Search

Introduction: Hepatic angioembolization is highly effective for hemorrhage control in hemodynamically stable patients with traumatic liver injuries and contrast extravasation. However, there is a paucity of data regarding the specific location of angioembolization within the hepatic arterial vasculature and its implications on patient outcomes., Methods: A post-hoc analysis of a multicenter prospective observational study across 23 centers was performed. Adult patients undergoing main hepatic artery angioembolization or segmental hepatic artery angioembolization within 8 hours of arrival were included. The primary outcome was liver-related complications, defined as perihepatic fluid collection, bile leak/biloma, pseudoaneurysm, hepatic necrosis, and/or hepatic abscess. Secondary outcomes were liver-related complication interventions, length of stay, and mortality., Results: A total of 55 patients underwent hepatic angioembolization, with 23 (41.8%) undergoing main hepatic artery angioembolization and 32 (58.2%) receiving segmental hepatic artery angioembolization. Both groups were comparable in age, vitals, mechanism of injury, liver injury grade distribution, and injury severity score (all P > .05). The main hepatic artery angioembolization group had greater rates of overall liver-related complications (65.2% vs 31.2%, P = .039), specifically perihepatic fluid collection (26.1% vs 6.3%, P = .040) and bile-leak/biloma (34.8% vs 12.5%, P = .048). Main hepatic artery angioembolization had greater rates of 2 or more liver-related complications (47.8% vs 9.4%, P = .001) and readmission within 30 days (30.4% vs 9.4%, P = .046). No significant differences were observed in hospital length of stay and mortality (all P > .05)., Conclusions: Main hepatic artery angioembolization is associated with increased rates of liver-related complications, multiple liver-related complications, and readmission within 30 days compared with segmental hepatic artery angioembolization. Thus, main hepatic artery angioembolization should be reserved for use only when segmental hepatic artery angioembolization is not feasible, albeit with significantly increased morbidity., Competing Interests: Conflict of Interest/Disclosure The authors have no relevant financial disclosures., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Prior studies evaluating observation versus angioembolization (AE) for blunt liver injuries (BLT) with contrast extravasation (CE) on computed tomography imaging have yielded inconsistent conclusions, primarily due to limitations in single-center and/or retrospective study design. Therefore, this multicenter study aims to compare an observation versus AE-first approach for BLT, hypothesizing decreased liver-related complications (LRCs) with observation., Methods: We conducted a post hoc analysis of a multicenter, prospective observational study (2019-2021) across 23 centers. Adult patients with BLT + CE undergoing observation or AE within 8 hours of arrival were included. The primary outcome was LRCs, defined as perihepatic fluid collection, bile leak/biloma, pseudoaneurysm, hepatic necrosis, and/or hepatic abscess. A multivariable logistic regression analysis was used to evaluate risk factors associated with LRCs., Results: From 128 patients presenting with BLT + CE on imaging, 71 (55.5%) underwent observation-first and 57 (45.5%) AE-first management. Both groups were comparable in age, vitals, mechanism of injury, and shock index (all p > 0.05), however the AE group had increased frequency of American Association for the Surgery of Trauma Grade IV injuries (51.0% vs. 22.0%, p = 0.002). The AE cohort demonstrated increased rates of in-hospital LRCs (36.8% vs. 12.7%, p = 0.038), emergency department representation (25.0% vs. 10.0%, p = 0.025), and hospital readmission for LRCs (12.3% vs. 1.4%, p = 0.012). However, the two cohorts had similar mortality rates (5.7% vs. 5.3%, p = 0.912). After adjusting for age, ISS, and grade of liver injury, an AE-first approach had a similar associated risk of LRCs compared with observation-first management (odds ratio, 1.949; 95% confidence interval, 0.673-5.643; p = 0.219)., Conclusion: Patients with blunt liver injury and CE undergoing an observation-first approach were associated with a similar adjusted risk of LRCs and rate of mortality compared with AE-first approach. Overall, this calls for reevaluation of the role of routine AE in blunt liver trauma patients with CE. Future prospective randomized trials are needed to confirm these findings., Level of Evidence: Therapeutic/Care Management, Level IV., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: In patients with severe traumatic brain injury (TBI), clinicians must balance preventing venous thromboembolism (VTE) with the risk of intracranial hemorrhagic expansion (ICHE). We hypothesized that low molecular weight heparin (LMWH) would not increase risk of ICHE or VTE as compared to unfractionated heparin (UH) in