Shock Index is a Stronger Predictor of Outcomes in Older Compared to Younger Patients.

INTRODUCTION: The shock index (SI) is a known predictor of unfavorable outcomes in trauma. This study seeks to examine and compare the SI values between geriatric patients and younger adults. METHODS: We conducted a retrospective study of the Trauma Quality Improvement Program database from 2017 to 2019. All patients≥ 25 y with injury severity score ≥ 16 were included. Age groups were defined as 25-44 y (group A), 45-64 y (group B), and ≥65 y (group C). SI was calculated for all patients. The primary outcome was mortality and secondary outcomes were need for blood transfusion and need for major surgical intervention (consisting angiography, exploratory laparotomy, and thoracotomy). RESULTS: A total of 244,943 patients were studied. The SI was highest in group A (0.82 ± 0.33) and lowest in group C (0.62 ± 0.30) (P < 0.001). Mortality rate of group C (17%) was significantly higher than group A (9.7%) and B (11.3%) (P < 0.001). In group A, each 0.1 increase in SI was associated with mortality (odds ratio [OR] = 1.079), need for blood transfusion (OR = 1.225) and need for major surgical intervention (OR = 1.347) (P < 0.001 for all). In group C, each 0.1 increase in SI was associated with mortality (OR = 1.126), need for blood transfusion (OR = 1.318), and need for major surgical intervention (OR = 1.648) (P < 0.001 for all). The area under the curve of SI was significantly higher in group C compared to other groups for needing a major surgical intervention and need for blood transfusion (P < 0.05 for both). CONCLUSIONS: These results highlight the significance of the SI as a valuable indicator in geriatric patients with severe trauma. The findings show that SI predicts outcomes in geriatrics more strongly than in younger counterparts.

Is there a need for fresh frozen plasma and platelet transfusion in trauma patients receiving submassive transfusion?

Background: Blood transfusions have become a vital intervention in trauma care. There are limited data on the safety and effectiveness of submassive transfusion (SMT), that is defined as receiving less than 10 units packed red blood cells (PRBCs) in the first 24 hours. This study aimed to evaluate the efficacy and safety of fresh frozen plasma (FFP) and platelet transfusions in patients undergoing SMT. Methods: This is a retrospective cohort, reviewing the Trauma Quality Improvement Program database spanning 3 years (2016 to 2018). Adult patients aged 18 years and older who had received at least 1 unit of PRBC within 24 hours were included in the study. We used a multivariate regression model to analyze the cut-off units of combined resuscitation (CR) (which included PRBCs along with at least one unit of FFP and/or platelets) that leads to survival improvement. Patients were then stratified into two groups: those who received PRBC alone and those who received CR. Propensity score matching was performed in a 1:1 ratio. Results: The study included 85 234 patients. Based on the multivariate regression model, transfusion of more than 3 units of PRBC with at least 1 unit of FFP and/or platelets demonstrated improved mortality compared with PRBC alone. Among 66 319 patients requiring SMT and >3 units of PRBCs, 25 978 received PRBC alone, and 40 341 received CR. After propensity matching, 4215 patients were included in each group. Patients administered CR had a lower rate of complications (15% vs 26%), acute respiratory distress syndrome (3% vs 5%) and acute kidney injury (8% vs 11%). Rates of sepsis and venous thromboembolism were similar between the two groups. Multivariate regression analysis indicated that patients receiving 4 to 7 units of PRBC alone had significantly higher ORs for mortality than those receiving CR. Conclusion: Trauma patients requiring more than 3 units of PRBCs who received CR with FFP and platelets experienced improved survival and reduced complications. Level of evidence: Level III retrospective study.

Propensity weighted analysis of chemical venous thromboembolism prophylaxis agents in isolated severe traumatic brain injury: An EAST sponsored multicenter study.

