87.08 Uniform Grading Of Hemorrhagic Emergency General Surgery Diseases

Posted on January 26, 2017

G. Tominaga2, J. Schulz3, R. Barbosa4,5, S. Agarwal5, G. Utter6, N. McQuay7, C. Brown8, M. Crandall1  1University Of Florida,Surgery,Jacksonville, FL, USA 2Scripps Memorial Hospital,Surgery,La Jolla, CA, USA 3Massachusetts General Hospital,Boston, MA, USA 4Pacific Surgical P.C.,Portland, OR, USA 5University Of Wisconsin,Surgery,Madison, WI, USA 6University Of California – Davis,Surgery,Sacramento, CA, USA 7Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA 8University Medical Center Brackenridge,Surgery,Austin, TX, USA

Introduction:  Consistent grading of Emergency General Surgery (EGS) diseases is important for comparison of outcomes and development of EGS registries.  The American Association for the Surgery of Trauma (AAST) Patient Assessment Committee has previously developed a grading system for measuring anatomic severity of 16 inflammatory/infectious EGS diseases.  The purpose of this project was to develop a uniform grading template for hemorrhagic EGS diseases cared for by acute care surgeons and apply the template to common hemorrhagic EGS diseases.

Methods:  The AAST Patient Assessment Committee reviewed the literature and examined the existing grading systems available for common hemorrhagic EGS diseases.  A uniform grading template for EGS diseases was formulated and applied to four common EGS bleeding diseases:  bleeding esophageal varices (EV), hemorrhage from colonic diverticulosis (CD), bleeding peptic ulcer disease (PUD), and ruptured abdominal aortic aneurysm (AAA).

Results: A grading template was created with Grade I – occult hemorrhage, Grade II – minimal hemorrhage with no active bleeding, Grade III – limited hemorrhage with no active bleeding, Grade IV – moderate hemorrahge with active bleeding, and Grade V – large volume hemorrhage.  The template was applied to four hemorrhagic EGS diseases as noted in the table.

Conclusion: We have developed a grading template for hemorrhagic EGS diseases and have applied them to four hemorrhagic diseases commonly managed by acute care surgeons.  We believe that physiologic parameters, volume loss, and rate of bleeding are essential co-determinants of outcomes in hemorrhagic conditions.  However, adding to this an understanding of the anatomic progression of disease may help inform treatment decisions and predict outcomes.

 

87.07 Upper Extremity DVT Following Port Insertion: What Are The Risk Factors?

Posted on January 26, 2017

O. Tabatabaie1, G. G. Kasumova1, T. S. Kent2, M. F. Eskander1, A. Fadayomi1, S. Ng1, J. F. Critchlow2, N. E. Tawa3, J. F. Tseng1  1Beth Israel Deconess Medical Center,Surgical Outcomes Analysis & Research (SOAR),Boston, MA, USA 2Beth Israel Deaconess Medical Center,Department Of Surgery,Boston, MA, USA 3Beth Israel Deaconess Medical Center,Division Of Surgical Oncology,Boston, MA, USA

Introduction:

Totally implantable venous access devices (ports) are widely used for long-term central venous access, especially for cancer chemotherapy. Upper extremity DVT (U-DVT) is a reported complication of ports, however, prophylaxis remains controversial due to low event rates in the general population. The aim of this study was to determine the risk factors of U-DVT to help identify patients at increased risk who could potentially benefit from prophylaxis.

Methods:

Healthcare Cost and Utilization Project’s Florida State Ambulatory Surgery and Services Database (SASD) was queried between 2007-2011 for patients who underwent outpatient port insertion by CPT code. Patients were followed in the SASD, State Inpatient Database (SID) and State Emergency Department Database (SEDD) for U-DVT occurrence. The cohort was divided into a test cohort and a validation cohort based on the port placement time (2009-2011 and 2007-2008 for test and validation cohorts; respectively). A multivariable logistic regression model was developed to identify risk factors for U-DVT in patients with a port. The model was then tested on the validation cohort.

Results:
Of the 51,049 patients identified in the test cohort, 926 (1.81%) had at least one U-DVT coded at a follow-up visit. The mean age of the test cohort was 62.3 (SD=13.2) and there was a slight female predominance (61.94%). The median time of U-DVT development after port placement was 133 days (IQR: 47-297). Patients who had a U-DVT were more likely to be younger (61.2 vs 62.6), black (vs white, OR=1.9), a smoker (OR=1.29) or have an Elixhauser score of 1-2 (vs. 0; OR=1.22). They also had increased odds of having a history of hypercoagubility (OR=7.68), catheter-related complication at the time of port placement (OR=3.96), autoimmune disease, (OR=1.72), or a non-cancer indication for port placement (vs. genitourinary cancers; OR=2.74). Other univariate predictors were Medicaid insurance (vs. private insurance; OR=1.42), all-cause 30-day readmission (OR=2.44), previous DVTs (OR= 1.95) and end-stage renal disease (OR=4.94). All of the univariate predictors had a P-values<0.05. On multivariate analysis, age>65, black race, 30-day readmission, hypercoagubility, ESRD, indication for port placement and catheter complication were independent predictors of U-DVT (see Figure for details). C-statistics of the model for the test and validation cohorts were 0.68 and 0.66; respectively.

Conclusion:
Our model can be used to identify patients at increased risk of U-DVT after port insertion. Utility of DVT prophylaxis should be investigated in this group of patients in future prospective trials.
 

87.06 The Expedited Discharge Of Patients With Multiple Traumatic Rib Fractures Is Cost Effective

Posted on January 26, 2017

N. Fox1, M. Minarich1, M. Dalton1, K. Twaddell1, J. Hazelton1  1Cooper University Hospital,Camden, NJ, USA

Introduction: Rib fractures cause significant morbidity and mortality in trauma patients. It is well documented that optimizing pain control, mobilization and respiratory care decreases complications. However, the impact of these interventions on hospital costs and length of stay is not well defined.  We hypothesized patients with multiple rib fractures can be discharged within three hospital days resulting in decreased hospital costs. We also sought to identify patients that were not able to meet this discharge goal.