patients with severe TBI., Methods: Patients ≥ 18 years of age with isolated severe TBI (AIS ≥ 3), admitted to 24 level I and II trauma centers between January 1, 2014 to December 31, 2020 and who received subcutaneous UH and LMWH injections for chemical venous thromboembolism prophylaxis (VTEP) were included. Primary outcomes were VTE and ICHE after VTEP initiation. Secondary outcomes were mortality and neurosurgical interventions. Entropy balancing (EBAL) weighted competing risk or logistic regression models were estimated for all outcomes with chemical VTEP agent as the predictor of interest., Results: 984 patients received chemical VTEP, 482 UH and 502 LMWH. Patients on LMWH more often had pre-existing conditions such as liver disease (UH vs LMWH 1.7 % vs. 4.4 %, p = 0.01), and coagulopathy (UH vs LMWH 0.4 % vs. 4.2 %, p < 0.001). There were no differences in VTE or ICHE after VTEP initiation. There were no differences in neurosurgical interventions performed. There were a total of 29 VTE events (3 %) in the cohort who received VTEP. A Cox proportional hazards model with a random effect for facility demonstrated no statistically significant differences in time to VTE across the two agents (p = 0.44). The LMWH group had a 43 % lower risk of overall ICHE compared to the UH group (HR = 0.57: 95 % CI = 0.32-1.03, p = 0.062), however was not statistically significant., Conclusion: In this multi-center analysis, patients who received LMWH had a decreased risk of ICHE, with no differences in VTE, ICHE after VTEP initiation and neurosurgical interventions compared to those who received UH. There were no safety concerns when using LMWH compared to UH., Level of Evidence: Level III, Therapeutic Care Management., Competing Interests: Declaration of competing interest The authors have no conflict of interest to disclose., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: High-grade liver injuries with extravasation (HGLI ​+ ​Extrav) are associated with morbidity/mortality. For low-grade injuries, an observation (OBS) first-strategy is beneficial over initial angiography (IR), however, it is unclear if OBS is safe for HGLI ​+ ​Extrav. Therefore, we evaluated the management of HGLI ​+ ​Extrav patients, hypothesizing IR patients will have decreased rates of operation and mortality., Methods: HGLI ​+ ​Extrav patients managed with initial OBS or IR were included. The primary outcome was need for operation. Secondary outcomes included liver-related complications (LRCs) and mortality., Results: From 59 patients, 23 (39.0%) were managed with OBS and 36 (61.0%) with IR. 75% of IR patients underwent angioembolization, whereas 13% of OBS patients underwent any IR, all undergoing angioembolization. IR patients had an increased rate of operation (13.9% vs. 0%, p ​= ​0.049), but no difference in LRCs (44.4% vs. 43.5%) or mortality (5.6% vs. 8.7%) versus OBS patients (both p ​> ​0.05)., Conclusion: Over 60% of patients were managed with IR initially. IR patients had an increased rate of operation yet similar rates of LRCs and mortality, suggesting initial OBS reasonable in appropriately selected HGLI ​+ ​Extrav patients., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Patients with traumatic brain injury (TBI) are at high risk of venous thromboembolism events (VTE). We hypothesized that early chemical VTE prophylaxis initiation (≤24 hours of a stable head CT) in severe TBI would reduce VTE without increasing risk of intracranial hemorrhage expansion (ICHE)., Methods: A retrospective review of adult patients 18 years or older with isolated severe TBI (Abbreviated Injury Scale score, ≥ 3) who were admitted to 24 Level I and Level II trauma centers from January 1, 2014 to December 31 2020 was conducted. Patients were divided into those who did not receive any VTE prophylaxis (NO VTEP), who received VTE prophylaxis ≤24 hours after stable head CT (VTEP ≤24) and who received VTE prophylaxis >24 hours after stable head CT (VTEP>24). Primary outcomes were VTE and ICHE. Covariate balancing propensity score weighting was utilized to balance demographic and clinical characteristics across three groups. Weighted univariate logistic regression models were estimated for VTE and ICHE with patient group as predictor of interest., Results: Of 3,936 patients, 1,784 met inclusion criteria. Incidences of VTE was significantly higher in the VTEP>24 group, with higher incidences of DVT in the group. Higher incidences of ICHE were observed in the VTEP≤24 and VTEP>24 groups. After propensity score weighting, there was a higher risk of VTE in patients in VTEP >24 compared with those in VTEP≤24 (odds ratio, 1.51; 95% confidence interval, 0.69-3.30; p = 0.307), however was not significant. Although, the No VTEP group had decreased odds of having ICHE compared with VTEP≤24 (odds ratio, 0.75; 95% confidence interval, 0.55-1.02, p = 0.070), the result was not statistically significant., Conclusion: In this large multi-center analysis, there were no