Peter E. Fischer

A Clinical Tool for the Prediction of Venous Thromboembolism in Pediatric Trauma Patients

IMPORTANCE Although rare, the incidence of venous thromboembolism (VTE) in pediatric trauma patients is increasing, and the consequences of VTE in children are significant. Studies have demonstrated increasing VTE risk in older pediatric trauma patients and improved VTE rates with institutional interventions. While national evidence-based guidelines for VTE screening and prevention are in place for adults, none exist for pediatric patients, to our knowledge. OBJECTIVES To develop a risk prediction calculator for VTE in children admitted to the hospital after traumatic injury to assist efforts in developing screening and prophylaxis guidelines for this population. DESIGN, SETTING, AND PARTICIPANTS Retrospective review of 536,423 pediatric patients 0 to 17 years old using the National Trauma Data Bank from January 1, 2007, to December 31, 2012. Five mixed-effects logistic regression models of varying complexity were fit on a training data set. Model validity was determined by comparison of the area under the receiver operating characteristic curve (AUROC) for the training and validation data sets from the original model fit. A clinical tool to predict the risk of VTE based on individual patient clinical characteristics was developed from the optimal model. MAIN OUTCOME AND MEASURE Diagnosis of VTE during hospital admission. RESULTS Venous thromboembolism was diagnosed in 1141 of 536,423 children (overall rate, 0.2%). The AUROCs in the training data set were high (range, 0.873-0.946) for each model, with minimal AUROC attenuation in the validation data set. A prediction tool was developed from a model that achieved a balance of high performance (AUROCs, 0.945 and 0.932 in the training and validation data sets, respectively; P = .048) and parsimony. Points are assigned to each variable considered (Glasgow Coma Scale score, age, sex, intensive care unit admission, intubation, transfusion of blood products, central venous catheter placement, presence of pelvic or lower extremity fractures, and major surgery), and the points total is converted to a VTE risk score. The predicted risk of VTE ranged from 0.0% to 14.4%. CONCLUSIONS AND RELEVANCE We developed a simple clinical tool to predict the risk of developing VTE in pediatric trauma patients. It is based on a model created using a large national database and was internally validated. The clinical tool requires external validation but provides an initial step toward the development of the specific VTE protocols for pediatric trauma patients.

Propofol infusion syndrome: A lethal condition in critically injured patients eliminated by a simple screening protocol

UNLABELLED Propofol infusion syndrome (PIS) is defined by arrhythmia, rhabdomyolysis, lactic acidosis, and unrecognized leads to death. We sought to determine the incidence of PIS in trauma patients and evaluate the efficacy of a prospective screening protocol in this patient population. MATERIALS AND METHODS In Phase I of the before-and-after study (1st January, 2005-31st December, 2005), trauma patients who received propofol were evaluated. Records were reviewed for demographics, injury severity, propofol time, dose, and rates, laboratory values, and adverse events. Patients were identified with PIS based on two of the following criteria: (1) cardiac arrhythmia/collapse, (2) metabolic acidosis, (3) rhabdomyolysis, and (4) acute kidney injury. Phase II (1st January, 2006-31st December, 2011) consisted of a prospective screening protocol (elevated lactate or creatine phosphokinase (CPK)) to identify patients at risk for PIS. RESULTS 207 patients were identified in Phase I. 6 (2.9%) developed PIS with a 50% mortality. No differences were seen in age, gender, or mechanism. PIS patients were more injured (median ISS 44 vs 26, p=0.04; median head AIS 5 vs 4, p=0.003) and received more propofol (median 50,350 vs 9770 mg, p=0.001) with longer infusion times (413 vs 65 h, p=0.001). Sodium, creatinine, and CPK levels were higher in those that developed PIS (160 vs 145 mmol/L, p=0.001; 4.3 vs 1.1mg/dL, p=0.005; 59,871 vs 520 U/L; p=0.002). Pre-screening PIS incidence was 2.9% (6/207), but after screening (January 2006) the incidence dropped to 0.19% (2/1038, p<0.001). CONCLUSIONS PIS is a morbid and lethal entity associated with sedation of critically injured patients. A simple screening procedure utilizing serum CPK (<5000 U/L) can essentially eliminate the development of PIS.

