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Journal of Trauma and Acute Care Surgery, The
Journal Prestige (SJR): 1.747  Citation Impact (citeScore): 3 Number of Followers: 36  Hybrid journal (It can contain Open Access articles)ISSN (Print) 2163-0755 - ISSN (Online) 2163-0763 Published by LWW Wolters Kluwer  [330 journals]
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- FEATURED ARTICLES FOR CME CREDIT DECEMBER 2023
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Abstract: No abstract available
PubDate: Fri, 01 Dec 2023 00:00:00 GMT-
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- Meetings/Courses
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Abstract: No abstract available
PubDate: Fri, 01 Dec 2023 00:00:00 GMT-
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- Rethinking limb tourniquet conversion in the prehospital environment
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Authors: Holcomb; John B.; Dorlac, Warren C.; Drew, Brendon G.; Butler, Frank K.; Gurney, Jennifer M.; Montgomery, Harold R.; Shackelford, Stacy A.; Bank, Eric A.; Kerby, Jeff D.; Kragh, John F.; Person, Michael A.; Patterson, Jessica L.; Levchuk, Olha; Andriievskyi, Mykola; Bitiukov, Glib; Danyljuk, Oleksandr; Linchevskyy, Oleksandr
Abstract:
No abstract available
PubDate: Mon, 20 Nov 2023 00:00:00 GMT-
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- Book review: Current therapy of trauma and surgical critical care, 3rd
edition, editors: Asensio and Meredith-
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Authors: Esposito; Thomas J.
Abstract: No abstract available
PubDate: Thu, 21 Sep 2023 00:00:00 GMT-
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- Chest Wall Injury Society recommendation for surgical stabilization of
nonunited rib fractures to decrease pain, reduce opiate use, and improve
patient reported outcomes in patients with rib fracture nonunion after
trauma-
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Authors: Forrester; Joseph D.; Bauman, Zachary M.; Cole, Peter A.; Edwards, John G.; Knight, Ariel W.; LaRoque, Michael; Raffa, Taylor; White, Thomas W.; Kartiko, Susan
Abstract:
BACKGROUND Rib fractures are common injuries which can be associated with acute pain and chronic disability. While most rib fractures ultimately go on to achieve bony union, a subset of patients may go on to develop non-union. Management of these nonunited rib fractures can be challenging and variability in management exists.METHODS The Chest Wall Injury Society’s Publication Committee convened to develop recommendations for use of surgical stabilization of nonunited rib fractures (SSNURF) to treat traumatic rib fracture nonunions. PubMed, Embase, and the Cochrane database were searched for pertinent studies. Using a process of iterative consensus, all committee members voted to accept or reject the recommendation.RESULTS No identified studies compared SSNURF to alternative therapy and the overall quality of the body of evidence was rated as low. Risk of bias was identified in all studies. Despite these limitations, there is lower-quality evidence suggesting that SSNURF may be beneficial for decreasing pain, reducing opiate use, and improving patient reported outcomes among patients with symptomatic rib nonunion. However, these benefits should be balanced against risk of symptomatic hardware failure and infection.CONCLUSION This guideline document summarizes the current CWIS recommendations regarding use of SSNURF for management of rib nonunion.LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
PubDate: Tue, 19 Sep 2023 00:00:00 GMT-
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- Surgical stabilization of rib fractures is associated with better return
on investment for a health care institution than nonoperative management-
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Authors: Bauman; Zachary M.; Khan, Hason; Cavlovic, Lindsey; Raposo-Hadley, Ashley; Todd, Sydney J.; King, Tylor; Cahoy, Kevin; Kamien, Andrew; Cemaj, Samuel; Sheppard, Olabisi; Matos, Miguel; Berning, Bennett; Evans, Charity H.; Cantrell, Emily
Abstract:
BACKGROUND Surgical stabilization of rib fractures (SSRFs) continues to gain popularity due to patient benefits. However, little has been produced regarding the economic benefits of SSRF and its impact on hospital metrics such as Vizient. The aim of this study was to explore these benefits hypothesizing SSRF will demonstrate positive return on investment (ROI) for a health care institution.METHODS This is a retrospective review of all rib fracture patients over 5 years at our Level I trauma center. Patients were grouped into SSRF versus nonoperative management. Basic demographics were obtained including case mix index (CMI). Outcomes included narcotic requirements in morphine milliequivalents prior to discharge, mortality, and discharge disposition. Furthermore, actual hospital length of stay (ALOS) versus Vizient expected length of stay were compared between cohorts. Contribution margin (CM) was also calculated. Independent t-test, paired t-test, and linear regression analysis were performed, and significance set at p < 0.05.RESULTS A total of 1,639 patients were included; 230 (14%) underwent SSRF. Age, gender, and Injury Severity Score were similar. Surgical stabilization of rib fracture patients had more ribs fractured (7 vs. 4; p < 0.001) and more patients with flail chest (43.5% vs. 6.7%; p < 0.001). Surgical stabilization of rib fracture patients also had a significantly higher CMI (4.33 vs. 2.78; p = 0.001). Narcotic requirements and mortality were less in the SSRF cohort; 155 versus 246 morphine milliequivalents (p < 0.001) and 1.7% versus 7.1% (p = 0.003), respectively. Surgical stabilization of rib fracture patients were more likely to be discharged home (70.4% vs. 63.7%; p = 0.006). Surgical stabilization of rib fracture patients demonstrated shorter ALOS where nonoperative management patients demonstrated longer ALOS compared with Vizient expected length of stay. Contribution margins for SSRF patients were significantly higher and linear regression analysis showed a CM $1,128.14 higher per patient undergoing SSRF (p < 0.001).CONCLUSION Patients undergoing SSRF demonstrate a significant ROI for a health care organization. Despite SSRF patients having a higher CMI, they were able to be discharged sooner than expected by Vizient calculations resulting in better a CM.LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
PubDate: Fri, 15 Sep 2023 00:00:00 GMT-
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- Contemporary management of common bile duct stone: What you need to know
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Authors: Hwang; Franchesca; Bukur, Marko
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Choledocholithiasis is a common presentation of symptomatic cholelithiasis encountered by the acute care surgeon. There is a wide spectrum of variation in management of this disease due to evolutions in laparoscopic and endoscopic techniques. Intricacies in management are related to the timing of diagnosis as well as locally available imaging modalities, surgical expertise, and ancillary advanced endoscopy and interventional radiological support. While individual patient demographics and institutional characteristics will determine management of choledocholithiasis, it is incumbent for the treating surgeon to be well versed in all manners of therapy currently available. The objective of this review is to provide an evidence-based summary of the contemporary management of choledocholithiasis.
