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Introduction: Pneumonia is a known complication following rib fractures. This study was undertaken to identify clinical and demographic factors associated with the development of pneumonia among trauma patients with rib fractures., Methods: This retrospective study examined trauma patients with one or more rib fractures, who were admitted for inpatient management during the time period 2012 through 2017. Variables studied included age, gender, injury severity score (ISS), mechanism of injury, smoking status, alcohol use, administration of influenza and pneumococcal vaccine, number and side of rib fracture(s), pulmonary contusion, pneumothorax, flail chest, spirometer use, blood transfusion, and intravenous fluid administration., Results: Among 78 cases and 74 controls (matched for age and ISS), patients who developed pneumonia were more likely to be male, have higher number of rib fractures, alcohol consumption of 1-5 drinks per day, and a higher initial volume of intravenous fluids during first 24 h. Patients with pneumonia were more likely to be treated with incentive spirometry. There were no difference in age, ISS, smoking status, side of rib fractures, pulmonary contusion, pneumothorax, flail chest, influenza vaccination, pneumonia vaccination, or mechanism of injury between the two groups., Conclusion: Risk factors for the development of pneumonia following rib fractures include male gender, higher number of rib fractures, alcohol consumption, and higher rates of intravenous fluid administration during the initial 24 h following trauma., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Splenic artery embolization (SAE) is a staple adjunct in the management of blunt splenic trauma. We examined complications of SAE over an 11-year period., Methods: Patients who underwent SAE were identified. Demographic data and the location of the SAE-proximal, distal, or combined-were noted. Major and minor complications were identified., Results: Of 1,383 patients with blunt splenic trauma, 298 (21.5%) underwent operative management, and 1,085 (78.5%) underwent nonoperative management (NOM). SAE was performed in 8.1% of the NOM group. Major complications which occurred in 14% of patients, included splenic abscesses, infarction, cysts, and contrast-induced renal insufficiency. Three-fourths of patients with major complications underwent distal embolization. There were more complications in patients who underwent distal embolization (24% distal vs 6% proximal alone; P = .02). Minor complications, which occurred in 34% of patients, included left-sided pleural effusions, coil migration, and fever., Conclusions: SAE is a useful tool for managing splenic injuries. Major and minor complications can occur. Distal embolization is associated with more major complications., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Splenectomy impairs the ability to combat infection, especially with encapsulated organisms. However, there is limited understanding of the impact of splenic arterial embolisation on immune function. Our hypothesis was that embolisation would not impair systemic immune function. This study examines elements of cellular and humoral immunity in patients undergoing splenic embolisation or splenectomy for trauma., Patients and Methods: Splenic embolisation (SE) and splenectomy patients (S) were compared to blunt trauma patients without splenic injury (NS). Lymphocyte counts, natural-killer cells, serum complement (C3, C4), and properdin levels were assayed., Results: No significant differences in total, helper, or suppressor T-lymphocytes, complement (C3, C4), or properdin were found. B-lymphocyte counts were higher in S (602±445cells/mm(3)) than SE (238±114cells/mm(3)) or NS (293±153cells/mm(3)) (p=.003 for pairwise comparisons). S also had more natural killer T-cells than NS (325±170cells/mm(3) vs. 174±116cells/mm(3), p=.004)., Conclusion: Splenic embolisation does not alter the measured immunologic parameters. The absence of sensitive markers for splenic immune function limits the ability to assess the impact of embolisation for trauma., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: Abdominal computed tomography scanning (AbdCTS) is the standard of care in the evaluation of blunt trauma patients. The liberal use of AbdCTS coupled with advancing imaging technology often results in the detection of incidental findings., Objectives: We sought to characterize the incidence and prevalence of such findings, describe the lesions most frequently seen on AbdCTS performed on patients admitted to a Level I trauma center, and develop a plan for follow-up through our performance improvement process., Methods: AbdCTS reports of all admissions to a Level I trauma center between January 2000 and December 2002 were reviewed. Incidental findings identified were classified into benign anatomic variants, benign pathologic lesions, and pathologic lesions requiring further work-up., Results: A total of 3,113 patients were evaluated by AbdCTS during this time period. There were 1474 incidental findings in 1,103 patients. Seventy-five percent of patients with incidental lesions had no traumatic findings. Benign anatomic variants were present in 1.8%, benign pathologic findings in 27.5%, and pathologic findings requiring work-up in 6.1%. Congenital renal anomalies and duplicate inferior vena cava were the most common benign anatomical findings. Renal and hepatic cysts were the most frequent benign lesions and non-calcified pulmonary nodules and adrenal masses were the pathologic lesions most commonly seen., Conclusions: Incidental findings are seen in up to 35% of trauma AbdCTS. No concomitant traumatic injuries are present in up to 75% of these patients. Protocols for appropriate intervention or arrangements for follow-up care need to be incorporated into the care of the trauma patients., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to assess the impact of care guidelines for patients with isolated blunt splenic trauma on length of stay (LOS) and patient charges., Methods: We conducted a review of the hospital trauma registry and identified patients admitted with blunt splenic injury from 2000 to 2007. Splenic injury guidelines were initiated in November 2004. Patients with other major injuries were excluded. Patients were grouped according to their American Association for the Surgery of Trauma (AAST) splenic injury grade, I-V. Hospital LOS, intensive care unit (ICU) LOS, and patient charges before and after the guidelines were compared., Results: We identified 137 patients with isolated splenic injuries. Sixty-three patients were admitted before and 70 patients after implementation of the guidelines. ICU and hospital LOS were significantly decreased after the guidelines (ICU LOS, 1.35 days before, 0.80 after [P < .01]; and hospital LOS, 4.17 before, 3.27 after [P < .01]). When grouped by AAST grade, grade II injuries had a decrease in hospital LOS (4.5 before vs 2.29 after; P < .01) and ICU LOS (1.43 before vs 0.29 after; P < .01). Adjusted hospital charges showed no significant increase overall after the guideline implementation (mean hospital charges before $23,047 vs after, $24,116; P = .62)., Conclusion: Implementing guidelines for the observation of blunt splenic injury decreased the overall hospital LOS and ICU LOS at our institution, but hospital charges remained the same. Trauma programs should institute splenic injury guidelines to reduce resources needed for the care of isolated splenic injuries.

