Antiplatelet Agent Reversal Is Unnecessary in Blunt Traumatic Brain Injury Patients Not Requiring Immediate Craniotomy.

BACKGROUND: The need to reverse the coagulation impairment caused by chronic antiplatelet agents in traumatic brain injury (TBI) patients with acute traumatic intracerebral hemorrhage (TICH) remains controversial. We sought to determine whether emergent platelet transfusion reduces the incidence of hemorrhage expansion, mortality, or need for neurosurgical intervention such as intracranial pressure (ICP) monitoring, burr holes, or craniotomy. METHODS: All adult blunt TICH patients (age ≥16 years) over a 4-year period were retrospectively reviewed. Patients with penetrating TBI, blunt TBI without TICH on admission computed tomography (CT), receiving warfarin, not on antiplatelet agents, or requiring immediate operative intervention were excluded. Patients were divided into 2 groups depending on whether they received a platelet transfusion: reversal group (RV) versus no reversal group (NR). Patient outcomes were analyzed using Mann-Whitney U and Fisher's exact tests. RESULTS: 169 blunt TBI patients on chronic antiplatelet therapy were studied (102 RV group, 67 NR group). The groups were well matched with regard to age, Injury Severity Score, Abbreviated Injury Scale-head, Glasgow Coma Score, mechanism of injury, need for intubation, time to initial CT scan, and hospital length of stay. Immediate platelet transfusion did not alter the occurrence of TICH extension on follow-up CT (26% vs 21%, P = .71), TBI-specific mortality (9% vs 13%, P = .45), need for ICP monitor (2% vs 3%, P = 1.0), burr hole (1% vs 3%, P = .56), or craniotomy (1% vs 3%, P = .56). DISCUSSION: Immediate platelet transfusion is unnecessary in blunt TBI patients on chronic antiplatelet therapy who do not require immediate craniotomy.

Simulation-Based Testing of Pager Interruptions During Laparoscopic Cholecystectomy.

OBJECTIVE: To determine if pager interruptions affect operative time, safety, or complications and management of pager issues during a simulated laparoscopic cholecystectomy. DESIGN: Twelve surgery resident volunteers were tested on a Simbionix Lap Mentor II simulator. Each resident performed 6 randomized simulated laparoscopic cholecystectomies; 3 with pager interruptions (INT) and 3 without pager interruptions (NO-INT). The pager interruptions were sent in the form of standardized patient vignettes and timed to distract the resident during dissection of the critical view of safety and clipping of the cystic duct. The residents were graded on a pass/fail scale for eliciting appropriate patient history and management of the pager issue. Data was extracted from the simulator for the following endpoints: operative time, safety metrics, and incidence of operative complications. The Mann-Whitney U test and contingency table analysis were used to compare the 2 groups (INT vs. NO-INT). SETTING: Level I trauma center; Simulation laboratory. PARTICIPANTS: Twelve general surgery residents. RESULTS: There was no significant difference between the 2 groups in any of the operative endpoints as measured by the simulator. However, in the INT group, only 25% of the time did the surgery residents both adequately address the issue and provide effective patient management in response to the pager interruption. CONCLUSION: Pager interruptions did not affect operative time, safety, or complications during the simulated procedure. However, there were significant failures in the appropriate evaluations and management of pager issues. Consideration for diversion of patient care issues to fellow residents not operating to improve quality and safety of patient care outside the operating room requires further study.

Nonoperative management rather than endovascular repair may be safe for grade II blunt traumatic aortic injuries: An 11-year retrospective analysis.

