Nikolay Bugaev

Resuscitative Thoracotomy: An Update

Background: Resuscitative thoracotomy is a heroic procedure that may offer the only survival hope for trauma patients in extremis. However, this operation has been the subject of much debate and its use, feasibility, outcomes, and cost are being continuously re-evaluated. Methods: This is a review of the most current (after 2000) literature on resuscitative thoracotomy, based on computer database searches for studies on resuscitative thoracotomy, emergency department thoracotomy, and emergency thoracotomy. Studies were selected for inclusion in this review based on their relevance and contribution to our understanding of resuscitative thoracotomy. Results: A total of 37 studies were included, and the following resuscitative thoracotomy–related topics were critically discussed: indications, biochemical profile, long-term outcome, organ donation, pre-hospital use, military use, international aspects, intra-aortic balloon occlusion, suspended animation, and cost and occupational exposure. Conclusions: This review demonstrates that the indications for resuscitative thoracotomy become clearer and that new information is available regarding its use in the pre-hospital urban environment and military settings. Furthermore, it points to new strategies to supplement resuscitative thoracotomy including intra-aortic balloon occlusion and suspended animation. Finally, it sheds light on the long-term outcomes, organ donation, and cost and occupational exposure following resuscitative thoracotomy.

Variability in interhospital trauma data coding and scoring: A challenge to the accuracy of aggregated trauma registries.

BACKGROUND Analyses of data aggregated in state and national trauma registries provide the platform for clinical, research, development, and quality improvement efforts in trauma systems. However, the interhospital variability and accuracy in data abstraction and coding have not yet been directly evaluated. METHODS This multi-institutional, Web-based, anonymous study examines interhospital variability and accuracy in data coding and scoring by registrars. Eighty-two American College of Surgeons (ACS)/state-verified Level I and II trauma centers were invited to determine different data elements including diagnostic, procedure, and Abbreviated Injury Scale (AIS) coding as well as selected National Trauma Data Bank definitions for the same fictitious case. Variability and accuracy in data entries were assessed by the maximal percent agreement among the registrars for the tested data elements, and 95% confidence intervals were computed to compare this level of agreement to the ideal value of 100%. Variability and accuracy in all elements were compared (&khgr;2 testing) based on Trauma Quality Improvement Program (TQIP) membership, level of trauma center, ACS verification, and registrar’s certifications. RESULTS Fifty registrars (61%) completed the survey. The overall accuracy for all tested elements was 64%. Variability was noted in all examined parameters except for the place of occurrence code in all groups and the lower extremity AIS code in Level II trauma centers and in the Certified Specialist in Trauma Registry– and Certified Abbreviated Injury Scale Specialist–certified registrar groups. No differences in variability were noted when groups were compared based on TQIP membership, level of center, ACS verification, and registrar’s certifications, except for prehospital Glasgow Coma Scale (GCS), where TQIP respondents agreed more than non-TQIP centers (p = 0.004). CONCLUSION There is variability and inaccuracy in interhospital data coding and scoring of injury information. This finding casts doubt on the validity of registry data used in all aspects of trauma care and injury surveillance.

Management and outcome of patients with blunt splenic injury and preexisting liver cirrhosis

BACKGROUND The response of liver cirrhosis (LC) patients to abdominal trauma, including blunt splenic injury (BSI) is unfavorable. To better understand the response to BSI in LC patients, the present study reviewed a much larger group of such patients, derived from the National Trauma Data Bank. METHODS The National Trauma Data Bank was queried for 2002 to 2010, and all adult BSI patients without severe brain trauma were identified. LC and non-LC patients were compared using nonoperative management (NOM) failure and mortality as primary outcomes. Predictors of these outcomes in LC patients were identified. RESULTS Of the 77,753 identified BSI patients, 289 (0.37%) had LC. Overall, 90% of the patients underwent initial NOM (86% in LC and 90% in non-LC patients, p = 0.091) with a global 90% success rate. Compared with non-LC patients, LC patients had a lower NOM success rate (83% vs. 90%, p = 0.004) despite increased use of splenic artery angioembolization (13% vs. 8%, p = 0.001). LC patients also had more complications per patient, an increased hospital and intensive care unit lengths of stay, and a higher mortality (22% vs. 6%, p < 0.0001), which was independent of the treatment paradigm. In the LC group, mortality in those who underwent immediate surgery was 35% versus 46% in failed NOM (p = 0.418) and 14% (p = 0.019) in successful NOM patients. LC patients who did not require surgery were more likely to survive than those who had surgery alone (adjusted odds ratio [AOR], 0.30). Preexisting coagulopathy (AOR, 3.28) and Grade 4 to 5 BSI (AOR, 11.6) predicted NOM failure in LC patients, whereas male sex (AOR, 4.34), hypotension (AOR, 3.15), preexisting coagulopathy (AOR, 3.06), and Glasgow Coma Scale (GCS) score of less than 13 (AOR, 6.33) predicted mortality. CONCLUSION LC patients have a higher rate of complications, mortality, and NOM failure compared with non-LC patients. Because LC patients with failed NOM have a mortality rate similar to those undergoing immediate surgery, judgment must be exerted in selecting initial management options. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

Magnitude of rib fracture displacement predicts opioid requirements.