Background: Blunt thoracic aortic injuries (BTAI) have a high mortality rate. For survivors, chest X-ray (CXR) findings are used to determine the need for further diagnostic testing with chest computerized tomography with angiography (CTA) or conventional angiography. We set to determine the adequacy of utilizing CXR alone as a screening tool for BTAI., Methods: All patients diagnosed with BTAI at a level I trauma-center during a 7-year-period were identified. CXRs of these patients and those of a control group of blunt trauma patients with an injury severity score >15 were reviewed by four trauma surgeons blinded to the diagnosis. Based on each CXR viewed, the surgeons decided if they would have proceeded to chest CTA, angiography, or required no further studies to rule out BTAI., Results: In the 7-year-period, 83 patients had BTAI. CXRs were available in 45 patients. The four surgeons viewed 96 CXRs including those of 51 controls. Based on the CXR appearance in patients with BTAI, the surgeons chose to proceed to chest CTA in 38 patients (84.4%), conventional aortography in two patients (4.4%), and no further testing in five patients (11.2%). A widened mediastinum (75%) and loss of the aorto-pulmonary window (40%) were the most frequent CXR abnormalities. Patients with BTAI were more likely to have an abnormal CXR-40 of 45 (88.8%) patients when compared with the controls-25 of 51 (49%)patients-p < 0.001., Conclusions: Although CXR is a sensitive screening modality, it failed to identify the possibility of BTAI in 11% of patients. The liberal use of chest CTA after high speed motor vehicle crashes is recommended to minimize the incidence of missed BTAI.

