Gregory J. Jurkovich

Management of patients with anterior abdominal stab wounds: a Western Trauma Association multicenter trial.

BACKGROUNDnThe optimal management of hemodynamically stable, asymptomatic patients with anterior abdominal stab wounds (AASWs) remains controversial. The goal is to identify and treat injuries in a safe, cost-effective manner. Common evaluation strategies include local wound exploration (LWE)/diagnostic peritoneal lavage (DPL), serial clinical assessments (SCAs), and computed tomography (CT) imaging. The purpose of this multicenter study was to evaluate the clinical course of patients managed by the various strategies, to determine whether there are differences in associated nontherapeutic laparotomy (NONTHER LAP), emergency department (ED) discharge, or complication rates.nnnMETHODSnA multicenter, Institutional Review Board-approved study enrolled patients with AASWs. Management was individualized according to surgeon/institutional protocols. Data on the presentation, evaluation, and clinical course were recorded prospectively.nnnRESULTSnThree hundred fifty-nine patients were studied. Eighty-one had indications for immediate LAP, of which 84% were therapeutic. ED D/C was facilitated by LWE, CT, and DPL in 23%, 21%, and 16% of patients, respectively. On the other hand, LAP based on abnormalities on LWE, CT, and DPL were NONTHER in 57%, 24%, and 31% of patients, respectively. Twelve percent of patients selected for SCA ultimately had LAP (33% were NONTHER); there was no apparent morbidity due to delay in intervention.nnnCONCLUSIONSnShock, evisceration, and peritonitis warrant immediate LAP after AASW. Patients without these findings can be safely observed for signs or symptoms of bleeding or hollow viscus injury. To limit the number of hospital admissions, we propose a uniform strategy using LWE to ascertain the depth of penetration; the patient may be safely discharged in the absence of peritoneal violation. Peritoneal penetration, absent evidence of ongoing hemorrhage or hollow viscus injury, should not be considered an indication for LAP, but rather an indication for admission for SCAs. We suggest that a prospective multicenter trial be performed to document the safety and cost-effectiveness of such an approach.

Collaborative Care Intervention Targeting Violence Risk Behaviors, Substance Use, and Posttraumatic Stress and Depressive Symptoms in Injured Adolescents: A Randomized Clinical Trial

IMPORTANCEnViolence and injury risk behaviors, alcohol and drug use problems, and posttraumatic stress disorder (PTSD) and depressive symptoms occur frequently among adolescents presenting to acute care medical settings after traumatic physical injury.nnnOBJECTIVEnTo test the effectiveness of a stepped collaborative care intervention targeting this constellation of risk behaviors and symptoms in randomly sampled hospitalized adolescents with and without traumatic brain injury.nnnDESIGN, SETTING, AND PARTICIPANTSnA pragmatic randomized clinical trial was conducted at a single US level I trauma center. Participants included 120 adolescents aged 12 to 18 years randomized to intervention (nu2009=u200959) and control (nu2009=u200961) conditions.nnnINTERVENTIONSnStepped collaborative care intervention included motivational interviewing elements targeting risk behaviors and substance use as well as medication and cognitive behavioral therapy elements targeting PTSD and depressive symptoms.nnnMAIN OUTCOMES AND MEASURESnAdolescents were assessed at baseline before randomization and 2, 5, and 12 months after injury hospitalization. Standardized instruments were used to assess violence risk behaviors, alcohol and drug use, and PTSD and depressive symptoms.nnnRESULTSnThe investigation attained more than 95% adolescent follow-up at each assessment point. At baseline, approximately one-third of the participants endorsed the violence risk behavior of carrying a weapon. Regression analyses demonstrated that intervention patients experienced significant reductions in weapon carrying compared with controls during the year after injury (groupu2009×u2009time effect, F3,344u2009=u20093.0; Pu2009=u2009.03). At 12 months after the injury, 4 (7.3%) intervention patients vs 13 (21.3%) control patients reported currently carrying a weapon (relative risk,u20090.31; 95% CI, 0.11-0.90). The intervention was equally effective in reducing the risk of weapon carrying among injured adolescents with and without traumatic brain injury. Other treatment targets, including alcohol and drug use problems and high levels of PTSD and depressive symptoms, occurred less frequently in the cohort relative to weapon carrying and were not significantly affected by the intervention.nnnCONCLUSIONS AND RELEVANCEnCollaborative care intervention reduced the risk of adolescent weapon carrying during the year after the injury hospitalization. Future investigation should replicate this preliminary observation. If the finding is replicated, orchestrated investigative and policy efforts could systematically implement and evaluate screening and intervention procedures targeting youth violence prevention at US trauma centers.nnnTRIAL REGISTRATIONnclinicaltrials.gov identifier: NCT00619255.

