15.20 The Utility of Shock Index In Trauma To Predict the Need for Massive Blood Transfusion Protocol

Posted on January 18, 2018

R. Latifi1, E. Tilley1, D. Samson1, A. A. El-Menyar1  1Westchester Medical Center,Surgery,Valhalla, NY, USA

Introduction: Post-traumatic significant bleeding represents a major challenge and needs immediate detection and treatment. Predicting which patients will require massive blood transfusion protocol (MTP) is still an art, more then a science. Shock index (SI) is a simple quick mathematic equation (heart rate/systolic blood pressure) that has shown a prognostic implication in trauma patients at certain cutoffs that differ from one study to another. In these studies, higher SI was associated with unfavorable outcomes. We aimed to evaluate the value of SI in predicting the need for MTP in trauma patient a Level 1 Trauma center

Methods: We conducted a retrospective analysis for trauma patients who received blood transfusion in the trauma room between 2012 and 2016.  Data included patient demographics, heart rate, systolic and diastolic blood pressures , pulse pressure (PP) , mechanism of injury, Injury Severity Score (ISS), New Injury Severity Score (NISS) , Trauma and Injury Severity Score (TRISS), need for blood transfusion, MTP, hospital length of stay (HLOS) and mortality.  Patients < 14 years old or with incomplete clinical data were excluded. Patients were classified into group I (SI<0.8) and group II
( SI ≥0.8). Comparisons were performed by Chi Square, and Student T test, whenever applicable.  Correlation coefficient r measured the strength and direction of a linear relationship between the variables. 

Results:There were 2808 patients eligible for the study, of them 531 (19%) had SI ≥ 0.8 and 273 (9.5%) who received blood transfusion. Of those who were transfused, 14.6% received MTP. In comparison to lower SI, patients with SI≥0.8 were 11 year younger (42±20 vs 53±23), sustained more penetrating injury (9.4% vs 6.7%), had greater ISS (15±12 vs 10.5±8), higher NISS (19±15 vs 14±11), lower TRISS (0.90±0.20 vs 0.96±0.10) and received more blood transfusion (21.2% vs 7.1%) and MTP (10.2% vs 1%),p=0.001 for all. Patients with high SI also had longer HLOS (10.6 vs 6.7 days, p=0.001) and higher mortality (6.2% vs 3.4%, p=0.004). There were correlations between SI and PP(r=-0.53), HLOS(r=0.15), ISS(r=0.21), NISS(r=0.20), and TRISS(r=-0.20), p=0.001 for all.

Conclusion:Shock index can be used early to predict the need of blood transfusion and correlates with PP, HLOS, ISS, NISS, and TRISS.  However, its cutoff values for risk stratification and prognostication needs further evaluation in trauma patients.
 

16.01 Trauma Center Transfer of Elderly Patients with Mild Traumatic Brain Injury Improves Outcomes

Posted on January 18, 2018

A. M. Velez1, S. G. Frangos2, C. J. DiMaggio2,3, C. D. Berry2, M. Bukur2  1New York University School Of Medicine,Department Of Surgery,New York, NY, USA 2New York University School Of Medicine,Department Of Surgery, Division Of Trauma And Acute Care Surgery,New York, NY, USA 3New York University School Of Medicine,Department Of Population Health,New York, NY, USA

Introduction:  Accidents causing Traumatic Brain Injury (TBI) are common in the elderly. Hospitals frequently transfer these patients to designated Trauma Centers (TC) for management. Recent studies have suggested some of these injuries may be safely observed or even discharged from the Emergency Department, an issue that has not been evaluated on a national level. The objective of this study was to examine whether TC transfer of elderly patients with mild TBI is associated with improved outcomes.

Methods:  This was a retrospective study utilizing the National Trauma Databank 2015 dataset. Patients over 65 years of age who suffered injuries resulting in mild TBI (positive Head CT and GCS ≥13) were included. Demographic, injury, and outcomes data were abstracted. Patients were dichotomized by transfer to a designated Level I/II TC vs. not. Multivariate regression was used to derive adjusted outcomes for our primary outcome of mortality. Secondary outcomes assessed were complications and discharge disposition.

Results: 19,664 patients met inclusion criteria with a mean age of 78.1 years. 70% of patients were transferred to a Level I/II TC with the remainder treated at lower tier or non-designated centers. Only 4.2% of transfers came from centers without neurosurgeons, while 80% of transferring centers had > 3 neurosurgeons. Patients transferred to Level I/II TCs were more likely to be Caucasian and have Medicare funding. Falls were the predominant cause of injury with Median Head AIS (4) and GCS (15) being similar between groups. Patients transferred to Level I/II TCs had a higher ISS (12 vs. 10, p <0.001). No neurosurgical interventions were required in any of the patients. Mortality was significantly lower in patients transferred to Level I/II TCs (5.6% vs. 6.2%, Adjusted Odds Ratio (AOR) 0.84, p=0.011). Patients treated at Level I/II TCs were also less likely to be discharged to Skilled Nursing Facilities (26.4% vs. 30.2%, AOR 0.80, p <0.001).

Conclusion: In a large, multi-center sample we demonstrate improved outcomes when elderly patients with mild TBI are transferred to Level I/II TCs. These findings suggest elderly patients with mild TBI are a heterogeneous group that warrants appropriate trauma triage. Which patients with mild TBI require Level I/II TC care should be examined prospectively.

 

15.19 Needs Assessment Of Bleeding Control Training In Law Enforcement

Posted on January 18, 2018

J. Bailey1, M. Iwanicki1, D. H. Livingston1, A. Fox1  1New Jersey Medical School,Newark, NJ, USA

Introduction:  The Hartford Consensus identifies law enforcement officers (LEO) as critical first responders who work in hostile environments and should be trained in bleeding control (BC). There is great emphasis to expand BC to the public, who could act as immediate responders. While universal education of BC is a laudable goal, identifying individuals who have the greatest likelihood of utilizing BC maneuvers is the optimal use of scarce resources. We postulate that LEO have little training in BC. With increasing numbers of mass casualties, we believe that the LEO community is the ideal group for BC efforts to be focused. The goal of this study was perform a needs assessment and to identify gaps in knowledge in LEO. 

