Association Between Geospatial Access to Trauma Center Care and Motor Vehicle Crash Mortality in the United States.

BACKGROUND: Motor vehicle crashes (MVCs) are a leading cause of preventable trauma death in the United States (US). Access to trauma center care is highly variable nationwide. The objective of this study was to measure the association between geospatial access to trauma center care and MVC mortality. METHODS: This was a population-based study of MVC-related deaths that occurred in 3,141 US counties (2017-2020). ACS and state-verified level I-III trauma centers were mapped. Geospatial network analysis estimated the ground transport time to the nearest trauma center from the population-weighted centroid for each county. In this way, the exposure was the predicted access time to trauma center care for each county population. Hierarchical negative binomial regression measured the risk-adjusted association between predicted access time and MVC mortality, adjusting for population demographics, rurality, access to trauma resources, and state traffic safety laws. RESULTS: We identified 92,398 crash fatalities over the four-year study period. Trauma centers mapped included 217 level I, 343 level II, and 495 level III trauma centers. The median county predicted access time was 47 min (IQR 26-71 min). Median county MVC mortality was 12.5 deaths/100,000 person-years (IQR 7.4-20.3 deaths/100,000 person-years). After risk-adjustment, longer predicted access times were significantly associated with higher rates of MVC mortality (>60 min vs. <15 min; MRR 1.36; 95%CI 1.31-1.40). This relationship was significantly more pronounced in urban/suburban vs. rural/wilderness counties (p for interaction, <0.001). County access to trauma center care explained 16% of observed state-level variation in MVC mortality. CONCLUSIONS: Geospatial access to trauma center care is significantly associated with MVC mortality and contributes meaningfully to between-state differences in road traffic deaths. Efforts to improve trauma system organization should prioritize access to trauma center care to minimize crash fatalities. LEVEL OF EVIDENCE: Level III, Epidemiological.

Angioembolization May Improve Survival in Patients With Severe Hepatic Injuries.

INTRODUCTION: Although reports on angioembolization (AE) show favorable results for severe hepatic trauma, information is lacking on its benefit in the management and mechanisms of injury (MOI). This study examined patient outcomes with severe hepatic injuries to determine the association of in-hospital mortality with AE. The hypothesis is that AE is associated with increased survival in severe hepatic injuries. METHODS: Demographics, age, sex, MOI, shock index (SI), ≥6 units packed red blood cells (PRBCs) per hospital length of stay (LOS), intensive care unit LOS, injury severity score (ISS), and AE were collected. The primary outcome was in-hospital mortality. Patients were stratified into groups according to MOI, AE, and operative vs non-operative management. Multivariable logistic regression determined the independent association of mortality with AE vs no AE and operative vs nonoperative management and modeled the odds of mortality controlling for MOI, AE vs no AE, age and ISS groups, SI >.9, and ≥6 units PRBCs/LOS. RESULTS: From 2013 to 2018, 2462 patients (1744 blunt; 718 penetrating) were treated for severe hepatic injuries. AE was used in only 21% of patients. Mortality rates increased with higher ISS and age. AE was associated with mortality when compared to patients who did not undergo AE. The strongest associations with mortality were ISS ≥25, transfusion ≥ 6 units PRBCs/LOS, and age ≥65 years. CONCLUSIONS: AE is underutilized in severe hepatic trauma. AE may be a valuable adjunct in the treatment of severe hepatic injuries especially in older patients and those needing exploratory laparotomy.

The Impact of Flame Burn Injuries on Patients Who Sustain Mild Injuries From Motor Vehicle Crashes.

