Contemporary Management of Pediatric Blunt Splenic Trauma: A National Trauma Databank Analysis.

PURPOSE: To quantify changes in the management of pediatric patients with isolated splenic injury from 2007 to 2015. MATERIALS AND METHODS: Patients under 18 years old with registered splenic injury in the National Trauma Data Bank (2007-2015) were identified. Splenic injuries were categorized into 5 management types: nonoperative management (NOM), embolization, splenic repair, splenectomy, or a combination therapy. Linear mixed models accounting for confounding variables were used to examine the direct impact of management on length of stay (LOS), intensive care unit (ICU) days, and ventilator days. RESULTS: Of included patients (n = 24,128), 90.3% (n = 21,789), 5.6% (n = 1,361), and 2.7% (n = 640) had NOM, splenectomy, and embolization, respectively. From 2007 to 2015, the rate of embolization increased from 1.5% to 3.5%, and the rate of splenectomy decreased from 6.9% to 4.4%. Combining injury grades, NOM was associated with the shortest LOS (5.1 days), ICU days (1.9 days), and ventilator days (0.5 day). Moreover, splenectomy was associated with longer LOS (10.1 days), ICU days (4.5 days), and ventilator days (2.1 days) than NOM. The average failure rate of NOM was 1.5% (180 failures/12,378 cases). Average embolization failure was 1.3% (6 failures/456 cases). Splenic artery embolization was associated with lower mortality than splenectomy (OR: 0.10, P <.001). No statistically significant difference was observed in mortality between embolization and NOM (OR: 0.96, P = 1.0). CONCLUSIONS: In pediatric splenic injury, NOM is the most utilized and associated with favorable outcomes, most notably in grades III to V pediatric splenic injury. If intervention is needed, embolization is effective and increasingly utilized most significantly in lower grade injuries.

Management of Splenic Trauma in Contemporary Clinical Practice: A National Trauma Data Bank Study.

BACKGROUND: To evaluate the utilization and efficacy of various treatments for management of adult patients with splenic trauma, highlighting the evolving role of splenic artery embolization. MATERIALS AND METHODS: The National Trauma Data Bank (NTDB) was queried for patients who sustained splenic trauma between 2007 and 2015, excluding those with death on arrival and selected nonsplenic high-grade injuries. Patients were categorized into (1) nonoperative management (NOM), (2) embolization, (3) splenectomy, (4) splenic repair, and (5) combined treatment groups. Evaluated outcomes included hospital length of stay (LOS), intensive care unit LOS, mortality, and NOM and embolization failures. RESULTS: Overall, 117,743 patients with splenic predominant trauma were included in this study. Over the 9-year study period, 85,793 (72.9%) were treated with NOM, 21,999 (18.9%) with splenectomy, 3895 (3.3%) with embolization, and 2131 (1.8%) with splenic repair. From 2007 to 2015, mortality rates declined from 7.6% to 4.7%. The rate of NOM did not significantly change over time, while embolization increased 369% (1.3%-4.8%). Failure of NOM was 4.4% in 2007 and decreased to 3.4% in 2015. Across all injury grades, NOM had the shortest LOS (8.3 days), followed by splenic repair (12.3), embolization (12.6), and splenectomy (13.8) (p < 0.001). When adjusted for various clinical factors including severity of splenic injury, mortality rates were 7.1% for splenectomy, 3.2% for embolization, and 2.5% for NOM. CONCLUSION: Most patients with splenic-dominant blunt trauma are managed with NOM. Over time, the use of embolization has increased while open surgery has declined, and mortality has improved for all treatment methods. Compared to splenectomy, embolization is associated with shorter hospital LOS but is still used relatively infrequently.

Emergency department visits resulting from electric scooter use in a major southeast metropolitan area.

PURPOSE: To determine the frequency, characteristics, and resource use related to the emergency department (ED) encounters resulting from electric scooter use in a major metropolitan area. METHODS: This Institutional Review Board-approved study was conducted at a four-hospital healthcare system. Our clinical data warehouse was retrospectively searched from 5/3/2018 (the date electric scooters were introduced) through 8/15/2019 for various forms of the word "scooter" in triage notes. Demographic variables, arrival mode, length of stay, disposition, and resource utilization, including diagnostic radiology, were extracted. RESULTS: Over the 471-day study window, 293 unique patients presented with e-scooter injuries (0.62 mean ED visits/day). When broken down into 8-h periods, there was a significant increase (p = 0.048) from Friday after 5 PM through Sunday night. Thirty-two percent of patients arrived at the ED during (newly enacted at the time of study) nighttime e-scooter ban hours (9 PM-4 AM). There was a range of one to nine diagnostic radiology examinations per patient, with 100% (293) of patients receiving at least one diagnostic radiology examination. A total of 710 diagnostic radiology examinations were performed on the entire cohort (mean 2.4 per patient): 77.2% (548) were radiographs and 22.1% (157) were computed tomography (CT). CONCLUSION: ED visits resulting from electric scooter injuries are common and increasing. E-scooter injury patients disproportionately present on evenings and weekends, possibly exacerbating already busy periods in the ED. Healthcare resource needs and availability should be considered when developing policy about electric scooter use and distribution, particularly involving emergency care providers in close proximity to e-scooter distribution centers.

