Matthew J. Eckert

An analysis of in-hospital deaths at a modern combat support hospital

BACKGROUND Analysis of the epidemiology and attribution of in-hospital deaths is a critical component of learning and process improvement for any trauma center. We sought to perform a detailed analysis of in-hospital deaths at a combat support hospital. METHODS All patients with trauma who survived to admission and subsequently died before transfer or discharge during a 1-year period were included. The timing, location, pathogenesis, and circumstances surrounding the death were recorded. Opportunities for improvement (OI) of care were identified for analysis. Cases were presented to a panel of experts, and preventability of the deaths was scored on a continuous 10-point scale. RESULTS There were 151 deaths, with the predominant mechanisms of gunshot wounds (GSW) (47%) and blast injuries (42%). Most had severe injuries, with a mean Injury Severity Score of 38, pH of 7.09, and base deficit of 12. Predominant causes of death were head injury (45%) and hemorrhage (32%), and 78% died within 1 hour of admission. Most deaths occurred during the intensive care (35%) or resuscitation phases (31%), but the majority of deaths among nonexpectant patients occurred during the operative phase (38%). OI were identified in 74 deaths (49%), and were found in 78% of nonexpectant deaths. Most improvement opportunities occurred during the resuscitation and transport phases. Most potential improvements were identified at the system level (54%) or individual provider level (42%). Preventability scoring showed excellent inter-rater reliability (r = 0.92, p < 0.001). Deaths with high preventability scores (mean >54) were primarily related to delays in hemorrhage control during the transportation (47%) or resuscitation (43%) phases, and attributed to the system (63%) and individual provider levels (70%). CONCLUSIONS In-hospital combat trauma-related deaths at a modern Combat support hospital differ significantly from their civilian counterparts, and present multiple OI of care and potential salvage. Delays in prehospital and in-hospital hemorrhage control are the primary contributors to potential preventability.

Colonic ischemia complicating open vs endovascular abdominal aortic aneurysm repair

OBJECTIVE Colonic ischemia (CI) is a known complication of both open abdominal aortic aneurysm (AAA) repair and endovascular aneurysm repair (EVAR). Despite a relatively low incidence of 1% to 6%, the associated morbidity and mortality are high. We sought to analyze factors that affect the development of CI on the basis of type of repair as well as associated outcomes from a large nationwide database. METHODS All admissions undergoing AAA repair were selected from the 2003 and 2004 Nationwide Inpatient Sample. Univariate and logistic regression analyses were used to compare outcome measures and identify independent predictors of development of colonic ischemic complications. RESULTS We identified 89,967 admissions for AAA repair (mean age, 69.9 years). Open elective repair was performed in 49% of cases, elective EVAR in 41%, and ruptured aneurysm repair in 9%. The overall incidence of CI was 2.2% (1941 cases); however, the incidence for specific procedures was significantly higher after repair of ruptured aneurysm (8.9%) and open elective repair (1.9%) than after EVAR (0.5%; both P < .001). Patients who developed CI were at increased risk for mortality (37.8% vs 6.7%), had longer hospital stays (21.5 vs 8.1 days), incurred higher hospital charges (

Breast Papillomas in the Era of Percutaneous Needle Biopsy

182,000 vs

Changing Patterns of In-Hospital Deaths Following Implementation of Damage Control Resuscitation Practices in US Forward Military Treatment Facilities

77,000), and were less likely to be discharged home from hospital (36% vs 71%; all P < .001). Independent predictors of development of CI included ruptured aneurysm (odds ratio [OR] = 6.4), female gender (OR = 1.6) and, in the setting of elective repair, open operation (OR = 3.1). CI was found to be a strong independent predictor of mortality in evaluations of both the entire cohort (OR = 4.5) and the elective open repair and EVAR (OR = 2.4) subgroups. CONCLUSIONS CI is significantly more common after open AAA repair and is associated with increased morbidity and a two- to fourfold increase in mortality.

Atypical Ductal Hyperplasia: Improved Accuracy with the 11-Gauge Vacuum-Assisted versus the 14-Gauge Core Biopsy Needle

BackgroundThe significance of breast papillomas detected on core needle biopsy (CNB) remains unclear. While those associated with malignancy or atypia are excised, no clear solution exists for benign papillomas. We sought to determine the indication for surgical excision, incidence of malignancy, significance, and natural history.MethodsIn this retrospective review, patients were divided into benign, atypical, or malignant cohorts based on initial results. While patients with malignant or atypical features were encouraged to undergo surgical excision, no standard recommendation was given for benign papillomas. Mammographic features, method of initial diagnosis, pathology results, and follow-up data were analyzed.ResultsBetween January 1994 to December 2005, 5,257 CNBs were performed at our tertiary level medical center. 206 patients were diagnosed with 215 breast papillomas. 174 (81%) papillomas were benign, 26 (12%) were associated with atypia, and 15 (7%) were associated with malignancy. Two benign papillomas (1.1%) developed into cancer over an average of 53 months. Average follow-up of those patients not undergoing excision for benign papilloma was 41 months; we had 92 patients with greater than two year follow-up and 57 patients with greater than four year follow-up. Of patients with atypia or malignancy associated with papilloma, there was a 26% and 87% associated rate of malignancy, respectively.ConclusionsBenign breast papillomas diagnosed by CNB have a low risk of malignancy and do not need excision. However, they should be considered high risk lesions which require serial radiographic monitoring. Papillomas associated with atypia or malignancy should continue to be excised.

Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma and tranexamic acid study (PED-TRAX).

IMPORTANCE Analysis of combat deaths provides invaluable epidemiologic and quality-improvement data for trauma centers and is particularly important under rapidly evolving battlefield conditions. OBJECTIVE To analyze the evolution of injury patterns, early care, and resuscitation among patients who subsequently died in the hospital, before and after implementation of damage control resuscitation (DCR) policies. DESIGN, SETTING, AND PARTICIPANTS In a review of the Joint Theater Trauma Registry (2002-2011) of US forward combat hospitals, cohorts of patients with vital signs at presentation and subsequent in-hospital death were grouped into 2 time periods: pre-DCR (before 2006) and DCR (2006-2011). MAIN OUTCOMES AND MEASURES Injury types and Injury Severity Scores (ISSs), timing and location of death, and initial (24-hour) and total volume of blood products and fluid administered. RESULTS Of 57,179 soldiers admitted to a forward combat hospital, 2565 (4.5%) subsequently died in the hospital. The majority of patients (74%) were severely injured (ISS > 15), and 80% died within 24 hours of admission. Damage control resuscitation policies were widely implemented by 2006 and resulted in a decrease in mean 24-hour crystalloid infusion volume (6.1-3.2 L) and increased fresh frozen plasma use (3.2-10.1 U) (both P < .05) in this population. The mean packed red blood cells to fresh frozen plasma ratio changed from 2.6:1 during the pre-DCR period to 1.4:1 during the DCR period (P < .01). There was a significant increase in mean ISS between cohorts (pre-DCR ISS = 23 vs DCR ISS = 27; P < .05) and a marked shift in injury patterns favoring more severe head trauma in the DCR cohort. CONCLUSIONS AND RELEVANCE There has been a significant shift in resuscitation practices in forward combat hospitals indicating widespread military adoption of DCR. Patients who died in a hospital during the DCR period were more likely to be severely injured and have a severe brain injury, consistent with a decrease in deaths among potentially salvageable patients.

Efficacy of Three Topical Hemostatic Agents Applied by Medics in a Lethal Groin Injury Model

BackgroundPercutaneous stereotactic core needle biopsy (CNB) has become the primary diagnostic modality for evaluating nonpalpable, mammographically detected breast lesions. Atypical ductal hyperplasia (ADH) uncovered by CNB confers a significant risk of harboring an occult malignancy in the excisional biopsy specimen; therefore, we sought to determine the benefits of upsizing biopsy needles from 14- to 11-gauge.MethodsPatients with isolated ADH diagnosed by CNB were included for analysis in this retrospective review. Mammographic description, number of needle passes, pathology results, and follow-up data were analyzed and compared to our previously published institutional results with the 14-gauge needle.ResultsFrom June 1996 until July 2006, 4,579 CNBs were performed at our tertiary level medical facility. Seventy eight of 88 patients (89%) diagnosed with ADH on CNB with an 11-gauge vacuum-assisted needle underwent open surgical excision. Of these patients, nine (11%) were upgraded to ductal carcinoma in-situ (DCIS) while five (6%) had invasive cancer (IC), giving a total underestimation rate of 17%. These results differ from our previously published series of 14-gauge CNB which revealed an underestimation rate of 36%. Mean number of passes obtained at time of biopsy, mean age of patients, and characteristic radiographic abnormalities were similar for malignant and benign diagnoses.Conclusion11-gauge CNB technique reduces sampling error and improves accuracy, but does not eliminate the risk of missing an underlying malignancy. Surgical excision of ADH identified by CNB is required for definitive diagnosis.