Methods:  Over 6 months, 7 Bleeding Control Basics classes were conducted in New York and New Jersey for multiple law enforcement agencies. In addition, 2 civilian classes were conducted. Anonymous, voluntary surveys were collected from all participants following the classes. Responses were tabulated and analyzed using SPSS.

Results: 190 participants were taught and completed evaluations (100% response rate). 51% had prior experience utilizing bleeding control techniques, with 47% trained on direct pressure, 40% on tourniquet use, and 20% on hemostatic agents. 71% of those with experience had previous military training; of those with military training, 96% had received BC training. Military experience did not differ between LEO and civilians. Of participants, just 14% carried bleeding control kits on their person, and 6% had ever utilized a tourniquet in an emergency setting. 

Conclusion: Prior military experience conferred BC experience. LEO without military experience had no more knowledge than civilians. Despite knowledge, only a handful of LEO carry BC kits and would be ill-prepared to treat bleeding patients following trauma or mass casualty events. All class participants rated the education highly. This study clearly identified training gaps and illustrates the necessity of BC training in the LEO population. We strongly believe that BC Basics should be a mandatory component of the LEO curriculum nationwide.

 

15.16 PECARN Head Clinical Prediction Rules Show Potential of Decreasing Head CT at a Single Institution

Posted on January 18, 2018

I. Abd El-shafy1,2, N. L. Denning1, M. L. Reppucci,1, J. T. Avarello1, M. Mittler1, N. A. Christopherson1, J. M. Prince1  1North Shore University And Long Island Jewish Medical Center,Pediatric Surgery,Manhasset, NY, USA 2Maimonides Medical Center,Surgery,Brooklyn, NY, USA

Early identification of clinically-important traumatic brain injury (ciTBI) is essential for providing acute intervention for pediatric patients with head trauma. Approximately 50% of children in North American emergency departments receive a CT following head trauma, highlighting the need to limit radiation exposure. The use of the PECARN head injury clinical prediction rules have been shown to reduce the number of head CTs completed without an increase in missed injuries.  We sought to define the potential impact of strict adherence to PECARN guidelines at a newly designated level I ACS-verified pediatric trauma center.

Methods

A retrospective chart review was conducted of all pediatric head trauma patients with GCS of 14 or greater who underwent a head CT, at a level 1 ACS-verified pediatric trauma center in 2015.  Patients with coagulative disorders, neurological comorbidities, or whose mechanism of injury is related to suspected child abuse were excluded. Children transferred from an outside hospital specifically for head CT were also excluded. Data collected included basic demographics, the severity of the injury, loss of consciousness, components of clinical presentation used in the PECARN algorithm, CT scan findings, and the presence of clinically important traumatic brain injury (ciTBI). We used clinical events used by PECARN to define ciTBI. Descriptive statistics were used to describe the sample and determine the percent of subjects classified by the PECARN algorithm; namely, CT recommended vs. CT not recommended. All analysis was conducted in SAS version 9.4 (SAS Institute, Inc., Cary, NC).

 

Results

A total of 381 pediatric subjects presented to the ED with head trauma that received a head CT. 16 subjects were removed because their head CT was canceled and never performed. Patients had an average age of 8.33 ± 6.01 years with a male predominance of 63.76%. The PECARN algorithm classified 331 (86.88%) as no CT recommended, 38 (9.97%) as CT recommended and 12 (3.15%) could not be classified due to missing data points. Among all subjects with a definitive PECARN classification, either recommending head CT or not, there were no injuries or positive CT finding.

Discussion

In patients with minor head trauma discharged from the emergency room, who underwent a head CT there may have been an over utilization of head CT with 90% receiving a non-indicated head CT based on PECARN head injury clinical prediction rules at a single institution. This has led our institution to embark on the further incorporation of PECARN head injury clinical prediction rules in evaluating pediatric head trauma. 

 

15.17 Outcomes After Massive Transfusion In Trauma Patients: Variability Among Trauma Centers

Posted on January 18, 2018

M. Hamidi1, M. Zeeshan1, A. Tang1, E. Zakaria1, L. Gries1, T. O’Keeffe1, N. Kulvatunyou1, A. Jain1, B. Joseph1  1University Of Arizona,Tucson, AZ, USA

Introduction:
Exsanguinating trauma patients often require massive blood transfusion (defined as transfusion of 10 or more pRBC units within first 24 hours). The outcomes of patients requiring massive transfusion remains unclear. The aim of our study is to assess the outcomes of trauma patients receiving massive transfusion at different trauma centers. 

Methods:
We performed two years (2013-2014) retrospective analysis of the Trauma Quality Improvement program (TQIP) and included all adult trauma patients who received massive blood transfusion (MBT). We analyzed blood products given within the first 24 hours. Outcome measures were blood products received, overall mortality, mortality in the first 24 hours, complications and massive blood transfusion relationship with trauma center’s level. 

 

Results:
A total of 416,957 patients were analyzed of which 4236 received MBT and were included in our study. Mean age was 40.6+20 years, 78.2% (n=35315) were males. Median ISS was 32 [16-40], median [IQR] GCS 8[3-15]. Mean Blood transfusion in the first 24 hours was 20+13 units, mean plasma transfusion was 13+11 units, while 4+6 units platelets and 2+6 units of cryoprecipitate were transfused in the first 24 hours. Overall mortality was 43.5%(n=1976) while 12.2%(n=556) were discharged home and 7%(n=320) were discharged to a skilled nursing facility (SNIF). Out of the 25% which died, 64% (n=1265) died on the first day, while 8.8 (n=173) died on the second day. 51.4% (n=2184) received MBT in level I while 14% (n=592) received MBT in level II trauma centers. On regression analysis after controlling for demographics and injury severity patients who were treated at Level I trauma center had lower adjusted odds of mortality (OR 0.75; 95%CI [0.3-0.8], p=0.02) compare to level II center.  In addition, there was no difference in the adjusted odds of mortality based on teaching status of the hospital (p=0.61)(Community and non-teaching hospitals vs. University Hospitals). 

Conclusion:
Hemorrhage continues to remain one of the most common cause of death after trauma. Almost half of the patients who receive massive transfusion died. Patients who receive massive blood transfusion in a Level I trauma centers are more likely to survive compared to level II trauma centers. Further studies are required to explore the differences in management of trauma centers to improve outcomes.

