Alexander L. Eastman

CTA-Based Screening Reduces Time to Diagnosis and Stroke Rate in Blunt Cervical Vascular Injury

BACKGROUND Advances in computed tomography capabilities have enabled trauma surgeons to screen for and diagnose the severity of blunt cervical vascular injury (BCVI) using computed tomographic angiography (CTA) alone. We hypothesized that the use of CTA-alone screening and diagnostic methods would reduce the time interval from admission to diagnosis and, hence, also reduce the stroke rates associated with these injuries. METHODS All patients admitted to a level I trauma center after December 1999 at risk for BCVI were screened. Until March 2005, patients were screened with cervical catheter angiography (CA). Subsequently, a CTA-alone screening/diagnostic program was initiated simultaneously with standardized interdisciplinary treatment guidelines for BCVI. Data for controls were subsequently obtained by reviewing trauma registry records. RESULTS Of 3012 trauma service admissions from April 2005 to July 2006, 26 patients were found to have BCVI diagnosed by CTA alone. A standardized, injury grade-based set of treatment guidelines were then initiated immediately based on CTA findings. Time to diagnosis and stroke rate in these patients were then compared with 79 patients found to have BCVI from December 1999 to March 2005 during CA-based screening. There were no differences in sex, mean age, Injury Severity Score, head/neck Abbreviated Injury Scale, or arrival Glasgow Coma Scale between the CA and CTA groups. With CA-based screening, the mean +/- SD time from trauma center admission to diagnosis was 31.2 +/- 41.1 hours. After transition to CTA screening in March 2005, this time was reduced to 2.65 +/- 3.3 hours (p < 0.001). During the era of CA-based screening, the overall stroke rate for BCVI at our institution was 15.2% (n = 12 of 79). After the initiation of CTA-based screening, the stroke rate was reduced to 3.8% (n = 1 of 26, p = 0.046). CONCLUSIONS The initiation of a CTA-based screening and diagnostic program, along with interdisciplinary standardized treatment guidelines, reduced the time to diagnosis of BCVI 12-fold and the institutional stroke rate due to BCVI fourfold. This may be due to earlier diagnosis and initiation of definitive therapy.

Emergency tracheal intubation immediately following traumatic injury: an Eastern Association for the Surgery of Trauma practice management guideline.

BACKGROUND The ABCs of trauma resuscitation begin with the airway evaluation, and effective airway management is imperative in the care of a patient with critical injury. The Eastern Association for the Surgery of Trauma Practice Management Guidelines committee aimed to update the guidelines for emergency tracheal intubation (ETI) published in 2002. These guidelines were made to assist clinicians with decisions regarding airway management for patients immediately following traumatic injury. The goals of the work group were to develop evidence-based guidelines to (1) characterize patients in need of ETI and (2) delineate the most appropriate procedure for patients undergoing ETI. METHODS A search of the National Library of Medicine and the National Institutes of Health MEDLINE database was performed using PubMed (www.pubmed.gov). RESULTS The search retrieved English-language articles published from 2000 to 2012 involving patients who had sustained blunt trauma, penetrating trauma, or heat-related injury and had developed respiratory system insufficiency or required ETI in the immediate period after injury (first 2 hours after injury). Sixty-nine articles were used to construct this set of practice management guidelines. CONCLUSION The data supported the formation of six Level 1 recommendations, four Level 2 recommendations, and two Level 3 recommendations. In summary, the decision to intubate a patient following traumatic injury is based on multiple factors, including the need for oxygenation and ventilation, the extent and mechanism of injury, predicted operative need, or progression of disease. Rapid sequence intubation with direct laryngoscopy continues to be the recommended method for ETI, although the use of airway adjuncts such as blind insertion supraglottic devices and video laryngoscopy may be useful in facilitating successful ETI and may be preferred in certain patient populations. There is no pharmacologic induction agent of choice for ETI; however, succinylcholine is the neuromuscular blockade agent recommended for rapid sequence intubation.

An evaluation of multidetector computed tomography in detecting pancreatic injury: results of a multicenter AAST study.

