Robert D. Barraco

Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: A multi-center study of the american association for the surgery of trauma

BACKGROUND Cervical spine clearance in the very young child is challenging. Radiographic imaging to diagnose cervical spine injuries (CSI) even in the absence of clinical findings is common, raising concerns about radiation exposure and imaging-related complications. We examined whether simple clinical criteria can be used to safely rule out CSI in patients younger than 3 years. METHODS The trauma registries from 22 level I or II trauma centers were reviewed for the 10-year period (January 1995 to January 2005). Blunt trauma patients younger than 3 years were identified. The measured outcome was CSI. Independent predictors of CSI were identified by univariate and multivariate analysis. A weighted score was calculated by assigning 1, 2, or 3 points to each independent predictor according to its magnitude of effect. The score was established on two thirds of the population and validated using the remaining one third. RESULTS Of 12,537 patients younger than 3 years, CSI was identified in 83 patients (0.66%), eight had spinal cord injury. Four independent predictors of CSI were identified: Glasgow Coma Score <14, GCSEYE = 1, motor vehicle crash, and age 2 years or older. A score of <2 had a negative predictive value of 99.93% in ruling out CSI. A total of 8,707 patients (69.5% of all patients) had a score of <2 and were eligible for cervical spine clearance without imaging. There were no missed CSI in this study. CONCLUSIONS CSI in patients younger than 3 years is uncommon. Four simple clinical predictors can be used in conjunction to the physical examination to substantially reduce the use of radiographic imaging in this patient population.

An evidence-based review: efficacy of safety helmets in the reduction of head injuries in recreational skiers and snowboarders.

BACKGROUND Approximately 600,000 ski- and snowboarding-related injuries occur in North America each year, with head injuries accounting for up to 20% of all injuries. Currently, there are no major institutional recommendations regarding helmet use for skiers and snowboaders in the United States, in part owing to previous conflicting evidence regarding their efficacy. The objective of this review was to evaluate existing evidence on the efficacy of safety helmets during skiing and snowboarding, particularly in regard to head injuries, neck and cervical spine injuries, and risk compensation behaviors. These data will then be used for potential recommendations regarding helmet use during alpine winter sports. METHODS The PubMed, Cochrane Library, and EMBASE databases were searched using the search string helmet OR head protective devices AND (skiing OR snowboarding OR skier OR snowboarder) for articles on human participants of all ages published between January 1980 and April 2011. The search yielded 83, 0, and 96 results in PubMed, Cochrane Library, and EMBASE, respectively. Studies published in English describing the analysis of original data on helmet use in relation to outcomes of interest, including death, head injury, severity of head injury, neck or cervical spine injury, and risk compensation behavior, were selected. Sixteen published studies met a priori inclusion criteria and were reviewed in detail by authors. RESULTS Level I recommendation is that all recreational skiers and snowboarders should wear safety helmets to reduce the incidence and severity of head injury during these sports. Level II recommendation/observation is that helmets do not seem to increase risk compensation behavior, neck injuries, or cervical spine injuries among skiers and snowboarders. Policies and interventions to increase helmet use should be promoted to reduce mortality and head injury among skiers and snowboarders. CONCLUSION Safety helmets clearly decrease the risk and severity of head injuries in skiing and snowboarding and do not seem to increase the risk of neck injury, cervical spine injury, or risk compensation behavior. Helmets are strongly recommended during recreational skiing and snowboarding.

