Failure rates of nonoperative management of low-grade splenic injuries with active extravasation: an Eastern Association for the Surgery of Trauma multicenter study.

Objectives: There is little evidence guiding the management of grade I-II traumatic splenic injuries with contrast blush (CB). We aimed to analyze the failure rate of nonoperative management (NOM) of grade I-II splenic injuries with CB in hemodynamically stable patients. Methods: A multicenter, retrospective cohort study examining all grade I-II splenic injuries with CB was performed at 21 institutions from January 1, 2014, to October 31, 2019. Patients >18 years old with grade I or II splenic injury due to blunt trauma with CB on CT were included. The primary outcome was the failure of NOM requiring angioembolization/operation. We determined the failure rate of NOM for grade I versus grade II splenic injuries. We then performed bivariate comparisons of patients who failed NOM with those who did not. Results: A total of 145 patients were included. Median Injury Severity Score was 17. The combined rate of failure for grade I-II injuries was 20.0%. There was no statistical difference in failure of NOM between grade I and II injuries with CB (18.2% vs 21.1%, p>0.05). Patients who failed NOM had an increased median hospital length of stay (p=0.024) and increased need for blood transfusion (p=0.004) and massive transfusion (p=0.030). Five patients (3.4%) died and 96 (66.2%) were discharged home, with no differences between those who failed and those who did not fail NOM (both p>0.05). Conclusion: NOM of grade I-II splenic injuries with CB fails in 20% of patients. Level of evidence: IV.

Safer neighborhoods? Violent crime and trauma volume pre/post targeted police interventions in Dallas, Texas.

BACKGROUND: Project Safe Neighborhoods: Dallas (PSND) is part of a national initiative that partners federal, state, and local stakeholders and law enforcement to reduce violent crime, especially firearm violence, in select communities. The authors' hospital is located centrally in PSND's target areas, and the trauma center's service area fully covers the target areas. This cohort study evaluated PSND's effectiveness by examining if PSND's April 2018 launch was associated with decreases in (1) violent crime or (2) the rate of patients presenting with firearm and assaultive injuries. METHODS: Data on violent crime (murder/non-negligent homicide, robbery, and aggravated assault) were obtained from all municipalities in the county for January 2015 - December 2020. Patient volume data were queried from the trauma registry for the same period. Nonlinear spatiotemporal models were used to calculate estimated rates and confidence intervals; derivatives were used to determine periods of significant change. Spatial point pattern tests assessed potential relocation of criminal activity. Given the importance of reducing violent crime, alpha was set at 0.05. RESULTS: The target areas' violent crime rate remained higher than the non-target areas' throughout the study period, and target area violent crime non-significantly increased after PSND's launch. Violent crime in the non-target area increased significantly between February 2018 and February 2019. Part of this increase was attributable to a 7-fold increase (odds ratio [95% confidence interval] = 7.32 [2.58, 30.65], p < 0.001) in one police patrol beat just outside of the target areas. After years of decreases, rates of patients presenting with assaultive injuries or firearm injuries began significantly increasing and nearly doubled within two years of PSND. CONCLUSIONS: Results suggest PSND was ineffective. Criminal activity in the target area was not reduced relative to its pre-intervention levels or relative to the non-target areas. Offenders may have moved outside the target areas to evade increased scrutiny. Additionally, rates of firearm and assaultive injuries increased. As trusted third parties, trauma centers should consider evaluating local crime and injury prevention programs for effectiveness.

Utilizing psoas muscle cross-sectional area to predict functional outcome.

Background: This study evaluated psoas muscle area (PMA) as a predictor of frailty and functional outcome in trauma patients. Methods: The cohort included 211 trauma patients admitted to an urban level I trauma center from March 2012 to May 2014 who consented to participate in a longitudinal study and underwent abdominal-pelvic computed tomography scans during their initial evaluation. Physical component scores (PCS) of the Veterans RAND 12-Item Health Survey were administered to assess physical functionality at baseline and at 3, 6, and 12 months after injury. PMA in mm2 and Hounsfield units was calculated using the Centricity PACS system. Statistical models were stratified by injury severity score (ISS), <15 or ≥15, and adjusted for age, sex, and baseline PCS. Follow-up PCS were analyzed using general linear regression models. Results: For participants with an ISS <15, increased PMA was significantly associated with higher PCS at 3 (P = 0.008), 6 (P = 0.02), and 12 months (P = 0.002), although this relationship was not statistically significant for ISS ≥15 (P = 0.85, 0.66, 0.61). Conclusion: For mild to moderately injured (but not seriously injured) patients, those with larger psoas muscles experience better functional outcomes after injury.

Role of Serial Phlebotomy in the Management of Blunt Solid Organ Injury in Adults.

BACKGROUND: The management of blunt spleen and liver trauma has become increasingly nonoperative. There is no consensus on timing or duration of serial hemoglobin and hematocrit monitoring in this patient population. OBJECTIVE: This study examined the clinical utility of serial hemoglobin and hematocrit monitoring. We hypothesized that most interventions occur early in the hospital course, based on hemodynamic instability or physical examination findings rather than serial monitoring. METHODS: We conducted a retrospective cohort study of adult trauma patients with blunt spleen or liver injury from November 2014 through June 2019 at our Level II trauma center. Interventions were classified as no intervention, surgical intervention, angioembolization, or packed red blood cell transfusion. Demographics, length of stay, total blood draws, laboratory values, and clinical triggers preceding intervention were reviewed. RESULTS: A total of 143 patients were studied, of whom 73 (51%) received no intervention, 47 (33%) received an intervention within 4 hr of presentation, and 23 (16%) had interventions beyond 4 hr. Of these 23 patients, 13 received an intervention based on phlebotomy results alone. Most of these patients (n = 12, 92%) received blood transfusion without further intervention. Only one patient underwent operative intervention based on serial hemoglobin results on hospital day 2. CONCLUSION: The majority of patients with these injury patterns either require no intervention or declare themselves promptly after arrival. Serial phlebotomy after initial triage and intervention may add little value in the management of blunt solid organ injury.

Feasibility assessment for use of Rh-positive blood products during emergency resuscitation in the North Texas trauma population.

The purpose of this study was to evaluate the extent to which a blood bank policy aimed at decreasing the risk of hemolytic disease of the fetus and newborn (HDFN) by limiting emergency-release blood to Rh-negative blood products is effective. We conducted a retrospective review of the trauma registry for all trauma patients evaluated at our level II trauma center. Patients who received blood products within 4 h of arrival were included. Focused chart review was performed to describe the ABO type, Rh blood type, and sex of the blood recipient in the study population. We identified 262 patients who received emergent transfusion, including 64 women. Four of the 64 women (6%) were Rh negative. Of these, one was of childbearing potential, which represents 0.4% of the 262 patients who received emergency-release blood products and 1.6% of the 64 women emergently transfused following trauma. During our study interval, 1527 units of blood were transfused to patients who could have received Rh-positive blood without concern for HDFN. The proscription against Rh-positive blood as an emergency-release blood product only minimally reduces the risk of development of future HDFN in our trauma population.

Cocoon abdomen after chronic peritoneal dialysis.

A 66-year-old man presented with nausea, vomiting, and ascites. At laparotomy, an extensive fibrosis of the peritoneum was found to encase the bowel in a cocoon-like fashion. A meticulous dissection was undertaken to strip this encapsulating membrane from the bowel. Histologic study of the excised tissue disclosed extensive hyalinized fibroconnective tissue.