Methods: A retrospective review of adult patients (≥18yrs) admitted to our Level 1 trauma center (2011-2013) with ≥  two rib fractures (n=202).  Patients were excluded if they were intubated, admitted to the ICU, required chest tube placement or sustained significant multi-system trauma.  Demographics, clinical characteristics, hospital costs and outcome data were analyzed.  Patients discharged within three hospital days of admission were considered to have achieved expedited discharge (ED). Univariate and multivariate analyses determined predictors of failure to achieve ED. A p value of <0.05 was considered significant.

Results:Study patients (n=202) were 60 ±  19 years of age with an injury severity score (ISS) of 10 ± 5, and 4 ± 2 rib fractures. Of 202 patients, 127 (63%) achieved ED while 75 (37%) did not. No differences in chest AIS, ISS, smoking status or history of pulmonary disease were identified between the two groups (all p >0.05). Average LOS (2 ± 1 vs. 7 ± 4 days;p < 0.001) and hospital costs were lower in the ED group  ($2,865 ± 1200 vs. $6,085 ± 3033;p <0.001)(Table 1). A lower percentage of ED patients required placement in rehabilitation facilities (6% vs. 48%; p<0.001). There were no readmissions within 30 days in either group. After controlling for potential confounding variables, multiple variable logistic regression analysis revealed that advancing age (OR 1.05 per year, 1.02-1.07) independently predicted failure to achieve ED.   

Conclusion:The majority of patients admitted to the hospital with multiple rib fractures can be discharged within three days. This expedited discharge results in significant cost savings to the hospital. Early identification of patients who cannot meet the goal of expedited discharge will allow for better allocation of resources.  

 

87.05 Intrahepatic Balloon Tamponade for Penetrating Liver Injury: Rarely Needed but Effective

Posted on January 26, 2017

L. M. Kodadek1, W. R. Leeper2, K. A. Stevens1, A. H. Haider3, D. T. Efron1, E. R. Haut1  1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA 2Schulich School Of Medicine And Dentistry,Surgery,London, ONTARIO, Canada 3Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA

Introduction:
Severe penetrating liver injuries are associated with high rates of morbidity and mortality. The objective of this study was to demonstrate the experience of a single urban, Level 1 trauma center with use of intrahepatic balloon tamponade for penetrating liver injuries.  

Methods:
This retrospective study queried the trauma registry for patients age 16 and older with traumatic liver injury (ICD-9 864.00-864.19) from penetrating injury undergoing exploratory laparotomy (procedure code 54.11, 54.12, 54.19) from 2000 through 2015. Operative notes were used to identify cases employing intrahepatic balloon tamponade. Charts were reviewed for patient characteristics, injury characteristics, morbidity, and in-hospital mortality. 

Results:
Of the 4,961 penetrating trauma patients admitted during the study period, 279 (5.6%) had liver injury and underwent exploratory laparotomy. Intrahepatic balloon tamponade was attempted in 9 patients (3.2%) for liver injury secondary to gunshot (8 patients) or stab wounds (1 patient). Seven cases (77.8%) utilized a penrose drain/red rubber catheter balloon and two cases utilized foley catheter balloon. One patient had the balloon immediately removed for increased hemorrhage after placement. Two of the 9 patients (22%) were in arrest at time of balloon placement and died during the index operation; both had retrohepatic IVC injury combined with cardiopulmonary injury. Among the 7 survivors, 2 had biliary injury requiring stent, 3 required hepatic angioembolization for definitive hemorrhage control, and 2 developed liver abscess. One patient, temporized with balloon tamponade, ultimately required left hepatectomy.  

Conclusion:
Although rarely needed, trauma surgeons must be prepared to use intrahepatic balloon tamponade as one surgical technique to control major hepatic injuries. This procedure can result in survival even after major penetrating liver injury. 
 

87.04 The Hospital Agent-based Model: Modular process modeling approach to the design of a trauma center

Posted on January 26, 2017

G. An1, G. An1  1University Of Chicago,Surgery,Chicago, IL, USA

Introduction:  The social, political and economic factors involved in becoming a Trauma Center (TC) are complex, invariably involving varied goals, expertise and expectations across a range of stakeholders. The failure to objectively optimize across these factors can have catastrophic consequences on the operations of institutions aiming to become a TC.  Operational viability must be a precondition if a hospital is to serve its community, and should represent a fundamental constraint on the planning for a TC. Traditional data-centric analyses cannot transparently generate the prospective scenarios needed to forecast the consequences of planning decisions. The generation of such scenarios requires the representation of health system population and process dynamics that: 1) allows for the modular representation of system components at varying levels of spatial-temporal granularity and 2) facilitates transparency by incorporating stakeholder involvement and interaction. Agent-based modeling has been extensively utilized to aid in decision analysis of multi-component/actor systems in business and social systems. Presented herein is an agent-based modeling framework for hospital operations that can be potentially expanded to the specifics of implementing a trauma center within an existing institution. 

Methods:  An abstracted Hospital Agent-based Model (HABM) was spatially sectioned into the emergency department (ED), radiology, OR, ICU and general care units. Individual patients and healthcare providers are represented as individual computational agents located in and moving among the regions of the hospital. Patient acuity was represented by a weighted stochastic likelihood of adverse events affected by provider response. Economic costs and returns were assigned to the actions of the various agents. Simulation experiments were performed with differing trauma populations and resourcing plans to identify process bottlenecks and critical operational tipping points between viable and non-viable scenarios. 

Results: The HABM generated spatio-temporal dynamics that could account for diurnal, weekly and seasonal variation in patient type and volume. Simulation outputs of patient and economic outcomes visualized decision trade offs and the impact on non-trauma care. Robust process bottlenecks were identified in: ED patient flow, non-emergent OR requirements and surgical subspecialty resources.  

