Plan Chest Film Versus Computed Tomography of the Chest as the Initial Imaging Modality for Blunt Thoracic Injury.

BACKGROUND: While chest X-ray (CXR) is an efficient tool for expeditious detection of life-threatening injury, chest computed tomography (CCT) is more sensitive albeit with added time, cost, and radiation. Thus far, there is limited evidence and lack of consensus on the best imaging practices. We sought to determine the association between imaging modality and outcomes in isolated blunt thoracic trauma. METHODS: The 2017-2020 TQIP database was queried for adult patients who sustained isolated blunt chest trauma and underwent chest imaging within 24 hours of admission. Patients who underwent CCT were 2:1 propensity-score-matched to those who underwent CXR. The primary outcome was mortality, and the secondary outcomes were hospital and ICU length of stay (LOS), ICU admission, need for and days requiring mechanical ventilation, complications, and discharge location. RESULTS: Propensity score matching yielded 17 716 patients with CCT and 8861 with CXR. While bivariate analysis showed lower 24-hr (CCT .2% vs CXR .4%, P = .0015) and in-hospital mortality (CCT 1.2% vs CXR 1.5%, P = .0454) in the CCT group, there was no difference in survival probability between groups (P = .1045). A higher percentage of CCT patients were admitted to the ICU (CCT 26.9% vs CXR 21.9%, P < .0001) and discharged to rehab (CCT .8% vs CXR .5%, P = .0178). DISCUSSION: CT offers no survival benefit over CXR in isolated blunt thoracic trauma. While CCT should be considered if clinically unclear, CXR likely suffices as an initial screening tool. These findings facilitate optimal resource allocation in constrained environments.

Utility of intracranial pressure monitoring in patients with traumatic brain injuries: a propensity score matching analysis of TQIP data.

PURPOSE: Intracranial pressure monitoring (ICPM) is central to traumatic brain injury (TBI) management, but its utility is controversial. METHODS: The 2016-2017 TQIP database was queried for isolated TBI. Patients with ICPM [(ICPM (+)] were propensity-score matched (PSM) to those without ICPM [ICPM (-)] and divided into three age groups by years (< 18, 18-54, ≥  55). RESULTS: PSM yielded 2125 patients in each group. Patients aged < 18 years had a higher survival probability (p = 0.013) and decreased mortality (p = 0.016) in the ICPM (+) group. Complications were higher and LOS was longer in ICPM (+) patients aged 18-54 years and ≥ 55 years, but not in patients aged < 18 years. CONCLUSIONS: ICPM (+) is associated with a survival benefit without an increase in complications in patents aged < 18 years. In patients aged ≥ 18 years, ICPM (+) is associated with more complications and longer LOS without a survival benefit.

Transfusion futility thresholds and mortality in geriatric trauma: Does frailty matter?

BACKGROUND: Data on massive transfusion (MT) in geriatric trauma patients is lacking. This study aims to determine geriatric transfusion futility thresholds (TT) and TT variations based on frailty. METHODS: Patients from 2013 to 2018 TQIP database receiving MT were stratified by age and frailty. TTs and outcomes were compared between geriatric and younger adults and among geriatric adults based on frailty status. RESULTS: The TT was lower for geriatric than younger adults (34 vs 39 units; p â€‹= â€‹0.03). There was no difference in TT between the non-frail, frail, and severely frail geriatric adults (37, 30 and 25 units, respectively, p â€‹> â€‹0.05). Geriatric adults had higher mortality than younger adults (63.1% vs 45.8%, p < 0.01). Non-frail geriatric adults had the highest mortality (69.4% vs 56.5% vs 56.2%, p < 0.01). CONCLUSIONS: Geriatric patients have a lower TT than younger adults, irrespective of frailty. This may help improve outcomes and optimize MT utilization.

The catch-22 of promotion: Is becoming department chair of surgery a threat to the triple threat?

BACKGROUND: Despite the "fourth threat" of administrative demands, department chairs of surgery are expected to continue being a "triple threat": productive in research, outstanding in teaching, and exemplary in practice. Increased demands despite limited time are the catch-22 of promotion. This study investigated the influence of becoming department chair on scholarly vigor. METHODS: The surgeons listed in the Society of Surgical Chairs Membership Directory website (n = 118) were included in this study. Three measures were compared during the pre- and post-promotion phases: (1) research productivity (annual publications); (2) authorship position in publications (first-authorship, co-authorship, and senior-authorship); and (3) scholarly impact (m-index and National Institute of Health funding). RESULTS: The median [interquartile range] number of publications per year increased post-promotion versus pre-promotion (7.64 [3.81-14.15] vs 4.12 [2.08-7.03], P < .0005). The median [interquartile range] number of first-authorship publications per year decreased (0.50 [0.00-1.00] vs 0.64 [0.32-1.22], P < .05), whereas the median [interquartile range] number of co-authorship (4.23 [1.98-9.70] vs 2.02 [1.02-3.95], P < .0005) and senior-authorship (1.87 [0.99-4.03] vs 1.00 [0.36-2.24], P < .0005) publications per year increased post-promotion. The mean ± standard deviation m-index increased post-promotion (1.67 ± 1.19 vs 1.23 ± 0.83, P < .01). The mean ± standard deviation annual National Institute of Health grant funding amount of 48% (n = 57) of the department chairs increased post-promotion ($365,000 ± $899,000 vs $98,000 ± $143,000 pre-promotion, P < .05). CONCLUSION: The fourth threat of administrative demands is not a threat to the triple threat. This study showed the department chairs' continued scholarly vigor after promotion, providing insight into their tenacity, resilience, and dedication.

