Rachel C. Dirks

This too shall pass: A study of ingested sharp foreign bodies.

BACKGROUND Gastrointestinal foreign body (GFB) ingestion is a common problem and often results in surgical consultation. Current literature is limited to case reports and fails to provide data regarding the management of sharp GFB ingestion. We hypothesized that patients who ingest sharp objects rarely have perforation or obstruction requiring surgical intervention. METHODS Patients presenting with GFBs from January 2005 to December 2015 at a level 1 trauma center with an acute care surgery program were retrospectively reviewed. Exclusion criteria were leaving without being seen, noningested GFB, unknown or blunt GFB, or if the GFB was not found on imaging. Data collected included patient demographics, length of stay, imaging, and interventions that were performed. RESULTS During the study period, there were 1,164 patients with 1,245 hospital visits for GFBs; 995 visits were excluded, resulting in 169 sharp GFB ingestion patients with 192 visits included in our study. The average age was 31. Sixty-five percent were men, and 41% were incarcerated. The average length of stay was 3 days, which was longer in patients with psychiatric holds and consultations. Of the 169 patients, 116 (69%) had no intervention and did not return for complications. Fifty-five endoscopies were performed with GFB removal in 30 cases. Seven patients (4%) underwent surgery, five of which had peritonitis. When evaluating the total study cohort, 134 (79%) of the patients had no procedure or a negative procedure. Patients requiring surgery had significantly larger objects (6 ± 3 cm) than those who had endoscopy (3 ± 2 cm) or no procedure (2 ± 1 cm). CONCLUSION Surgical intervention occurred in only seven (4%) patients with sharp GFB ingestions, and 79% of the patients required no intervention. Barring an acute abdomen or esophageal sharp GFBs, patients can be discharged with return precautions, admitted for necessary psychiatric care, or returned to custody for patients seeking secondary gain. Upper gastrointestinal larger GFBs should be removed endoscopically when possible. LEVEL OF EVIDENCE Therapeutic/care management study, level V.

Attempting to validate the overtriage/undertriage matrix at a Level I trauma center

BACKGROUND The Optimal Resources Document mandates trauma activation based on injury mechanism, physiologic and anatomic criteria and recommends using the overtriage/undertriage matrix (Matrix) to evaluate the appropriateness of trauma team activation. The purpose of this study was to assess the effectiveness of the Matrix method by comparing patients appropriately triaged with those undertriaged. We hypothesized that these two groups are different, and Matrix does not discriminate the needs or outcomes of these different groups of patients. METHODS Trauma registry data, from January 2013 to December 2015, at a Level I trauma center, were reviewed. Overtriage and undertriage rates were calculated by Matrix. Patients with Injury Severity Score (ISS) of 16 or greater were classified by activation level (full, limited, consultation), and triage category by Matrix. Patients in the limited activation and consultation groups were compared with patients with full activation by demographics, injuries, initial vital signs, procedures, delays to procedure, intensive care unit admission, length of stay, and mortality. RESULTS Seven thousand thirty-one patients met activation criteria. Compliance with American College of Surgeons tiered activation criteria was 99%. The Matrix overtriage rate was 45% and undertriage was 24%. Of 2,282 patients with an ISS of 16 or greater, 1,026 were appropriately triaged (full activation), and 1,256 were undertriaged. Undertriaged patients had better Glasgow Coma Scale score, blood pressure, and base deficit than patients with full activation. Intensive care unit admission, hospital stays, and mortality were lower in the undertriaged group. The undertriaged group required fewer operative interventions with fewer delays to procedure. CONCLUSION Despite having an ISS of 16 or greater, patients with limited activations were dissimilar to patients with full activation. Level of activation and triage are not equivalent. The American College of Surgeons Committee on Trauma full and tiered activation criteria are a robust means to have the appropriate personnel present based on the available prehospital information. Evaluation of the process of care, regardless of level of activation, should be used to evaluate trauma center performance. LEVEL OF EVIDENCE Therapeutic and care management, level III.

Use of endotracheal tubes with subglottic secretion drainage reduces ventilator-associated pneumonia in trauma patients.

