Michel B. Aboutanos

Emergency general surgery: definition and estimated burden of disease.

BACKGROUND Acute care surgery encompasses trauma, surgical critical care, and emergency general surgery (EGS). While the first two components are well defined, the scope of EGS practice remains unclear. This article describes the work of the American Association for the Surgery of Trauma to define EGS. METHODS A total of 621 unique International Classification of Diseases—9th Rev. (ICD-9) diagnosis codes were identified using billing data (calendar year 2011) from seven large academic medical centers that practice EGS. A modified Delphi methodology was used by the American Association for the Surgery of Trauma Committee on Severity Assessment and Patient Outcomes to review these codes and achieve consensus on the definition of primary EGS diagnosis codes. National Inpatient Sample data from 2009 were used to develop a national estimate of EGS burden of disease. RESULTS Several unique ICD-9 codes were identified as primary EGS diagnoses. These encompass a wide spectrum of general surgery practice, including upper and lower gastrointestinal tract, hepatobiliary and pancreatic disease, soft tissue infections, and hernias. National Inpatient Sample estimates revealed over 4 million inpatient encounters nationally in 2009 for EGS diseases. CONCLUSION This article provides the first list of ICD-9 diagnoses codes that define the scope of EGS based on current clinical practices. These findings have wide implications for EGS workforce training, access to care, and research.

Patient safety in trauma: maximal impact management errors at a level I trauma center.

BACKGROUND The Division of Research at JCAHO developed a taxonomy (common terminology and classification schema) to promote consistency in reporting and facilitate root cause analysis. We undertook a review of trauma management errors at our institution with maximal impact (death). The analysis was based on the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) taxonomy. METHODS Trauma deaths between 2001 and 2006 at our Level I trauma were peer-reviewed to identify errors in management. The errors are classified according to type, domain, and cause. RESULTS Seventy-six (9.9%) of 764 deaths had management errors contributing to potentially preventable deaths in 60 (errors in management might have contributed to death) and preventable deaths (management errors definitely contributed to death) in 16 patients. Questionable resuscitation was the commonest type and involved poor treatment in the majority. Errors were made in all domains but most commonly in the emergency department and the operating room and in the resuscitative phase. Human errors predominated. CONCLUSIONS Management errors in the basics of trauma care continue even in established trauma centers, despite guidelines, protocols, and continuous performance improvement. Standardized reporting such as the taxonomy may result in progressive collection of patient safety data and lead to innovations to minimize these errors.

Wartime civilian injuries: epidemiology and intervention strategies.

BACKGROUND Trauma is the most important public health risk in wartime. Most preventive effort have addressed the political etiology of armed conflicts and the secondary effects of war (food, water, shelter, sanitation, and vector control). Little to no efforts have addressed the direct prevention and control of war trauma. METHODS An extensive review of the literature, with compilation of the most important data. RESULTS Civilians are the major wartime targets in recent wars, and account for most of the killed and wounded. The trend has been toward a greater proportion of injuries from powerful explosive devices such as artillery shells and mines. Lessons learned from Bosnia and Lebanon show that the most effective way to achieve successful surveillance and injury prevention is to enhance the local skills and resources. CONCLUSIONS New approaches are needed to minimize trauma to civilians. Both political advocacy and local efforts (including modifying firearms and ammunition, bullet proof helmets for children, anti-sniper shields) are needed.

Preservation of splenic immunocompetence after splenic artery angioembolization for blunt splenic injury.

