Bardiya Zangbar

Superiority of frailty over age in predicting outcomes among geriatric trauma patients: A prospective analysis

IMPORTANCE The Frailty Index (FI) is a known predictor of adverse outcomes in geriatric patients. The usefulness of the FI as an outcome measure in geriatric trauma patients is unknown. OBJECTIVE To assess the usefulness of the FI as an effective assessment tool in predicting adverse outcomes in geriatric trauma patients. DESIGN, SETTING, AND PARTICIPANTS A 2-year (June 2011 to February 2013) prospective cohort study at a level I trauma center at the University of Arizona. We prospectively measured frailty in all geriatric trauma patients. Geriatric patients were defined as those 65 years or older. The FI was calculated using 50 preadmission frailty variables. Frailty in patients was defined by an FI of 0.25 or higher. MAIN OUTCOMES AND MEASURES The primary outcome measure was in-hospital complications. The secondary outcome measure was adverse discharge disposition. In-hospital complications were defined as cardiac, pulmonary, infectious, hematologic, renal, and reoperation. Adverse discharge disposition was defined as discharge to a skilled nursing facility or in-hospital mortality. Multivariate logistic regression was used to assess the relationship between the FI and outcomes. RESULTS In total, 250 patients were enrolled, with a mean (SD) age of 77.9 (8.1) years, median Injury Severity Score of 15 (range, 9-18), median Glasgow Coma Scale score of 15 (range, 12-15), and mean (SD) FI of 0.21 (0.10). Forty-four percent (n = 110) of patients had frailty. Patients with frailty were more likely to have in-hospital complications (odds ratio, 2.5; 95% CI, 1.5-6.0; P = .001) and adverse discharge disposition (odds ratio, 1.6; 95% CI, 1.1-2.4; P = .001). The mortality rate was 2.0% (n = 5), and all patients who died had frailty. CONCLUSIONS AND RELEVANCE The FI is an independent predictor of in-hospital complications and adverse discharge disposition in geriatric trauma patients. This index should be used as a clinical tool for risk stratification in this patient group.

The conjoint effect of reduced crystalloid administration and decreased damage-control laparotomy use in the development of abdominal compartment syndrome

BACKGROUND Anticipation of abdominal compartment syndrome (ACS) is a factor for performing damage-control laparotomy (DCL). Recent years have seen changes in resuscitation patterns and a decline in the use of DCL. We hypothesized that reductions in both crystalloid resuscitation and the use of DCL is associated with a reduced rate of ACS in trauma patients. METHODS We reviewed the records of all patients who underwent trauma laparotomies at our Level 1 trauma center over a 6-year period (2006–2011). We defined DCL as a trauma laparotomy in which the fascia was not closed at the initial operation. We defined ACS by elevated intravesical pressures and end-organ dysfunction. Our primary outcome measure was a development of ACS. RESULTS A total of 799 patients were included. We noted a significant decrease in the DCL rate (39% in 2006 vs. 8% in 2011, p < 0.001), the crystalloid volume per patient (mean [SD], 12.8 [7.8] L in 2006 vs. 6.6 [4.2] L in 2011; p < 0.001), rate of ACS (7.4% in 2006 vs. 0% in 2011, p < 0.001), and mortality rate (22.8% in 2006 vs. 10.6% in 2011, p < 0.001). However, we noted no significant changes in the mean Injury Severity Score (ISS) (p = 0.09), in the mean abdominal Abbreviated Injury Scale (AIS) score (p = 0.17), and in the mean blood product volume per patient (p = 0.67). On multivariate regression analysis, crystalloid resuscitation (p = 0.01) was the only significant factor associated with the development of ACS. CONCLUSION Minimizing the use of crystalloids and DCL was associated with better outcomes and virtual elimination of ACS in trauma patients. With the adaption of new resuscitation strategies, goals for a trauma laparotomy should be definitive surgical care with abdominal closure. ACS is a rare complication in the era of damage-control resuscitation and may have been iatrogenic. LEVEL OF EVIDENCE Epidemiologic/therapeutic study, level IV.

Acquired coagulopathy of traumatic brain injury defined by routine laboratory tests: which laboratory values matter?

