James M. Bardes

Evaluation and management of mild traumatic brain injury: An Eastern Association for the Surgery of Trauma practice management guideline

BACKGROUND An estimated 1.1 million people sustain a mild traumatic brain injury (MTBI) annually in the United States. The natural history of MTBI remains poorly characterized, and its optimal clinical management is unclear. The Eastern Association for the Surgery of Trauma had previously published a set of practice management guidelines for MTBI in 2001. The purpose of this review was to update these guidelines to reflect the literature published since that time. METHODS The PubMed and Cochrane Library databases were searched for articles related to MTBI published between 1998 and 2011. Selected older references were also examined. RESULTS A total of 112 articles were reviewed and used to construct a series of recommendations. CONCLUSION The previous recommendation that brain computed tomographic (CT) should be performed on patients that present acutely with suspected brain trauma remains unchanged. A number of additional recommendations were added. Standardized criteria that may be used to determine which patients receive a brain CT in resource-limited environments are described. Patients with an MTBI and negative brain CT result may be discharged from the emergency department if they have no other injuries or issues requiring admission. Patients taking warfarin who present with an MTBI should have their international normalized ratio (INR) level determined, and those with supratherapeutic INR values should be admitted for observation. Deficits in cognition and memory usually resolve within 1 month but may persist for longer periods in 20% to 40% of cases. Routine use of magnetic resonance imaging, positron emission tomography, nuclear magnetic resonance, or biochemical markers for the clinical management of MTBI is not supported at the present time.

Hepatic artery pseudoaneurysm: Delayed presentation after bicycle accident

A13-year-old boy presented to the emergency department with hematemesis. Nine days earlier, the patient was involved in a bicycle accident during which the handlebars struck against his right lower rib cage. He was seen at an outside facility complaining only of rib pain. Plain films were negative for traumatic abnormality. He was discharged home from the emergency room on that day. On posttrauma day 6, he returned to the outside facility complaining of hematemesis. An nasogastric tube returned heme-positive fluid, but no gross blood. Abdominal computed tomography (CT) showed hepatic laceration and a hematoma. He was sent home with instructions to rest. On posttrauma day 9, he experienced another episode of hematemesis, now with visible clots. He was referred to our facility for evaluation. He denied other complaints including melena. Abdomen was soft and mildly tender in the right upper quadrant. Rectal examination had no gross blood but hemepositive stool. He was not jaundiced. Medical history was significant for ADHD and OCD. He was taking Paxil-CR, Trazodone, and Focalin. There was no significant family or social history. CBC demonstrated anemia with Hgb/Hct of 10/28, total and conjugated bilirubin of 6 and 3.6, respectively, AST 252, and ALT 316. A CT of the abdomen was done (Fig. 1). CT revealed a grade III liver laceration and blood clots within the gallbladder lumen and mild intrahepatic biliary duct dilatation. On the basis of these findings, the working diagnosis was hemobilia secondary to trauma. He was admitted to the pediatric trauma service. He was made nothing by mouth and placed on maintenance fluids. The next day he was taken to interventional radiology for evaluation of hepatic blood supply. Hepatic arteriogram revealed a pseudoaneurysm of the superior branch of the right hepatic artery and no active extravasation (Fig. 2). Two coils were placed in the pseudoaneurysm. He was taken to the PICU for monitoring. Daily laboratory values showed gradual improvement of his liver function tests. On posttrauma day 13, he was discharged. Follow-up CT demonstrated unchanged embolization coils and a resolving hematoma. Hepatic artery pseudoaneurysm is a rare but serious condition. It can be seen after acute surgical injury, chronic damage, or most commonly after trauma. The presentation of symptoms may vary. They can present clinically silent or as massive hemorrhage. As in this case, signs of upper or lower gastrointestinal bleeding can be present. The majority of pseudoaneurysms are extrahepatic and occur in the right hepatic artery. The diagnosis is most commonly made with contrast-enhanced CT; however, this was not the case with our patient.1 Maintaining a high index of suspicion is important if a focally enhancing region of high attenuation is noted within a vascular structure.2 The sensitivity for CT has been found to be only 67%. Selective angiography is 100% sensitive.3 It has been suggested that if the initial CT suggests a hepatic pseudoaneurysm, then the patient should be taken for angiography.1 This allows for confirmation of the injury, and intervention can begin immediately. As a result, most of these cases are treated nonoperatively. If not treated, there is potential for delayed rupture and subsequent hemorrhage. Other possible complications include enteric fistula formation and infection or abscess formation.2

The Use of Radiofrequency Detection to Mitigate the Risk of Retained Surgical Sponges

Retained surgical sponges are a preventable complication that occurs in approximately 1 out of every 8000 operations. The risk of a retained surgical sponge increases with body mass index, emergent surgery, unplanned changes in procedure or unexpected intraoperative events, large intraoperative blood loss volumes, long duration of surgery, and the need for multiple operative teams. Risk increases 100-fold if there is a count discrepancy at the end of a procedure. Intraoperative radiography is only 67% sensitive for a retained surgical sponge. Use of a radiofrequency detection system reduces the risk of a retained surgical sponge and assists with count reconciliation.

