Mazhar Khalil

Shock index predicts mortality in geriatric trauma patients: an analysis of the National Trauma Data Bank

BACKGROUND Heart rate and systolic blood pressure are unreliable in geriatric trauma patients. Shock index (SI) (heart rate/systolic blood pressure) is a simple marker of worse outcomes after injury. The aim of this study was to assess the utility of SI in predicting outcomes. We hypothesized that SI predicts mortality in geriatric trauma patients. METHODS We performed a 4-year (2007–2010) retrospective analysis using the National Trauma Data Bank. Patients 65 years or older were included. Transferred patients, patients dead on arrival, missing vitals on presentation, and patients with burns and traumatic brain injury were excluded. A cutoff value of SI greater than or equal to 1 (sensitivity, 81%; specificity, 79%) was used to define hemodynamic instability. The primary outcome measure was mortality. Secondary outcome measures were need for blood transfusion, need for exploratory laparotomy, and development of in-hospital complications. Multiple logistic regressions were performed. RESULTS A total of 485,595 geriatric patients were reviewed, of whom 217,190 were included. The mean (SD) age was 77.7 (7.1) years, 60% were males, median Glasgow Coma Scale (GCS) score was 14 (range, 3–15), median Injury Severity Score (ISS) was 9 (range, 4–18), and mean (SD) SI was 0.58 (0.18). Three percent (n = 6,585) had an SI greater than or equal to 1. Patients with SI greater than or equal to 1 were more likely to require blood product requirement (p = 0.001), require an exploratory laparotomy (p = 0.01), and have in-hospital complications (p = 0.02). The overall mortality rate was 4.1% (n = 8,952). SI greater than or equal to 1 was the strongest predictor for mortality (odds ratio, 3.1; 95% confidence interval, 2.6–3.3; p = 0.001) in geriatric trauma patients. Systolic blood pressure (p = 0.09) and heart rate (p = 0.2) were not predictive of mortality. CONCLUSION SI is an accurate and specific predictor of morbidity and mortality in geriatric trauma patients. SI is superior to heart rate and systolic blood pressure for predicting mortality in geriatric trauma patients. Geriatric trauma patients with SI greater than or equal to 1 should be transferred to a Level 1 trauma center. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

Certified acute care surgery programs improve outcomes in patients undergoing emergency surgery: A nationwide analysis.

BACKGROUND Differences in outcomes among trauma centers (TCs) and non-TCs (NTCs) in patients undergoing emergency general surgery (EGS) are well established. However; the impact of development of certified acute care surgery (ACS) programs on patient outcomes remains unknown. The aim of this study was to evaluate outcomes in patients undergoing EGS across TCs, NTCs, and TCs with ACS (ACS-TC). METHODS National estimates for EGS procedures were abstracted from the National Inpatient Sample database. Patients undergoing emergent procedures (appendectomy, cholecystectomy, hernia repair, as well as small and large bowel resections) were included. TCs were identified based on American College of Surgeons’ verification. ACS-TC programs were recorded from the American Association for the Surgery of Trauma. Outcome measures were hospital length of stay, complications, and mortality. Regression analysis was performed after adjusting for age, sex, race, Charlson comorbidity index, and type of procedure. RESULTS A total of 131,410 patients undergoing EGS were analyzed. Patients managed in ACS-TCs had shorter hospital stay (p = 0.045) and lower complication rate (p = 0.041) compared with patients managed in both TCs and NTCs. There was no difference in mortality in patients managed across the groups; however, there was a trend toward lower mortality in patients managed in ACS-TCs in comparison with TCs (p = 0.064) and NTCs (p = 0.089). The overall hospital costs were lower for patients managed in ACS-TCs compared with TCs (p = 0.036). CONCLUSION TCs with ACS have improved outcomes in EGS procedures compared with both TCs and non-TCs. ACS training with the associated infrastructure standards may contribute to these improved outcomes. LEVEL OF EVIDENCE Therapeutic/care management study, level IV.

