86.07 BURDEN AND CHARACTERISTICS OF GLASS TABLE INJURIES

Posted on January 26, 2017

D. Chauhan1, C. Villegas1, R. Bueser1, S. Bonne1, D. Livingston1  1Rutgers – New Jersey Medical School,Department Of Trauma/critical Care,Newark, NJ, USA

Introduction:
Our trauma center has observed an increase in children with severe injuries from glass tables. This mechanism of injury is not well described. The goals of this study were to describe the burden of glass table injuries using the National Electronic Injury Surveillance System (NEISS) dataset and compare it to our data from a level 1 urban trauma center.

Methods:
The NEISS dataset from 2009 to 2015 was reviewed for glass table injuries. Data on demographics, injury severity, its description and outcomes were extracted. Cases were divided as they related to the glass shattering: definite, probable and not due to faulty glass. Similarly, our trauma registry was queried for all patients injured involving breaking glass tables from 2001 to 2016. An online search of 3 furniture websites was performed for details of the glass and safety information provided to consumers.  

Results:
3241 patients were reviewed in the NEISS data; 1151 definitely and 665 probably sustained injury due to the glass itself. Defined criteria (e.g. torso penetration or shock) to classify injury severity were developed and each injury was classified as mild or severe.  265 injuries were severe, 233 (88%) of which were due to faulty class.  There was a bimodal distribution in age with peaks at 2 and 22 years.  Demographics, injury pattern and disposition are shown in the Table and is compared to the 24 patients treated at our trauma center. No websites provided any safety instructions for glass tables. 113/300 (38%) tables examined had no information if the glass was tempered or on glass thickness. Currently there are no quality requirements for glass tables in the United States. 

Conclusion:
Glass table injuries are not uncommon, occasionally lethal and preventable. The burden is real, likely under reported and costly. Children are especially at risk. Warnings to consumers and enactment of glass standards by the Consumer Product Safety Commission is warranted. 
 

86.06 Current Practice Patterns and Burnout of Trauma and Acute Care Surgeons

Posted on January 26, 2017

N. Droz2, P. Parikh2, M. Whitmill2, K. M. Hendershot1  1University Of Alabama at Birmingham,Acute Care Surgery,Birmingham, Alabama, USA 2Wright State University,Trauma And Acute Care Surgery,Dayton, OH, USA

Introduction:

Providing 24/7 care for our patients and supervision for our residents/fellows is a cornerstone in the Trauma/Acute Care Surgeons (T/ACS) work-life.  Our previous work defined what the T/ACS current practice pattern is (majority in a group practice with shared responsibilities; majority take in-house call in 24 hour shifts and 3-7 calls per month; majority staying part or all of post-call day).

The purpose of our current study is to look at the T/ACS attitudes regarding their practice patterns, specifically related to their call schedule and post-call day.  Issues such as post-call fatigue and burnout related to their work schedule are also explored.

Methods:

An IRB-approved electronic survey was distributed nationally to Eastern Association for the Surgery of Trauma members.  Participants were asked about attitudes related to their call schedule and coverage they provide while on call.  They were also asked about fatigue and burnout related to their work schedule.

Results:

A total of 274 participants were analyzed (response rate 20%).  The majority like their call schedule structure and length of their call shifts (62% and 66%, respectively).  The scope of practice was liked by 77% with 14% not liking the elective surgery aspect of the practice.  The majority (86%) covers all trauma, emergency general surgery (EGS), and surgical critical care while on call and 75% feel this is an adequate amount of work to cover while on call.  The majority (83%) think they should get paid for trauma/EGS call.

 

Although 75% state they are able to get some rest while on call, 56% are “very tired” post-call and 29% have fallen asleep while driving post-call.  The majority (71%) is concerned about fatigue post-call; 67% are concerned about being over-worked, and 72% are concerned about burnout.  A change in their practice pattern could help with fatigue and feelings of being overworked according to 72% of participants.

Conclusion:

Despite the majority of T/ACS expressing concern about post-call fatigue, being overworked, and feelings of burnout, less than 20% have developed or implemented any innovative strategies to change the call structure and post-call day.  Change is often difficult, so trying to think outside the box and develop novel approaches to attendings’ practice patterns should be encouraged and shared with the larger trauma community.

 

86.05 Race and Insurance Status as Predictors of Outcomes and Care in Severe Thoracic Trauma

Posted on January 26, 2017

R. A. Rauh1, T. J. Zens1, G. Leverson1, M. V. Beems1, S. K. Agarwal1  1University Of Wisconsin,Trauma And Acute Care Surgery,Madison, WI, USA

Introduction:   

Healthcare disparities based on race and socioeconomic status have been documented in the literature; however, data on how these factors effect outcomes in patients experiencing severe thoracic trauma is lacking. This study aims to identify potential disparities in treatment and outcomes in this patient population.

Methods:

The National Trauma Data Bank was queried for all rib fracture patients with ISS scores>15 between 2007-2012. A univariate and multivarite logistic regression model was run which controlled for patient co-morbidities, age, ISS, and associated injuries.  Patient outcomes in length of stay, mortality, discharge disposition, and in hospital procedures were compared between patients of varying race and insurance status to white and privately insured patients, respectively.

