Areg Grigorian

Blunt cerebrovascular injury incidence, stroke-rate, and mortality with the expanded Denver criteria

Background: Blunt carotid and vertebral artery injury, collectively termed blunt cerebrovascular injury occur in less than 1% of blunt traumas. Conventional indications for screening miss up to 20% of blunt cerebrovascular injuries. Therefore, the expanded Denver criteria were created in 2012. We hypothesized the introduction of the expanded Denver criteria would lead to an increase in the national detection of blunt cerebrovascular injury with a subsequent decrease in stroke rate. Methods: The National Trauma Data Bank was queried for blunt trauma admissions. Patients were divided into 2 groups: pre–expanded Denver criteria (2007–2011) or post–expanded Denver criteria era (2013–2015). The primary endpoint was the incidence of blunt cerebrovascular injury, which was used as a surrogate for detection. Results: There were 10,183 blunt cerebrovascular injuries with 5,364 blunt cerebrovascular injuries in the pre–expanded Denver criteria group (0.19%) and 4,819 blunt cerebrovascular injuries in the post–expanded Denver criteria group (0.22%; P < .001). The stroke‐rate in the post–expanded Denver criteria was significantly higher (9.2% vs 5.5%; OR 2.73, CI 2.29–3.25, P < .001). The strongest associated injury with blunt cerebrovascular injury was skull‐base fracture (OR 3.61, CI 3.46–3.77, P < .001). Conclusion: The detection of blunt cerebrovascular injury has increased by 16% since the publication of the expanded Denver criteria. Skull‐base fracture is the strongest traumatic risk factor for blunt cerebrovascular injury. Although detection may have increased, the stroke‐rate nearly doubled in the post‐eDC era. This warrants future research.

New Palpable Mass in Right Breast

A 55-year-old postmenopausal female presents with a new mass in her right breast. She states that the mass has been there for about 3 months and has slowly grown in size. She first noticed it when she was taking a shower. The mass is not painful. She reports no nipple discharge, no nipple inversion, and no skin changes. She had her first menstrual period at age 11. Her only pregnancy was at age 35. Her mother and sister both had breast cancer. On physical examination, she has a 2 cm palpable, hard, ill-defined, immobile, non-tender mass in the upper outer quadrant of her right breast. There is no palpable axillary or supraclavicular adenopathy.

Use of laparoscopic colectomy increasing in trauma: comparison of laparoscopic vs. open colectomy

Laparoscopy accounts for > 70% of general surgical cases. Given the increased use of laparoscopy in emergent colorectal disease, we hypothesized that there would be an increased use of laparoscopic colectomy (LC) in trauma patients. In addition, we hypothesized increased length of stay (LOS) and mortality in trauma patients undergoing open colectomy (OC) vs. LC. This was a retrospective analysis using the National Trauma Data Bank (2008–2015). We included adult patients undergoing LC or OC. A multivariable logistic regression model was used for determining risk of LOS and mortality. We identified 19,788 (96.8%) patients undergoing OC and 644 (3.2%) who underwent LC. There was a 21-fold increased number of patients that underwent LC over the study period (p < 0.05), with approximately 119 per 10,000 trauma patients undergoing LC. The most common operation was a laparoscopic right hemicolectomy (27.5%). LC patients had a lower median injury severity score (ISS) (16 vs. 17, p < 0.001). There was no difference in LOS (p = 0.14) or mortality (p = 0.44) between the two groups. This remained true in patients with isolated colorectal injury. The use of LC has increased 21-fold from 2008 to 2015, with laparoscopic right hemicolectomy being the most common procedure performed. There was no difference in LOS, in-hospital complications, or mortality between the two groups. We suggest that LC should be considered in stable adult trauma patients undergoing colectomy. However, future prospective research is needed to help determine which trauma patients may benefit from LC.

Cirrhosis increases complication rate and overall mortality in patients with traumatic lung injury

Introduction Hepatic cirrhosis is associated with an increased mortality in trauma. However, the association between cirrhosis and outcomes in traumatic lung injury has not been investigated. We hypothesize that cirrhosis adversely affects mortality and increases complications after traumatic lung injury. Methods A retrospective analysis of the National Trauma Data Bank was performed between 2007 and 2015. Patients ≥ 18 years of age with traumatic lung injury were identified and grouped by the presence or absence of cirrhosis. Patients that died in the emergency department or those with a severe (grade > 3) abbreviated injury scale for head trauma were excluded. The primary outcome was mortality. Results Out of 6,774,260 patients, 578,883 (8.5%) presented with traumatic lung injury. Of these, 1971 (0.3%) had a concomitant diagnosis of cirrhosis. The cirrhotic group was significantly older (median age, 56 versus 42 years, p < 0.001) and more likely to be hypotensive on admission (9.3% versus 6.7%, p < 0.001). There was no difference in injury severity score (p > 0.05). Patients with cirrhosis had a significantly longer median length of stay (12.5 versus 8.8 days, p < 0.001), rates of acute kidney injury (7.6% versus 1.4%, p < 0.001), acute respiratory distress syndrome (7.3% versus 2.9%, p < 0.001), pneumonia (12.9% versus 5.9%, p < 0.001), and overall mortality (20.6% versus 5.6%, p < 0.001). After adjusting for significant covariates, cirrhosis (OR = 6.26, 95% CI = 5.49–7.14, p < 0.001) was found to be an independent risk factor for mortality in patients with traumatic lung injury. Conclusion Cirrhosis in patients with traumatic lung injury is associated with more than a sixfold higher risk of mortality and increased rates of complications such as acute kidney injury and acute respiratory distress syndrome. While much focus has been on increased mortality of cirrhosis in patients with concomitant abdominal solid organ or traumatic brain injury, our study suggests cirrhosis with traumatic lung injury to possibly be an even worse prognosticator.