BACKGROUND: The purpose of this study was to determine the differences in patient outcomes between motor vehicle crash (MVC) victims with an ISS < 15 and those with a similar ISS and a flame burn injury. METHODS: Data for patients involved in a MVC with a GCS ≥12 and an ISS < 15 with and without flame burn injury were reviewed from the American College of Surgeons National Trauma Data Bank between 2007 and 2017. International Classification of Diseases-9 and -10 revisions and External Injury Codes were used to identify patients who were divided into MVC only (Group 1) and MVC with additional flame burn injury (Group 2). In-hospital mortality was the primary outcome whereas secondary outcomes included ICU admission, ICU length of stay (LOS), hospital LOS, sepsis, deep vein thrombosis, acute respiratory distress syndrome, and pneumonia. Simple linear regression was used in the form of odds ratios to investigate risk factors for mortality and secondary outcomes. RESULTS: The mean LOS and ICU LOS were longer in Group 2 (5.9 vs 4.0 days, p-value <0.001, and 1.2 vs 0.6 days, p-value <0.001, respectively), with more patients being admitted to the ICU as well (22.9% vs 17.3%, p-value <0.001). Also, there were significantly higher rates of pneumonia (0.8% vs 0.5%, p-value 0.0014), deep vein thrombosis (0.6% vs 0.4%, p-value 0.028), and acute respiratory distress syndrome (0.5% vs 0.3%, p-value 0.004) in Group 2. Patients in Group 1 were older and more likely had hypertension, congestive heart failure, and COPD. There was no significant difference in mortality between Groups by odds ratios (OR 0.85, p-value 0.743) or raw percentages (0.3% vs 0.3%, p-value = 0.874). CONCLUSION: MVC victims with mild injuries who also sustain a burn injury are more likely to require admission to the ICU regardless of their comorbidities and more likely to develop respiratory complications, especially pneumonia and an increase in ICU and hospital LOS.

Treatment of penetrating cardiac wounds for the general surgeon on call.

ABSTRACT: "Scoop and run" approaches for severely injured patients have been adopted by emergency medical services over the past 40 years. This has resulted in more patients with severe injuries including penetrating cardiac wounds arriving at trauma centers and other acute care hospitals. General surgery trauma teams and general surgeons taking trauma call are the first responders for diagnosis, resuscitation, and operative management of injured patients. By natural selection, 96% to 98% of patients with signs of life on arrival to the trauma center after sustaining a penetrating cardiac wound have injuries that are amenable to repair by a general surgeon, fellow, or senior surgical resident without the need for a cardiothoracic surgeon or cardiopulmonary bypass.This literature and experience-based review summarizes the diagnostic and operative approaches that should be known by all trauma teams and general surgeons taking trauma call. In addition, it describes when a cardiothoracic surgeon should be consulted and briefly reviews how complex penetrating cardiac injuries are repaired.

The use of ultrasound in the acute setting: Lessons learned after 30 years.

This article describes the key events in the evolution of the surgeon's use of ultrasound for the evaluation of patients. The lessons learned may be relevant in the future as the issues encountered with the adoption of ultrasound by surgeons may be revisited.

Review article: History of venous trauma.

ABSTRACT: This is a literature review on the history of venous trauma since the 1800s, especially that to the common femoral, femoral and popliteal veins, with focus on the early 1900s, World War I, World War II, Korean War, Vietnam War, and then civilian and military reviews (1960-2020). In the latter two groups, tables were used to summarize the following: incidence of venous repair versus ligation, management of popliteal venous injuries, patency of venous repairs when assessed <30 days from operation, patency of venous repairs when assessed >30 days from operation, clinical assessment (edema or not) after ligation versus repair, incidence of deep venous thrombosis after ligation versus repair, and incidence of pulmonary embolism after ligation versus repair.There is a lack of the following in the literature on the management of venous injuries over the past 80 years: standard definition of magnitude of venous injury in operative reports, accepted indications for venous repair, standard postoperative management, and timing and mode of early and later postoperative assessment.Multiple factors have entered into the decision on venous ligation versus repair after trauma for the past 60 years, but a surgeon's training and local management protocols have the most influence in both civilian and military centers. Ligation of venous injuries, particularly those in the lower extremities, is well tolerated in civilian trauma, although there is the usual lack of short- and long-term follow-up as noted in many of the articles reviewed. LEVEL OF EVIDENCE: Review article, levels IV and V.

Early Achievement of Enteral Nutrition Protein Goals by Intensive Care Unit Day 4 is Associated With Fewer Complications in Critically Injured Adults.

