The impact of early hormonal therapy in catastrophic brain-injured patients and its effect on organ procurement.

The purpose of this study was to evaluate the impact of early hormonal therapy on organ procurement from catastrophic brain-injured patients. All catastrophic brain-injured patients admitted to a high-volume academic Level I trauma center who underwent successful organ procurement over a 3-year period (2006 to 2008) were reviewed. Patients were divided into two groups, those who received hormone therapy (HT) before brain death (BD) declaration and those who received HT after BD declaration. Thirty-two (60.4%) received HT before BD and 21 (39.6%) HT after BD. Trauma was the most common cause of brain injury in both groups (before BD 96.9 vs after BD 90.5%, P = 0.324). There were no significant differences in demographics and clinical data. Patients receiving HT before BD were more hypotensive on admission (28.2 vs 9.5%, P = 0.048); however, they required vasopressors less frequently (62.5 vs 100.0%, P = 0.001), for a shorter duration (17.2 ± 16.3 hours vs 33.1 ± 34.9 hours, P = 0.043), and at a lower dosage. Time from admission to procurement did not differ between the two groups (109.8 ± 83.1 hours vs 125.0 ± 79.9 hours, P = 0.505). Patients receiving HT before BD had significantly more organs procured (4.5 ± 1.5 vs 3.5 ± 1.3, P = 0.023). Although catastrophic brain-injured patients receiving early hormonal therapy were more hypotensive, they required less vasopressors and had higher procurement rates. The early use of hormonal therapy may decrease the need for vasopressors and increase the salvage of potentially transplantable organs.

Prospective evaluation of selective nonoperative management of torso gunshot wounds: when is it safe to discharge?

BACKGROUND: Selective nonoperative management (NOM) has been increasingly used for torso gunshot wounds (GSWs). The optimal observation time required to exclude a hollow viscus injury is not clear. The purpose of this study was to determine the safe period of observation before discharge. METHODS: All patients aged 16 years and older sustaining a torso GSW undergoing a trial of NOM were prospectively enrolled (January 2009 to January 2011). Patient demographics, initial computed tomography (CT) results, time to failure of NOM, operative procedures, and outcomes were collected. Failure of NOM was defined as the need for operation. RESULTS: A total of 270 patients sustained a GSW to the torso. Of those, 25 patients (9.3%) died in the emergency department and were excluded leaving 245 patients available for the analysis. Mean age was 26.5 years ± 9.9 years (16-62 years), 92.7% (227) were men, and mean Injury Severity Score scale was 13.8 ± 11.3 (1-45). Overall, 115 patients (46.9%) underwent immediate exploratory laparotomy based on clinical criteria (72.2% had peritonitis, 27.8% hypotension, 10.4% unevaluable, and 4.3% evisceration), and 130 patients (53.1%) underwent evaluation with CT for possible NOM. Of those, 39 patients (30.0%) had a positive CT and were subsequently operated on. All had significant intra-abdominal injuries requiring surgical management. A total of 91 patients (70.0%) underwent a trial of NOM (47 had equivocal CT findings and 44 had a negative examination). Of these, 8 patients (8.8%) failed NOM and underwent laparotomy (all had equivocal CT scans). Two patients had a nontherapeutic laparotomy; the remainder had stomach (50.0%), colon (25.5%), and rectal (12.5%) injuries. The mean time from admission to development of clinical or laboratory signs of NOM failure was 2 hours:43 minutes ± 2 hours:23 minutes (0 hour:31 minutes-6 hours:58 minutes). All patients failed within 24 hours of admission. CONCLUSION: In the initial evaluation of patients sustaining a GSW to the torso, clinical examination is essential for identifying those who will require emergency operation. For those undergoing a trial of NOM, all failures occurred within 24 hours of hospital admission, setting a minimum required observation period before discharge.

Effect of age on cervical spine injury in pediatric population: a National Trauma Data Bank review.