BACKGROUND Splenic artery angioembolization (SAE) is increasingly being used as an adjunct to nonoperative management for stable patients with blunt splenic injury (BSI). However, little is known about splenic immunocompetence after SAE. This study aims at assessing splenic immunocompetence after SAE for BSI. METHODS Peripheral blood was obtained from BSI patients (n = 8) who had SAE >6 months prior. Splenic immunocompetence was assessed by isolating mononuclear cells and incubating with CD4 and CD45RA and CD45RO antibody to analyze the proportion of T-cells expressing CD4 receptor, or coexpressing CD4 and either CD45RA or CD45RO receptors. Cells were counted by fluorescence-activated cell sorting and compared with trauma patients that had splenectomy for BSI also >6 months prior (n = 4, negative controls) and normal healthy volunteers with intact spleens (n = 4, positive controls). RESULTS The test was discriminatory for the asplenic state. %CD4 cells were significantly lower in splenectomized patients (16 ± 1) versus normal (40 ± 2), p < 0.05. This was due to significant decrease (8 ± 2 vs. 26 ± 4, p < 0.05) in %CD4CD45RA cells whereas the proportion of CD4CD45RO cells were maintained similar to normal. SAE patients had values (CD4, 36 ± 2, and CD4CD45RA, 24 ± 2) comparable to normal (p > 0.05) and significantly higher than splenectomized patients (p < 0.05). When the SAE group was subdivided into main (total, n = 4) and branch vessel (partial, n = 4) SAE, results were the same for both types of SAE. CONCLUSION Splenic immune function, measured by T-cell subset, generated only in the presence of an immunocompetent spleen, is preserved after SAE for BSI, main or partial.

Findings of a randomized controlled trial using limited transthoracic echocardiogram (LTTE) as a hemodynamic monitoring tool in the trauma bay

BACKGROUND We hypothesize that limited transthoracic echocardiogram (LTTE) is a useful tool to guide therapy during the initial phase of resuscitation in trauma patients. METHODS All highest-level alert patients with at least one measurement of systolic blood pressure less than 100 mm Hg, a mean arterial pressure less than 60 mm Hg, and/or a heart rate greater than 120 beats per minute who arrived to the trauma bay (TB) were randomized to have either LTTE performed (LTTEp) or not performed (non-LTTE) as part of their initial evaluation. Images were stored, and results were reported regarding contractility (good vs. poor), fluid status (empty inferior vena cava [hypovolemic] vs. full inferior vena cava [not hypovolemic]), and pericardial effusion (present vs. absent). Time from TB to operating room, intravenous fluid administration, blood product requirement, intensive care unit admission, and mortality were examined in both groups. RESULTS A total of 240 patients were randomized. Twenty-five patients were excluded since they died upon arrival to the TB, leaving 215 patients in the study. Ninety-two patients were in the LTTEp group with 123 patients in the non-LTTE group. The LTTEp and non-LTTE groups were similar in age (38 years vs. 38.8 years, p = 0.75), Injury Severity Score (ISS) (19.2 vs. 19.0, p = 0.94), Revised Trauma Score (RTS) (5.5 vs. 6.0, p = 0.09), lactate (4.2 vs. 3.6, p = 0.14), and mechanism of injury (p = 0.44). Strikingly, LTTEp had significantly less intravenous fluid than non-LTTE patients (1.5 L vs. 2.5 L, p < 0.0001), less time from TB to operating room (35.6 minutes vs. 79.1 min, p = 0.0006), higher rate of intensive care unit admission (80.4% vs. 67.2%, p = 0.04), and a lower mortality rate (11% vs. 19.5%, p = 0.09). Mortality differences were particularly evident in the traumatic brain injury patients (14.7% in LTTEp vs. 39.5% in non-LTTE, p = 0.03). CONCLUSION LTTE is a useful guide for therapy in hypotensive trauma patients during the early phase of resuscitation. LEVEL OF EVIDENCE Therapeutic study, level II.

A, B, C, D, echo: limited transthoracic echocardiogram is a useful tool to guide therapy for hypotension in the trauma bay--a pilot study.