Overuse of helicopter transport in the minimally injured: A health care system problem that should be corrected

BACKGROUND Mortality benefit has been demonstrated for trauma patients transported via helicopter but at great cost. This study identified patients who did not benefit from helicopter transport to our facility and demonstrates potential cost savings when transported instead by ground. METHODS We performed a 6-year (2007–2013) retrospective analysis of all trauma patients presenting to our center. Patients with a known mode of transfer were included in the study. Patients with missing data and those who were dead on arrival were excluded from the study. Patients were then dichotomized into helicopter transfer and ground transfer groups. A subanalysis was performed between minimally injured patients (ISS < 5) in both the groups after propensity score matching for demographics, injury severity parameters, and admission vital parameters. Groups were then compared for hospital and emergency department length of stay, early discharge, and mortality. RESULTS Of 5,202 transferred patients, 18.9% (981) were transferred via helicopter and 76.7% (3,992) were transferred via ground transport. Helicopter-transferred patients had longer hospital (p = 0.001) and intensive care unit (p = 0.001) stays. There was no difference in mortality between the groups (p = 0.6). On subanalysis of minimally injured patients there was no difference in hospital length of stay (p = 0.1) and early discharge (p = 0.6) between the helicopter transfer and ground transfer group. Average helicopter transfer cost at our center was

Managing older adults with ground-level falls admitted to a trauma service: the effect of frailty

18,000, totaling

Seasonal Variation in Emergency General Surgery

4,860,000 for 270 minimally injured helicopter-transferred patients. CONCLUSION Nearly one third of patients transported by helicopter were minimally injured. Policies to identify patients who do not benefit from helicopter transport should be developed. Significant reduction in transport cost can be made by judicious selection of patients. Education to physicians calling for transport and identification of alternate means of transportation would be both safe and financially beneficial to our system. LEVEL OF EVIDENCE Epidemiologic study, level III. Therapeutic study, level IV.

Secondary brain injury in trauma patients: The effects of remote ischemic conditioning

To determine whether frail elderly adults are at greater risk of fracture after a ground‐level fall (GLF) than those who are not frail.

The significance of platelet count in traumatic brain injury patients on antiplatelet therapy.

OBJECTIVE The aim of this study was to assess the seasonal variation in emergency general surgery (EGS) admissions. BACKGROUND Seasonal variation in medical conditions is well established; however, its impact on EGS cases remains unclear. METHODS The National Inpatient Sample (NIS) database was queried over an 8-year period (2004-2011) for all patients with diagnosis of acute appendicitis, acute cholecystitis, and diverticulitis. Elective admissions were excluded. The following data for each admission were recorded: age, sex, race, admission month, major operative procedure, hospital region, and mortality. Seasons were defined as follows: Spring (March, April, May), Summer (June, July, August), Fall (September, October, November), and Winter (December, January, February). X11 procedure and spectral analysis were performed to confirm seasonal variation. RESULTS A total of 63,911,033 admission records were evaluated of which 493,569 were appendicitis, 395,838 were cholecystitis, and 412,163 were diverticulitis. Seasonal variation is confirmed in EGS (F = 159.12, P < 0.0001) admissions. In the subanalysis, seasonal variation was found in acute appendicitis (F = 119.62, P < 0.0001), acute cholecystitis (F = 37.13, P < 0.0001), and diverticulitis (F = 69.90, P < 0.0001). The average monthly EGS admission in Winter was 11,322 ± 674. The average monthly EGS admission in Summer was higher than that of Winter by 13.6% (n = 1542; 95% CI: 1180-1904, P < 0.001). CONCLUSIONS Hospitalization due to EGS adheres to a consistent cyclical pattern, with more admissions occurring during the Summer months. Although the reasons for this variability are unknown, this information may be useful for hospital resource reallocation and staffing.

Use of prothrombin complex concentrate as an adjunct to fresh frozen plasma shortens time to craniotomy in traumatic brain injury patients.

BACKGROUND Management of traumatic brain injury (TBI) is focused on preventing secondary brain injury. Remote ischemic conditioning (RIC) is an established treatment modality that has been shown to improve patient outcomes secondary to inflammatory insults. The aim of our study was to assess whether RIC in trauma patients with severe TBI could reduce secondary brain injury. METHODS This prospective consented interventional trial included all TBI patients admitted to our Level 1 trauma center with an intracranial hemorrhage and a Glasgow Coma Scale (GCS) score of 8 or lower on admission. In each patient, four cycles of RIC were performed within 1 hour of admission. Each cycle consisted of 5 minutes of controlled upper limb (arm) ischemia followed by 5 minutes of reperfusion using a blood pressure cuff. Serum biomarkers of acute brain injury, S-100B, and neuron-specific enolase (NSE) were measured at 0, 6, and 24 hours. Outcome measure was reduction in the level of serum biomarkers after RIC. RESULTS A total of 40 patients (RIC, 20; control, 20) were enrolled. The mean (SD) age was 46.15 (18.64) years, the median GCS score was 8 (interquartile range, 3–8), and the median head Abbreviated Injury Scale (AIS) score was 3 (interquartile range, 3–5), and there was no difference between the RIC and control groups in any of the baseline demographics or injury characteristics including the type and size of intracranial bleed or skull fracture patterns. There was no difference in the 0-hour S-100B (p = 0.9) and NSE (p = 0.72) level between the RIC and the control group. There was a significant reduction in the mean levels of S-100B (p = 0.01) and NSE (p = 0.04) at 6 hours and 24 hours in comparison with the 0-hour level in the RIC group. CONCLUSION This study showed that RIC significantly decreased the standard biomarkers of acute brain injury in patients with severe TBI. Our study highlights the novel therapeutic role of RIC for preventing secondary brain insults in TBI patients. LEVEL OF EVIDENCE Therapeutic study, level III.