15.18 Less Than Stringent Glycemic Control Is Associated with Worse Outcomes in Trauma Patients

Posted on January 18, 2018

M. Rajaei1, P. Bosarge1, R. Griffin2, G. McGwin2, J. Jansen1, J. Kerby1  1UAB,Division Of Acute Care Surgery, Department Of Surgery, School Of Medicine,Birmingham, ALABAMA, USA 2UAB,Department Of Epidemiology, School Of Public Health,Birmingham, ALABAMA, USA 3UAB,Division Of Acute Care Surgery, Department Of Surgery, School Of Medicine,Birmingham, ALABAMA, USA 4UAB,Department Of Epidemiology, School Of Public Health,Birmingham, ALABAMA, USA

Introduction: Previous studies have identified hyperglycemia as an independent risk factor for poor outcomes in patients following traumatic injury. However, they have utilized serum glucose of ≥200 mg/dl to define the study population. The purpose of this study was to evaluate the effects of elevated admission glycosylated hemoglobin (HbA1C) on morbidity and mortality of trauma patients.

Methods: HbA1C on admission was obtained on all trauma patients presenting to an academic trauma service between January 2013 and June 2017. A HbA1C < 6.5 is defined by the American Diabetes Association as a more stringent A1C goal. Therefore, a HbA1C ≥ 6.5 was used to define our study population. A Cox proportional hazards model assuming equal time at risk and adjusted for age, sex, Injury Severity Score (ISS) and injury mechanism was used to estimate risk ratios (RRs) and associated 95% confidence intervals (CIs) for the association between HbA1C and specific outcomes of interest.

Results: Total of 10,586 patients were admitted to the trauma service during the period of study. Of these, 9,230 patients had admission HbA1C available and were included in the study. A total of 871 patients had a HbA1C ≥6.5 at admission. These patients were more likely to be Caucasian (74% vs. 66%, p<0.001) and were older (mean 59 vs. 42 years, p<0.001) compared to those with normal HbA1C. Individuals with HbA1C ≥6.5 had a longer hospital length of stay (mean 12 vs. 9 days, p<0.0001), ICU days (mean 13 vs. 10, p<0.001), and required longer ventilator assistance (mean 13 vs. 10, p=0.001). Despite having less severe injuries, patients with  HbA1C ≥6.5 had a 43% increased risk of developing pneumonia (RR 1.43, 95% CI 1.09-1.88), a 46% increased risk of death (RR 1.46, 95% CI 1.14-1.87), and a 2.2 fold increased risk of renal failure(RR 2.25, 95% CI 1.58-3.19).

Conclusion: Trauma patients with less than stringent glycemic control on admission are at increased risk of morbidity and mortality. These results can help identify patients at increased risk on admission following traumatic injury and help inform future trials evaluating glycemic control in trauma.

15.15 Outcomes of Trauma in Patients with Mental Illness: A Survey of the National Trauma Data Bank

Posted on January 18, 2018

R. E. Plevin1, A. Conroy1, C. Juillard1, M. M. Knudson1, R. A. Callcut1  1San Francisco General Hospital And The University Of California, San Francisco,Department Of Surgery,San Francisco, CALIFORNIA, USA

Introduction:

Mental illness is a significant public health concern in the United States, where 20% of adults carry a mental health diagnosis and 5% have been diagnosed with severe mental illness. Those with mental illness are predisposed to sustaining both intentional and unintentional injuries, but the impact of mental illness on trauma outcomes is largely unknown.  In 2012, the National Trauma Data Bank (NTDB) introduced a comorbidity of ‘Major Psychiatric Illness.’ We hypothesize that this vulnerable population is at greater risk of post-traumatic complications and consume more hospital resources compared to injured patients without mental illness.

Methods:
This is a retrospective cohort study of data from the 2012 National Sample Program (NSP) of the NTDB. Trauma patients were stratified into those with and without a diagnosed mental illness. Patients with self-inflicted injuries, those who died in the emergency room (ER), and those who were discharged or transferred directly from the ER to another facility were excluded. Patients were analyzed with respect to demographics, mechanism of injury, discharge disposition, length of stay, complications, and mortality. Multivariable regression analysis was performed to examine predictors of prolonged length of stay (LOS) and the impact of mental illness on complications.

Results:
In 2012, 146,069 patients who met the inclusion criteria were recorded in the NSP representing 633,007 injuries nationally after sample weighting. Approximately 6.9% of patients had a mental illness. Patients with mental illness were older and had more medical comorbidities. They were also more likely to be admitted to the hospital after a fall (51% vs. 41%, p < 0.01) and less likely to sustain trauma related to motor vehicles (37% vs. 29%, p < 0.01). Despite having lower injury severity scores (ISS, 10.8 vs. 11.7 p < 0.01) and mortality (1.8% vs. 2.7%, p < 0.01), patients with mental illness underwent more procedures (6.2 vs. 5.3, p < 0.05), had a longer LOS (6.9 days vs. 5.9 days, p < 0.05), and were more often discharged to a skilled nursing facility (SNF) or other inpatient facility (34% vs. 25%, p < 0.05). On logistic regression analysis, mental illness was an independent predictor for the development of pneumonia (p < 0.05), acute respiratory distress syndrome (ARDS, p < 0.05), urinary tract infection (UTI, p < 0.05), and acute renal failure (ARF, p < 0.05). 

Conclusion:
Compared to patients without such illness, the injured mentally ill are at greater risk of developing post-traumatic complications, have longer hospital stays, and are more likely to be discharged to a SNF or other inpatient facility despite lower injury severity. Future investigations are needed to better understand the etiology of these complications while primary injury prevention efforts should be directed toward methods that are effective in this vulnerable population. 

15.13 Persistent Lactic Acidemia at 12 Hours: Greater Mortality and Length of Stay in Pediatric Trauma

Posted on January 18, 2018

O. M. Kassar1, J. S. Young1  1University Of Virginia,Division Of Acute Care & Trauma Surgery,Charlottesville, VA, USA

Introduction:  Prior studies have demonstrated that persistent lactic acidemia at 24 hours is correlated with poor clinical outcomes and longer hospital stays in adult trauma patients. This study was intended to investigate this observation in the pediatric trauma population.

