Search

Background : The liberal utilization of computed tomography (CT) has significantly contributed to overall improvements in trauma care. However, the role and the current practice of the CT examinations in the management of patients with penetrating liver injuries are scantily documented. Aims : This study was aimed to assess the current practice and the role of the admission and follow-up CT in patients with penetrating liver injuries. Setting and Design : This is a retrospective study at a Level I trauma center. Study period is from 01/2005 to 12/2007. Methods : All patients with penetrating liver injuries were analyzed. Results : Overall, 178 patients with penetrating liver injuries were assessed. A total of 123 (69.1%) patients underwent emergent laparotomy without preoperative CT due to signs of peritonitis (47.8%), hypotension (16.3%), or a GCS of ≤8 (5.1%). In this group of patients, no nontherapeutic laparotomy occurred. The remaining 55 (30.9%) patients underwent CT scan evaluation on admission. Of these, 54.5% were selected for nonoperative management (NOM). Sensitivity and specificity of the admission CT to predict a positive laparotomy was 95.7% and 90.6%, respectively. Overall, 80.6% of isolated liver injuries were successfully managed nonoperatively. Thirty-three (18.5%) patients died within 72 h. In the remaining 145 patients, 33 liver-related complications occurred in 17.2% (25 of 145) of patients. Conclusion : Two-thirds of patients with penetrating liver injuries require emergent laparotomy, mainly due to associated injuries. The remaining one-third of patients, however, is amenable for an admission CT, which reliably predicts successful NOM. Moderate or severe injuries require follow-up CT because of the high incidence of asymptomatic liver-related complications.

Abstract Introduction Hepatic abscesses have been reported as a rare complication of diverticulitis of the bowel. This complication is recognized more commonly at the time of the diagnosis of diverticulitis, or ruptured diverticula, but also can be diagnosed prior to surgery, or postoperatively. Case presentation This report describes a man who developed an hepatic abscess within a simple hepatic cyst, two months after operation for ruptured diverticula of the sigmoid colon. The abscess was drained surgically and the patient made a complete recovery. Conclusion The development of an hepatic abscess in a pre-existing hepatic cyst, secondary to diverticulitis, is a rare complication. A high degree of clinical suspicion is required for immediate diagnosis and treatment.

Background: Timing of venous thromboembolism chemoprophylaxis (VTEPPx) in traumatic brain injury (TBI) is complex given concerns for potential worsening of hemorrhage. While timing of VTEPPx for TBI patients is known to vary at the patient level, to our knowledge, variation at the hospital level and correlation with quality metrics have not been quantified in a cohort of nonneurosurgical patients., Methods: This was a retrospective cohort study of the Trauma Quality Improvement database from 2018 to 2021. The primary outcome was variation in VTEPPx timing. This was ascertained by empirical Bayesian methodology using multilevel mixed-effects logistic regression. Secondary outcomes included the association of risk-adjusted VTEPPx timing and hospital characteristics such as volume and risk-adjusted mortality, which was assessed through Pearson's correlation coefficient (r). Risk-adjusted mortality was similarly calculated using multilevel mixed-effects modeling., Results: Of 132,028 patients included in the current study, 38.7% received care at centers in the earliest quartile of VTEPPx timing, classified as Early (others labeled Delayed). Patients receiving care at Early centers presented with severe TBI at a similar rate to Delayed (17.4% vs. 19.0%; absolute standardized mean difference, 0.04). Early center patients more commonly received unfractionated heparin as opposed to low-molecular-weight heparin compared with Delayed (40.5% vs. 27.6%; absolute standardized mean difference, 0.28). At the center level, 12% of observed variation in VTEPPx was attributable to differential hospital practices. Overall trauma volume (r = -0.22, p < 0.001) and TBI volume (r = -0.19, p < 0.001) were inversely