Controversies in Tracheostomy for Patients With COVID-19: The When, Where, and How.

COVID-19 has impacted how we deliver care to patients, and much remains unknown regarding optimal management of respiratory failure in this patient population. There are significant controversies regarding tracheostomy in patients with COVID-19 related to timing, location of procedure, and technique. In this narrative review, we explore the recent literature, publicly available guidelines, protocols from different institutions, and clinical reports to provide critical insights on how to deliver the most benefit to our patients while safeguarding the health care force. Consensus can be reached that patients with COVID-19 should be managed in a negative-pressure environment with proper personal protective equipment, and that performing tracheostomy is a complex decision that should be made through multidisciplinary discussions considering patient prognosis, institutional resources, staff experience, and risks to essential health care workers. A broad range of practices exist because there is no conclusive guidance regarding the optimal timing or technique for tracheostomy.

Improving the performance of the Revised Trauma Score using Shock Index, Peripheral Oxygen Saturation, and Temperature-a National Trauma Database study 2011 to 2015.

BACKGROUND: The Revised Trauma Score is the standard physiologic injury severity indicator used in trauma research and quality control. Shock index, peripheral oxygen saturation, and temperature have emerged as strong predictors for mortality and morbidity. We hypothesized that replacing systolic blood pressure and respiratory rate with age-adjusted shock index and peripheral oxygen saturation and adding temperature would generate a more accurate model, valid across all ages. METHODS: This is a retrospective database analysis using children and adults from the National Trauma Data Bank for years 2011 to 2015. Glasgow Coma Scale, systolic blood pressure, heart rate, respiratory rate, peripheral oxygen saturation, temperature, and shock index (calculated as heart rate/systolic blood pressure) were used as predictor variables, alone or in combination, in logistic models with survival as primary outcome. Bayesian information criterion and area under the receiver operator characteristic curve were used to compare models' performances. To adjust for age, models tested on the entire population (children and adults) used Z-scores derived on age-based homogenous intervals rather than the raw value. RESULTS: The analysis included 283,724 pediatric and 1,555,478 adult patients. Overall mortality was 0.7% and 2.7%, respectively. The Glasgow Coma Scale + shock index + peripheral oxygen saturation + temperature model outperformed the revised trauma score in both adults (Bayesian information criterion 296,345.94 vs 298,494.72; area under the receiver operator characteristic curve 0.831 vs 0.809, P < .001) and children (Bayesian information criterion 12,251.48 vs 12,283.48; area under the receiver operator characteristic curve 0.974 vs 0.968, P = .05) cohorts. On the merged (children and adults) cohort the Glasgow Coma Scale + Z-scores derived on age-based homogenous intervals + peripheral oxygen saturation + temperature model outperformed the Revised Trauma Score (Bayesian information criterion 313,814.78 vs 317,781.31; area under the receiver operator characteristic curve 0.852 vs 0.809, P < .001). CONCLUSIONS: Replacing systolic blood pressure and respiratory rate with shock index and peripheral oxygen saturation in the Revised Trauma Score model and adding temperature generated a more accurate model in both children and adults. Adjusting shock index for age rendered the model accurate across all ages. Calibration on population-derived nomograms of vital signs would further increase the model's accuracy and precision.

The adherence of adult trauma centers to American Pediatric Surgical Association guidelines on management of blunt splenic injuries.