ACGME case logs: Surgery resident experience in operative trauma for two decades.

BACKGROUND Surgery resident education is based on experiential training, which is influenced by changes in clinical management strategies, technical and technologic advances, and administrative regulations. Trauma care has been exposed to each of these factors, prompting concerns about resident experience in operative trauma. The current study analyzed the reported volume of operative trauma for the last two decades; to our knowledge, this is the first evaluation of nationwide trends during such an extended time line. METHODS The Accreditation Council for Graduate Medical Education (ACGME) database of operative logs was queried from academic year (AY) 1989–1990 to 2009–2010 to identify shifts in trauma operative experience. Annual case log data for each cohort of graduating surgery residents were combined into approximately 5-year blocks, designated Period I (AY1989–1990 to AY1993–1994), Period II (AY1994–1995 to AY1998–1999), Period III (AY1999–2000 to AY2002–2003), and Period IV (AY2003–2004 to AY2009–2010). The latter two periods were delineated by the year in which duty hour restrictions were implemented. RESULTS Overall general surgery caseload increased from Period I to Period II (p < 0.001), remained stable from Period II to Period III, and decreased from Period III to Period IV (p < 0.001). However, for ACGME-designated trauma cases, there were significant declines from Period I to Period II (75.5 vs. 54.5 cases, p < 0.001) and Period II to Period III (54.5 vs. 39.3 cases, p < 0.001) but no difference between Period III and Period IV (39.3 vs. 39.4 cases). Graduating residents in Period I performed, on average, 31 intra-abdominal trauma operations, including approximately five spleen and four liver operations. Residents in Period IV performed 17 intra-abdominal trauma operations, including three spleen and approximately two liver operations. CONCLUSION Recent general surgery trainees perform fewer trauma operations than previous trainees. The majority of this decline occurred before implementation of work-hour restrictions. Although these changes reflect concurrent changes in management of trauma, surgical educators must meet the challenge of training residents in procedures less frequently performed. LEVEL OF EVIDENCE Epidemiologic study, level III; therapeutic study, level IV.

A prospective, controlled clinical evaluation of surgical stabilization of severe rib fractures.