National analysis of testicular and scrotal trauma in the USA

Background To provide a descriptive analysis of scrotal and testicular trauma in the USA. Additionally, we hypothesized that motorcycle collision would have a higher association with scrotal or testicular trauma and subsequent scrotal or testicular operation, compared to a bicycle collision. Methods The National Trauma Data Bank (2007–2015) was queried to identify adult male patients with scrotal or testicular trauma. A multivariable logistic regression analysis was performed. Results A total of 8,030 patients (0.23%) had scrotal/testicular injury, with 44.6% involved in blunt trauma. A penetrating mechanism occurred in 50.5% of cases, with assault by firearm (75.8%) being the most common. The median age of the patients was 31 years and the median injury severity score was 8. Most had isolated scrotal or testicular trauma (74.5%), with 48.3% requiring scrotal or testicular operation, most commonly repair of laceration (37.3%). Patients involved in a motorcycle collision had higher risk for scrotal/testicular trauma (OR=5.40, CI=4.40–6.61, p=0.0004) and subsequent scrotal/testicular surgery (OR=4.93, CI=3.82–6.36, p=0.0005), compared to bicycle collision. Conclusion Scrotal or testicular trauma is rare but occurs most commonly after assault by firearm. Most patients only have isolated scrotal or testicular trauma, but nearly half require subsequent scrotal or testicular operation. Trauma patients presenting after a motorcycle collision have a higher association of scrotal or testicular trauma and subsequent surgery when compared to those involved in a bicycle collision.

Black Race and Body Mass Index Are Risk Factors for Rhabdomyolysis and Acute Kidney Injury in Trauma

Abstract Purpose: Obesity has been shown in a single-center study to be a risk factor for rhabdomyolysis. More recently, sickle cell trait, known to be more prevalent in blacks, has been shown to be a risk factor for rhabdomyolysis. We hypothesized that in trauma patients, black race and a higher body mass index (BMI) are associated with risk for rhabdomyolysis and acute kidney injury (AKI). Materials and Methods: The National Trauma Data Bank (NTDB) was queried (2013–2015) to identify patients age ≥18 years and grouped by BMI: normal (18.5–24.99 kg/m2), underweight (16.5–18.49 kg/m2), overweight (25–29.99 kg/m2), obese (30–34.99 kg/m2), severely obese (35–39.99 kg/m2), and morbidly obese (≥40 kg/m2). A multivariable logistic regression model was used to assess whether a higher BMI or black race was associated with rhabdomyolysis or AKI. Results: After adjusting for covariates, severe obesity (odds ratio (OR) = 1.42, confidence interval (CI) = 1.01–1.99, p < .001), morbid obesity (OR = 1.46, CI = 1.04–2.06, p < .001), and black race (OR = 1.52, CI = 1.24–1.88, p < .001) were associated with higher risk for rhabdomyolysis. Patients that were overweight (OR = 1.17, CI = 1.11–1.24, p < .001), obese (OR = 1.32, CI = 1.24–1.41, p < .001), severely obese (OR = 1.72, CI = 1.59–1.86, p < .001), morbidly obese (OR = 1.77, CI = 1.64–1.92, p < .001), or black (OR = 1.31, CI = 1.24–1.38, p < .001) were associated with higher risk for AKI. Conclusions: Black race was associated with an increased risk of rhabdomyolysis as well as AKI in trauma. BMI ≥25 kg/m2 was associated with increased risk for AKI with the morbidly obese having the highest risk. BMI ≥35 kg/m2 was found to be associated with increased risk of rhabdomyolysis. Future studies should investigate the role for routine screening of these high-risk populations and other potential associated factors such as adherence to weight-based fluid resuscitation.

