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Background: We sought to identify opportunities for interventions to mitigate complications of tube thoracostomy (TT)., Methods: Retrospective review of all trauma patients undergoing TT from 6/30/2016-6/30/2019. Multivariable logistic regression identified independent predictors of complications., Results: Out of 451 patients, 171 (37.9%) had at least one TT malpositioning or complication. Placement in the emergency department, placement by emergency medicine physicians, and body mass index >30 kg/m 2 were independent predictors of complication. Malpositioning increased the likelihood of early complication (6.5%-53.5%), and early complication increased the likelihood of late complication (4.3%-13.6%). Patients with a late complication had, on average, a 7.56 day longer hospital stay than patients without a late complication., Conclusion: TT complications were associated with placement in the emergency department, placement by emergency medicine physicians, and BMI>30 kg/m 2 . We identified associations between malpositioning, early complications, and late complications, and demonstrated that TT complications impact patient outcomes., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Drug-specific agents for the reversal of direct oral anticoagulants (DOACs) were recently approved. We hypothesized that the approval of these reversal agents would lead improved outcomes for trauma patients taking DOACs., Methods: A multicenter, prospective (2015-2018), observational study of all adult trauma patients taking DOACs who were admitted to one of fifteen participating trauma centers was performed. The primary outcome was mortality., Results: For 606 trauma patients on DOACs, those reversed were older (78 vs. 74, p = 0.007), more severely injured (ISS: 16 vs. 5, p < 0.0001), had more severe head injuries (Head AIS: 2.9 vs. 1.3, p < 0.0001), and higher mortality (11% vs. 3%, p = 0.001). Patients who received drug-specific agents (idarucizumab, andexanet alfa) had higher mortality (30% vs. 8%, p = 0.04) than those reversed with factor concentrates. However, the low usage of drug-specific reversal agents limits our ability to assess their efficacy and safety., Conclusions: DOAC reversal was not independently associated with mortality. At present, the overall usage of drug-specific reversal agents is too sparing to meaningfully assess outcomes in trauma., Competing Interests: Declaration of competing interest There are no conflicts of interest to report., (Copyright © 2020. Published by Elsevier Inc.)

Background: Venous thromboembolism (VTE) in patients with major pelvic fractures who undergo preperitoneal pelvic packing (PPP) has not been investigated. We hypothesized that patients who undergo PPP are at high risk for VTE, thus early prophylactic anticoagulation and screening duplex are warranted., Study Design: All patients requiring PPP from 2015 to 2019 were reviewed. Management and outcomes were analyzed., Results: During the study period, 79 patients underwent PPP. Excluding the early deaths, 17 patients had deep venous thrombosis (DVT) and 6 had pulmonary emboli (PE); 4 patients had both DVT/PE. Overall mortality was 15%. Thirty-two patients underwent screening duplex within 72 h of admission and 10 were positive for DVT., Conclusion: Patients with complex pelvic trauma undergoing PPP have a 23% incidence of DVT and an additional 8% incidence of PE. 31% of screening ultrasounds are positive. The overall mortality was 15%. With a high incidence of VTE in this patient population, we recommend screening duplex ultrasounds., (Copyright © 2020. Published by Elsevier Inc.)