BACKGROUND: In patients with severe traumatic brain injury (TBI), clinicians must balance preventing venous thromboembolism (VTE) with the risk of intracranial hemorrhagic expansion (ICHE). We hypothesized that low molecular weight heparin (LMWH) would not increase risk of ICHE or VTE as compared to unfractionated heparin (UH) in patients with severe TBI. METHODS: Patients ≥ 18 years of age with isolated severe TBI (AIS ≥ 3), admitted to 24 level I and II trauma centers between January 1, 2014 to December 31, 2020 and who received subcutaneous UH and LMWH injections for chemical venous thromboembolism prophylaxis (VTEP) were included. Primary outcomes were VTE and ICHE after VTEP initiation. Secondary outcomes were mortality and neurosurgical interventions. Entropy balancing (EBAL) weighted competing risk or logistic regression models were estimated for all outcomes with chemical VTEP agent as the predictor of interest. RESULTS: 984 patients received chemical VTEP, 482 UH and 502 LMWH. Patients on LMWH more often had pre-existing conditions such as liver disease (UH vs LMWH 1.7 % vs. 4.4 %, p = 0.01), and coagulopathy (UH vs LMWH 0.4 % vs. 4.2 %, p < 0.001). There were no differences in VTE or ICHE after VTEP initiation. There were no differences in neurosurgical interventions performed. There were a total of 29 VTE events (3 %) in the cohort who received VTEP. A Cox proportional hazards model with a random effect for facility demonstrated no statistically significant differences in time to VTE across the two agents (p = 0.44). The LMWH group had a 43 % lower risk of overall ICHE compared to the UH group (HR = 0.57: 95 % CI = 0.32-1.03, p = 0.062), however was not statistically significant. CONCLUSION: In this multi-center analysis, patients who received LMWH had a decreased risk of ICHE, with no differences in VTE, ICHE after VTEP initiation and neurosurgical interventions compared to those who received UH. There were no safety concerns when using LMWH compared to UH. LEVEL OF EVIDENCE: Level III, Therapeutic Care Management.

Fragmentation of Care After Geriatric Trauma: A Nationwide Analysis of outcomes and Predictors.

The health care system for the elderly is fragmented, that is worsened when readmission occurs to different hospitals. There is limited investigation into the impact of fragmentation on geriatric trauma patient outcomes. The aim of this study was to compare the outcomes following readmissions after geriatric trauma. The Nationwide Readmissions Database (2016-2017) was queried for elderly trauma patients (aged ≥65 years) readmitted due to any cause. Patients were divided into 2 groups according to readmission: index vs non-index hospital. Outcomes were 30 and 180-day complications, mortality, and the number of subsequent readmissions. Multivariable logistic regression was performed to analyze the independent predictors of fragmentation of care. A total of 36,176 trauma patients were readmitted, of which 3856 elderly patients (aged ≥65 years) were readmitted: index hospital (3420; 89%) vs non-index hospital (436; 11%). Following 1:2 propensity matching, elderly with non-index hospital readmission had higher rates of death and MI within 180 days (P = .01 and .02, respectively). They had statistically higher 30 and 180-day pneumonia (P < .01), CHF (P < .01), arrhythmias (P < .01), MI (P < .01), sepsis (P < .01), and UTI (P < .01). On multivariable binary logistic regression analysis, pneumonia (OR 1.70, P = .03), congestive heart failure (CHF) (OR 1.80, P = .03), female gender (OR .72, P = .04), and severe Head and Neck trauma (AIS≥3) (OR 1.50, P < .01) on index admission were independent predictors of fragmentation of care. While the increase in time to readmission (OR 1.01, P < .01) was also associated independently with non-index hospital admission. Fragmented care after geriatric trauma could be associated with higher mortality and complications.

Intraoperative Nerve Stimulation as an Approach for the Surgical Treatment of Genitofemoral Neuralgia.

BACKGROUND Genitofemoral neuralgia is a pain syndrome that involves injury to the genitofemoral nerve and is frequently iatrogenic. We report intraoperative nerve localization using ultrasound, nerve stimulation, and the cremasteric reflex in the surgical treatment of genitofemoral neuralgia. CASE REPORT A 49-year-old man with a history of extracorporeal membrane oxygenation with cannulation sites in bilateral inguinal regions presented with right groin numbness and pain following decannulation. His symptoms corresponded to the distribution of the genitofemoral nerve. He had a Tinel's sign over the midpoint of his inguinal incision. A nerve block resulted in temporary resolution of his symptoms. Due to the presence of a pacemaker, peripheral nerve neuromodulation was contraindicated. He underwent external neurolysis and neurectomy of the right genitofemoral nerve. Following direct stimulation and ultrasound for localization, the nerve was further localized intraoperatively using nerve stimulation with monitoring for the presence of the cremasteric reflex. At his 1-month postoperative visit, his right medial thigh pain had resolved and his right testicular pain 50% improved; his residual pain continued to improve at last evaluation 3 months after surgery. CONCLUSIONS We report the successful use of nerve stimulation and the cremasteric reflex to aid in identification of the genitofemoral nerve intraoperatively for the treatment of genitofemoral neuralgia.

Non-operative management of cirrhotic patients with acute calculous cholecystitis: How effective is it?