PubDate: Tue, 12 Sep 2023 00:00:00 GMT-
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- Better late than never—a single-center review of delayed rib fixation
for symptomatic rib fractures and nonunions-
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Authors: Bauman; Zachary M.; Khan, Hason; Cavlovic, Lindsey; Todd, Sydney; Cemaj, Samuel; Daubert, Trevor; Raposo-Hadley, Ashley; Matos, Miguel; Sheppard, Olabisi; Berning, Bennett; Kamien, Andrew; Evans, Charity H.; Cantrell, Emily
Abstract:
BACKGROUND Surgical stabilization of rib fractures (SSRFs) has become an emerging therapy for treatment of patients with rib fractures. More commonly, it is used in the acute setting; however, delayed SSRF can be utilized for symptomatic rib fracture nonunions. Here, we describe our institution's experience with delayed SSRF, hypothesizing it is safe and resolves patient symptoms.METHODS This is a retrospective review of patients presenting to our Level I trauma center to undergo delayed SSRF for symptomatic nonunions from January 2017 to September 2022. Delayed SSRF was defined as SSRF over 2 weeks in the outpatient setting. Basic demographics were obtained. Outcomes of interest included mean pain score (preoperatively and postoperatively), intensive care unit (ICU) and hospital length of stay (LOS), and resolution of preoperative symptoms, specifically chest wall instability, with return to activities of daily living (ADLs).RESULTS Forty-four patients met inclusion criteria with a total of 156 symptomatic nonunion rib fractures that received delayed SSRF. The average age was 59.2 ± 11.9 years and median number of days from injury to SSRF was 172.5 (interquartile range, 27.5–200). The average number rib fractures plated per patient 3.5 ± 1.8. Only three patients required ICU admission postoperatively for no longer than 2 days. Median hospital LOS was 2 days (interquartile range 1–3 days). Average preoperative and postoperative pain score was 6.8 ± 1.9 and 2.02 ± 1.5, respectively (p < 0.001). Chest wall instability and preoperative symptoms resolved in 93.2% of patients postoperatively (p < 0.001). Two patients (4.5%) had postoperative complications that resolved after additional surgical intervention. Rib fracture healing was demonstrated on radiographic imaging during postoperative follow-up.CONCLUSION Delayed SSRF is safe and demonstrates significant resolution of preoperative symptoms by decreasing pain, improving chest wall stability, and allowing patients to return to activities of daily living.LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
PubDate: Tue, 12 Sep 2023 00:00:00 GMT-
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- Response to letter to the editor regarding article: Management of the open
abdomen: A systematic review with meta-analysis and practice management
guideline from the Eastern Association for the Surgery of Trauma-
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Authors: Mahoney; Eric J.; Bugaev, Nikolay; Appelbaum, Rachel; Goldenberg-Sandau, Anna; Baltazar, Gerard A.; Posluszny, Joseph; Dultz, Linda; Kartiko, Susan; Kasotakis, George; Como, John; Klein, Eric
Abstract: No abstract available
PubDate: Fri, 08 Sep 2023 00:00:00 GMT-
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- Common postbariatric surgery emergencies for the acute care surgeon: What
you need to know-
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Authors: Cheng; Vincent; Samakar, Kamran; Dobrowolsky, Adrian B.; Nguyen, James D.; Abel, Stuart A.; Pakula, Andrea; Bernard, Andrew; Martin, Matthew J.
Abstract:
The field of bariatric and metabolic surgery has changed rapidly over the past two decades, with an exponential increase in case volumes being performed because of its proven efficacy for morbid obesity and obesity-related comorbidities. Although this increased volume of procedures has been accompanied by significant decrease in postoperative complication rates, there are numerous potential complications after bariatric surgery that may require urgent or emergent surgical evaluation or interventions. Many of these risks extend well beyond the early postoperative period and can present months to years after the index procedure. Acute care surgeons are increasingly covering most or all of the emergency general surgery services at many centers and must be familiar with the numerous bariatric surgical procedures being performed and their individual complication profile to provide optimal care for these frequently challenging patients. This article provides a focused and concise review of the common bariatric procedures being performed, their early and late complication profiles, and a practical guide to the optimal diagnostic evaluations, surgical interventions, and perioperative management options. The author group includes both acute care surgeons and bariatric surgeons with significant experience in the emergency management of the complicated postbariatric surgical patient.LEVEL OF EVIDENCE Literature Synthesis and Expert Opinion; Level V.