Results: 

A cohort of 69,424 patients were selected for analysis.  87.1% of patients were white, 10.2% African American and 1.98% Asian. 14.2% of patients were covered by private insurance vs. 30.1% by Medicare and 21.5% by Medicaid.  34.1% were uninsured.  Uninsured (OR = 1.753; CI = 1.468- 2.094), Medicaid (OR = 1.568; CI = 1.295-1.898), and Medicare (OR = 2.768; CI = 2.313-3.313) patients had higher in-hospital mortality than privately insured patients. Uninsured patients (OR = 0.804; CI = 0.745, 0.867) were less likely to exceed the median hospital stay, while Medicaid (OR = 1.445 CI = 1.331-1.568) and African American patients (OR = 1.144, CI= 1.083-1.208)  were more likely exceed the median hospital stay than those privately insured.  Medicare (OR = 1.103; CI = 1.004-1.212) and Medicaid (OR = 1.328; CI =1.210-1.458) patients were more likely to receive an epidural during the course of care than privately insured patients, but there were no other statistically significant differences with regards to race or insurance status. Medicaid (OR=1.330; CI = 1.216-1.453) and African American patients (OR = 1.081; CI= 1.018-1.148) were more likely to require mechanical ventilation than privately insured or White patients.  Finally, uninsured patients (OR=0.572; CI = 0.505-0648) were less likely to receive continuing medical care after hospitalization in a nursing facility or acute care rehab center.  In contrast, Medicaid (OR=1.412; CI = 1.249-1.595) and Medicare (OR = 3.661; CI = 3.252- 4.121) patients were more likely to be discharged one of these facilities.

Conclusion: 

When examining healthcare disparities among thoracic trauma patients, we documented less significant differences among racial groups than among insurance statuses.  Overall, we found the uninsured were more likely to be discharged early to their homes while Medicare and Medicaid patients were more likely to be discharged to a care facilities such as nursing homes or acute care hospitals. We also found the privately insured had lower mortality than Medicare, Uninsured and Medicare patients.  Further research is needed on whether changes implemented by Affordable Care Act have helped to eliminate this disparities.

86.04 Time to Surgical Source Control in Intra-Abdominal Infections

Posted on January 26, 2017

R. Chang1, M. Scerbo1, L. Moore1, A. Macaluso1, C. Wade1, J. Holcomb1  1University Of Texas Health Science Center At Houston,Surgery,Houston, TX, USA

Background: Although many infections can be treated with antibiotic therapy alone, intra-abdominal infections (IAI) often require surgical intervention to achieve adequate source control. Time to initiation of appropriate antibiotic therapy is a well-described quality metric in the treatment of life-threatening infections (sepsis), but time to operation for source control has not been amply investigated for surgical sources of infection. We hypothesized that decreased time to laparotomy (TTL) to achieve surgical source control was associated with improved outcomes in patients presenting with IAI.

Methods: Billing codes were used to identify adult patients who underwent laparotomy from 2011-2015 at a single center. These were screened to identify patients who presented to the emergency department (ED) with IAI, underwent laparotomy for source control, and had hospital stay >24 hours. TTL was defined as the time from ED triage to initiation of laparotomy. The SOFA score was calculated using parameters obtained in the ED. The primary outcome was survival to hospital discharge; the secondary outcome was ICU-free days. Using SOFA score as a covariate, we constructed multivariable logistic and linear regression models to test the hypothesis that decreased TTL was associated with increased survival and increased ICU-free days respectively.

Results: Of the 54 patients included for analysis, 46 (85%) survived to hospital discharge. Overall incidence of sepsis (defined as change in baseline SOFA ≥2) was 57%. Median ICU-free days was 26 with interquartile range of 15 to 30. Survivors had lower SOFA scores (median 2 vs 7, p<0.01) but similar TTL (median 16 vs 17 hours, p>0.05) compared to non-survivors. For patients with sepsis, TTL was also similar between survivors and non-survivors (median 15 vs 17 hours, p>0.05). Perforated hollow viscus accounted for 54% of infectious sources (colorectal 20%, small bowel 17%, stomach 17%), and intra-abdominal abscess accounted for 46%.

Decreased TTL was not associated with improved survival (odds ratio 1.00, 95% confidence interval [CI] 0.98 – 1.02) on multivariable logistic regression, but was significantly associated with increased ICU-free days (relative risk -0.05, 95% CI -0.10 to -0.01) on multivariable linear regression.

Conclusion: Although there was no difference in mortality, decreased TTL was associated with increased ICU-free days in patients presenting with IAI requiring laparotomy. Despite the emphasis on time to initiation of antibiotic therapy, comparatively little attention has been paid to time to surgical source control, even though both are needed to treat certain cases of IAI.

86.03 Laboratory versus clinically-evident coagulopathy: results from PROHS

Posted on January 26, 2017

R. Chang1, E. Fox1, T. Greene1, M. Swartz1, S. DeSantis1, D. Stein6, E. Bulger4, S. Melton8, M. Goodman2, M. Schreiber5, M. Zielinski3, T. O’Keeffe9, K. Inaba7, J. Tomasek1, J. Podbielski1, C. Wade1, J. Holcomb1  1University Of Texas Health Science Center At Houston,Houston, TX, USA 2University Of Cincinnati,Cincinnati, OH, USA 3Mayo Clinic,Rochester, MN, USA 4University Of Washington,Seattle, WA, USA 5Oregon Health And Science University,Portland, OR, USA 6University Of Maryland,Baltimore, MD, USA 7University Of Southern California,Los Angeles, CA, USA 8University Of Alabama At Birmingham,Birmingham, AL, USA 9University Of Arizona Medical Center,Tuscon, AZ, USA

Introduction: Laboratory evidence of coagulopathy is observed in 25% of severely injured trauma patients, but clinically-evident coagulopathy (CC) is not well-described. This study investigates the characteristics of CC and seeks to identify any potentially modifiable prehospital risk factors of CC.

 

Methods: The Prehospital Resuscitation on Helicopters Study (PROHS) was a prospective observational study of adult trauma patients transported by helicopter from the scene to one of nine Level 1 trauma centers in 2015. Predefined highest-risk criteria were any of the following during helicopter transport: heart rate >120 bpm, SBP ≤90 mmHg, penetrating truncal injury, tourniquet application, pelvic binder application, or intubation. Patients meeting any highest-risk criteria were divided into 2 groups based on presence of CC, defined as surgeon-confirmed bleeding from uninjured sites or injured sites not controllable by normal means (e.g. sutures). Purposeful multiple logistic regression was performed to identify potentially modifiable prehospital risk factors of CC.