INTRODUCTION It is unknown whether the magnitude of rib fracture (RF) displacement predicts pain medication requirements in blunt chest trauma patients. METHODS Adult blunt RF patients undergoing computed tomography (CT) of the chest admitted to an urban Level 1 trauma center (2007–2012) were retrospectively reviewed. Pain management in those with displaced RF (DRF), nondisplaced RF (NDRF), or combined DRF and NDRF (CRF) was compared by univariate analysis. Linear regression models were developed to determine whether total opioid requirements [expressed as log morphine equianalgesic dose (MED)] could be predicted by the magnitude of RF displacement (expressed as the sum of the Euclidean distance of all displaced RF) or number of RF, after adjusting for patient and injury characteristics. RESULTS There were 245 patients, of whom 39 (16%) had DRF only, 77 (31%) had NDRF only, and 129 (53%) had CRF. Opioids were given to 224 patients (91%). Compared to DRF (mean, 1.7 RF per patient) and NDRF patients (2.4 RF per patient), those with CRF (6.8 RF per patient) were older and had more RF per patient and a higher Injury Severity Score (ISS) and MED (251 vs 53 and 105 mg, respectively, p < 0.0001 and p = 0.0045). They also more frequently received patient-controlled analgesia. Patients with displaced RF had a lower mean ISS and MED and received more epidural analgesia compared with patients with NDRF. Total MED was associated with both the magnitude of RF displacement (p < 0.0001) and the number of RF (p < 0.0001). Every 5-mm increase in total displacement predicted a 6.3% increase in mean MED (p = 0.0035), while every additional RF predicted an 11.2% increase in MED (p = 0.0001). These associations included adjustment for age, ISS, and presence of chest tubes. CONCLUSION The magnitude of RF displacement and the number of RF predicted opioid requirements. This information may assist in anticipating patients with blunt RF who might have higher analgesic requirements. LEVEL OF EVIDENCE Therapeutic study, level IV.

Admission patterns of stable patients with isolated orthopedic or neurosurgical injuries.

OBJECTIVE Although the disposition of stable patients with isolated orthopedic or neurosurgical injuries affects care and resource utilization, no guidelines for optimal admission are available. This study aims to provide the platform for developing such guidelines for these patients by characterizing their admission patterns in trauma centers (TCs). METHODS This study is a Web-based survey of Trauma Medical Directors of Level I and Level II American College of Surgeons (ACS)–verified TCs. RESULTS E-questionnaire was sent to 234 (98%) of 240 ACS-verified Level I and Level II TCs, and 122 (52%) responded. Responses indicate that stable patients with isolated orthopedic injuries and no indication or with an indication for emergent surgery are mostly (58 vs. 31%, p < 0.0001, 59 vs. 37%, p < 0.0001) admitted to the trauma service (TS). Conversely, when surgery was urgent, patients are equally admitted to the TS and orthopedic service (OS). When specific injuries were queried, patients with closed pelvic fractures are mostly admitted to the TS (81 vs. 18%, p < 0.0001), whereas patients with upper extremity injuries are preferentially admitted to the OS (58% vs. 31%, p < 0.05). Patients with isolated lower extremity fractures are equally admitted to the two services. Patients with isolated major traumatic brain injury (TBI) are mostly (78.6% vs. 21.4%, p < 0.0001) admitted to the TS, regardless of the need for emergent surgery. Similarly, most patients with minor TBI are admitted to the TS, independent of the presence of CT scan findings. The majority (73.9% vs. 26.1%, p < 0.0001) of patients with isolated spine injury are admitted to the TS, independent of the level of injury, the presence of multilevel injury, an indication for surgery, or the existence of neurological deficits. CONCLUSION Most stable patients with isolated neurosurgical injuries in ACS-verified Level I and Level II TCs are initially admitted to the TS. The admission of patients with isolated orthopedic injuries is selective. These findings can facilitate investigating the clinical, logistical, and financial effect of this practice.