associated with risk-adjusted VTEPPx timing. In addition, centers initiating VTEPPx earlier had lower overall (r = 0.17, p < 0.001) and TBI-related mortality (r = 0.17, p < 0.001)., Conclusion: There is significant center-level variation in timing of VTEPPx among TBI patients. Earlier VTEPPx was associated with improved center outcomes overall and among TBI patients, supporting usage of VTEPPx timing as a holistic measure of quality., Level of Evidence: Prognostic and Epidemiological; Level III., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Small bowel obstruction (SBO) is a common cause of hospital admission leading to resource utilization. The majority of these patients require non-operative management (NOM) which can lead to increased length of stay (LOS), readmissions, resource utilization, and throughput delays. Early surgical consultation (SC) for SBO may improve efficiency and outcomes. Methods: We implemented an institution-wide intervention (INT) to encourage early SC (<1 day of diagnosis) for SBO patients in July 2022. A retrospective analysis was performed on all patients with SBO requiring NOM from January 2021 to June 2023, categorized into pre- and post-INT groups. The primary outcome was the number of SC's and secondary outcomes were early SC (<1 day of diagnosis), utilization of SBFT, LOS, 30-day readmission, and costs of admission. Results: A total of 670 patients were included, 438 in the pre-INT and 232 in the post-INT group. Overall, SBFT utilization was significantly higher in cases with SC (17.2% vs 41.4%, P < .001). Post-INT patients were more likely to receive SC (94.0% vs 83.3%, P < .001) and increased SBFT utilization (47.0% vs 33.6%, P = .001). Additionally, early SC improved significantly in the post-INT group (74.3% vs 65.7%, P = .03). There was no difference in LOS between groups (4.0 vs 3.8 days, P = .48). There was a trend toward decreased readmission rates in the INT group at 30 days (7.3% vs 11.0%, P = .13) and reduced direct costs in the INT group (US$/admission = 8467 vs 8708, P = .1). Conclusion: Hospital-wide interventions to increase early surgical involvement proved effective by improving early SC, increased SBFT utilization, and showed a trend towards decreased readmission rates and direct costs., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Within component therapy of massive transfusion protocol (MTP) in trauma, thawed plasma is particularly susceptible to expiring without use given its short 5-day shelf life. Optimizing the number of thawed products without compromising safety is important for hospital resource management. The goal is to examine thawed plasma utilization rates in trauma MTP events and optimize the MTP cooler content at our Level I trauma center., Methods: Trauma MTP activations from 01/2019 to 12/2022 were retrospectively reviewed. During the study period, blood products were distributed in a 12:12:1 ratio of packed red blood cells (pRBC): plasma: platelets per cooler, with up to 4 additional units of low-titer, group O whole blood (LTOWB) available. The primary measure was percent return of unused, thawed plasma., Results: There were 367 trauma MTP activations with a median (IQR) activation call-to-first cooler delivery time of 8 (6-10) minutes. 73.0% of thawed plasma was returned to the blood bank unused. In one third of MTP activations, all dispensed plasma was returned. The majority (74.1%) of patients required 6 or fewer units of plasma. In 81.5% of activations, 10 or fewer units of plasma and 10 or fewer units of pRBC were used., Discussion: The majority of trauma MTP requirements may be accommodated with a reduced cooler content of 6 units pRBC, 6 units plasma, and 1 pheresis platelets, buffered by up to 4 units LTOWB (approximates 4 units of pRBC/4 units plasma), in conjunction with a sub-10min cooler delivery time. Follow-up longitudinal studies are needed., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: The role of robotic surgery in the nonelective setting remains poorly defined. Accessibility, patient acuity, and high turn-over may limit its applicability and utilization. The goal is to characterize the role of robotic cholecystectomy (CCY) in a busy acute care surgery (ACS) practice at a quaternary medical center, and compare surgical