 

Results: Of the 2341 patients enrolled, 1058 (45%) met highest risk criteria and were divided into CC (n=43, 4%) and not CC (n=1015, 96%) groups. CC patients were older (median age 50 vs 38), more severely injured (median ISS 30 vs 17), and were more likely to have had penetrating trauma (33% vs 19%), prehospital RBCs and/or plasma (56% vs 12%), and laboratory evidence of coagulopathy on admission (86% vs 46%) (all p<0.05). Prehospital crystalloid volumes were similar (median 200 vs 250ml), and transfusion ratios were balanced. CC patients had increased mortality at 30 days (60% vs 15%, p<0.01); although the leading cause of death was TBI in both groups (54% vs 66%), exsanguination was increased in CC patients (38% vs 18%, p<0.01). Transport time, prehospital RBC or plasma units, and crystalloid volume were not significant predictors of CC on multiple logistic regression after controlling for age, ISS, mechanism, admission GCS, and availability of prehospital blood products.

 

Conclusion:

Despite the relatively common finding of laboratory evidence of coagulopathy, CC was rare (4%) but associated with substantial mortality. No obvious modifiable prehospital risk factors of CC were identified.

86.02 Do Traffic Law Violators Have Differing Attitudes About Their Driving Behaviors?

Posted on January 26, 2017

J. A. Vosswinkel1, K. L. Ladowski1, J. E. McCormack1, R. S. Jawa1  1Stony Brook University Medical Center,Stony Brook, NY, USA

Introduction: Despite advances in engineering, motor vehicle crashes remain a leading cause of injury morbidity and mortality, due in great part to driver behaviors such as speeding and inattention.

Methods: In 2015, the County’s Traffic & Parking Violation Agency began offering a 3 hour traffic violator course as part of a plea deal to reduce points/fines. Course instructors include representatives from agencies with a vested interest in traffic safety; county police department, defense lawyer and/or judge, trauma center, and a local human service agency. The course is divided into 2 sections based on type of violation received: Dangerous Driver (DD) program for speeding and/or aggressive driving and Inattentive Driver (ID) program for cell phone violations. Both courses cover similar content including traffic laws, judicial consequences of unsafe driving, and emotional/physical consequences of unsafe driving. After the course, participants are given an anonymous post-then-pre survey about their driving behavior. The Likert-type answers are coded numerically (1=Not At All, 2=A little, 3=somewhat, 4=A lot). Retrospective data analysis was performed using Student’s t-test.

Results: There were 214 surveys (139DD, 75 ID) collected from 11 classes (7DD, 4ID). We analyzed 5 key questions about their driving behavior: 1.Worried it could result in legal consequences; 2.Worried it could cause injury; 3.Want to change driving behavior to avoid legal consequences; 4.Want to change driving behavior to avoid causing injury; 5.Believe can improve driving behavior. Results presented below. Of note, the final 3 columns compare the mean change in attitudes between the DD and ID program. Furthermore, the DD overall scores were significantly higher both pre (DD=14.5±3.2, ID=12.7±3.1) and post (DD=17.4±3.4, ID=16.0±3.5)(p <.001), but there was no significant difference in the overall score increases between groups (DD=2.6±4.4, ID=2.9±3.8, p=0.60).

Conclusion: On course completion, both groups were more likely to agree with statements that worried about their driving behavior and more likely wanted to change their driving behavior. Although both group’s overall scores increased similarly, there were underlying differences in the attitudes of driving behavior between the DD and ID groups.  Overall, ID were less likely to worry about their driving behavior and less strongly felt they needed to change their driving behavior compared to the DD both before and after the class. These findings are similar to other studies that have concluded that drivers who operate cell phones tend to overestimate their driving ability and underestimate the demands of driving.  Further study is warranted.

86.01 Laproscopic Cholecystectomy In The Acute Care Surgery Model: Risk Factors And Complications

Posted on January 26, 2017

E. Sweet1, E. Seabold1, K. Herzing1, R. Markert1, A. Gans1, A. Ekeh1  1Wright State University,Surgery,Dayton, OH, USA

Introduction:
The Acute Care Surgery (ACS) model has been widely popularized over the last decade – fusing the care of Trauma and Emergency General Surgery patients. Laparoscopic Cholecystectomies (LC) are commonly performed by ACS teams typically for acute indications admitted from the Emergency Department. We reviewed LCs performed by an ACS service with > 3000 Trauma annual admissions, focusing on outcomes and risk factors for complications in the emergent setting.

Methods:
All patients who underwent LC on our ACS service over a 26 month period (Jan 2014-Feb 2016) were identified. Data including demographic data, BMI, indications for surgery, time of day of surgery (am or pm), surgeon years of experience, rate of conversion to open, bile leaks, major biliary injury and other complications were collected. Risk factors for complications were analyzed using Chi-squared and Mann-U Whitney tests.

Results:
There were 547 patients who had LC in the studied period (70.2% female, mean age 46 years, meanBMI 32.4 kg/m2) performed by 11 surgeons. Indications for surgery included Acute Cholecystitis(46.8%), Symptomatic Cholelithiasis (25.2%) and Gallstone pancreatitis (6.6%) Mean surgery time was 79±50 mins and 5.7% of cases were performed "after hours." Conversion to open rate was 6%. Minor bile leaks were present in 3.8%, retained stones in 1.1%, post-op bleeding in 1.1% and major duct injury in 0.9%. Statistical analysis did not identify any risk factors for bile leaks, majorbiliary injury or other complications.

