An AAST-MITC analysis of pancreatic trauma: Staple or sew? Resect or drain?

INTRODUCTION: Pancreatic trauma results in high morbidity and mortality, in part caused by the delay in diagnosis and subsequent organ dysfunction. Optimal operative management strategies remain unclear. We therefore sought to determine CT accuracy in diagnosing pancreatic injury and the morbidity and mortality associated with varying operative strategies. METHODS: We created a multicenter, pancreatic trauma registry from 18 Level 1 and 2 trauma centers. Adult, blunt or penetrating injured patients from 2005 to 2012 were analyzed. Sensitivity and specificity of CT scan identification of main pancreatic duct injury was calculated against operative findings. Independent predictors for mortality, adult respiratory distress syndrome (ARDS), and pancreatic fistula and/or pseudocyst were identified through multivariate regression analysis. The association between outcomes and operative management was measured. RESULTS: We identified 704 pancreatic injury patients of whom 584 (83%) underwent a pancreas-related procedure. CT grade modestly correlated with OR grade (r 0.39) missing 10 ductal injuries (9 grade III, 1 grade IV) providing 78.7% sensitivity and 61.6% specificity. Independent predictors of mortality were age, Injury Severity Score (ISS), lactate, and number of packed red blood cells transfused. Independent predictors of ARDS were ISS, Glasgow Coma Scale score, and pancreatic fistula (OR 5.2, 2.6-10.1). Among grade III injuries (n = 158, 22.4%), the risk of pancreatic fistula/pseudocyst was reduced when the end of the pancreas was stapled (OR 0.21, 95% CI 0.05-0.9) compared with sewn and was not affected by duct stitch placement. Drainage alone in grades IV (n = 25) and V (n = 24) injuries carried increased risk of pancreatic fistula/pseudocyst (OR 8.3, 95% CI 2.2-32.9). CONCLUSION: CT is insufficiently sensitive to reliably identify pancreatic duct injury. Patients with grade III injuries should have their resection site stapled instead of sewn and a duct stitch is unnecessary. Further study is needed to determine if drainage alone should be employed in grades IV and V injuries. LEVEL OF EVIDENCE: Epidemiologic/Diagnostic study, level III.

Isolated severe traumatic brain injuries sustained during combat operations: demographics, mortality outcomes, and lessons to be learned from contrasts to civilian counterparts.

BACKGROUND: Severe traumatic brain injuries occurring in the context of modern military conflict are entities about which little has been reported. We reviewed the epidemiology of these injuries from the Joint Trauma Theater Registry (JTTR), contrasting these results with civilian counterparts from the National Trauma Databank (NTDB). METHODS: Isolated severe brain injuries (defined as head abbreviated injury scale [AIS] ≥3 and no other body region AIS>2) were queried from the JTTR over a period from 2003 to 2007. The demographics and outcomes of these injuries were reviewed. These results were then contrasted to findings of similar patients, age 18 years to 55 years, over the same period from the NTDB using propensity score matching derived from age, gender, systolic blood pressure, Glasgow Coma Scale, and AIS. RESULTS: JTTR review identified 604 patients meeting study criteria, with a mean age of 25.7 years. Glasgow Coma Scale was ≤8 in 27.8%, and 98.0% were men. Hypotension at presentation was noted in 5.5%. Blast (61.9%) and gunshot wound (19.5%) mechanisms accounted for the majority of combat injuries. Intracranial pressure monitoring was used in 15.2%, and 27.0% underwent some form of operative cranial decompression, lobectomy, or debridement. When compared with matched civilian NTDB counterparts, JTTR patients were significantly more likely to undergo intracranial pressure monitoring (13.8% vs. 1.7%; p<0.001) and operative neurosurgical intervention (21.5% vs. 7.2%; p<0.001). Mortality was also significantly better among military casualties overall (7.7% vs. 21.0%; p<0.001; odds ratio, 0.32 [0.16-0.61]) and particularly after penetrating mechanisms of injury (5.6% vs. 47.9%; p<0.001; odds ratio, 0.07 [0.02-0.20]) compared with propensity score-matched NTDB counterparts. CONCLUSION: Patients sustaining severe traumatic brain injury during military operations represent a unique population. Comparison with civilian counterparts has inherent limitations but reveals higher rates of neurosurgical intervention performed after penetrating injuries and a corresponding improvement in survival. Many factors likely contribute to these findings, which highlight the need for additional research on the optimal management of penetrating brain injury.

Automatic pre-hospital vital signs waveform and trend data capture fills quality management, triage and outcome prediction gaps.

Trauma Triage errors are frequent and costly. What happens in pre-hospital care remains anecdotal because of the dual responsibility of treatment (resuscitation and stabilization) and documentation in a time-critical environment. Continuous pre-hospital vital signs waveforms and numerical trends were automatically collected in our study. Abnormalities of pulse oximeter oxygen saturation (< 95%) and validated heart rate (> 100/min) showed better prediction of injury severity, need for immediate blood transfusion, intra-abdominal surgery, tracheal intubation and chest tube insertion than Trauma Registry data or Pre-hospital provider estimations. Automated means of data collection introduced the potential for more accurate and objective reporting of patient vital signs helping in evaluating quality of care and establishing performance indicators and benchmarks. Addition of novel and existing non-invasive monitors and waveform analyses could make the pulse oximeter the decision aid of choice to improve trauma patient triage.