Nicole A. Stassen

Selective Nonoperative Management of Blunt Splenic Injury: An Eastern Association for the Surgery of Trauma Practice Management Guideline

BACKGROUND During the last century, the management of blunt force trauma to the spleen has changed from observation and expectant management in the early part of the 1900s to mainly operative intervention, to the current practice of selective operative and nonoperative management. These issues were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the Practice Management Guidelines for Non-operative Management of Blunt Injury to the Liver and Spleen published online in 2003. Since that time, a large volume of literature on these topics has been published requiring a reevaluation of the current EAST guideline. METHODS The National Library of Medicine and the National Institute of Health MEDLINE database was searched using Pub Med (www.pubmed.gov). The search was designed to identify English-language citations published after 1996 (the last year included in the previous guideline) using the keywords splenic injury and blunt abdominal trauma. RESULTS One hundred seventy-six articles were reviewed, of which 125 were used to create the current practice management guideline for the selective nonoperative management of blunt splenic injury. CONCLUSION There has been a plethora of literature regarding nonoperative management of blunt splenic injuries published since the original EAST practice management guideline was written. Nonoperative management of blunt splenic injuries is now the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury, patient age, or the presence of associated injuries. Its use is associated with a low overall morbidity and mortality when applied to an appropriate patient population. Nonoperative management of blunt splenic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and has an operating room available for urgent laparotomy. Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention. Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt splenic injuries. Repeat imaging should be guided by a patient’s clinical status. Adjunctive therapies like angiography with embolization are increasingly important adjuncts to nonoperative management of splenic injuries. Despite the explosion of literature on this topic, many questions regarding nonoperative management of blunt splenic injuries remain without conclusive answers in the literature.

The management of the open abdomen in trauma and emergency general surgery: part 1-damage control.

BACKGROUND The open abdomen technique, after both military and civilian trauma, emergency general or vascular surgery, has been used in some form for the past 30 years. There have been several hundred citations on the indications and the management of the open abdomen. Eastern Association for the Surgery of Trauma practice management committee convened a study group to organize the worlds literature for the management of the open abdomen. This effort was divided into two parts: damage control and the management of the open abdomen. Only damage control is presented in this study. Part 1 is divided into indications for the open abdomen, temporary abdominal closure, staged abdominal repair, and nutrition support of the open abdomen. METHODS A literature review was performed for more than 30 years. Prospective and retrospective studies were included. The reviews and case reports were excluded. Of 1,200 articles, 95 were selected. Seventeen surgeons reviewed the articles with four defined criteria. The Eastern Association for the Surgery of Trauma primer was used to grade the evidence. RESULTS There was only one level I recommendation. A patient with documented abdominal compartment syndrome should undergo decompressive laparotomy. CONCLUSION The open abdomen technique remains a heroic maneuver in the care of the critically ill trauma or surgical patient. For the best outcomes, a protocol for the indications, temporary abdominal closure, staged abdominal reconstruction, and nutrition support should be in place.

Nonoperative management of blunt hepatic injury: An Eastern Association for the Surgery of Trauma practice management guideline

Background During the last century, the management of blunt force trauma to the liver has changed from observation and expectant management in the early part of the 1900s to mainly operative intervention, to the current practice of selective operative and nonoperative management. These issues were first addressed by the Eastern Association for the Surgery of Trauma in the Practice Management Guidelines for Nonoperative Management of Blunt Injury to the Liver and Spleen published online in 2003. Since that time, a large volume of literature on these topics has been published requiring a reevaluation of the previous Eastern Association for the Surgery of Trauma guideline. Methods The National Library of Medicine and the National Institutes of Health MEDLINE database were searched using PubMed (www.pubmed.gov). The search was designed to identify English-language citations published after 1996 (the last year included in the previous guideline) using the keywords liver injury and blunt abdominal trauma. Results One hundred seventy-six articles were reviewed, of which 94 were used to create the current practice management guideline for the selective nonoperative management of blunt hepatic injury. Conclusion Most original hepatic guidelines remained valid and were incorporated into the greatly expanded current guidelines as appropriate. Nonoperative management of blunt hepatic injuries currently is the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury or patient age. Nonoperative management of blunt hepatic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and an operating room available for urgent laparotomy. Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention. Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt hepatic injuries. Repeated imaging should be guided by a patient’s clinical status. Adjunctive therapies like angiography, percutaneous drainage, endoscopy/endoscopic retrograde cholangiopancreatography and laparoscopy remain important adjuncts to nonoperative management of hepatic injuries. Despite the explosion of literature on this topic, many questions regarding nonoperative management of blunt hepatic injuries remain without conclusive answers in the literature.

