Dimitra Skiada

The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA)

INTRODUCTION Aortic occlusion (AO) for resuscitation in traumatic shock remains controversial. Resuscitative endovascular balloon occlusion of the aorta (REBOA) offers an emerging alternative. METHODS The American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry prospectively identified trauma patients requiring AO from eight ACS Level 1 centers. Presentation, intervention, and outcome variables were collected and analyzed to compare REBOA and open AO. RESULTS From November 2013 to February 2015, 114 AO patients were captured (REBOA, 46; open AO, 68); 80.7% were male, and 62.3% were blunt injured. Aortic occlusion occurred in the emergency department (73.7%) or the operating room (26.3%). Hemodynamic improvement after AO was observed in 62.3% [REBOA, 67.4%; open OA, 61.8%); 36.0% achieving stability (systolic blood pressure consistently >90 mm Hg, >5 minutes); REBOA, 22 of 46 (47.8%); open OA, 19 of 68 (27.9%); p =0.014]. Resuscitative endovascular balloon occlusion of the aorta (REBOA) access was femoral cut-down (50%); US guided (10.9%) and percutaneous without imaging (28.3%). Deployment was achieved in Zones I (78.6%), II (2.4%), and III (19.0%). A second AO attempt was required in 9.6% [REBOA, 2 of 46 (4.3%); open OA, 9 of 68 (13.2%)]. Complications of REBOA were uncommon (pseudoaneurysm, 2.1%; embolism, 4.3%; limb ischemia, 0%). There was no difference in time to successful AO between REBOA and open procedures (REBOA, 6.6 ± 5.6 minutes; open OA, 7.2 ± 15.1; p = 0.842). Overall survival was 21.1% (24 of 114), with no significant difference between REBOA and open AO with regard to mortality [REBOA, 28.2% (13 of 46); open OA, 16.1% (11 of 68); p = 0.120]. CONCLUSION Resuscitative endovascular balloon occlusion of the aorta has emerged as a viable alternative to open AO in centers that have developed this capability. Further maturation of the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database is required to better elucidate optimal indications and outcomes. LEVEL OF EVIDENCE Therapeutic/care management study, level IV.

Intracranial pressure monitoring in severe head injury: compliance with Brain Trauma Foundation guidelines and effect on outcomes: a prospective study

OBJECT The Brain Trauma Foundation (BTF) has established guidelines for intracranial pressure (ICP) monitoring in severe traumatic brain injury (TBI). This study assessed compliance with these guidelines and the effect on outcomes. METHODS This is a prospective, observational study including patients with severe blunt TBI (Glasgow Coma Scale score ≤ 8, head Abbreviated Injury Scale score ≥ 3) between January 2010 and December 2011. Demographics, clinical characteristics, laboratory profile, head CT scans, injury severity indices, and interventions were collected. The study population was stratified into 2 study groups: ICP monitoring and no ICP monitoring. Primary outcomes included compliance with BTF guidelines, overall in-hospital mortality, and mortality due to brain herniation. Secondary outcomes were ICU and hospital lengths of stay. Multiple regression analyses were deployed to determine the effect of ICP monitoring on outcomes. RESULTS A total of 216 patients met the BTF guideline criteria for ICP monitoring. Compliance with BTF guidelines was 46.8% (101 patients). Patients with subarachnoid hemorrhage and those who underwent craniectomy/craniotomy were significantly more likely to undergo ICP monitoring. Hypotension, coagulopathy, and increasing age were negatively associated with the placement of ICP monitoring devices. The overall in-hospital mortality was significantly higher in patients who did not undergo ICP monitoring (53.9% vs 32.7%, adjusted p = 0.019). Similarly, mortality due to brain herniation was significantly higher for the group not undergoing ICP monitoring (21.7% vs 12.9%, adjusted p = 0.046). The ICU and hospital lengths of stay were significantly longer in patients subjected to ICP monitoring. CONCLUSIONS Compliance with BTF ICP monitoring guidelines in our study sample was 46.8%. Patients managed according to the BTF ICP guidelines experienced significantly improved survival.