PubDate: Wed, 30 Aug 2023 00:00:00 GMT-
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- Anatomy of the anterior ribs and the composition of the costal margin: A
cadaver study-
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Authors: Patel; Arjun; Privette, Alicia; Bauman, Zachary; Hansen, Adam; Kubalak, Steven; Eriksson, Evert
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BACKGROUND Traditional rib anatomy and costal margin teaching contends that the costal margin consists of a combined costal cartilage made up of ribs 7 to 10. Variations in 9th and 10th rib anatomy have been observed. We sought to evaluate the variability of interchondral joints and the make-up of the costal margin.METHODS Cadaveric dissections were performed to evaluate the anatomy of the anterior ribs and the composition of the costal margin. Experienced chest wall surgeons evaluated this anatomy through a standardized dissection and assessment. Dissection videos were performed to allow for further review/assessment.RESULTS Bilateral chest wall anatomy of 30 cadavers was evaluated (15 male, 15 female). The average age was 78 ± 12 years, and all patients were Caucasian. In all patients, the first rib attached to the manubrium, the second rib attached to the manubriosternal junction, and ribs 3 to 6 attached directly to the sternum. Interchondral joints were present between ribs 4/5—3%, 5/6—68%, 6/7—83%, 7/8—72%. Ribs combining to form a common costal cartilage via cartilaginous unions were observed between 6/7—3%, 7/8—45%, 8/9—30%, and 9/10—20%.The 8th rib attached directly to the sternum without joining the 7th rib in 10% of cadavers. The 8th and 9th ribs had free tips in 45% and 60% of evaluations, respectively. The 10th rib was found to have a hooked tip in 25% of cases and was a floating rib without attachment to the 9th rib 52% of the time. Rib tip mobility was noted in ribs 8, 9, and 10 in 52%, 70%, and 90%, respectively.CONCLUSION Interchondral joints are common between ribs 5 and 8. Significant variability exists in the chest wall and costal margin compared with traditional teaching. It is important for chest wall surgeons treating diseases of the costal margin to appreciate this anatomic variability.
PubDate: Wed, 30 Aug 2023 00:00:00 GMT-
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- Why are there no data' Critically ill patients deserve better protection
from both regulatory authorities and surgeons-
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Authors: Kirkpatrick; Andrew W.; Coccolini, Federico; Minor, Samuel
Abstract: No abstract available
PubDate: Fri, 11 Aug 2023 00:00:00 GMT-
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- American Association for the Surgery of Trauma/American College of
Surgeons—Committee on Trauma Clinical Consensus-Driven Protocol for
glucose management in the post-resuscitation intensive care unit adult
trauma patient-
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Authors: Jacovides; Christina L.; Skeete, Dionne A.; Werner, Nicole L.; Toschlog, Eric A.; Agarwal, Suresh; Coopwood, Ben; Crandall, Marie; Tominaga, Gail T.
Abstract:
No abstract available
PubDate: Thu, 10 Aug 2023 00:00:00 GMT-
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- Costal margin injuries and trans-diaphragmatic intercostal hernia:
Presentation, management and outcomes according to the Sheffield
classification-
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Authors: Byers; Jonathan L.; Rao, Jagan N.; Socci, Laura; Hopkinson, David N.; Tenconi, Sara; Edwards, John G.
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BACKGROUND Costal margin rupture (CMR) injuries are under-diagnosed and inconsistently managed, while carrying significant symptomatic burden. We hypothesized that the Sheffield Classification system of CMR injuries would relate to injury patterns and management options.METHODS Data were collected prospectively between 2006 and 2023 at a major trauma center in the United Kingdom. Computed tomography scans were interrogated and injuries were categorized according to the Sheffield Classification. Clinical, radiologic, management and outcome variables were assessed.RESULTS Fifty-four patients were included in the study. Intercostal hernia (IH) was present in 30 patients and associated with delayed presentation (p = 0.004), expulsive mechanism of injury (i.e. such as occurs with coughing, sneezing, or retching), higher body mass index (p < 0.001), and surgical management (p = 0.02). There was a bimodal distribution of the level of the costal margin rupture, with IH Present and expulsive mechanism injuries occurring predominantly at the ninth costal cartilage, and IH Absent cases and other mechanisms at the seventh costal cartilage (p < 0.001). There were correlations between the costal cartilage being thin at the site of the CMR and the presence of IH and expulsive etiology (p < 0.001). Management was conservative in 23 and surgical in 31 cases. Extrathoracic mesh IH repairs were performed in 3, Double Layer Mesh Repairs in 8, Suture IH repairs in 5, CMR plating in 8, CMR sutures in 2, and associated Surgical Stabilization of Rib Fractures in 11 patients. There was one postoperative death. There were seven repeat surgical procedures in five patients.CONCLUSION The Sheffield Classification is associated statistically with presentation, related chest wall injury patterns, and type of definitive management. Further collaborative data collection is required to determine the optimal management strategies.LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
PubDate: Thu, 03 Aug 2023 00:00:00 GMT-
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- Patients with both traumatic brain injury and hemorrhagic shock benefit
from resuscitation with whole blood-
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Authors: Hatton; Gabrielle E.; Brill, Jason B.; Tang, Brian; Mueck, Krislynn M.; McCoy, C. Cameron; Kao, Lillian S.; Cotton, Bryan A.