outcomes and resource utilization between robotic and laparoscopic CCY., Methods: Adult patients who underwent robotic (Da Vinci Xi) or laparoscopic CCY between 01/2021-12/2022 by an ACS attending within 1 week of admission were included. Primary outcomes included time from admission to surgery, off hour (weekend and 6p-6a) cases, operation time, and hospital costs, to reflect "feasibility" of robotic compared to laparoscopic CCY. Secondary outcomes encompassed surgery-related outcomes and complications., Results: The proportion of robotic CCY increased from 5% to 32% within 2 years. In total 361 laparoscopic and 89 robotic CCY were performed. Demographics and gallbladder disease severity were similar. Feasibility measures-operation time, case start time, time from admission to surgery, proportion of off-hour cases, and cost-were comparable between robotic and laparoscopic CCY. There were no differences in surgical complications, common bile duct injury, readmission, or mortality. Conversion to open surgery occurred more often in laparoscopic cases (5% vs 0%, P = .02, OR = 1.05)., Discussion: Robotic CCY is associated with fewer open conversions and otherwise similar outcomes compared to laparoscopic CCY in the non-elective setting. Incorporation of robotic CCY in a busy ACS practice model is feasible with available resources., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: The aim was to leverage electronic health record (EHR) smartphrases to improve compliance with the modified Brain Injury Guidelines (mBIG)., Methods: Smartphrases were developed for the trauma team and radiology and implemented December 2022. Traumatic brain injury (TBI) patients meeting mBIG inclusion from 03/2021- 07/2023 were reviewed. Smartphrase usage and clinical compliance with mBIG (measured by percent reduction of repeat head imaging, ICU admissions, and neurosurgery consults) were compared pre- and post-intervention., Results: 268 cases were examined. Post-intervention, mBIG1 patients had significantly fewer neurosurgery consults (82.4 ​% vs. 50.0 ​%, OR ​= ​0.21, p ​= ​0.03), while mBIG2 patients had significantly fewer repeat head CTs (91.0 ​% vs. 66.7 ​%, OR ​= ​0.2, p ​= ​0.01), ICU admissions (66.7 ​% vs. 38.5 ​%, OR ​= ​0.31, p ​= ​0.02) and neurosurgery consults (93.9 ​% vs. 56.4 ​%, OR ​= ​0.08, p ​< ​0.01)., Conclusion: Standardized smartphrases can streamline workflow and significantly improve trauma team compliance with best practice guidelines for TBI and reduce unnecessary imaging, consults, and costly ICU admissions., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: The American College of Surgeons (ACS) Committee on Trauma has established a framework for trauma center quality improvement. Despite efforts, recent studies show persistent variation in patient outcomes across national trauma centers. We aimed to investigate whether risk-adjusted mortality varies at the hospital level and if high-performing centers demonstrate better adherence to ACS Verification, Review, and Consultation (VRC) program quality measures., Methods: We analyzed data from the 2018-2021 ACS TQIP Participant Use Files, focusing on adult admissions at ACS-verified Level I or II trauma centers for blunt, penetrating, or isolated traumatic brain injury. We used mixed-effects models to assess center-specific risk-adjusted mortality and identified high-performing centers (HPTC), defined as those with the lowest decile of overall risk-adjusted mortality. We compared patient and hospital characteristics, outcomes, and adherence to ACS-VRC quality measures between HPTC and non-HPTC., Results: Over the study period, 1,498,602 patients across 442 Level I and II trauma centers met inclusion criteria: 65.3% presenting with blunt injury, 9.3% with penetrating injury, and 25.4% with isolated TBI. Management at HPTC was associated with lower odds of major complications, failure-to-rescue and takeback. Furthermore, HPTC status was associated with increased odds of adherence to several ACS-VRC quality measures, including balanced resuscitation (Odds Ratio [OR] 1.40, 95%Confidence Interval [CI] 1.29-1.51), appropriate pediatric admissions (OR 1.88, 95%CI 1.07-3.68), and substance abuse screening (AOR 1.14, 95%CI 1.12-1.16)., Conclusion: Significant variation in risk-adjusted