A team approach to effectively discharge trauma patients

BACKGROUND Trauma patients represent a high-volume and high-acuity population. This makes discharge planning difficult. Discharged by noon is a metric shown to correlate with hospital throughput. Improvements in efficiency will be needed to improve resource utilization and increase discharge by noon rate. This study aimed to evaluate the impact of a standardized discharge team on length of stay and discharge by noon. MATERIALS AND METHODS A university level I trauma center implemented a discharge team composed of a trauma attending and an advanced practice provider. This team is tasked with evaluating patients on the discharge list daily. This allowed patients ready for discharge to be evaluated and discharged before noon. A retrospective review was performed to analyze discharge by noon rates before and after implementation of the discharge team. RESULTS A total of 3053 patients were discharged before the implementation of the discharge team and 3801 after. Discharges by noon increased from 25.5% to 51.2% in the post. For patients with an injury severity score >15, this same improvement was seen, 22.5% to 51.9%. Similar improvements were seen when controlling for final discharge disposition and primary payer status. CONCLUSIONS By establishing a separate discharge team, large improvements can be seen in the discharge by noon rate. These improvements were maintained when controlling for injury severity score, final discharge disposition, and insurance status. Significant savings are possible in both charges to the patient and direct costs to the facility. The utilization of a discharge team should be considered at similar facilities.

Severe traumatic brain injuries in children: Does the type of trauma center matter?

BACKGROUND Traumatic brain injury (TBI) is the leading cause of death among injured children. Depending on geographic location, and trauma resources, pediatric patients may be treated at pediatric (PTC), adult (ATC), or mixed trauma centers (MTC). The effect of the type of trauma center on outcomes in severe TBI is not known. METHODS NTDB study (2007-2014), level 1 trauma centers, patients ≤14years with severe isolated TBI (head AIS≥3 and extracranial AIS≤2). Demographic, clinical and injury characteristics were abstracted. Logistic regression was used to compare outcomes between the three types of trauma centers. RESULTS 10,402 patients met inclusion criteria. 4430 (42.6%) were admitted in PTC, 4044 (38.9%) in ATC and 1928 (18.5%) in MTC. Overall, 39.9% of patients had head AIS 3, 55.5% had AIS 4 and 4.6% AIS 5. Mortality was 3.2% (2.0% in PTC, 4.5% in ATC and 3.3% in MTC). On logistic regression, treatment at ATC was associated with significantly higher mortality than PTC (OR 1.55, p=0.011). There was no significant difference between PTC and MTC (p=0.394). There was no significant difference in mortality between the 3 types of trauma centers in the subgroups of patients with head AIS 3 or 5. However, patients with head AIS 4 treated at MTC had significantly lower mortality (OR 0.163, 95% CI 0.053-0.501, p=0.002). CONCLUSION Patients with isolated severe TBI treated at PTC have significantly better survival than patients treated at ATC, but not MTC. In the subgroup of patients with isolated TBI and a head AIS score of 4, patients treated at MTC have improved survival than those treated at PTC. LEVEL OF EVIDENCE III.

Foreign Body Retained in the Esophagus for More Than a Decade: Thoracic Esophagotomy for Retrieval

A foreign body (FB) lodged in the esophagus is not uncommon. Although endoscopic removal is successful in the majority of cases, it could prove to be difficult in those whose foreign bodies are large or have been incarcerated for a long time. We describe the case of a 23-year-old woman who had a FB in her esophagus for at least 13 years. She became symptomatic 2 years before presentation, but presented for treatment when dysphagia to both solids and liquids developed. Endoscopic retrieval of the incarcerated FB was unsuccessful, and she eventually required thoracotomy and esophagotomy for its extraction.

Thyroid Hormone Abnormalities

Thyroid hormone is a permissive hormone with action throughout the body, and dysregulation of thyroid hormone can have significant clinical effects. It is imperative for the treating physician to have a clear understanding of the presentation and clinical consequences of these abnormalities in order to provide timely and effective treatment. This chapter presents an overview of common thyroid disease in the ICU including sick euthyroid syndrome, thyroiditis, hyperthyroidism, and hypothyroidism. The rare, but life-threatening, conditions, thyroid storm and myxedema coma, are also reviewed, as are initial treatment regimens. Finally, the use of thyroid hormone after brain death is discussed.