Abstract:
BACKGROUND Hemorrhagic shock in the setting of traumatic brain injury (TBI) reduces cerebral blood flow and doubles mortality. The optimal resuscitation strategy for hemorrhage in the setting of TBI is unknown. We hypothesized that, among patients presenting with concomitant hemorrhagic shock and TBI, resuscitation including whole blood (WB) is associated with decreased overall and TBI-related mortality when compared with patients receiving component (COMP) therapy alone.METHODS An a priori subgroup of prospective, observational cohort study of injured patients receiving emergency-release blood products for hemorrhagic shock is reported. Adult trauma patients presenting November 2017 to September 2020 with TBI, defined as a Head Abbreviated Injury Scale of ≥3, were included. Whole blood group patients received any cold-store low-titer Group O WB units. The COMP group received fractionated blood components alone. Overall and TBI-related 30-day mortality, favorable discharge disposition (home or rehabilitation), and 24-hour blood product utilization were assessed. Univariate and inverse probabilities of treatment-weighted multivariable analyses were performed.RESULTS Of 564 eligible patients, 341 received WB. Patients who received WB had a higher injury severity score (median, 34 vs. 29), lower scene blood pressure (104 vs. 118), and higher arrival lactate (4.3 vs. 3.6, all p < 0.05). Univariate analysis noted similar overall mortality between WB and COMP; however, weighted multivariable analyses found WB was associated with decreased overall mortality and TBI-related mortality. There were no differences in discharge disposition between the WB group and COMP group.CONCLUSION In patients with concomitant hemorrhagic shock and TBI, WB transfusion was associated with decreased overall mortality and TBI-related mortality. Whole blood should be considered a first-line therapy for hemorrhage in the setting of TBI.LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
PubDate: Mon, 24 Jul 2023 00:00:00 GMT-
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- Injury pattern and clinical outcome in patients with and without chest
wall injury after cardiopulmonary resuscitation-
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Authors: Hadesi; Parsa; Rossi Norrlund, Rauni; Caragounis, Eva-Corina
Abstract:
BACKGROUND Cardiopulmonary resuscitation (CPR), although lifesaving may cause chest wall injury (CWI) because of the physical force exerted on the thorax. The impact of CWI on clinical outcome in this patient group is unclear. The primary aim of this study was to investigate the incidence of CPR-related CWI and the secondary aim to study injury pattern, length of stay (LOS), and mortality in patients with and without CWI.METHODS This is a retrospective study of adult patients who were admitted to our hospital due to cardiac arrest (CA) during 2012 to 2020. Patients were identified in the Swedish CPR Registry and those undergoing CT of the thorax within 2 weeks after CPR were included. Patients with traumatic CA, chest wall surgery prior or after CA were excluded. Demographic data, type and length of CPR, type of CWI, LOS on mechanical ventilator (MV), in intensive care unit (ICU) and in hospital (H), and mortality were studied.RESULTS Of 1,715 CA patients, 245 met the criteria for inclusion. The majority (79%) of the patients suffered from CWI. Chondral injuries and rib fractures were more common than sternum fractures (95% vs. 57%), and 14% had a radiological flail segment. Patients with CWI were older (66.5 ± 15.4 vs. 52.5 ± 15.2, p < 0.001). No difference was seen in MV-LOS (3 [0–43] vs. 3 [0–22]; p = 0.430), ICU-LOS (3 [0–48] vs. 3 [0–24]; p = 0.427), and H-LOS (5.5 [0–85] vs. 9.0 [1–53]; p = 0.306) in patients with or without CWI. Overall mortality within 30 days was higher with CWI (68% vs. 47%, p = 0.007).CONCLUSION Chest wall injuries are common after CPR and 14% of patients had a flail segment on CT. Elderly patients have an increased risk of CWI, and a higher overall mortality is seen in patients with CWI.LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
PubDate: Wed, 05 Jul 2023 00:00:00 GMT-
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- Surgical management of traumatic sternal body nonunions: Technical tricks
and clinical experience-
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Authors: LaRoque; Michael C.; Brahme, Indraneel S.; Cole, Peter A.
