Using chest X-ray to predict tube thoracostomy in traumatic pneumothorax: A single-institution retrospective review.

BACKGROUND: Traumatic pneumothorax (PTX) is a common occurrence in thoracic trauma patients, with a majority requiring tube thoracostomy (TT) for management. Recently, the "35-mm" rule has advocated for observation of patients with PTX less than 35 mm on chest computed tomography (CT) scan. This rule has not been examined in chest x-ray (CXR). We hypothesize that a similar size cutoff can be determined in CXR predictive of need for tube thoracostomy. METHODS: We performed a single-institution retrospective review of patients with traumatic PTX from 2018 to 2022, excluding those who underwent TT prior to CXR. Primary outcomes were size of pneumothorax on CXR and need for TT; secondary outcome was failed observation, defined as TT more than 4 hours after presentation. To determine the size cutoff on CXR to predict TT need, area under the receiver operating curve (AUROC) analyses were performed and Youden's index calculated (significance at p < 0.05). Predictors of failure were calculated using logistic regression. RESULTS: There were 341 pneumothoraces in 304 patients (94.4% blunt trauma, median injury severity score 14). Of these, 82 (24.0%) had a TT placed within the first 4 hours. Fifty-five of observed patients (21.2%) failed, and these patients had a larger PTX on CXR (8.6 mm [5.0-18.0 mm] vs. 0.0 mm [0.0-2.3 mm] ( p < 0.001)). Chest x-ray PTX size correlated moderately with CT size (r = 0.31, p < 0.001) and was highly predictive of need for TT insertion (AUC 0.75, p < 0.0001), with an optimal size cutoff predicting TT need of 38 mm. CONCLUSION: Chest x-ray imaging size was predictive of need for TT, with an optimal size cutoff on CXR of 38 mm, approaching the "35-mm rule." In addition to size, failed observation was predicted by presenting lactic acidosis and need for supplemental oxygen. This demonstrates this cutoff should be considered for prospective study in CXR. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Contemporary Rural Trauma Care.

The development of organized trauma systems has led to improved care for trauma patients, including those injured in rural areas. However, persistent disparities have led to increased awareness of the ongoing need for improvement. Our objective is to highlight distinctive aspects of rural trauma and propose opportunities for advancing rural trauma care.

Fatal opioid overdoses geospatially cluster with level 1 trauma centers in Ohio.

OBJECTIVE: Ohio is consistently ranked as one of the worst states for opioid overdose deaths. Traumatic injury has been linked to opioid overdose deaths, yet the location of trauma centers has not been explored. We examined whether geospatial clustering occurred between county-level opioid overdose deaths (OODs) and trauma center levels. METHODS: We obtained 2019 county-level data from the Ohio Department of Health for fatal overdoses from prescription opioids. We obtained the total number of opioid doses prescribed in 2019 per county from the Ohio Automated Rx Reporting System and American College of Surgeons designated trauma center locations within Ohio from their website. We used geospatial analysis to assess if clustering occurred between trauma center level and prescription opioid overdose deaths at a county level. RESULTS: There were 42 trauma centers located within 21 counties: 7 counties had level 1, and 14 counties had only level 2/level 3. There was no difference in rates of opioid doses prescribed per 100,000 people between counties with level 1 trauma centers and only level 2/level 3. However, prescription OODs rates were significantly higher in counties with level 1 trauma centers (37.6 vs 20, P = .02). Geospatial clustering was observed between level 1 trauma centers and prescription opioid overdose deaths at the county level (P < .01). CONCLUSION: Geospatial clustering exists between prescription OODs and level 1 trauma center locations in Ohio. Improved at-risk patient identification and targeted community outreach represent opportunities for trauma providers to tackle the opioid epidemic.

Academic Medical Centers Experienced Higher Rates of Post-Operative Health-Care-Associated Infections during the COVID-19 Pandemic: A Post Hoc Analysis of an Eastern Association for the Surgery of Trauma Multicenter Trial.