Conclusion: The delivery of Trauma care is a complex, multi-factorial process that has cascading effects on hospital operations. The HABM can dynamically represent a wide range of processes and data types currently utilized in hospital operations research, and serve as a participatory, interactive platform for “virtual Kaizen” scenario exploration among stakeholders. The transparency of the underlying assumptions and expectations provided by the HABM may also serve to aid in community, policy and political engagement.

 

87.03 Eye-Tracking Devices: A Novel Communication Method for Mechanically Ventilated ICU Patients

Posted on January 26, 2017

E. Duffy1, J. Garry1, J. Vosswinkel1, D. Fitzgerald1, K. Grant1, C. Minardi1, M. Dookram1, R. S. Jawa1  1Stony Brook University Medical Center,Stony Brook, NY, USA

Introduction:  Mechanically ventilated patients cannot communicate verbally, creating challenges in addressing their needs. They must rely on alternative means for communication: writing, head nodding, communication boards (CB), etc. It has been suggested that this deficit may be addressed with eye-tracking devices (ETD), tablet-like devices that allow screen selection and enunciation of requests through eye gaze tracking. These devices have traditionally been used by patients with neurodegenerative diseases.  We hypothesized that ETDs would be useful in mechanically ventilated surgery/trauma intensive care unit (SICU) patients.

 

Method: A prospective pilot study was conducted in a tertiary care SICU.  A convenience sample was recruited over 5 weeks; the study was conducted Monday-Friday. All adult (age > 18) patients expected to continuously receive mechanical ventilation for > 48 hours, with a RASS score ≥-1 to ≤1 were evaluated. Exclusion criteria included TBI patients with GCS <15, stroke, eye injury, non-English speakers, and pregnant women. Patients were asked five basic needs questions (pain, temperature, position, suctioning) with the ETD and the CB, in random order. Patients were also prompted to communicate anything else they wished. Response accuracy was verified with head nod, hand movement, or blinking. An occupational therapist or SICU nurse served as an objective observer. Both the patient and the observer were surveyed at the end of the session regarding their experience.

 

Results: Of the 95 patients screened, 90 were excluded: mechanically ventilated <48 hours or not ventilated (n=62), TBI with GCS <15 (n=10), cognitive impairment (n=6), RASS score <-1 or >+1 (n=10), and eye impairment (n=2). Of the remaining 5 patients, 2 patients declined participation and 3 patients were enrolled. Accuracy to yes/no questions was equivalent between the ETD and the CB (Both accurate 10/12, 83% responses), but greater with the ETD for free response answers (2/2 responses for ETD and 2/3 responses for CB). Patient preference for communication was split evenly among the three options: ETD (1), CB (1), baseline form of communication (1). The observer preferred baseline communication (2/3 patients), to the CB (1/3 patients), and the ETD (0/3) for basic and complex communication.

 

Conclusions: Previous studies theorized that a substantial proportion of mechanically ventilated ICU patients can use ETDs. Our study found a limited proportion of eligible patients, likely due to strict inclusion/exclusion criteria.  The major criteria limiting participation were short duration of mechanical ventilation and low RASS score. In terms of optimal communication method, too few patients were enrolled to make any definitive conclusions. As such, the protocol has been being modified to include patients for whom mechanical ventilation is expected for >24 hours. Increased coordination with caregivers during sedation vacations will be pursued.

87.02 Pulse Waveform Analysis vs. Pulmonary Artery Catheterization in Orthotopic Liver Transplantation

Posted on January 26, 2017

J. M. Yee1, A. M. Strumwasser1, R. Hogen1, K. Dhanireddy2, S. Biswas1, P. J. Cobb1, D. H. Clark1  1University Of Southern California,Trauma, Acute Care Surgery, And Surgical Critical Care,Los Angeles, CA, USA 2University Of Southern California,Solid Organ Transplantation,Los Angeles, CA, USA

Introduction:
Hemodynamic monitoring in end-stage liver disease (ESLD) is controversial given difficulties in assessing volume responsiveness (VR) and cardiac function (CFx). Pulse waveform analysis (PWA) may supplant pulmonary artery catheterization (PAC) as a non-invasive modality. We hypothesize that PWA is equivalent to PAC for assessing VR and CFx post-orthotopic liver transplantation (OLT). Our specific aims were to determine if post-OLT PWA and PAC data are concordant for measures of VR and CFx, vary pre-and-post extubation, and impact cardiovascular management decisions.

Methods:
Between 2014-2015, (N=49) simultaneous PWA and PAC data (303 paired measurements) were obtained. Bland-Altman analysis determined variability and bias for CFx (cardiac index, CI), VR (stroke volume index, SVI), and vascular resistance (systemic vascular resistance index, SVRI). Reference ranges: CI 2.8-4.2 L/min/m2, SVI 33-47 ml/m2, SVRI 1200-2500 dynes/m2/cm5. Data were concordant if measurements agreed. For discordant data, cardiovascular management decisions (inotrope/pressor) were determined. Patients on post-OLT vasopressors, with vascular disease and/or ventilated < 8 ml/kg IBW.

Results:
Mean difference (ventilated) was 0.06 [-0.25,0.37] L/min/m2, 1.34 [-1.93,4.6] ml/m2, 736 [584,889] dynes/m2/cm5, and (extubated) was 0.17 [-0.2,0.54] L/min/m2, 2.67 [-2.19,7.52] ml/m2, 660 [416,904] dynes/m2/cm5 for CI, SVI, and SVRI respectively. 98.6%, 97.1%, 98% of ventilated patient data and 95.1%, 95.1%, 96.7% of extubated patient data for CI, SVI, and SVRI respectively, fell within 95% of these limits. For clinical interventions, PAC led to 5 unnecessary interventions whereas PWA led to 3.