Diluting the benefits of hemostatic resuscitation: A multi-institutional analysis

BACKGROUND Although minimization of crystalloids is a widely adopted practice in the resuscitation of patients with severe hemorrhage, its direct impact on high-ratio resuscitation (HRR) outcomes has not been analyzed. We hypothesize that HRR patients will have worse outcomes from crystalloid use. METHODS This was a 4-year retrospective multi-institutional analysis (MIA) of patients who received massive transfusion protocol (MTP) managed with damage-control laparotomy. Ratios of fresh frozen plasma–packed red blood cell (PRBC) were calculated and divided in two groups: HRR (1–1:2) and low-ratio resuscitation (LRR < 1:2). Major outcome of interest was to analyze the direct impact of 24-hour crystalloid volume on HRR MTP patients who received 10 or more units of PRBC. Statistical analysis included analysis of variance, Fisher’s exact, Kaplan-Meier (KM) survival curves, and multiple logistic regression. RESULTS Total of five Level I trauma centers participated with 451 patients who received MTP with 10 or more units of PRBC (fresh frozen plasma/PRBC ratios, n = 365 (80.9%) HRR vs. n = 86 (19.0%) LRR. Overall 24-hour KM survival for the HRR versus LRR was 85.2% versus 68.6% (p = 0.0004). The volume of crystalloids on KM survival curve in HRR MTP patients was not significant for mortality (p = 0.52). Morbidity odds ratios (95% confidence interval) for complications were not significant for HRR but were for crystalloids: bacteremia, 1.05 (1.0–1.1); adult respiratory distress syndrome, 1.13 (1.0–1.2), and acute renal failure, 1.05 (1.0–1.1). CONCLUSION Our MIA results support previous studies with decreased mortality in HRR group when compared with LRR. This is the first MIA to demonstrate increased morbidity from crystalloid use in HRR. Within all MTPs with 10 or more units of PRBC, HRR was not a predictor of morbidity, but crystalloid volume was. Caution in overzealous use of crystalloid during HRR is warranted. LEVEL OF EVIDENCE Therapeutic study, level IV.

Current management of hemorrhage from severe pelvic fractures: Results of an American association for the surgery of trauma multi-institutional trial.

BACKGROUND There is no consensus as to the optimal treatment paradigm for patients presenting with hemorrhage from severe pelvic fracture. This study was established to determine the methods of hemorrhage control currently being used in clinical practice. METHODS This prospective, observational multi-center study enrolled patients with pelvic fracture from blunt trauma. Demographic data, admission vital signs, presence of shock on admission (systolic blood pressure < 90 mm Hg or heart rate > 120 beats per minute or base deficit < −5), method of hemorrhage control, transfusion requirements, and outcome were collected. RESULTS A total of 1,339 patients with pelvic fracture were enrolled from 11 Level I trauma centers. Fifty-seven percent of the patients were male, with a mean ± SD age of 47.1 ± 21.6 years, and Injury Severity Score (ISS) of 19.2 ± 12.7. In-hospital mortality was 9.0 %. Angioembolization and external fixator placement were the most common method of hemorrhage control used. A total of 128 patients (9.6%) underwent diagnostic angiography with contrast extravasation noted in 63 patients. Therapeutic angioembolization was performed on 79 patients (5.9%). There were 178 patients (13.3%) with pelvic fracture admitted in shock with a mean ± SD ISS of 28.2 ± 14.1. In the shock group, 44 patients (24.7%) underwent angiography to diagnose a pelvic source of bleeding with contrast extravasation found in 27 patients. Thirty patients (16.9%) were treated with therapeutic angioembolization. Resuscitative endovascular balloon occlusion of the aorta was performed on five patients in shock and used by only one of the participating centers. Mortality was 32.0% for patients with pelvic fracture admitted in shock. CONCLUSION Patients with pelvic fracture admitted in shock have high mortality. Several methods were used for hemorrhage control with significant variation across institutions. The use of resuscitative endovascular balloon occlusion of the aorta may prove to be an important adjunct in the treatment of patients with severe pelvic fracture in shock; however, it is in the early stages of evaluation and not currently used widely across trauma centers. LEVEL OF EVIDENCE Prognostic study, level II; therapeutic study, level III.

Emergency surgery for acute diverticulitis: which operation? A National Surgical Quality Improvement Program study.