Injury in the aged: geriatric trauma care at the crossroads

In the 2010 US Census, the number of persons age 65 years and older constituted 13% of the population and is projected to constitute 22% of the population by 2020.1 As the US population ages, there is an increasing volume of GTPs; injury is now the seventh leading cause of death for those age 65 years.2 Geriatric trauma is increasing both in absolute number and as a proportion of annual volume presenting to trauma centers. Based on the National Trauma Data Bank, the proportion of trauma patients aged 65 years or older in Level I and II trauma centers increased from 23% in 2003 to 30% in 2009. This is likely a significant underestimate because most GTPs are treated at lower-level or nontrauma centers.3,4 In Washington State, for example, the annual number of GTPs in the state registry has increased from 4,266 in 2000 to 11,226 in 2012, an increase from 30% to 42% of the total trauma population. Clearly, the management of injury in geriatric patients will continue to be a major challenge for trauma care providers. In his presidential address to the AAST entitled “For the care of the undeserved,” Dr. Robert Mackersie identified the growing population of elderly injured patients as medically underserved in terms of limited trauma center access, age-related treatment biases, and as a result, deprived of many of the recent advances in modern trauma care.5 To specifically address these inequalities, he convened an Ad Hoc Geriatric Committee and charged it, “To advise the AAST regarding the problems, issues, and needs of the geriatric patient.” What follows is the work product of the Committee in responding to President Mackersie’s charge. The initial priority was to survey the membership of the AAST to better understand the current conditions under which hospitalized GTPs are receiving care. The second task of the Committee was to enumerate the major problems associated with the care of GTPs and to suggest potential solutions to the identified problems. While the Committee does not presume infallibility in its pronouncements, the material presented is intended to initiate discussion, stimulate research, and to ultimately result in evidence-based guidelines that will better serve this “underserved” segment of our population.

Evaluation and management of mild traumatic brain injury: An Eastern Association for the Surgery of Trauma practice management guideline

BACKGROUND An estimated 1.1 million people sustain a mild traumatic brain injury (MTBI) annually in the United States. The natural history of MTBI remains poorly characterized, and its optimal clinical management is unclear. The Eastern Association for the Surgery of Trauma had previously published a set of practice management guidelines for MTBI in 2001. The purpose of this review was to update these guidelines to reflect the literature published since that time. METHODS The PubMed and Cochrane Library databases were searched for articles related to MTBI published between 1998 and 2011. Selected older references were also examined. RESULTS A total of 112 articles were reviewed and used to construct a series of recommendations. CONCLUSION The previous recommendation that brain computed tomographic (CT) should be performed on patients that present acutely with suspected brain trauma remains unchanged. A number of additional recommendations were added. Standardized criteria that may be used to determine which patients receive a brain CT in resource-limited environments are described. Patients with an MTBI and negative brain CT result may be discharged from the emergency department if they have no other injuries or issues requiring admission. Patients taking warfarin who present with an MTBI should have their international normalized ratio (INR) level determined, and those with supratherapeutic INR values should be admitted for observation. Deficits in cognition and memory usually resolve within 1 month but may persist for longer periods in 20% to 40% of cases. Routine use of magnetic resonance imaging, positron emission tomography, nuclear magnetic resonance, or biochemical markers for the clinical management of MTBI is not supported at the present time.

Practice management guidelines for the diagnosis and management of injury in the pregnant patient: the EAST Practice Management Guidelines Work Group.

Trauma during pregnancy has presented very unique challenges over the centuries. From the first report of Ambrose Pare of a gunshot wound to the uterus in the 1600s to the present, there have existed controversies and inconsistencies in diagnosis, management, prognostics, and outcome. Anxiety is heightened by the addition of another, smaller patient. Trauma affects 7% of all pregnancies and requires admission in 4 of 1000 pregnancies. The incidence increases with advancing gestational age. Just over half of trauma during pregnancy occurs in the third trimester. Motor vehicle crashes comprise 50% of these traumas, and falls and assaults account for 22% each. These data were considered to be underestimates because many injured pregnant patients are not seen at trauma centers. Trauma during pregnancy is the leading cause of nonobstetric death and has an overall 6% to 7% maternal mortality. Fetal mortality has been quoted as high as 61% in major trauma and 80% if maternal shock is present. The anatomy and physiology of pregnancy make diagnosis and treatment difficult.

Odontoid fractures in the elderly: should we operate?