Abstract:
BACKGROUND Rarely, traumatic sternum fractures may result in nonunion, which can have drastic, negative implications. Literature on traumatic sternal nonunion reconstruction outcomes is limited to case reports. We present the surgical principles and report clinical outcomes for seven patients following surgical reconstruction of a traumatic sternal body nonunion.METHODS Consecutive adult patients with a nonunion after a traumatic sternum fracture who underwent reconstruction using locking plate technology and iliac crest bone graft at a Level I trauma center from 2013 to 2021 were identified. Demographic, injury, and surgery data was collected, and postoperative patient-reported outcome (PRO) scores were obtained. Patient-reported outcome scores included the one-question single assessment numeric evaluation (SANE), and the combined 10-question global physical health and global mental health values. Injuries were classified and all fractures were mapped onto a sternum template. Postoperative radiographs were reviewed for union.RESULTS Of the study's seven patients, five were female, and the mean age was 58 years. Mechanism of injury included motor vehicle collision (5) and blunt object chest trauma (2). The mean time from initial fracture to nonunion fixation was 9 months. Four of the seven patients achieved in-clinic follow-up at ≥12 months (mean = 14.3 months), while the other three achieved ≥6 months of in-clinic follow-up. Six patients completed outcomes surveys ≥12 months after surgery (mean = 28.9 months). Mean PRO scores at final follow-up included: SANE of 75 (out of 100), and global physical health and global mental health of 44 and 47, respectively (US population mean = 50).Six of seven patients achieved known radiographic union.CONCLUSION We describe an effective and practical method of achieving stable fixation in traumatic sternal body nonunions as evidenced by the positive clinical outcomes of a seven-patient series. Despite the variation in presentation and fracture morphology of this rare injury, the surgical technique and principles outlined can serve as a useful tool for chest wall surgeons.LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
PubDate: Wed, 05 Jul 2023 00:00:00 GMT-
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- Health care utilization outcomes in patients with blunt chest wall trauma
following discharge from the emergency department: A retrospective,
observational data-linkage study-
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Authors: Battle; Ceri; Hutchings, Hayley; Rafferty, James; Toghill, Hannah; Akbari, Ashley; Watkins, Alan
Abstract:
BACKGROUND Although much is published reporting clinical outcomes in the patients with blunt chest wall trauma who are admitted to hospital from the ED, less is known about the patients’ recovery when they are discharged directly without admission. The aim of this study was to investigate the health care utilization outcomes in adult patients with blunt chest wall trauma, discharged directly from ED in a trauma unit in the United Kingdom.METHODS This was a longitudinal, retrospective, single-center, observational study incorporating analysis of linked datasets, using the Secure Anonymised Information Linkage databank for admissions to a trauma unit in the Wales, between January 1, 2016, and December 31, 2020. All patients 16 years or older with a primary diagnosis of blunt chest wall trauma discharged directly home were included. Data were analyzed using a negative binomial regression model.RESULTS There were 3,205 presentations to the ED included. Mean age was 53 years, 57% were male, with the predominant injury mechanism being a low velocity fall (50%). 93% of the cohort sustained between 0 and 3 rib fractures. Four percent of the cohort were reported to have chronic obstructive pulmonary disease, and 4% using preinjury anticoagulants. On regression analysis, inpatient admissions, outpatient appointments and primary care contacts all significantly increased in the 12-week period postinjury, compared with the 12-week period preinjury (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.33–1.99; p < 0.001; OR, 1.28; 95% CI, 1.14–1.43; p < 0.001; OR, 1.02; 95% CI, 1.01–1.02; p < 0.001, respectively). Risk of health care resource utilization increased significantly with each additional year of age, chronic obstructive pulmonary disease and preinjury anticoagulant use (all p < 0.05). Social deprivation and number of rib fracture did not impact outcomes.CONCLUSION The results of this study demonstrate the need for appropriate signposting and follow-up for patients with blunt chest wall trauma presenting to the ED, not requiring admission to the hospital.LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
PubDate: Wed, 05 Jul 2023 00:00:00 GMT-
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- A metabolomic and proteomic analysis of pathologic hypercoagulability in
traumatic brain injury patients after dura violation-
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Authors: Coleman; Julia R.; D’Alessandro, Angelo; LaCroix, Ian; Dzieciatkowska, Monika; Lutz, Patrick; Mitra, Sanchayita; Gamboni, Fabia; Ruf, Wolram; Silliman, Christopher C.; Cohen, Mitchell J.
Abstract:
BACKGROUND The coagulopathy of traumatic brain injury (TBI) remains poorly understood. Contradictory descriptions highlight the distinction between systemic and local coagulation, with descriptions of systemic hypercoagulability despite intracranial hypocoagulopathy. This perplexing coagulation profile has been hypothesized to be due to tissue factor release. The objective of this study was to assess the coagulation profile of TBI patients undergoing neurosurgical procedures. We hypothesize that dura violation is associated with higher tissue factor and conversion to a hypercoagulable profile and unique metabolomic and proteomic phenotype.METHODS This is a prospective, observational cohort study of all adult TBI patients at an urban, Level I trauma center who underwent a neurosurgical procedure from 2019 to 2021. Whole blood samples were collected before and then 1 hour following dura violation. Citrated rapid and tissue plasminogen activator (tPA) thrombelastography (TEG) were performed, in addition to measurement of tissue factory activity, metabolomics, and proteomics.RESULTS Overall, 57 patients were included. The majority (61%) were male, the median age was 52 years, 70% presented after blunt trauma, and the median Glasgow Coma Score was 7. Compared with pre-dura violation, post-dura violation blood demonstrated systemic hypercoagulability, with a significant increase in clot strength (maximum amplitude of 74.4 mm vs. 63.5 mm; p < 0.0001) and a significant decrease in fibrinolysis (LY30 on tPAchallenged TEG of 1.4% vs. 2.6%; p = 0.04). There were no statistically significant differences in tissue factor. Metabolomics revealed notable increases in metabolites involved in late glycolysis, cysteine, and one-carbon metabolites, and metabolites involved in endothelial dysfunction/arginine metabolism/responses to hypoxia. Proteomics revealed notable increase in proteins related to platelet activation and fibrinolysis inhibition.CONCLUSION A systemic hypercoagulability is observed in TBI patients, characterized by increased clot strength and decreased fibrinolysis and a unique metabolomic and proteomics phenotype independent of tissue factor levels.
PubDate: Wed, 05 Jul 2023 00:00:00 GMT-
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- Evaluating the impact of timing to rib fixation in patients with traumatic
brain injury: A nationwide analysis-
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Authors: Lagazzi; Emanuele; Argandykov, Dias; de Roulet, Amory; Proaño-Zamudio, Jefferson A.; Romijn, Anne-Sophie C.; Abiad, May; Rafaqat, Wardah; Velmahos, George C.; Hwabejire, John O.; Paranjape, Charudutt N.
