Rondi B. Gelbard

Falls in the elderly: a modern look at an old problem

BACKGROUND Falls are a leading cause of unintentional injury among adults, especially those over 65 years of age. With increasing longevity and improving access to health care, falls are affecting a more mobile senior citizen population that does not fit the typical profile. We set out to evaluate the current nature of these falls in the elderly. METHODS This is a 2-year retrospective chart review of all falls in patients 65 years or older at an urban Level I trauma center. Demographics, location and height of fall, associated injuries, and outcomes were obtained from chart review. RESULTS There were 400 patients meeting inclusion criteria. The cohort had a mean age of 78.3 ± 8.8 years, 50% were male, and 72.5% had at least 1 comorbidity. Non-ground level falls (Non-GLF) were recorded in 56 patients (14%). These patients suffered a significantly higher injury burden. Non-GLF were associated with significantly higher intensive care unit length of stay (2.6 ± 5.6 vs 4.6 ± 6.7 days, P = .016) and a trend toward higher mortality than GLF. CONCLUSIONS Falls remain a source of considerable healthcare expenditure, especially among the elderly. Non-GLF account for 14% of cases and are associated with a significantly higher burden of injury and morbidity. Fall prevention strategies should include these active older individuals at risk of high-level falls.

Effect of delaying same-admission cholecystectomy on outcomes in patients with diabetes

Recent studies have suggested that same‐admission delayed cholecystectomy is a safe option. Patients with diabetes have been shown to have less favourable outcomes after cholecystectomy, but the impact of timing of operation for acute cholecystitis during the same admission is unknown.

Injury to the conduction system: management of life-threatening arrhythmias after penetrating cardiac trauma

BACKGROUND Life-threatening conduction abnormalities after penetrating cardiac injuries (PCIs) are rare, and rapid identification and treatment of these arrhythmias are critical to survival. This study highlights diagnosis and management strategies for conduction abnormalities after PCI. METHODS Patients with life-threatening arrhythmias after PCI were identified at an urban, level I trauma center registry. RESULTS Seventy-one patients survived to reach the hospital after PCI. Of these, 3 (4%) survivors (male = 3, mean age 41.3, median injury severity score = 25) had critical conduction abnormalities after cardiorrhaphy. All patients had multichamber and atrioventricular nodal injury. After initial cardiorrhaphy and control of hemorrhage, all patients had sustained hypotension with bradycardia from complete heart block. Two patients had ventricular septal defects requiring repair. All 3 patients survived. CONCLUSIONS Rapid recognition of injury to the cardiac conduction system after PCI as a source of sustained hypotension is essential to early restoration of cardiac function and survival.

Percutaneous pedicle screw fixation for an unstable thoracic spine fracture after a traumatic degloving injury.

Unstable spinal fractures require urgent surgical intervention to relieve compression of the spinal cord, correct spinal deformity, stabilise the spine and prevent further neurological injury. We report the case of a young man with a thoracic chance fracture in the setting of a devastating degloving injury, whose fracture was stabilised using minimally invasive, percutaneous pedicle screw fixation. We discuss the advantages of using a minimally invasive technique for spinal fixation and its role in the treatment of complicated, multisystem trauma patients.

Universal screening for intimate partner and sexual violence in trauma patients: An EAST multicenter trial

BACKGROUND A single-center trial recently demonstrated a prevalence of 14% of intimate partner and sexual violence (IPSV) among both male and female trauma patients, regardless of mechanism of injury. We aimed to determine if this phenomenon was similar to rates in other trauma centers by assessing the feasibility of universal screening and determining the prevalence and association of IPSV with other trauma-associated comorbidities. METHODS We designed an Eastern Association for the Surgery of Trauma–supported multicenter, prospective observational cohort study involving four Level I trauma centers throughout the United States. Screening occurred from March 2015 to April 2016. We performed universal screening of adult trauma patients using the validated HITS (Hurt, Insult, Threaten, Scream) and SAVE (sexual violence) screening surveys. Trauma recidivism, substance use, and mental illness were also measured and were classified as “trauma-associated comorbidities.” Chi-squared test compared categorical variables with significance at p <0.05. Parametric data is presented as mean ± standard deviation. RESULTS A total of 2,034 eligible trauma patients were screened by clinical social workers at each site over 1 year. The mean age was 37.05 ± 20.32 with 63% men, 37% women, and one transgendered participant. The overall rate of IPSV was 11.4%. The proportion of positive screens for men was 9.3%, with variability between centers (3.8–72.7%), and for women was 16.1% (15.3–50.0%) (p < 0.001). The transgendered patient screened positive for IPSV. Of patients who screened positive for IPSV, 60.0% had one or more trauma-associated comorbidity compared to 15.1% of patients who screened negative (p < 0.001). CONCLUSION More than one in nine trauma patients is at risk of IPSV, regardless of gender or mechanism of injury. IPSV may be a risk factor for other trauma-associated comorbidities. LEVEL OF EVIDENCE Prognostic/Epidemiologic, level II; Care Management, level III.