Conclusion:
ACS services are capable of performing a high volume of LCs with low complication and conversion to open rates. The majority of LCs were for emergent indications. No correlations between complications and patient age, gender, BMI, indications for surgery, surgeon experience or time of day of operation were found. The ACS model is well suited to address needs of patients acute biliary disease. 
 

85.20 Nationwide Evaluation of Pediatric Non-Cardiac Thoracic Trauma

Posted on January 26, 2017

I. I. Maizlin1, R. T. Russell1  1University Of Alabama at Birmingham,Pediatric Surgery,Birmingham, Alabama, USA

Introduction:  Trauma is the single greatest cause of mortality in the pediatric population. While chest trauma accounts for less than 10% of trauma affecting children, it is relevant because of the considerable mortality associated with it. We aim to identify nationwide trends in circumstances and clinical outcomes resulting from pediatric non-cardiac thoracic accidents.  

Methods: The National Trauma Database (2010-2012) was reviewed for patients ≤19 years of age admitted with diagnosis of non-cardiac thoracic trauma. Patients were stratified into 3 age groups: 1-9 years, 10-16 years, 17-19 years. Demographics, patterns of injury, and outcomes were evaluated, with chi-square and ANOVA tests used for analysis. 

Results: 59,027 children (67.4% male, 59.0% white) were admitted with thoracic injuries, with mean age of 14.2 ± 5.5 years. 68.4% of the children were injured in motor vehicle accidents, 17.2% in assaults, and 6.6% in falls. 43.1% of the accidents resulted in lung contusions, 16.7% pneumo- or hemothorax, 9.0% rib fractures, 7.4% open chest wounds. Mean hospital stay was 6.7 days (compared to 5.0 days in the overall pediatric trauma population), with 45.4% of the patients admitted to the ICU, and 23% requiring ventilator support. As compared to the overall national trauma mortality rate in this population of 2.7%, children experiencing thoracic trauma had a much higher mortality rates of 7.3%. When evaluating etiologies by age group (Table 1), youngest patients were more likely to suffer thoracic trauma as a result of accidents and falls, while trauma in the oldest patients was more likely to be caused by assaults and self-inflicted injuries. Compared to younger age groups, patients 17-19 years old were most common group to present with thoracic trauma, with the highest mean thoracic Abbreviated Injury Score (AIS) and the longest mean hospital stay (7.22 days, p<0.001). However, the youngest group had the highest rate of ICU admissions (48.7%, p=0.007), greatest rate of ventilator requirements (24.6%, p=0.011) and highest associated mortality (8.3%, p=0.001). Despite no difference in Injury Severity Score (16.03 vs. 16.10 vs. 16.77, p=0.280), the youngest group was also associated with higher rates of concurrent head trauma (18.6% vs. 13.8% vs. 12.2%, p<0.001) and higher mean head AIS (3.32 vs. 3.17 vs. 3.14, p=0.002). 

Conclusion:  Thoracic trauma results in a significant number of pediatric injuries and trauma-related admissions, especially in the 17-19 year old age-group. However, children below age 9 were most likely to suffer from associated morbidities and mortality, possibly due to a higher rate of concurrent head traumas.
 

85.19 Emergency Abdominal Surgery: Is it Time to Move to Laproscopic Approach?

Posted on January 26, 2017

A. CHEAITO1, A. CHEAITO1  1University Of California – Los Angeles,General Surgery,Los Angeles, CA, USA

Background: Emergent abdominal surgery carries a considerable risk of mortality and postoperative complications. Population-based studies evaluating laparoscopy and outcomes compared with open surgery have concentrated on elective settings. As such, data assessing emergent laparoscopic abdominal surgeries are limited. Our goal was to evaluate the current usage and outcomes of laparoscopic surgery in the emergent setting at a single tertiary academic center.

 

Materials and

Methods: We report a retrospective review of 165 patients who underwent emergent surgery over a 3 year period. Demographics, perioperative clinical variables evaluated. Primary outcomes (30 day mortality) and secondary outcomes (length of hospitalization, prolonged ileus, wounds infection, pneumonia, sepsis, need for secondary procedure, median operative time, conversion rate, and cost) were evaluated.

 

Results: A total of 16 patients died within 30 days of surgery. In all, 58 of the patients were treated with laproscopy with a 30 day mortality of 6.9% vs 11.2% for open surgery (P=0.4). 3.4% patients had pneumonia in the laproscopy group compared to 16.8% in the open group (p=0.012); 55.1 % of the open group required secondary intervention compared to only 27.6% in the laproscopy group (P=0.01). 100% of all laproscopic cases had all layers of their wound closed compared to 77.6% of open cases (P=0.01). More patients in the open group required blood transfusions compared to the laproscopic group (28% vs 8.6%, P=0.05).

Discussion: Laparoscopy has begun to be the preferred method to manage emergent surgical abdomen, but only few reports are available actually. Our analysis revealed lthat only 50% of emergent abdominal surgeries are performed laparoscopically. Outcomes following laparoscopic surgery in this setting resulted in reduced mortality, length of stay, lower complication rates, and less discharges to skilled nursing facilities. Increased adoption of laparoscopy in the emergent setting should be considered.

85.18 Reversal of Antiplatelet Therapy in Traumatic Intracranial Hemorrhage: Does Timing Matter?

Posted on January 26, 2017

A. Malik2, M. Messina3, U. Pandya1  1Grant Medical Center,Trauma Services,Columbus, OH, USA 2Northeastern Ohio Medical University,Rootstown, OH, USA 3Ohio University,Heritage College Of Medicine,Athens, OH, USA

Introduction: The utility of antiplatelet therapy reversal with platelet transfusion in patients with traumatic intracranial hemorrhage remains controversial.  Several studies have examined this topic but few have investigated whether the timing of platelet transfusion has any effect on outcomes.