Inferior vena cava filters: Indications and management

Purpose of review The purpose of this review was to examine recent studies concerning the use of inferior vena cava (IVC) filters. Recent findings In the past 18 months, the American College of Chest Physicians released the 9th edition of their guideline for the prevention and treatment of venous thromboembolism. There have also been a number of studies reviewing the use of IVC filters in select populations for the prophylactic prevention of pulmonary embolism. Trauma continues to be the leading indication for prophylactic filters in a number of series, but further studies have demonstrated some benefit of prophylactic filters in the bariatric and spine surgery populations. The IVC filter complication rate remains low; however, so does the retrieval rate for potentially removable filters. These retrieval rates are increased with use of dedicated patient tracking mechanisms. Finally, there have been a number of technology updates in the hardware itself, focusing on strut design. Summary Despite little change in the society guidelines, the use of vena cava filters (VCFs) continues to rise. Overall, the use of IVC filters, especially in prophylactic situations, will remain controversial until randomized, controlled trials are performed within each specific patient population.

Vasopressor use after initial damage control laparotomy increases risk for anastomotic disruption in the management of destructive colon injuries

BACKGROUND Management of destructive colon injuries during damage control (DC) laparotomy is debated. The authors reviewed a single institutions experience with destructive colon injuries to identify risk factors for anastomotic failure after colon reconstruction. METHODS The authors identified all trauma patients sustaining destructive colon injuries between 2002 and 2011 from their medical centers trauma registry. Anastomotic leak was defined as suture or staple line disruption or enteral fistula formation. RESULTS Of 171 identified patients, 68 had DC procedures, 41 (60%) had subsequent anastomoses performed during the same hospitalization, and 27 (40%) were diverted. The colon anastomotic leak rate in patients who underwent DC laparotomy was higher than in patients who were reconstructed at the primary operation in a non-DC setting (17% vs 6%, P = .09). The use of vasopressors after the initial DC operation more than quadrupled the leak rate to 50% (P = .02). CONCLUSIONS Colonic anastomotic disruptions yield deadly consequences, and diversion rather than anastomosis should be used in patients who require vasopressor support after the initial DC procedure.

Penetrating duodenal trauma: A 19-year experience.

BACKGROUND Multiple techniques are used for repair in duodenal injury ranging from simple suture repair for low-grade injuries to pancreaticoduodenectomy for complicated high-grade injuries. Drains, both intraluminal and extraluminal, are placed variably depending on associated injuries and confidence with the repair. It is our contention that a simplified approach to repair will limit complications and mortality. The major complication of duodenal leak (DL) was the outcome used to assess methods of repair in this study. METHODS After early deaths from associated vascular injuries were excluded, patients with a penetrating duodenal injury admitted during a 19-year period ending in 2014 constituted the study population. RESULTS A total of 125 patients with penetrating duodenal injuries were included. Overall, the leak rate was 8% with two duodenal-related mortalities. No differences were seen in patients who had a DL as compared with no leak with respect to demographics, injury severity, or admission variables. Patients with DL were more likely to have a major vascular injury (60% vs. 23%, p = 0.02) and a combined pancreatic injury (70% vs. 31%, p = 0.03). No differences were identified by repair technique, location, or grade of injury. DLs were more likely to have an extraluminal drain (90% vs. 45%, p = 0.008). CONCLUSION Primary suture repair should be the initial approach considered for most injuries. Major vascular injuries and concomintant pancreatic injuries were associated with most leaks; therefore, adjuncts to repair including intraluminal drainage and pyloric exclusion should be considered on the initial operation. Extraluminal drains should be avoided unless required for associated injuries. LEVEL OF EVIDENCE Therapeutic/care management study, level IV.

Complications of bariatric surgery: the acute care surgeon's experience.