BACKGROUND : Treatment of odontoid fractures remains controversial. There are conflicting data in the literature with regard to timing of operative fixation (OP), as well as whether OP should be performed. Within our own institution, treatment is variable depending largely on surgeon preference. This study was undertaken in an attempt to develop management consensus by examining outcomes in elderly patients with odontoid fractures and comparing OP to a nonoperative (non-OP) approach. METHODS : The trauma registry of our level I trauma center was queried for elderly (age > or = 60) patients with odontoid fractures from January 2000 to May 2006. Patients were then grouped according to treatment, early-OP (< or =3 days posttrauma), late-OP (>3 days), or non-OP treatment. Patient characteristics that were evaluated and compared among the three groups included age, Injury Severity Score, preexisting conditions, and the type of odontoid fracture. Outcomes evaluated included in-hospital mortality, ventilator days, hospital length of stay (HLOS), need for tracheostomy and percutaneous endoscopic gastrostomy (PEG), and the complications of urinary tract infection (UTI), deep vein thrombosis (DVT), and pneumonia. Differences among groups were tested using analysis of variance, Students t test, chi, and Fishers exact test. RESULTS : The non-OP patients were significantly older than either operative group (mean, 82.4 for non-OP; 77.4 for early-OP; and 76.4 for late-OP; p = 0.006 non-OP compared with either operative group). Injury Severity Score, number of preexisting conditions, mechanism of injury, and distribution of type of odontoid fractures were similar among all three groups. There was no statistically significant difference in mortality among the three groups (11.7% early-OP, 8.7% late-OP, and 17.6% non-OP). There was also no difference among all three groups with respect for the need for tracheostomy and PEG and the development of UTI or pneumonia. However, there were significantly less DVTs in the non-OP group compared with the early-OP group (2.9% vs. 17.6%, p = 0.02). The percentage of patients discharged to a skilled nursing facility was similar among all three groups. The non-OP group had a significant decrease in both ventilator days and HLOS when compared with the operative groups. Only 2.9% of non-OP patients returned for OP for nonunion of the odontoid fracture. CONCLUSIONS : Despite being an older population, elderly patients with odontoid fracture who were managed non-OP had similar mortality, UTI, and pneumonia rates compared with their younger counterparts who underwent OP. The need for tracheostomy and PEG and discharge disposition was similar among all three groups. Elderly patients with odontoid fracture managed non-OP had a reduction in HLOS and ventilator days compared with either operative group and less DVT compared with the early operative group. Based on these results, non-OP management should be given strong consideration in elderly patients with traumatic odontoid fractures.

Prevention of fall-related injuries in the elderly: an eastern association for the surgery of trauma practice management guideline

BACKGROUND Fall-related injuries among the elderly (age 65 and older) are the cause of nearly 750,000 hospitalizations and 25,000 deaths per year in the United States, yet prevention research is lagging. Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, the Eastern Association for the Surgery of Trauma produced this practice management guideline to answer the following injury prevention–related population, intervention, comparator, outcomes (PICO) questions: PICO 1: Should bone mineral–enhancing agents be used to prevent fall-related injuries in the elderly? PICO 2: Should hip protectors be used to prevent fall-related injuries in the elderly? PICO 3: Should exercise programs be used to prevent fall-related injuries in the elderly? PICO 4: Should physical environment modifications be used to prevent fall-related injuries in the elderly? PICO 5: Should risk factor screening be used to prevent fall-related injuries in the elderly? PICO 6: Should multiple interventions tailored to the population or individual be used to prevent fall-related injuries in the elderly? METHODS A comprehensive search and review of all the available literature was performed. We used the GRADE methodology to assess the breadth and quality of the data specific to our PICO questions. RESULTS We reviewed 50 articles that met our inclusion and exclusion criteria as they applied to our PICO questions. CONCLUSION Given the data constraints, we offer the following suggestions and recommendations: PICO 1: We conditionally recommend vitamin D and calcium supplementation for frail elderly individuals. PICO 2: We conditionally recommend hip protectors for frail elderly individuals, in the appropriate environment. PICO 3: We conditionally recommend evidence-based exercise programs for frail elderly individuals. PICO 4: We conditionally recommend physical environment modification for frail elderly people. PICO 5: We conditionally recommend frailty screening for the elderly. PICO 6: We strongly recommend risk stratification with targeted comprehensive risk-reduction strategies tailored to particular high-risk groups. LEVEL OF EVIDENCE Systematic review, level III.