Methods: Medical records of all patients admitted to a level 1 trauma center from 1/1/14 to 3/31/16 with blunt traumatic intracranial hemorrhage who were taking pre injury antiplatelet therapy were retrospectively analyzed.  Patients on concurrent pre injury anticoagulant therapy were excluded.  Per institutional guideline, patients on pre injury clopidogrel received 2 doses of platelets while patients on pre injury aspirin received 1 dose of platelets.  Time from hospital presentation to start of platelet transfusion was determined and patients were categorized as either receiving early transfusion (≤ 240 minutes) or late transfusion (> 240 minutes).  Primary outcomes of interest included intracranial hematoma expansion and in-hospital mortality.  Presence of hematoma expansion was determined by radiologic interpretation comparing initial and repeat head CT imaging.   P-values < 0.05 were considered statistically significant.  Multivariate regression analysis was used to control for potentially confounding variables.

Results:A total of 276 patients met inclusion criteria with 97 in the early transfusion group and 151 in the late transfusion group.  There were no significant differences in age, head abbreviated injury scale, or gender between the groups.  Patients in the early group had a significantly higher injury severity score (18.7 ± 8.79 versus 15.0 ± 7.90, p=0.0006) and significantly lower admission Glasgow coma scale (13.1 ± 3.83 versus 14.2 ± 2.57, p= 0.003).   The early transfusion group had a higher rate of hematoma expansion (36.9% versus 18.8%) and a higher mortality (22.7% versus 5.3%).  After multivariate regression analysis, however, there was no significant difference in hematoma expansion or mortality between the early and late transfusion groups.

Conclusion:After correcting for confounders, patients on pre injury antiplatelet therapy who received early platelet transfusion after traumatic intracranial hemorrhage did not have significantly different rates of mortality or hematoma expansion than patients who received later platelet transfusion.  Early platelet transfusion may not be beneficial in this patient population.

 

85.17 Primary Non-Hodgkin Lymphoma of the Gallbladder: Characteristics and Outcomes of 106 Patients

Posted on January 26, 2017

A. Ayub1, S. Rehmani1, A. Al Ayoubi1, W. Raad1, J. McGinty2, G. Kim2, F. Y. Bhora1  1Mount Sinai School Of Medicine,Division Of Thoracic Surgery / Department Of Surgery / Mount Sinai West,New York, NY, USA 2Mount Sinai School Of Medicine,Department Of Surgery / Mount Sinai West,New York, NY, USA

Introduction:  Primary Non-Hodgkin lymphoma of the gallbladder (PNHLGB) is extremely rare with limited available data. In this study, we sought to evaluate the clinical features and outcomes of patients with PNHLGB utilizing a population-based database.

Methods:  Surveillance, Epidemiology, and End Results (SEER) database was queried for patients with gallbladder cancer between 1973 and 2013. Only patients with histologically proven PNHLGB were included.  Demographics, tumor characteristics, and outcomes were assessed. 

Results: Of 150 gallbladder lymphomas in the SEER database, 106 cases had PNHLGB and were included in the study. The mean age at diagnosis was 71 (±15) years. PNHLGB primarily afflicted whites (92%) with a male: female of 1.03: 1. Diffuse large B-cell lymphoma (DLBCL) was the most common histological subtype (33%); majority (61%) had loco-regional disease. Surgical resection was performed in 85% cases. Median overall survival of the whole cohort was 41 months with a 5-year survival rate of 40%. In multivariate analysis, increasing age at diagnosis (p<0.001) was associated with increased hazards of death, surgical resection had a protective effect (p=0.007), while gender, race, tumor histology and disease stage were not associated with overall survival (Figure). 

Conclusion: This study represents the largest series of PNHLGB to be reported. Compared to other gastrointestinal lymphomas reported in the literature, PNHLGB appears to have worse prognosis and surgical resection provides survival benefit. Further studies with information regarding adjunctive therapies are warranted.  

 

85.16 Outcomes of Cholecystectomy in Patients with End Stage Renal Disease

Posted on January 26, 2017

I. Olorundare1, S. DiBrito1, C. Holscher1, C. Haugen1, D. Segev1  1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA

Introduction:  Patients diagnosed with End Stage Renal Disease (ESRD) are a growing population who are at risk of cholelithiasis and cholecystitis and may require surgical management. Despite this, previous studies of outcomes in this population have been limited by small sample size and a lack of generalizability. We studied outcomes of ESRD patients following cholecystectomy in a large nationally representative database

Methods: We used the Nationwide Inpatient Sample to study 40,765 ESRD and 5.4 million non-ESRD patients who underwent cholecystectomy from 2000-2011. Postoperative complications were defined by ICD-9 codes. Mortality, complication rates, LOS, and hospital costs were compared using hierarchical logistic regression, hierarchical negative binomial regression, and mixed effects log-linear models respectively.

Results:ESRD patients had significantly higher mortality and postoperative complication rates than non-ESRD peers (5.0% vs 0.7%, p<0.001) and (23.1% vs 12.8%, p<0.001) respectively on primary admission. After accounting for patient and hospital level factors, ESRD patients had a greater risk of mortality (OR 4.03, 95% CI 3.08 – 5.26) and postoperative complications (OR 2.42, 95% CI 2.09 – 2.81). In particular, they were at a greater risk of infectious (OR 2.98, 95% CI 2.68 – 3.32), mechanical wound (OR 2.21, 95% CI 1.82 – 2.69), and intraoperative complications (OR 1.53, 95% CI 1.32 – 1.78). Median length of stay (LOS) was longer in ESRD patients (8 vs 3 days, p<0.001) as were median hospital costs ($17169 vs $8762, p<0.001). In adjusted analysis, ESRD patients were at significantly greater risk of extended LOS (RR 1.48, 95% CI 1.45 – 1.50) and higher costs (Ratio 1.36, 95% CI 1.34 – 1.39).