BACKGROUND Coagulopathy is a major determinant of disability and death in patients with traumatic intracranial hemorrhage. However, the correlation between coagulopathy defined by routine coagulation tests and clinical outcomes in traumatic brain injury (TBI) is not well defined. The aim of our study was to determine the effect of coagulopathy diagnosed by routine laboratory tests on outcomes in TBI patients. METHODS We performed a retrospective cohort analysis of all isolated TBI patients exclusive of prehospital antiplatelet and anticoagulants with coagulation tests, namely, international normalized ratio (INR), platelet count, and partial thromboplastin time at admission. We defined coagulopathy by an INR of 1.5 or greater, partial thromboplastin time of 35 or greater, or platelet count of 100 × 103/µL or less. Outcome measures were progression on repeat head computed tomography (RHCT), need for neurosurgical intervention, and mortality. RESULTS A total of 591 patients were enrolled, with a mean (SD) age of 47.4 (26.5) years and 67% being male. Of the patients, 13.3% were coagulopathic at admission. Platelet count of 100 × 103/µL or less was an independent predictor of progression on RHCT (odd ratio [OR], 4; 95% confidence interval [CI], 1.7–10), need for neurosurgical intervention (OR, 3.6; 95% CI, 1.2–6.1), and mortality (OR, 2.6; 95% CI, 1.1–4.8). INR was an independent predictor of progression on RHCT (OR, 2; 95% CI, 1.1–4.3). CONCLUSION Routine bedside coagulation parameters at admission play an important role in predicting outcomes in blunt TBI. Platelet count is the strongest predictor for progression of initial insult on RHCT, need for neurosurgical intervention, and mortality. LEVEL OF EVIDENCE Prognostic study, level III.

Mild and moderate pediatric traumatic brain injury: Replace routine repeat head computed tomography with neurologic examination

BACKGROUND Opinion is divided on the role of routine repeat head computed tomography (RHCT) for guiding clinical management in pediatric patients with blunt head trauma. We hypothesize that routine RHCT does not lead to change in management in mild and moderate traumatic brain injury (TBI). METHODS This is a 3-year retrospective study of all patients of age 2 years to 18 years with blunt TBI admitted to our Level 1 trauma center with an abnormal head CT. Indications for RHCT (routine vs. neurologic deterioration) and their findings (progression or improvement) were recorded. Neurosurgical intervention was defined as extraventricular drain placement, craniectomy, or craniotomy. Primary outcome was a change in management after RHCT. RESULTS A total of 291 pediatric patients were identified; of which 191 patients received an RHCT. Routine RHCT did not lead to neurosurgical intervention in the mild and moderate TBI group. In patients who received RHCT due to neurologic decline (n = 7), radiographic progression was seen on 85% of the patients (n = 6), with subsequent neurosurgical interventions in three patients. Two of these patients had a Glasgow Coma Scale (GCS) score of less than 8 at admission. CONCLUSION Our study showed that the neurologic examination can be trusted and is reliable in pediatric blunt TBI patients in determining when an RHCT scan is necessary. We recommend that RHCT is required routinely in patients with intracranial hemorrhage with GCS score of 8 or less and in patients with GCS greater than 8 and that RHCT be performed only when there are clinical indications. LEVEL OF EVIDENCE Diagnostic/therapeutic study, level IV.

Overuse of helicopter transport in the minimally injured: A health care system problem that should be corrected

BACKGROUND Mortality benefit has been demonstrated for trauma patients transported via helicopter but at great cost. This study identified patients who did not benefit from helicopter transport to our facility and demonstrates potential cost savings when transported instead by ground. METHODS We performed a 6-year (2007–2013) retrospective analysis of all trauma patients presenting to our center. Patients with a known mode of transfer were included in the study. Patients with missing data and those who were dead on arrival were excluded from the study. Patients were then dichotomized into helicopter transfer and ground transfer groups. A subanalysis was performed between minimally injured patients (ISS < 5) in both the groups after propensity score matching for demographics, injury severity parameters, and admission vital parameters. Groups were then compared for hospital and emergency department length of stay, early discharge, and mortality. RESULTS Of 5,202 transferred patients, 18.9% (981) were transferred via helicopter and 76.7% (3,992) were transferred via ground transport. Helicopter-transferred patients had longer hospital (p = 0.001) and intensive care unit (p = 0.001) stays. There was no difference in mortality between the groups (p = 0.6). On subanalysis of minimally injured patients there was no difference in hospital length of stay (p = 0.1) and early discharge (p = 0.6) between the helicopter transfer and ground transfer group. Average helicopter transfer cost at our center was