Objective: We hypothesized that failure to achieve protein goals early in the critical care course via enteral nutrition is associated with increased complications. BACKGROUND: Although robust randomized controlled trials are lacking, present data suggest that early, adequate nutrition is associated with improved outcomes in critically ill patients. Injured patients are at risk of accumulating significant protein debt due to interrupted feedings and intolerance. METHODS: Critically injured adults who were unable to be volitionally fed were included in this retrospective review. Data collected included demographics, injury characteristics, number and types of operations, total prescribed and delivered protein and calories during the first 7 days of critical care admission, complications, and outcomes. Group-based trajectory modeling was applied to identify subgroups with similar feeding trajectories in the cohort. RESULTS: There were 274 patients included (71.2% male). Mean age was 50.56  ±â€Š19.76 years. Group-based trajectory modeling revealed 5 Groups with varying trajectories of protein goal achievement. Group 5 fails to achieve protein goals, includes more patients with digestive tract injuries (33%, P = 0.0002), and the highest mean number of complications (1.52, P = 0.0086). Group 2, who achieves protein goals within 4 days, has the lowest mean number of complications (0.62, P = 0.0086) and operations (0.74, P = 0.001). CONCLUSIONS: There is heterogeneity in the trajectory of protein goal achievement among various injury pattern Groups. There is a sharp decline in complication rates when protein goals are reached within 4 days of critical care admission, calling into question the application of current guidelines to healthy trauma patients to tolerate up to 7 days of nil per os status and further reinforcing recommendations for early enteral nutrition when feasible.

The First Reported Case of Metoprolol-Induced Pemphigus Foliaceus in the United States: A Critical Report and Review of Literature.

Pemphigus is a rare family of autoimmune disorders characterized by epithelial and mucosal blisters. Pemphigus foliaceus (PF) commonly affects the scalp, face, and trunk. Lesions often arise as superficial blisters and develop into scaly, crusted erosions. Management includes corticosteroids with immunosuppressants. Novel therapies include immunoadsorption and active clinical trials. We present the only reported case of metoprolol-induced PF in the United States (US), with an extremely complicated hospital course.  A 66-year-old male patient with a history of hypertension, diabetes, and hyperlipidemia presented to his doctor with a blistering, pruritic rash that started after switching to metoprolol for hypertension treatment.  PF is very rare in North America. Given its solely superficial penetration, it creates no direct fatal complication. However, the developing blisters and subsequent wounds are susceptible to a wide array of secondary infections, which can be life-threatening.

Timing of Cholecystectomy after Emergent Endoscopic Retrograde Cholangiopancreatography for Cholangitis.

Debate remains regarding the timing of laparoscopic cholecystectomy after emergent endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis. We hypothesized that patients undergoing early laparoscopic cholecystectomy would have fewer operative complications and a lower conversion rate. This study is a retrospective review of an ERCP database from 2012 to 2016 of adults with a diagnosis of cholangitis secondary to choledocholithiasis who underwent ERCP followed by a laparoscopic cholecystectomy. Patient demographics, ERCP details, timing of operation (<72 hours vs >72 hours after ERCP), complications, and mortality were recorded. Analysis included chi-square, Fisher's exact, and Wilcoxon rank-sum tests, where appropriate. In the 127 patients (65 per cent male; median age, 67 years; 48 (38%) early surgery), there were no differences in demographics, BMI, vital signs, or laboratory values. Patients in the late surgery group were more likely to have a Charlson Comorbidity Index > 3 (P = 0.002), require pre-operative endoscopic sphincterotomy (P < 0.002), need pre-operative insertion of a ductal stent (P < 0.03), and had more postoperative complications (P = 0.04). Patients in the late laparoscopic cholecystectomy group had more comorbidities and suffered more complications.

To Sleep, Perchance to Dream: Acute and Chronic Sleep Deprivation in Acute Care Surgeons.