Methods:  This retrospective analysis included 1037 pediatric patients (0-17 years old) admitted to a level I trauma center between 1995 and 2015. Criteria for inclusion were length of stay greater than one day, initial lactate drawn, and more than one lactate drawn if initial lactate was elevated. Elevated lactate was defined as lactate greater than or equal to 2.5mmol/L. Time to lactate clearance, defined as return of lactic acid level less than 2.5mmol/L, was recorded in hours. Primary outcomes included mortality and length of stay. Statistical analyses were performed using SPSS statistical software (IBM Corp.) and Microsoft Excel (Microsoft Corp). For all statistical tests, a p value less than 0.05 was considered statistically significant.

Results: The majority of pediatric trauma admissions resulted from MVC (68.6%) followed by falls (14.9%). Mean injury severity score was 12 and mean length of stay was six days among all patients. Of 1037 patients, only 17 died. Patients were divided into five cohorts based on time to lactate clearance. Increased mortality correlated with longer time to lactate clearance and trended toward significance. Statistically significant differences in both mortality (0.62% vs 14.5%) and length of stay (five vs nine days) were observed between patients with and without lactate clearance within 12 hours, respectively.

Conclusion: Contrary to observations in adult trauma populations, pediatric patients experience significantly increased mortality after only 12 hours of persistent lactic acidemia. Lactate clearance before 12 hours in pediatric trauma patients is associated with both improved outcomes and shorter length of stay.

 

 

 

15.14 Intravenous+Inhaled Colistin Vs. Intravenous Monotherapy For Multi-Resistant Gram-Negative Pneumonia

Posted on January 18, 2018

W. Terzian3, S. P. Stawicki3, L. E. Bratis2, M. Turki2, N. D. Civic1, C. V. Murphy4  1St. Luke’s University Health Network,Department Of Pharmacy,Bethlehem, PA, USA 2St. Luke’s University Health Network,Center For Critical Care,Bethlehem, PA, USA 3St. Luke’s University Health Network,Department Of Surgery,Bethlehem, PA, USA 4Ohio State University,Department Of Pharmacy,Columbus, OH, USA

Introduction: Continued increase of multi-drug resistant (MDR) gram-negative (GN) infections, including Pseudomonas spp and Acinetobacter spp, prompted re-examination of  Colistin – an antibiotic abandoned in the 1970s due to nephro- and neurotoxicity – as an alternative for recalcitrant MDR-GN pneumonia. Colistin may be administered intravenously or as an inhaled-intravenous combination. Effectiveness of combination therapy has been examined previously; however, no definitive evidence exists to either support or refute this approach. The current meta-analysis examines potential benefits of combination intravenous-inhaled colistin (IVIC) regimen compared to intravenous colistin monotherapy (ICM) in patients with MDR-GN pneumonia.

Methods: An exhaustive English-language literature review was performed using Google™ Scholar, PubMed, and EBSCO Internet repositories. Out of 119 potential candidate studies, 6 retrospective reports met the inclusion criteria of: (a) directly comparing the two therapy groups (IVIC versus ICM); (b) sufficient scientific quality, including detailed descriptions of comparator groups and corresponding outcomes; and (c) describing similar microbiologic pathogen mix. Meta-analytic techniques were utilized to pool clinical results from the six studies, with selected clinical outcomes of mortality (6 studies), microbiologic cure (4 studies), and clinical cure (4 studies) being reported.

Results: The overall quality of data reporting for all three studies included was low. Combined data on microbiologic cure demonstrated no differences between IVIC and ICM regimens (OR 2.076, 95%CI 0.453-1.929, p=0.165). For clinical cure and mortality, pooled analyses demonstrate potential benefit to combined (IVIC) therapy. More specifically, IVIC colistin use is associated with both increased clinical cure (OR 2.857, 95%CI 1.385-5.890, p=0.004) and lower mortality (OR 0.603, 95%CI 0.384-0.949, p=0.029). Key study results are summarized in Table 1.

Conclusion: Addition of aerosolized Colistin to intravenous Colistin may improve clinical cure and mortality for patients with MDR-GN pneumonia. In terms of microbiologic cure, current results show a trend toward improved outcomes with the IVIC approach. Results of this exploratory meta-analysis support the use of IVIC as the primary therapeutic approach. Large, sufficiently powered prospective trials are needed to confirm the benefit of combination IVIC therapy for MDR-GN pneumonia, especially with regard to microbiologic cure.

15.11 Obesity is Associated with Increased Lower Extremity Injuries in Frontal Motor Vehicle Collisions

Posted on January 18, 2018

K. He1, N. Wang2, P. Zhang1,2, S. Holcombe1,2, S. Wang1,2  2International Center For Automotive Medicine,Ann Arbor, MI, USA 1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction:  Obesity has become a disease of epidemic proportions nationally and internationally, leading to significant changes in patient morphomic variability. Obese body habitus has been associated with changing motor vehicle collision (MVC) injury patterns due to greater kinetic energy and thicker subcutaneous tissue. In particular, excess posterior subcutaneous adipose tissue (e.g. buttock fat) has been shown in cadaver tests to allow increased forward excursion of the femur and lower extremity, which is hypothesized to result in increased lower extremity (LE) injuries in obese patients. While the clinical significance of LE injuries has been underestimated on injury severity scales due their low mortality risk, LE injuries have been shown to have considerable societal burden approaching that of fatality. Moreover, compared to their normal weight counterparts, overweight patients are at risk for prolonged disability and increased healthcare utilization in the rehabilitation period. In this study, we hypothesize that obese occupants experience greater risk of lower extremity injuries in frontal MVCs. 

Methods:  Vehicle and demographics data from 1996-2015 were extracted from the University of Michigan International Center for Automotive Medicine crash database. Morphomics data were processed from Computed Tomography scans obtained from the initial trauma evaluation. We fitted logistic regression models using crash, demographic, and morphomic variables for occupants with and without maximum abbreviated injury scale greater than 2 (MAIS2+) LE injuries. The performance of logistic regression models was assessed using the Akaike Information Criterion (AIC), and the area under the receiver operating characteristic curve (AUC). The top 100 models were selected by AIC, and the importance of each variable was calculated using weighted frequencies. Odds ratios and confidence intervals (CI) for obesity-related morphomic factors and lower extremity injury were calculated for a belted male in a 25 miles-per-hour frontal crash.