Background: We sought to examine health-care-associated infections (HAIs) among patients undergoing an appendectomy at academic medical centers (AMCs) and non-AMCs during the coronavirus disease 2019 (COVID-19) peri-pandemic. We hypothesized that AMCs would have higher rates of post-operative HAIs during the first wave of the pandemic. Patients and Methods: We performed a post hoc analysis of a prospective, observational, multi-center study of patients aged >18 years who underwent an appendectomy for acute appendicitis before (pre-CoV), during (CoV), and after pandemic restrictions were lifted (post-CoV). Patients were grouped according to hospital type (AMC vs. non-AMC). Our primary outcome was the incidence of post-operative HAIs. Results: There were 1,003 patients; 69.5% (n = 697) were treated at AMCs and 30.5% (n = 306) at non-AMCs. Patients at AMCs had greater rates of concomitant COVID-19 infections (5.5% vs. 0.7%; p < 0.0001) and worse operative appendicitis severity (p = 0.01). Greater rates of HAIs were seen at AMCs compared with non-AMCs (4.9% vs. 2%; p = 0.03). Surgical site infections were the most common HAI and occurred more often at AMCs (4.3% vs. 1.6%; p = 0.04). Only during CoV were there more HAIs at AMCs (5.1% vs. 0.3%; p = 0.02). Undergoing surgery at an AMC during CoV was a risk factor for HAIs (adjusted odds ratio [aOR], 8.55; 95% confidence interval [CI], 1.03-71.03; p = 0.04). Conclusions: During the COVID-19 pandemic, appendectomies performed at AMCs were an independent risk factor for post-operative HAIs. Our findings stress the importance of adherence to standard infection prevention efforts during future healthcare crises.

Broad vs Narrow Spectrum Antibiotics in Common Bile Duct Stones: A Post Hoc Analysis of an Eastern Association for the Surgery of Trauma Multicenter Study.

BACKGROUND: Antimicrobial guidance for common bile duct stones during the perioperative period is limited. We sought to examine the effect of broad-spectrum (BS) vs narrow-spectrum (NS) antibiotics on surgical site infections (SSIs) in patients with common bile duct stones undergoing same-admission cholecystectomy. STUDY DESIGN: We performed a post hoc analysis of a prospective, observational, multicenter study of patients undergoing same-admission cholecystectomy for choledocholithiasis and/or acute biliary pancreatitis between 2016 and 2019. We excluded patients with cholangitis, perforated cholecystitis, and nonbiliary infections on admission. Patients were divided based on receipt of BS or NS antibiotics. Our primary outcome was the incidence of SSIs, and secondary outcomes included hospital length of stay, acute kidney injury (AKI), and 30-day readmission for SSI. RESULTS: The cohort had 891 patients: 51.7% (n= 461) received BS antibiotics and 48.3% (n = 430) received NS antibiotics. Overall antibiotic duration was longer in the BS group than in the NS group (6 vs 4 d, p = 0.01); however, there was no difference in rates of SSI (0.9% vs 0.5%, p = 0.7) or 30-day readmission for SSI (1.1% vs 1.2%, p = 1.0). Hospital length of stay was significantly longer in the BS group (p < 0.001) as were rates of AKI (5% vs 1.4%, p = 0.001). On multivariable regression, BS antibiotic use was a risk factor for AKI (adjusted odds ratio 2.8, 95% CI 1.16 to 7.82, p = 0.02). CONCLUSION: The incidence of SSI and 30-day readmission for SSI was similar between antibiotic groups. However, BS antibiotic use was associated with a longer hospitalization and greater likelihood of AKI.

Planning for the Worst: The impact of a comprehensive, risk associated treatment protocol on unanticipated ICU admissions in patients affected by rib fractures.