BACKGROUND: The Society of Vascular Surgery (SVS) guidelines currently suggest thoracic endovascular aortic repair (TEVAR) for grade II-IV and nonoperative management (NOM) for grade I blunt traumatic aortic injury (BTAI). However, there is increasing evidence that grade II may also be observed safely. The purpose of this study was to compare the outcome of TEVAR and NOM for grade I-IV BTAI and determine if grade II can be safely observed with NOM. METHODS: The records of patients with BTAI from 2004 to 2015 at a Level I trauma center were retrospectively reviewed. Patients were separated into two groups: TEVAR versus NOM. All BTAIs were graded according to the SVS guidelines. Minimal aortic injury (MAI) was defined as BTAI grade I and II. Failure of NOM was defined as aortic rupture after admission or progression on subsequent computed tomography (CT) imaging requiring TEVAR or open thoracotomy repair (OTR). Statistical analysis was performed using Mann-Whitney U and χ tests. RESULTS: A total of 105 adult patients (≥16 years) with BTAI were identified over the 11-year period. Of these, 17 patients who died soon after arrival and 17 who underwent OTR were excluded. Of the remaining 71 patients, 30 had MAI (14 TEVAR vs. 16 NOM). There were no failures in either group. No patients with MAI in either group died from complications of aortic lesions. Follow-up CT imaging was performed on all MAI patients. Follow-up CT scans for all TEVAR patients showed stable stents with no leak. Follow-up CT in the NOM group showed progression in two patients neither required subsequent OTR or TEVAR. CONCLUSIONS: Although the SVS guidelines suggest TEVAR for grade II-IV and NOM for grade I BTAI, NOM may be safely used in grade II BTAI. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Surgical Management of Solid Organ Injuries.

Surgery used to be the treatment of choice in patients with solid organ injuries. This has changed over the past 2 decades secondary to advances in noninvasive diagnostic techniques, increased availability of less invasive procedures, and a better understanding of the natural history of solid organ injuries. Now, nonoperative management (NOM) has become the initial management strategy used for most solid organ injuries. Even though NOM has become the standard of care in patients with solid organ injuries in most trauma centers, surgeons should not hesitate to operate on a patient to control life-threatening hemorrhage.

Analysis of Mortality in Traumatically Injured Patients Based on Body Mass Index and Mechanism Reveals Highest Mortality among the Underweight in Comparison with the Ideal Weight Patients.

The purpose of this study was to evaluate the effect of body mass index (BMI) on mortality after traumatic injury. The records of patients from 2012 to 2015 were retrospectively reviewed. The patients were stratified into the following groups based on admission BMI (kg/m2): underweight (UW) (BMI <19), ideal weight (IW) (BMI = 19-24.9), overweight (OW) (BMI = 25-29.9), obese (OB) (BMI = 30-39.9), and morbid obese (MO) (BMI >40). The groups were well matched with no significant differences in demographics and Injury Severity Score. Morality for the IW group was compared with the remaining BMI groups. A total of 6049 patients were identified. In comparison with IW group, the UW mortality was significantly higher (IW vs UW, 4.1% vs 8.8%, P = 0.001); however, the there was no significant difference with remaining groups. There was also no significant difference in mortality between IW and the remaining groups for patients that went directly to the operating room or for patients that had penetrating trauma (stab wounds and gunshot wounds). However, for blunt trauma, the mortality was significantly higher for UW (IW vs UW, 4.3% vs 9.4%, P = 0.001), no different for IW vs OW (4.3% vs 3.7%, P = 0.3), and significantly lower for IW vs OB (4.3% vs 2.8%, P = 0.04) and for IW vs MO (4.3% vs 1.0%, P = 0.03). After traumatic injuries, it is the underweight patients (BMI <19) and not the obese, that are at a significantly higher risk for overall mortality; this difference is especially evident after blunt trauma where obesity may actually confer a protective role.

To nearly come full circle: Nonoperative management of high-grade IV-V blunt splenic trauma is safe using a protocol with routine angioembolization.