Conclusion:
Comparing PAC and PWA, mean differences for CI and SVI fall within acceptable ranges of bias with high degree of concordance whereas SVRI data appears to have proportional variability outside of normal ranges. PWA may be used as an alternative to PAC post-OLT to assess VR and CFx.
 

87.01 The Impact of a National Sporting Event on The Epidemiology of Injury at a Regional Trauma Center

Posted on January 26, 2017

N. J. Walsh1, R. L. Lassiter1, A. Schlafstein1, P. B. Ham1, J. R. Yon2, A. Talukder1, K. F. O’Malley1, S. B. Holsten1, C. J. Mentzer1,3  1Medical College Of Georgia,Trauma/Critical Care, Department Of Surgery,Augusta, GA, USA 2Swedish Medical Center,Englewood, CO, USA 3University Of Miami,Trauma/Critical Care, Department Of Surgery,Miami, FL, USA

Introduction: The influence of mass gatherings on both local and national health systems has been described but Trauma System utilization during a nationally recognized and televised sporting event has not been reported. A single Regional Trauma Center’s (RTC) institutional database was queried for a 10 year period to elucidate the relationship between an annual mass gathering and utilization of trauma services.

Methods: A retrospective analysis of trauma patients presenting to the RTC during the week of the large annual sporting event (ASE) between 2005 and 2014 was performed using the institution’s trauma database. We compared week of event in April to corresponding weeks in March and May, which were used as controls for each year in the study period. The number of patients, mechanisms of injury (MOI), patient characteristics, and outcomes were investigated.

Results: 1,041 patients presented during the period of study. Patients during the ASE were older (mean 37.4 years vs 36.7 years, p <0.0001), had more recorded diagnoses (10.2 vs 7.0, p <0.001), lower injury severity scores (10.2 vs 10.6, p <0.001), shorter hospital lengths of stay (LOS) (4.7 days vs 5.3 days, p <0.0001), and ICU length of stay (LOS) (5.6 vs 5.9 days, p < 0.001).  There was no significant difference in the average number of adult or pediatric traumas per week, MOI, or mortality.

Conclusion: In a metro area population of 500,000, despite an increase of 20-25% during the Annual Sporting Event, there was no increase in the raw number of trauma hospitalizations.  The injured patients had more comorbidities but sustained less severe injuries with shorter ICU and hospital LOS.

 

86.20 Penetrating Gastric Trauma – Significance of Acid Suppression and Decompression

Posted on January 26, 2017

D. G. Davila1, A. Goldin1, B. Appel1, N. Kugler1, T. Neideen1  1Medical College Of Wisconsin,Trauma/Critical Care,Milwaukee, WI, USA

Introduction:
Penetrating gastric injuries comprise a small portion of traumatic injuries. A paucity of data exists regarding current management, including acid suppression and nasogastric (NG) decompression. 

Methods:
A single-institution retrospective of adult patients with penetrating gastric injuries between January 2004 and December 2014 was conducted. The primary study endpoint was 30-day mortality. Secondary endpoints included organ-space infections. Patients with >48 hours of proton pump inhibitor or H2 blocker were considered managed by acid suppression; >48 hours of NG management was considered decompressed.

Results:
A total of 167 patients were identified with the majority (77.2%) the result of a gunshot injury. The cohort was predominantly (90%) male at an average age of 30.4 years and ISS score of 16.5. Twenty-one patients died within 24-hours with four additional in-hospital deaths. The liver was the most common (42%) associated injury, followed by the diaphragm and the colon. Forty-five patients had two or more operations prior to closure. A single missed gastric injury was identified on second-look. There were no instances of gastric repair breakdown with no difference in complication rates between one or two layer repair (p=0.73). Organ-space infections were identified in 31 (21%) patients, most likely the result of an alternative source. Neither acid suppression nor NG tube was significantly associated with death (p=0.29 and p=0.64, respectively) or organ-space infection (p=0.89and p=0.11, respectively). 

Conclusion:
Neither acid suppression nor NG tube decompression appear to protect against death nor the infectious morbidity associated with penetrating gastric injuries. 
 

86.19 Variability in the Practice of Resuscitative Thoracotomy for Trauma Patients

Posted on January 26, 2017

E. E. Lee1,2, J. K. Canner2, L. Lam1, E. R. Haut2  2Johns Hopkins Bloomberg School Of Public Health,Center For Surgical Trials And Outcomes Research,Baltimore, MD, USA 1University Southern California,General Surgery,Los Angeles, CALIFORNIA, USA

Introduction:
Resuscitative thoracotomy (RT) remains a controversial procedure, with ongoing discussion about the benefits, salvage rates and potential risks. Despite published guidelines, there likely is wide variation in the use of this procedure. We sought to characterize nationwide variation in the use of this procedure.

Methods:
We performed a retrospective study using the National Trauma Data Bank (NTDB) from 2007-2014. We included all penetrating or blunt trauma patients who were potentially eligible for RT based on having all three of the following criteria: those presenting to the ED with a heart rate of 0, systolic blood pressure of 0, and a Glasgow Coma Scale motor score of 1. We examined variation between trauma centers in the institutional rates of RT. We identified factors associated with the odds of a patient receiving an RT. Statistical significance was predetermined as a p-value <0.05.

Results:
Of the 39,053 patients from 852 institutions, 4,143 (10.6%) underwent RT. Significant factors associated with a patient’s odds of receiving an RT included age, sex, race, injury severity, mechanism of injury, hospital trauma level designation, hospital teaching status, and region. Some hospital variation in the use of RT is related to patient characteristics. However, significant variation based on regional and institutional differences is also present.

Conclusion:
In order to ensure consistency in practices, standardization of indications for RT should be encouraged across the country.

