Laura F. Teisch

Decreased mortality after prehospital interventions in severely injured trauma patients.

BACKGROUND We test the hypothesis that prehospital interventions (PHIs) performed by skilled emergency medical service providers during ground or air transport adversely affect outcome in severely injured trauma patients. METHODS Consecutive trauma activations (March 2012 to June 2013) transported from the scene by air or ground emergency medical service providers were reviewed. PHI was defined as intubation, needle decompression, tourniquet, cricothyroidotomy, or advanced cardiac life support. RESULTS In 3,733 consecutive trauma activations (71% blunt, 25% penetrating, 4% burns), age was 39 years, 74% were male, Injury Severity Score (ISS) was 5, and Glasgow Coma Score (GCS) was 15, with 32% traumatic brain injury (TBI) and 7% overall mortality. Those who received PHI (n = 130, 3.5% of the trauma activations) were more severely injured: ISS (26 vs. 5), GCS (3 vs. 15), TBI (57% vs. 31%), Revised Trauma Score (RTS, 5.45 vs. 7.84), Trauma and Injury Severity Score (TRISS, 1.32 vs. 4.89), and mortality (56% vs. 5%) were different (all p < 0.05) than those who received no PHI. Air crews transported 22% of the patients; more had TBI, blunt injury, high ISS, and long prehospital times (all p < 0.05), but mortality was similar to those transported by ground. In the most severely injured patients with signs of life who received a PHI, the ISS, prehospital times, and proportions of TBI, blunt trauma, and air transport were similar, but mortality was significantly lower (43% vs. 23%, p= 0.021). CONCLUSION In our urban trauma system, PHIs are associated with a lower incidence of mortality in severely injured trauma patients and do not delay transport to definitive care. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III; therapeutic study, level IV.

Association Between American Board of Surgery In-Training Examination Scores and Resident Performance

IMPORTANCE The American Board of Surgery In-Training Examination (ABSITE) is designed to measure progress, applied medical knowledge, and clinical management; results may determine promotion and fellowship candidacy for general surgery residents. Evaluations are mandated by the Accreditation Council for Graduate Medical Education but are administered at the discretion of individual institutions and are not standardized. It is unclear whether the ABSITE and evaluations form a reasonable assessment of resident performance. OBJECTIVE To determine whether favorable evaluations are associated with ABSITE performance. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional analysis of preliminary and categorical residents in postgraduate years (PGYs) 1 through 5 training in a single university-based general surgery program from July 1, 2011, through June 30, 2014, who took the ABSITE. EXPOSURES Evaluation overall performance and subset evaluation performance in the following categories: patient care, technical skills, problem-based learning, interpersonal and communication skills, professionalism, systems-based practice, and medical knowledge. MAIN OUTCOMES AND MEASURES Passing the ABSITE (≥30th percentile) and ranking in the top 30% of scores at our institution. RESULTS The study population comprised residents in PGY 1 (n = 44), PGY 2 (n = 31), PGY 3 (n = 26), PGY 4 (n = 25), and PGY 5 (n = 24) during the 4-year study period (N = 150). Evaluations had less variation than the ABSITE percentile (SD = 5.06 vs 28.82, respectively). Neither annual nor subset evaluation scores were significantly associated with passing the ABSITE (n = 102; for annual evaluation, odds ratio = 0.949; 95% CI, 0.884-1.019; P = .15) or receiving a top 30% score (n = 45; for annual evaluation, odds ratio = 1.036; 95% CI, 0.964-1.113; P = .33). There was no difference in mean evaluation score between those who passed vs failed the ABSITE (mean [SD] evaluation score, 91.77 [5.10] vs 93.04 [4.80], respectively; P = .14) or between those who received a top 30% score vs those who did not (mean [SD] evaluation score, 92.78 [4.83] vs 91.92 [5.11], respectively; P = .33). There was no correlation between annual evaluation score and ABSITE percentile (r(2) = 0.014; P = .15), percentage correct unadjusted for PGY level (r(2) = 0.019; P = .09), or percentage correct adjusted for PGY level (r(2) = 0.429; P = .91). CONCLUSIONS AND RELEVANCE Favorable evaluations do not correlate with ABSITE scores, nor do they predict passing. Evaluations do not show much discriminatory ability. It is unclear whether individual resident evaluations and ABSITE scores fully assess competency in residents or allow comparisons to be made across programs. Creation of a uniform evaluation system that encompasses the necessary subjective feedback from faculty with the objective measure of the ABSITE is warranted.

Admission Hyperglycemia Predicts Infectious Complications After Burns.