significant differences in VTE based on timing of initiation of VTE prophylaxis. Patients who never received VTE prophylaxis had decreased odds of ICHE. Further evaluation of VTE prophylaxis in larger randomized studies will be necessary for definitive conclusions., Level of Evidence: Therapeutic Care Management; Level III., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: The management of liver injuries in hemodynamically stable patients is variable and includes primary treatment strategies of observation (OBS), angiography (interventional radiology [IR]) with angioembolization (AE), or operative intervention (OR). We aimed to evaluate the management of patients with liver injuries with active extravasation on computed tomography (CT) imaging, hypothesizing that AE will have more complications without improving outcomes compared with OBS., Methods: This is a prospective, multicenter, observational study. Patients who underwent CT within 2 hours after arrival with extravasation (e.g., blush) on imaging were included. Exclusion criteria included cirrhosis, nontraumatic hemorrhage, transfers from outside facilities, and pregnancy. No hemodynamic exclusion criteria were used. The primary outcome was liver-specific complications. Secondary outcomes include length of stay and mortality. Angioembolization patients were compared with patients treated without AE. Propensity score matching was used to match based on penetrating mechanism, liver injury severity, arrival vital signs, and early transfusion., Results: Twenty-three centers enrolled 192 patients. Forty percent of patients (n = 77) were initially OBS. Eleven OBS patients (14%) failed nonoperative management and went to IR or OR. Sixty-one patients (32%) were managed with IR, and 42 (69%) of these had AE as an initial intervention. Fifty-four patients (28%) went to OR+/- IR. After propensity score matching (n = 34 per group), there was no difference in baseline characteristics between AE and OBS. The AE group experienced more complications with a higher rate of IR-placed drains for abscess or biloma (22% vs. 0%, p = 0.01) and an increased overall length of stay ( p = 0.01). No difference was noted in transfusions or mortality., Conclusion: Observation is highly effective with few requiring additional interventions. Angioembolization was associated with higher rate of secondary drain placement for abscesses or biloma. Given this, a trial of OBS and avoidance of empiric AE may be warranted in hemodynamically stable, liver-injured patient with extravasation on CT., Level of Evidence: Therapeutic/Care Management; Level II., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Medical errors are known to occur even in a controlled setting with adequate resources. The few studies on mass-casualty events and disaster exercises suggest errors may be amplified in these situations. We hypothesized that both the documentation and medical care provided during a pediatric disaster drill would be substandard when compared with routine care at the same institution., Methods: Charts from the disaster exercise and matched charts from actual admitted patients were retrospectively reviewed for the presence of triage classification, allergies, weight, physical exam, vital signs, diagnosis, disposition time, disposition location, disposition instructions, and disposition vitals signs and for the appropriateness of diagnoses, medications, procedures, and disposition. Errors were quantified and classified into negligible, likely to cause temporary harm, or potential to cause admission or permanent harm. The drill charts were compared to actual charts by Fischer's Exact Test., Results: Drill charts contained a significantly greater proportion of errors in regards to performance of procedures, administration of medication, and accuracy of diagnosis. Sixteen percent of these errors were judged as having the potential to cause permanent harm or admission. The exercise charts contained a significantly greater number of omissions in documentation in 9 of the 10 areas evaluated., Discussion: Both the documentation and the quality of care provided during our exercise were deficient when compared with conventional care. Opportunities allowing providers to clearly document pertinent information, and linking of this documentation to relevant prompts and algorithms may minimize this potential for error.

Objective: The purpose of this report is to describe an innovative idea for hospital pediatric victim disaster planning., Design: This is a descriptive manuscript outlining an innovative approach to exercise planning., Setting: All hospitals., Patients: In this report, we describe a model set of patients for pediatric disaster simulation., Results: An epidemiologically based set of mock victims., Conclusions: We believe that by enhancing pediatric disaster simulation exercises, hospital personnel and decision makers will be better prepared for an actual disaster event involving pediatric victims.