mortality persists across trauma centers. Given the association between adherence to quality measures and high-performance, multidisciplinary efforts to refine and implement guidelines are warranted., (Copyright © 2024 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: The modified Brain Injury Guidelines (mBIG) were developed to stratify traumatic brain injuries (TBIs) and improve health care utilization by selectively requiring repeat imaging, intensive care unit admission, and neurosurgical (NSG) consultation. The goal of this study is to assess safety and potential resource savings associated with the application of mBIG on interhospital patient transfers for TBI., Methods: Adult patients with TBI transferred to our Level I trauma center from January 2017 to December 2022 meeting mBIG inclusion criteria were retrospectively stratified into mBIG1, mBIG2, and mBIG3 based on initial clinicoradiological factors. At the time, our institution routinely admitted patients with TBI and intracranial hemorrhage (ICH) to the intensive care unit and obtained a repeat head computed tomography with NSG consultation, independent of TBI severity or changes in neurological examination. The primary outcome was progression of ICH on repeat imaging and/or NSG intervention. Secondary outcomes included length of stay and financial charges. Subgroup analysis on isolated TBI without significant extracranial injury was performed., Results: Over the 6-year study period, 289 patients were classified into mBIG1 (61; 21.1%), mBIG2 (69; 23.9%), and mBIG3 (159; 55.0%). Of mBIG1 patients, 2 (2.9%) had radiological progression to mBIG2 without clinical decline, and none required NSG intervention. Of mBIG2, 2 patients (3.3%) progressed to mBIG3, and both required NSG intervention. More than 35% of transferred patients had minor isolated TBI. For mBIG1 and mBIG2, the median hospitalization charges per patient were $152,296 and $149,550, respectively, and the median length of stay was 4 and 5 days, respectively, with the majority downgraded from the intensive care unit within 48 hours., Conclusion: Clinically significant progression of ICH occurred infrequently in 1.5% of patients with mBIG1 and mBIG2 injuries. More than 35% of interfacility transfers for minor isolated TBI meeting mBIG1 and 2 criteria are low value and may potentially be safely deferred in an urban health care setting., Level of Evidence: Therapeutic/Care Management; Level IV., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.)

Background: California issued stay-at-home (SAH) orders to mitigate COVID-19 spread. Previous studies demonstrated a shift in mechanisms of injuries (MOIs) and decreased length of stay (LOS) for the general trauma population after SAH orders. This study aimed to evaluate the effects of SAH orders on geriatric trauma patients (GTPs), hypothesizing decreased motor vehicle collisions (MVCs) and LOS., Methods: A post-hoc analysis of GTPs (≥65 years old) from 11 level-I/II trauma centers was performed, stratifying patients into 3 groups: before SAH (1/1/2020-3/18/2020) (PRE), after SAH (3/19/2020-6/30/2020) (POST), and a historical control (3/19/2019-6/30/2019) (CONTROL). Bivariate comparisons were performed., Results: 5486 GTPs were included (PRE-1756; POST-1706; CONTROL-2024). POST had a decreased rate of MVCs (7.6% vs 10.6%, P = .001; vs 11.9%, P < .001) and pedestrian struck (3.4% vs 5.8%, P = .001; vs 5.2%, P = .006) compared with PRE and CONTROL. Other mechanisms of injury, LOS, mortality, and operations performed were similar between cohorts. However, POST had a lower rate of discharge to skilled nursing facility (SNF) (20% vs 24.5%, P = .001; and 20% vs 24.4%, P = .001)., Conclusion: This retrospective multicenter study demonstrated lower rates of MVCs and pedestrian struck for GTPs, which may be explained by decreased population movement as a result of SAH orders. Contrary to previous studies on the generalized adult population, no differences in other MOIs and LOS were observed after SAH orders. However, there was a lower rate of discharge to SNF, which may be related to a lack of resources due to the COVID-19 pandemic, and thus potentially negatively impacted recovery of GTPs.Keywords., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Antithrombin III (ATIII) deficiency