Background: Most blunt splenic injuries (BSI) are treated with nonoperative management (NOM) or embolization (EMBO). Little is known about the hematologic changes associated with these treatments. We aim to assess the temporal changes of hematologic markers in trauma patients who undergo splenectomy (SPL), packing and splenorrhaphy (P/S), EMBO, or NOM. We hypothesize that differences in trends of hematologic markers exist in patients undergoing EMBO or SPL, compared to NOM., Methods: An 8-year review of adult patients with BSI and underwent SPL, EMBO, P/S, or NOM. White blood cell count (WBC), hematocrit (HCT) and platelet count (PLT) at presentation to 14 days post-admission were analyzed; post-procedural complications were reviewed. Temporal trends were compared using linear mixed-effects models., Results: 478 patients sustained BSI, 298 (62.3%) underwent NOM, 100 (29.2%) SPL, 42 (8.8%) EMBO, and 38 (8.0%) P/S. After adjustment for age, ISS and splenic injury grade, SPL patients had a significantly higher upward trend compared to other management strategies (p < 0.05). Infection further increased this trend. Starting on day 6, SPL patients with infections had significantly higher WBC than those without infection. SPL and P/S were more likely than NOM to develop infections after adjustment for confounders (HR = 3.64; 95%CI: 1.79-7.39 and HR = 2.59; 95%CI: 1.21-5.55, respectively). Day 6 WBC>16,000 cells/ml post-SPL had a positive predictive value (PPV) of 65.2% and negative predictive value (NPV) of 76.9% for infections. Among P/S, Day 6 WBC >10,200 cells/ml had a PPV = 50% and NPV = 86.7% for infections., Conclusions: We observed distinct patterns of hematologic markers following BSI managed with SPL, EMBO, P/S, and NOM. Day 6 WBC increases after SPL or P/S should raise suspicion of infections and trigger a diagnostic investigation., Competing Interests: Declaration of competing interest The manuscript has been submitted solely to this journal and has not previously been published in any form in another publication. The authors have no conflicts of interest related to this manuscript., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Indications for angioembolization (AE) following liver injury are not clearly defined. This study evaluated the outcomes and complications of hepatic AE. We hypothesize hepatic angioembolization is a useful adjunct to non-operative management of liver injury but with significant morbidity., Methods: Subjects were identified utilizing trauma registries from centers in a regional trauma network from 2010 to 2017 with an Abbreviated Injury Scale (AIS) coded hepatic injury and an ICD9/10 for hepatic angiography (HA)., Results: 1319 patients with liver injuries were identified, with 30 (2.3%) patients undergoing HA: median ISS was 26, and median liver AIS was 4. Twenty-three subjects required AE. 81% had extravasation on CT from a liver injury. 63% underwent HA as initial intervention. 43% of AE subjects had liver-related complications with 35% 30-day readmission but with zero 30-day mortality., Conclusions: While there were zero reported deaths, a high rate of morbidity and readmission was found. This may be due to the angioembolization or the liver injury itself., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Differentiation between SBO that will resolve with supportive measures and those requiring surgery remains challenging. WSC administration may be diagnostic and therapeutic. The purpose of this study was to evaluate use of a SBO protocol using WSC challenge. A protocol was implemented at five tertiary care centers. Demographics, prior surgical history, time to operation, complications, and LOS were analyzed. 283 patients were admitted with SBO; 13% underwent immediate laparotomy; these patients had a median LOS of 7.5 days. The remaining 245 were candidates for WSC challenge. Of those, 80% received contrast. 139 (71%) had contrast passage to the colon. LOS in these patients was 4 days. Sixty-five patients (29%) failed contrast passage within 24 h and underwent surgery. LOS was 9 days. 8% of patients in whom contrast passage was observed at 24 h nevertheless subsequently underwent surgery. 4% of patients who failed WSC challenge did not proceed to surgery. Our multicenter trial revealed that implementation of a WSC protocol may facilitate early recognition of partial from complete obstruction., (Copyright © 2019. Published by Elsevier Inc.)

Differentiating SBO that will resolve conservatively from those requiring surgery remains challenging. Water-soluble contrast administration may be diagnostic and therapeutic. Our study evaluated use of a WSC challenge protocol. We hypothesize that protocol use discriminates between surgical SBO and obstructions which can be managed non-operatively. Demographics, prior surgeries, time to operation, complications, and LOS were analyzed. 108 patients were admitted with SBO. 13% underwent immediate laparotomy with concern for bowel compromise; these had a median LOS of 8.5 days. 91 received WSC protocol. Of these, 77% had contrast passage to the colon. Of the 48 in whom contrast passed between 0 and 12 h, LOS was 2 days. Of the 22 patients in whom contrast passed between 12 and 24 h, LOS was 4.5 days. 21 had failure of contrast passage; 18 of those underwent surgery after 24 h as a result. Of the 21 patients who failed WSC challenge, median LOS was 8 days. WSC protocol implementation facilitates early recognition of partial from complete obstruction and may decrease LOS. Our findings warrant further evaluation with a multicenter trial., (Copyright © 2019. Published by Elsevier Inc.)