A Simplified Set of Trauma Triage Criteria to Safely Reduce Overtriage: A Prospective Study

BACKGROUND Early administration of tranexamic acid (TXA) has been associated with a reduction in mortality and blood product requirements in severely injured adults. It has also shown significantly reduced blood loss and transfusion requirements in major elective pediatric surgery, but no published data have examined the use of TXA in pediatric trauma. METHODS This is a retrospective review of all pediatric trauma admissions to the North Atlantic Treaty Organization Role 3 hospital, Camp Bastion, Afghanistan, from 2008 to 2012. Univariate and logistic regression analyses of all patients and select subgroups were performed to identify factors associated with TXA use and mortality. Standard adult dosing of TXA was used in all patients. RESULTS There were 766 injured patients 18 years or younger (mean [SD] age, 11 [5] years; 88% male; 73% penetrating injury; mean [SD], Injury Severity Score [ISS], 10 [9]; mean [SD] Glasgow Coma Scale [GCS] score, 12 [4]). Of these patients, 35% required transfusion in the first 24 hours, 10% received massive transfusion, and 76% required surgery. Overall mortality was 9%. Of the 766 patients, 66 (9%) received TXA. The only independent predictors of TXA use were severe abdominal or extremity injury (Abbreviated Injury Scale [AIS] score ≥ 3) and a base deficit of greater than 5 (all p < 0.05). Patients who received TXA had greater injury severity, hypotension, acidosis, and coagulopathy versus the patients in the no-TXA group. After correction for demographics, injury type and severity, vitals, and laboratory parameters, TXA use was independently associated with decreased mortality among all patients (odds ratio, 0.3; p = 0.03) and showed similar trends for subgroups of severely injured (ISS > 15) and transfused patients. There was no significant difference in thromboembolic complications or other cardiovascular events. Propensity analysis confirmed the TXA-associated survival advantage and suggested significant improvements in discharge neurologic status as well as decreased ventilator dependence. CONCLUSION TXA was used in approximately 10% of pediatric combat trauma patients, typically in the setting of severe abdominal or extremity trauma and metabolic acidosis. TXA administration was independently associated with decreased mortality. There were no adverse safety- or medication-related complications identified. LEVEL OF EVIDENCE Therapeutic study, level IV.

Ventilator-associated pneumonia in injured patients: Do you trust your Gram's stain?

BACKGROUND Advanced topical hemostatic agents are increasingly utilized to control traumatic hemorrhage. We sought to determine the efficacy of three chitosan based hemostatic agents in a lethal groin injury model when applied by combat medic first responders. METHODS After creation of a standardized femoral artery injury in a goat model, medics attempted hemorrhage control with standard gauze dressing followed by randomization to one of three hemostatic agents in this two tiered study. In the first tier, medics were randomized to either a chitosan based one-sided wafer (OS) or a dual-sided, flexible, roll (DS). In the second tier, medics were randomized to the flexible DS dressing or a chitosan powder (CP). Efficacy of gauze, each chitosan agent, proper application, and participant surveys were obtained and included for analysis using univariate techniques. RESULTS From January 2007 to June 2007, 55 (45%) DS, 36 (29%) OS, and 32 (26%) CP agents were used to treat 123 actively bleeding arterial injuries in 62 animals. Standard gauze failed to stop hemorrhage in 122 (99%) groins. Although all three chitosan agents were marginally effective at 2 min, the recommended time for application, hemostasis improved after 4 min. The DS dressing was the most effective, controlling hemorrhage 76% at 4 min. Of the failures, 3 (23%) DS and 9 (53%) OS were due to improper application. End-user survey results demonstrated that medics preferred the DS dressing 77% and 60% over the OS and CP, respectively. CONCLUSIONS Chitosan based bandages are significantly more effective at hemorrhage control compared to standard gauze field dressings. The dual-sided chitosan dressing demonstrated better hemorrhage control than the one-sided dressing and the chitosan powder, and was less likely to fail despite application errors.

Incidence of low vitamin A levels and ocular symptoms after Roux-en-Y gastric bypass

BACKGROUND Many trauma systems have adopted complex triage algorithms that are difficult to use and contain poorly validated variables. OBJECTIVE To prospectively evaluate the performance of our institutions current triage system compared with a simplified system using only 4 highly predictive variables. DESIGN, SETTING, AND PATIENTS A prospective observational study of trauma patients in a 9-month period at an academic level II trauma center was undertaken. All trauma admissions were analyzed for the need for immediate emergency interventions or operative procedures. The accuracy and safety of the current triage system was compared with a simplified triage protocol using only 4 variables (hypotension, mental status, altered respirations, and penetrating truncal wound). Overtriage and undertriage rates were compared, and detailed analysis of all undertriaged patients was performed. MAIN OUTCOME MEASURES Rates of overtriage, undertriage, morbidity, and mortality. RESULTS There were 244 trauma team activations, with 21% requiring urgent intervention. Existing criteria produced an overtriage rate of 79%, an undertriage rate of 1%, and mistriage in 14%. Using the simplified criteria, the overtriage rate was reduced to 12% and the undertriage rate was increased to 4% (both P < .05). Undertriaged patients were all hemodynamically stable, with 4 requiring tube thoracostomy only and 4 undergoing nonemergent laparotomy (2 nontherapeutic laparotomies, 1 bladder repair, and 1 bowel mesenteric injury). There were no deaths among undertriaged patients with either system. CONCLUSIONS Using a simplified triage system can safely reduce the rate of overtriage. This could conserve resources, reduce mistriage from misunderstood guidelines, and improve specificity by including only those variables with high predictive value.