BACKGROUND The optimal surgical management of acute diverticulitis is still a controversial and unresolved issue. While the Hartmann’s procedure (`) is the most commonly performed operation, primary anastomosis (PA), with or without proximal diversion, has also been used with increasing frequency. METHODS This is a National Surgical Quality Improvement Program database study including all patients requiring emergency surgery for acute diverticulitis. Three operative approaches were analyzed: HP, colectomy with PA, and colectomy with PA with proximal diversion (PAPD). Mortality and postoperative outcomes were compared between the three groups using a logistical regression model. RESULTS There were 1,314 patients who required emergent operation for acute diverticulitis, 75.4% underwent HP, 21.7% underwent PA, and 2.9% underwent PAPD. Thirty-day mortality was 7.3%, 4.6%, and 1.6% for HP, PA, and PAPD respectively (p = 0.163), while surgical site infections occurred in 19.7%, 17.9%, and 13.2%, respectively (p = 0.59). After multivariable analysis adjusting for age, alcohol consumption, comorbidities, steroid use, preoperative laboratory values, hemorrhage at admission and laparoscopic surgery, the adjusted odds ratio for 30-day mortality comparing PA with HP was 0.77 (95% confidence interval [CI], 0.38–1.56; p = 0.465), 0.47 (95% CI, 0.06–3.74; p = 0.479) comparing PAPD with HP, and 1.62 (95% CI, 0.19–13.78; p = 0.658) comparing PA with PAPD. In addition, the three groups did not have significantly different adjusted odds ratio for the development of surgical infectious complications, acute kidney injury, cardiovascular incidents, or venous thromboembolism after surgery. CONCLUSION Resection and PA in patients undergoing an emergency operation for acute diverticulitis is a safe alternative to the HP, with no significant difference in mortality or postoperative surgical site infections. LEVEL OF EVIDENCE Therapeutic study, level IV.

Is Prehospital Endotracheal Intubation Associated with Improved Outcomes In Isolated Severe Head Injury? A Matched Cohort Analysis

INTRODUCTION Prehospital endotracheal intubation (ETI) following traumatic brain injury in urban settings is controversial. Studies investigating admission arterial blood gas (ABG) patterns in these instances are scant. HYPOTHESIS Outcomes in patients subjected to divergent prehospital airway management options following severe head injury were studied. METHODS This was a retrospective propensity-matched study in patients with isolated TBI (head Abbreviated Injury Scale (AIS) ≥ 3) and Glasgow Coma Scale (GCS) score of ≤ 8 admitted to a Level 1 urban trauma center from January 1, 2003 through October 31, 2011. Cases that had prehospital ETI were compared to controls subjected to oxygen by mask in a one to three ratio for demographics, mechanism of injury, tachycardia/hypotension, Injury Severity Score, type of intracranial lesion, and all major surgical interventions. Primary outcome was mortality and secondary outcomes included admission gas profile, in-hospital morbidity, ICU length of stay (ICU LOS) and hospital length of stay (HLOS). RESULTS Cases (n = 55) and controls (n = 165) had statistically similar prehospital and in-hospital variables after propensity matching. Mortality was significantly higher for the ETI group (69.1% vs 55.2% respectively, P = .011). There was no difference in pH, base deficit, and pCO2 on admission blood gases; however the ETI group had significantly lower pO2 (187 (SD = 14) vs 213 (SD = 13), P = .034). There was a significantly increased incidence of septic shock in the ETI group. Patients subjected to prehospital ETI had a longer HLOS and ICU LOS. CONCLUSION In isolated severe traumatic brain injury, prehospital endotracheal intubation was associated with significantly higher adjusted mortality rate and worsened admission oxygenation. Further prospective validation of these findings is warranted.

