Routine computed tomography after recent operative exploration for penetrating trauma: What injuries do we miss?

BACKGROUND: Patients with penetrating trauma who cannot be stabilized undergo operative intervention without preoperative imaging. In such cases, postoperative imaging may reveal additional injuries not identified during the initial operative exploration. The purpose of this study is to explore the utility of postoperative CT imaging in the setting of penetrating trauma. METHODS: This was a retrospective analysis of patients with penetrating trauma treated at an urban Level 1 trauma center between 2010 and 2015. Patients were included if they underwent an emergent laparotomy without preoperative imaging. Patients were excluded if they had prior imaging or concomitant blunt injury. For the purposes of this study, occult injury was defined as a CT scan finding not mentioned in the first operative report. Descriptive statistics were used to compare patient characteristics who had received imaging immediately postoperatively with those who had not. RESULTS: During the 5-year study period, 328 patients who had a laparotomy for penetrating trauma over the study period, 225 patients met the inclusion criteria. Seventy-three (32%) patients underwent CT scanning immediately postoperatively with occult injuries identified in 38 (52%) patients. The most frequent occult injuries were orthopedic (20 of 43) and genitourinary (9 of 43). Importantly, 10 (26%) of the 38 patients required an intervention for these occult injuries. Those selected for immediate postoperative imaging were more likely to have sustained gunshot wounds and were significantly more severely injured (higher Injury Severity Score and longer length of hospital stay) when compared to patients who did not receive immediate imaging. CONCLUSION: We recommend the use of immediate postoperative CT after emergent laparotomy especially when there is a high index of suspicion for spine or genitourinary injuries and in patients who have sustained ballistic penetrating injuries. LEVEL OF EVIDENCE: Therapeutic/care management, level IV; diagnostic tests or criteria, level IV.

Randomized controlled trial to evaluate the effectiveness of a video game as a child pedestrian educational tool.

BACKGROUND: Injury is the number one cause of death and disability in children in the United States and an increasingly important public health problem globally. While prevention of injuries is an important goal, prevention efforts are currently fragmented, poorly funded, and rarely studied. Among school-aged children, pedestrian crashes are a major mechanism of injury. We hypothesized that we could develop a game-based educational tool that would be effective in teaching elementary school children the principles of pedestrian safety. METHODS: Between November 2011 and June 2013, second- and third-grade children in Los Angeles Unified School District were randomly assigned to play a unique interactive video game (Ace's Adventure) about pedestrian safety or to a traditional didactic session about pedestrian safety. A pretest and posttest were administered to the study participants. Afterward, study participants were observed for appropriate pedestrian behavior on a simulated street set called Street Smarts. All statistical analyses were performed using SAS version 9.2. RESULTS: A total of 348 study participants took the pretest and posttest. There were 180 who were randomized to the didactic and 168 who were randomized to the video game. The didactic group demonstrated a higher mean score increase (1.01, p < 0.0001) as compared with the video game group (0.44, p < 0.0001). However, observation of study participants revealed that participants who played the video game, as compared with the didactic group, more frequently exhibited appropriate behavior during the following: exiting a parked car (p = 0.01), signaling to a car that was backing up (p = 0.01), signaling to a stopped car (p = 0.0002), and crossing the street (p = 0.01). CONCLUSION: Students who played the educational video game about pedestrian safety performed similarly to those who attended a more traditional and labor-intensive didactic learning. Innovative educational methods, such as game playing, could significantly change our approach to injury prevention and have the potential to decrease the burden of injury among children worldwide.

Future of acute care surgery: a perspective from the next generation.

BACKGROUND: Access to emergent surgical care has been identified as a crisis in the United States. To address this challenge, the American Association for Surgery of Trauma has developed a fellowship in acute care surgery (ACS) to reestablish broad-based surgical capabilities. But the viability of this new discipline will rest on the interests of the next generation of surgeons. The objective of this study was to determine key factors influencing the choice of surgical specialties among medical students with a focus on their interest in trauma/ACS (T/ACS). METHODS: An online questionnaire was distributed to students at four medical schools affiliated with Level I trauma centers, one of which also has an ACS fellowship. The survey was sent to medical students at all levels (first to fourth year). Students with an interest in surgery as a career were asked to complete the survey and rank factors and experiences influencing career selection on a scale of 1 (no influence) to 10 (critical). Students were also asked to select their top five surgical specialties. RESULTS: Three hundred thirty-seven students interested in surgery responded. Mean age was 26 years ± 0.2 years (range, 20-37 years), 58% were men, and 86% were single. Respondents were distributed evenly over medical schools and medical school years. The three most popular career choices were orthopedics (16%), T/ACS (12%), and pediatric surgery (8%). As students progressed through medical school, lifestyle factors such as predictable hours and family time became more important in influencing their career choice. Overall, 115 students (34%) selected emergent surgery (T/ACS) as one of their top three career choices. Factors that were ranked significantly higher by students interested in T/ACS were related to professional satisfaction. These students also placed less emphasis on lifestyle factors when choosing a surgical career. CONCLUSIONS: Our results indicate that there is a reassuring interest to address the growing demand for emergency surgery among current medical students exposed to a broad range of T/ACS patients in Level I trauma centers. The T/ACS model is in accordance with the drives of these students looking for a diverse and challenging profession. Academic societies should make further efforts to encourage medical students to pursue T/ACS.