BACKGROUND: The objective of this study was to characterize the incidence, risk factors, and patterns of cervical spine injury (CSI) in different pediatric developmental ages. METHODS: A retrospective review of the National Trauma Data Bank was conducted for the period of January 2002 through December 2006 to identify pediatric patients admitted following blunt trauma. Patients were stratified into 4 developmental age groups: infants/toddlers (age 0-3 years), preschool/young children (age 4-9 years), preadolescents (age 10-13 years), and adolescents (age 14-17 years). Patients with a CSI were identified by the International Classification of Diseases, Ninth Revision codes. Demographics, clinical injury data, level of CSI, and outcomes were abstracted and analyzed. RESULTS: A total of 240,647 patients met the inclusion criteria. Of these, 1.3% (n = 3,035) sustained a CSI. The incidence of CSI in the stratified age groups was 0.4% in infants/toddlers, 0.4% in preschool/young children, 0.8% in preadolescents, and 2.6% in adolescents. The level of CSI (upper [C1-C4] vs lower [C5-C7]) according to the age groups was as follows: infants and toddlers, 70% vs 25%; preschool/young children, 74% vs 17%; preadolescents, 52% vs 37%; and adolescents, 40% vs 45%, respectively. The adjusted risk for CSI increased 2-fold in preadolescents and 5-fold in adolescents. CONCLUSION: The incidence of pediatric CSI increases in a stepwise fashion after 9 years of age. We noted an increase in lower CSI and a decrease in upper CSI after the age of 9 years. The incidence of upper CSI compared with lower CSI was higher in preadolescents (52% vs 37%) and almost equal in adolescents (40% vs 45%).

The diagnostic accuracy of 64-slice computed tomography in detecting clinically significant arterial bleeding after pelvic fractures.

The purpose of this study was to determine the diagnostic accuracy of the 64-slice multidetector computed tomography (MDCT) in detecting active pelvic arterial bleeding associated with blunt pelvic fractures. We hypothesized that this modality yields high accuracy. We conducted a retrospective review of all MDCT detected pelvic fractures over an 18-month period admitted to LAC+ USC Medical Center, a Level 1 trauma center. The main outcome was the presence of contrast extravasation (CE) on admission MDCT, consistent with clinically significant arterial bleeding requiring a subsequent embolization or intraoperative ligation of pelvic arteries. Overall, 127 patients met study criteria and 12 per cent (n = 15) had CE on admission MDCT of which four were managed conservatively. Eighty-two per cent (n = 9) of the remaining 11 patients who went on to have invasive procedure had active arterial bleeding that required embolization or surgical ligation. Two of the 112 (1.8%) patients without CE on their admission MDCT were subjected to embolization after further investigation with angiography as a result of the severity of their pelvic fracture and continuous transfusion requirements. The calculated sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of the 64-slice MDCT to identify clinically relevant arterial bleeding were 82, 95, 60, 98, and 94 per cent, respectively. The modern 64-slice MDCT provides relatively high diagnostic accuracy in detecting a clinically relevant arterial hemorrhage after blunt pelvic fracture. Nevertheless, in patients with clinical signs of ongoing hemorrhage, timely angiography or operative intervention is warranted, even in the absence of MDCT contrast extravasation.

Closed suction drain after isolated hollow viscus injury: a friend or foe?

BACKGROUND: The objective of this study was to investigate associations between closed suction intra-abdominal drain placement in isolated hollow viscus injury (HVI) and intra-abdominal deep surgical site infections (DSSI). PATIENTS: Patients undergoing emergent trauma laparotomy at a Level I trauma center after isolated HVI from January 2006 to December 2008 were identified. Study variables extracted from institutional trauma registry and patient electronic medical records included demographics, clinical characteristics, abdominal injuries, drain placement, DSSI, septic events, intensive care unit and hospital length of stay, and mortality. Diagnosis of DSSI was based on abdominal computed tomography scan demonstrating an intra-abdominal collection combined with fever and increased white blood cell count. Patients were analyzed according to the HVI severity and the type of intervention performed: primary repair versus resection and primary reanastomosis. To identify independent associations between surgical management of HVI and DSSI, logistic regression analysis was used. RESULTS: Overall, 131 patients met the study criteria; 20% (n = 26) received an intra-abdominal drain. The incidence of DSSI was significantly higher in patients who received a drain (31% vs. 9%, p = 0.001). No associated risk for development of DSSI in patients who underwent drain placement after primary repair versus resection and primary reanastomosis was demonstrated. Stepwise logistic regression analysis identified the following independent risk factors for development of DSSI: drain utilization (adjusted odds ratio, 3.7; 95% confidence interval, 1.15-11.9; p < 0.028), and Injury Severity Score ≥16 (adjusted odds ratio, 5.6; 95% confidence interval, 1.9-16.9; p < 0.002). In-hospital survival was unchanged with respective interventions. CONCLUSION: Intra-abdominal drain placement after isolated HVI repair is associated with almost fourfold adjusted increased incidence of DSSI. Prospective validation of drain utilization in these instances is warranted.

Liver cirrhosis and traumatic brain injury: a fatal combination based on National Trauma Databank analysis.