BACKGROUND Limited transthoracic echocardiogram (LTTE) has been introduced as a technique to direct resuscitation in intensive care unit (ICU) patients. Our hypothesis is that LTTE can provide meaningful information to guide therapy for hypotension in the trauma bay. METHODS LTTE was performed on hypotensive patients in the trauma bay. Views obtained included parasternal long and short, apical, and subxyphoid. Results were reported regarding contractility (good vs. poor), fluid status (flat inferior vena cava [hypovolemia] vs. fat inferior vena cava [euvolemia]), and pericardial effusion (present vs. absent). Need for surgery, ICU admission, Focused Assessment with Sonography for Trauma examination results, and change in therapy as a consequence of LTTE findings were examined. Data were collected prospectively to evaluate the utility of this test. RESULTS A total of 148 LTTEs were performed in consecutive patients from January to December 2011. Mean age was 46 years. Admission diagnosis was 80% blunt trauma, 16% penetrating trauma, and 4% burn. Subxyphoid window was obtained in all patients. Parasternal and apical windows were obtained in 96.5% and 11%, respectively. Flat inferior vena cava was associated with an increased incidence of ICU admission (p < 0.0076) and therapeutic operation (p < 0.0001). Of the 148 patients, 27 (18%) had LTTE results indicating euvolemia. The diagnosis in these cases was head injury (n = 14), heart dysfunction (n = 5), spinal shock (n = 4), pulmonary embolism (n = 3), and stroke (n = 1). Of the patients, 121 had LTTE results indicating hypovolemia. Twenty-eight hypovolemic patients had a negative or inconclusive Focused Assessment with Sonography for Trauma examination finding (n = 18 penetrating, n = 10 blunt), with 60% having blood in the abdomen confirmed by surgical exploration or computed tomographic scan. Therapy was modified as a result of LTTE in 41% of cases. Strikingly, in patients older than 65 years, LTTE changed therapy in 96% of cases. CONCLUSION LTTE is a useful tool to guide therapy in hypotensive patients in the trauma bay. LEVEL OF EVIDENCE Diagnostic study, level III.

Significance of motor vehicle crashes and pelvic injury on fetal mortality: a five-year institutional review.

BACKGROUND Motor vehicle crashes (MVC) are the leading cause of maternal injury during pregnancy. It is estimated that 1,300 to 13,000 fetal deaths/yr result from maternal MVC. METHODS Pregnant women with injuries were identified by ICD-9 codes containing pregnancy and injury from hospital medical records and Trauma/ED registries. Records were reviewed for demographic data, fetal gestational age, mechanism of injury, injuries sustained, Glasgow Coma Score, loss of consciousness (LOC), Injury Severity Score (ISS), and maternal and fetal outcome. Fishers exact test, t test, and logistic regression analysis were performed to analyze statistical analysis. RESULTS From 2001 to 2005, 29,066 pregnant patients were seen at our institution. Five thousand two hundred forty-four of these patients visited the ED, and 294 of them reported injuries. One hundred forty-eight (50.3%) patients were involved in MVC. The average maternal age was 23.8 years. The mean gestational age was 20 weeks. The majority of patients were drivers (n=97, 70%) versus passengers (n=42, 30%), and 66% were restrained versus 34% unrestrained. There were no maternal deaths; however, seven mothers (4.7%) had poor fetal outcome (six fetal deaths and one hydrops fetalis). Increased maternal age, LOC, high ISS, and pelvic injury were risk factors for poor fetal outcome. Logistic regression revealed LOC and pelvic injury to be independent risk factors. CONCLUSIONS Increased maternal age, LOC, and maternal pelvic fractures sustained during MVC contribute toward high ISS and significantly impacts fetal outcome. Despite fetal gestational age, aggressive radiographic pursuit of pelvic fractures may be warranted.

What are we missing: results of a 13-month active follow-up program at a level I trauma center.

BACKGROUND Poor follow-up by patients with trauma results in a lack of knowledge of postdischarge health-related issues. This study reports on postdischarge health-related issues discovered by a program of active postdischarge contact or follow-up. METHODS All patients discharged home from the trauma service were followed up in the following manner: within 4 weeks of discharge, telephonic follow-up was attempted three times followed by scanning of electronic records. Failing that, other physicians (specialists or primary care) were contacted. Once contact was established, the patient, family member, or physician was questioned about the general well-being, any specific health-related issue, and the resolution. RESULTS During the 13-month study period ending September 2007, a total of 1,353 patients met entry criteria. Contact was established with 692 (51%). Of these, 116 (17%) were found to have significant health issues: (1) severe uncontrolled pain, 45; (2) missed injury, 17 (spine fractures, 4; clavicle or hand or foot fractures, 6; facial bone fractures, 3; soft tissue, 3; hematuria, 1); (3) wound infections, 17; (4) other infections, 17 (urinary, 8; pulmonary, 7; blood stream, 2) (5) venous thromboembolism, 10; and (6) other, 9 (psychiatric, 6; nontraumatic, 3). One patient died at home within 24 hours of discharge. The issues were significant enough for the patients to seek medical care (outpatient, 39; emergency department visits, 52; hospitalization, 24). CONCLUSION A significant proportion of patients with trauma have moderate to severe health-related issues postdischarge that are often not found by the trauma team or the trauma registry. Active follow-up can identify the nature of the medical issues and help in designing system changes to reduce or eliminate them.

