Faculty Bibliography

BACKGROUND:The mangled extremity (ME) is a limb with a multisystem injury (soft tissue, bone, nerves, or vessels). We hypothesized that trauma patients who present with mangled lower extremities (ME) experience a higher rate of venous thromboembolism when matched against trauma patients of similar injury burden without ME. MATERIALS AND METHODS/METHODS:Data were abstracted from the Trauma Quality Improvement Program database from 2013 to 2016. Baseline comparisons were made between patients with and without ME. Propensity score matching with logistic regression modeling on the matched sample was performed controlling for patient gender, race, insurance status, age, injury severity score, Charlson comorbidity index, presence of significant other non-ME trauma, use of and time to prophylactic anticoagulation, placement of an inferior vena cava filter, and if immediate operative intervention was performed. RESULTS:A total of 1060 patients presented with an ME. Compared with other trauma patients, those with ME tended to be younger and male. They were more likely to receive prophylactic anticoagulation and an inferior vena cava filter. After propensity score matching, ME was statistically significantly associated with pulmonary embolism (PE) but not deep venous thrombosis (average treatment effect on the treated 1.7%, P = 0.04; and 1.4%, P = 0.22, respectively). These results were confirmed in a logistic regression on the matched sample (odds ratios 1.6, P = 0.11 for deep venous thrombosis, and odds ratio 3.2, P = 0.006 for PE). CONCLUSIONS:Patients with mangled lower extremities experience higher rates of PE. Based on these findings, institutions may consider evaluating their own VTE rates and chemoprophylaxis protocols in those with MEs.

BACKGROUND:Early thoracotomy (ET) is a procedure performed on patients in extremis. Identifying factors associated with ET survival may allow for optimization of guidelines and improved patient selection. OBJECTIVES/OBJECTIVE:The objective of this study was to assess whether ETs performed at Level I trauma centers (TC) are associated with improved survival. METHODS:This was a retrospective study utilizing the National Trauma Databank 2014-2015. We included all thoracotomies performed within 1 h of hospital arrival. Patients were stratified according to TC designation level. Patient demographics, outcomes, and center characteristics were compared. We conducted multivariable regression with survival as the outcome. RESULTS:There were 3183 ETs included in this study; 2131 (66.9%) were performed at Level I TCs. Patients treated at Level I and non-Level I TCs had similar median injury severity scores, as well as signs of life and systolic blood pressures on admission. Patients treated at Level I TCs had significantly higher survival rates (21.6% vs. 16.3%, p < 0.001), with 40% greater odds of survival after controlling for injury-specific factors and emergency medical services transportation time (adjusted odds ratio 1.40, 95% confidence interval 1.04-1.89, p = 0.03). Penetrating injuries had 23.1% survival after ET vs. 12.9% for blunt injuries (adjusted odds ratio 1.86, 95% confidence interval 1.37-2.53, p < 0.001). CONCLUSIONS:ETs performed at Level I TCs were associated with 40% greater odds of survival compared with ETs at non-Level I TCs. This demonstrates that factors extrinsic to the patient may play a role in survival of severely injured patients.

Introduction: Increasing evidence suggests that disparities in outcomes exist among patients with traumatic brain injury (TBI), but much less is known about such disparities in the elderly. The objective of this study was to determine if race and insurance status are associated with mortality among elderly patients with isolated moderate and severe TBI.
Method(s): A 4-year retrospective analysis of the Trauma Quality Improvement Program database (2013-2016) was performed to identify patients aged 60 and older with isolated moderate or severe TBI. Patients were stratified by race and insurance status comparing demographic characteristics and outcomes. A logistic regression analysis was performed to determine the relationship between race, insurance status, and mortality among elderly patients with isolated moderate and severe TBI.
Result(s): A total of 27,951 patients with isolated TBI were identified. Of those, 7.8% were black with 50.2% having insurance and 79.5% were white with 45.3% having insurance. The overall mortality rate was 9.22% with no significant differences in Head AIS. Black patients with insurance were significantly older (73 vs 63, p<0.001) and had more comorbidities (1 [0,2] vs 0 [0,1], p=0.002) when compared with black patients without insurance. With the exception of age, no significant differences were found among white patients. After adjusting for confounding variables, black race was independently associated with decreased mortality (AOR 0.69, 95% CI 0.5-0.96, p= 0.016).
Conclusion(s): Black race, independent of insurance, is associated with decreased mortality among older adults with isolated moderate and severe TBI. The role of race in affecting mortality following TBI warrants further investigation.
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Introduction: Venous thromboembolism (VTE) represents a significant source of morbidity after traumatic brain injury (TBI). The safety and timing of VTE chemoprophylaxis after TBI remain a concern, given the risk of intracranial hemorrhage progression. We evaluated the safety of anti-factor Xa assay-guided dosing for chemoprophylaxis in adult TBI patients. We hypothesized that Xa assay-guided chemoprophylaxis would be safe compared with fixed-dosing.
Method(s): An observational analysis of adult TBI patients was performed at a Level I trauma center from August 2016 to September 2017. Patients in the assay-guided group received an initial enoxaparin dose of 0.5 mg/kg, with peak anti-factor Xa activity measured 4 hours after the third dose. Prophylactic range was defined as 0.2 to 0.5 IU/mL with dose adjustment of +/-10 mg based on the assay result. The assay-guided group compared with historical fixed-dose controls, and a TBI cohort from the most recent Trauma Quality Improvement Program data set.
Result(s): Of the 179 patients included in the study, 85 patients were in the assay-guided group and 94 were in the fixed-dose group. Relative to the fixed-dose group, the assay-guided group had a lower Glasgow Coma Scale score and higher Injury Severity Score (Table). The proportion of severe (Abbreviated Injury Scale head >=4) TBI, intracranial hemorrhage progression, and VTE rates were similar between groups. However, the assay-guided group had chemoprophylaxis initiated earlier and had a higher percentage of low molecular weight heparin use relative to the Trauma Quality Improvement Program sample.
Conclusion(s): Early initiation of low molecular weight heparin anti-factor Xa assay-guided VTE prophylaxis is safe in TBI patients. These findings should be validated prospectively in a multicenter study. [Figure presented]
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Introduction: Hemoperitoneum can be a life-threating condition in cirrhotic patients who have a limited compensatory reserve during hemorrhagic shock. We aim to review the literature on the different etiologies associated with non-traumatic hemoperitoneum (NTH), summarizing the most relevant conditions associated with spontaneous and iatrogenic peritoneal and retroperitoneal bleeding that may occur in cirrhotic patients and to illustrate the most relevant diagnostic strategies and optimal management. Area covered: This review encompasses the current literature in hemoperitoneum in cirrhotic patients in the absence of abdominal trauma. Established diagnostic procedures, therapeutic interventions and potential novel targets are reported and discussed. Expert opinion: To ensure the optimal management regardless of the underlying etiology of NTH, the first goal for the clinician is to obtain immediate hemodynamic stabilization with supportive measures and to control the source of bleeding. The latter can be achieved with angiographic embolization, which is usually the first choice, or with open surgery. Other therapeutic options according to specific etiologies include transjugular intrahepatic portosystemic shunt (TIPS), balloon-occluded retrograde transvenous obliteration (BRTO), balloon-occluded anterograde transvenous obliteration (BATO) or intra operative radio frequency (RF).

