Diagnostic and therapeutic considerations in cases of civilian intravascular ballistic embolism: a review of case reports.

Background: Ballistic embolism (BE) is a rare complication of firearm injuries notoriously associated with a vexing clinical picture in the trauma bay. Unless considered early, the associated confusion can lead to needless delay in the management of the patient with a gunshot wound. Despite this known entity, there is a relative paucity of high-grade evidence regarding complications, management, and follow-up in these patients. Methods: An electronic database literature search was conducted to identify cases of acute intravascular BE in pediatric and adult civilians occurring during index hospitalization, filtered to publications during the past 10 years. Exclusion criteria included non-vascular embolization, injuries occurring in the military setting, and delayed migration defined as occurring after discharge from the index hospitalization. Results: A total of 136 cases were analyzed. Nearly all cases of BE occurred within 48 hours of presentation. Compared with venous emboli, arterial emboli were significantly more likely to be symptomatic (71% vs. 7%, p<0.001), and 43% of patients developed symptoms attributable to BE in the trauma bay. In addition, arterial emboli were significantly less likely to be managed non-invasively (19% vs. 49%, p<0.001). Open retrieval was significantly more likely to be successful compared with endovascular attempts (91% vs. 29%, p<0.001). Patients with arterial emboli were more likely to receive follow-up (52% vs. 39%) and any attempt at retrieval during the hospitalization was significantly associated with outpatient follow-up (p=0.034). All but one patient remained stable or had clinically improved symptoms after discharge. Conclusion: Consideration for BE is reasonable in any patient with new or persistent unexplained signs or symptoms, especially during the first 48 hours after a penetrating firearm injury. Although venous BE can often be safely observed, arterial BE generally necessitates urgent retrieval. Patients who are managed non-invasively may benefit from follow-up in the first year after injury.

PREVENTion of CLots in Orthopaedic Trauma (PREVENT CLOT): a randomised pragmatic trial protocol comparing aspirin versus low-molecular-weight heparin for blood clot prevention in orthopaedic trauma patients.

INTRODUCTION: Patients who sustain orthopaedic trauma are at an increased risk of venous thromboembolism (VTE), including fatal pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin (LMWH) for VTE prophylaxis in orthopaedic trauma patients. However, emerging literature in total joint arthroplasty patients suggests the potential clinical benefits of VTE prophylaxis with aspirin. The primary aim of this trial is to compare aspirin with LMWH as a thromboprophylaxis in fracture patients. METHODS AND ANALYSIS: PREVENT CLOT is a multicentre, randomised, pragmatic trial that aims to enrol 12 200 adult patients admitted to 1 of 21 participating centres with an operative extremity fracture, or any pelvis or acetabular fracture. The primary outcome is all-cause mortality. We will evaluate non-inferiority by testing whether the intention-to-treat difference in the probability of dying within 90 days of randomisation between aspirin and LMWH is less than our non-inferiority margin of 0.75%. Secondary efficacy outcomes include cause-specific mortality, non-fatal PE and deep vein thrombosis. Safety outcomes include bleeding complications, wound complications and deep surgical site infections. ETHICS AND DISSEMINATION: The PREVENT CLOT trial has been approved by the ethics board at the coordinating centre (Johns Hopkins Bloomberg School of Public Health) and all participating sites. Recruitment began in April 2017 and will continue through 2021. As both study medications are currently in clinical use for VTE prophylaxis for orthopaedic trauma patients, the findings of this trial can be easily adopted into clinical practice. The results of this large, patient-centred pragmatic trial will help guide treatment choices to prevent VTE in fracture patients. TRIAL REGISTRATION NUMBER: NCT02984384.

Removal of the Prehospital Tourniquet in the Emergency Department.

BACKGROUND: Life-threatening hemorrhage from extremity injuries can be effectively controlled in the prehospital environment through direct pressure, wound packing, and the use of tourniquets. Early tourniquet application has been prioritized for rapid control of severe extremity hemorrhage and is a cornerstone of prehospital trauma resuscitation guidelines. Emergency physicians must be knowledgeable regarding the initial assessment and appropriate management of patients who present with a prehospital tourniquet in place. DISCUSSION: An interdisciplinary group of experts including emergency physicians, trauma surgeons, and tactical and Emergency Medical Services physicians collaborated to develop a stepwise approach to the assessment and removal (discontinuation) of an extremity tourniquet in the emergency department after being placed in the prehospital setting. We have developed a best-practices guideline to serve as a resource to aid the emergency physician in how to safely remove a tourniquet. The guideline contains five steps that include: 1) Determine how long the tourniquet has been in place; 2) Evaluate for contraindications to tourniquet removal; 3) Prepare for tourniquet removal; 4) Release the tourniquet; and 5) Monitor and reassess the patient. CONCLUSION: These steps outlined will help emergency medicine clinicians appropriately evaluate and manage patients presenting with tourniquets in place. Tourniquet removal should be performed in a systematic manner with plans in place to immediately address complications.