BACKGROUND: There is no agreed upon triage criteria to identify traumatic rib fracture patients at the highest risk for decline. We developed a comprehensive triage tool that assigns patients to high, moderate, and low risk categories. The primary outcome of our study was to evaluate unplanned intensive care unit (ICU) admissions. METHODS: We conducted a single-center, retrospective review at our level 1 trauma center comparing two cohorts of patients (≥18 years of age) six months before and after implementation of our risk-associated rib fracture protocol. RESULTS: After implementation of the risk-associated rib fracture protocol, the unplanned ICU admission rate decreased from 6.60% (PRE) to 2.60% (POST) (p = 0.014). CONCLUSIONS: Implementation of our rib fracture protocol demonstrates that a comprehensive triage tool with a cascading risk associated treatment plan reduces in-hospital clinical decline of patients with traumatic rib fractures, as measured by unplanned ICU admissions.

The NOpioid Project: a prospective observational feasibility study examining the implementation of a non-narcotic post-operative pain control regimen.

BACKGROUND: Post-operative prescription of opioids has fueled an increase in opioid-associated morbidity and mortality. Alternative post-operative pain control with non-opioid pharmaceuticals can help counteract this effect. We investigated a non-opioid pain management protocol following emergent laparoscopic appendectomy and laparoscopic cholecystectomy. METHODS: Our tertiary referral center performed a prospective observational feasibility study of patients from October 2019 to 2020 who underwent emergent laparoscopic appendectomies and cholecystectomies. Patients aged 18-65 with no prior history of chronic pain or opioid abuse, no contraindications to taking acetaminophen and ibuprofen, and Glomerular Filtration Rate > 60 ml/min were included. Counseling was provided about non-narcotic pain control. Patients were not prescribed narcotics at discharge and were instead prescribed ibuprofen and acetaminophen. Patients were surveyed at their 2-week post-operative appointment to assess pain control and other patient-reported outcomes, including quality of life (QOL). RESULTS: Fifty-one patients met the inclusion criteria and completed the postoperative survey. Thirty-two were female (63%), average age 38, and BMI 30.4. 30 (59%) underwent laparoscopic appendectomy for acute non-perforated appendicitis and 21 (41%) underwent laparoscopic cholecystectomy for acute cholecystitis or symptomatic cholelithiasis. 88% of patients felt satisfied or neutral with their post-operative pain control at discharge. After 2 weeks, 34 patients (66.7%) rated QOL as high, 17 (33.3%) rated QOL as moderate, and none rated QOL as poor. Fascial suture was not associated with poor outcomes. Anxiety, depression, alcohol use, and prior abdominal surgery were not associated with increased need for post-operative narcotics. There were no significant differences between appendectomy and cholecystectomy in satisfaction with pain control or QOL (p > 0.05). CONCLUSION: Patients undergoing surgery have an increased risk of developing an opioid disorder. The NOpioid Project demonstrated a non-narcotic multimodal pain regimen can be effectively adopted in the post-operative period after an emergent laparoscopic appendectomy or emergent laparoscopic cholecystectomy.

Inhibition of platelet function is common following even minor injury.

BACKGROUND: Hemorrhage remains the leading cause of preventable death following injury. Whereas significant attention has been paid to the coagulation cascade, there are fewer studies evaluating platelet dysfunction following injury. Thrombelastogram platelet mapping (TEG-PM) allows for the measurement of maximal potential clot strength and clot strength selectively caused by arachidonic acid and adenosine disphosphate receptors on the platelet. The purpose of this study was to determine the incidence and magnitude of receptor-specific platelet dysfunction following injury in patients who are not otherwise pharmacologically anticoagulated. METHODS: A retrospective study of adult trauma patients evaluated at a Level I trauma center from August 2013 to September 2014 was conducted. Platelet function was assessed using TEG-PM. Patients on any anticoagulant or antiplatelet medication were excluded. Patients were divided into those with and without radiographically evident traumatic brain injury (TBI). Demographic variables, Injury Severity Score (ISS), injury pattern, laboratory test results, and mortality were abstracted. Statistical comparisons were made using the Student's t test or Mann-Whitney U-test. RESULTS: The study includes 459 patients, 92% following blunt injury. Median ISS was 5. Patients with TBI (n = 102) were significantly older (median age, 54 years vs. 35 years), were more severely injured (median ISS, 10 vs. 4), had a longer stay and higher mortality (9% vs. 0.3%). Maximal potential clot strength was normal in all cohorts, but the arachidonic acid and adenosine diphosphate pathways were significantly inhibited (30% ± 26% and 58% ± 27%, respectively). There was no correlation between TEG-PM values and ISS, length of stay, or mortality. There was no difference in the TBI cohort. There were no significant differences in TEG-PM parameters in those with an ISS greater than 14. There was no significant change in TEG-PM following platelet transfusion. CONCLUSION: Marked platelet inhibition is common following minor injury. Whereas the clinical significance of this finding remains unknown, the results of this study should be factored in the overall resuscitative strategy. LEVEL OF EVIDENCE: Prognostic/epidemiogic study, level III.