Acquired A amyloidosis from injection drug use presenting with atraumatic splenic rupture in a hospitalized patient: a case report.

INTRODUCTION: Little is known about splenic rupture in patients who develop systemic acquired A amyloidosis. This is the first report of a case of atraumatic splenic rupture in a patient with acquired A amyloidosis from chronic injection drug use. CASE PRESENTATION: A 58-year-old Caucasian man with a long history of injection drug use, hospitalized for infective endocarditis, experienced atraumatic splenic rupture and underwent splenectomy. Histopathological and microbiological analyses of the splenic tissue were consistent with systemic acquired A amyloidosis, most likely from injection drug use, that led to splenic rupture without any recognized trauma or evidence of bacterial embolization to the spleen. CONCLUSION: In patients with chronic inflammatory conditions, including the use of injection drugs, who experience acute onset of left upper quadrant pain, the diagnosis of atraumatic splenic rupture must be considered.

Surgical training and global health: initial results of a 5-year partnership with a surgical training program in a low-income country.

HYPOTHESIS: Surgical trainees in the United States have a growing interest in both clinical experiences and structured training opportunities in global health. Global health training and exposure can be integrated into a surgical residency program. DESIGN: The global health activities of surgical residents and faculty in 1 department were evaluated from January 1, 1998, to June 1, 2008, using a survey and personal interviews. RESULTS: From January 1, 1998, to December 31, 2002, 4 faculty members made more than 20 overseas volunteer medical expeditions, but only 1 resident participated in global health activities. In 2003, a relationship with a surgical training program in a developing country was established. Ten residents and 12 faculty members have made overseas trips during the last 5 years, and 1 international surgeon has visited the United States. During their research block, 4 residents completed 1- to 3-month clinical rotations and contributed to mentored research projects. Three residents completed a university-based Global Health Clinical Scholars Program, and 3 obtained master's degrees in public health. A joint conference in injury-trauma research was also conducted. A faculty member is based overseas with clinical and research responsibilities, and another is completing a master's degree in public health. CONCLUSIONS: Global health training and exposure for residents can be effectively integrated into an academic surgical residency program through relationships with training programs in low-income countries. Legitimate academic experiences improve the success of these programs. Reciprocity with collaborative partners must be ensured, and sustained commitment and funding remain a great challenge to such programs. The long-term effect on the development of global health careers is yet to be determined.

Airbag deployment and improperly restrained children: a lethal combination.

BACKGROUND: Airbag deployment is an acknowledged mechanism of serious trauma in children involved in motor vehicle crashes. From a review of national databases, we determined the number and types of fatal and nonfatal injuries to children caused by airbag deployment and child restraint system use. We also reviewed the relevant literature and provide information useful for caregivers and health care professionals in hopes of reducing future injuries. METHODS: We retrospectively reviewed 263 reported cases in which airbag deployment caused fatal or nonfatal injuries in children from reports released by the National Highway and Transportation Safety Administration and the National Pediatric Trauma Registry. Data were collected from January 1993 to December 2002 and imported into a database program for analysis. RESULTS: Of the 263 pediatric injuries caused by airbag deployment, 159 were fatal, and 104 were nonfatal. The peak incidence occurred in 1998, when 58 children were reported injured. Head injuries were most frequent, involving 170 children (64.6%), followed by spinal injuries, involving 100 children (38.0%). For children in their first year of life, head injuries were the sole mechanism of fatality. Of all children studied, only six (2.3%) were properly restrained. CONCLUSION: Airbag deployment in motor vehicle crashes is a well-recognized mechanism of morbidity and mortality in the pediatric population. Most injuries include trauma to the head and spine, which can have significant long-term consequences. Although the reported incidence of such injuries is decreasing, many children are improperly restrained. In our study, only 2.3% of children were properly restrained, suggesting that proper child restraint and seating position could have prevented most injuries.

Recovery at one year following isolated traumatic brain injury: a Western Trauma Association prospective multicenter trial.