Abstract:
BACKGROUND Early surgical stabilization of rib fractures (SSRF) is associated with improved inpatient outcomes in patients with multiple rib fractures. However, there is still a paucity of data examining the optimal timing of SSRF in patients with concomitant traumatic brain injury (TBI). This study aimed to assess whether earlier SSRF was associated with improved outcomes in patients with multiple rib fractures and TBI.METHODS We performed a retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program 2017–2020, including adult patients with TBI and multiple rib fractures who had undergone SSRF. The outcomes were post-procedural length of stay (LOS), hospital LOS, intensive care unit (ICU) LOS, in-hospital mortality, ventilator days, and tracheostomy rate. Multilevel mixed-effects regression analyses accounting for patient, injury, and hospital characteristics as well as institutional SSRF volume were used to assess the association between timing to SSRF and the outcomes of interest. As a sensitivity analysis, propensity-score matching was performed to compare patients who underwent early (
PubDate: Thu, 29 Jun 2023 00:00:00 GMT-
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- Defining the emergency general surgery patient population in the era of
ICD-10: Evaluating an established crosswalk from ICD-9 to ICD-10 diagnosis
codes-
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Authors: Dalton; Michael K.; Sokas, Claire M.; Castillo-Angeles, Manuel; Semco, Robert S.; Scott, John W.; Cooper, Zara; Salim, Ali; Havens, Joaquim M.; Jarman, Molly P.
Abstract:
INTRODUCTION In 2015, the United States moved from the International Classification of Diseases, Ninth Revision (ICD-9), to the International Classification of Diseases, Tenth Revision (ICD-10), coding system. The American Association for the Surgery of Trauma Committee on Severity Assessment and Patient Outcomes previously established a list of ICD-9 diagnoses to define the field of emergency general surgery (EGS). This study evaluates the general equivalence mapping (GEM) crosswalk to generate an equivalent list of ICD-10–coded EGS diagnoses.METHODS The GEM was used to generate a list of ICD-10 codes corresponding to the American Association for the Surgery of Trauma ICD-9 EGS diagnosis codes. These individual ICD-9 and ICD-10 codes were aggregated by surgical area and diagnosis groups. The volume of patients admitted with these diagnoses in the National Inpatient Sample in the ICD-9 era (2013–2014) was compared with the ICD-10 volumes to generate observed to expected ratios. The crosswalk was manually reviewed to identify the causes of discrepancies between the ICD-9 and ICD-10 lists.RESULTS There were 485 ICD-9 codes, across 89 diagnosis categories and 11 surgical areas, which mapped to 1,206 unique ICD-10 codes. A total of 196 (40%) ICD-9 codes have an exact one-to-one match with an ICD-10 code. The median observed to expected ratio among the diagnosis groups for a primary diagnosis was 0.98 (interquartile range, 0.82–1.12). There were five key issues identified with the ability of the GEM to crosswalk ICD-9 EGS diagnoses to ICD-10: (1) changes in admission volumes, (2) loss of necessary modifiers, (3) lack of specific ICD-10 code, (4) mapping to a different condition, and (5) change in coding nomenclature.CONCLUSION The GEM provides a reasonable crosswalk for researchers and others to use when attempting to identify EGS patients in with ICD-10 diagnosis codes. However, we identify key issues and deficiencies, which must be accounted for to create an accurate patient cohort. This is essential for ensuring the validity of policy, quality improvement, and clinical research work anchored in ICD-10 coded data.LEVEL OF EVIDENCE Diagnostic Test/Criteria; Level III.
PubDate: Thu, 29 Jun 2023 00:00:00 GMT-
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- Resuscitative endovascular balloon occlusion of the aorta and
resuscitative thoracotomy are associated with similar outcomes in
traumatic cardiac arrest-
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Authors: Koh; Ezra Y.; Fox, Erin E.; Wade, Charles E.; Scalea, Thomas M.; Fox, Charles J.; Moore, Ernest E.; Morse, Bryan C.; Inaba, Kenji; Bulger, Eileen M.; Meyer, David E.
Abstract:
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive alternative to resuscitative thoracotomy (RT) for patients with hemorrhagic shock. However, the potential benefits of this approach remain subject of debate. The aim of this study was to compare the outcomes of REBOA and RT for traumatic cardiac arrest.METHODS A planned secondary analysis of the United States Department of Defense-funded Emergent Truncal Hemorrhage Control study was performed. Between 2017 and 2018, a prospective observational study of noncompressible torso hemorrhage was conducted at six Level I trauma centers. Patients were dichotomized by REBOA or RT, and baseline characteristics and outcomes were compared between groups.RESULTS A total of 454 patients were enrolled in the primary study, of which 72 patients were included in the secondary analysis (26 underwent REBOA and 46 underwent resuscitative thoracotomy). Resuscitative endovascular balloon occlusion of the aorta patients were older, had a greater body mass index, and were less likely to be the victims of penetrating trauma. Resuscitative endovascular balloon occlusion of the aorta patients also had less severe abdominal injuries and more severe extremity injuries, although the overall injury severity scores were similar. There was no difference in mortality between groups (88% vs. 93%, p = 0.767). However, time to aortic occlusion was longer in REBOA patients (7 vs. 4 minutes, p = 0.001) and they required more transfusions of red blood cells (4.5 vs. 2.5 units, p = 0.007) and plasma (3 vs. 1 unit, p = 0.032) in the emergency department. After adjusted analysis, mortality remained similar between groups (RR, 0.89; 95% confidence interval, 0.71–1.12, p = 0.304).CONCLUSION Resuscitative endovascular balloon occlusion of the aorta and RT were associated with similar survival after traumatic cardiac arrest, although time to successful aortic occlusion was longer in the REBOA group. Further research is needed to better define the role of REBOA in trauma.LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
PubDate: Thu, 29 Jun 2023 00:00:00 GMT-
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- Timing, triage, and mode of emergency general surgery interfacility
transfers in the United States: A scoping review-
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Authors: Silver; David S.; Teng, Cindy; Brown, Joshua B.