Results: 243 occupants were included in our logistic regression. We used four vehicle variables, three demographic variables, and six morphomic variables, which resulted in over 8,000 models. The final model predicting MAIS2+ included crash, demographic, and morphomics variables and resulted in an AUC of 0.807. BMI was the most important variable in our final model. The odds ratios for lower extremity injury between posterior top of spine to back skin distance (buttock fat) percentiles were (N=250): Q25 (25th percentile) and Q75: 1.7 (95% CI 1.2, 2.6); Q10 and Q90: 2.8 (95% CI 1.4, 5.9); Q5 and Q95: 4.1 (95% CI 1.5, 11); Q1 and Q99: 6.5 (95% CI 1.7, 25).

Conclusion: Overweight and obese patients are at higher risk for lower extremity injuries in frontal MVCs. Body fat morphomic variables such as the thickness of buttock fat are biomechanically significant and can be used to predict risk for lower extremity injury in frontal MVCs.

 

15.12 Penetrating Cardiac Trauma: A Ten-Year Experience at a Regional Trauma Center

Posted on January 18, 2018

J. A. Enriquez3, R. M. Clark1, B. B. Coffman2, S. W. Lu1, S. D. West1, M. Wang1, T. R. Howdieshell1  1University Of New Mexico HSC,Department Of Surgery,Albuquerque, NM, USA 2University Of New Mexico HSC,Department Of Pathology,Albuquerque, NM, USA 3University Of New Mexico HSC,School Of Medicine,Albuquerque, NM, USA

Introduction:
Penetrating cardiac trauma is a devastating injury associated with high morbidity and mortality. Modern imaging techniques such as ultrasound (Focused Assessment with Sonography for Trauma, FAST) and computed tomography (CT) have changed the way penetrating cardiac trauma patients are evaluated while operative methods have remained relatively unchanged. Rural trauma centers are uniquely poised to explore the natural history of these injuries including the likelihood of survival after prolonged prehospital transfer. 

Methods:
A retrospective review of a prospectively maintained comprehensive trauma database was conducted of all penetrating cardiac injuries treated at our center spanning a 10-year period. Medical records were abstracted to gather patient demographics, medical comorbidities, presentation, type and anatomic location of injury, trauma bay resuscitation, operative intervention and outcomes including survival and complications. Data were compiled using RedCap database software and descriptive statistics were generated. Comparisons were evaluated using either Chi square or Students t test analysis. 

Results:
During the study period, our center treated a total of 102 patients with penetrating cardiac injuries. Twenty-four percent of subjects were transferred from rural locations within the region with 95% of rural patients surviving to hospital discharge. Stab wounds accounted for 63% of injury mechanisms while 33% of patients had gunshot wounds (GSW). The majority of cardiac injuries resulted from wounding within the anatomic cardiac box (89%) with axillary (17%) and periclavicular (8%) wounds being less common. Fifty-two percent of patients underwent real-time FAST examination in the trauma resuscitation area with 49% of FAST scans demonstrating pericardial effusion and 24% of exams deemed negative for abnormality (false negative). CT was used in 21% of cases with cardiac injury (61%), hemothorax (39%) and mediastinal hemorrhage (22%) accounting for the most common radiographic findings. The majority (79%) of patients underwent operative intervention shortly after arrival to the trauma center including 11 emergency resuscitative thoracotomies (11%). Ultimately, 56% of subjects survived to hospital discharge. The vast majority of deaths occurred in the emergency department shortly after arrival. 

Conclusion:
The unique geographic arrangement of New Mexico provides an opportunity to understand the natural history of penetrating cardiac trauma and the effects of prehospital management on survival.  These data suggest that survival to presentation to a trauma center portends a high likelihood of survival to discharge for injured rural patients. Modern diagnostic techniques include ultrasound examination as well as advanced cross sectional modalities. These procedures demonstrated surprisingly low sensitivity for cardiac injury in our series.  
 

15.10 End of Life Decision Making for Geriatric Trauma Intensive Care Patients

Posted on January 18, 2018

M. Wooster4, A. Stassi5, J. Kurtz3, J. Hill2, M. Bonta6, M. C. Spalding2  2Grant Medical Center,Trauma And Acute Care Surgery,Columbus, OH, USA 3Doctor’s Hospital,General Surgery,Columbus, OH, USA 4Indiana University School Of Medicine,Trauma And Acute Care Surgery,Indianapolis, IN, USA 5University Of South Carolina, Palmetto Health-Richland,Trauma And Acute Care Surgery,Columbia, SC, USA 6Riverside Methodist Hospital,Trauma And Acute Care Surgery,Columbus, OH, USA

Introduction:  The geriatric trauma population is growing and fraught with poor physiological response to injury and high mortality rates. We investigated end of life (EOL) decision making of geriatric trauma patients. We hypothesize that age, religion, injury severity score (ISS), decision maker, pre-existing medical conditions, living wills/advanced directives/do not resuscitate status, and in-hospital complications will affect decision making regarding continued life support (CLS) versus withdrawal of care (WOC). 

Methods:  We performed a retrospective review of geriatric trauma patients at a level I and level II trauma center from January 1, 2007 to December 31, 2014. 274 patients met inclusion criteria with 144 patients undergoing CLS and 130 WOC.

Results: 35,747 geriatric trauma patients were admitted. Age, Catholicism, insurance type, massive transfusion protocol, antithrombotic therapy, ventilator days, ICU length of stay (LOS), and overall LOS were found to be statistically significant (p<0.05) predictors of WOC. After logistic regression, insurance type and Injury Severity Score were found to be significant (p=0.013/0.045). WOC patients had shorter time to palliative consultation. Patients with geriatrics consultation were 16.1 times more likely to undergo CLS (p=0.026). There was no difference in outcomes relative to patients advanced directives/living will/do not resuscitate status prior to hospital admission. However, 16% (44/274) of patients who underwent CLS or WOC had an advanced directive/living will/do not resuscitate status prior to hospital admission eventually progressed to WOC.

Conclusion: Our study examined the complex nature of EOL decisions and revealed difficulty in discerning progression to WOC versus CLS based on demographics, pre-hospital, and in-hospital factors. We also observed an apparent disconnect between the patient's wishes via living wills/advanced directives/do not resuscitate orders and fulfillment during EOL decision-making. Both geriatric and palliative care consultations are encouraged and may influence end of life decision making in geriatric trauma patients.