Background: Blunt Bowel and Mesenteric injuries (BBMI) can present diagnostic difficulties and are occasionally recognized in a delayed fashion. Most studies evaluating these injuries predate multidetector Computerized Tomography (CT) scan technology. We set out to analyze whether the current era of multislice CT scanning has led to changes in the incidence of missed injuries in BBMI or altered the patterns of diagnosis., Methods: All patients with blunt small and large intestinal injury as well as mesenteric lacerations, recognized in the operating room (OR) between November 2000 and December 2006 were identified from the trauma registry. A 4 slice helical multidetector CT scanner was in use for abdominal CT scans during the first portion of the study (November 2000-July 2005) whereas a 16 slice scanner was in use in the second portion (July 2005-December 2006). Rectal injuries and serosal tears were excluded., Results: Eighty-two patients were identified with BBMI. Twenty-five patients went directly to the OR for laparotomy after a positive Diagnostic Peritoneal Lavage, a positive Focused Abdominal Sonogram or other injury. Of the 57 patients who underwent CT, findings indicating possible BBMI were present in 46 patients (80.7%). These included free fluid without solid organ injury (50.9%), free air (10.5%), active mesenteric bleeding (10.5%), and bowel swelling (5.3%). Eleven patients (19.3%) had delayed bowel or mesenteric injury recognition with the diagnosis ultimately made by repeat CT or in the OR (range, 1-10 days)., Conclusion: Missed injuries remain common in BBMI even in the current era of multislice CT scanners. Free fluid w/o solid organ injury, though not specific, continues to be an important finding. Adjuncts to CT continue to be necessary for the optimal diagnosis of bowel injuries.

Background: The goals of this study were to determine the incidence and duration of hypotension and hypoxia in the prehospital setting in patients with potentially survivable brain injuries, and to prospectively examine the association of these secondary insults with mortality and disability at hospital discharge., Methods: Trauma patients with suspected brain injuries underwent continuous blood pressure and pulse oximetry monitoring during helicopter transport. Postadmission inclusion criteria were (1) diagnosis of acute traumatic brain injury (TBI) confirmed by computed tomography (CT) scan, operative findings, or autopsy findings; and (2) Head Abbreviated Injury Scale (AIS) score of > or = 3 or Glasgow Coma Scale (GCS) score of < or = 12 within the first 24 hours of admission. Patients were excluded with (1) no abnormal intracranial findings on the patient's CT scan; (2) determination of a nonsurvivable injury (based on an AIS score of 6 for any body region; or, (3) death in less than 12 hours after injury. Primary outcome measures included mortality and Disability Rating Scale score at discharge., Results: We enrolled 150 patients into the study. Fifty-seven patients had at least one secondary insult; 37 had only hypoxic episodes, 14 had only hypotensive episodes, and 6 patients had both. Demographics and injury characteristics did not differ between those with and those without secondary insults. The mortality for patients without secondary insults was 20%, compared with 37% for patients with hypoxic episodes, 8% for patients with hypotensive episodes, and 24% for patients with both. The Disability Rating Scale score at discharge was significantly higher in patients with secondary insults. Using multivariate analysis, the calculated odds ratio of mortality caused by prehospital hypoxia after head injury was 2.66 (p < 0.05)., Conclusions: Secondary insults after TBI are common, and these insults are associated with disability. Hypoxia in the prehospital setting significantly increases the odds of mortality after brain injury controlled for multiple variables.

Background: Nonoperative management (NOM) of splenic trauma is now the standard in stable trauma patients. Splenic artery embolization (SAE) is an increasingly used adjunct to NOM. We examined complications arising from SAE., Methods: Patients admitted to a level I trauma center with splenic trauma over a 26-month period were identified. Management method, operative or nonoperative, was noted. SAE patients were analyzed in detail., Results: There were 284 splenic trauma admissions. Ninety-three patients underwent operative management, and 191 received NOM. Fifteen patients (7.8%) underwent SAE. Embolization was proximal in 10, distal in 1, and combined in 4 patients. No NOM failures occurred. Major complications (27%) included splenic bleeding, splenic infarction, splenic abscess, and contrast-induced renal insufficiency. Minor complications of fever, pleural effusions, and coil migration occurred in 53% of patients. No relationship between SAE location and the presence of complications was noted., Conclusions: SAE is an effective and safe procedure. Both major and minor complications can arise after SAE.