86.18 The Effect of Presence of a State Trauma System on Intentional Firearm-Related Mortality Rate

Posted on January 26, 2017

C. K. Cantrell1, R. Griffin1, T. Swain1, K. Hendershot1  1University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction:  Firearm injury is one of the leading causes of death in individuals in the United States. Many factors play into mortality from firearm injuries. Two factors in mortality are time from injury to treatment and the quality of the treatment received. One recommendation that the ACS COT introduced in attempt to decrease firearm injury fatalities, as well as fatalities from other mechanisms of injury, was for each state to unify their trauma centers and create a statewide trauma system. Illinois, in 1971, was the first state to undergo this transition. Most of these transitions have been more recent, with the percent of states with a trauma system nearly doubling in the past 15 years while the rate of firearm incidents continues to rise.

Methods:  For this cross-sectional study, data on firearm-related intentional deaths (i.e., suicides and homicides excluding legal intervention) were collected by state for years 2000-2014 from the CDC’s Web-based Injury Statistics Query and Reporting System (WISQARS). For each state, the presence of a state trauma system was determined by year as derived from state Public Health Department information. A General Estimating Equations negative binomial regression was used to estimate rate ratios (RRs) for the association between presence of a state trauma system and intentional mortality rate using the state’s population as an offset.

Results: The proportion of states with a state trauma system nearly doubled from 40% (n=20) in 2000 to 78% (n=39) in 2014 (see Graph 1). Overall, there was no association between presence of a state trauma system and intentional firearm-related mortality rate (RR 0.94, 95% CI 0.81-1.09). The lack of association remained for both firearm homicides (RR 0.83, 95% CI 0.63-1.07) and suicides (RR 0.98, 95% CI 0.82-1.16). The lack of association was observed across 5-year categories, though there was noted difference in the associations by year for firearm homicide, with 23% decrease in the rate observed among states with a trauma system in 2005-2009 (RR 0.77, 95% CI 0.58-1.03) while a near-null effect was observed for 2010-2014 (RR 0.91, 95% CI 0.62-1.32). Near-null associations were observed across the board for firearm suicide rate.

Conclusion: The lack of effect of trauma system presence on firearm suicide rate is not unexpected given the high case fatality rate of these injuries. Though presence of a state trauma system is not associated with the mortality rate, it would be of interest to determine whether the case fatality rate of intentional injury varies by presence of a trauma system.
 

86.17 Variation of Packed Red Blood Cell Unit Age in a Massively Transfused Trauma Patient Population

Posted on January 26, 2017

A. R. Jones1, R. L. Griffin2, R. Patel6, H. E. Wang5, M. B. Marques6, J. Pittet4, J. Kerby3  6University Of Alabama at Birmingham,Department Of Pathology,Birmingham, Alabama, USA 1University Of Alabama at Birmingham,School Of Nursing,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,School Of Public Health,Birmingham, Alabama, USA 3University Of Alabama at Birmingham,Acute Care Surgery,Birmingham, Alabama, USA 4University Of Alabama at Birmingham,Anesthesiology & Perioperative Medicine,Birmingham, Alabama, USA 5University Of Alabama at Birmingham,Emergency Medicine,Birmingham, Alabama, USA

Introduction:  Transfusion of stored older (≥ 21 days) packed red blood cells (PRBCs) has been associated with increased trauma morbidity and mortality. The age of PRBCs used in trauma patients is unknown. We sought to determine trauma center variations in the age of PRBCs used in massive transfusion.

Methods:  We used data from the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial, a 12-center randomized trial comparing 1:1:1 with 1:1:2 plasma: platelet: PRBC transfusion ratios in massively transfused (≥ 10 units PRBCs) trauma patients. We categorized PRBC age as: <10, 10-14, 15-20, or ≥ 21 days. We compared the transfused PRBC age distribution between trauma centers using the Kruskal-Wallis test. We examined the correlation between center-level PRBC age using Spearman’s correlation.

Results: The study centers transfused a total of 19,655 PRBC units (median 1,434 units [IQR 946, 1,974] per center). Median PRBC age was 9 days (IQR 2-22). Median PRBC age varied by trauma center (5 days [IQR 1-16] to 21 days [IQR 3-30]) (p < 0.0001). The proportion of PRBC age varied across trauma centers; < 10 days 43-66%, 10-14 days 2-20%, 15-20 days 7-19%, ≥ 21 days 5-47% (Figure 1). There were strong negative correlations between the trauma center proportions of ≥ 21 day and < 10 day PRBCs (r = -0.89, p = 0.0001), and ≥ 21 day and 10-14 days PRBCs (r = -0.96, p < 0.0001).

Conclusion: Among trauma centers participating in the PROPPR trial, there was a wide variation in the age of transfused PRBCs.

 

86.16 Fecal Diversion in Traumatic Intraperitoneal Rectal Injuries: How much is too much?

Posted on January 26, 2017

P. S. Prakash1, D. Jafari2, R. N. Smith1, C. A. Sims1  1The Hospital Of The University Of Pennsylvania,Division Of Trauma, Surgical Critical Care, And Emergency Surgery,Philadelphia, PA, USA 2The Hospital Of The University Of Pennsylvania,Department Of Emergency Medicine,Philadelphi, PA, USA

Introduction:
Traumatic intraperitoneal rectal injuries can be managed with repair or resection and primary anastomosis similar to colonic injuries, yet controversy still exists at an institutional level on optimal management of such injuries during initial surgical intervention. We sought to characterize the incidence of fecal diversion and the associated morbidity in the management of intraperitoneal rectal injuries. 

Methods:
We conducted a retrospective cohort study at a level 1 trauma center using a prospective database from 2005-2015.  Adult patients with intraperitoneal rectal injuries after blunt and penetrating trauma were included. Operative procedures were determined after review of electronic reports and clinical characteristics and outcomes were compared between groups using appropriate statistical methods. Significance was defined as p < 0.05.