BACKGROUND Previous studies of surgical stabilization of rib fractures (SSRF) have been limited by small sample sizes, retrospective methodology, and inclusion of only patients with flail chest. We performed a prospective, controlled evaluation of SSRF as compared with optimal medical management for severe rib fracture patterns among critically ill trauma patients. We hypothesized that SSRF improves acute outcomes. METHODS We conducted a 2-year clinical evaluation of patients with any of the following rib fracture patterns: flail chest, three or more fractures with bicortical displacement, 30% or greater hemithorax volume loss, and either severe pain or respiratory failure despite optimal medical management. In the year 2013, all patients were managed nonoperatively. In the year 2014, all patients were managed operatively. Outcomes included respiratory failure, tracheostomy, pneumonia, ventilator days, tracheostomy, length of stay, daily maximum incentive spirometer volume, narcotic requirements, and mortality. Univariate and multivariable analyses were performed. RESULTS Seventy patients were included, 35 in each group. For the operative group, time from injury to surgery was 2.4 day, operative time was 1.5 hours, and the ratio of ribs fixed to ribs fractured was 0.6. The operative group had a significantly higher RibScore (4 vs. 3, respectively, p < 0.01) and a significantly lower incidence of intracranial hemorrhage (5.7% vs. 28.6%, respectively, p = 0.01). After controlling for these differences, the operative group had a significantly lower likelihood of both respiratory failure (odds ratio, 0.24; 95% confidence interval, 0.06–0.93; p = 0.03) and tracheostomy (odds ratio, 0.18; 95% confidence interval, 0.04–0.78; p = 0.03). Duration of ventilation was significantly lower in the operative group (p < 0.01). The median daily spirometry value was 250 mL higher in the operative group (p = 0.04). Narcotic requirements were comparable between groups. There were no mortalities. CONCLUSION In this evaluation, SSRF as compared with the best medical management improved acute outcomes among a group of critically ill trauma patients with a variety of severe fracture patterns. LEVEL OF EVIDENCE Therapeutic study, level II.

Surgical stabilization of severe rib fractures.

R ib fractures are common and lead to prolonged pain, dyspnea, and health care expenditures. Traditionally, even the most severe fracture patterns have beenmanaged nonoperatively. However, an improved understanding of rib biomechanics, advancements in fixation systems, the development of musclesparring techniques, and favorable outcomes research have led to a renewed interest in surgical stabilization of rib fractures (SSRF). Furthermore, because SSRF lies at the confluence of trauma, orthopedic, and thoracic surgery, it is a well-suited procedure for the acute care surgeon to master. Many trauma centers now routinely perform SSRF, and expert panels have recognized the utility of this procedure. However, there remains a lack of consensus regarding both indications and technique. The following is a description of our approach to patients with severe rib fractures; we are currently collecting prospectively outcomes data related to this management protocol and would encourage other centers considering adoption of SSRF to do the same.

The effect of epidural placement in patients after blunt thoracic trauma.

BACKGROUND In studies of trauma patients with rib fractures, conclusions on the benefits derived from epidural analgesia are inconsistent. The purpose of this study was to further evaluate placement and efficacy of epidural analgesia nationwide. METHODS This was a retrospective cohort study of prospectively gathered data from the National Study on Cost and Outcomes of Trauma database, a multisite prospective study of injured patients aged 18 years to 84 years. Patients were treated at 69 participating hospitals (18 Level I trauma centers and 51 nontrauma centers) across the United States. Our analysis was limited to patients with a blunt mechanism of injury and a thoracic maximum Abbreviated Injury Scale (MAXAIS) score of 2 or greater. Excluded were patients who were not potential candidates for epidural placement, such as patients with significant head and spine injuries (head MAXAIS score > 2 or spine MAXAIS score > 2), significant neurologic impairment (best motor Glasgow Coma Scale [GCS] score < 4), unstable pelvic fractures, coagulopathy, or those who died within 48 hours. RESULTS The National Study on Cost and Outcomes of Trauma database contains 5,043 patients, of whom 836 (16.5%) were identified as potential candidates for epidural placement. Of patients included in the study, 100 patients (12%) had epidural catheters placed. The likelihood of epidural catheter placement was significantly higher in trauma centers as compared with nontrauma centers (adjusted odds ratio, 3.06; 95% confidence interval [CI] 1.80–5.22). In the epidural group compared with those not receiving a catheter, the adjusted (including trauma center status) odds of death in patients with three or more rib fractures at 30, 90, and 365 days was 0.08 (95% CI, 0.01–0.43), 0.09 (95% CI, 0.02–0.42), and 0.12 (95% CI, 0.04–0.42), respectively. CONCLUSION Trauma centers are more likely to place epidural catheter in patients with rib fractures. In this multicenter study, epidural catheter placement was associated with a significantly decreased risk of dying in patients with blunt thoracic injury of three or more rib fractures. LEVEL OF EVIDENCE Therapeutic study, level II.