INTRODUCTION: Nonoperative management (NOM) of hemodynamically stable high-grade (IV-V) blunt splenic trauma remains controversial given the high failure rates (19%) that persist despite angioembolization (AE) protocols. The NOM protocol was modified in 2011 to include mandatory AE of all grade (IV-V) injuries without contrast blush (CB) along with selective AE of grade (I-V) with CB. The purpose of this study was to determine if this new AE (NAE) protocol significantly lowered the failure rates for grade (IV-V) injuries allowing for safe observation without surgery and if the exclusion of grade III injuries allowed for the prevention of unnecessary angiograms without affecting the overall failure rates. METHODS: The records of patients with blunt splenic trauma from January 2000 to October 2014 at a Level I trauma center were retrospectively reviewed. Patients were divided into two groups and failure of NOM (FNOM) rates compared: NAE protocol (2011-2014) with mandatory AE for all grade (IV-V) injuries without CB and selective AE for grade (I-V) with CB versus old AE (OAE) protocol (2000-2010) with selective AE for grade (I-V) with CB. RESULTS: Seven hundred twelve patients underwent NOM with 522 (73%) in the OAE group and 190 (27%) in the NAE group. Evolving from the OAE to the NAE strategy resulted in a significantly lower FNOM rate for the overall group (grade I-V) (OAE vs. NAE, 4% to 1%, p = 0.04) and the grade (IV-V) group (OAE vs. NAE, 19% vs. 3%, p = 0.01). Angiograms were avoided in 113 grade (I-III) injuries with no CB; these patients had NOM with observation alone and none failed. CONCLUSIONS: A protocol using mandatory AE of all high-grade (IV-V) injuries without CB and selective AE of grade (I-V) with CB may provide for optimum salvage with safe NOM of the high-grade injuries (IV-V) and limited unnecessary angiograms. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Computed tomography of the head in children with mild traumatic brain injury.

Pediatric Emergency Care Applied Research Network (PECARN) guidelines have a near 100 per cent negative predictive value for clinically important traumatic brain injury (ciTBI) in children with mild head injury (Glasgow Coma Score [GCS] 14 or 15). Our goal was to retrospectively apply their criteria to our database to determine the potential impact on the rates of unnecessary head computed tomography (CT) and ciTBI detection. The records of pediatric patients with GCS 14 to 15 that had a head CT for suspected TBI after blunt trauma from 2008 to 2010 were reviewed. Of 493 children, CT was negative in 447 (91%), but findings were present in 46 (9%). Applying PECARN recommendations, 178 (36%) met all six criteria but still underwent head CT; all were negative. The remaining 315 (64%) missed one or more PECARN criteria and underwent CT; only 46 (15%) had findings, and two (0.6%) required surgery. There were no false-negatives. The negative predictive value for ciTBI was 100 per cent. Observance of PECARN guidelines identifies children who do not require CT, increasing the yield of finding a ciTBI among those who cannot satisfy all six criteria.

More harm than good: antiseizure prophylaxis after traumatic brain injury does not decrease seizure rates but may inhibit functional recovery.

BACKGROUND: The purposes of this study were to examine the current Brain Trauma Foundation recommendation for antiseizure prophylaxis with phenytoin during the first 7 days after traumatic brain injury (TBI) in preventing seizures and to determine if this medication affects functional recovery at discharge. METHODS: The records of adult (age ≥ 18 years) patients with blunt severe TBI who remained in the hospital at least 7 days after injury were retrospectively reviewed from January 2008 to January 2010. Clinical seizure rates during the first 7 days after injury and functional outcome at discharge were compared for the two groups based on antiseizure prophylaxis, no prophylaxis (NP) versus phenytoin prophylaxis (PP). Statistical analysis was performed using χ2. RESULTS: A total of 93 adult patients who met the previously mentioned criteria were identified (43 [46%] NP group vs. 50 [54%] PP group). The two groups were well matched. Contrary to expectation, more seizures occurred in the PP group as compared with the NP group; however, this did not reach significance (PP vs. NP, 2 [4%] vs. 1 [2.3%], p = 1). There was no significant difference in the two groups (PP vs. NP) as far as disposition are concerned, mortality caused by head injury (4 [8%] vs. 3 [7%], p = 1), discharge home (16 [32%] vs. 17 [40%], p = 0.7), and discharge to rehabilitation (30 [60%] vs. 23 [53%], p = 0.9). However, with PP, there was a significantly longer hospital stay (PP vs. NP, 36 vs. 25 days, p = 0.04) and significantly worse functional outcome at discharge based on Glasgow Outcome Scale (GOS) score (PP vs. NP, 2.9 vs. 3.4, p < 0.01) and modified Rankin Scale score (2.3 ± 1.7 vs. 3.1 ± 1.5, p = 0.02). CONCLUSION: PP may not decrease early posttraumatic seizure and may suppress functional outcome after blunt TBI. These results need to be verified with randomized studies before recommending changes in clinical practice and do not apply to penetrating trauma. LEVEL OF EVIDENCE: Therapeutic study, level IV; epidemiologic study, level III.

