Trauma surgeon performance of appendectomy in 5-year- to 10-year-old children is safe and decreases length of hospital stay.

BACKGROUND: Even in metropolitan areas, on-call pediatric surgeons may not always be immediately available for surgical care of appendicitis, potentially leading to delays in care. In 2012, the in-house trauma group at a suburban Level 1 trauma center (none with formal pediatric fellowship training) assumed surgical care of 5-year- to 10-year-old children with appendicitis, who had previously been cared for by pediatric surgeons. We propose to compare the outcomes of the trauma and pediatric surgery groups. METHODS: Retrospective chart review of 5-year- to 10-year-olds undergoing emergency appendectomy at a suburban Level 1 trauma center between January 2007 and December 2016 was performed. Patients were classified as having surgery performed by the trauma surgery group or the pediatric surgery group. Patient characteristics, clinical course, and outcomes were compared. RESULTS: A total of 220 patients were identified for study, 138 in the trauma group and 82 in the pediatric surgery group. Patients cared for by the trauma group were more likely to be female (47% vs. 32%; p = 0.03), were less likely to be diagnosed without imaging (2% vs. 26%; p < 0.0001), had a shorter time from diagnosis to surgery (214 vs. 318 minutes; p = 0.01), were more likely to have laparoscopic surgery (70% vs. 55%; p = 0.04), had a shorter operative time (40 vs. 49 minutes; p < 0.0001), and had a shorter length of stay (32 vs. 41 hours; p < 0.0001), despite more of them needing to be transferred from outside hospitals (60% vs. 37%; p < 0.001). There were no significant differences in patient age, rate of perforated appendicitis, 30-day readmissions, surgical site infections, or unanticipated procedures. CONCLUSIONS: Trauma surgeon performance of emergency appendectomy in 5-year- to 10-year-old children decreased length of hospitalization with similar complication rates as compared with pediatric surgeons. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Not every trauma patient with a radiographic head injury requires transfer for neurosurgical evaluation: Application of the brain injury guidelines to patients transferred to a level 1 trauma center.

BACKGROUND: Patients with radiographically-identified traumatic brain injury are often transferred to our regional trauma center for neurosurgical evaluation, yet few injuries require neurosurgical intervention. Transfer is costly, inconvenient, and potentially risky in inclement weather. We propose that previously-published brain injury guidelines (BIG)1 can help to determine which patients could avoid mandatory transfer. METHODS: Retrospective chart review of patients transferred between January 2012 and December 2013 was performed. Patients were classified as having minor (BIG 1), moderate (BIG 2), or severe (BIG 3) head injuries based on previously-published guidelines. Patient characteristics and outcomes were compared. RESULTS: No BIG 1 patients deteriorated or required surgical intervention. One BIG 2 patient required a non-emergent operation and another was readmitted with a worsened injury. In the BIG 3 group, 11.9% required neurosurgical procedures and 20% died. CONCLUSIONS: The BIG classification can help stratify patients for whom transfer is considered.

Predictors of mortality in close proximity blast injuries during Operation Iraqi Freedom.

BACKGROUND: Blast injury is an increasingly common problem faced by military surgeons in the field. Because of urban terrorism worldwide, blast injury is becoming more common in the civilian sector as well. Blast injuries are often devastating and can overwhelm medical resources. We sought to determine whether simple factors easily obtained from the clinical history and primary survey could be used to triage patients more effectively. STUDY DESIGN: A retrospective review of 18 consecutive close-proximity blast injury patients presenting to a forward deployed surgical unit in Iraq was performed. Patients' injuries and outcomes were recorded. We compared the presence of sustained hypotension, penetrating head injury, multiple (three or more) long-bone fractures, and associated fatalities (whether another patient involved in the same explosion died) between nonsurvivors and survivors using Fisher's exact test. RESULTS: All patients who presented alive but exhibited sustained hypotension (n = 5) died, versus 0% who did not exhibit sustained hypotension (n = 9, p < 0.01). There was no marked increase in mortality with presence of multiple long-bone fractures, penetrating head injury, or associated fatalities individually. Having two or more of these factors was associated with a mortality of 86% (6 of 7) versus 20% (2 of 10, p = 0.015) in those who had less than two factors. CONCLUSIONS: Blast injury can overwhelm military and civilian trauma systems alike. Sustained hypotension and presence of two or more easily determined factors, including three or more long-bone fractures, penetrating head injury, and associated fatalities, are associated with increased mortality and can potentially help triage patients and allocate scarce resources more efficiently.