Age less than 55 years, normal Glasgow Coma Score (GCS), and absence of hypotension are traditional criteria for the selection of adult patients with blunt splenic trauma for observation. The objective of this study is to challenge these criteria. Two hundred twelve patients who presented with blunt splenic injury between 1992 and 1997 were identified from the Trauma Registry at our Level I trauma center. The patients were divided into three groups: 100 patients (47%) were observed, 108 (51%) underwent immediate splenorrhaphy or splenectomy, and 4 (2%) failed observation. The three groups were compared by participants' ages, GCSs, and histories of hypotension. No statistical differences were noted between the successfully observed patients and those requiring immediate surgery with respect to these criteria. Of the 4 patients who failed observation, all were younger than 55 years, all had a GCS >12, and all were normotensive. Our findings suggest that traditional criteria used to select patients for splenic trauma observation are not absolute indicators and should be liberalized: patients can be successfully observed despite having criteria that, in the past, would have led to immediate operative intervention.

Background: Early tracheostomy has been advocated for ventilator-dependent patients with blunt trauma, but its advantages have not been examined critically., Methods: We retrospectively reviewed our experience with all patients with blunt trauma undergoing tracheostomy during the 6-year period from 1990 to 1995. Patients undergoing tracheostomy within the first 6 days of hospitalization were designated as early recipients (ET) and those undergoing the procedure at 7 or more days were defined as late recipients (LT)., Results: The entire study group consisted of 157 patients. The ET group contained 62 patients and the LT group contained 95 patients. No statistical differences were noted between the 2 groups with respect to sex distribution, injury severity scores, probability of survival scores, or mortality rates. The mean stay in the intensive care unit for the ET group was 15 days compared with 29 days for the LT group (P < or = .001). The mean total hospital stay for the ET group was 33 days compared with 68 days for the LT group (P < or = .001). The mean estimated per-patient hospital charges for only room and ventilator care were $36,609 for the ET group compared with $73,714 for the LT group., Conclusions: ET in this patient group resulted in significantly lowered use of resources with no adverse effect on outcome.

A motor vehicle passenger sustained an acute traumatic lumbar hernia caused by an improperly positioned seat belt. Diagnosis was confirmed on computed tomographic scan, and the defect repaired primarily.

Traumatic bilateral renal artery thrombosis is a rare injury. We found 15 cases previously reported. An additional case report of a 54-year-old man is presented with a review of the literature. The diagnosis was made by computed tomography and confirmed by angiography. Successful revascularization was performed. A high index of suspicion, early diagnosis, and prompt revascularization are essential in obtaining optimal results without hypertension or permanent impairment of renal function.

In this prospective study of 40 patients sustaining blunt chest trauma, the value of single-photon-emission computed tomography (SPECT)-thallium scanning in the prediction of morbidity due to cardiac contusion was examined. Twelve patients developed cardiac complications--arrhythmias, ventricular conduction defects, and pericarditis. The sensitivity of SPECT-thallium scans was 55.6%, and the specificity was 32.1%, with an accuracy of 37.8%. Accuracy of the initial electrocardiogram (ECG) was 85%, with a sensitivity of 91.7% and a specificity of 82.1%. Patients with a normal ECG on admission rarely developed cardiac complications. It is concluded that SPECT-thallium is not a useful screening tool in this patient population.

Pancreaticoduodenectomy has been decried as a means of managing combined pancreatic and duodenal trauma. In order to test this harsh assessment, we have reviewed our experience with this procedure in this setting. Six young males with a mean injury severity score of 15.4 underwent pancreaticoduodenectomy for trauma. Four patients sustained penetrating trauma and two patients suffered blunt injuries; each was felt by clinical assessment to have pancreatic ductal disruption combined with significant duodenal injury. Four patients underwent pancreaticoduodenectomy primarily, while two patients underwent initial drainage and diverticulization. The four patients undergoing immediate resection had a mean hospital stay of 28 days (18-42 days) and did not require further surgical intervention. All are alive and well six months to nine years later. The two patients with drainage and repair of their injuries had a mean hospital stay of 115 days (84-147 days) and required additional laparotomies for pancreatic leaks, enterocutaneous fistulae, or drainage of abscesses. Pancreaticoduodenectomy was ultimately performed in each case, and both have survived. Pancreaticoduodenectomy continues to have a role in the management of combined pancreatic and duodenal injuries.