An analysis of shock index as a correlate for outcomes in trauma by age group.

BACKGROUND: Shock index as the ratio of heart rate to systolic blood pressure is a simple triage tool that correlates well with various outcomes in trauma patients. Concern has been raised regarding the accuracy of shock index in older patients. We sought to investigate the effects of age on the accuracy of shock index. METHODS: This is a retrospective review of data from a level I trauma center. Shock index was calculated for 16,269 patients, and they were stratified into age groups by decade. The correlation between prehospital shock index for each of the age groups and for several outcome variables were evaluated by Pearson correlation coefficients. Logistic regression was used to evaluate an increase in shock index during transit and its relationship with mortality. RESULTS: All correlation values for patients between 16 and 60 years of age were positive (P < .05). In patients who are older than 80 years, none of the correlations with the outcome variables were statistically significant. In patients older than 60 years, an increased shock index during transit correlated with an increase in mortality rates. CONCLUSION: As expected, prehospital shock index alone has diminishing accuracy for patients older than 60 years of age and should be interpreted cautiously by trauma triage personnel. Shock index alone in patients younger than 60, and its increase during transit in patients older than 60, can be used as a valuable tool for the prehospital triage of trauma patients when determining the need for transport to a trauma center, preparation of resources, or activation of the trauma team.

At first blush: absence of computed tomography contrast extravasation in Grade IV or V adult blunt splenic trauma should not preclude angioembolization.

BACKGROUND: To clarify the role, indications, and outcomes for angioembolization (AE) of nonoperatively managed (NOM) splenic trauma, the implications of absent contrast blush (CB) on computed tomography of high-grade (IV-V) blunt splenic trauma (BST) in adults were analyzed. METHODS: All BST patients presenting at a single institution from July 2000 to December 2011 were retrospectively reviewed. Grade of injury (American Association for the Surgery of Trauma scale), CB on initial computed tomography, numbers of NOM and undergoing AE, and failures of NOM were analyzed. Statistical analysis was performed using χ(2). RESULTS: Of the 1,056 total BST patients, 556 (64%) were hemodynamically stable and eligible for NOM; 95 NOM patients (17%) had CB. AE was performed in 88 of these, with angiographic extravasation found in 86 (97.7%), and 3 of these 88 (3.4%) failed NOM. The remaining 7 CBs were observed without AE, of which 5 (71.4%) failed NOM (p = 0.0004). Of all 556 NOM patients, 51 (9.5%) had high-grade injuries without CB; 20 of these (39%) underwent AE, 17 (85.0%) underwent angiographic extravasation, and there were no NOM failures in this group. The other 31 high-grade injuries without CB or AE had 8 failures of NOM (26%) (p = 0.03). CONCLUSION: The strong correlation of CB with active bleeding on angiogram mandates AE for CB in all BST undergoing NOM. However, the absence of CB in high-grade (IV-V) BST does not reliably exclude active bleeding. This may be the reason for the high reported failure rates of NOM in high-grade (IV-V) BST because AE is not typically performed in the absence of CB. These data suggest that all hemodynamically stable high-grade (IV-V) BST in adults should undergo AE regardless of CB to optimize the success and safety of NOM. LEVEL OF EVIDENCE: Therapeutic study, level III.