Glen A. Franklin

Evolution in the Management of Hepatic Trauma: A 25-Year Perspective

ObjectiveTo define the changes in demographics of liver injury during the past 25 years and to document the impact of treatment changes on death rates. Summary Background DataNo study has presented a long-term review of a large series of hepatic injuries, documenting the effect of treatment changes on outcome. A 25-year review from a concurrently collected database of liver injuries documented changes in treatment and outcome. MethodsA database of hepatic injuries from 1975 to 1999 was studied for changes in demographics, treatment patterns, and outcome. Factors potentially responsible for outcome differences were examined. ResultsA total of 1,842 liver injuries were treated. Blunt injuries have dramatically increased; the proportion of major injuries is approximately 16% annually. Nonsurgical therapy is now used in more than 80% of blunt injuries. The death rates from both blunt and penetrating trauma have improved significantly through each successive decade of the study. The improved death rates are due to decreased death from hemorrhage. Factors responsible include fewer major venous injuries requiring surgery, improved outcome with vein injuries, better results with packing, and effective arterial hemorrhage control with arteriographic embolization. ConclusionsThe treatment and outcome of liver injuries have changed dramatically in 25 years. Multiple modes of therapy are available for hemorrhage control, which has improved outcome.

A multicenter evaluation of whether gender dimorphism affects survival after trauma.

BACKGROUND The frequency of women who have sustained severe injuries has increased over the past 30 years. The purpose of this study was to evaluate whether severely injured women have a survival advantage over men. To address this issue, we undertook a multicenter evaluation of the effects of gender dimorphism on survival in trauma patients. METHODS Patient information was collected from the databases of three level I trauma centers. We included all consecutive patients who were admitted to these centers over a 4-year period. We evaluated the effects of age, gender, mechanism of injury, pattern of injury, Abbreviated Injury Score (AIS), and Injury Severity Score (ISS) on survival. RESULTS A total of 20,261 patients were admitted to the three trauma centers. Women who were younger than 50 years of age (mortality rate 5%) experienced a survival advantage over men (mortality rate 7%) of equal age (odds ratio 1.27, P <0.002). This advantage was most notably found in the more severely injured (ISS >25) group (mortality rate 28% in women versus 33% in men). This difference was not attributable to mechanism of injury, severity of injury, or pattern of injury. CONCLUSIONS Severely injured women younger than 50 years of age have a survival advantage when compared with men of equal age and injury severity. Young men have a 27% greater chance of dying than women after trauma. We conclude that gender dimorphism affects the survival of patients after trauma.

Prehospital hypotension as a valid indicator of trauma team activation.

BACKGROUND Criteria for trauma team activation are continually being evaluated to ensure proper utilization of resources. We examined the impact of prehospital (PH) hypotension (systolic blood pressure < or = 90) on outcome (operative intervention and mortality) and its usefulness as an indicator for trauma team activation. METHODS A database was created by using the trauma registry for all nonburned, injured patients from July of 1993 through October of 1998 at our Level I trauma center. RESULTS Of 6,976 patients (83% blunt injury) in the database, 4,437 had a PH blood pressure recorded. Documented PH hypotension was present in 791 patients. Hypotension persisted in the emergency department (ED) in 299 patients, but 193 of them showed minimal or no signs of life on arrival. Four hundred ninety-two patients had PH hypotension but normal ED systolic blood pressure, and 130 patients developed ED hypotension after normal PH systolic blood pressure. Nearly half of the patients with hypotension were taken from the ED directly to the operating room primarily for hemorrhage control procedures. The early and late mortality rates of patients with PH and ED hypotension were 12% and 32%, respectively. Other PH interventions had minimal effect on mortality in the hypotensive patient. CONCLUSION Prehospital hypotension remains a valid indicator for trauma team activation. Even though most of the non-DOA patients (492 of 598) were stable on arrival to the ED, nearly 50% required operative intervention, and an additional 25% required intensive care unit admission. The trauma team should be activated and involved with these patients early.

The need for early angiographic embolization in blunt liver injuries.