Ground level falls are associated with significant mortality in elderly patients

BACKGROUND Falls from height are considered to be high risk for multisystem injury. Ground-level falls (GLF) are often deemed a low-energy mechanism of injury (MOI) and not a recommended triage criterion for trauma team activation. We hypothesize that in elderly patients, a GLF may represent a high-risk group for injury and concurrent comorbidities that warrant trauma service evaluation and should be triaged appropriately. METHODS This is a retrospective study based on the National Trauma Data Bank. All patients with MOI consistent with GLF were identified. Demographics, type and severity of injuries, and outcomes were analyzed. RESULTS We identified 57,302 patients with GLF. The group had 34% men, with mean age of 68 years ± 17 years and injury severity score of 8 ± 5. Overall mortality was 3.2%. There were 32,320 elderly patients (older than 70 years). The mortality in the elderly was significantly higher than the nonelderly (4.4% vs. 1.6%, p < 0.0001). The elderly were more likely to sustain long-bone fracture (54.5% vs. 35.9%, p < 0.0001), pelvic fracture (7.6% vs. 2.4%, p < 0.0001), and intracranial injury (10.6% vs. 8.7%, p<0.0001). Multivariate analysis showed that Glasgow Coma Scale (GCS) score <15 (odds ratio, 4.98) and older than 70 years (odds ratio, 2.75) were significant predictors of mortality inpatients after GLF. CONCLUSIONS Patients older than 70 years and with GCS score <15 represent a group with significant inhospital mortality.

Helicopters and the civilian trauma system: national utilization patterns demonstrate improved outcomes after traumatic injury.

BACKGROUND The role of helicopter transport (HT) in civilian trauma care remains controversial. The objective of this study was to compare patient outcomes after transport from the scene of injury by HT and ground transport using a national patient sample. METHODS Patients transported from the scene of injury by HT or ground transport in 2007 were identified using the National Trauma Databank version 8. Injury severity, utilization of hospital resources, and outcomes were compared. Stepwise logistic regression was used to determine whether transport modality was a predictor of survival or discharge to home after adjusting for covariates. RESULTS There were 258,387 patients transported by helicopter (16%) or ground (84%). Mean Injury Severity Score was higher in HT patients (15.9 ± 12.3 vs. 10.2 ± 9.5, p < 0.01), as was the percentage of patients with Injury Severity Score >15 (42.6% vs. 20.8%; odds ratio [OR], 2.83; 95% confidence interval [CI], 2.76-2.89). HT patients had higher rates of intensive care unit admission (43.5% vs. 22.9%; OR, 2.58; 95% CI, 2.53-2.64) and mechanical ventilation (20.8% vs. 7.4%; OR, 3.30; 95% CI, 3.21-3.40). HT was a predictor of survival (OR, 1.22; 95% CI, 1.17-1.27) and discharge to home (OR, 1.05; 95% CI, 1.02-1.07) after adjustment for covariates. CONCLUSIONS Trauma patients transported by helicopter were more severely injured, had longer transport times, and required more hospital resources than those transported by ground. Despite this, HT patients were more likely to survive and were more likely to be discharged home after treatment when compared with those transported by ground. Despite concerns regarding helicopter utilization in the civilian setting, this study shows that HT has merit and impacts outcome.

Prophylactic antibiotics adversely affect nosocomial pneumonia in trauma patients.