The purpose of this study was to evaluate the impact of liver cirrhosis on in-hospital outcomes in victims of isolated traumatic brain injury (TBI). This was a National Trauma Databank study over a 5-year period, including patients with isolated TBI. Propensity scores were calculated to match cirrhotic with noncirrhotic TBI patients in a 1:2 ratio. Primary outcomes included mortality, hospital and surgical intensive care unit length of stay, and ventilator days. Of the 35,005 patients with isolated TBI, 47 (0.13%) had documented liver cirrhosis. After matching with 94 noncirrhotic, isolated TBI patients, no differences with regards to demographic and clinical injury characteristics were observed comparing the two groups. The mean SICU length of stay for cirrhotic and noncirrhotic patients was 5.4 ± 8.8 days and 3.7 ± 7.0 days, respectively (P = 0.079). Cirrhotic patients experienced significantly more ventilator days compared with their noncirrhotic counterparts (2.9 ± 6.4 days vs 2.0 ± 6.4 days; P = 0.001). Overall mortality in the study population was 23.4 per cent with significantly higher in-hospital mortality among cirrhotic versus noncirrhotic TBI patients [34.0% vs 18.1%; odds ratio (95% confidence interval): 2.34 (1.05-5.20); P = 0.035]. Traumatic brain injury in conjunction with liver cirrhosis is associated with two-fold increased mortality and significantly prolonged ventilator requirements when compared with their noncirrhotic counterparts of isolated TBI.

Sex-related differences in childhood and adolescent self-inflicted injuries: a National Trauma Databank review.

BACKGROUND: Recent reports have demonstrated increasing lethality among young women after inflicted injuries (SII). The aim of this study was to examine sex differences in the methods and outcomes of childhood and adolescent SII. METHODS: The National Trauma Databank (v 7.0) was used to identify all patients 18 years or younger who sustained a SII. Demographic data, clinical data, and outcomes were compared between male and female patients. RESULTS: During the study period, a total of 1853 (61.1%) male and 1182 (38.9%) female patients sustained a SII. The most common SII mechanism in male patients was gunshot wound (32.1% vs 6.8%, P < .001); in female patients, poisoning (45.6% vs 9.6%, P < .001). For younger patients (<12 years) hanging was the most common method for both male and female patients (36.5% and 29.2%, respectively). The most lethal method in both male and female patients was gunshot wound (32.3% and 38.0%, respectively). This was followed by hanging which had a high rate of lethality particularly in male adolescents 14 years or younger (36.5% and 33.2% for males <12 years and 12-14 years, respectively). CONCLUSION: Self-inflicted injuries in childhood and adolescence show distinct sex differences primarily with regard to mechanism. Males favor shooting; females, poisoning; younger ages, hanging. Gunshot wound and hanging were the 2 most lethal methods of self-inflicted injury.

Early coagulopathy after isolated severe traumatic brain injury: relationship with hypoperfusion challenged.

INTRODUCTION: The purpose of this study was to examine the incidence of tissue hypoperfusion in victims of severe traumatic brain injury (sTBI) and to determine the associations between hypoperfusion and TBI coagulopathy. METHODS: This is a retrospective analysis of a prospectively collected cohort admitted to the surgical intensive care unit from June 2005 to December 2007 sustaining isolated sTBI, defined as sTBI [head Abbreviated Injury Scale (AIS) ≥ 3] with chest, abdomen, and extremity AIS < 3. Criteria for TBI-associated early coagulopathy included isolated sTBI in conjunction with thrombocytopenia (platelet count < 100,000 per mm³) or elevated international normalized ratio > 1.2 or prolonged activated partial thromboplastin time > 36 seconds at admission. Hypoperfusion was defined by the presence of an arterial base deficit (BD) > 6 mmol/L. Univariate and multivariate analysis was performed to identify associations among hypoperfusion, coagulopathy, and mortality. RESULTS: A total of 132 patients met the study criteria. TBI-associated early coagulopathy occurred in 48 patients (36.4%). With increasing head injury severity, the incidence of coagulopathy increased in a stepwise fashion. Mean BD values and mean lactate values were significantly higher among patients with coagulopathy compared with their noncoagulopathic counterparts at hospital admission. The coagulopathic cohort presented more frequently with a BD > 6 mmol/L at admission (39.6% vs. 20.2%, p = 0.016). In the stepwise logistic regression analysis, head AIS = 5 and an admission BD > 6 mmol/L were independently associated with early coagulopathy. Coagulopathy was associated with increased mortality in patients after blunt head trauma, adjusted odds ratio (95% confidence interval): 3.79 (1.06-13.51); adjusted p = 0.04. CONCLUSION: Hypoperfusion is an independent risk factor for the development of early coagulopathy in patients with isolated sTBI. Nevertheless, early coagulopathy after sTBI does not occur exclusively in patients experiencing tissue hypoperfusion.