BACKGROUND Patients sustaining traumatic injuries have a higher incidence of ventilator-associated pneumonia (VAP) compared with other critically ill patient populations. Previous studies of patients with predominantly medical diagnoses and use of endotracheal tubes allowing subglottic secretion drainage (ETT-SSD) have shown significant reduction in VAP rates. We hypothesized that the use of ETT-SSD would reduce VAP in trauma patients. METHODS A retrospective review from 2010 to 2014 of adult trauma patients orotracheally intubated for more than 48 hours was performed at a Level 1 trauma center. Patients were compared based on standard endotracheal tube (ETT) versus ETT-SSD for the primary outcome VAP per 1,000 ventilator days. The diagnosis of VAP was made by quantitative bronchoalveolar lavage cultures as defined by Centers for Disease Control and Prevention criteria. Patients with ETT-SSD were matched to patients with ETT based on age group, sex, mechanism of injury, head and chest Abbreviated Injury Scale (AIS) score, and Injury Severity Score (ISS). RESULTS Of 1,135 patients included in the study, 667 patients had ETT and 468 had ETT-SSD. Groups did not differ by demographics, mechanism of injury, Glasgow Coma Scale (GCS) score, alcohol intoxication, or ISS. Patients with ETT-SSD had significantly higher head AIS score but lower chest AIS score. In matched cohorts, ETT-SSD had a lower VAP rate (5.7 vs. 9.3 for ETT, p = 0.03), decreased ventilator days (12 vs. 14, p = 0.04), and decreased intensive care unit length of stay (13 days vs. 16 days, p = 0.003). CONCLUSION After controlling for confounding factors, ETT-SSD decreased VAP rate, ventilator days, and intensive care unit length of stay in trauma patients. In this high-risk patient population, we recommend routine use of ETT-SSD to decrease VAP. LEVEL OF EVIDENCE Therapeutic/care management study, level III.

Base deficit is superior to lactate in trauma

BACKGROUND Base Deficit (BD) and lactate have been used as indicators of shock and resuscitation. This study was done to determine the association of BD and lactate and to determine if one is superior. METHODS A retrospective review from 3/2014-12/2016 was performed. Data included demographics, systolic BP, ISS, BD, lactate, blood transfusion, and outcomes. BD and lactate were modeled continuously and categorically and compared. RESULTS 1191 patients were included. BD and lactate correlated strongly (r = -0.76 p < 0.001). Higher lactate and more negative BD were associated with transfusion and mortality. On multivariate regression, only BD was associated with transfusion (OR = 0.8, p < 0.001). As a categorical variable, worsening BD was associated with decreased BP, higher ISS, increased transfusions and worse outcomes. CONCLUSIONS BD and lactate are strongly related. BD was superior to lactate in assessing the need for transfusion. The BD categories discriminate high risk trauma patients better than lactate.

After the embo: predicting non-hemorrhagic indications for splenectomy after angioembolization in patients with blunt trauma

Background Successful non-operative management (NOM) of blunt splenic trauma is enhanced with splenic angioembolization (SAE). Patients may still require splenectomy post-SAE for splenic infarction/necrosis. Prior studies have used white blood cell count (WBC), platelet count (PLT), and PLT:WBC ratio after splenectomy to predict complications, but none have evaluated these findings prior to splenectomy in patients who have undergone SAE. Changes in these values may indicate clinically significant splenic infarction, facilitating management of these patients. Methods Patients admitted to an American College of Surgeons verified level 1 trauma center from January 2007 to August 2017 who underwent SAE were identified. Patients with successful NOM after SAE (SAE/NOM) were compared with those requiring splenectomy (SAE/SPLEN). Data included demographics, splenic injury grade, Injury Severity Score (ISS), time to SAE and splenectomy, intensive care unit and hospital length of stay (LOS), and complete blood count. Lab values were analyzed immediately post-SAE (time 1) and day 5 post-SAE (or day of discharge) for SAE/NOM patients and day of SPLEN for SAE/SPLEN patients (time 2). Data were analyzed using Mann-Whitney U, χ2 tests, and receiver operating characteristic (ROC) curves with significance attributed to P<0.05. Results Of 124 patients undergoing SAE, 16 (13%) later required SPLEN for infarction/necrosis at a median of 5 days post-SAE (IQR: 3–10 days). SAE/SPLEN and SAE/NOM patients did not differ by age, gender, ISS, or grade of splenic injury. SAE/SPLEN patients had longer hospital LOS (23 vs. 10 days, P<0.001). WBC, PLT, and PLT:WBC ratio did not differ between the groups at time 1. At time 2, WBC was higher and PLT:WBC ratio was lower in SAE/SPLEN patients. Using ROC curves at time 2, the area under the curve was 0.90 (P<0.001) for WBC and 0.71 (P<0.007) for PLT:WBC ratio. Discussion Patients requiring splenectomy for clinically significant infarction/necrosis after SAE develop leukocytosis and decreased PLT:WBC ratio when compared with SAE/NOM patients. Monitoring these parameters allows more prompt diagnosis and operative intervention. Level of evidence Therapeutic/care management, level III.