Abstract:
Interfacility transfer of emergency general surgery (EGS) patients continues to rise, especially in the context of ongoing system consolidation. This scoping review aims to identify and summarize the literature on triage, timing, and mode of interfacility emergency general surgery transfer. While common, EGS transfer systems are not optimized to improve outcomes or ensure value-based care. We identified studies investigating emergency general surgery interfacility transfer using Ovid Medline, EMBASE, and Cochrane Library between 1990 and 2022. English studies that evaluated EGS interfacility timing, triage or transfer mode were included. Studies were assessed by two independent reviewers. Studies were limited to English-language articles in the United States. Data were extracted and summarized with a narrative synthesis of the results and gaps in the literature. There were 423 articles identified, of which 66 underwent full-text review after meeting inclusion criteria. Most publications were descriptive studies or outcomes investigations of interfacility transfer. Only six articles described issues related to the logistics behind the interfacility transfer and were included. The articles were grouped into the predefined themes of transfer timing, triage, and mode of transfer. There were mixed results for the impact of transfer timing on outcomes with heterogeneous definitions of delay and populations. Triage guidelines for EGS transfer were consensus or expert opinion. No studies were identified addressing the mode of interfacility EGS transfer. Further research should focus on better understanding which populations of patients require expedited transfer and by what mode. The lack of high-level data supports the need for robust investigations into interfacility transfer processes to optimize triage using scarce resources and optimized value-based care.
PubDate: Tue, 20 Jun 2023 00:00:00 GMT-
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- Patient-controlled analgesia for the management of adults with acute
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Authors: Sim; Guek Gwee; See, Amanda Huimin; Quah, Li Juan Joy
Abstract:
BACKGROUND Patient-controlled analgesia (PCA) has potential as a form of analgesia for trauma patients in the emergency department (ED). The objective of this review was to evaluate the effectiveness and safety of PCA for the management of adults with acute traumatic pain in the ED. The hypothesis was that PCA can effectively treat acute trauma pain in adults in the ED, with minimal adverse outcomes and better patient satisfaction compared with non-PCA modalities.METHODS MEDLINE (PubMed), Embase, SCOPUS, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched from inception date to December 13, 2022. Randomized controlled trials involving adults presenting to the ED with acute traumatic pain who received intravenous (IV) analgesia via PCA compared with other modalities were included. The Cochrane Risk of Bias tool and the Grading of Recommendation, Assessment, Development, and Evaluation approach were used to assess the quality of included studies.RESULTS A total of 1,368 publications were screened, with 3 studies involving 382 patients meeting the eligibility criteria. All three studies compared PCA IV morphine with clinician-titrated IV morphine boluses. For the primary outcome of pain relief, the pooled estimate was in favor of PCA with a standard mean difference of −0.36 (95% confidence interval, −0.87 to 0.16). There were mixed results concerning patient satisfaction. Adverse event rates were low overall. The evidence from all three studies was graded as low-quality because of a high risk of bias from lack of blinding.CONCLUSION This study did not demonstrate a significant improvement in pain relief or patient satisfaction using PCA for trauma in the ED. Clinicians wishing to use PCA to treat acute trauma pain in adult patients in the ED are advised to consider the available resources in their own practice settings and to implement protocols for monitoring and responding to potential adverse events.LEVEL OF EVIDENCE Systematic Review/Meta-Analyses; Level III.
PubDate: Fri, 16 Jun 2023 00:00:00 GMT-
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- Age-related changes in thromboelastography profiles in injured children
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Authors: Morgan; Katrina M.; Abou-Khalil, Elissa; Strotmeyer, Stephen; Richardson, Ward M.; Gaines, Barbara A.; Leeper, Christine M.
