Nasim Ahmed

Management of liver trauma in adults.

The liver is one of the most commonly injured organs in abdominal trauma. Recent advancements in imaging studies and enhanced critical care monitoring strategies have shifted the paradigm for the management of liver injuries. Nonoperative management of both low- and high-grade injuries can be successful in hemodynamically stable patients. Direct suture ligation of bleeding parenchymal vessels, total vascular isolation with repair of venous injuries, and the advent of damage control surgery have all improved outcomes in the hemodynamically unstable patient population. Anatomical resection of the liver and use of atriocaval shunt are rarely indicated.

Report Card on Surgical Care Improvement Project (SCIP): Nationwide Inpatient Sample Infection Data 2001–2006

BACKGROUNDnThe administration of appropriate antibiotics in a timely fashion with discontinuation post-operatively is the first of the Surgical Care Improvement Project (SCIP) initiatives and was expected to reduce post-operative infections significantly. This study aimed at determining whether SCIP has had an effect on surgical site infections (SSIs).nnnMETHODSnA retrospective cohort study was conducted to evaluate the infection rates of adult patients (age≥18 years) having elective cholecystectomies, laparoscopic cholecystectomies, and colectomies from 2001-2006 using the Nationwide Inpatient Sample (NIS) database. The population consisted of all patients older than 18 years who had colon resection or cholecystectomy and were discharged from a hospital included in the NIS. Annual infection rates were determined for each of the operations.nnnRESULTSnPost-operative infections rose steadily and significantly (p<0.0001) in colon surgery from 2001 to 2006. A significant increase in SSIs also was seen in open (p=0.0001) and laparoscopic (p<0.0001) cholecystectomy from 2001 to 2006. Length of stay was significantly longer in infected than in non-infected patients.nnnCONCLUSIONnThe factors that contributed to the observed increase in the infection rate should be identified to improve the SCIP initiatives.

Sensitivity and specificity of CT scan and angiogram for ongoing internal bleeding following torso trauma

Background Occult internal bleeding in the trauma patient which remains undiagnosed and unaddressed has the potential to result in morbidity or mortality. Advancements in CT and angiography have played an integral role in the management of this patient population. Objective The purpose of the study was to identify the sensitivity and specificity of CT scan and angiography in detecting ongoing internal bleeding. Methods Consecutive patients who sustained torso trauma and subsequently underwent CT scan and angiography were included in this study. Data reviewed included clinical information, CT scan and angiography readings. Extravasations of contrast from CT scan and/or angiogram were considered positive for ongoing internal bleeding. Results From January 2002 through July 2007, 113 adult trauma patients sustaining torso trauma underwent CT scan of chest or abdomen followed by angiography. Sixty-six patients were negative for extravasation from either of the tests. Twenty-four of 35 patients had both positive CT scans and angiograms. Eleven patients with positive CT scans did not have bleeding on angiogram. Similarly, 12 out of 36 patients with positive angiograms did not show any extravasation of contrast on CT scan. Both modalities had a specificity of 100% based on clinical definition. The sensitivities of CT scan and angiogram were 74.5% and 76.6%, respectively. They were not significantly different (p=0.95). The negative predictive values for CT and angiogram were 84.6% and 85.7%. They were not significantly different (p=0.95) either. When CT scan was used alone, 25.5% of bleeding patients were missed. Conclusions The sensitivity of CT scan and angiography at detecting ongoing bleeding was around 75% across the torso injury spectrum.

Risk stratification of survival in injured patients with cardiopulmonary resuscitation within the first hour of arrival to trauma centre: retrospective analysis from the national trauma data bank

Background The purpose of this study was to evaluate overall survival and associated survival factors for patients with trauma who had cardiopulmonary resuscitation (CPR) within 1 hour after arrival to a hospital. Methods Retrospective patient data was retrieved from the 2007–2010 edition of the US National Trauma Data Bank. Inhospital survival was the primary outcome; only patients with a known outcome were included in the analysis. Summary statistics and univariate analyses were first reported. Eighty per cent of the patients were then randomly selected and used for multivariate logistic regression analysis. The identified risk factors were further assessed for discrimination and calibration with the remaining patients with trauma using area under the curve (AUC) analysis and a Hosmer-Lemeshow test. Results From 19 310 total cases that were reviewed, only 2640 patients required CPR within 1 hour of hospital arrival and met the additional inclusion criteria. Of these patients, 2309 (87.5%) died and 331 (12.5%) survived to discharge. There were statistical differences for race (p=0.003), initial systolic BP (p<0.001), initial pulse (p<0.001), cause of injury (p<0.001), presence of head injury (p=0.02), Injury Severity Score (ISS) (p<0.001), Glasgow Coma Scale (GCS) total score (p<0.001) and GCS motor score (p<0.001); though not all were clinically significant. The multiple logistic regression model (AUC=0.72) identified lower ISS, higher GCS motor score, Caucasian race, American College of Surgeons (ACS) level 2 trauma designation and higher initial SBP as the most predictive of survival to hospital discharge. Conclusion Approximately 13% of patients who had CPR within an hour of arrival to a trauma centre survived their injury. Therefore, implementation of an aggressive first hour in-hospital resuscitation strategy may result in better survival outcomes for this patient population.

Initial systolic blood pressure and ongoing internal bleeding following torso trauma.