Stimulant drugs are associated with violent and penetrating trauma: A prospective study with confirmatory serum LC-TOF/MS testing

Background: Substance abuse is associated with traumatic injuries. Prior studies of drug use and injury have relied on urine drug of abuse screens, which have false positives, false negatives and inability to detect novel drugs. Our study characterizes the relationship between injury mechanism and drugs of abuse detected in serum via confirmatory testing. Methods: This prospective observational study was conducted from Jan–Sept 2012 at a level 1 trauma center on trauma patients > 13 years who had blood drawn for routine tests. Demographic, injury and standard laboratory data were abstracted from patient charts. Comprehensive serum drug testing was done using liquid chromatography‐time‐of‐flight mass spectrometry (LC‐TOF/MS, LC1200‐TOF/MS 6230, Agilent, Santa Clara, CA). Results: Of 272 patients, 71.0% were male, 30.5% had violent injury type and 32.4% had a penetrating injury mechanism. Violent injury type and penetrating injury mechanisms were more frequent in patients who were male, younger age, Black, or Hispanic (p < 0.05 for all). LC‐TOF/MS showed that 46.0% were positive for at least one drug. Stimulant drugs were associated with violent injury type (OR 2.9; 95% CI 1.64–5.15) and penetrating injury mechanism (OR 3.3; 95% CI 1.86–5.82). Tobacco use was associated with violent injury type (OR 3.9; 95% CI 2.25–6.77) and penetrating injury mechanism (OR 4.14; 95%CI 2.4–7.14). Conclusions: Many drugs are present in trauma patients that are not routinely detected on urine drug of abuse tests. Both stimulant drugs and cigarette smoking are indicators of multidimensional hazardous behaviors, which were associated with more violent and penetrating trauma.

Current outcomes of blunt open pelvic fractures: how modern advances in trauma care may decrease mortality

Background Open pelvic fracture, caused by a blunt mechanism, is an uncommon injury with a high mortality rate. In 2008, evidence-based algorithm for managing pelvic fractures in unstable patients was published by the Western Trauma Association (WTA). The use of massive transfusion protocols has become widespread as has the availability and use of pelvic angiography. The purpose of this study was to evaluate the outcome of open pelvic fractures in association with related advances in trauma care. Methods A retrospective review was performed, at an American College of Surgeon verified level I trauma center, of patients with blunt open pelvic fractures from January 2010 to April 2016. The WTA algorithm, including massive transfusion protocol, and pelvic angiography were uniformly used. Data collected included injury severity score, demographic data, transfusion requirements, use of pelvic angiography, length of stay, and disposition. Data were compared with a similar study from 2005. Results During the study period, 1505 patients with pelvic fractures were analyzed; 87 (6%) patients had open pelvic fractures. Of these, 25 were from blunt mechanisms and made up the study population. Patients in both studies had similar injury severity scores, ages, Glasgow Coma Scale, and gender distributions. Use of angiography was higher (44% vs. 16%; P=0.011) and mortality was lower (16% vs. 45%; P=0.014) than in the 2005 study. Conclusions Changes in trauma care for patients with open blunt pelvic fracture include the use of an evidence-based algorithm, massive transfusion protocols and increased use of angioembolization. Mortality for open pelvic fractures has decreased with these advances. Level of evidence Level IV.

Novel method of delivery of continuous positive airway pressure for apnea testing during brain death evaluation

Background There are several methods for apnea testing for the evaluation of neurological death, including oxygen via T-piece, oxygen cannula inserted into the endotracheal tube, and continuous positive airway pressure (CPAP). Lung suitability for transplantation is determined in part by the partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2; P:F) ratio. We hypothesized that delivery of CPAP during apnea testing using a novel method would improve post-test P:F ratios. Methods A retrospective review was performed at a level I trauma center for all patients undergoing apnea testing from 2010 to 2016. The CPAP system used a flow-inflating bag and was made available in 2012. It was used at the discretion of the clinician. Patients were classified as having an apnea test by CPAP or by non-CPAP method (T-piece, oxygen cannula in endotracheal tube, etc). The two groups were compared for baseline characteristics and the primary outcome of postapnea test P:F ratio. Results During the study period, 145 patients underwent apnea testing; 67 patients by the CPAP method and 78 by non-CPAP method. There were no significant differences in demographics, mechanism of brain injury, pneumonia rate, smoking status, or antibiotic usage between the two groups. The pretest P:F ratio was similar between groups, but the CPAP group had significantly higher post-test P:F ratio (304 vs 250, p=0.02). There were no reported complications arising from CPAP use. Conclusions We describe a novel method of delivering CPAP by a flow-inflating bag during examination for brain death. This method led to improved oxygenation, P:F ratios, and may decrease barotrauma. The flow-inflating bag was inexpensive, easily implemented, and without adverse effects. Multicentered, prospective trials are needed to elicit significant benefit in lung donation and transplantation. Level of evidence Level IV, diagnostic tests.