Alcohol level and injury severity: is the floppy patient myth true?

BACKGROUND: The impact of inebriation on severity of injury is unclear. The few studies to date on this topic are limited to a particular mechanism of injury (MOI), injury pattern, or blood alcohol level (BAL). Therefore, we sought to determine the impact of BAL on injury pattern and severity across all MOI. We hypothesize that there is no relationship between BAL and injury severity when controlling for MOI. MATERIALS AND METHODS: After institutional review board approval, a retrospective study was performed at an adult trauma center from January 1, 2012-December 31, 2012. All MOI were included. Injury severity was assessed using the injury severity score (ISS). Chi square and analysis of variance were used to examine the relationship between BAL, injury pattern, and ISS within each MOI. Multivariate regression analysis examined the BAL-ISS association adjusting for MOI, gender, and age. RESULTS: Of 1397 patients, the mean age was 44 ± 19, ISS was 7.5 ± 6.8, BAL was 93 ± 130 mg/dL, and 70% were male. Rib fracture (P = 0.002) and hemothorax and/or pneumothorax (P = 0.0009) were negatively associated with BAL, whereas concussion and soft tissue injury had a positive association with BAL (P < 0.0001). An increasing BAL had a negative correlation with ISS after fall from standing (P < 0.001), whereas bicycle collisions had a positive association (P = 0.027). Across all MOI, there was no significant association between BAL and ISS. CONCLUSIONS: BAL is associated with ISS, in specific MOI; however, across all MOI, there was no significant association between BAL and ISS. Inebriated patients should be triaged with the same clinical index of suspicion for injury as sober patients.

Timing of death after traumatic injury--a contemporary assessment of the temporal distribution of death.

BACKGROUND: The trimodal distribution of traumatic death was first described by Trunkey in 1983, which demonstrated that most deaths occur in the first 24 h. We postulate that since 1983, the time-to-death histogram described has shifted. METHODS: A retrospective analysis identifying timing of death was conducted on the National Trauma Data Bank (version 7.2) from 2002 to 2006. Early death was defined as death within 24 h of admission. International Classification of Diseases ninth edition codes with greater than 20% early deaths were called "high-risk codes". Bivariate analyses were conducted to assess the association between demographics, injury factors, and death. Pearson's χ(2) test was used to compare timing of death by region of injury. Multivariate logistic regression was conducted to show the effect of region of injury on death while controlling for demographic factors and injury type. RESULTS: The cohort includes 898,982 patients. The study population was predominantly male (66%) and Caucasian (62%). Mean age and injury severity score were 45 ± 20.3 and 11 ± 10, respectively. Overall mortality rate was 5% with 56% dying early. Head/neck, thorax, and abdomen/pelvis injuries were more prevalent in overall deaths (35%, 22%, and 11%, respectively). Thorax and abdomen/pelvis injuries predicted early death (odds ratio 2.03 and 1.39, respectively). CONCLUSIONS: The prevalence of early death has decreased since 1983, but the majority of deaths still occur within 24 h of injury. Ample opportunity remains to impact mortality in the first 24 h after injury.

Metastatic Renal Cell Carcinoma to the Thyroid 23 Years After Nephrectomy.