The American Association for the Surgery of Trauma Organ Injury Scale 2018 update for computed tomography-based grading of renal trauma: a primer for the emergency radiologist.

The most widely used trauma injury grading system is the Organ Injury Scale (OIS) by the American Association for the Surgery of Trauma (AAST). The AAST OIS for renal trauma was revised in 2018 to reflect necessary updates based on decades of experience with computed tomography (CT)-based injury diagnosis and, specifically, to better incorporate vascular injuries, which were not comprehensively addressed in the original OIS. In this review article, we describe CT findings of the AAST OIS for the kidney according to the 2018 revision, with an emphasis on real-world application, and highlight important differences from the prior grading scheme. Routine use of this grading system allows for a standardized classification of the range of renal injuries to aid in management, adding value in the imaging care of trauma patients.

The Introduction and Development of the H-index for Imaging Utilizers: A Novel Metric for Quantifying Utilization of Emergency Department Imaging.

OBJECTIVE: The objective was to develop a novel metric for quantifying patient-level utilization of emergency department (ED) imaging. METHODS: Using 2009 to 2015 Truven Health MarketScan commercial claims and encounters database, all ED visits and associated imaging services were identified. To measure imaging resource intensity, total imaging relative value units (RVUs) were calculated for each patient per ED visit. An individual's annual imaging h-index is defined as the largest number, h, such that h ED visits by that individual in a given year is associated with total medical imaging RVUs of a value of at least h. RESULTS: Over 7 years, in a sample of 86,506,362 privately insured individuals (232,919,808 person-years) in all 50 states and the District of Columbia, 38,973,716 ED visits were identified. A total of 9.5% of person-years had one ED visit and 2.7% had two or more (the remainder had none). From 2009 to 2015, the percentage of ED patients undergoing imaging increased from 25.1% to 34.6%. Individuals with two or more ED visits each associated with two or more imaging RVUs (ED imaging h-index ≥ 2) comprised 0.2% of the sample and 1.4% of ED visitors; however, they accounted for 4.0% of ED visits and the use of 18.6% of imaging resources. From 2009 to 2015, imaging resource allocation for such patients increased from 16.5% to 21.0%. CONCLUSIONS: The ED imaging h-index allows identification of patients who undergo significant ED imaging, based on a single-digit patient-specific metric that incorporates both annual ED visit number and medical imaging resource intensity per visit. While ED patients with an ED imaging h-index ≥ 2 represented a minuscule fraction of privately insured individuals, they were associated with one-fifth of all ED imaging resources.

The state of emergency radiology fellowships in North America and the development of a standardized curriculum.

BACKGROUND AND OBJECTIVES: The number of emergency radiology (ER) training programs in North America is small compared to the projected growth in demand for ER-trained radiologists. To date, there is no consensus-based training curriculum that sets a standard for all ER fellowship training programs. This study seeks to (1) identify the programmatic measures currently used in North American ER fellowship programs and (2) gather the perspectives of existing ER fellowship program directors (PD) and their recommendations for minimum and ideal curricular standards. METHODS: We distributed an 18-question survey to the PDs of every North American ER fellowship program (N = 15). Surveys were completed during the 2016-2017 academic year. We performed a cross-sectional analysis to gain an understanding of existing training curricula, expected areas of competency by the end-of-training, and PD opinions of what a standard ER training curriculum should contain. RESULTS: The data revealed heterogeneity in programmatic structure across the continent, as well as some areas of agreement. PD suggestions for a standard ER training curriculum showed consistency in many areas, including competency and proficiency expectations and clinical exposures, with some variability. These data were used to inform the creation of the first curricular standard for ER fellowship training. CONCLUSION: This study yielded the creation of a standard fellowship training resource for the field of ER. This deliverable serves as a curricular guideline for existing ER fellowships, as well as a model for new ER fellowship programs.