BACKGROUND Efforts to determine the suitability of low-grade pancreatic injuries for nonoperative management have been hindered by the inaccuracy of older computed tomography (CT) technology for detecting pancreatic injury (PI). This retrospective, multicenter American Association for the Surgery of Trauma-sponsored trial examined the sensitivity of newer 16- and 64-multidetector CT (MDCT) for detecting PI, and sensitivity/specificity for the identification of pancreatic ductal injury (PDI). METHODS Patients who received a preoperative 16- or 64-MDCT followed by laparotomy with a documented PI were enrolled. Preoperative MDCT scans were classified as indicating the presence (+) or absence (-) of PI and PDI. Operative notes were reviewed and all patients were confirmed as PI (+), and then classified as PDI (+) or (-). As all patients had PI, an analysis of PI specificity was not possible. PI patients formed the pool for further PDI analysis. As sensitivity and specificity data were available for PDI, multivariate logistic regression was performed for PDI patients using the presence or absence of agreement between CT and operative note findings as an independent variable. Covariates were age, gender, Injury Severity Score, mechanism of injury, presence of oral contrast, presence of other abdominal injuries, performance of the scan as part of a dedicated pancreas protocol, and image thickness < or =3 mm or > or =5 mm. RESULTS Twenty centers enrolled 206 PI patients, including 71 PDI (+) patients. Intravenous contrast was used in 203 studies; 69 studies used presence of oral contrast. Eight-nine percent were blunt mechanisms, and 96% were able to have their duct status operatively classified as PDI (+) or (-). The sensitivity of 16-MDCT for all PI was 60.1%, whereas 64-MDCT was 47.2%. For PDI, the sensitivities of 16- and 64-MDCT were 54.0% and 52.4%, respectively, with specificities of 94.8% for 16-MDCT scanners and 90.3% for 64-MDCT scanners. Logistic regression showed that no covariates were associated with an increased likelihood of detecting PDI for either 16- or 64-MDCT scanners. The area under the curve was 0.66 for the 16-MDCT PDI analysis and 0.77 for the 64-MDCT PDI analysis. CONCLUSION Sixteen and 64-MDCT have low sensitivity for detecting PI and PDI, while exhibiting a high specificity for PDI. Their use as decision-making tools for the nonoperative management of PI are, therefore, limited.

Improving survival from active shooter events: The hartford consensus

T recent mass casualty shooting events in the United States have had a profound effect on all segments of society. The medical, law enforcement, fire/rescue, and EMS communities have each felt the need to respond. It is important that these efforts occur in a coordinated manner to generate policies that will enhance survival of the victims of these events. Such policies must provide a synchronized multi-agency approach that is immediately available within the communities affected by such tragedies. The American College of Surgeons brought together senior leaders from all the aforementioned disciplines to produce a document that will stimulate discussion and ultimately lead to strategies to improve survival for the victims. A day-long conference on April 2, 2013, in Hartford, Connecticut obtained input from medical, law enforcement, fire/rescue, EMS first responders, and military experts. The conference relied upon data and evidence from existing military and recent civilian experiences, and was sensitive to the multiple agencies that play a role in responding to mass casualty shootings. The meeting, known as the Hartford Consensus Conference, produced a concept paper entitled ‘‘Improving Survival from Active Shooter Events.’’ The purpose of this document is to promote local, state, and national policies to improve survival in these uncommon, but horrific events. The following short essay describes methods to minimize loss of life in these terrible incidents.

A randomized, double-blinded, placebo-controlled pilot trial of anticoagulation in low-risk traumatic brain injury: The Delayed Versus Early Enoxaparin Prophylaxis I (DEEP I) study.