Suboptimal compliance with evidence-based guidelines in patients with traumatic brain injuries: Clinical article

OBJECTnEvidence-based management (EBM) guidelines for severe traumatic brain injuries (TBIs) were promulgated decades ago. However, the extent of their adoption into bedside clinical practices is not known. The purpose of this study was to measure compliance with EBM guidelines for management of severe TBI and its impact on patient outcome.nnnMETHODSnThis was a retrospective study of blunt TBI (11 Level I trauma centers, study period 2008-2009, n = 2056 patients). Inclusion criteria were an admission Glasgow Coma Scale score ≤ 8 and a CT scan showing TBI, excluding patients with nonsurvivable injuries-that is, head Abbreviated Injury Scale score of 6. The authors measured compliance with 6 nonoperative EBM processes (endotracheal intubation, resuscitation, correction of coagulopathy, intracranial pressure monitoring, maintaining cerebral perfusion pressure ≥ 50 cm H2O, and discharge to rehabilitation). Compliance rates were calculated for each center using multivariate regression to adjust for patient demographics, physiology, injury severity, and TBI severity.nnnRESULTSnThe overall compliance rate was 73%, and there was wide variation among centers. Only 3 centers achieved a compliance rate exceeding 80%. Risk-adjusted compliance was worse than average at 2 centers, better than average at 1, and the remainder were average. Multivariate analysis showed that increased adoption of EBM was associated with a reduced mortality rate (OR 0.88; 95% CI 0.81-0.96, p < 0.005).nnnCONCLUSIONSnDespite widespread dissemination of EBM guidelines, patients with severe TBI continue to receive inconsistent care. Barriers to adoption of EBM need to be identified and mitigated to improve patient outcomes.

A consensus-based criterion standard for trauma center need.

BACKGROUND In civilian trauma care, field triage is the process applied by prehospital care providers to identify patients who are likely to have severe injuries and immediately need the resources of a trauma center. Studies of the efficacy of field triage have used various measures to define trauma center need because no “criterion standard” exists, making cross-study comparisons difficult. This study aimed to develop a consensus-based functional criterion standard definition of trauma center need. METHODS Local and national experts were recruited for participation. Blinded key informant interviews were conducted in order of availability until no new themes emerged. Themes identified during the interviews were used to develop a Modified Delphi survey, which was electronically delivered via Survey Monkey. The trauma center need criteria were refined iteratively based on participant responses. Participants completed additional surveys until there was at least 80% agreement for each criterion. RESULTS Fourteen experts were recruited. Five participated in key informant interviews. A Modified Delphi survey was administered five times (four modifications based on the expert’s responses). After the fifth round, there was at least 82% agreement on each criterion. The final definition included 10 time-specific indicators: major surgery, advanced airway, blood products, admission for spinal cord injury, thoracotomy, pericardiocentesis, cesarean delivery, intracranial pressure monitoring, interventional radiology, and in-hospital death. CONCLUSION We developed a consensus-based functional criterion standard definition of needing the resources of a trauma center, which may help to standardize field triage research and quality assurance in trauma systems as well as allow for cross study comparisons.

The Impact of Trauma-center Care on Mortality and Function Following Pelvic Ring and Acetabular Injuries