2019 Recommended Limb Tourniquets in Tactical Combat Casualty Care.

Military and civilian trauma can be distinctly different but the leading cause of preventable trauma deaths in the prehospital environment, extremity hemorrhage, does not discriminate. The current paper is the most comprehensive review of limb tourniquets employable in the tactical combat casualty care environment and provides the first update to the CoTCCC-recommended limb tourniquets since 2005. This review also highlights the lack of unbiased data, official reporting mechanisms, and official studies with established criteria for evaluating tourniquets. Upon review of the data, the CoTCCC voted to update the recommendations in April 2019.

Prospective validation of the Parkland Grading Scale for Cholecystitis.

BACKGROUND: The Parkland Grading Scale for Cholecystitis (PGS) was developed as an intraoperative grading scale to stratify gallbladder (GB) disease severity during laparoscopic cholecystectomy (LC). We aimed to prospectively validate this scale as a measure of LC outcomes. METHODS: Eleven surgeons took pictures of and prospectively graded the initial view of 317 GBs using PGS while performing LC (LIVE) between 9/2016 and 3/2017. Three independent surgeon raters retrospectively graded these saved GB images (STORED). The Intraclass Correlation Coefficient (ICC) statistic assessed rater reliability. Fisher's Exact, Jonckheere-Terpstra, or ANOVA tested association between peri-operative data and gallbladder grade. RESULTS: ICC between LIVE and STORED PGS grades demonstrated excellent reliability (ICC = 0.8210). Diagnosis of acute cholecystitis, difficulty of surgery, incidence of partial and open cholecystectomy rates, pre-op WBC, length of operation, and bile leak rates all significantly increased with increasing grade. CONCLUSIONS: PGS is a highly reliable, simple, operative based scale that can accurately predict outcomes after LC. TABLE OF CONTENTS SUMMARY: The Parkland Grading Scale for Cholecystitis was found to be a reliable and accurate predictor of laparoscopic cholecystectomy outcomes. Diagnosis of acute cholecystitis, surgical difficulty, incidence of partial and open cholecystectomy rates, pre-op WBC, operation length, and bile leak rates all significantly increased with increasing grade.

A comparison of cholecystitis grading scales.

BACKGROUND: Previously, our group developed the Parkland grading scale for cholecystitis (PGS) to stratify gallbladder (GB) disease severity that can be determined immediately when performing laparoscopic cholecystectomy (LC). In prior studies, PGS demonstrated excellent interrater reliability and was internally validated as an accurate measure of LC outcomes. Here, we compare PGS against a more complex cholecystitis severity score developed by the national trauma society, American Association for the Surgery of Trauma (AAST), which requires clinical, operative, imaging, and pathologic inputs, as a predictor of LC outcomes. METHODS: Eleven acute care surgeons prospectively graded 179 GBs using PGS and filled out a postoperative questionnaire regarding the difficulty of the surgery. Three independent raters retrospectively graded these GBs using PGS from images stored in the electronic medical record. Three additional surgeons then assigned separate AAST scores to each GB. The intraclass correlation coefficient statistic assessed rater reliability for both PGS and AAST. The PGS score and the median AAST score became predictors in separate linear, logistic, and negative binomial regression models to estimate perioperative outcomes. RESULTS: The average intraclass correlation coefficient of PGS and AAST was 0.8647 and 0.8341, respectively. Parkland grading scale for cholecystitis was found to be a superior predictor of increasing operative difficulty (R, 0.566 vs. 0.202), case length (R, 0.217 vs. 0.037), open conversion rates (area under the curve, 0.904 vs. 0.757), and complication rates (area under the curve, 0.7039 vs. 0.6474) defined as retained stone, small-bowel obstruction, wound infection, or postoperative biliary leak. Parkland grading scale for cholecystitis performed similar to AAST in predicting partial cholecystectomy, readmission, bile leak rates, and length of stay. CONCLUSION: Both PGS and AAST are accurate predictors of LC outcomes. Parkland grading scale for cholecystitis was found to be a superior predictor of subjective operative difficulty, case length, open conversion rates, and complication rates. Parkland grading scale for cholecystitis has the advantage of being a simpler, operative-based scale which can be scored at a single point in time. LEVEL OF EVIDENCE: Single institution, retrospective review, level IV.