BACKGROUND Although nonoperative management of blunt liver injury (BLI) has become standard practice, adjuncts to nonoperative therapy, such as angiographic embolization, have not been well characterized. METHODS Patients with BLI were retrospectively identified at our American College of Surgeons-verified Level I trauma center from January 1997 through February 2001. Patients were stratified into four groups: those who received angiographic embolization (AE) as an early intervention when BLI was initially diagnosed (EARLY-AE); those who underwent AE after liver-related operation or later in the hospital course (LATE-AE); those treated with operation only (OR-ONLY); and nonoperative patients who also did not undergo AE (NO-OR). RESULTS There were 126 patients with BLI, of whom 94 were NO-OR, 20 were OR-ONLY, 6 had LATE-AE, and 6 had EARLY-AE. The NO-OR group had significantly lower liver Abbreviated Injury Scale scores. Liver Abbreviated Injury Scale scores were not different between the EARLY-AE, LATE-AE, and OR-ONLY groups. Liver-related mortality was not lower for those treated with AE. There was a trend toward lower mortality for just the EARLY-AE group compared with the LATE-AE and OR-ONLY groups (0% vs. 50% and 35%). The number of units of packed red blood cells transfused and the number of liver-related operations were lower in the EARLY-AE compared with the LATE-AE group, but liver-related complications were not different between the EARLY-AE, LATE-AE, or OR-ONLY groups. AE was successful in arresting hemorrhage in 83% of the cases. CONCLUSION In this small series, we observed similar morbidity and mortality with AE compared with operative therapy. EARLY-AE did decrease blood use and the number of liver-related operations. AE can be performed on severely injured patients with comparable liver-related mortality and complications. Further study of the timing of and outcomes from AE is needed.

Prophylactic antibiotics adversely affect nosocomial pneumonia in trauma patients.

BACKGROUND Little data are available regarding the impact that prolonged prophylactic antibiotic use (>48 hours) has on the development of nosocomial pneumonia. This retrospective study was conducted to assess the effect that prolonged prophylactic antibiotic use has on the development of nosocomial pneumonia and antibiotic use complications. METHODS The records of patients who contracted nosocomial pneumonia during mechanical ventilation were retrospectively reviewed. These patients then were classified into two groups: those who received prolonged prophylactic antibiotics before the diagnosis of pneumonia and those who did not receive antibiotics. RESULTS For the patients who received prolonged prophylactic antibiotics, the first pneumonia was diagnosed later, the causative organisms were more likely to be resistant or Gram-negative bacteria, and the incidence of antibiotic complications were two times greater than for patients who did not receive extended antibiotic prophylaxis. CONCLUSION Justification for the use and duration of prolonged (>48 hours) prophylactic antibiotics requires careful reevaluation because this practice is associated with significant clinical complications that lead to increased use of patient resources, lengthened hospital stay, and higher cost.

Hospital cost is reduced by motorcycle helmet use.

BACKGROUND The purpose of this study was to identify the impact of motorcycle helmet use on patient outcomes and cost of hospitalization, in a state with a mandatory helmet law. METHODS Patients admitted after motorcycle crashes from July 1996 to October 2000 were reviewed, including demographics, Injury Severity Score, length of stay, injuries, outcome, helmet use, hospital cost data, and insurance information. Statistical analysis was performed comparing helmeted to unhelmeted patients using analysis of variance, Students test, and regression analysis. RESULTS We admitted 216 patients: 174 wore helmets and 42 did not. Injury Severity Score correlated with both length of stay and cost of hospitalization. Mortality was not significantly different in either group. Failure to wear a helmet significantly increased incidence of head injuries (Students test, p < 0.02), but not other injuries. Helmet use decreased mean cost of hospitalization by more than

Integrating emergency general surgery with a trauma service: impact on the care of injured patients.

6,000 per patient. CONCLUSION Failure to wear a helmet adds to the financial burden created by motorcycle-related injuries. Therefore, individuals who do not wear helmets should pay higher insurance premiums.

Impact of recent trends of noninvasive trauma evaluation and nonoperative management in surgical resident education.