Inflammation and hypermetabolism post burn predisposes to hyperglycemia and insulin resistance. The authors hypothesize that admission hyperglycemia predicts infectious outcomes. A retrospective review of all patients greater than 20 years of age admitted for initial burn management from January 2008 to December 2013 was conducted. Nonthermal injuries, transfers, and those without admission glucose or histories were excluded. Hyperglycemia was defined as admission glucose ≥150 mg/dl. Patients were grouped as follows: euglycemic without diabetes (control), euglycemic with diabetes (−H+D), hyperglycemic without diabetes (+H−D), and hyperglycemic with diabetes (+H+D). Outcomes included infection, mortality, length of stay, and disposition. Comparisons were made using Fisher’s exact test and multiple logistic regression. A total of 411 patients were analyzed. No significant differences between any of the groups and controls were noted in race, inhalation injury, or obesity. All three groups had higher mortality compared with controls. Longer hospital stays were noted only in +H−D. +H−D and +H+D were less likely to be discharged home than controls. +H−D had higher rates of bacteremia, +H−D and +H+D had higher rates of pneumonia, and −H+D and +H−D had higher rates of urinary tract infection. Regression for infection and mortality outcomes with TBSA, age, diabetes, hyperglycemia, obesity, race, gender, and inhalation injury as covariates was performed. Hyperglycemia was the only independent predictor of bacteremia (area under curve [AUC] = 0.736). Hyperglycemia was also a predictor of pneumonia and urinary tract infection (AUC = 0.766 and 0.802, respectively). The only independent predictors of mortality were age, TBSA, and inhalation injury (AUC = 0.892). Acute glucose dysregulation may be more important than diabetes in predicting infectious outcomes after burns. Therefore, admission glucose may have prognostic value.

Pediatric vascular injury: experience of a level 1 trauma center.

BACKGROUND Our purpose was to analyze modern major vascular injury (MVI) patterns in pediatric trauma, interventions performed, and outcomes at a level 1 trauma center. MATERIALS AND METHODS From January 2000-December 2012, all pediatric admissions (≤17 y) were reviewed. RESULTS Of 1928 pediatric admissions, 103 (5.3%) sustained MVI. This cohort was 85% male, age 15 ± 3 y, 55% black, 58% penetrating, injury severity score of 23 ± 15, with a length of stay of 8 (5) days. Firearm-related injury (47%) was the most common mechanism. Location of injuries included the extremities (50.5%), abdomen/pelvis (29.1%), and chest/neck (20.4%). Operative procedures included repair/bypass (71.4%), ligation (12.4%), amputation (10.5%), or temporary shunt (2.9%). Only three injuries (2.9%) were treated endovascularly. MVI patients had a mortality rate of 19.4%, higher than the overall pediatric trauma population of 3.5% (P < 0.001). After logistic regression, independent risk factors of mortality were vascular injury to the neck (odds ratio [OR]: 6.5; confidence interval (CI): 1.1-39.3), abdomen/pelvis (OR: 16.3; CI: 3.13-80.2), and chest (OR: 49.0; CI: 3.0-794.5). CONCLUSIONS MVI in children more commonly results from firearm-related injury. The mortality rate associated with MVI is profoundly higher than that of the overall pediatric trauma population. These findings underscore the major public health concern of firearm-related injury in children.

Spontaneous pneumomediastinum, pneumopericardium and epidural pneumatosis: insights on clinical management.

Abstract Spontaneous pneumomediastinum is a benign condition that has been reported, however the association with epidural pneumatosis is much less common. A 27-year-old male presented with concomitant air in the epidural space, mediastinum and pericardium after illicit drug use and engagement in sexual activity. The patient was hemodynamically stable. Non-invasive tests ruled out aerodigestive injury. The patient was discharged after a short observation without intervention. Invasive and potentially risky diagnostic tests may be safely avoided in patients who remain asymptomatic with this unique presentation.

Scald Burns From Hair Braiding.

Only one previous case report has described scald burns secondary to hair braiding in pediatric patients. The present case study is the largest to date of scald burns as a result of hair braiding in children and adults. Charts of all 1609 female patients seen at a single burn center from 2008 to 2014 were retrospectively reviewed to identify patients with scald burns attributed to hair braiding. Demographics, injury severity, injury patterns, and complications were analyzed. Twenty-six patients (1.6%) had scald burns secondary to hair braiding with median TBSA 3%. Eighty-five percent of patients were pediatric with median age 8 years. Injury patterns were as follows: back (62%), shoulder (31%), chest (15%), buttocks (15%), abdomen (12%), arms (12%), neck (12%), and legs (4%). No patients required operative intervention. Three patients were admitted to the hospital. Two patients required time off from school for 6 and 10 days post burn for recovery. Complications included functional limitations (n = 2), hypertrophic scarring (n = 1), cellulitis requiring antibiotics (n = 1), and anxiety requiring medical/psychological therapy (n = 2). This peculiar mechanism of injury not only carries inherent morbidity that includes the risks of functional limitations, infection, and psychological repercussions but also increases usage of resources through hospital admissions and multiple clinic visits. Further work in the form of targeted outreach programs is necessary to educate the community regarding this preventable mechanism of injury.