BACKGROUND Little data are available regarding the impact that prolonged prophylactic antibiotic use (>48 hours) has on the development of nosocomial pneumonia. This retrospective study was conducted to assess the effect that prolonged prophylactic antibiotic use has on the development of nosocomial pneumonia and antibiotic use complications. METHODS The records of patients who contracted nosocomial pneumonia during mechanical ventilation were retrospectively reviewed. These patients then were classified into two groups: those who received prolonged prophylactic antibiotics before the diagnosis of pneumonia and those who did not receive antibiotics. RESULTS For the patients who received prolonged prophylactic antibiotics, the first pneumonia was diagnosed later, the causative organisms were more likely to be resistant or Gram-negative bacteria, and the incidence of antibiotic complications were two times greater than for patients who did not receive extended antibiotic prophylaxis. CONCLUSION Justification for the use and duration of prolonged (>48 hours) prophylactic antibiotics requires careful reevaluation because this practice is associated with significant clinical complications that lead to increased use of patient resources, lengthened hospital stay, and higher cost.

Helicopters Improve Survival in Seriously Injured Patients Requiring Interfacility Transfer for Definitive Care

BACKGROUND Helicopter transport (HT) is frequently used for interfacility transfer of injured patients to a trauma center. The benefits of HT over ground transport (GT) in this setting are unclear. By using a national sample, the objective of this study was to assess whether HT impacted outcomes following interfacility transfer of trauma patients. METHODS Patients transferred by HT or GT in 2007 were identified using the National Trauma Databank (version 8). Injury severity, resource utilization, and survival to discharge were compared. Stepwise logistic regression was used to determine whether transport modality was a predictor of survival after adjusting for covariates. Regression analysis was repeated in subgroups with Injury Severity Score (ISS)≤15 and ISS>15. RESULTS There were 74,779 patients transported by helicopter (20%) or ground (80%). Mean ISS was higher in patients transported by helicopter (17±11 vs. 12±9; p<0.01) as was the proportion with ISS>15 (49% vs. 28%; odds ratio [OR], 2.53; 95% confidence interval [CI], 2.43-2.63). Patients transported by helicopter had higher rates of intensive care unit admission (54% vs. 29%; OR, 2.86; 95% CI, 2.75-2.96), had shorter transport time (61±55 minutes vs. 98±71 minutes; p<0.01), and had shorter overall prehospital time (135±86 minutes vs. 202±132 minutes; p<0.01). HT was not a predictor of survival overall or in patients with ISS≤15. In patients with ISS>15, HT was a predictor of survival (OR, 1.09; 95% CI, 1.02-1.17; p=0.01). CONCLUSIONS Patients transported by helicopter were more severely injured and required more hospital resources than patients transported by ground. HT offered shorter transport and overall prehospital times. For patients with ISS>15, HT was a predictor of survival. These findings should be considered when developing interfacility transfer policies for patients with severe injuries.

Mechanism of injury and special consideration criteria still matter: an evaluation of the national trauma triage protocol

BACKGROUND The Centers for Disease Control recently updated the National Trauma Triage Protocol. This field triage algorithm guides emergency medical service providers through four decision steps (physiologic [PHY], anatomic [ANA], mechanism, and special considerations) to identify patients who would benefit from trauma center care. The study objective was to analyze whether trauma center need (TCN) was accurately predicted solely by the PHY and ANA criteria using national data. METHODS Trauma patients aged 18 years and older were identified in the NTDB (2002-2006). PHY data and ANA injuries (International Classification of Diseases, ninth revision codes) were collected. TCN was defined as Injury Severity Score (ISS)>15, intensive care unit admission, or need for urgent surgery. Test characteristics were calculated according to steps in the triage algorithm. Logistic regression was performed to determine independent association of criteria with outcomes. Receiver operating characteristic curves were constructed for each model. RESULTS A total of 1,086,764 subjects were identified. Sensitivity of PHY criteria was highest for ISS>15 (42%) and of ANA criteria for urgent surgery (37%). By using PHY and ANA steps, sensitivity was highest (56%) and undertriage lowest (45%) for ISS>15. Undertriage for TCN based on actual treating trauma center level was 11%. CONCLUSION Current PHY and ANA criteria are highly specific for TCN but result in a high degree of undertriage when applied independently. This implies that additional factors such as mechanism of injury and the special considerations included in the Centers for Disease Control decision algorithm contribute significantly to the effectiveness of this field triage tool.