BACKGROUND: Nonoperative management (NOM) is commonly utilized in hemodynamically stable children with blunt splenic injuries (BSI). Guidelines published by the American Pediatric Surgical Association over the past 15 years support this approach. We sought to determine the rates and outcomes of NOM in pediatric BSI and compare trends between pediatric (PTC), mixed (MTC) and adult trauma centers (ATC). METHODS: This was a retrospective database analysis of the NTDB data from 2011 to 2015 including pediatric patients with BSI, as described by ICD-9-CM Codes 865.00-865.09. Patients with head injuries with AIS > 2, multiple intraabdominal injuries, and transfers-out were excluded. According to ACS and/or state designation, trauma facilities were defined as PTC (level I/II pediatric only), MTC (level I/II adult and pediatric) and ATC (level I/II adult only). OM group was defined as presence of procedure codes reflecting exploratory laparotomy/laparoscopy and/or any splenic procedures. NOM group consisted of patients who were observed, transfused or had transarterial embolization (TAE). Variables analyzed were age, ISS, spleen AIS, amount and type of blood products transfused, and intensive care unit (ICU) and hospital (H) length of stay (LOS). RESULTS: 5323 children met the inclusion criteria. 11.4% received care at PTC (NOM, 97%), 40.7% at MTC (NOM, 89.9%) and 47.8% at ATC (NOM, 83.8%) (P < 0.001). In NOM group, PTC patients had the highest spleen AIS (3.46 ±â€¯0.95, P < 0.001). TAE was predominantly used at MTC and ATC (P = 0.001). MTC and ATC were more likely to transfuse than PTC (P = 0.002). MTC and ATC OM rates were lower in children aged ≤12 than in children aged >12 (P < 0.001). Splenectomy rate was 1.5% at PTC, 8.4% at MTC, and 14.4% at ATC (P < 0.001). In OM group, PTC patients had a higher ISS (P = 0.018) and spleen AIS (P = 0.048) than both MTC and ATC. The proportion of patients treated by NOM at ATC increased during the 5-year period studied (P = 0.015). Treatment at MTC or ATC increased the risk for OM by 3.89 and 5.36 times respectively (P < 0.001). CONCLUSIONS: PTCs still outperform ATCs in NOM success rates despite higher ISS and splenic injury grades. From 2011 to 2015, ATC OM rates dropped from 17% to 12.4% suggesting increased adoption of the APSA guidelines. Further educational initiatives may help augment this trend. LEVEL OF EVIDENCE: II TYPE OF STUDY: Retrospective.

Interprofessional Communication Goes Up When the Electronic Health Record Goes Down.

OBJECTIVE: The electronic health record (EHR) has been faulted for the erosion of interprofessional communication and the patient-physician relationship. Surgical residents may be susceptible to communication workarounds facilitated by the EHR, but the full extent is not well understood. A recent ransomware attack with the abrupt return to paper charting provided a unique opportunity to investigate the impact of the EHR on surgical residents' interprofessional communication. We sought to explore how surgical residents perceived communications during the 2-month period when the EHR was inaccessible. DESIGN: General surgery residents who rotated through the regional tertiary referral medical center and level I trauma center were invited to participate in a semistructured interview about communication with one another, faculty, staff, and patients during the downtime. A grounded theory approach was used to analyze the data. SETTING: Regional tertiary referral medical center and level I trauma center. PARTICIPANTS: General surgery residents who rotated through the affected site. RESULTS: Ten general surgery residents were interviewed. Interviews revealed that the abrupt loss of the EHR impacted communication in three major ways: (1) engendered more professional courtesy and collegiality, (2) prioritized bedside patient care over documentation demands, and (3) encouraged more explicit and deliberate communications. CONCLUSIONS: Our study demonstrates that the loss of the EHR encourages surgery residents interprofessional communication. With healthcare becoming increasingly digital, active efforts should be made to preserve the communication benefits by optimizing existing and emerging technology to facilitate direct face-to-face interactions.

Dietary advanced glycation end-products, its pulmonary receptor, and high mobility group box 1 in aspiration lung injury.

BACKGROUND: Gastric aspiration is a significant cause of acute lung injury and acute respiratory distress syndrome. Environmental risk factors, such as a diet high in proinflammatory advanced glycation end-products (AGEs), may render some patients more susceptible to lung injury after aspiration. We hypothesized that high dietary AGEs increase its pulmonary receptor, RAGE, producing an amplified pulmonary inflammatory response in the presence of high mobility group box 1 (HMGB1), a RAGE ligand and an endogenous signal of epithelial cell injury after aspiration. MATERIALS AND METHODS: CD-1 mice were fed either a low AGE or high AGE diet for 4 wk. After aspiration injury with acidified small gastric particles, bronchoalveolar lavage and whole-lung tissue samples were collected at 5 min, 1 h, 5 h, and 24 h after injury. RAGE, soluble RAGE (sRAGE), HMGB1, cytokine and chemokine concentrations, albumin levels, neutrophil influx, and lung myeloperoxidase activity were measured. RESULTS: We observed that high AGE-fed mice exhibited greater pulmonary RAGE levels before aspiration and increased bronchoalveolar lavage sRAGE levels after aspiration compared with low AGE-fed mice. Lavage HMGB1 levels rose immediately after aspiration, peaking at 1 h, and strongly correlated with sRAGE levels in both dietary groups. High AGE-fed mice demonstrated higher cytokine and chemokine levels with increased pulmonary myeloperoxidase activity over 24 h versus low AGE-fed mice. CONCLUSIONS: This study indicates that high dietary AGEs can increase pulmonary RAGE, augmenting the inflammatory response to aspiration in the presence of endogenous damage signals such as HMGB1.