INTRODUCTION: Nonoperative management (NOM) of acute calculous cholecystitis (ACC) in patients with cirrhosis was proposed. We examined the outcomes of cirrhotic patients with ACC treated with cholecystectomy compared to NOM. METHODS: We analyzed the 2017-Nationwide Readmissions Database including cirrhotic patients with ACC. Patients were stratified: cholecystectomy, percutaneous cholecystostomy (PCT), and antibiotics only. PRIMARY OUTCOMES: complications, failure of NOM. SECONDARY OUTCOMES: mortality, length of stay (LOS), and charges. RESULTS: 3454 patients were identified. 1832 underwent cholecystectomy, 360 PCT, and 1262 were treated with antibiotics. PCT patients had higher mortality 16.9% vs. the antibiotics group 10.9% vs. cholecystectomy group 4.2%. PCT patients had longer LOS, but lower charges compared to the operative group. Failure of NOM was 28.2%. On regression, PCT was associated with mortality. CONCLUSION: ACC remains a morbid disease in cirrhosis patients. One in three failed NOM, had longer LOS, and higher mortality. Further studies are warranted to identify predictors of NOM failure. LEVEL OF EVIDENCE: Level III, prognostic.

Early VTE prophylaxis in severe traumatic brain injury: A propensity score weighted EAST multicenter study.

BACKGROUND: Patients with traumatic brain injury (TBI) are at high risk of venous thromboembolism events (VTE). We hypothesized that early chemical VTE prophylaxis initiation (≤24 hours of a stable head CT) in severe TBI would reduce VTE without increasing risk of intracranial hemorrhage expansion (ICHE). METHODS: A retrospective review of adult patients 18 years or older with isolated severe TBI (Abbreviated Injury Scale score, ≥ 3) who were admitted to 24 Level I and Level II trauma centers from January 1, 2014 to December 31 2020 was conducted. Patients were divided into those who did not receive any VTE prophylaxis (NO VTEP), who received VTE prophylaxis ≤24 hours after stable head CT (VTEP ≤24) and who received VTE prophylaxis >24 hours after stable head CT (VTEP>24). Primary outcomes were VTE and ICHE. Covariate balancing propensity score weighting was utilized to balance demographic and clinical characteristics across three groups. Weighted univariate logistic regression models were estimated for VTE and ICHE with patient group as predictor of interest. RESULTS: Of 3,936 patients, 1,784 met inclusion criteria. Incidences of VTE was significantly higher in the VTEP>24 group, with higher incidences of DVT in the group. Higher incidences of ICHE were observed in the VTEP≤24 and VTEP>24 groups. After propensity score weighting, there was a higher risk of VTE in patients in VTEP >24 compared with those in VTEP≤24 (odds ratio, 1.51; 95% confidence interval, 0.69-3.30; p = 0.307), however was not significant. Although, the No VTEP group had decreased odds of having ICHE compared with VTEP≤24 (odds ratio, 0.75; 95% confidence interval, 0.55-1.02, p = 0.070), the result was not statistically significant. CONCLUSION: In this large multi-center analysis, there were no significant differences in VTE based on timing of initiation of VTE prophylaxis. Patients who never received VTE prophylaxis had decreased odds of ICHE. Further evaluation of VTE prophylaxis in larger randomized studies will be necessary for definitive conclusions. LEVEL OF EVIDENCE: Therapeutic Care Management; Level III.

Improving blunt cerebrovascular injury screening in motor vehicle collision patients: Does airbag deployment matter?

BACKGROUND: Motor vehicle collisions (MVCs) can cause blunt cerebrovascular injury (BCVI). Exploring MVC characteristics that increase BCVI may reduce missed injuries. This study aims to evaluate the association between airbag deployment and BCVI. METHODS: We analyzed the 2016-Trauma Quality Improvement Database including adult MVC drivers. Patients were stratified: airbag deployment(A+) and no-airbag deployment(A-). Outcomes were BCVI, and cervical spine injuries (CSI). RESULTS: A total of 122,973 patients were identified: A+: 106,492, and A-: 16,481. The incidence of BCVI was 1907 (1.6%): and CSI was 20,711 (16.8%). A+ patients had a higher rate of BCVI (1.6% vs. 1.1%; p < 0.001), but a lower rate of CSI (16.2% vs. 21.4%; p < 0.001). On regression analysis, A+ was associated with BCVI (1.419[1.184-1.701]; p < 0.001) but was protective for CSI (0.767[0.672-0.878]; p < 0.001). CONCLUSION: A+ may be an unrecognized risk factor for BCVI even for patients without a CSI. Expanding BCVI screening criteria to include A+ may reduce missed injuries. LEVEL OF EVIDENCE: Level III, prognostic.