Blunt abdominal aortic injury: A Western Trauma Association multicenter study

BACKGROUND Blunt abdominal aortic injury (BAAI) is a rare injury. The objective of the current study was to examine the presentation and management of BAAI at a multi-institutional level. METHODS The Western Trauma Association Multi-Center Trials conducted a study of BAAI from 1996 to 2011. Data collected included demographics, injury mechanism, associated injuries, interventions, and complications. RESULTS Of 392,315 blunt trauma patients, 113 (0.03%) presented with BAAI at 12 major trauma centers (67% male; median age, 38 years; range, 6–88; median Injury Severity Score [ISS], 34; range, 16–75). The leading cause of injury was motor vehicle collisions (60%). Hypotension was documented in 47% of the cases. The most commonly associated injuries were spine fractures (44%) and pneumothorax/hemothorax (42%). Solid organ, small bowel, and large bowel injuries occurred in 38%, 35%, and 28% respectively. BAAI presented as free aortic rupture (32%), pseudoaneurysm (16%), and injuries without aortic external contour abnormality on computed tomography such as large intimal flaps (34%) or intimal tears (18%). Open and endovascular repairs were undertaken as first-choice therapy in 43% and 15% of cases, respectively. Choice of management varied by type of BAAI: 89% of intimal tears were managed nonoperatively, and 96% of aortic ruptures were treated with open repair. Overall mortality was 39%, the majority (68%) occurring in the first 24 hours because of hemorrhage or cardiac arrest. The highest mortality was associated with Zone II aortic ruptures (92%). Follow-up was documented in 38% of live discharges. CONCLUSION This is the largest BAAI series reported to date. BAAI presents as a spectrum of injury ranging from minimal aortic injury to aortic rupture. Nonoperative management is successful in uncomplicated cases without external aortic contour abnormality on computed tomography. Highest mortality occurred in free aortic ruptures, suggesting that alternative measures of early noncompressible torso hemorrhage control are warranted. LEVEL OF EVIDENCE Epidemiologic study, level III; therapeutic study, level IV.

Prospective derivation of a clinical decision rule for thoracolumbar spine evaluation after blunt trauma: An American Association for the Surgery of Trauma Multi-Institutional Trials Group Study.

BACKGROUND Unlike the cervical spine (C-spine), where National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian C-spine Rules can be used, evidence-based thoracolumbar spine (TL-spine) clearance guidelines do not exist. The aim of this study was to develop a clinical decision rule for evaluating the TL-spine after injury. METHODS Adult (≥15 years) blunt trauma patients were prospectively enrolled at 13 US trauma centers (January 2012 to January 2014). Exclusion criteria included the following: C-spine injury with neurologic deficit, preexisting paraplegia/tetraplegia, and unevaluable examination. Remaining evaluable patients underwent TL-spine imaging and were followed up to discharge. The primary end point was a clinically significant TL-spine injury requiring TL-spine orthoses or surgical stabilization. Regression techniques were used to develop a clinical decision rule. Decision rule performance in identifying clinically significant fractures was tested. RESULTS Of 12,479 patients screened, 3,065 (24.6%) met inclusion criteria (mean [SD] age, 43.5 [19.8] years [range, 15–103 years]; male sex, 66.3%; mean [SD] Injury Severity Score [ISS], 8.8 [7.5]). The majority underwent computed tomography (93.3%), 6.3% only plain films, and 0.2% magnetic resonance imaging exclusively. TL-spine injury was identified in 499 patients (16.3%), of which 264 (8.6%) were clinically significant (29.2% surgery, 70.8% TL-spine orthosis). The majority was AO Type A1 282 (56.5%), followed by 67 (13.4%) A3, 43 (8.6%) B2, and 32 (6.4%) A4 injuries. The predictive ability of clinical examination (pain, midline tenderness, deformity, neurologic deficit), age, and mechanism was examined; positive clinical examination finding resulted in a sensitivity of 78.4% and a specificity of 72.9%. Addition of age of 60 years or older and high-risk mechanism (fall, crush, motor vehicle crash with ejection/rollover, unenclosed vehicle crash, auto vs. pedestrian) increased sensitivity to 98.9% with specificity of 29.0% for clinically significant injuries and 100.0% sensitivity and 27.3% specificity for injuries requiring surgery. CONCLUSION Clinical examination alone is insufficient for determining the need for imaging in evaluable patients at risk of TL-spine injury. Addition of age and high-risk mechanism results in a clinical decision-making rule with a sensitivity of 98.9% for clinically significant injuries. LEVEL OF EVIDENCE Diagnostic test, level III.