Conclusion:ESRD patients experience higher postoperative mortality, complication rates, hospital costs and an extended length of stay following cholecystectomy when compared to non-ESRD peers. Interventions targeting better control of postoperative wound and infectious complications may allow for improvement in overall outcomes of ESRD patients following cholecystectomy. 

 

85.14 A Comparison of Low Tidal Volume Ventilation to Airway Pressure Release Ventilation in ARDS Patients

Posted on January 26, 2017

K. L. Haines1, H. S. Jung1, S. K. Agarwal1  1University Of Wisconsin,Surgery,Madison, WI, USA

Introduction:  Acute respiratory distress syndrome (ARDS) is currently associated with 30-40% mortality and responsible for approximately 75,000 deaths in the United States yearly. Low tidal volume ventilation [the Acute Respiratory Distress Syndrome Network (ARDSNet) strategy] and Airway Pressure Release Ventilation (APRV) are routinely used for these patients.  Past studies comparing known injurious ventilator strategies have shown increases in cytokines after 1 hour of exposure with a return to baseline between 1-6 hours after re-institution of a protective strategy.  This study was undertaken to determine if these modes could be compared at this rate in the same critically ill patients.

Methods:  This was a prospective blinded randomized comparison trial of ARDSNet and APRV in clinically stable consented subjects with ARDS for less than 7 days prior to enrollment.  Patients were randomized to APRV followed by ARDSNet or ARDSNet followed by APRV. Arterial blood gasses and physiologic parameters were collected for analysis prior to intervention, 6 hours, and 12 hours.  Patients with respiratory failure for greater than 14 days, a diagnosis of ARDS for greater than 7 days, or history of lung disease prior to evaluation were excluded.

Results:15 patients were screened for the study, 6 qualified, 4 were able to complete the study and be randomized.  No patients in this trail had symptoms of Left sided heart failure and none were on vasopressors at any point in the trial.  Patients were on the ventilator for 3±1 day prior to study initiation.  Pre-intervention measures were RR 16±3, PEEP 8±2, PIP 24±4, Plateau Pressure 20±5, MAP 89±13, Temp 38±0.1, and Riker 4±1.  There was no difference in Fi02 48±10 for any patient throughout the intervention and oxygen saturation improved or was unchanged in all patients throughout the trial period.  Respiratory rate was unchanged throughout the trial in all patients. No adverse events occurred in this study. Data are mean ± STDEV unless otherwise stated.  

Conclusion: Data from the trial shows that ARDSNet and APRV can both be utilized quickly and safely back to back in surgical critical care patients with ARDS despite being known injurious ventilator strategies.  Not one patient was harmed by this intervention, and all except one patients oxygenation parameters improved.  This will allow further studies to evaluate biomarkers of lung injury in the same surgical critical care patients back to back to see how these ventilator strategies correlate with the degree of lung injury on the molecular level.   

 

85.13 Personalized Massive Transfusions: A Primer for Rural and Critical Access Hospitals

Posted on January 26, 2017

J. Tung1, K. A. Hollenbach1, S. Desjardins1, B. S. Prato1, T. E. Hayes1, R. S. Kramer1, J. F. Rappold1  1Maine Medical Center,Acute Care Surgery,Portland, ME, USA

Introduction: Recent evidence supports the use of a 1:1:1 ratio of packed red blood cells (pRBC)/fresh frozen plasma (FFP)/platelets (Plts) for trauma patients undergoing massive transfusions (MT). For many rural and critical access hospitals (RCAH) this is not feasible. Additionally, new evidence supports altering the definition of MT from ≥ 10units pRBC/24 hrs to ≥ 3 units pRBC/h which seems to better predict injury severity and mortality. The purpose of this study was to evaluate a personalized MT process coordinated and run by a single dedicated transfusion medicine specialist in a resource constrained rural Level I trauma center.

Methods: A retrospective review of all trauma patients admitted to our rural Level I trauma center was conducted from 1 January 2014 to 31 December 2015. Data on the amount of blood products transfused, mechanism of injury, injury severity score (ISS), patient outcomes and standard demographic data were collected. Additionally, a MT algorithm was developed and employed by the dedicated transfusion specialist allowing for a consistent approach to all institutional MTs.

Results: see Table.

Conclusion: In this small retrospective study of a rural trauma center the addition of a dedicated transfusion medicine specialist appears to result in improved survival among trauma patients requiring MT despite not being able to support a 1:1:1 transfusion ratio. Whether this is related to increased use of cryoprecipitate and/or the evolving experience of the transfusion specialist remains to be determined. This methodology has broad implications for RCAH facilities and warrants additional study for validation. Further, the use of fresh whole blood (FWB) may offer a solution for facilities unable to support a dedicated transfusion specialist and who are unable to meet the preferred 1:1:1 transfusion ratio

 

85.12 Assessment of Hemodynamic Response to Fluid Resuscitation Of Patients With Intra-abdominal Sepsis in LMICS.

Posted on January 26, 2017

E. ABAHUJE1, R. RIVIELLO2, F. NTIRENGANYA1  1National University Of Rwanda,SURGERY,Butare, , Rwanda 2Brigham And Women’s Hospital,Boston, MA, USA

Introduction:
Management of patients with severe sepsis and septic shock due to intra-abdominal infection includes resuscitation with intravenous fluids, anti-microbial therapy and timely control of the source of infection. These patients need to achieve adequate hemodynamic status before being taken to the operating room. Several parameters (urinary output, vital signs, inferior vena cava collapsibility index, and central venous pressure) are being used to assess hemodynamic response to fluids resuscitation, but the options are still few in limited resource settings. This study aimed at assessing if a bedside performed ultrasound to assess the inferior vena cava collapsibility index is superior to urinary output in assessing hemodynamic response to fluid resuscitation.