Background: Multi-detector computed tomography imaging is now the reference standard for identifying solid organ injuries, with a high sensitivity and specificity. However, delayed splenic hemorrhage (DSH), defined as no identified injury to the spleen on the index scan but delayed bleeding from a splenic injury, has been reported. We hypothesized that the occurrence of DSH would be minimized by utilization of modern imaging techniques., Methods: Data was retrospectively collected from 2006 to 2016 in 12 adult Level I and II trauma centers. All patients had an initial CT scan demonstrating no splenic injury but subsequently were diagnosed with splenic bleeding. Demographic, injury characteristics, imaging parameters and results, interventions and outcomes were collected., Results: Of 6867 patients with splenic injuries, 32 cases (0.4%) of blunt splenic hemorrage were identified. Patients were primarily male, had blunt trauma, severely injured (ISS 32 (9-57) and with associated injuries. Injuries of all grades were identified up to 16 days following admission. Overall, half of patients required splenectomy. All index images were obtained using multi-detector CT (16-320 slice). Secondary review of imaging by two trauma radiologists judged 72% (n = 23) of scans as suboptimal. This was due to poor scan quality primary from artifact(23), single phase contrast imaging (16), and/or poor contrast bolus timing or volume (6). Notably, only 28% of scans in patients with DSH were performed with optimal scanning techniques., Conclusion: This is the largest reported series of DSH in the era of modern imaging. Although the incidence of DSH is low, it still occurs despite the use of multi-detector imaging and when present, is associated with a high rate of splenectomy. Most cases of DSH can be attributed to missed diagnosis from suboptimal index imaging and ultimately be avoided., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Choledocholithiasis is present in up to 15% of cholecystectomy patients. Treatment can be surgical, endoscopic, or via interventional radiology. We hypothesized significant heterogeneity between hospitals exists in the approach to suspected common duct stones., Methods: A retrospective review of patients that had a preoperative MRCP, endoscopic ultrasound, endoscopic retrograde cholangiopancreatogram (ERCP), or intra-operative cholangiogram was performed. Comparisons were by Wilcoxon-Mann-Whitney tests with significance of p < 0.05 for paired variables and p < 0.017 for multiple comparisons., Results: Twelve participating institutions identified 1263 patients (409 men and 854 women) with a median age of 49 years (IQR: 31-94). Liver function tests (LFT's) were elevated in 939 patients (75%), median bilirubin level 1.75 mg/dl (IQ: 0.8-3.7 mg/dl) and median common duct size 7 mm (IQR 5-10 mm). The most common initial procedure was cholecystectomy with IOC at seven institutions, endoscopy at four and MRCP at one., Conclusion: Significant variation exists within the surgical community regarding suspected common duct stones. These results underscore the need for a protocol for common duct stones to minimize multiple, redundant interventions., (Copyright © 2019. Published by Elsevier Inc.)

Background: Open pelvic fractures are life-threatening injuries. Preperitoneal pelvic packing (PPP) has been suggested to be ineffective for hemorrhage control in open pelvic fractures. We hypothesize that PPP is effective at hemorrhage control in patients with open pelvic fractures and reduces mortality., Methods: Patients undergoing PPP from 2005 to 2015 were analyzed. Patients with open pelvic fractures were defined as direct communication of the bony injury with overlying soft tissue, vagina, or rectum., Results: During the 10-year study, 126 patients underwent PPP; 14 (11%) sustained an open pelvic fracture. After PPP, 1 patient (7%) underwent angioembolization with a documented arterial blush. PPP controlled pelvic hemorrhage in all patients. Overall mortality rate was 7% with one death due to traumatic brain injury., Conclusions: PPP is effective for hemorrhage control in patients with open pelvic fractures. PPP should be used in a standard protocol for hemodynamically unstable patients with pelvic fractures regardless of associated perineal injuries., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: The literature regarding outcomes in patients on irreversible antithrombotic therapy (IAT) undergoing urgent laparoscopic appendectomy is limited. The aim of this multicenter retrospective study was to examine the impact of prehospital IAT on outcomes in this population., Methods: From 2010 to 2014, seven institutions from the Southwest Surgical Multicenter Trials (SWSC MCT) group conducted a retrospective study to evaluate the clinical course of all patients on IAT who underwent urgent/emergent laparoscopic appendectomy. The IAT+ group was subdivided into IAT+ (Aspirin only) and IAT+ (Aspirin-Plavix). These groups were matched 1:1 to controls. The primary outcomes were estimated blood loss (EBL) and transfusion requirement. Secondary outcomes included infections (SSI - Surgical Site Infection, DSI - Deep Space Infection, and OSI - Organ Space Infection), hospital length of stay (HLOS), complications, 30-day readmissions, and mortality., Results: Out of the 2903 patients included in the study, 287 IAT+ patients were identified and matched in a 1:1 ratio to 287 IAT-patients. In the IAT+ vs IAT-analysis, no significant differences in EBL (p = 1.0), transfusion requirement during the preoperative (p = 0.5), intraoperative (p = 0.3) or postoperative periods (p = 0.5), infectious complications (SSI; p = 1.0, DSI; p = 1.0, and OSI; p = 0.1), overall complications (p = 0.3), HLOS (p = 0.7), 30-day readmission (p = 0.3), or mortality (p = 0.1) were noted. Similarly, outcomes in the IAT+ (Aspirin only) and IAT+ (Aspirin-Plavix) subgroups failed to demonstrate any significant differences when compared to controls., Conclusions: Our analysis suggests that IAT is not associated with worse outcomes in urgent/emergent laparoscopic appendectomy. Prehospital use of IAT should not be used to delay laparoscopic appendectomy., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Many laparoscopic procedures are now performed on an outpatient basis. We hypothesize laparoscopic appendectomy can be safely performed as an outpatient procedure., Methods: Seven institutions adopted a previously described outpatient laparoscopic appendectomy protocol for uncomplicated appendicitis. Patients were dismissed unless there was a clinical indication for admission. Patient demographics, success with outpatient management, time of dismissal, morbidity, and readmissions were analyzed., Results: Two hundred six men and one hundred seventy women with a mean age of 35.4 years were included in the protocol. Seventy-eight patients (21%) had pre-existing comorbidities. 299 patients (80%) were managed as outpatients. There were no conversions to open appendectomy. Postoperative morbidity was 5%. The time of patient dismissals was evenly distributed throughout the day and night. Twelve patients (3%) required readmission. Outpatient follow-up occurred in 63% of patients., Conclusions: An outpatient laparoscopic appendectomy protocol was successfully applied at multiple institutions with low morbidity and low readmission rates. Application of this practice nationally could reduce length of stay and decrease overall health care costs for acute appendicitis., (Copyright © 2017. Published by Elsevier Inc.)

Although one might think surgery and parenting have little in common, there are clear parallels. Historically there has been little formal education for either role. Educators and parents relied on modelling the behavior of others, or trial and error techniques. Mentorship and role models have played a critical role in professional development and continue to have a profound impact. Over the past two decades there has been a marked increase in the resources that are available. Coaching, debriefing, deliberate practice, and formal training are now incorporated in residency programs. Specific lessons from parenthood that can be applied to surgical education include: providing a framework, learning through graduated responsibility, communicating expectations, creating a culture, setting the example, encouraging resilience, promoting autonomy, providing feedback, and navigating failure. The final lesson from parenthood: trust that you have taught them well. And you have to let them go., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: The prevalence and impact of hypercoagulability (hypo) in severely injured patients early after injury remains unclear. We hypothesize that the predominant phenotype of postinjury coagulopathy is hypercoagulability (hyper) and it is associated with increased mortality., Material and Methods: Blood samples from 141 healthy volunteers assayed with thrombelastography (TEG) were used to identify thresholds of hypo and hypercoagulability (above 95th/below the 5 th percentile) in four TEG indices. These cutoffs were subsequently evaluated in severely injured trauma patients (ISS>15) from two level 1 trauma centers., Results: 2540 patients with a median ISS of 25 were analyzed. Normal TEG was present in 36% of patients. Hyper was found in 38% of patients, with mixed (11%) and hypo (15%) being less common. Compared to normal coagulation patients and after controlling for age, sex, blood pressure, and injury hyper (0.013), mixed (p < 0.001) and hypo (p < 0.001) were all independent predictors of mortality., Conclusion: These data support the ongoing need for goal directed resuscitation in trauma patients, it appears the optimal resuscitation strategy should be targeted towards normalization of coagulation status as both early hyper and hypocoagulability are associated with increased mortality., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: We implemented expanded screening criteria for blunt cerebrovascular injuries (BCVIs) in an attempt to capture the remaining 20% of patients not historically identified