Julie Wynne

Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture--update and systematic review.

BACKGROUND Hemorrhage from pelvic fracture is common in victims of blunt traumatic injury. In 2001, the Eastern Association for the Surgery of Trauma (EAST) published practice management guidelines for the management of hemorrhage in pelvic trauma. Since that time there have been new practice patterns and larger experiences with older techniques. The Practice Guidelines Committee of EAST decided to replace the 2001 guidelines with an updated guideline and systematic review reflecting current practice. METHODS Building on the previous systematic literature review in the 2001 EAST guidelines, a systematic literature review was performed to include references from 1999 to 2010. Prospective and retrospective studies were included. Reviews and case reports were excluded. Of the 1,432 articles identified, 50 were selected as meeting criteria. Nine Trauma Surgeons, an Interventional Radiologist, and an Orthopedic Surgeon reviewed the articles. The EAST primer was used to grade the evidence. RESULTS Six questions regarding hemorrhage from pelvic fracture were addressed: (1) Which patients with hemodynamically unstable pelvic fractures warrant early external mechanical stabilization? (2) Which patients require emergent angiography? (3) What is the best test to exclude extrapelvic bleeding? (4) Are there radiologic findings which predict hemorrhage? (5) What is the role of noninvasive temporary external fixation devices? and (6) Which patients warrant preperitoneal packing? CONCLUSIONS Hemorrhage due to pelvic fracture remains a major cause of morbidity and mortality in the trauma patient. Strong recommendations were made regarding questions 1 to 4. Further study is needed to answer questions 5 and 6.

Predicting hospital discharge disposition in geriatric trauma patients: is frailty the answer?

BACKGROUND The frailty index (FI) has been shown to predict outcomes in geriatric patients. However, FI has never been applied as a prognostic measure after trauma. The aim of our study was to identify hospital admission factors predicting discharge disposition in geriatric trauma patients. METHODS We performed a 1-year prospective study at our Level 1 trauma center. All trauma patients 65 years or older were enrolled. FI was calculated using 50 preadmission variables. Patient’s discharge disposition was dichotomized as favorable outcome (discharge home, rehabilitation) or unfavorable outcomes (discharge to skilled nursing facility, death). Multivariate logistic regression was performed to identify factors that predict unfavorable outcome. RESULTS A total of 100 patients were enrolled, with a mean (SD) age of 76.51 (8.5) years, 59% being males, median Injury Severity Score (ISS) of 14 (range, 9–18), median head Abbreviated Injury Scale (h-AIS) score of 2 (2–3), and median Glasgow Coma Scale (GCS) score of 13 (12–15). Of the patients, 69% had favorable outcome, and 31% had unfavorable outcome. On univariate analysis, FI was found to be a significant predictor for unfavorable outcome (odds ratio, 1.8; 95% confidence interval, 1.2–2.3). After adjusting for age, ISS, and GCS score in a multivariate regression model, FI remained a strong predictor for unfavorable discharge disposition (odds ratio, 1.3; 95% confidence interval, 1.1–1.8). CONCLUSION The concept of frailty can be implemented in geriatric trauma patients with similar results as those of nontrauma and nonsurgical patients. FI is a significant predictor of unfavorable discharge disposition and should be an integral part of the assessment tools to determine discharge disposition for geriatric trauma patients. LEVEL OF EVIDENCE Prognostic study, level II.

Damage control laparotomy: a vital tool once overused.

BACKGROUND Trauma surgery is in constant evolution as is the use of damage control laparotomy (DCL). The purpose of this study was to report the change in usage of DCL over time and its effect on outcome. METHODS Trauma patients requiring laparotomies during a 3-year (2006-2008) period were reviewed. DCL was defined as laparotomy when fascia was not closed at the first operation. RESULTS There were 14,534 trauma patients evaluated, and 843 laparotomies were performed on 532 patients during the study period. The number of patients requiring open laparotomies slightly increased while the demographics and Injury Severity Score were similar during the study period. The number of patient requiring DCL significantly decreased from 36.3% (53 of 146) in 2006 to 8.8% (15 of 170) in 2008 (p < 0.001). During this same time period, the mortality rate for patients requiring open laparotomy significantly decreased from 21.9% in 2006 to 12.9% in 2008 (p = 0.05). The decreased use of DCL resulted in a 33.3% reduction in the number of laparotomies performed. The decrease in average costs and charges is projected to result in savings of

Initial experiences and outcomes of telepresence in the management of trauma and emergency surgical patients

2.2 million and

Prothrombin complex concentrate: an effective therapy in reversing the coagulopathy of traumatic brain injury.

5.8 million, respectively. CONCLUSIONS The use of DCL was significantly decreased by 78% during the study with significantly improved outcome. The improved outcome and decreased resource utilization can reduce health care costs and charges. Although DCL may be a vital aspect of trauma surgery, it can be used more selectively with improved outcome.

Factor IX complex for the correction of traumatic coagulopathy.

BACKGROUND Teletrauma programs allow rural patients access to advanced trauma and emergency medical services that are often limited to urban areas. METHODS A retrospective analysis of 59 teleconsults between 5 rural hospitals and a level I trauma center was performed. The objectives of this study were to report the initial experience with a telemedicine program connecting 5 rural hospitals with a level I trauma center. RESULTS A total of 59 trauma and general surgery patients were evaluated. Of those, 35 (59%) were trauma patients, and 24 (41%) were general surgery patients. Fifty patients (85%) were from the first hospital at which teletrauma was established. For 6 patients, the teletrauma consults were considered potentially lifesaving; 17 patients (29%) were kept in the rural hospitals (8 trauma and 9 general surgery patients). Treating patients in the rural hospitals avoided transfers, saving an average of

Improving Survival Rates after Civilian Gunshot Wounds to the Brain

19,698 per air transport or

The BIG (brain injury guidelines) project: defining the management of traumatic brain injury by acute care surgeons.

2,055 per ground transport. CONCLUSIONS The telepresence of a trauma surgeon aids in the initial evaluation, treatment, and care of patients, improving outcomes and reducing the costs of trauma care.

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

BACKGROUND Coagulopathy in patients with traumatic brain injury (TBI) is a well-studied concept. Prothrombin complex concentrate (PCC) has been shown to be an effective treatment modality for correction of TBI coagulopathy. However, its use and effectiveness compared with recombinant factor VII (rFVIIa) in TBI has not been established. The purpose of this study was to compare PCC and rFVIIa for the correction of TBI coagulopathy. METHODS All patients with a TBI and an induced or acquired coagulopathy whom received rFVIIa or PCC at our Level I trauma center during a 4-year period were reviewed. Data collected included demographics, changes in international normalized ratio and blood products transfusion, craniotomy rates, and time to neurosurgical intervention, thromboembolic complications, and mortality differences. RESULTS The study was composed of 85 TBI patients, of whom 64 patients received PCC while 21 patients received rFVIIa. PCC group were more likely to be on coumadin (44% vs. 14%, p = 0.01). There was a significant decline in packed red blood cell transfusion and fresh frozen plasma after PCC administration (p < 0.01). There was no statistically significant difference in the craniotomy rate (28% vs. 10 %, p = 0.1) or the mean time to intervention between the two groups (201 [33] vs. 230 [10], p = 0.9). Mortality rates were lower in the PCC group compared with rFVIIa (67% vs. 47%, p = 0.02). Subsequent thromboembolic event was seen in one patient on rFVIIa. Mean cost of treatment per patient on PCC was

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

1,007 compared with