BACKGROUND Complications of bariatric surgeries are common, can occur throughout the patients lifetime, and can be life-threatening. We examined bariatric surgical complications presenting to our acute care surgery service. METHODS Records were reviewed from January 2007 to June 2013 for patients presenting with a complication after bariatric surgery. RESULTS Laparoscopic Roux-en-Y gastric bypass was the most common index operation (n = 20), followed by open Roux-en-Y gastric bypass (n = 6), laparoscopic gastric band (n = 4), and vertical banded gastroplasty (n = 3). Diagnoses included internal hernia (n = 10), small bowel obstruction (n = 5), lap band restriction (n = 4), biliary disease (n = 3), upper GI bleeding or ulcer (n = 3), ischemic bowel (n = 2), marginal ulcer (n = 2), gastric outlet obstruction (n = 2), perforated ulcer (n = 2), intussusception (n = 1), and incarcerated ventral hernia (n = 1). Operations were required in 91% of the patients. Laparoscopic outcomes were similar to open; however, open cases were more emergent (23.5% vs 69.2%) and had longer hospital length of stay (4.8 ± 3.5 vs 11.0 ± 10.3 days, P < .05). All patients survived. CONCLUSIONS The acute care surgeon will encounter complications of bariatric surgery. Internal hernias or obstructive etiologies are the most common presentations and often require emergent or urgent surgery.

Guidance Document for the Prehospital Use of Tranexamic Acid in Injured Patients

Abstract Tranexamic acid (TXA) is being administered already in many prehospital air and ground systems. Insufficient evidence exists to support or refute the prehospital administration of TXA, and results are pending from several prehospital studies currently in progress. We have created this document to aid agencies and systems in best practices for TXA administration based on currently available best evidence. This document has been endorsed by the American College of Surgeons–Committee on Trauma, the American College of Emergency Physicians, and the National Association of EMS Physicians.

Do not waste your time: straight to magnetic resonance imaging for pediatric burners and stingers

BACKGROUND Permanent neurologic injury in pediatric patients with burner and stinger syndrome (BSS) is unlikely. This study aims to assess the feasibility of clinical observation without extensive radiologic workup in this selective population. METHODS A retrospective study was conducted of patients aged younger than 18 years evaluated at a level I trauma center from 2012 to 2014. Patients were grouped according to positive deficit (PD) or negative deficit (ND) upon physical examination. Demographics, clinical findings, and outcomes were analyzed. RESULTS Thirty patients (ND, n = 14; PD, n = 16) were evaluated for BSS, most often as a result of injurious football tackle. Age and length of stay were similar between groups. Injury Severity Score was lower in the ND group than the PD group (1.6 ± 1.2 vs 3.8 ± 3.1, respectively; P< .05). Cervical computed tomography was performed on 11 patients (78.6%) in the ND group and 15 patients (93.8%) in the PD group at considerable added cost, with only 1 positive result in the ND group and none in the PD group. Magnetic resonance imaging (MRI) revealed 2 positive findings in each group, and no surgical interventions were indicated. Ten ND (71.4%) and 12 PD (75%) patients reported complete resolution of symptoms at discharge (P> .05). CONCLUSIONS Children presenting with BSS experience temporary symptoms that resolve without surgical intervention. Magnetic resonance imaging identified more injuries than computed tomographic imaging; therefore, we suggest that management for BSS should include observation, serial neurologic examinations, and MRI evaluation as appropriate.

Spinal Motion Restriction in the Trauma Patient – A Joint Position Statement

Abstract The American College of Surgeons Committee on Trauma (ACS-COT), American College of Emergency Physicians (ACEP), and the National Association of EMS Physicians (NAEMSP) have previously offered varied guidance on the role of backboards and spinal immobilization in out-of-hospital situations. This updated consensus statement on spinal motion restriction in the trauma patient represents the collective positions of the ACS-COT, ACEP and NAEMSP. It has further been formally endorsed by a number of national stakeholder organizations. This updated uniform guidance is intended for use by emergency medical services (EMS) personnel, EMS medical directors, emergency physicians, trauma surgeons, and nurses as they strive to improve the care of trauma victims within their respective domains.

Hematologic changes with aging

The age-related hematologic changes of older trauma victims include a baseline anemia and hypercoagulability. These patients have less responsive bone marrow and are slower to repopulate cell lines following injury and hemorrhage. Pre-injury medication profiles for older patients will often include at least one anticoagulant, and understanding of its mechanism and reversal can be lifesaving. The geriatric trauma patient is challenging, and knowledge of both natural and iatrogenic hematologic changes is paramount to their care.