 

15.09 Blunt Cerebrovascular Injury: Does Early Therapy Alter Injury Grade?

Posted on January 18, 2018

A. Kaple2, I. Catanescu1, M. C. Spalding1  1Grant Medical Center,Trauma,Columbus, OHIO, USA 2Ohio University,Heritage College Of Osteopathic Medicine,Dublin, OHIO, USA

Introduction:  Blunt cerebrovascular injury (BCVI) affects 1-2% of all traumas and leads to increased risk of stroke and neurological sequelae if not treated. However, many cases of BCVIs occur in a poly-trauma setting, delaying the initiation of antiplatelet therapies (APT). Such cases include comorbidities like solid organ injury and traumatic brain injury. Though studies have suggested that it is safe to start APT in certain cases, there is a lack of data in regards to timing of therapy initiation. The purpose of our study was to analyze the change in grade of BCVI as a function of initiation of APT.
 

Methods:  This was a retrospective study of blunt traumas with radiographic BCVI diagnosis performed at a level one trauma center from October 2016 to July 2017. Initially, the cohort included 115 patients. Exclusion criteria was defined as; injuries by a penetrating mechanism, atherosclerotic vessels, or confounding artifact on imaging. 104 blunt trauma patients with 153 total blood vessel injuries comprised the study population. Variables analyzed included; neurological exam, medication used for APT, time to initiate treatment, and angiographic findings. Primary outcomes were; death, stroke, resolution or progression of BCVI. Secondary outcomes included; hospital and ICU stay, DVT, sepsis, and cardiac arrest. We defined early treatment as an initiation under 48 hours, between 2-10 days, and greater than 10 days. Patients were organized by Grade of BCVI, and then compared between different treatment initiation times.
 

Results: Out of 153 BCVIs, 58.2% were Grade 1, 17.6% were Grade 2, 15.7% were Grade 3, 8.5% were Grade 4, and no Grade 5 injuries were encountered. There was a significantly higher mortality for patients with a Grade 4 BCVI (p < 0.05). Regarding the outcomes of Grade 1 BCVIs, there were significant differences when compared to other grades (p < 0.05).  However, there was no statistical significance in the timing of treatment versus BCVI progression (p=0.73). For BCVIs treated under 48 hours, 59.6% improved.  When treated between 2 and 10 days, 56.3% of BCVIs improved. BCVIs treated after 10 days had an improvement rate of 66.7%. Treatment arms were no different between those injuries that remained the same and those that were not treated (Table 1). 
 

Conclusion: Our study found that Grade 4 BCVI mortality was statistically significant, as well as Grade 1 BCVIs and outcomes. However, when we analyzed BCVI progression, we found that there was no statistical significance between progression and early treatment time. It appears that early treatment may not need to be initiated promptly; however, we acknowledge a limitation is that this calculation is underpowered.  Future research will continue to compile BCVI data to enhance our sample size so that a potentially efficacious time period is found to initiate APT.    

 

15.04 The Positive Impact of Methadone Treatment on Trauma Patient Outcomes

Posted on January 18, 2018

S. M. Miller1, S. N. Lueckel1, D. S. Hefferenan1, A. H. Stephen1, M. D. Connolly1, T. Kheirbek1, W. G. Cioffi1, C. A. Adams1, S. F. Monaghan1  1Brown University School Of Medicine,Surgery,Providence, RI, USA

Introduction:  Each day 78 people die from opioid-related overdoses in the United States. With heightened public awareness, the number of people in methadone treatment programs has increased. Methadone treatment was not intended to be a chronic medication and we predict methadone treatment will be associated with adverse outcomes in trauma patients. 

Methods:  The trauma registry of a single level-one trauma center was queried between 2011 and 2016 for patients who were tested for drug use and were grouped based on their methadone use. First demographic and outcome measures were compared among all patients. Then, case-control matching (2 controls for every case) was then performed for between groups, matching for age, gender, Glasgow coma scale (GCS), and injury severity score (ISS). Regression analysis was used to identify variables affecting patient outcomes. Alpha was set to 0.05. 

Results:6848 patients tested for drugs on admission were identified from the trauma registry; 175 were in the methadone group and 6673 were controls. Patients on methadone were younger (43 years vs 52, p<.001) but had similar gender, racial and ethnicity group distributions. There was no significant difference in mechanism of injury, ISS, or GCS on admission. Methadone patients were more likely to have a psychiatric illness (29% vs 17%, p<.001), to smoke (62% vs 31, p<.001) and to use illegal drugs (90% vs 63%, p<.001), while they were less likely to have hypertension (15% vs 32%, p<.001), diabetes (6% vs 11%, p<.05), and congestive heart failure (2% vs 5%, p<.05). The hospital mortality was lower in the methadone group (3% vs 6%, p<.05). Case-control matching yielded a cohort of 509 patients, 170 of whom were on methadone. In the matched sample (with similar age, gender, GCS and ISS), methadone patients were more likely to have a psychiatric illness (30% vs 7%, p<.001), to smoke (62% vs 45%, p<.001) and to use illegal drugs (89% vs 68%, p<.001). Similarly, methadone patients demonstrated lower mortality (2% vs 17%, p<.001) but were observed to have longer lengths of stay in the hospital (9 days vs 7, p<.05). In addition, patients receiving methadone treatment were less likely to be discharged home with no services (51% vs 82%, p<.001). Regression analyses revealed that methadone patients had lower mortality (OR = 21, 95% CI 5.5-79, p<.001) when adjusting for patient and injury characteristics. 

Conclusion: Counter to our hypothesis, patients on methadone were more likely to survive than those not taking methadone. Chronic narcotics may have a salutary effect on injured-induced immune-inflammatory activation. However, patients on methadone were hospitalized for two days longer. This potentially speaks to difficulty in placing patients with services due to the methadone use. 

 

15.07 National Trends in Use and Outcomes of Nonoperative Management versus Splenectomy at Trauma Hospitals

Posted on January 18, 2018

T. Bongiovanni1, A. Stey1, A. Conroy1, C. Wybourn1, R. A. Callcut1  1University Of California – San Francisco,Zuckerberg San Francisco General Hospital, Department Of Surgery, General And Trauma Surgery,San Francisco, CA, USA

Introduction: In 2003, national guidelines were first published recommending potential benefit to non-operative management for hemodynamically stable patients suffering splenic injury.  In 2012, updated guidelines supported extension of non-operative therapy to higher-grade injuries and older patients in the presence of hemodynamic stability.  This study investigates the adoption of non-operative therapy by examining national trends and associated outcomes.