Methods:
This study was carried out on patients of 18 years and above who presented with intra-abdominal infection and who needed intravenous fluid resuscitation prior to being taken to the operating room. At admission, before intravenous fluids (IVF) administration, the baseline inferior vena cava collapsibility index (IVC-CI) and vital parameters were recorded. After initiation of resuscitation with IVF, serial measurement of IVC-CI and urinary output were recorded every two hours until the decision was made to take the patient to the operating room.

Results:

24 patients were enrolled, 79.2% were male . Time from onset of the symptoms to time of admission to our hospital ranged from 1 to 21 days with a mean duration of symptoms of 4.7 days. 4 patients (16%) had altered mental status as a result of septic shock.

 50% off all the patients had generalized peritonitis due to gangrenous bowel as the clinical diagnosis.

 

The mean of difference between time of hemodynamic response based on IVC-CI versus urinary output was 2 hours. Mean time from admission to time of fluid response based on inferior vena cava collapsibility index was 0.708 (0.39-1.03) while the mean time from admission to time of hemodynamic response based on urinary output was 2.708 (1.85-3.57) with a p-value less than 0.05 (0.000)

Conclusion:
This study suggests that measurement of the inferior vena cava collapsibility index can provide early detection of hemodynamic response to fluid therapy in patients with intra-abdominal infection with spontaneous breathing compared to urinary output.

85.11 Worsening head bleeds in the anticoagulated elderly: delayed CT head fails to change management

Posted on January 26, 2017

D. Scantling1, R. Gruner1, R. Kucejko1, S. Reid1, B. McCracken1  1Hahnemann University Hospital,Surgery,Philadelphia, PA, USA

Introduction:

Increases in active lifespan have created a new generation of elderly trauma patients. The majority of these

patients suffer blunt trauma and many are anticoagulated. The literature regarding routine use of repeat

head CT in elderly patients with an initial ICH on CT is varied when no clinical change has occurred. We

hypothesized that routine delayed CT-head (D-CTH) in elderly blunt trauma victims would not change clinical

management.

Methods:

A retrospective chart review using our institutional trauma registry of patients ≥65 years sustaining blunt

head injuries from 2010-2012 was performed. Patients on anticoagulation who had an ICH present on initial

CT who received routine D-CTH were included. Of 268 anticoagulated elderly patients admitted for blunt

head injury, 25 met inclusion criteria. 9 patients were excluded for clinical deterioration before second CTH.

Demographics, injuries, medications, laboratory values, LOS, GCS, and management were analyzed.

Results:

Of the 25 patients who met inclusion criteria, 4/25 (16%) asymptomatic patients had a worsened ICH on D-

CTH. One had a change in management due to D-CTH (4%, p=0.16) and underwent craniotomy. The

median GCS of all included patients was 15. Patients who were found to have a worsening ICH had a median

GCS of 14. The single patient, who received a craniotomy as a result of an early repeat CTH, had an

admitting GCS of 9. 3 of 4 patients with worsened incidental D-CTH required no intervention. One patient

was found to have a worsening bleed on 2 nd D-CTH with a stable 3 rd D-CTH. After developing neurologic

changes (aphasia), a 4 th CTH resulted in hematoma evacuation after identifying a worsened ICH.

Conclusion:

Elderly trauma patients taking anticoagulants with an ICH on initial CTH, who have an adequate baseline

mental status and are clinically asymptomatic, do not necessitate routine D-CTH and may over utilize

healthcare resources. D-CTH in patients with a stable, unchanged neurologic exam does not alter clinical

management. In patients with diminished GCS or unreliable neurologic examination obscuring clinical

changes, it may be reasonable to routinely obtain repeat CTH.

85.10 Deadliest Catch: The Epidemiology of Fishing Related Injuries Presenting to US Emergency Departments

Posted on January 26, 2017

A. Talukder1, C. J. Mentzer3, P. Martinez-Quinones1, S. B. Holsten1, J. R. Yon2  1Augusta University,Department Of General Surgery, Medical College Of Georgia,Augusta, GA, USA 2Swedish Medical Center,Acute Care Surgery,Englewood, CO, USA 3University Of Miami,Trauma And Critical Care, Surgery,Miami, FL, USA

Introduction: Recreational fishing is a pastime undertaken by an estimated 35.2-57.9 million Americans. Traditionally viewed as a low risk activity, the equipment and environmental aspects of fishing pose some inherent risk.

Methods: Fishing related injuries captured by the US Consumer Product Safety Commission National Electronic Injury Surveillance System (NEISS) from 2010 to 2014 that presented to US Emergency Departments were reviewed. Injury context, severity and outcomes were examined.

Results: 6,673 patients were included in the NEISS from 2010 to 2014. 80.44% of the patients were male and Caucasian, 58.76% of injuries occurred primarily in two distinct age groups 11-20 (1,214) and 41-50 (1,021). The most common reported injury was related to the presence of a foreign body (3,726) and affected primarily the extremities (3,055). Distribution of extremity injury was as follows: Finger (1,734), Toe (69), Foot (213), Hand (435), Upper Leg (61), Upper Arm (46), Ankle (17), Lower Leg (176), Knee (37), Wrist (26), Lower Arm (202) and elbow (18). The majority, 96.5%, of all patients were treated and released while 2.7% of all patients were admitted. Further analysis of injury patterns and disposition was completed.

Conclusion: The most commonly injured body part was the upper extremity, primarily the finger due to laceration, puncture, or foreign body–usually a fishing hook. Inpatient admission most frequently occurred following presentation of acute onset chest pain, head injuries, syncope, and drowning. The identification of specific activity related injury patterns will allow for the development of identifiable preventive measures.