Thyroid carcinoma is an uncommon form of human cancer, with an outstanding overall cure rate. This excellent prognosis is based on the fact that well over 99% of thyroid cancers are primary tumors. Metastatic cancer to the thyroid remains very rare. We report a case of clear cell renal carcinoma metastatic to the thyroid gland 23 years after nephrectomy.

Average chest wall thickness at two anatomic locations in trauma patients.

BACKGROUND: Needle thoracostomy is the emergent treatment for tension pneumothorax. This procedure is commonly done using a 4.5cm catheter, and the optimal site for chest wall puncture is controversial. We hypothesize that needle thoracostomy cannot be performed using this catheter length irrespective of the site chosen in either gender. METHODS: A retrospective review of all chest computed tomography (CT) scans obtained on trauma patients from January 1, 2011 to December 31, 2011 was performed. Patients aged 18 and 80 years were included and patients whose chest wall thickness exceeded the boundary of the images acquired were excluded. Chest wall thickness was measured at the 2nd intercostal (ICS), midclavicular line (MCL) and the 5th ICS, anterior axillary line (AAL). Injury severity score (ISS), chest wall thickness, and body mass index (BMI) were analyzed. RESULTS: 201 patients were included, 54% male. Average (SD) BMI was 26 (7)kg/m(2). The average chest wall thickness in the overall cohort was 4.08 (1.4)cm at the 2nd ICS/MCL and 4.55 (1.7)cm at the 5th ICS/AAL. 29% of the overall cohort (27 male and 32 female) had a chest wall thickness greater than 4.5cm at the 2nd ICS/MCL and 45% (54 male and 36 female) had a chest wall thickness greater than 4.5cm at the 5th ICS/AAL. There was no significant interaction between gender and chest wall thickness at either site. BMI was positively associated with chest wall thickness at both the 2nd and 5th ICS/AAL. CONCLUSION: A 4.5cm catheter is inadequate for needle thoracostomy in most patients regardless of puncture site or gender.

Serum creatine kinase levels are associated with extremity compartment syndrome.

BACKGROUND: Limb compartment syndrome (CS) is a difficult diagnosis. Accurate measurement of compartment pressure is user dependent, and there is no consensus on values to define CS. Given the prevalence of extremity CS, difficulty in timely diagnosis, and ramifications of a delay in diagnosis, a precise and reliable means for early diagnosis is needed. The purpose of our study was to determine if a threshold serum creatinine kinase (CK) level is associated with the development of CS. METHODS: All patients with isolated tibial/fibula fractures or extremity CS admitted to a three-hospital consortium from July 1, 2001, to June 30, 2011, were identified retrospectively using coded data. Age, basic metabolic panel, lactic acid, CK, and troponin I levels were abstracted. Univariate and multivariate regression analysis was undertaken using maximum and minimum values for each laboratory test to evaluate the association between the test and CS versus tibia/fibula fracture. RESULTS: Of the 97 patients in the study, 39 had CS. Tests most strongly associated with CS were maximum CK, minimum calcium, minimum blood urea nitrogen (BUN), maximum chloride, maximum lactate, and minimum HCO3. On univariate analysis, only maximum CK had adequate correlation with CS. Optimal cut points were maximum CK of greater than 4,000 U/L. Using the model CK level of greater than 4,000 U/L, chloride level of greater than 104 mg/dL, and BUN level of less than 10 mg/dL, 0 of 6 patients had CS when all three variables were absent. When one, two, or three variables were present, the percentage of patients with CS was 36%, 80%, and 100%, respectively. Using a cut point of two or more of these three variables being positive produced sensitivity, specificity, positive and negative prediction values, and total accuracy of 0.85, 0.87, 0.76, 0.92, and 0.86, respectively. CONCLUSION: CK level greater than 4,000 U/L is associated with CS. A model combining maximal CK level greater than 4,000 U/L, maximal chloride level greater than 104 mg/dL, and minimal BUN level less than 10 mg/dL has a 100% association with CS. LEVEL OF EVIDENCE: Diagnostic study, level III.