BACKGROUNDnLower mortality and improved physical function following major polytrauma have been associated with treatment at level-I trauma centers compared with that at hospitals without a trauma center (nontrauma centers). This study investigated the impact of trauma-center care on outcomes after pelvic and acetabular injuries.nnnMETHODSnMortality and quality-of-life-related scores were compared among patients treated in eighteen level-I trauma centers and fifty-one nontrauma centers in fourteen U.S. states. Complete data were obtained on 829 adult trauma patients (eighteen to eighty-four years old) who had at least one pelvic ring or acetabular injury (Orthopaedic Trauma Association [OTA] classification of 61 or 62). We used inverse probability of treatment weighting to adjust for observable confounding.nnnRESULTSnAfter adjusting for case mix, we found that, for patients with more severe acetabular injuries (OTA 62-B or 62-C), in-hospital mortality was significantly lower at trauma centers compared with nontrauma centers (relative risk [RR], 0.10; 95% confidence interval [CI], 0.02 to 0.47), as was death within ninety days (RR, 0.10; 95% CI, 0.02 to 0.47) and within one year (RR, 0.21; 95% CI, 0.06 to 0.76). Patients with combined pelvic ring and acetabular injuries treated at a trauma center had lower mortality at ninety days (RR, 0.34; 95% CI, 0.14 to 0.82) and at one year (RR, 0.30; 95% CI, 0.14 to 0.68). Care at trauma centers was also associated with mortality risk reduction for those with unstable pelvic ring injuries (OTA 61-B or 61-C) at one year (RR, 0.71; 95% CI, 0.24 to 0.91). Seventy-eight percent of included subjects discharged alive were available for interview at twelve months. For those with more severe acetabular injuries, average absolute differences in the Short Form-36 (SF-36) physical function component and the Musculoskeletal Function Assessment at one year were 11.4 (95% CI, 5.3 to 17.4) and 13.2 (1.7 to 24.7), respectively, indicating statistically and clinically significant improved outcomes following treatment at a trauma center for those patients.nnnCONCLUSIONSnMortality was reduced for patients with unstable pelvic and severe acetabular injuries when care was provided in a trauma center compared with a nontrauma center. Moreover, those with severe acetabular fractures experienced improved physical function at one year. Patients with these injuries represent a well-defined subset of trauma patients for whom our findings suggest preferential triage or transfer to a level-I trauma center.

Intra-abdominal injury following blunt trauma becomes clinically apparent within 9 hours

BACKGROUND The diagnosis of blunt abdominal trauma can be challenging and resource intensive. Observation with serial clinical assessments plays a major role in the evaluation of these patients, but the time required for intra-abdominal injury to become clinically apparent is unknown. The purpose of this study was to determine the amount of time required for an intra-abdominal injury to become clinically apparent after blunt abdominal trauma via physical examination or commonly followed clinical values. METHODS A retrospective review of patients who sustained blunt trauma resulting in intra-abdominal injury between June 2010 and June 2012 at a Level 1 academic trauma center was performed. Patient demographics, injuries, and the amount of time from emergency department admission to sign or symptom development and subsequent diagnosis were recorded. All diagnoses were made by computed tomography or at the time of surgery. Patient transfers from other hospitals were excluded. RESULTS Of 3,574 blunt trauma patients admitted to the hospital, 285 (8%) experienced intra-abdominal injuries. The mean (SD) age was 36 (17) years, the majority were male (194 patients, 68%) and the mean (SD) Injury Severity Score (ISS) was 21 (14). The mean (SD) time from admission to diagnosis via computed tomography or surgery was 74 (55) minutes. Eighty patients (28%) required either surgery (78 patients, 17%) or radiographic embolization (2 patients, 0.7%) for their injury. All patients who required intervention demonstrated a sign or symptom of their intra-abdominal injury within 60 minutes of arrival, although two patients were intervened upon in a delayed fashion. All patients with a blunt intra-abdominal injury manifested a clinical sign or symptom of their intra-abdominal injury, resulting in their diagnosis within 8 hours 25 minutes of arrival to the hospital. CONCLUSION All diagnosed intra-abdominal injuries from blunt trauma manifested clinical signs or symptoms that could prompt imaging or intervention, leading to their diagnosis within 8 hours 25 minutes of arrival to the hospital. All patients who required an intervention for their injury manifested a sign or symptom of their injury within 60 minutes of arrival. LEVEL OF EVIDENCE Therapeutic study, level IV. Epidemiologic study, level III.