Trauma and emergency general surgery patients should be extubated with an open abdomen.

BACKGROUND: Open abdomen (OA) and temporary abdominal closure (TAC) are common techniques to manage several surgical problems in trauma and emergency general surgery (EGS). Patients with an OA are subjected to prolonged mechanical ventilation. This can lead to increased rates of ventilator-associated pneumonia (VAP). We hypothesized that patients who were extubated with an OA would have a decrease in ventilator hours and as a result would have a lower rate of VAP without an increase in extubation failures. METHODS: A retrospective review was performed of all trauma and EGS patients managed at our institution with OA and TAC from January 2014 to February 2016. Patients were divided into cohorts consisting of those who were successfully extubated with an OA and those who were not. The number of extubation events and ventilator-free hours were calculated for each patient. Adverse events such as the need for reintubation with an OA and VAP were collected. RESULTS: Fifty-two patients (20 trauma, 32 EGS) were managed with an OA and TAC during the study period. Twenty-five patients (6 trauma, 19 EGS) had at least one extubation event with an OA. Median extubation events per patient was 3 (interquartile range, 1-5). The median ventilator-free hours for patients who were extubated was 101 hours (interquartile range, 39.42-260.46). Patients that were never extubated with an OA had higher rates of VAP (30.8% vs. 3.8%, p = 0.01). CONCLUSION: This study provides much needed data regarding the feasibility of extubation in trauma and EGS patients managed with an OA and TAC. Benefits of early extubation may include lower VAP rates in this population. Plans for reexploration hinder the decision to extubate in these patients. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Post-Mortem Evaluation of Potentially Survivable Hemorrhagic Death in a Civilian Population.

BACKGROUND: Although the survivability of military extremity hemorrhage is well documented, equivalent civilian data are limited. We analyzed statewide autopsy records in Maryland to determine the number of hemorrhagic deaths that might have been potentially survivable with prompt hemorrhage control. Similar analyses of battlefield deaths led to life-saving changes in military medical practice. STUDY DESIGN: This is a retrospective study of decedent records. The objective is to estimate the number of hemorrhagic deaths that might have been prevented by prompt placement of an extremity tourniquet. Maryland autopsy records from 2002 to 2016 were selected using the following search terms: amputation, arm/arms, avulsion, exsanguination, extremity/extremities, leg/legs. The records were analyzed by applying a checklist of previously developed military criteria to characterize deaths as potentially survivable or nonsurvivable with prompt use of a tourniquet. Suicides and decedents less than 18 years old were excluded. The study did not use information about living participants. Two expert reviewers independently evaluated and scored the death records. Deaths were classified as either potentially survivable or nonsurvivable. A third reviewer broke any ties. RESULTS: There were 288 full autopsy records included in the final analysis. Of the eligible decedents reviewed during the 14-year period, 124 of 288 had potentially survivable wounds; 164 had nonsurvivable wounds. CONCLUSIONS: Over the 14-year study interval, 124 Maryland decedents-an average of 9 per year-might have been saved with prompt placement of a tourniquet. If extrapolated, approximately 480 people in the US might be saved per year. These results provide evidence to support educating and equipping the public to provide bleeding control.

Inability to predict subprophylactic anti-factor Xa levels in trauma patients receiving early low-molecular-weight heparin.

BACKGROUND: Standard low-molecular-weight heparin dosing may be suboptimal for venous thromboembolism prophylaxis. We aimed to identify independent predictors of subprophylactic Xa (subXa) levels in trauma patients treated under a novel early chemoprophylaxis algorithm. METHODS: A retrospective analysis of trauma patients from July 2016 to June 2017 who received enoxaparin 40 mg twice daily and had peak Xa levels drawn was performed. Patients were divided into cohorts based on having a subXa (<0.2 IU/mL) or prophylactic (≥0.2 IU/mL) Xa level. RESULTS: In all, 124 patients were included, of which 38 (31%) had subXa levels, and 17 (14%) had Xa levels greater than 0.4 IU/mL. Of the subXa cohort, 35 (92%) had their dosage increased, and the repeat Xa testing that was done in 32 revealed that only 75% reached prophylactic levels. The median time to the initiation of chemoprophylaxis was 21.9 hours (interquartile range [IQR], 11.45-35.07 hours). Patients who were defined as having lower risk of having a complication as a result of bleeding had a shorter time to starting prophylaxis than those at higher risk (18.39 hours [IQR 5.76-26.51 hours] vs. 29.5 hours [IQR 16.23-63.07 hours], p < 0.01).There was no difference in demographics, weight, body mass index, creatinine, creatinine clearance, injury severity score, type of injury, weight-based dose, time to chemoprophylaxis, or bleeding complications between the cohorts. No independent predictors of subXa level were identified on multivariable logistic regression. CONCLUSIONS: A significant number of trauma patients fail to achieve prophylactic Xa levels. Intrinsic factors may prevent adequate prophylaxis even with earlier administration and higher dosing of low-molecular-weight heparin. LEVEL OF EVIDENCE: Therapeutic, level IV.