Surgical Trends in the Management of Duodenal Injury

BackgroundSurgical management of traumatic duodenal injury remains challenging. While various surgical techniques have been described in the attempt to reduce complications and mortality, recent data suggests that surgical approach using less invasive procedures might be associated with improved patient outcomes. The purpose of this study was to determine the recent trend of surgical procedures performed for patients with duodenal injury and their outcome.MethodsA retrospective analysis of the National Trauma Data Bank (NTDB) from 2002 to 2014 was performed. A total of 2163 patients who sustained a traumatic duodenal injury requiring surgical intervention were included. Patient characteristics, injury data, procedures, and outcomes were examined. Types of duodenal procedures and patient outcomes were compared between two study periods (2002–2006 vs. 2007–2014).ResultsThe median age was 27 (IQR 20–39), 78.9% were male, and 63.8% sustained penetrating duodenal injury. The median injury severity score was 18 (IQR 13–26). In patients with isolated duodenal injury, the later study period (2007–2014) was significantly associated with the increased use of primary repair (OR 1.77; 95% CI 1.11–2.83, p = 0.017). Overall mortality was 11.7%. Patients in the later study group were significantly associated with lower odds of inhospital mortality (OR 0.47, 95% CI 0.22–0.95, p = 0.041).ConclusionsA progressive trend toward less invasive procedures for duodenal injury was noted in the current study. Inhospital mortality has improved in the late study period.

Antifibrinolytics in a rural trauma state: assessing the opportunities

Background Tranexamic acid (TXA) has demonstrated improved mortality among trauma patients. However, recent evidence from urban US trauma centers has failed to show a benefit among the civilian population. TXA in rural states has not been evaluated. This study aimed to evaluate the current use of TXA in the rural trauma population. Methods A retrospective observational review at a level 1 trauma center based in a rural environment. Records were reviewed for TXA indications. TXA indication was defined as: systolic blood pressure <90 mm Hg, blood transfusion, or with a clinical concern for ongoing bleeding. Patients were ineligible if the time since injury was >3 hours. Results 400 patients were evaluated. 54% of patients met indications for TXA. 14% of these received TXA. 30.4% with an indication for TXA were ineligible due to arrival beyond 3 hours from time of injury. 135 patients arrived as transfers, 265 from the scene. There was no difference in TXA indications between scene and transfers (73 vs 144, p=1). Transfers were more likely to arrive beyond the 3-hour window (59 vs 7, p=0.001). Mortality for patients treated with TXA was 12.5%. This was not significantly different from patients not treated with TXA (19%). Discussion In a rural system, long transfers exclude most patients from treatment with TXA. A multicenter rural trauma center study will be needed to better define the optimal use of TXA in rural populations. Level of evidence Level IV data: therapeutic/care management.

Defining the gastroesophageal junction in trauma: Epidemiology and management of a challenging injury

BACKGROUND Injuries to the gastroesophageal (GE) junction are infrequently encountered because of the high mortality of associated injuries. Consequently, there is a paucity of literature on the patient demographics and treatment options. The aim of this study was to examine the epidemiology, surgical management, and outcomes of these rare injuries. METHODS Patients presenting to LAC + USC Medical Center (January 2008 to August 2016) with traumatic esophageal or gastric injury (DRG International Classification of Diseases—9th Rev.—Clinical Modification and 10th Rev. codes) were extracted from the trauma registry. Patient charts were reviewed, and all patients who sustained an injury to the GE junction were enrolled. Patient demographics, injury characteristics, procedures, and outcomes were analyzed. RESULTS Of the 238 patients who sustained an injury to the esophagus or stomach during the study period, 28 (12%) were found to have a GE junction injury. Mean age was 26 years (range, 14–57 years), 89% male. Mechanism of injury was penetrating in 96% (n = 27), the majority of which were gunshot wounds (n = 22, 81%). Most patients (n = 18, 64%) were taken directly to the operating room. Ten (36%) underwent computed tomography scan before going to the operating room, all demonstrating a GE junction injury. All patients underwent repair via laparotomy. One (4%) also required thoracotomy to facilitate delayed reconstruction. GE junction injuries were typically managed with primary repair (n = 22, 79%). Associated injuries were frequent (n = 26, 93%), and injury severity was high (mean Injury Severity Score, 25 [9–75]). Mortality was 25% (n = 7), and all patients required intensive care unit admission. Most did not require total parenteral nutrition (n = 25, 89%) or a surgically placed feeding tube (n = 26, 93%). Of the 13 patients who presented for clinical follow-up, all but one (n = 12, 92%) were eating independently by the first clinic visit. CONCLUSION GE junction injuries are uncommon and occur almost exclusively after penetrating trauma. Patients are severely injured with a high mortality rate and frequently have associated intracavitary injuries. Most can be fixed through the abdomen alone and do not require thoracotomy for repair. Despite the severity of injuries, the majority of survivors are eating independently by the first clinic visit. LEVEL OF EVIDENCE Epidemiological, level V.