Results:
Overall, 24 patients were identified to have an intraperitoneal rectal injury in a 10 year period.  Mean age was 29.6 years (16-69 range). Twenty-one (87%) were male and 20 (83%) were due to penetrating injury. The mean AIS was 3.58 (SD=0.58) and TRISS 0.9 (SD=0.19). All patients survived to discharge. On presentation, mean GCS was 13.5 (SD=3.4), systolic pressure 129 (SD=27), and temperature 97F (SD=1.5). The mean red blood cells transfused on arrival in the trauma bay was 0.7 units (0-5 range).  Twenty-two (92%) had a fecal diversion (FD), while only 2 (8%) had a primary repair (PR). Of those who had FD, 18 (82%) received an end colostomy, 4 (18%) a diverting loop colostomy.  Overall, 7 (32%) of patients who underwent FD had a post-operative complication. Seventeen (77%) FDs had a colostomy reversal on separate admission.

Conclusion:
Although the treatment strategy for colorectal trauma has advanced during the last part of the twentieth century, complication rates are high and standard management for colorectal trauma remains a controversial issue. Though the literature suggests that intraperitoneal rectal injuries can effectively be managed by primary repair or resection with primary anastomosis, fecal diversion appears to still dominate management strategies, despite associated morbidity. 
 

86.15 Is Routine Echocardiography Useful in Evaluating Blunt Cardiac Injuries?

Posted on January 26, 2017

R. Uhlich1, P. Hu1, L. D. Raff1, J. D. Kerby1, P. L. Bosarge1  1University Of Alabama at Birmingham,Acute Care Surgery/Surgery/Medicine,Birmingham, Alabama, USA

Introduction:  The use of echocardiography (ECHO) in the trauma patients with suspected blunt cardiac injury (BCI) has been suggested for assessment of arrhythmia or unexplained hypotension.  Despite this recommendation, the diagnostic value of echocardiography is poorly defined.  The purpose of this study was to assess the utility of obtaining diagnostic echocardiography in the patient with BCI. 

Methods:  A retrospective study was conducted at a single verified American College of Surgeons Level I trauma center from June 2014 to July 2016. The study population was limited to trauma patients diagnosed with BCI using electrocardiogram who had an arrhythmia noted. Demographic and medical history data were collected on all patients.  The primary outcome of interest was need for cardiac intervention in the acute hospitalization to include cardiac surgery or cardiac catheterization in any form; secondary outcomes included echocardiography findings and mortality at 48 hours and 30 days.

Results:  BCI was diagnosed in 89 patients over a two-year study period.  ECHO was obtained in 57 of these patients. Of the 57 patients with ECHO performed, only one patient (1.8%) demonstrated significant cardiac wall motion abnormalities (ejection fraction=35%), who had a prior history of congestive heart failure. Of the remaining patients, left ventricular ejection fraction averaged 53.7% (+/- 5.2). No patient required cardiac surgery or cardiac catheterization.  One death (1.8%) occurred within 48 hours of admission; Overall 30-day mortality was 12.5%. No deaths were attributed to cardiac causes. 

Conclusion:  Despite recommendations of obtaining ECHO for patients with arrhythmias related to BCI, echocardiography adds little additional information to the overall care of these patients.  Patients with BCI rarely need cardiac intervention in the absence of associated hypotension suggesting valvular compromise or potential cardiac rupture.  Echocardiography should be limited to only BCI patients who present with hypotension.

 

86.14 Pulmonary Contusions In Elderly Blunt Trauma Are Infrequently Seen On CXR And Are Highly Morbid

Posted on January 26, 2017

A. Bader1, M. Morris1, J. A. Vosswinkel1, J. E. McCormack1, E. C. Huang1, R. S. Jawa1  1Stony Brook University Medical Center,Stony Brook, NY, USA

Introduction:  In patients with blunt chest trauma, pulmonary contusions are variably identified. However, there is limited research on the outcomes of elderly patients with pulmonary contusion.    

Methods:  We retrospectively reviewed the trauma registry for all admissions aged ≥65 years, admitted following blunt trauma with a thoracic injury.  Emergency Room deaths were excluded. The medical records of patients with pulmonary contusions were subsequently reviewed for additional details.

Results: There were 960 patients age ≥65 years admitted with thoracic trauma, of which 180 had  pulmonary contusions (PC) and 780 had no pulmonary contusion (NO). The major mechanisms of injury were MVC/MCC (52.22% PC, 35.64% NO, p<0.001) followed by falls (38.89% PC, 58.72% NO, p<0.001). Rib fractures were present in 80% of PC and 73.5% of NO patients, p=0.09. Hemothorax/pneumothorax was more prevalent in those with pulmonary contusions (44.44% PC vs 19.23% NO, p<0.001). While 98.3% of PC patients had chest AIS≥3, 41.9% of NO patients had chest AIS≥3, p<0.001. Hospitalization outcomes are presented in the table. Chart review of PC patients noted that pulmonary contusion was identified in only 34/180 patients on initial CXR. An additional 22 patients were noted to have pulmonary contusion on a subsequent CXR. A CT thorax was performed in 174 patients within 24 hours of admission. This CT scan identified the pulmonary contusion. Further, rib fractures were identified in 80% of PC patients.

Conclusion: Pulmonary contusions in the elderly blunt trauma population were infrequently identified on CXR.  They are associated with severe chest injury. Their presence is associated with substantial morbidity and mortality. The data suggest the need for increased vigilance for pulmonary contusion such as early chest CT scan performance in this population. Further study is warranted. 

86.13 Quality Improvement Process Lowers Effective Radiation Dosage in Pediatric Trauma Imaging

Posted on January 26, 2017

H. Naseem2, P. Montgomery3, K. D. Bass1,2  1State University Of New York At Buffalo,Department Of Surgery, Jacobs School Of Medicine And Biomedical Sciences,Buffalo, NY, USA 2Women And Children’s Hospital Of Buffalo,Department Of Pediatric Surgery,Buffalo, NY, USA 3Women And Children’s Hospital Of Buffalo,Department Of Pediatric Radiology,Buffalo, NY, USA

Introduction: Radiation safety has been a concern in pediatric trauma with recent efforts at reducing computed tomography (CT) imaging. A previous study at our institurion showed an inverse relationship between age group and effective dose (ED).  Our purpose was to evaluate current data for changes in the trend.