Association of Heparin-Induced Thrombocytopenia With Bacterial Infection in Trauma Patients

Association of Heparin-Induced Thrombocytopenia With Bacterial Infection in Trauma Patients Heparin-induced thrombocytopenia (HIT) is a rare complication that has been reported to occur in 0.36% of trauma patients and is caused by antibody formation to complexes between heparin and platelet-factor 4 (PF4), leading to platelet activation and subsequent thrombosis.1,2 An earlier report demonstrated that PF4 can bind to bacteria, inducing an autoimmune response similar to the major antigen in HIT.3 We hypothesized that trauma patients with HIT have a higher incidence of bacterial infection during their hospitalization compared with patients without HIT. In addition, we provide a descriptive analysis of HIT in trauma patients.

Risk of hysterectomy and salpingectomy or oophorectomy compared to repair after pelvic gynecologic trauma

PurposePelvic gynecologic trauma (PGT) includes injury to the uterus, ovaries or fallopian tubes. We hypothesized Injury Severity Score (ISS) ≥ 25, hypotension on admission and age ≥ 51 (average age for menopause) would be independent risk factors for resection compared to repair.MethodsA retrospective analysis of the National Trauma Data Bank was performed between 2007 and 2015.ResultsOf 2,040,235 female patients, 1938 (< 0.1%) presented with PGT with the majority sustaining injury to the ovary or fallopian tubes (52.9%). Most patients were managed nonoperatively (77.1 vs 22.9%). On multivariable analysis, in patients with injury to the uterus, ISS ≥ 25 (OR 3.52, CI 1.67–7.48, p < 0.05) was associated with higher risk for hysterectomy compared to repair. In patients with injury to the ovaries or fallopian tubes, gunshot wound (OR 3.73, CI 1.43–9.68, p < 0.05) was associated with a higher risk for salpingectomy or oophorectomy compared to repair. Age ≥ 51 and hypotension on admission were not independent risk factors for resection in patients with PGT. Operative treatment was associated with a lower risk for mortality in patients with an injury to the uterus (OR 0.27, CI 0.14–0.51, p < 0.001) or ovaries/fallopian tubes (OR 0.37, CI 0.19–0.72, p < 0.001) compared to those managed nonoperatively.ConclusionIn the largest study reported, PGT occurred in < 0.1% of traumas involving women. Patients with ISS ≥ 25 have higher risk for hysterectomy compared to repair. Gunshot injuries have higher risk for salpingectomy or oophorectomy compared to repair. Hypotension on arrival or age ≥ 51 are not independent risk factors for resection in PGT. Operative management is associated with lower risk of mortality in PGT patients.

Rising mortality in patients with combined burn and trauma

Combined trauma in the burn patient has been previously shown to have higher mortality. With improved critical care and multidisciplinary approach, we hypothesized the risk of mortality in combined burn and trauma has decreased. A retrospective analysis of trauma, burn and combined burn-trauma patients in the National Trauma Data Bank was performed comparing years 2007-2015 to years 1994-2002. The impact of burn injuries on mortality in patients with minor trauma has decreased (OR 2.45, CI 2.26-2.66, p<0.001 compared to OR 4.04, CI 4.51-4.66, p<0.001) in years 2007-2015 while the impact of burn injuries on mortality in patients with severe trauma has increased (OR 1.37, CI 1.29-1.47, p<0.001 compared to OR 1.26, CI 1.05-1.51, p<0.001). When controlling for known risk factors of mortality in burn and trauma, the contribution of the severity of trauma on mortality in combined burn-trauma patients with total body surface area ≥20% is negligible. In contrast, an increase in percentage of total body surface area burned is associated with a step-wise increase in mortality for all combined burn-trauma patients. However, the largest impact is seen in patients with minor trauma. This population represents a unique overlap of patients where future collaborative research can help identify best practices and improve outcomes.

National risk factors for blunt cardiac injury: Hemopneumothorax is the strongest predictor

BACKGROUND Blunt cardiac injury (BCI) can occur after chest trauma and may be associated with sternal fracture (SF). We hypothesized that injuries demonstrating a higher transmission of force to the thorax, such as thoracic aortic injury (TAI), would have a higher association with BCI. METHODS We queried the National Trauma Data Bank (NTDB) from 2007-2015 to identify adult blunt trauma patients. RESULTS BCI occurred in 15,976 patients (0.3%). SF had a higher association with BCI (OR = 5.52, CI = 5.32-5.73, p < 0.001) compared to TAI (OR = 4.82, CI = 4.50-5.17, p < 0.001). However, the strongest independent predictor was hemopneumothorax (OR = 9.53, CI = 7.80-11.65, p < 0.001) followed by SF and esophageal injury (OR = 5.47, CI = 4.05-7.40, p < 0.001). CONCLUSION SF after blunt trauma is more strongly associated with BCI compared to TAI. However, hemopneumothorax is the strongest predictor of BCI. We propose all patients presenting after blunt chest trauma with high-risk features including hemopneumothorax, sternal fracture, esophagus injury, and TAI be screened for BCI. SUMMARY Using the National Trauma Data Bank, sternal fracture is more strongly associated with blunt cardiac injury than blunt thoracic aortic injury. However, hemopneumothorax was the strongest predictor.