BACKGROUND:A federal assault weapons ban has been proposed as a way to reduce mass shootings in the U.S. (U.S). The Federal Assault Weapons Ban (A.W.B.) of 1994 made the manufacture and civilian use of a defined set of automatic and semi-automatic weapons and large capacity magazines illegal. The ban expired in 2004. The period from 1994 to 2004 serves as a single-arm pre-post observational study to assess the effectiveness of this policy intervention. METHODS:Mass shooting data for 1981 to 2017 were obtained from three well-documented, referenced, and open-source sets of data, based on media reports. We calculated the yearly rates of mass shooting fatalities as a proportion of total firearm homicide deaths and per U.S. POPULATION/METHODS:We compared the 1994-2004 federal ban period to non-ban periods, using simple linear regression models for rates and a Poison model for counts with a year variable to control for trend. The relative effects of the ban period were estimated with odds ratios. RESULTS:Assault rifles accounted for 430 or 85.8% of the total 501 mass-shooting fatalities reported (95% CI 82.8, 88.9) in 44 mass-shooting incidents. Mass shootings in the U.S. accounted for an increasing proportion of all firearm-related homicides (coefficient for year = 0.7, p = 0.0003), with increment in year alone capturing over a third of the overall variance in the data (Adjusted R-squared = 0.3). In a linear regression model controlling for yearly trend, the federal ban period was associated with a statistically significant 9 fewer mass shooting related deaths per 10,000 firearm homicides (p = 0.03). Mass-shooting fatalities were 70% less likely to occur during the federal ban period (Relative Rate = 0.30, 95% CI 0.22,0.39). CONCLUSIONS:Mass-shooting related homicides in the U.S. were reduced during the years of the federal assault weapons ban of 1994 to 2004. STUDY TYPE/METHODS:Observational LEVEL OF EVIDENCE: III/IV.

Introduction: Veno-venous extracorporeal membrane oxygenation (VV ECMO) may improve survival in trauma patients with respiratory failure. However, many consider traumatic brain injury (TBI) an absolute contraindication for VV ECMO as systemic anticoagulation could worsen intracranial injury. We evaluated outcomes and complications in patients with TBI treated with VV ECMO. Methods: We retrospectively reviewed TBI patients >= 18 years of age admitted between January 1st 2007 and December 31st 2017 treated with VV ECMO. Demographics, injury specific data, pre-ECMO and ECMO data were collected. The primary outcome was survival to discharge. Secondary outcomes included progression of intracranial hemorrhage, bleeding complications, and episodes of oxygenator thrombosis requiring exchange. Medians and interquartile range were reported where appropriate. Results: 13 patients with TBI received VV ECMO support during the study period. The median age was 28 years old [IQR 25-37.5] and 85% were male. Median admission GCS was 5 [IQR 3-13.5]. Median injury severity score (ISS) was 48 [IQR 33.5-66]. Median head AIS was 4 [IQR 3.5-4.5] with median head AIS 3 [IQR 3-4] in survivors. Median pre-ECMO PaO2:FiO2 ratio was 58 [IQR 47-74.5]. Median time from injury to VV ECMO cannulation was 5 days [IQR 0.75-13]. Median time on ECMO was 192 hours [IQR 48-384]. Five (38.4%) patients survived to hospital discharge. Cause of death included: multisystem organ failure in 4, removal of life sustaining therapy in 3 and death by neurologic criteria in 1. 6 patients (46%) received systemic anticoagulation (A/C). No patient had worsening of intracranial hemorrhage on CT. 1 patient was diagnosed with TBI after initiation of VV ECMO. There were two minor bleeding complications in patients on A/C, neither was related to TBI. 4 patients required oxygenator change; 2 in patients on A/C. Conclusion: VV ECMO is safe in patients with TBI and can be used without A/C in high risk TBI patients without increased oxygenator thrombosis. TBI is not a contraindication to the use of VV ECMO in severe respiratory failure