Determining suicide risk in trauma patients using a universal screening program.

BACKGROUND: Trauma patients may be at elevated risk for subsequent suicide; however, it is unclear whether patients at risk can be identified during their initial presentation following injury. The objectives of this study were to evaluate the use of a standardized clinical decision support system for suicide risk screening developed by our hospital system and to determine the incidence of positive suicide screenings in our trauma population. METHODS: Adult trauma patient screenings were performed by nursing staff during the triage process using the Columbia Suicide Severity Rating Scale, Clinical Practice Screener, Recent (C-SSRS). Adult trauma patients who had a suicide risk screening completed from February 2015 to November 2015 were evaluated retrospectively. Patients were divided into cohorts consisting of those with positive and negative screening assessments. Significance was set at α = 0.05. Statistical analysis was performed using Student t test and a χ test where appropriate. RESULTS: Overall, 3,623 of 3,712 patients (98%) completed a suicide risk screening during the study period. Those who went unscreened were not evaluated due to altered mental status/intubation/emergent surgery (97%), death (1%), or an unwillingness to cooperate (2%). The suicide risk screening result was positive in 161 of 3,623 patients (4%) in the study cohort. On univariate analysis, patients with a positive suicide risk screen result were more likely to be white (43% vs 32%; p = 0.01), identify English as their primary language (91% vs 73%; p < 0.01), have insurance coverage (48% vs 28%; p < 0.01), and were more likely to initiate a low-level trauma activation (27% vs 16%; p <0.01) than those who had a negative screening result. A positive suicide risk assessment result was moderately associated with patients of white race (odds ratio, 1.83; 95% confidence interval, 1.27-2.65) on multivariable logistic regression. CONCLUSION: Our universal suicide screening process identifies an at-risk subpopulation of trauma patients. LEVEL OF EVIDENCE: Prognostic study, level III; therapeutic, level IV.

Can CT imaging of the chest, abdomen, and pelvis identify all vertebral injuries of the thoracolumbar spine without dedicated reformatting?

BACKGROUND: The main objective of this study was to compare detection rates of clinically significant thoracolumbar spine (TLS) fracture between computed tomography (CT) imaging of the chest, abdomen, and spine (CT CAP) and CT for the thoracolumbar spine (CT TL). METHODS: We retrospectively identified patients at our institution with a TLS fracture over a two-year period that had both CT CAP and reformatted CT TL imaging. The sensitivity of CT CAP to identify fracture was calculated for each fracture type. RESULTS: A total of 516 TLS fractures were identified in 125 patients using reformatted CT TL spine imaging. Overall, 69 of 512 fractures (13%) were missed on CT CAP that were identified on CT TL. Of those, there were no clinically significant missed fractures. CONCLUSIONS: CT CAP could potentially be used as a screening tool for clinically significant TLS injuries.

The Parkland grading scale for cholecystitis.

BACKGROUND: Gallbladders (GBs) with severe inflammation have longer operative times and an increased risk for complications. We propose a grading system using intraoperative images to better stratify GB inflammation. METHODS: After reviewing the intraoperative images of GBs obtained during several hundred laparoscopic cholecystectomies, we developed a five-tiered grading system based on anatomy and inflammatory changes. Fifty intraoperative photographs were taken prior to dissection and then distributed to 11 surgeons who rated each GB's severity per the grading system. The two-way random effects Intraclass Correlation Coefficient (ICC) was used to assess the reliability among the raters. RESULTS: The ICC among the raters of GB severity was 0.804 (95% CI: 0.733 to 0.867; p = 0.0001). Nineteen GB images had greater than 82% agreement and 16 were clustered around GBs with severe inflammation (grades 3-5). CONCLUSION: This study proposes a simple, reliable grading system that characterizes GB complexity based on inflammation and anatomy.

Population-based estimate of trauma-related deaths for law enforcement personnel: Risks for death are higher and increasing over time.