 

85.08 Evaluation and Management of Metacarpal and Phalanx Fractures at a Community Hospital

Posted on January 26, 2017

D. S. Urias1, E. Lotton1, K. Shayesteh1  1Conemaugh Memorial Medical Center,Surgery,Johnstown, PA, USA

Introduction:

Hand fractures are the second most common fracture in the upper extremity and can be missed in the setting of life threatening injuries. These fractures contribute to a loss in millions of dollars in days off work and billions in healthcare annually. The associated loss of function/pain, and high estimated health care/productivity costs have encouraged us to investigate fracture patterns of the hand in the trauma population to determine if a link was present. Thus help trauma services decrease morbidity by decreasing the time to intervention and decrease the economic burden.

Methods:

We conducted a retrospective, observational study, at Duke Life Point-Conemaugh Memorial Medical Center a rural Level 1 Trauma center in Johnstown, PA, to investigate the mechanism, patterns of injury and management for fractures of the phalanges/metacarpals encountered in trauma patients. The study period was January 2011 – October 2014 and included all patients evaluated and admitted by the trauma department with hand fractures.

Results:

During the four year period, 4,378 trauma patients were evaluated and admitted, of which 2% experienced 107 fractures of the hand. The most common mechanism of injury was motor vehicle accident (MVA) occurring 59% of the time. Metacarpal fractures accounted for the majority of the fractures at 61% with phalangeal fractures accounting for 39%. The little metacarpal was the most commonly fractured bone contributing to 21% of all fractures. When categorized by mechanism of injury the most common fracture for those involved in an MVA was the little metacarpal at 22% and the thumb metacarpal was the second most common at 19%.

Conclusion:

The fracture pattern identified in our study is an adjunct to the National Hospital Ambulatory Medical Care Survey of 1998 of all emergency room visits, where they reported on both hand and forearm fractures. They found falls to be the most common mechanism at 47% (MVA ranked fourth at 7%), with the metacarpals accounting for 18% of all hand and forearm fractures. Thus, our study provides additional data for evaluating the trauma patient in the acute setting to decrease the likelihood of missed injuries.

85.07 Repeat CT Scan Improves Accuracy in Evaluating for Delayed Exploration after Blunt Abdominal Trauma

Posted on January 26, 2017

M. A. Brooke1, G. P. Victorino1  1University Of California – San Francisco,General Surgery,San Francisco, CA, USA

Introduction: Computed tomography (CT) imaging has an established role in the initial evaluation of blunt abdominal trauma. What is less clear is the role of CT in guiding delayed exploration in patients initially managed non-operatively. Our hypothesis was that repeat CT would accurately identify the need for an exploratory laparotomy in this clinical situation.

Methods: From 2005-2014, we reviewed all blunt abdominal trauma patients at our institution who received an admission CT scan. We identified 52 patients who underwent repeat CT of the abdomen within 72 hours for the documented, specific purpose of re-evaluating potential intra-abdominal injuries. CT findings were categorized into either presence or absence of an indication for exploration based on the CT, allowing a sensitivity analysis.

Results: Of the 52 patients who met our inclusion criteria, 9 underwent surgical exploration of the abdomen and 43 did not. Three of the explorations were negative for significant intra-abdominal injuries. Admission clinical indicators such as GCS, ISS, and AIS were not statistically different between the operative and non-operative groups. The second CT was performed significantly earlier after the first scan in patients who received an operation compared to the non-operative group (10.3 vs. 33.2 hours, p=0.003). Compared with initial abdominal CT scan, repeat CT scan was found to increase the sensitivity for the detection of an operative indication from 67 to 100%, while also improving the specificity, positive predictive value (PPV) and negative predictive value (NPV)(Table 1).

Conclusions: Repeat CT scan of the abdomen may be useful in evaluating blunt trauma patients initially managed non-operatively for delayed operative intervention. The second CT scan improves the sensitivity of CT evaluation to 100% while also increasing the specificity, PPV, and NPV. Repeat CT can help guide decision-making in those patients lacking clinical signs mandating exploration.

 

85.05 Hip Fracture Patients Exhibit Improved Outcomes Compared To Uninjured Patients After A Fall

Posted on January 26, 2017

R. Lindborg1, A. Jambhekar1, V. Chan1, B. Fahoum1, J. Rucinski1  1New York Methodist Hospital,Brooklyn, NY, USA

Introduction:
Falls are the leading cause of injury, death, and disability in senior citizens. Up to 1% of falls lead to hip fractures which are associated with significant morbidity and decreased functional outcomes. In contrast the population of patients who fall and do not suffer any traumatic injuries has not been well studied.  The objective of this study was to determine if falls in elderly patients result in similar hospitalization outcomes.

Methods:

Data was prospectively collected on 153 patients who fell from July 1, 2015 to February 29, 2016. All patients over the age of 65 who were also evaluated by Trauma Surgery were included. Patients were divided into those with hip fractures (n = 123) and those with no injuries (n = 25). Length of stay (LOS), mortality, discharge disposition, and 30 day readmission rate were analyzed using the student’s unpaired T-test and chi square tests.

Results:
LOS was similar between the groups with an average of 5.08 +/- 1.99 days for uninjured patients compared to 6.06 +/- 1.14 days for patients with hip fractures (p = 0.25). The two groups had equal mortality rates (4% vs. 4.1%, p = 1.0). Hip fracture patients were more likely to be discharged to subacute rehabilitation facilities (74.8% vs. 32%, p < 0.0001). Additionally, 30 day readmission rates were significantly lower for patients with hip fractures (0.8% vs. 16%; p<0.0001).

Conclusion:
Falls in the elderly are associated with significant morbidity. In the current study, patients with hip fractures and those with no injuries had similar lengths of stay and mortality rates. Hip fracture patients were more likely to be discharged to a rehabilitation facility and less likely to be readmitted within 30 days in part due to established systems of care. All elderly patients who fall require multidisciplinary care to improve outcomes regardless of the injury sustained.
 

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