Child Passenger Safety: An Evidence-Based Review

STATEMENT OF THE PROBLEM Motor vehicle crashes are the number one cause of death in the United States in children aged 14 years and younger, the number two cause of death in toddlers, and the number one cause of death in the 5to 14-year-old age group. Proper restraint use can reduce these injuries and fatalities as shown in the literature. However, according to SAFE KIDS study, 8% of children are incorrectly restrained.1 Legislative efforts have been directed at reduction of these numbers. Two means to this end are primary and secondary laws. A primary law allows motorists to be pulled over and cited if noted to be in violation of that law. A secondary law does not allow motorists to be stopped for violating that law but instead mandates that motorists be stopped and cited for another violation before dealing with the one in question. All 50 states and the District of Columbia2 have some form of child restraint laws; however, only half are primary and none have detention options. Data regarding adults show primary laws are more effective in increasing compliance. Despite these efforts, passenger vehicle occupant deaths among children were only 16% lower in 2004 than in 1975.3 In 2004, 5 children died and 586 were injured each and every day in motor vehicle crashes in the United States. Of those killed, half were unrestrained. In 2005, 29% or almost one-third of children younger than 1 year who were killed in motor vehicle crashes were totally unrestrained. Fifty-six percent of children aged 9 years to 12 years who were killed in motor vehicle crashes the same year were also totally unrestrained.4 This is obviously a public health issue of the greatest magnitude. The safety of our children is paramount. Therefore, we, in the Child Passenger Safety Workgroup of the Eastern Association for Surgery of Trauma (EAST) Practice Management Guideline Committee, examined the literature concerning the following questions to be answered. QUESTIONS TO BE ADDRESSED

Motor Vehicle Collision-Related Injuries in the Elderly: An Eastern Association for the Surgery of Trauma Evidence-Based Review of Risk Factors and Prevention.

Advancements in car and road safety in the US have led to a drop in the number of overall fatalities per million miles traveled in recent decades. However, elderly individuals (aged 65 and older) remain more likely to die or be severely injured due to motor vehicle collisions (MVCs) than younger people. As the elderly population continues to grow, the number of elderly injured by MVCs is also expected to increase. In this article, the authors investigate MVC-related injury prevention strategies aimed at elderly drivers and pedestrians. An evidence-based review of risk factors and prevention is conducted. The authors determine that injury prevention research is lagging and they recommend further research to strengthen future evidence-based guidelines.

Effectiveness of the “Timed Up and Go” (TUG) and the Chair test as screening tools for geriatric fall risk assessment in the ED

Objective We sought to evaluate the effectiveness of the “Timed Up and Go” (TUG) and the Chair test as screening tools in the Emergency Department (ED), stratified by sex. Methods This prospective cohort study was conducted at a Level 1 Trauma center. After consent, subjects performed the TUG and the Chair test. Subjects were contacted for phone follow‐up and asked to self‐report interim falling. Results Data from 192 subjects were analyzed. At baseline, 71.4% (n = 137) screened positive for increased falls risk based on the TUG evaluation, and 77.1% (n = 148) scored below average on the Chair test. There were no differences by patient sex. By the six‐month evaluation 51 (26.6%) study participants reported at least one fall. Females reported a non‐significant higher prevalence of falls compared to males (29.7% versus 22.2%, p = 0.24). TUG test had a sensitivity of 70.6% (95% CI: 56.2%–82.5%), a specificity of 28.4% (95% CI: 21.1%–36.6%), a positive predictive (PP) value 26.3% (95% CI: 19.1%–34.5%) and a negative predictive (NP) value of 72.7% (95% CI: 59.0%–83.9%). Similar results were observed with the Chair test. It had a sensitivity of 78.4% (95% CI: 64.7%–88.7%), a specificity of 23.4% (95% CI: 16.7%–31.3%), a PP value 27.0% (95% CI: 20.1%–34.9%) and a NP value of 75.0% (95% CI: 59.7%–86.8%). No significant differences were observed between sexes. Conclusions There were no sex specific significant differences in TUG or Chair test screening performance. Neither test performed well as a screening tool for future falls in the elderly in the ED setting.