BACKGROUND Our group has created an algorithm for venous thromboembolism prophylaxis after traumatic brain injury (TBI), which stratifies patients into low, moderate, and high risk for spontaneous injury progression and tailors a prophylaxis regimen to each arm. We present the results of the Delayed Versus Early Enoxaparin Prophylaxis I study, a double-blind, placebo-controlled, randomized pilot trial on the low-risk arm. METHODS In this two-institution study, patients presenting within 6 hours of injury with prespecified small TBI patterns and stable scans at 24 hours after injury were randomized to receive enoxaparin 30 mg bid or placebo from 24 to 96 hours after injury in a double-blind fashion. An additional computed tomography scan was obtained on all subjects 24 hours after starting treatment (and therefore 48 hours after injury). The primary end point was the radiographic worsening of TBI; secondary end points were venous thromboembolism occurrence and extracranial hemorrhagic complications. RESULTS A total of 683 consecutive patients with TBI were screened during the 28 center months. The most common exclusions were for injuries larger than the prespecified criteria (n = 199) and preinjury anticoagulant use (n = 138). Sixty-two patients were randomized to enoxaparin (n = 34) or placebo (n = 28). Subclinical, radiographic TBI progression rates on the scans performed 48 hours after injury and 24 hours after start of treatment were 5.9% (95% confidence interval [CI], 0.7–19.7%) for enoxaparin and 3.6% (95% CI, 0.1–18.3%) for placebo, a treatment effect difference of 2.3% (95% CI, −14.42–16.5%). No clinical TBI progressions occurred. One deep vein thrombosis occurred in the placebo arm. CONCLUSION TBI progression rates after starting enoxaparin in small, stable injuries 24 hours after injury are similar to those of placebo and are subclinical. The next Delayed Versus Early Enoxaparin Prophylaxis studies will assess efficacy of this practice in a powered study on the low-risk arm and a pilot trial of safety of a 72-hour time point in the moderate-risk arm. LEVEL OF EVIDENCE Therapeutic study, level II.

A multi-institutional analysis of prehospital tourniquet use

BACKGROUND Recent military studies demonstrated an association between prehospital tourniquet use and increased survival. The benefits of this prehospital intervention in a civilian population remain unclear. The aims of our study were to evaluate tourniquet use in the civilian population and to compare outcomes to previously published military experience. We hypothesized that incorporation of tourniquet use in the civilian population will result in an overall improvement in mortality. METHODS This is a preliminary multi-institutional retrospective analysis of prehospital tourniquet (MIA-T) use of patients admitted to nine urban Level 1 trauma centers from January 2010 to December 2013. Patient demographics and mortality from a previous military experience by Kragh et al. (Ann Surg. 2009;249:1–7) were used for comparison. Patients younger than 18 years or with nontraumatic bleeding requiring tourniquet application were excluded. Data were analyzed using a two-tailed unpaired Student’s t test with p < 0.05 as significant. RESULTS A total of 197 patients were included. Tourniquets were applied effectively in 175 (88.8%) of 197 patients. The average Injury Severity Score (ISS) for MIA-T versus military was 11 ± 12.5 versus 14 ± 10.5, respectively (p = 0.02). The overall mortality and limb amputation rates for the MIA-T group were significantly lower than previously seen in the military population at 6 (3.0%) of 197 versus 22 (11.3%) of 194 (p = 0.002) and 37 (18.8%) of 197 versus 97 (41.8%) of 232 (p = 0.0001), respectively. CONCLUSION Our study is the largest evaluation of prehospital tourniquet use in a civilian population to date. We found that tourniquets were applied safely and effectively in the civilian population. Adaptation of this prehospital intervention may convey a survival benefit in the civilian population. LEVEL OF EVIDENCE Epidemiologic study, level V.

A prospective evaluation of the use of routine repeat cranial CT scans in patients with intracranial hemorrhage and GCS score of 13 to 15