Antibiotics for appendicitis! Not so fast.

BACKGROUND Platelet dysfunction has been attributed to progression of initial intracranial hemorrhage (ICH) on repeat head computed tomographic (RHCT) scans in patients on prehospital antiplatelet therapy. However, there is little emphasis on the effect of platelet count and progression of ICH in patients with traumatic brain injury. The aim of this study was to determine the platelet count cutoff for progression on RHCT and neurosurgical intervention in patients on antiplatelet therapy. METHODS We performed a prospective cohort analysis of all traumatic brain injury patients with an ICH on prehospital antiplatelet therapy. Antiplatelet therapy was defined as aspirin, clopidogrel, or a combination of both. Admission platelet count was recorded and used for analysis. Receiver operating characteristic curves were plotted to identify the optimal platelet count for progression on RHCT scan and neurosurgical intervention in patients on antiplatelet therapy. RESULTS A total of 264 patients were enrolled. Platelet count of 135,000/µL or less (area under the curve, 0.80) and platelet count of 95,000/µL or less (area under the curve, 0.92) were the optimal threshold points for progression on RHCT scan and neurosurgical intervention, respectively. Patients with platelet count of 135,000/µL or less were 12.4 times (95% confidence interval, 7.1–18.4) more likely to have progression on RHCT scan and patients with platelet count 95,000/µL or less were 31.5 times (95% confidence interval, 19.7–96.2) more likely to require neurosurgical intervention. CONCLUSION A platelet count of less than 135,000/µL in patients on antiplatelet therapy is predictive of both radiographic and clinical worsening. This is a clinically relevant target intended to help tailor and improve management in patients on antiplatelet therapy. LEVEL OF EVIDENCE Therapeutic study, level III.

Metoprolol improves survival in severe traumatic brain injury independent of heart rate control

BACKGROUND The use of prothrombin complex concentrate (PCC) to reverse acquired (coagulopathy of trauma) and induced coagulopathy (preinjury warfarin use) is well defined. OBJECTIVE To compare outcomes in patients with traumatic brain injury without warfarin therapy receiving PCC as an adjunct to fresh frozen plasma (FFP) therapy compared with patients receiving FFP therapy alone. METHODS All patients with traumatic brain injury coagulopathy without warfarin therapy who received PCC (25 IU/kg) in conjunction with FFP or FFP alone at our Level I trauma center were reviewed. Coagulopathy was defined as an international normalized ratio >1.5. The groups (PCC + FFP vs FFP alone) were matched using propensity score matching on a 1:2 ratio for age, sex, Glasgow Coma Scale score, Injury Severity Score, head Abbreviated Injury Scale score, and international normalized ratio (INR) on presentation. The primary outcome measure was time to craniotomy. Secondary outcome measures were blood product requirements, cost of therapy, and mortality. RESULTS A total of 1641 patients were reviewed, 222 of whom were included (PCC + FFP, 74; FFP, 148). The mean ± standard deviation age was 46.4 ± 21.7 years, the median (range) Glasgow Coma Scale score was 8 (3-12), and the mean ± standard deviation INR on presentation was 1.92 ± 0.6. PCC + FFP therapy was associated with an accelerated correction of INR (P = .001) and decrease in overall pack red blood cell (P = .035) and FFP (P = .041) administration requirement. Craniotomy was performed in 26.1% of patients (n = 58). Patients who received PCC + FFP therapy had faster time to craniotomy (P = .028) compared with patients who received FFP therapy alone. CONCLUSION PCC as an adjunct to FFP decreases the time to craniotomy with faster correction of INR and concomitant decrease in the need for blood product requirement in patients with traumatic brain injury exclusive of prehospital warfarin therapy.