BACKGROUND: Trauma-related deaths remain an important public health problem. One group susceptible to death due to traumatic mechanisms is US law enforcement (LE). We hypothesized that LE officers experienced a higher chance of violent death compared with the general US population and that risks have increased over time. METHODS: The National Institute on Occupational Safety and Health National Occupational Mortality Surveillance is a population-based survey of occupational deaths. It includes data for workers who died during 1985 to 1998 in one of 30 US states (EARLY period). Additional deaths were added from 23 US states in 1999, 2003 to 2004, 2007 to 2010 (LATE period). Mortality rates are estimated by calculating proportionate mortality ratios (PMR). A PMR above 100 is considered to exceed the average background risk for all occupations. All adults older than 18 years whose primary occupation was listed as "law enforcement worker" were included in the analysis. RESULTS: Law enforcement personnel were more likely to die from an injury compared with the general population (Fig. 1). The overall PMR for injury in EARLY was 111 (95% confidence interval [CI], 108-114; p < 0.01), and for LATE was 118 (95% CI, 110-127; p < 0.01). Four mechanisms of death reached statistical significance: motor vehicle traffic (MVT)-driver, MVT-other, intentional self-harm, and assault/homicide. The highest PMR in EARLY was associated with firearms (PMR, 272; 95% CI, 207-350; p < 0.01). The highest PMR in LATE was associated with death due to being a driver in an MVT (PMR, 194; 95% CI, 169-222; p < 0.01). There were differences in risk of death by race and sex. White females had the highest PMR due to assault and homicide (PMR, 317; 95% CI, 164-554; p < 0.01). All groups had similar risks of death due to intentional self-harm (PMR, 130-171). CONCLUSION: The risk of death for US LE officers is high and increasing over time, suggesting an at-risk population that requires further interventions. Targeted efforts based on risk factors, such as sex and race, may assist with the development of prevention programs for this population. LEVEL OF EVIDENCE: Epidemiologic study, level II.

Cannabis Use Has Negligible Effects Following Severe Traumatic Injury.

Nearly half of all states have legalized medical marijuana or recreational-use marijuana. As more states move toward legalization, the effects on injured patients must be evaluated. This study sought to determine effects of cannabis positivity at the time of severe injury on hospital outcomes compared with individuals negative for illicit substances and those who were users of other illicit substances. A Level I trauma center performed a retrospective chart review covering subjects over a 2-year period with toxicology performed and an Injury Severity Score (ISS) of more than 16. These individuals were divided into the negative and positive toxicology groups, further divided into the marijuana-only, other drugs-only, and mixed-use groups. Differences in presenting characteristics, hospital length of stay, intensive care unit (ICU) stays, ventilator days, and death were compared. A total of 8,441 subjects presented during the study period; 2,134 (25%) of these had toxicology performed; 843 (40%) had an ISS of more than 16, with 347 having negative tests (NEG); 70 (8.3%) substance users tested positive only for marijuana (MO), 323 (38.3%) for other drugs-only, excluding marijuana (OD), and 103 (12.2%) subjects showed positivity for mixed-use (MU). The ISS was similar for all groups. No differences were identified in Glasgow Coma Scale (GCS), ventilator days, blood administration, or ICU/hospital length of stay when comparing the MO group with the NEG group. Significant differences occurred between the OD group and the NEG/MO/MU groups for GCS, ICU length of stay, and hospital charges. Cannabis users suffering from severe injury demonstrated no detrimental outcomes in this study compared with nondrug users.

Evaluating Pre Burn Center Intubation Practices: An Update.

A significant proportion of patients appeared to arrive at our American Burn Association-verified burn center intubated without clear benefit. The current study aims to evaluate regional prehospital intubation practices and their outcomes. All consecutive admissions from November 2012 to June 2014 were reviewed for data points associated with intubation. Demographics and outcomes for patients who were intubated before arrival or within 24 hours of admission were compared using χ, Fisher's exact test, and the Kruskal-Wallis test as appropriate. During this period, 958 patients were admitted. Of these, 120 were intubated before arrival, and 91 survived their injuries. Of these 91 survivors, 45 were extubated within 2 days, suggesting unnecessary intubation rate in 37.5%. Intubation-related complications were roughly three times as common among those intubated before arrival (12.5% vs 4.4%). Patients intubated before arrival to our burn center had a shorter median duration of intubation (1.0 vs 4.0 days), median hospital LOS (5.0 vs 22.0 days), and median intensive care unit length of stay (3.0 vs 10.0 days). Furthermore, we found a significant difference in the pattern of ventilator support duration between those arriving intubated, with a median of 2.0 days, and those intubated at our burn center, with a median of 5.5 days. Patients intubated by pre burn center providers have shorter intubation durations and shorter hospitalizations, suggesting inappropriate use of resources. Impending loss of airway appears unlikely among patients with adequate gas exchange at the time of examination. The current criteria for prehospital intubation should be revised to more accurately identify those who truly benefit from advanced airway maneuvers.