BACKGROUND: Age has been shown to be a primary determinant of survival following isolated traumatic brain injury (TBI). We have previously reported that patients > or =65 years who survived mild TBI have decreased functional outcome at 6 months compared with younger patients. The purpose of this study was to further investigate the effect of age on outcome at 1 year in all patients surviving isolated TBI. METHODS: The Western Trauma Association multicenter prospective study included all patients sustaining isolated TBI defined as Abbreviated Injury Scale score for Head > or = 3 with an Abbreviated Injury Scale score in any other body area < or = 1. Outcome data included discharge disposition, Glasgow Outcome Scale score (1 = dead to 5= full recovery) and modified Functional Independence Measure (FIM) score measuring feeding, expression, and locomotion (1 = total dependence to 4 = total independence) for each component at discharge and 1 year. RESULTS: In all, 295 patients were enrolled with a follow-up of 82%, resulting in 241 study patients. An additional five patients died from non-TBI causes and were excluded. The mean and median times for the last follow-up in the 236 remaining patients were 307 and 357 days, respectively. Patients were divided into four age ranges: 18 to 29 years (n = 66), 30 to 44 years (n = 54), 45 to 59 years (n = 50), and > or =60 years (n = 65). More severe TBIs, as measured by admitting Glasgow Coma Scale (GCS), were observed in the youngest group compared with all others but there were no differences in mean GCS between the remaining three groups. There were no differences in neurosurgical intervention between the groups. Age was a major determinant in the outcome at discharge and last follow-up. Patients over 60 years discharged with a GOS < or =4 were less likely to improve at 1 year than all other groups (37% versus 63 to 85%; p < or = 0.05). Patients between 18 and 29 years of age had the lowest mean Glasgow Outcome Scale and discharge FIM scores, which correlated with the low admission GCS. Despite the increased severity of TBI, this group had the best FIM score at 1 year. In contrast, patients older than 60 years had the least improvement and had a significantly lower final FIM score at 1 year compared with all other groups. CONCLUSION: Older patients following isolated TBI have poorer functional status at discharge and make less improvement at 1 year compared with all other patients. These worse outcomes occur despite what appears to be less severe TBI as measured by a higher GCS upon admission. Differences in outcome begin to appear even in patients between 45 and 59 years. Further investigations with more detailed outcome instruments are required to better understand the qualitative limitations of a patient's recovery and to devise strategies to maximize functional improvement following TBI. Age is an exceedingly important parameter affecting recovery from isolated TBI.

The effect of age on functional outcome in mild traumatic brain injury: 6-month report of a prospective multicenter trial.

OBJECTIVE: Elderly patients (aged 60 years and older) have been demonstrated to have an increased mortality after isolated traumatic brain injury (TBI); however, the prognosis of those patients surviving their hospitalization is unknown. We hypothesized that surviving elderly patients would also have decreased functional outcome, and this study examined the functional outcome of patients with isolated TBI at discharge and at 6 months posthospitalization. METHODS: This was a multicenter prospective study of all patients with isolated moderate to severe TBI defined as Head Abbreviated Injury Scale score of 3 with an Abbreviated Injury Scale score in any other body area of 1. Patients surviving to discharge gave their consent and were enrolled. Data collected included demographics, Glasgow Coma Scale (GCS) score at admission, and neurosurgical interventions. Outcome data included discharge disposition and Glasgow Outcome Scale score and modified Functional Independence Measure (FIM) score at discharge and at 6 months. RESULTS: Two hundred thirty-five patients were enrolled, with 44 (19%) aged greater than or equal to 65 years. Mechanisms of injury were falls (34%), assaults (28%), motor vehicle collisions (14%), pedestrian (11%), and other (12%). Falls were more common in the older patients and assaults in the younger group. The mean admitting GCS score was 12.8 (95% confidence interval [CI], 12.4-13.3), with older patients having a higher mean GCS score, 14.1 (95% CI, 13.6-14.6) versus 12.5 (95% CI, 12.0-13.1; p = 0.03). There were no differences in the percentage of patients admitted to the intensive care unit or requiring neurosurgical intervention between younger and older patients. Because there were few elderly patients with low GCS scores who survived to discharge, outcome measures focused on those patients with GCS scores of 13 to 15. A greater percentage of elderly were discharged to rehabilitation (28% vs. 16%, p =0.08). The mean discharge FIM score was 10.4 (95% CI, 9.8-11.0) for the elderly versus 11.4 (95% CI, 11.1-11.7) for the young (p =0.001), with 68% elderly and 89% young discharged with total independent scores of 11 to 12. At 6 months, the difference narrowed, but the mean FIM score was still greater for the young group, 11.7 (95% CI, 11.6-11.9) versus 11.0 (95% CI, 10.6-11.4; p < 0.001). CONCLUSION: Functional outcome after isolated mild TBI as measured by the Glasgow Outcome Scale and modified FIM is generally good to excellent for both elderly and younger patients. Older patients required more inpatient rehabilitation and lagged behind their younger counterparts but continued to recover and improve after discharge. Although there were statistically significant differences in the FIM score at both discharge and 6 months, the clinical importance of these small differences in the mean FIM score to the patient's quality of life is less clear. Measurable improvement in functional status during the first 6 months after injury is observed in both groups. Aggressive management and care of older patients with TBI is warranted, and efforts should be made to decrease inpatient mortality. Continued follow-up is ongoing to determine whether these outcomes persist at 12 months.