Methods: Retrospective review of the institutional trauma registry for patients who received computed tomography (CT) imaging from 1/1/2013 to 6/30/2014. Variables collected were age, gender, CT dose length product and body area scanned. Effective dose (ED) was calculated for five age groups. Factorial ANOVA analysis was used to calculate statistical significance. 

Results: There were 312 patients that met criteria and 415 CT scans: 86 abdomen/pelvis, 21 chest, 36 facial, 259 head, and 13 neck scans. The ED for chest scans was 6.52±4.38 mSv and 0.57±0.38 mSv for facial scans (p<0.001). The ED was highest in the large child age group with a mean of 3.14±3.34 mSv and lowest in the toddler age group with a mean of 1.50±0.98 (p<0.001). In comparison to data from 2008-2011, the overall ED was lower across all age groups and showed an inverse relationship to the previous trend of higher ED in younger patients, especially noted in CT abdomen/pelvis (Fig 1).

Conclusion: There was a direct relationship between age and effective dose contradictory to the previous data. Overall effective dose radiation was also lower for CT scans compared to previous data. Concerted efforts of justification, optimization, and documentation lowered effective dose radiation in pediatric trauma patients.

 

86.11 Ethnic Disparities in Traumatic Brain Injury Care Referral in a Hispanic-Majority Population

Posted on January 26, 2017

H. C. Budnick1, A. Tyroch1, S. Milan1  1Texas Tech University Health Sciences Center In El Paso Paul L. Foster School Of Medicine,Department Of Surgery,El Paso, TX, USA

Introduction:

Traumatic brain injury (TBI) is a leading cause of death in the United States and the largest and most swiftly growing population of these injuries in the United States is among the Hispanic population. Functional outcomes for TBI cases can be significantly improved by post-hospitalization rehabilitation including intensive physical, occupational, and cognitive rehabilitation. This treatment is usually accomplished by discharge to post-hospitalization care following the acute period. In studying the referral to these facilities, Hispanics have been shown to have the lowest physician referral rate nationally. However, this relationship has not been studied in a population where Hispanics are by far the majority. This study seeks to determine if differences exist between ethnic groups in referral of TBI patients to post-hospitalization care in the Hispanic-majority population of El Paso, Texas. 

Methods:
This study included 1,124 patients over the age of 18 who presented to University Medical Center in El Paso, Texas between the years of 2005-2015 with acute TBI. The patients’ age, sex, race, residence, admission GCS, GCS-Motor, Injury Severity Score (ISS), ICU and hospital length of stay (LOS), mechanism of injury, and discharge referral were extracted. The data was analyzed in univariate and multivariate analysis using SPSS.

Results:
The discharge disposition was found to be significantly different between the Hispanic and the non-Hispanic populations. 70.2% of Hispanic patients were sent home without post-hospitalization care whereas only 53.5% of the non-Hispanic patients were sent home. Hispanics were also sent to acute care facilities 6.9% of the time and to rehabilitation centers 18.5% of the time compared to non-Hispanics who were sent to acute care facilities 10.8% of the time and to rehabilitation 27.5% of the time. Further, the ages of presentation, mechanism of injury, LOS, ISS, GCS, and GCS-M were comparable between the ethnic groups.

Conclusion:
The Hispanic population has been shown to be discharged to post-hospitalization care facilities at a lower rate as compared to non-Hispanic populations. This remains true even where the overwhelming majority of the population is Hispanic such as El Paso, Texas. Further, when risk factors for poor outcomes were stratified by ethnicity, there was no appreciable difference. This suggests that TBI patients of comparable traumatic severity and functional outcome probability but different ethnicities are discharged without further care at different rates.
 

86.10 CPR after Brain Injury caused Traumatic Cardiac Arrest is a Futile Endeavor

Posted on January 26, 2017

L. D. Raff1, P. Hu1, R. Uhlich1, J. D. Kerby1, P. L. Bosarge1  1University Of Alabama at Birmingham,Acute Care Surgery/ Surgery/Medicine,Birmingham, Alabama, USA

Introduction:  The use of cardiopulmonary resuscitation (CPR) following traumatic arrest historically leads to dismal survival rates. Recently, major critical care organizations have endorsed that interventions should be considered inappropriate when there is no reasonable expectation that the patient will improve sufficiently to survive outside the acute care setting or have meaningful neurological recovery.  To date, very little information has been published to suggest if patients with traumatic brain injury (TBI) benefit from CPR and what functional outcomes can be expected if the patient has return of spontaneous circulation (ROSC).  The purpose of this study is to determine the outcome of patients with obvious traumatic brain injury that required CPR.

Methods:  We identified all adult trauma patients that presented with traumatic cardiac arrest from June 1, 2014 to August 1, 2016. Data regarding demographics, mechanism of injury, cardiac rhythm, resuscitation duration, resuscitation procedures, blood product utilization, mortality data, and disposition from hospital were collected. 

Results:  Among 183 cases of CPR due to traumatic arrest, 21 were identified as having an obvious traumatic brain injury.  Of those 21 patients, 18 (85.7%) had penetrating trauma to the head.  The mean age was 39.7 (± 17.4) years and 38.1% were women.  The median prehospital CPR time was 10 (0-50) minutes; the median hospital CPR time was 9 (0-59) minutes; and the median total CPR time was 23 (2-89) minutes.  ROSC occurred in only 2 patients (9.5%) who had a median CPR time of 4 (2-6) minutes.  No patient that presented in asystole had ROSC (0 of 10) versus 20% of those patients that presented in any other cardiac rhythm other than asystole (p=0.065).  Of the two patients that had ROSC, both patients were subsequently declared brain dead yielding no survivors for this patient group.