BACKGROUND Scheduled repeat head computed tomography after mild traumatic brain injury has been shown to have limited use for predicting the need for an intervention. We hypothesized that repeat computed tomography in persons with intracranial hemorrhage and a Glasgow Coma Scale (GCS) score of 13 to 15, without clinical progression of neurologic symptoms, does not impact the need for neurosurgical intervention or discharge GCS scores. METHODS This prospective cohort study followed all patients presenting to our urban Level I trauma center with intracranial hemorrhage and a GCS score of 13 to 15 from February 2010 to December 2010. Subjects were divided into two groups: those in whom repeat CT scans were performed routinely (ROUTINE) and those in whom they were performed selectively (SELECTIVE) based on changes in clinical examination. CT scanning decisions were made at the discretion of the neurosurgical service attending physician. RESULTS One hundred forty-five patients met the inclusion criteria (ROUTINE, n = 92; SELECTIVE, n = 53). Group demographics, including age, sex, and presenting GCS score were not significantly different. Of SELECTIVE patients, six (11%) required a repeat head computed tomography for a neurologic change, with one having a radiographic progression of hemorrhage (16%) versus 26 (28%) of 92 in the ROUTINE group showing a radiographic progression. No patient in either group required medical or neurosurgical intervention based on repeat scan. The number of CT scans performed differed between the two groups (three scans in ROUTINE vs. one scan in SELECTIVE, p < 0.001), as did the intensive care unit (2 days vs. 1 day, p < 0.001) and hospital (5 days vs. 2 days, p < 0.001) lengths of stay. Discharge GCS score was similar for both groups (15 vs. 15, p = 0.37). One death occurred in the SELECTIVE group, unrelated to intracranial findings. The negative predictive value of a repeat CT scan leading to neurosurgical intervention with no change in clinical examination was 100% for both groups. CONCLUSION A practice of selective repeat head CT scans in patients with traumatic brain injury admitted with a GCS score of 13 to 15 decreases use of the test and is associated with decreased hospital length of stay, without impacting discharge GCS scores. LEVEL OF EVIDENCE Diagnostic study, level II.

Prestorage leukoreduction abrogates the detrimental effect of aging on packed red cells transfused after trauma: a prospective cohort study.

BACKGROUND The aim of this study was to prospectively duplicate previous retrospective findings showing that prestorage leukoreduction blunts the detrimental effect of aging on banked packed red blood cells transfused after injury. METHODS Over 19 months, trauma patients transfused with ≥4 U of packed red blood cells and surviving ≥24 hours were followed. The age of each unit was collected. RESULTS The cohort consisted of 153 patients. All models showed no association between advancing blood age and the likelihood of developing multiple-organ dysfunction syndrome or infections, regardless of whether the mean age of blood was analyzed as a continuous variable, as a percentage of blood received that was <14 days old, or as a dichotomized value >14 or <14 days old. CONCLUSIONS This prospective study duplicates previous retrospective findings of an abrogation of the detrimental effects of advancing mean packed red blood cell age on outcomes after trauma by performing prestorage leukoreduction.

The Hartford Consensus: THREAT, A Medical Disaster Preparedness Concept

Mass murder through active shooter and explosive events has been at the forefront of our news. Despite improvements in both law enforcement tactics and emergency trauma care, additional integration of the core functions of the public safety response to these events has the potential to maximize survivability. From the mass casualty shooting at Columbine High School in Littleton, CO, through the shootings at SandyHook Elementary School in Newtown, CT, an examination of events will demonstrate some improvement. However, we must continue to hone our response. Perhaps no incident has changed both law enforcement and fire/rescue/emergencymedical services (EMS) response like the Columbine High School shooting. At that time, traditional law enforcement response doctrine dictated waiting for tactical personnel to arrive to secure the school. During this waiting time, some of the fatalities and some of the morbidity among survivors were due to unchecked hemorrhage and shock. Nearly 8 years later, a clear transition in active shooter response was evident on the campus of Virginia Tech University, where the initial response included 2 tactical medics who provided care, predominantly hemorrhage control and airway management, long before the scene was secured. The mass casualty shooting incident at Foot Hood military base resulted in 13 dead and 31 wounded. An officer was able to stop the shooter, but sustained bilateral thigh wounds with significant hemorrhage from the left lower extremity. An Army medic

Hartford Consensus: A Call to Action for THREAT, a Medical Disaster Preparedness Concept

Received October 23, 2013; Revised December 9, 20 December 10, 2013. From Hartford Hospital, University of Connecticut, Hartfor Burns); Federal Bureau of Investigation (Wade, Fabbri) and t on Tactical Combat Casualty Care, Department of Defense, System (Butler), Washington, DC; Tulane University Depa gery, New Orleans, LA (McSwain); Dallas Police Departme western Medical Center, Dallas, TX (Eastman); and Massach Hospital, Boston, MA (Conn). Correspondence address: Lenworth M Jacobs, MD, MPH, F Hospital, 80 Seymour St, Hartford, CT 06102. email: len hhchealth.org