with earlier protocols. We hypothesized that these expanded criteria would capture the additional 20% of BCVI patients not previously identified., Methods: Screening criteria for BCVI were expanded in 2011 after identifying new injury patterns. The study population included 4 years prior (2007 to 2010; classic) and following (2011 to 2014; expanded) implementation of expanded criteria., Results: BCVIs were identified in 386 patients: 150 during the classic period (2.36% incidence) and 236 in the expanded period (2.99% incidence). In the expanded period, 155 patients were imaged based on classic screening criteria, 62 on expanded criteria (21 complex skull fractures, 20 upper rib fractures, 6 mandible fractures, 2 scalp degloving, 1 great vessel injury, and 12 combination), and 19 for other injuries and symptoms., Conclusions: There was a significant increase in the identification of BCVI following the adoption of expanded screening criteria, resulting in a substantial reduction of missed injuries. Expanded criteria should be adopted when screening for BCVI., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The need for mechanical ventilation (MV) after spinal cord injury (SCI) is a risk factor for prolonged critical care. The "purpose" of this study was to identify the level of cervical SCI that requires MV, thereby defining candidates for tracheostomy., Methods: Patients with cervical SCI over a 15-year period were reviewed., Results: One hundred sixty-three patients sustained cervical SCI. Of 76 complete injuries, 91% required MV for greater than 48 hours. By injury level, MV incidence was 100% for C2-4, 91% for C5, 79% for C6, and 80% for C7. Only one quarter of patients with incomplete SCI required MV for greater than 48 hours; Glascow Coma Score and Injury Severity Score were significantly worse compared with patients not requiring MV., Conclusions: Factors influencing the decision for tracheostomy in cervical SCI patients include the presence of a complete SCI, anatomic level of injury, Glascow Coma Score, Injury Severity Score, and associated thoracic injury. Patients with complete cervical SCI often require prolonged MV. Conversely, the minority of incomplete SCI required MV; the need for tracheostomy was likely performed for associated injuries. Utilizing identified factors permits a thoughtful approach to tracheostomy in this patient population., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Penetrating cardiac injuries (PCI) causing tamponade causes subendocardial ischemia, arrhythmias, and cardiac arrest. Pericardial drainage is an important principle, but where drainage should be performed is debated. We hypothesize that drainage in the emergency department (ED) does not delay definitive repair., Methods: Over a 16-year period, patients sustaining PCI were reviewed., Results: Seventy-eight patients with PCI survived to the operating room (OR), with 39 undergoing ED thoracotomy. An additional 39 patients underwent pericardial drainage, 17 (44%) in the ED and 22 in the OR. Comparing the ED with OR pericardial drainage groups, they had a similar ED systolic pressure (99 ± 25 vs 99 ± 34), heart rate (103 ± 16 vs 85 ± 37), median time to the OR (20 vs 22 min), and mortality (12% vs 23%)., Conclusions: ED pericardial drainage for PCI did not appear to delay operation and had an acceptably low mortality rate. Pericardial drainage is a viable option for stabilization before definitive surgery when surgical intervention is not immediately available in the hemodynamically marginal patient., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Although blunt cerebrovascular injuries (BCVIs) are a well-recognized sequela of trauma in adults, there have been few reports in children. The investigators questioned whether adult screening protocols are appropriate in the pediatric population. The purpose of this study was to describe the incidence, injury patterns, and stroke rates of pediatric patients sustaining BCVIs., Methods: Pediatric patients (aged ≤ 18 years) diagnosed with BCVIs at a regional level I trauma center and a pediatric level I trauma center since 1996 were reviewed., Results: Forty-five patients sustained BCVIs (60% male; mean age, 13 ± .7 years; mean Injury Severity Score, 23 ± 2). Three patients exsanguinated, and 10 presented with stroke; neurologic changes occurred 17 ± 6 hours after injury (range, 1-72 hours). Screening indications were present in 30%. Thirty-two asymptomatic patients were diagnosed. All but 1 received antithrombotic agents; 1 patient had neurologic deterioration despite heparinization. Comparing asymptomatic patients with those with stroke, there was a significant difference in age (15 vs 11 years)., Conclusions: More than two-thirds of patients presenting with stroke did not have screening indications according to adult protocols. With the availability of noninvasive diagnostic imaging such as computed tomographic angiography, broader screening guidelines for children should be instituted., (Copyright © 2012 Elsevier Inc. All rights reserved.)