Conclusion:  In patients with obvious TBI that present in traumatic arrest, overall ROSC is poor.  When ROSC occurs overall mortality remains high as these patients do not survive the neurological insult.   When patients present in traumatic arrest with asystole, efforts to continue resuscitation should be terminated.  Performance of CPR in patients with obvious TBI upon hospital presentation should be considered futile interventions.

 

86.09 Characterization of Vascular Anatomy for REBOA and Endovascular Procedures

Posted on January 26, 2017

N. C. Wang1, P. E. Rabban1, X. Yan2, R. L. Goulson1, B. A. Derstine1, G. L. Su1, H. Lee2, J. L. Eliason1, S. C. Wang1  1University Of Michigan,Surgery,Ann Arbor, MI, USA 2University Of Michigan,Electrical Engineering & Computer Science,Ann Arbor, MI, USA

Introduction: Non-compressible torso hemorrhage is a major cause of mortality in battlefield as well as civilian trauma settings. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been pioneered by the military to stabilize patients. This technique is starting to be used in civilian trauma settings for the management of torso hemorrhage. To support the design of catheter enhancements and inform medical personnel of optimal balloon placement without fluoroscopy, a broad survey of the variation of aortic geometry is needed.

Methods:  This study measured aortic geometry using the computed tomography (CT) scans of 1769 trauma patients between the ages of 18-50. A custom set of MATLAB algorithms was used to semi-automatically process the aorta for each scans. The centerline and radii of the aorta were measured for these scans from the femoral artery at the level of each femoral head, through the bifurcation, and up into the aortic arch. Additionally vascular landmarks were placed including the aortic bifurcation (AoBi), kidney, celiac, SMA, and left subclavian branches. These landmarks define the aortic zones, zone I (left subclavian to celiac), zone II (celiac to lowest renal artery), and zone III (renal artery to AoBi)

Results: Within our population, the median length (interquartile range in parentheses) of zone I was 223.7 mm (210-237 mm). Zone III was a significantly smaller region, with a length of 87.0 mm (76-96 mm). The distance from the left femoral artery at the femoral head to the AoBi was 195.8 mm (186-206 mm) in men, and 193.0 mm (184-202 mm) in women, with the distance from the right femoral artery to the AoBi being slightly longer than the left at 200.7 mm (191-210 mm) in men and 198.6 mm (189-208 mm) in women.

            The median luminal diameters of the left and right femoral artery were 6.07 mm (5-7 mm) and 6.11 (5-7 mm) respectively. Aortic diameter was largest near the left subclavian, 20.5 mm (19-22 mm). The diameter decreased down the aorta to 18.6 mm (17-21 mm) at the celiac branch, 16.7 mm (15-19 mm) at the lowest renal artery, and 14.3 mm (13-16 mm) at the aortic bifurcation.

Conclusion: Overall, there is significant variation within the population in terms of vascular anatomy. As REBOA is being advocated for use in zone III, to control lower abdominal hemorrhage, it’s important to understand the size and lengths of the vasculature to ensure safe placement within the intended zone. Current catheters range in size up to 14 Fr (4.6 mm), increasing risk of damage to small femoral arteries; recent experience in a Japanese civilian population reported a high incidence of flow occlusion to the lower extremity. The current report may aid in the development and clinical application of novel endovascular devices. 

86.08 Characterizing the Relationship Between Age and Venous Thromboembolism in Adult Trauma Patients

Posted on January 26, 2017

A. J. Nastasi1,2, J. K. Canner1, B. D. Lau1, M. B. Streiff3, J. K. Aboagye1, K. J. Van Arendonk1, P. S. Kraus6, D. B. Hobson5, D. Shaffer5, E. R. Haut1,4  1Johns Hopkins University,Surgery,Baltimore, MD, USA 2Johns Hopkins University,Epidemiology,Baltimore, MD, USA 3Johns Hopkins University,Hematology,Baltimore, MD, USA 4Johns Hopkins University,Health Policy And Management,Baltimore, MD, USA 5Johns Hopkins University,Nursing,Baltimore, MD, USA 6Johns Hopkins University,Pharmacy,Baltimore, MD, USA

Introduction:
Venous thromboembolism (VTE) is a great burden in trauma; however, current guidelines lack recommendations regarding the prevention of VTE in older adult trauma patients. Furthermore, the appropriate method of modeling age in VTE models is currently unclear.

Methods:
3,598,881 patients between the years 2008 and 2014 in the National Trauma Data Bank (NTDB) and 505,231 patients between 2009-2013 from the National Inpatient Sample (NIS) were analyzed. Multiple logistic regression of VTE on age was performed. Based on unadjusted VTE incidence, age was modeled as a linear spline with a knot at age 65.

Results:
In the NTDB, 34,202 (0.95%) patients were diagnosed with VTE while 1,709,881 (47.5%) patients were ≥65 years. In both the fully adjusted NTDB and NIS model, age was positively associated with VTE incidence until age 65 (NTDB: aOR 1.018, 95% CI 1.017 – 1.019, p < 0.001; NIS: aOR 1.025, 95% CI 1.022 – 1.027, p < 0.001). In patients ≥65 years, age was inversely associated with VTE in the NTDB model (aOR 0.995, 95% CI 0.992 – 0.999, p = 0.006) and not associated with VTE risk in the NIS model (aOR 0.998, 95% CI 0.994 – 1.002, p = 0.26).

Conclusion:
VTE risk in adult trauma patients appears to steadily increase with age until 65 years, after which risk appears to level off or even slightly decrease. These findings should be considered when creating standardized guidelines for VTE prevention in older adults as well when modeling age in VTE models of adult trauma patients.
 

 

 

 

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