Trainee Knowledge of Imaging Appropriateness and Safety: Results of a Series of Surveys From a Large Academic Medical Center

OBJECTIVE In order to provide high quality care to their patients and utilize imaging most judiciously, physician trainees should possess a working knowledge of appropriate use, radiation dose, and safety. Prior work has suggested knowledge gaps in similar areas. We aimed to evaluate the knowledge of imaging appropriateness, radiation dose, and MRI and contrast safety of physician trainees across a variety of specialties. METHODS Between May 2016 and January 2017, three online surveys were distributed to all interns, residents, and fellows in ACGME accredited training programs at a large academic institution over two academic years. RESULTS Response rates to three surveys ranged from 17.2% (218 of 1266) for MRI and contrast material safety, 19.1% (242 of 1266) for imaging appropriateness, to19.9% (246 of 1238) for radiation dose. Overall 72% (509 of 706) of survey respondents reported regularly ordering diagnostic imaging examinations, but fewer than half (47.8%; 470 of 984) could correctly estimate radiation dose across four commonly performed imaging studies. Only one third (34%; 167 of 488) of trainees chose appropriate imaging in scenarios involving pregnant patients. Trainee post-graduate year was not significantly correlated with overall radiation safety scores, and no significant difference was found between radiation safety or appropriate imaging scores of those who participated in a medical school radiology elective vs. those who did not. A total of 84% (57 of 68) of radiology trainees and 43% (269 of 630) of non-radiology trainees considered their knowledge adequate but that correlated only weakly correlated to actual knowledge scores (p<0.001). Most trainees (73%, 518 of 706) agreed that more training in these areas would have beneficial effects on patient care. CONCLUSIONS Knowledge gaps pertaining to appropriateness and imaging safety exist among many trainees. In order to enhance the value of imaging at the population level, further work is needed to assess the most appropriate method and stage of training to address these knowledge gaps.

The Trauma Bay Environment

The purpose of the trauma resuscitation area is to receive, triage, assess, stabilize, and if necessary transfer critically injured patients. The design of the trauma resuscitation area should maximize efficient patient inflow, treatment, and outflow. Communication between members of the trauma team, at all levels of patient triage and resuscitation, is critical. This chapter will discuss the overall trauma resuscitation environment, including the general physical design of the area and the layout of the individual trauma bay. The chapter will discuss the importance of preparedness and the need to consider the daily expected patient load as well as additional surge capacity in case of mass casualty events.

Immediate post-traumatic pulmonary embolism is not associated with right ventricular dysfunction.

BACKGROUND Post-traumatic pulmonary embolic events are associated with significant morbidity. Computed tomographic (CT) measurements can be predictive of right ventricular (RV) dysfunction after pulmonary embolus. However, it remains unclear whether these physiologic effects or clinical outcomes differ between early (<48 hours) vs late (≥48 hours) post-traumatic pulmonary embolism (PE). METHODS All patients with traumatic injury and CT evidence of PE between 2008 and 2013 were identified. The study population was divided into 2 groups based on the time of diagnosis of the PE. The primary outcome was PE-related mortality. RESULTS Fifty patients were identified (14 early PE and 36 late PE). Patients sustaining a late PE had a higher PE-related mortality rate (16.7% vs 0%), larger RV diameters, RV/left ventricular diameter ratios, RV volumes, and RV/left ventricular volume ratios (all P < .05). CONCLUSIONS Early post-traumatic PE appears to be associated with fewer RV physiologic changes than late post-traumatic PE and may be representative of primary pulmonary thrombosis. It remains to be seen whether early CT findings of PE should be managed according to previously established guidelines for embolic disease.