Flange Fracture and Dislocation: An Unusual Complication of Percutaneous Tracheostomy.

Percutaneous dilational tracheostomy (PDT) is a commonly used technique in intensive care units (ICUs) for persistent respiratory failure. Early complications of placement includeairway loss, bleeding, and tracheal ring fracture. Tracheostomy tube fracture is a rarely reported complication that can lead to loss of airway and require emergent intervention. We present two case reports of tracheostomy flange fracture and dislocation after PDT. Shortly after insertion, the tracheostomy flange was incidentally noted to have irreparably fractured and separated from the outer cannula. Both patients were orotracheally intubated and converted to open revisional surgical tracheostomy. Outer cannula separation from the flange is a rare but important complication of PDT due to the risk of occult airway loss. The tracheostomy tube supplied in the PDT set is manufactured in three parts and the plastic outer cannula is snapped to the silicone flange during manufacturing. The flange is not meant to be separated during insertion or use. PDT insertion requires significant force to be exerted, as the catheter has to travel through the subcutaneous tissue of the neck before entering the trachea. These cases suggest that the junction of the flange and the outer cannula may be a weak point and that fracture and dislocation at that site may occur due to excessive or misdirected force. Dislocation may cause loss of airway and a need for orotracheal intubation as performed in our cases. Understanding this complication and carefully examining the flange after placement is essential for early recognition to avoid loss of airway.

Direct Peritoneal Resuscitation (DPR) Improves Acute Physiology and Chronic Health Evaluation (APACHE) IV and Acute Physiology Score When Used in Damage Control Laparotomies: Prospective Cohort Study on 37 Patients.

INTRODUCTION: Using direct peritoneal resuscitation (DPR) as an adjunct when managing patients undergoing damage control laparotomy (DCL) shows promising results. We report our initial experience in utilizing DPR when managing patients who underwent DCL for emergent surgery at the index operation. MATERIALS AND METHODS: We prospectively collected data on 37 patients between August 2020 to October 2021 who underwent DCL with open abdomens after the index operation and utilized DPR. DPR was performed using peritoneal lavage with DIANEAL PD-2-D 2.5% Ca 3.5 mEq/L at a rate of 400ml/hour. Patients' physiological scores and clinical outcomes were evaluated. RESULTS: 86% required DCL and DPR due to septic abdomen/bowel ischemia. The median (interquartile range [IQR]) age was 62 years (53-70); 62% were male, and median (IQR) body mass index was 30.0kg/m2 (25.5-38.4). On DPR initiation, median (IQR) APACHE-IV score was 48 (33-64) and median (IQR) Acute Physiology Score (APS) was 31 (18-54). After initiation, median (IQR) APACHE-IV score and median (IQR) APS were 39 (21-62) and 19 (11-56), respectively, and both showed significant improvement in survivors (p<0.05). Median (IQR) DPR duration was four days (2-8) and primary abdominal closure was achieved in 30 patients (81%). There were eight mortalities (21.6%) within 30 days postoperatively, of which seven were within 3-24 days due to uncontrolled sepsis/multiple organ failure. The most frequent complication was surgical-site infection recorded in 12 patients (32%). Twenty-four patients (67%) were discharged home/transferred to a rehab center/nursing home. CONCLUSION: DPR application showed significant improvement of APACHE-IV score and APS in patients with peritonitis/septic abdomen.

Characteristics of survivors of civilian public mass shootings: An Eastern Association for the Surgery of Trauma multicenter study.

BACKGROUND: Firearm injury remains a public health crisis. Whereas there have been studies evaluating causes of death in victims of civilian public mass shootings (CPMSs), there are no large studies evaluating injuries sustained and treatments rendered in survivors. The purpose of this study was to describe these characteristics to inform ideal preparation for these events. METHODS: A multicenter, retrospective study of CPMS survivors who were treated at designated trauma centers from July 1, 1999 to December 31, 2017, was performed. Prehospital and hospital variables were collected. Data are reported as median (25th percentile, 75th percentile interquartile range), and statistical analyses were carried out using Mann-Whitney U, χ2, and Kruskal-Wallis tests. Patients who died before discharge from the hospital were excluded. RESULTS: Thirty-one events involving 191 patients were studied. The median number of patients seen per event was 20 (5, 106), distance to each hospital was 6 (6, 10) miles, time to arrival was 56 (37, 90) minutes, number of wounds per patient was 1 (1, 2), and Injury Severity Score was 5 (1, 17). The most common injuries were extremity fracture (37%) and lung parenchyma (14%). Twenty-nine percent of patients did not receive paramedic-level prehospital treatment. Following arrival to the hospital, 27% were discharged from the emergency department, 32% were taken directly to the operating room/interventional radiology, 16% were admitted to the intensive care unit, and 25% were admitted to the ward. Forty percent did not require advanced treatment within 12 hours. The most common operations performed within 12 hours of arrival were orthopedic (15%) and laparotomy (15%). The most common specialties consulted were orthopedics (38%) and mental health (17%). CONCLUSION: Few CPMS survivors are critically injured. There is significant delay between shooting and transport. Revised triage criteria and a focus on rapid transport of the few severely injured patients are needed. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Colonic perforation due to inadvertent intraperitoneal LVAD driveline placement.