Objective: Recent studies have suggested that an initial systolic blood pressure (SBP) in the range of 90–110 mmHg in a trauma patient may be indicative of hypoperfusion and is associated with poor patient outcome. However, the use of initial SBP as a surrogate for predicting internal bleeding is yet to be validated. The purpose of this study was to assess the presenting SBPs in patients with torso trauma and evidence of ongoing internal hemorrhage. Setting and Design: This was a retrospective chart review conducted at the Level II Trauma Center. Patients and Methods: Adult patients who sustained trauma and underwent chest and/or abdominal computed tomography (CT) scans and angiography were included in the study. Demographic and clinical information was extracted from patients who had CT scan and angiography. Extravasation of contrast material on CT scan and angiography was considered positive for ongoing internal bleeding. Results: From January 2002 through July 2007, a total of 113 consecutive patients were included in this study. Forty-seven patients had evidence of ongoing internal bleeding (41.6%; 95% confidence interval: 32.4%, 51.2%). When comparing patients with and without ongoing bleeding, these two groups were similar in their gender, race, pulse, injury severity score and shock index. However, bleeding patients were typically older [mean (standard deviation): 44.5 (20.5) vs 37.3 (19.1) years; P = 0.051], had a lower initial SBP [116.2 (36.0) vs 130.0 (30.4) mmHg; P = 0.006] and had a higher Glasgow coma scale (GCS) [13.1 (4.0) vs 12.1 (4.4); P = 0.09]. From a multivariate logistic regression analysis, older age (P = 0.046) and lower SBP (P = 0.01) were significantly associated with bleeding, when controlled for gender, race and GCS. Among the 47 patients with ongoing bleeding, only seven patients (15%) had a SBP lower than 90 mmHg and 25 patients (53%) had a SBP higher than or equal to 120 mmHg. The spleen was the most frequently injured organ identified with active bleeding. Conclusions: Initial SBP cannot predict the ongoing internal bleeding.

Assessing the impact of blood alcohol concentration on the rate of in-hospital mortality following traumatic motor vehicle crash injury: A matched analysis of the National Trauma Data Bank

BACKGROUNDnThe purpose of this study was to compare the outcomes of trauma patients who were injured in a motor vehicle crash and tested positive for alcohol upon hospital arrival versus those who tested negative.nnnMETHODSnStudy data came from the US National Trauma Data Bank (2007-2010). Any blood alcohol concentration (BAC) found at or above the legal limit (≥0.08u2009g/dL) was considered alcohol positive, and if no alcohol was identified through testing, the patient was considered alcohol negative. Patients demographics including age >u2009=u200914, race, gender, drug test results, systolic blood pressure, heart rate, injury severity score (ISS), and Glasgow Coma Scale (GCS) were included in the study. Propensity score and exact pair matching were performed between the groups using baseline characteristics.nnnRESULTSnFrom a total of 88,794 patients, 30.9% tested positive and 69.1% tested negative for alcohol. There were significant differences found between the groups regarding age, gender, race, and GCS (all pu2009<u20090.001) as well as a significantly higher in-hospital mortality rate (3.5% vs. 2.7%, pu2009<u20090.001) and median time to patient expiration (4 vs. 3 days, pu2009<u20090.001) in the alcohol negative group. After running both matching scenarios, there was no evidence of a significant difference seen in the rates of in-hospital mortality or the median time to patient expiration between the alcohol groups in either matched comparison.nnnCONCLUSIONnPatients who tested positive for alcohol following a traumatic motor vehicle crash showed no significant increase in in-hospital mortality or time to expiration when compared to propensity score and exact matched patients who tested negative for alcohol.

Examining the Influence of Blood Alcohol Level on the Incidence of Pneumonia & Sepsis Complications Following Traumatic Injury

BACKGROUNDnThe purpose of this study was to examine the impact of blood alcohol concentration (BAC) on the occurrence of pneumonia and sepsis among traumatic injury victims.nnnMETHODSnRetrospective study data were retrieved from the 2007-2010 National Trauma Data Bank and included all patients ≥14 years of age, with a blunt or penetrating injury, who were taken to a level 1 or level 2 trauma center, had complete systolic blood pressure and heart rate records, and had a confirmed blood alcohol test at the time of hospital arrival. Patients characteristics and outcome information were compared between two groups (those with a BAC above the legal limit [>0.08xa0g/dL] and those with a negative BAC result), followed by propensity score matching and a follow-up paired analysis.nnnRESULTSnOf 279,460 patients, 92,960 tested positive for alcohol with a BAC above the legal limit. There were clear demographic differences between the groups (pxa0<xa00.001). Therefore, propensity score matching was performed to better balance the groups and the resulting standardized mean differences of less than 10% indicated successful matching. When comparing the occurrence of both pneumonia and sepsis between the matched pairs, there was a statistically significantly higher rate of pneumonia in the alcohol positive patients, 8.0% vs. 7.3%, (pxa0=xa00.03), but no significant clinical difference. Additionally, no significant difference was observed for the rate of sepsis across the groups (pxa0=xa00.62).nnnCONCLUSIONnPatients who tested positive for alcohol following a traumatic injury showed a statistically higher incidence of pneumonia, but there was no clinically significant difference. Additionally, there was no significant difference identified in the incidence of sepsis between the BAC groups.