National Emergency X-Radiography Utilization Study criteria is inadequate to rule out fracture after significant blunt trauma compared with computed tomography.

BACKGROUND EAST guidelines now recommend computed tomography (CT) to evaluate cervical spine (c-spine) fractures after blunt trauma in patients who do not meet National Emergency X-Radiography Utilization Study criteria (NC), yet no imaging is required in those patients who do meet these criteria. NC are based on patients with both minor and severe (trauma team activation [TTA]) trauma. The purpose of this study was to evaluate the NC using CT as the gold standard in TTA patients. METHODS We prospectively evaluated 2,606 blunt TTA patients at our Level I trauma center. NC defined as alertness (Glasgow Coma Scale [GCS] score = 15), evidence of intoxication, clinically distracting injury, midline c-spine tenderness, or neurologic deficits were documented. CT was used to determine the accuracy of these criteria. RESULTS There were 157 patients with c-spine fractures and 2,449 patients without c-spine fractures. The fracture group was older (age, 43.4 years ± 19.3 years fracture group vs. 37.7 years ± 17.5 years no fracture group, p = 0.0003) with a lower GCS score (fracture group 13.7 ± 4.5 vs. no fracture group 14.4 ± 3.6, p = 0.0001) and initial systolic blood pressure (132.5 mm Hg ± 23.4 mm Hg vs. 139.9 mm Hg vs. 23.5 mm Hg, p = 0.0009). The sensitivity and specificity of clinical examination for all patients were 82.8% (130 of 157) and 45.7% (1,118 of 2,449), respectively. The positive predictive value (PPV) and negative predictive value (NPV) were 8.9% (130 of 1,461) and 97.6% (1,118 of 1,145), respectively. Patients with a GCS score of 15 had a sensitivity of 77%, specificity of 52.3%, PPV of 8.5%, and NPV of 97.5% for clinical examination. In those patients with the GCS score of 15, no intoxication or distracting injury, clinical examination had a sensitivity of 59.4%, specificity of 79.5%, PPV of 12.5%, and NPV of 97.5%. Of 26 patients with missed injuries based on NC, 19 (73.1%) required further intervention (16 collars, 2 OR, 1 Halo). CONCLUSION As in our previous trial, NC is inaccurate compared with CT to diagnose c-spine fractures in TTA patients. CT should be used in all blunt TTA patients regardless of whether they meet NC.

Brief violence interventions with community case management services are effective for high-risk trauma patients.

BACKGROUND Currently there are few data that brief violence intervention (BVI) and community case management services (CCMS) are effective for trauma patients admitted for interpersonal violence in terms of recidivism, service utilization, or alcohol abuse. The objective of this study is to assess outcomes for a cohort of young trauma patients in a prospective, randomized trial comparing BVI with BVI + CCMS. METHODS Intentionally injured patients, aged 10 years to 24 years, admitted to a Level I trauma center were randomized to receive a brief in-hospital psychoeducational violence intervention alone (Group I) or in combination with a 6 months wraparound CCMS (Group II) that included vocational, employment, educational, housing, mental health, and recreational assistance. Recidivism, alcohol use, and hospital and community service utilization were assessed at 6 weeks (6W) and 6 months (6M). RESULTS Seventy-five of 376 eligible injured patients were randomized into Group I and II. The two groups had similar demographics, injuries, and clinical outcomes. After discharge, percent clinic visits maintained was 57% in both the groups. Group II showed better hospital service utilization, CMS, and risk factor reduction at 6W and 6M. One patient in each group sustained a reinjury at 6M. CONCLUSIONS In-hospital BVI with community wraparound case management interventions can improve hospital and community service utilization both short- and long-term for high-risk injured patients. Longer follow-up is needed to show sustained reduction.