BACKGROUND: Acute and chronic sleep deprivation are significantly associated with depressive symptoms and are thought to be contributors to the development of burnout. In-house call inherently includes frequent periods of disrupted sleep and is common among acute care surgeons. The relationship between in-house call and sleep deprivation among acute care surgeons has not been previously studied. The goal of this study was to determine prevalence and patterns of sleep deprivation in acute care surgeons. STUDY DESIGN: A prospective study of acute care surgeons with in-house call responsibilities from 2 level I trauma centers was performed. Participants wore a sleep-tracking device continuously over a 3-month period. Data collected included age, sex, schedule of in-house call, hours and pattern of each sleep stage (light, slow wave, and rapid eye movement [REM]), and total hours of sleep. Sleep patterns were analyzed for each night, excluding in-house call, and categorized as normal, acute sleep deprivation, or chronic sleep deprivation. RESULTS: There were 1,421 nights recorded among 17 acute care surgeons (35.3% female; ages 37 to 65 years, mean 45.5 years). Excluding in-house call, the average amount of sleep was 6.54 hours, with 64.8% of sleep patterns categorized as acute sleep deprivation or chronic sleep deprivation. Average amount of sleep was significantly higher on post-call day 1 (6.96 hours, p = 0.0016), but decreased significantly on post-call day 2 (6.33 hours, p = 0.0006). Sleep patterns with acute and chronic sleep deprivation peaked on post-call day 2, and returned to baseline on post-call day 3 (p = 0.046). CONCLUSIONS: Sleep patterns consistent with acute and chronic sleep deprivation are common among acute care surgeons and worsen on post-call day 2. Baseline sleep patterns were not recovered until post-call day 3. Future study is needed to identify factors that affect physiologic recovery after in-house call and further elucidate the relationship between sleep deprivation and burnout.

"Show Me the Data": A Recipe for Quality Improvement Success in an Academic Surgical Department.

BACKGROUND: Surgeons in academic medical centers have traditionally taken a siloed approach to reducing postoperative complications. We initiated a project focusing on transparency and sharing of data to engage surgeons in collaborative quality improvement. Its key features were the development of a comprehensive department quality dashboard and the creation of the Clinical Operations Council that oversaw quality. The purpose of this study was to assess the impact of those efforts. STUDY DESIGN: We compared inpatient outcomes before and after our intervention, allowing one quarter as the diffusion period. The outcomes analyzed were: risk-adjusted length of stay, mortality, direct cost and unadjusted incidence of complications, and 30-day all-cause readmissions, as determined by the Vizient Clinical Database. We examined the outcomes of three groups: group 1 (surgery); group 2, all other surgical departments (other surgery); and group 3, all other patients (non-surgery). Two-tailed Student's t-test was used for analysis and p < 0.05 was considered statistically significant. RESULTS: Group 1 demonstrated statistically significant improvements in mortality (p = 0.01), length of stay (p = 0.002), cost (p = 0.0001), and complications (p = 0.02), and the all-cause readmission rate was unchanged, resulting in mean decrease of 0.55 length of stay days and direct cost savings of $2,300 per surgical admission. The comparison groups had only modest decreases in some of the analyzed outcomes and an increase in complication rates. CONCLUSIONS: These data suggest that a collaborative, data-driven, and transparent approach to assessing the quality of surgical care can yield significant improvements in patient outcomes.

Management of extremity fasciotomy sites prospective randomized evaluation of two techniques.

INTRODUCTION: Morbidity from the treatment of extremity compartment syndrome is underappreciated. Closure technique effectiveness has yet to be definitively established. METHODS: A randomized non-blinded prospective study was performed involving patients who underwent an extremity fasciotomy following trauma. Shoelace wounds were strapped with vessel loops under tension and VAC wounds were treated with a standard KCI VAC dressing. After randomization, patients returned to the OR every 96 h until primarily closed or skin grafted. RESULTS: 21 patients were consented for randomization with 11 (52%) successfully closed at the first re-operation. After interim analysis the study was closed early with 5/5 (100%) of wounds treated with the shoelace technique closed primarily and only 1/9 (11%) of VAC wounds closed primarily (p = 0.003). Overall primary closure was achieved in 74% of patients. CONCLUSIONS: Aggressive attempts at wound closure lead to an increased early closure rate. For wounds that remain open after the first re-operation, a simple shoelace technique is more successful than a wound VAC for achieving same hospital stay skin closure.