Does the need for noncardiac surgery during ventricular assist device therapy impact clinical outcome

BACKGROUND The role of the ventricular assist device (VAD) in the management of heart failure is expanding. Despite its success, the clinical course for patients requiring noncardiac surgery (NCS) during VAD support is not well described. The objective of this study was to identify VAD patients requiring NCS (+NCS) and compare outcomes with those not requiring NCS (-NCS). METHODS Patients undergoing VAD implant from 2000 to 2007 were reviewed. NCS procedures, survival, and complications were collected. Survival at 1 year from implant, overall survival at the study conclusion, survival time from implant, and outcome of VAD therapy were compared between groups. RESULTS We enrolled 142 subjects. Demographics did not differ between groups. Twenty-five subjects (18%) underwent 27 NCS procedures. Perioperative survival was 100% and 28-day survival was 64%. Survival to discharge was 56%. Bleeding occurred in 48%. Infection occurred in 33%. Estimated blood loss was 355 mL, and the international normalized ratio at time of NCS was 1.9. Laparoscopy was performed in 3 cases. There was no difference in 1-year survival (59% vs 54%), survival at study conclusion (44% vs 46%) or survival time (517 vs 523 days) between +NCS subjects and -NCS subjects. There were similar causes of death in both groups. The +NCS group was on VAD support longer (245 vs 87 days; P < .01), and less likely to undergo heart transplantation (12% vs 35%; P < .01). CONCLUSION NCS is not uncommon during VAD therapy. Bleeding and infection were common complications. Despite this, NCS seems to be feasible and safe and does not seem to increase mortality in the VAD population.

Systolic blood pressure criteria in the National Trauma Triage Protocol for geriatric trauma: 110 is the new 90.

BACKGROUND Undertriage is a concern in geriatric patients. The National Trauma Triage Protocol (NTTP) recognized that systolic blood pressure (SBP) less than 110 mm Hg may represent shock in those older than 65 years. The objective was to evaluate the impact of substituting an SBP of less than 110 mm Hg for the current SBP of less than 90 mm Hg criterion within the NTTP on triage performance and mortality. METHODS Subjects undergoing scene transport in the National Trauma Data Bank (2010–2012) were included. The outcome of trauma center need was defined as Injury Severity Score (ISS) greater than 15, intensive care unit admission, urgent operation, or emergency department death. Geriatric (age > 65 years) and adult (age, 16–65 years) cohorts were compared. Triage characteristics and area under the curve (AUC) were compared between SBP of less than 110 mm Hg and SBP of less than 90 mm Hg. Hierarchical logistic regression was used to determine whether geriatric patients newly triaged positive under this change (SBP, 90–109 mm Hg) have a risk of mortality similar to those triaged positive with SBP of less than 90 mm Hg. RESULTS There were 1,555,944 subjects included. SBP of less than 110 mm Hg had higher sensitivity but lower specificity in geriatric (13% vs. 5%, 93% vs. 99%) and adult (23% vs. 10%, 90% vs. 98%) cohorts. AUC was higher for SBP of less than 110 mm Hg individually in both geriatric and adult (p < 0.01) cohorts. Within the NTTP, the AUC was similar for SBP of less than 110 mm Hg and SBP of less than 90 mm Hg in geriatric subjects but was higher for SBP of less than 90 mm Hg in adult subjects (p < 0.01). Substituting SBP of less than 110 mm Hg resulted in an undertriage reduction of 4.4% with overtriage increase of 4.3% in the geriatric cohort. Geriatric subjects with SBP of 90 mm Hg to 109 mm Hg had an odds of mortality similar to those of geriatric patients with SBP of less than 90 mm Hg (adjusted odds ratio, 1.03; 95% confidence interval, 0.88–1.20; p = 0.71). CONCLUSION SBP of less than 110 mm Hg increases sensitivity. SBP of less than 110 mm Hg has discrimination as good as that of SBP of less than 90 mm Hg, with superior improvements in undertriage relative to overtriage in geriatric patients. Geriatric patients newly triaged to be positive under this change have a risk of mortality similar to those under the current SBP criterion. This change in SBP criteria may be merited in geriatric patients, warranting further study to consider elevation to a Step 1 criterion in the NTTP. LEVEL OF EVIDENCE Diagnostic study, level IV.