BACKGROUND: Left ventricular assist devices (LVAD) are placed for patients with advanced heart failure or cardiogenic shock as destination therapy or as a bridge to cardiac transplantation. Significant complications associated with LVAD placement include bleeding, infection, pump thrombosis, right heart failure, device malfunction and stroke. The case below illustrates inadvertent intraperitoneal driveline placement causing colonic perforation and the subsequent management. CASE PRESENTATION: A 54 year old male with a history of Wolff-Parkinson-White syndrome resulting in multiple readmissions for heart failure, ultimately required placement of a left ventricular assist device (LVAD). Several weeks later, he was found to have stool draining from the driveline site. The patient was taken to the operating room for limited exploration by the Cardiothoracic Surgery team and a bowel injury was identified and repaired. Three days after this repair, stool was once again leaking from the driveline site, requiring re-exploration by the Acute Care Surgery team. Intraoperatively, the prior repair was found to be leaking and multiple intra-abdominal abscesses were discovered. The transverse colon was resected and left in discontinuity. On a planned second look operation, the LVAD driveline was relocated to be extra-peritoneal and a colostomy was formed. DISCUSSION AND CONCLUSION: This case demonstrates the importance of early recognition and involvement of an Acute Care Surgeon in the management of this complex problem. Appropriate treatment involves a complete exploration, source control, driveline relocation and possible fecal diversion. Although the incidence of this complication is low, it must be considered in the differential in a septic LVAD patient.

Vitamin C and thiamine are associated with lower mortality in sepsis.

BACKGROUND: The efficacy of vitamin C (VitC) and thiamine (THMN) in patients admitted to the intensive care unit (ICU) with sepsis is unclear. The purpose of this study was to evaluate the effect of VitC and THMN on mortality and lactate clearance in ICU patients. We hypothesized that survival and lactate clearance would be improved when treated with thiamine and/or VitC. METHODS: The Philips eICU database version 2.0 was queried for patients admitted to the ICU in 2014 to 2015 for 48 hours or longer and patients with sepsis and an elevated lactate of 2.0 mmol/L or greater. Subjects were categorized according to the receipt of VitC, THMN, both, or neither. The primary outcome was in-hospital mortality. Secondary outcome was lactate clearance defined as lactate less than 2.0 mmol/L achieved after maximum lactate. Univariable comparisons included age, sex, race, Acute Physiology Score III, Acute Physiology and Chronic Health Evaluation (APACHE) IVa score, Sequential Organ Failure Assessment, surgical ICU admission status, intubation status, hospital region, liver disease, vasopressors, steroids, VitC and THMN orders. Kaplan-Meier curves, logistic regression, propensity score matching, and competing risks modeling were constructed. RESULTS: Of 146,687 patients from 186 hospitals, 7.7% (n = 11,330) were included. Overall mortality was 25.9% (n = 2,930). Evidence in favor of an association between VitC and/or THMN administration, and survival was found on log rank test (all p < 0.001). After controlling for confounding factors, VitC (adjusted odds ratio [AOR], 0.69 [0.50-0.95]) and THMN (AOR, 0.71 [0.55-0.93]) were independently associated with survival and THMN was associated with lactate clearance (AOR, 1.50 [1.22-1.96]). On competing risk model VitC (AOR, 0.675 [0.463-0.983]), THMN (AOR, 0.744 [0.569-0.974]), and VitC+THMN (AOR, 0.335 [0.13-0.865]) were associated with survival but not lactate clearance. For subgroup analysis of patients on vasopressors, VitC+THMN were associated with lactate clearance (AOR, 1.85 [1.05-3.24]) and survival (AOR, 0.223 [0.0678-0.735]). CONCLUSION: VitC+THMN is associated with increased survival in septic ICU patients. Randomized, multicenter trials are needed to better understand their effects on outcomes. LEVEL OF EVIDENCE: Therapeutic Study, Level IV.