Impact of a Novel Preoperative Patient-centered Surgical Wellness Program.

OBJECTIVE: The objective of this study was to evaluate if a preoperative wellness bundle significantly decreases the risk of hospital acquired infections (HAI). BACKGROUND: HAI threaten patient outcomes and are a significant burden to the healthcare system. Preoperative wellness efforts may significantly decrease the risk of infections. METHODS: A group of 12,396 surgical patients received a wellness bundle in a roller bag during preoperative screening at an urban academic medical center. The wellness bundle consisted of a chlorhexidine bath solution, immuno-nutrition supplements, incentive spirometer, topical mupirocin for the nostrils, and smoking cessation information. Study staff performed structured patient interviews, observations, and standardized surveys at key intervals throughout the perioperative period. Statistics compare HAI outcomes of patients in the wellness program to a nonintervention group using the Fisher's exact test, logistic regression, and Poisson regression. RESULTS: Patients in the nonintervention and intervention groups were similar in demographics, comorbidity, and type of operations. Compliance with each element was high (80% mupirocin, 72% immuno-nutrition, 71% chlorhexidine bath, 67% spirometer). The intervention group had statistically significant reductions in surgical site infections, Clostridium difficile, catheter associated urinary tract infections, and patient safety indicator 90. CONCLUSIONS: A novel, preoperative, patient-centered wellness program dramatically reduced HAI in surgical patients at an urban academic medical center.

Optimizing Nutrition for the Surgical Patient: An Evidenced Based Update to Dispel Five Common Myths in Surgical Nutrition Care.

Traditional practices in the delivery of nutrition to the surgical patient include reliance on nonspecific laboratory markers to define malnutrition, prolonged periods of nil per os, early and liberal initiation of parenteral nutrition, withholding enteral feedings based on gastric residual volume measurements, and pursuing feeding tube access for most patients unable to take oral nutrition. However, recent studies call into question all of these practices. This review aims to provide evidenced-based support to abandon these myths regarding nutrition delivery and offer practical up-to-date advice for best practices in patient care.

Increased trauma activation is not equally beneficial for all elderly trauma patients.

BACKGROUND: Physiologic changes in the elderly lead to higher morbidity and mortality after injury. Increasing level of trauma activation has been proposed to improve geriatric outcomes, but the increased cost to the patient and stress to the hospital system are significant downsides. The purpose of this study was to identify the age at which an increase in activation status is beneficial. METHODS: A retrospective review of trauma patients 70 years or older from October 1, 2011, to October 1, 2016, was performed. On October 1, 2013, a policy change increased the activation criteria to the highest level for patients 70 years or older with a significant mechanism of injury. Patients who presented prior to (PRE) were compared with those after the change (POST). Data collected included age, Injury Severity Score (ISS), length of stay (LOS), complications, and mortality. Primary outcome was mortality, and secondary outcome was LOS. Multivariable regressions controlled for age, ISS, injury mechanism, and number of complications. RESULTS: A total of 4,341 patients met the inclusion criteria, 1,919 in PRE and 2,422 in POST. Mean age was 80.4 and 81 years in PRE and POST groups, respectively (p = 0.0155). Mean ISS values were 11.6 and 12.4 (p < 0.0001) for the PRE and POST groups. POST had more Level 1 activations (696 vs. 220, p < 0.0001). After controlling for age, ISS, mechanism of injury, and number of complications, mortality was significantly reduced in the POST group 77 years or older (odds ratio, 0.53; 95% confidence interval, 0.3-0.87) (Fig. 1). Hospital LOS was significantly reduced in the POST group age 78 years or older (regression coefficient, -0.55; 95% confidence interval, -1.09 to -0.01) (Fig. 2). CONCLUSIONS: This study suggests geriatric trauma patients 77 years or older benefit from the highest level of trauma activation with shorter LOS and lower mortality. A focused approach to increasing activation level for elderly patients may decrease patient cost. LEVEL OF EVIDENCE: Therapeutic/Care Management, level IV.