Methods:  The National Trauma Data Bank National Sample Program weighted file was used to conduct an observational and serial cross-sectional cohort study between January 1, 2008 and December 31, 2012, identifying hospitalizations during which a patient greater than 12 years old was diagnosed with a traumatic splenic injury. 

Results: Among the almost 3.5 million unique patients in the database, there were 47,212 splenic injuries documented from the years 2008-2012 (69% men, mean [SD] 37.8 [18.1] years) for traumatic splenic injury, of which 9,961 (21%) underwent operative intervention.

Interestingly, there was as overall decrease in reporting of splenic injuries by 2011 and 2012, though there was no change in OR use (210 per 1000 injuries in 2008 vs 220 per 1000 injuries in 2012).  Over the 5 year study period, there was no improvement in the mean length of stay (11.5 days in 2008, 11.0 days in 2012) or in the number of ICU days (4.81 days in 2008, 5.13 days in 2012). However, the rates of transfusion have increased dramatically from 2008 to 2012 (FFP transfusion 3.0% to 8.2%, p<0.001, platelet transfusion 1.4% to 4.8%, p<0.001, pRBC 9.3% to 18.7%, p<0.001). 

In multivariate regression, controlling for age, injury severity score, GCS upon arrival, transfusions of FFP, platelets, prbcs, race, and tachycardia or hypotension in the emergency department, there was no significant difference in survival among each year of analysis. 

Conclusion: Within 5 years of the initial recommendations for non-operative therapy, the rate of surgical intervention had plateaued and remained stable in the subsequent years 2008-2012.  However, the rate of transfusion has continued to climb suggesting that patient exposure to blood products has increased while attempting splenic preservation.  Further investigation should be done to better elucidate the reasons for increased transfusions requirement, and possible delayed care in these patients. 
 

15.08 Outcomes After TBI in Patients on P2Y12 Inhibitors: Is There a Need for Platelet Transfusion?

Posted on January 18, 2018

F. S. Jehan1, M. Zeeshan1, A. Jain1, T. O’Keeffe1, N. Kulvatunyou1, A. Tang1, L. Gries1, E. Zakaria1, B. Joseph1  1University Of Arizona,Tucson, AZ, USA

Introduction:
A significant portion of patients sustaining traumatic brain injury (TBI) are on antiplatelet medications. The role of the cyclooxygenase inhibitor (Aspirin) is well studied; however, the reversal of P2Y12 inhibitors after intracranial hemorrhage remains unclear. The aim of our study is to evaluate outcomes after traumatic brain injury in patients who are on preinjury P2Y12 inhibitors.

Methods:
We analyzed our prospectively maintained traumatic brain injury database from 2014-2106 and included all patients with intracranial hemorrhage (ICH) who were on P2Y12 inhibitors (Clopidogrel, Prasugrel, Ticagrelor). Regression analysis was performed adjusting for the age, gender, race, admission Glasgow coma scale (GCS) score, transfusion of blood products, severity of injury, type and size of ICH. Outcome measures included progression of ICH, adverse discharge disposition (SNiF), and mortality.

Results:
A total 243 patients with ICH were on preinjury P2Y12 inhibitor met our inclusion criteria and were analyzed. Mean age was 55 + 18 years, 58% were males and 60% were white while the median [IQR] ISS was 14[9-22]. 74% received platelet transfusion after admission. The mean units of platelet transfusion were 1.6 + 2 units. On regression analysis after controlling for confounders, patients who received platelet transfusion had lower rate of progression of ICH on repeat head CT scan (OR: 0.77; 95%CI [0.4-0.8], p=0.01), and decreased rate of neurosurgical intervention (OR: 0.86; 95%CI [0.32-0.9], p=0.03) compared to those who did not. Overall mortality was 11%. In addition, patients on P2Y12 inhibitors who received platelet transfusion had lower odds of discharge to a skilled nursing facility SNiF (OR: 0.71; 95%CI [0.5-0.0.8], p=0.02) and mortality (OR: 0.85; 95%CI [0.44-0.91], p=0.02) as well compared to those patients who did not receive platelet transfusion. 

Conclusion:
Platelet transfusion after traumatic ICH in patients on P2Y12 inhibitors is associated with decreased risk of progression and neurosurgical intervention after traumatic intracranial hemorrhage. In addition, patients with platelet transfusion had lower mortality and were less likely to be discharged to a SNiF. Further randomized studies are required to unify the practice of platelet transfusion after ICH in patients on P2Y12 inhibitors to improve outcomes.
 

15.02 Obese Patients Have a Higher Need for Dialysis After Trauma

Posted on January 18, 2018

A. Grigorian1, N. T. Nguyen1, B. Smith1, B. J. Williams1, S. Schubl1, V. Joe1, D. Elfenbein1, J. Nahmias1  1University Of California – Irvine,Division Of Trauma, Burns & Surgical Critical Care,Orange, CA, USA

Introduction: Obesity is a well-known risk factor for diabetes and hypertension which are the leading causes of end-stage renal disease (ESRD). Obesity is also a risk factor for the development of acute kidney injury (AKI). The effect of obesity on the need for dialysis in trauma has not been elucidated. We hypothesized that patients with a higher body mass index (BMI) will have a higher risk for need of dialysis after trauma.

Methods: This was a retrospective analysis using the National Trauma Data Bank. We included all patients 18 years of age and older. Patients were grouped based on their BMI: normal (18.5-24.99 kg/m2), obese (30-34.99 kg/m2), severely obese (35-39.99 kg/m2) and morbidly obese (> 40 kg/m2). The primary outcome was the need for dialysis. Patients with chronic renal failure were excluded from the analysis since a high proportion of these patients may have been on dialysis prior to their admission. We performed a multivariate linear regression analysis after controlling for significant cofactors.