BACKGROUND There has been considerable discussion on the national level on the future of trauma surgery as a specialty. One of the leading directions for the field is the integration of emergency general surgery as a wider and more attractive scope of practice. However, there is currently no information on how the addition of an emergency general surgery practice will affect the care of injured patients. We hypothesized that the care of trauma patients would be negatively affected by adding emergency general surgery responsibilities to a trauma service. METHODS Our institution underwent a system change in August 2001, where an emergency general surgery (ES) practice was added to an established trauma service. The ES practice included emergency department and in-house consultations for all urgent surgical problems except thoracic and vascular diseases. There were no trauma staff changes during the study period. Trauma registry data (demographics, injuries, injury severity, and procedures) and performance improvement data (peer-review judgments for all identified errors, denied days, audit filters, and deaths) were abstracted for two 15-month periods surrounding this system change. Chi-square, Fishers exact, and t tests provided between-group comparisons. RESULTS The trauma staff evaluated a total of 5,874 patients during the 30-month study. There were 1,400 (51%) trauma admissions in the pre-ES group and 1,504 (48%) in the post-ES group, of which 1,278 and 1,434, respectively, met severity criteria for report to our statewide database (Pennsylvania Trauma Outcome Study [PTOS]). There were 163 (12.7% of PTOS) deaths in the pre-ES group compared with 171 (11.9% PTOS) deaths in the post-ES group (p = not significant [NS]). There was one death determined to be preventable by the peer review process for the pre-ES group, and none in the post-ES group. Both groups had 10 potentially preventable deaths, with the remaining mortalities being categorized as nonpreventable (p = NS). Unexpected deaths by TRISS methodology were 36 (2.8%) and 41 (2.9%) for the two groups, respectively (p = NS). There was no difference in the number of provider-specific complications between the groups (23, [1.8%] vs. 19 [1.3%], p = NS). The addition of emergency surgery has resulted in an additional average daily workload of 1.3 cases and 1.2 admissions. CONCLUSION Despite an increase in trauma volume over the study period, the addition of emergency surgery to a trauma service did not affect the care of injured patients. The concept of adding emergency surgery responsibilities to trauma surgeons appears to be a valid way to increase operative experience without compromising care of the injured patient.

Early VATS for blunt chest trauma: a management technique underutilized by acute care surgeons.

BACKGROUND The use of ultrasonography and nonoperative management of solid organ injury has become standard practice in many trauma centers. Little is known about the effects of these changes on resident educational experience. METHODS We retrospectively reviewed resident evaluation of abdominal trauma and trauma operative experience as reported to the residency review committee between 1994 and 1999. RESULTS A total of 4,052 patients underwent one or more of three diagnostic modalities. The nontherapeutic laparotomy rate as a result of positive diagnostic peritoneal lavages decreased from 35% to 14%. Although resident operative trauma experience was stable because of increases in operative burns and nonabdominal trauma, the number of abdominal procedures declined. CONCLUSION Noninvasive diagnostic tests have allowed more rapid trauma evaluation and fewer nontherapeutic laparotomies. As nonoperative experience grows, the opportunity for operative experience decreases. These trends may adversely affect the education of residents and suggest that novel approaches are needed to ensure adequate operative experience in trauma.

The evolving management of venous bullet emboli: a case series and literature review.

BACKGROUND Retained hemothorax and/or empyema is a commonly recognized complication of penetrating chest injuries that may be treated by early video-assisted thoracoscopy (VATS). However, the use of VATS in blunt chest trauma is less well defined. Our acute care surgeon (ACS) group aggressively treats complications of penetrating chest trauma with VATS, and our results suggested that the early use of VATS by ACS should be expanded. MATERIALS A retrospective review of Trauma Center admissions between January 2007 and December 2009 was performed to identify patients with blunt thoracic injuries who underwent VATS. RESULTS Eighty-three patients underwent VATS to manage thoracic complications arising from their blunt chest trauma. All operations were performed by ACS. The majority of patients (73%, 61 of 83) were treated with VATS for retained hemothorax, 18% for empyema (15 of 83), and 10% for persistent air leak (8 of 83). All (15) patients who developed empyema had chest tubes placed in the emergency department. No patient treated with VATS for a persistent air leak required further operation or conversion to thoracotomy. VATS performed ≤5 days after injury was associated with a lower conversion to open thoracotomy (8% vs. 29.4%, p < 0.05). Hospital length of stay (LOS) was significantly lower for patients receiving VATS ≤5 days after injury (11 ± 6 vs. 16 ± 8, p < 0.05). No patient treated with VATS ≤5 days had persistent empyema; however, five patients treated with VATS for retained hemothorax or empyema >5 days after injury required further intervention for thoracic infection. Multivariate analysis demonstrated that both a diagnosis of empyema and VATS >5 days after injury were predictors of increased LOS and increased conversion to thoracotomy. CONCLUSIONS Early VATS can decrease hospital LOS and thoracotomy rate in patient suffering blunt thoracic injuries. ACS can perform this procedure safely and effectively.