may result from hereditary or acquired reduction in ATIII levels and is associated with an increase in venous thromboembolism (VTE) in the general population. VTE is a potentially preventable complication in the critically ill surgical patients. The objective of this study was to evaluate the relation between ATIII levels and VTE in surgical intensive care unit (SICU) patients., Methods: All patients admitted to the SICU from January 2017 to April 2018 who had ATIII levels drawn were included in the study. An ATIII level below 80% of normal was considered low. The rate of VTE during the same admission was compared among patients with normal and low levels of ATIII. Prolonged length of stay (LOS >10 days) and mortality were also measured., Results: Of the 227 patients included, 59.9% were male. The median age was 60 years. Overall, 66.9% of patients had low ATIII levels. Trauma patients had a higher rate of normal ATIII levels, whereas those weighing more than 100 kg had a higher rate of low ATIII levels. Patients with low ATIII levels had higher VTE rates compared with those with normal ATIII levels (28.9% vs. 16%, p=0.04). Patients with low ATIII levels also had prolonged LOS (76.3% vs. 60%, p=0.01) and increased mortality (21.7% vs. 6.7%, p<0.01). Trauma patients with VTE were more likely to have normal ATIII levels (38.5% in low ATIII cohort vs. 61.5% VTE in normal ATIII cohort, p<0.01)., Conclusion: Critically ill surgical patients with low ATIII levels have higher incidence of VTE, longer LOS, and higher mortality. In contrast, critically ill trauma patients may have high incidence of VTE even with normal ATIII levels., Level of Evidence: III., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Patients suspected of syncope frequently undergo laboratory and imaging studies to determine the etiology of the syncope. Variability exists in these workups across institutions. The purpose of this study was to evaluate the utilization and diagnostic yield of these workups and the patient characteristics associated with syncopal falls., Methods: A multi-institutional retrospective review was performed on adult patients admitted after a fall between 1/2017-12/2018. Syncopal falls were compared to non-syncopal falls., Results: 4478 patients were included. There were 795 (18%) patients with a syncopal fall. Electrocardiogram, troponin, echocardiogram, CT angiography (CTA), and carotid ultrasound were more frequently tested in syncope patients compared to non-syncope patients. Syncope patients had higher rates of positive telemetry/Holter monitoring, CTAs, and electroencephalograms., Conclusion: Patients who sustain syncopal falls frequently undergo diagnostic testing without a higher yield to determine the etiology of syncope., Competing Interests: Declaration of competing interest There are no funding sources to report. There are no conflicts of interest to report., (Copyright © 2022 Elsevier Inc. All rights reserved.)

COVID-19 stay-at-home (SAH) orders were impactful on adolescence, when social interactions affect development. This has the potential to change adolescent trauma. A post-hoc multicenter retrospective analysis of adolescent (13-17 years-old) trauma patients (ATPs) at 11 trauma centers was performed. Patients were divided into 3 groups based on injury date: historical control (CONTROL:3/19/2019-6/30/2019, before SAH (PRE:1/1/2020-3/18/2020), and after SAH (POST:3/19/2020-6/30/2020). The POST group was compared to both PRE and CONTROL groups in separate analyses . 726 ATPs were identified across the 3 time periods. POST had a similar penetrating trauma rate compared to both PRE (15.8% vs 13.8%, P = .56) and CONTROL (15.8% vs 14.5%, P = .69). POST also had a similar rate of suicide attempts compared to both PRE (1.2% vs 1.5%, P = .83) and CONTROL (1.2% vs 2.1%, P = .43). However, POST had a higher rate of drug positivity compared to CONTROL (28.6% vs 20.6%, P = .032), but was similar in all other comparisons of alcohol and drugs to PRE and POST periods (all P > .05). Hence ATPs were affected differently than adults and children, as they had a similar rate of penetrating trauma, suicide attempts, and alcohol positivity after SAH orders. However, they had increased drug positivity compared to the CONTROL, but not PRE group.