Primary prevention of contact sports-related concussions in amateur athletes: a systematic review from the Eastern Association for the Surgery of Trauma

Background Awareness of the magnitude of contact sports-related concussions has risen exponentially in recent years. Our objective is to conduct a prospectively registered systematic review of the scientific evidence regarding interventions to prevent contact sports-related concussions. Methods Using the Grading of Recommendations Assessment, Development, and Evaluation methodology, we performed a systematic review of the literature to answer seven population, intervention, comparator, and outcomes (PICO) questions regarding concussion education, head protective equipment, rules prohibiting high-risk activity and neck strengthening exercise for prevention of contact sports-related concussion in pediatric and adult amateur athletes. A query of MEDLINE, PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature, and Embase was performed. Letters to the editor, case reports, book chapters, and review articles were excluded, and all articles reviewed were written in English. Results Thirty-one studies met the inclusion criteria and were applicable to our PICO questions. Conditional recommendations are made supporting preventive interventions concussion education and rules prohibiting high-risk activity for both pediatric and adult amateur athletes and neck strengthening exercise in adult amateur athletes. Strong recommendations are supported for head protective equipment in both pediatric and adult amateur athletes. Strong recommendations regarding newer football helmet technology in adult amateur athletes and rules governing the implementation of body-checking in youth ice hockey are supported. Conclusion Despite increasing scientific attention to sports-related concussion, studies evaluating preventive interventions remain relatively sparse. This systematic review serves as a call to focus research on primary prevention strategies for sports-related concussion. Level of evidence IV. PROSPERO registration number #42016043019.

The profile of blunt traumatic infratentorial cranial bleed types

Infratentorial traumatic intracranial bleeds (ICBs) are rare and the distribution of subtypes is unknown. To characterize this distribution the National Trauma Data Bank (NTDB) 2014 was queried for adults with single type infratentorial ICB, n = 1,821: subdural hemorrhage (SDH), subarachnoid hemorrhage (SAH), epidural hemorrhage (EDH), and intraparenchymal hemorrhage (IPH). Comparisons were made between the groups with statistical significance determined using chi squared and t-tests. SDH occurred in 29% of patients, mostly in elderly on anti-coagulants (13%) after a fall (77%), 42% of them underwent craniotomy, their mortality was the lowest (4%). SAH was the most common (56%) occurring mostly from traffic related injuries (27%). Furthermore, 9% of them had a severe head injury Glasgow Coma Scale ≤8 (GCS), but had the lowest Injury Severity Score (ISS, median 8) as well as a short hospital length of stay, 5.1 ± 6.2 days. These patients were most likely to be discharged to home (64%). They had the lowest mortality (4%). EDH was the least common ICB (5%), occurred in younger patients (median age 49 years), and it had the highest percentage of associated injuries (13%). EDH patients presented with the poorest neurological status (26% GCS ≤8, ISS median 25) and were operated on more than any other ICB type (55%). EDH was the highest mortality (9%) ICB type and had a low discharge to home rate (58%). IPH was uncommon (10%). Infratentorial bleeds types have different clinical courses, and outcomes. Understanding these differences can be useful in managing these patients.

Bicyclist safety behaviors in an urban northeastern, United States city: an observational study

Bicycling is gaining popularity in the United States, and laws and safety recommendations are being established to keep bicyclists safer. To improve road safety for bicyclists, there is a need to characterize their compliance with road laws and safety behaviors. Adult bicyclists were observed at three high-traffic intersections in Boston, MA, with state recommendations of wearing a helmet and riding in a bike lane. State law compliance for displaying reflectors during the day and of a front light and a rear light/reflector at night, obeying traffic signals, and giving pedestrians the right of way was also observed. Variables were compared between personal and shared/rented bicyclists and analyzed by time of day. A total of 1,685 bicyclists were observed. Because of the speed of the bicyclists and obstructed views, only a sampling of 802 bicyclists was observed for reflectors/front light. Overall, 74% wore a helmet, 49% had reflectors/front lights, 95% rode in bike lanes, 87% obeyed traffic signals, and 99% gave the right of way to pedestrians. Compared with shared bicyclists (n = 122), personal bicyclists (n = 1563) had a higher helmet-wearing behaviors (77% vs. 39%, p = .0001). Shared bicyclists had a higher (p = .0001) compliance with reflectors/lights (100%) than personal bicyclists (39%, n = 265). Boston bicyclists ride in bike lanes, obey traffic signals, give pedestrians the right of way, and wear helmets while having suboptimal compliance with light/reflector use. Educational programs and stricter law enforcement aimed at these safety behaviors should be part of the effort to improve safety for all road users.