Prospective Evaluation of Treatment of Open Fractures: Effect of Time to Irrigation and Debridement

IMPORTANCE The standard practice of irrigation and debridement (I&D) of open fractures within 6 hours of injury remains controversial. OBJECTIVE To prospectively evaluate the effect of the time from injury to the initial I&D on infectious complications. DESIGN, SETTING, AND PARTICIPANTS A total of 315 patients who were admitted to a level 1 trauma center with open extremity fractures from September 22, 2008, through June 21, 2011, were enrolled in a prospective observational study and followed up for 1 year after discharge (mean [SD] age, 33.9 [16.3] years; 79% were male; and 78.4% were due to blunt trauma). Demographics, mechanism of injury, time to I&D, operative intervention, and incidence of local infectious complications were documented. Patients were stratified into 4 groups based on the time of I&D (<6 hours, 7-12 hours, 13-18 hours, and 19-24 hours after injury). Univariate and multivariable analysis were used to determine the effect of time to I&D on outcomes. MAIN OUTCOMES AND MEASURES Development of local infectious complications at early (<30 days) or late (>30 days and <1 year) intervals from admission. RESULTS The most frequently injured site was the lower extremity (70.2%), and 47.9% of all injuries were Gustilo classification type III. There was no difference in fracture location, degree of contamination, or antibiotic use between groups. All patients underwent I&D within 24 hours. Overall, 14 patients (4.4%) developed early wound infections, while 10 (3.2%) developed late wound infections (after 30 days). The infection rate was not statistically different on univariate (<6 hours, 4.7%; 7-12 hours, 7.5%; 13-18 hours, 3.1%; and 19-24 hours, 3.6%; P = .65) or multivariable analysis (<6-hour group [reference], P = .65; 7- to 12-hour group adjusted odds ratio [AOR] [95% CI], 2.1 [0.4-10.2], P = .37; 13- to 18-hour group AOR [95% CI], 0.8 [0.1-4.5], P = .81; 19- to 24-hour group AOR [95% CI], 1.1 [0.2-6.2], P = .90). Time to I&D did not affect the rate of nonunion, hardware failure, length of stay, or mortality. CONCLUSIONS AND RELEVANCE In this prospective analysis, time to I&D did not affect the development of local infectious complications provided it was performed within 24 hours of arrival.

Relationship of creatine kinase elevation and acute kidney injury in pediatric trauma patients.

BACKGROUND Rhabdomyolysis following trauma has been associated with renal impairment. Nevertheless, the literature is scant in risk assessment of acute kidney injury (AKI) and survival in children experiencing posttraumatic rhabdomyolysis. METHODS After institutional review board approval was obtained, the registry of an urban trauma center was reviewed for pediatric (age < 18 years) trauma admissions with available creatine kinase (CK) values. Variables extracted included demographics and trauma severity indices along with serum creatine, CK, and Blood Urea Nitrogen (BUN) values. AKI was defined per pediatric RIFLE (Risk, Injury, Failure, Loss, End stage) definition. Regression models were deployed to determine the independent risk factors for AKI and CK levels. RESULTS Overall, 521 patients constituted the study sample. AKI occurred in 70 patients (13.4%), with correlation to CK values in excess of 3,000 IU/L (41.4% vs. 4.9%, adjusted p < 0.001). Independent risk factors for AKI proved to be CK level of 3,000 or greater (adjusted odds ratio [AOR], 11.02; 95% confidence interval [CI], 4.56–26.64; p < 0.001), Injury Severity Score (ISS) of 15 or less (AOR, 0.25; 95% CI, 0.10–0.61), Glasgow Coma Scale (GCS) score of 8 or less (AOR, 15.00; 95% CI, 4.98–44.94), abdominal Abbreviated Injury Scale (AIS) score of 3 or less (AOR, 3.14; 95% CI, 1.04–5.36), imaging studies with contrast of 3 or less (AOR, 3.81; 95% CI, 1.37–10.57), blunt mechanism of injury (AOR, 2.76; 95% CI, 1.17–6.49), administration of nephrotoxic agents (AOR, 4.81; 95% CI, 1.23–18.79), and requirement for fluids administration in the emergency department (AOR, 2.36; 95% CI, 1.04–5.36). Mortality in the study sample with CK values of 3,000 or greater versus less than 3,000 IU/L did not reach statistical significance (25.0% vs. 9.3%, adjusted p = 0.787). CONCLUSION AKI in pediatric posttraumatic rhabdomyolysis occurs in 13% of trauma patients. CK values of 3,000 IU/L or greater pose a significant adjusted risk for AKI. Aggressive monitoring of CK values in pediatric trauma patients is warranted. LEVEL OF EVIDENCE Prognostic study, level III.