Abstract:
BACKGROUND The role of age in mediating coagulation characteristics in injured children is not well defined. We hypothesize thromboelastography (TEG) profiles are unique across pediatric age groups.METHODS Consecutive trauma patients younger than 18 years from a Level I pediatric trauma center database from 2016 to 2020 with TEG obtained on arrival to the trauma bay were identified. Children were categorized by age according to the National Institute of Child Health and Human Development categories (infant, ≤1 year; toddler, 1–2 years; early childhood, 3–5 years; older childhood, 6–11 years; adolescent, 12–17 years). Thromboelastography values were compared across age groups using Kruskal-Wallis and Dunn's tests. Analysis of covariance was performed controlling for sex, Injury Severity Score (ISS), arrival Glasgow Coma Scale (GCS) score, shock, and mechanism of injury.RESULTS In total, 726 subjects were identified; 69% male, median (interquartile range [IQR]) ISS = 12 (5–25), and 83% had a blunt mechanism. On univariate analysis, there were significant differences in TEG α-angle (p < 0.001), MA (p = 0.004), and fibrinolysis 30 minutes after MA (LY30) (p = 0.01) between groups. In post hoc tests, the infant group had significantly greater α-angle (median, 77; IQR, 71–79) and MA (median, 64; IQR, 59–70) compared with other groups, while the adolescent group had significantly lower α-angle (median, 71; IQR, 67–74), MA (median, 60; IQR, 56–64), and LY30 (median, 0.8; IQR, 0.2–1.9) compared with other groups. There were no significant differences between toddler, early childhood, and middle childhood groups. On multivariate analysis, the relationship between age group and TEG values (α-angle, MA, and LY30) persisted after controlling for sex, ISS, GCS, shock, and mechanism of injury.CONCLUSION Age-associated differences in TEG profiles across pediatric age groups exist. Further pediatric-specific research is required to assess whether the unique profiles at extremes of childhood translate to differential clinical outcomes or responses to therapies in injured children.LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
PubDate: Thu, 15 Jun 2023 00:00:00 GMT-
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- Early career acute care surgeons' priorities and perspectives: A
mixed-methods analysis to better understand full-time employment-
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Authors: Murphy; Patrick B.; Coleman, Jamie; Maring, Morgan; Pokrzywa, Courtney; Deshpande, David; Hafiz Al Tannir, Abdul; Biesboer, Elise A.; Morris, Rachel S.; Figueroa, Juan; de Moya, Marc
Abstract:
BACKGROUND Understanding the expectations of early career acute care surgeons will help clarify the practice and employment models that will attract and retain high-quality surgeons, thereby sustaining our workforce. This study aimed to outline the clinical and academic preferences and priorities of early career acute care surgeons and to better define full-time employment.METHODS A survey on clinical responsibilities, employment preferences, work priorities, and compensation was distributed to early career acute care surgeons in the first 5 years of practice. A subset of agreeable respondents underwent virtual semistructured interviews. Both quantitative and thematic analysis were used to describe current responsibilities, expectations, and perspectives.RESULTS Of 471 surgeons, 167 responded (35%), the majority of whom were assistant professors within the first 3 years of practice (80%). The median desired clinical volume was 24 clinical weeks and 48 call shifts per year, 4 weeks less than their median current clinical volume. Most respondents (61%) preferred a service-based model. The top priorities cited in choosing a job were geography, work schedule, and compensation. Qualitative interviews identified themes related to defining full-time employment, first job expectations and realities, and the often-misaligned system and surgeon.CONCLUSION Understanding the perspectives of early career surgeons entering the workforce is important particularly in the field of acute care surgery where no standard workload or practice model exists. The wide variety of expectations, practice models, and schedule preferences may lead to a mismatch between surgeon desires and employment expectation. Consistent employment standards across our specialty would provide a framework for sustainability.LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
PubDate: Thu, 15 Jun 2023 00:00:00 GMT-
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- Longitudinal study evaluating post-ICU syndrome differences between acute
care surgery and trauma SICU survivors-
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Authors: Bottom-Tanzer; Samantha F.; Poyant, Janelle O.; Louzada, Maria T.; Abela, Daniele; Boudouvas, Abbey; Poon, Eileen; Power, Liam; Kim, Woon Cho; Hojman, Horacio M.; Bugaev, Nikolay; Johnson, Benjamin P.; Bawazeer, Mohammed A.; Mahoney, Eric J.
Abstract:
BACKGROUND Post-intensive care unit (ICU) syndrome (PICS) occurs at an exorbitant rate in surgical ICU (SICU) survivors. It remains unknown if critical illness due to trauma versus acute care surgery (ACS) may represent different pathophysiologic entities. In this longitudinal study, we determined if admission criteria in a cohort of trauma and ACS patients were associated with differences in the occurrence of PICS.METHODS Patients were 18 years or older, admitted to a Level I trauma center to the trauma or ACS services, remained in the SICU for ≥72 hours, and were seen in an ICU Recovery Center at 2 weeks, 12 weeks, and 24 weeks after hospital discharge. Post-ICU syndrome sequelae were diagnosed by dedicated specialist staffing using clinical criteria and screening questionnaires. The PICS symptoms were distilled into physical, cognitive, and psychiatric categories. Preadmission histories, hospital courses, and recovery data were collected via retrospective chart review.RESULTS One hundred twenty-six patients were included: 74 (57.3%) trauma patients and 55 (42.6%) ACS patients. Prehospital psychosocial histories were similar between groups. Acute care surgery patients had a significantly longer hospital course, higher APACHE II and III scores, were intubated for longer, and had higher rates of sepsis, acute renal failure, open abdomen, and hospital readmissions. At the 2-week follow-up visit, ACS patients had higher rates of PICS sequelae (ACS, 97.8% vs. trauma 85.3%; p = 0.03), particularly in the physical (ACS, 95.6% vs. trauma 82.0%, p = 0.04), and psychiatric domains (ACS, 55.6% vs. trauma 35.0%, p = 0.04). At the 12-week and 24-week visits, rates of PICS symptoms were comparable between groups.CONCLUSION The occurrence of PICS is extraordinarily high in both trauma and ACS SICU survivors. Despite entering the SICU with similar psychosocial histories, the two cohorts have different pathophysiologic experiences, which are associated with a higher rate of impairment in the ACS patients during early follow-up.LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
PubDate: Wed, 14 Jun 2023 00:00:00 GMT-
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