Managing older adults with ground-level falls admitted to a trauma service: the effect of frailty

18,000, totaling

Seasonal Variation in Emergency General Surgery

4,860,000 for 270 minimally injured helicopter-transferred patients. CONCLUSION Nearly one third of patients transported by helicopter were minimally injured. Policies to identify patients who do not benefit from helicopter transport should be developed. Significant reduction in transport cost can be made by judicious selection of patients. Education to physicians calling for transport and identification of alternate means of transportation would be both safe and financially beneficial to our system. LEVEL OF EVIDENCE Epidemiologic study, level III. Therapeutic study, level IV.

Mild traumatic brain injury defined by Glasgow Coma Scale: Is it really mild?

To determine whether frail elderly adults are at greater risk of fracture after a ground‐level fall (GLF) than those who are not frail.

Secondary brain injury in trauma patients: The effects of remote ischemic conditioning

OBJECTIVE The aim of this study was to assess the seasonal variation in emergency general surgery (EGS) admissions. BACKGROUND Seasonal variation in medical conditions is well established; however, its impact on EGS cases remains unclear. METHODS The National Inpatient Sample (NIS) database was queried over an 8-year period (2004-2011) for all patients with diagnosis of acute appendicitis, acute cholecystitis, and diverticulitis. Elective admissions were excluded. The following data for each admission were recorded: age, sex, race, admission month, major operative procedure, hospital region, and mortality. Seasons were defined as follows: Spring (March, April, May), Summer (June, July, August), Fall (September, October, November), and Winter (December, January, February). X11 procedure and spectral analysis were performed to confirm seasonal variation. RESULTS A total of 63,911,033 admission records were evaluated of which 493,569 were appendicitis, 395,838 were cholecystitis, and 412,163 were diverticulitis. Seasonal variation is confirmed in EGS (F = 159.12, P < 0.0001) admissions. In the subanalysis, seasonal variation was found in acute appendicitis (F = 119.62, P < 0.0001), acute cholecystitis (F = 37.13, P < 0.0001), and diverticulitis (F = 69.90, P < 0.0001). The average monthly EGS admission in Winter was 11,322 ± 674. The average monthly EGS admission in Summer was higher than that of Winter by 13.6% (n = 1542; 95% CI: 1180-1904, P < 0.001). CONCLUSIONS Hospitalization due to EGS adheres to a consistent cyclical pattern, with more admissions occurring during the Summer months. Although the reasons for this variability are unknown, this information may be useful for hospital resource reallocation and staffing.

A critical analysis of secondary overtriage to a Level I trauma center.

Abstract Introduction: Conventionally, a Glasgow Coma Scale (GCS) score of 13–15 defines mild traumatic brain injury (mTBI). The aim of this study was to identify the factors that predict progression on repeat head computed tomography (RHCT) and neurosurgical intervention (NSI) in patients categorized as mild TBI with intracranial injury (intracranial haemorrhage and/or skull fracture). Methods: This study performed a retrospective chart review of all patients with traumatic brain injury who presented to a level 1 trauma centre. Patients with blunt TBI, an intracranial injury and admission GCS of 13–15 without anti-platelet and anti-coagulation therapy were included. The outcome measures were: progression on RHCT and need for neurosurgical intervention (craniotomy and/or craniectomy). Results: A total of 1800 patients were reviewed, of which 876 patients were included. One hundred and fifteen (13.1%) patients had progression on RHCT scan. Progression on RHCT was 8-times more likely in patients with subdural haemorrhage ≥10 mm, 5-times more likely with epidural haemorrhage ≥10 mm and 3-times more likely with base deficit ≥4. Forty-seven patients underwent a neurosurgical intervention. Patients with displaced skull fracture were 10-times more likely and patients with base deficit >4 were 21-times more likely to have a neurosurgical intervention. Conclusion: In patients with intracranial injury, a mild GCS score (GCS 13–15) in patients with an intracranial injury does not preclude progression on repeat head CT and the need for a neurosurgical intervention. Base deficit greater than four and displaced skull fracture are the greatest predictors for neurosurgical intervention in patients with mild TBI and an intracranial injury.