thousands of deaths annually. The aging population is associated with an increased use of anticoagulation and antiplatelet agents which complicates traumatic brain injury. The use of antiplatelet agents significantly increases baseline risk of intracranial hemorrhage. However, routine platelet transfusion in an attempt to reverse the effects of antiplatelet agents may be detrimental. Here, we report a case of an elderly woman with mild traumatic brain injury, who suffered a tragic demise after platelet transfusion.

Addition of Advanced Practice Providers May Improve ABSITE Scores Through Enhanced Resident Education.

BACKGROUND: Resident work hour restrictions and required protected didactic time limit their ability to perform clinical duties and participate in structured education. Advanced practice providers (APPs) have previoulsy been shown to positively impact patients' outcomes and overall hospital costs. We describe a model in which nurse practitioners (NPs) improve resident education and American Board of Surgery In Training Examination (ABSITE) scores by providing support to our trauma and acute care surgery (ACS) service thereby protecting resident didactic time. MATERIALS AND METHODS: A new educational model aimed to improve ABSITE scores was created, increasing protected resident didactic time. The addition of three full-time NPs to the ACS service allowed implementation of this redesigned academic curriculum to be put into effect without neglecting patient or service-related responsibilities that were previously fulfilled by resident staff. Resident ABSITE results including standard score, percent correct, and percentile were compared before and after the educational changes were instituted. RESULTS: Eleven residents' scores were included. For each ABSITE score, we used a mixed model with time and postgraduate year (PGY) level as fixed effects and subject ID as a random effect. The interaction term between PGY level and time was not significant and removed from the model. A significant main effect of PGY level and of time was then observed. A statistically significant improvement in ABSITE scores after intervention was observed across all the PGY levels. Standard score increased 77.3 points (P-value = 0.001), percent correct increased 5.9% (P-value = 0.002), and percentile increased 23.8 (P-value = 0.02). Following the educational reform, no residents scored below the 35th percentile. CONCLUSIONS: Utilization of NPs on our ACS service provided adequate service coverage, allowing the implementation of an educational reform increasing protected resident education time and improved ABSITE scores.

Injury Severity Score alone predicts mortality when compared to EMS scene time and transport time for motor vehicle trauma patients who arrive alive to hospital.

OBJECTIVE: This study aims to identify the association, if any, between prehospital scene time, prehospital transport time, and Injury Severity Score (ISS) with in-hospital mortality. METHODS: A retrospective analysis was performed on patients at least 18 years of age who arrived to the hospital alive via emergency medical services (EMS) after a motor vehicle collision (MVC) between 1992 and 2016. These patients were divided into groups based on minutes spent at the scene and in transport. The ISS of the in-hospital mortalities, as well as the entire patient sample for each time frame, was collected. Patients without documented scene time, transport time, or ISS were excluded. RESULTS: Four thousand one hundred ninety-four patients were captured when analyzing scene time, though only 3,980 met inclusion criteria. In addition, 4,177 patients were captured when analyzing transport time, though only 3,979 met inclusion criteria. Scene time and transport time were not statistically significant predictors of in-hospital mortality (P = .31 and P = .458, respectively). ISS was found to be a statistically significant predictor of in-hospital mortality (P < .001). CONCLUSIONS: ISS predicts mortality independent of scene time or transport time for patients who arrive to the hospital alive following an MVC at Guthrie Robert Packer Hospital. Limitations of our study include inability to capture prehospital deaths and inability to correlate ISS with prehospital injury severity scores.

Fulminant Hepatic Failure and Fatal Cerebral Edema Following Clostridium perfringens Bacteremia: Case Report and Review of Literature.

Clostridium perfringens (CP) bacteremia is a rare but rapidly fatal infection. Only 36 cases of CP bacteremia with gas containing liver abscesses on image studies have been reported in the literature since 1990. In this report, we describe a 65-year-old diabetic male with CP bacteremia which progressed into fulminant hepatic failure with subsequent fatal cerebral edema.