Results: There were 1,221,990 patients included in the study. The obese group differed from the normal BMI group by age (median, 52.0 vs 38.0), history of diabetes (17.7% vs 6.8%), amount of traumatic brain injury (27.6% vs 30.5%) and lower extremity injury (26.2% vs 23.8%) but no difference in injury severity score (p>0.05). The severely obese group were older (median, 53.0 vs 38.0), had more ESRD (1.5% vs 1.1%) and hypertension (41.6% vs 24.6%). Morbidly obese patients were older (median, 50.0 vs 38.0) and had more lower extremity injuries (30.6% vs 23.8%). There was no difference among groups in regards to ICU stay and ventilatory days (p>0.05). Morbidly obese patients had a higher incidence of rhabdomyolysis (0.1% vs 0.02%), AKI (1.1% vs 0.4%) and mortality (3.1% vs 2.8%). After adjusting for covariates, we found that BMI > 30 kg/m2 (Odds ratio [OR]=1.21, confidence intervals [CI] 1.10-1.33, p<0.001), BMI > 35 kg/m2 (OR=1.50, CI=1.34-1.80, p<0.001) and > 40 kg/m2 (OR=1.84, CI=1.64-2.06, p<0.001) had a stepwise increased need for dialysis after trauma.

Conclusion: Trauma patients with a BMI > 30 kg/m2 are associated with increased risk for dialysis in a large database. This holds true even after controlling for multiple well-known risk factors for acute renal failure in trauma patients. Aggressive screening and treatment of obese trauma patients may help prevent acute renal failure requiring dialysis.

 

15.03 Supratherapeutic INR in the Elderly Trauma Patient: Is It Lethal?

Posted on January 18, 2018

D. Sharma1, L. Sadri1, A. Rogers1, G. Filosa1, Q. Yan1, R. Shadis1, R. Josloff1, T. Vu1  1Abington Memorial Hospital,Abington, PA, USA

Introduction:  Elderly patients (>65 years) often present to the trauma bay on anticoagulants with an elevated INR. Among these patients, traumatic brain injury (TBI) is a common mechanism of injury. We aim to investigate if elderly patients presenting with supratherapeutic INRs have increased mortality compared to those with therapeutic and subtherapeutic INRs after blunt trauma. For patients with TBI, we will also determine if a supratherapeutic INR has higher risk of mortality.

Methods:  A retrospective chart review was performed for patients on the trauma service from 2010 to 2015 at Abington Jefferson Hospital, a level 2 trauma center. Elderly patients on anticoagulation with blunt traumatic injury were divided into three cohorts based on INR: subtherapeutic (< 2.0), therapeutic (2.0-3.5), and supratherapeutic INR (>3.5). The primary outcome of mortality and relative risk (RR) was determined for each group, with the therapeutic group serving as the control. The data was then stratified by mechanism of injury (TBI versus other polytrauma) and mortality and relative risk was reported by INR cohorts.

Results: 

Seven hundred and forty-seven patients were included. In this group, 189 patients were subtherapeutic (25%), 440 were therapeutic (59%), and 118 were supratherapeutic (16%). There was no statistically significant difference in mortality rates between the subtherapeutic group and therapeutic group (RR: 0.58; 95% CI: 0.24-1.40; P = 0.23). However, compared to the therapeutic group, the supratherapeutic group had a statistically significant increase in mortality (RR: 2.18; 95% CI: 1.16-4.07; P= 0.015).  

Of the 220 patients with TBI, the mortality of the subtherapeutic (N = 53), therapeutic (N = 123) and supratherapeutic group (N = 26) was 1.9%, 12.2% and 46.2%, respectively. The RR of death of the subtherapeutic group compared to therapeutic group was 0.15 and not statistically significant (95% CI: 0.02-1.14; P = 0.067). However, compared to the therapeutic group, the supratherapeutic group had a significantly higher risk of mortality (RR: 3.78; 95% CI: 2.02-7.11; P < 0.0001).  

Of 545 patients without TBI, the mortality of the subtherapeutic (N = 136), therapeutic (N = 317) and supratherapeutic groups (N = 92) were 3.7%, 2.8% and 2.2%, respectively. Compared to the therapeutic group, the RR of death was not statistically significant for the subtherapeutic (p=0.64) or supratherapeutic group (P = 0.73).

 

Conclusion: Elderly trauma patients with supratherapeutic INRs have a significantly higher risk of death during hospitalization than those with therapeutic or subtherapeutic INRs. Furthermore, those with traumatic brain injury and supratherapeutic INRs also have a significantly higher risk of death. Therefore, elderly patients on anticoagulants with supratherapeutic INRs warrant purposeful and aggressive monitoring given the increased risk of mortality following blunt traumatic injury.
 

14.15 Risk factors and economic implications of opioid poisoning in trauma

Posted on January 18, 2018

W. C. Kethman1, L. Sceats1, L. Tennakoon1, K. L. Staudenmayer1  1Stanford University,Division Of Trauma And Critical Care,Palo Alto, CA, USA

Introduction:  The CDC reported that 11.5M non-institutionalized adults misused opioids in 2015. Exposure to opioids through legal prescriptions is thought to contribute to this opioid crisis. Another exposure to prescribed opioids may occur during inpatient hospitalization, and inpatients may be at risk for an extreme version of this exposure, opioid poisoning. Despite our current understanding of the opioid epidemic, limited data exists on the occurrences of opioid misuse in vulnerable populations such as the hospitalized trauma patient. 

Methods:  This is a retrospective multi-institutional cohort study utilizing data from the 2008-2014 Nationwide Inpatients Sample, Healthcare cost and utilization Project, and Agency for Healthcare Research and Quality database. Patients were included in the study if they were 18 years or older and had a primary ICD-9 diagnosis of trauma and any diagnosis of opioid poisoning. Trauma characteristics were further evaluated using the ICDPIC module. Costs were determined using cost-to-charge ratio files. Unadjusted and adjusted analyses were performed and all reported values represent weighted estimates. 

Results: Overall, 9,314,780 trauma patients were included in this analysis, of which, 2,970 (0.03%) suffered from opioid poisoning. The rates of opioid poisonings during these years have remained unchanged over the study period (p=0.21). In multiple logistic regression analysis, ISS >15 (OR 0.58, 95% CI 0.43-0.79, p=0.001), increasing age (OR 0.98, 95% CI 0.98-0.99, p<0.001), and isolated extremity injuries (OR 0.6, 95% CI 0.46-0.79, p<0.001) were associated with lower odds ratio of opioid poisoning. In contrast, female gender (OR 1.5, 95% CI 1.3-1.9, p<0.001) was associated with higher risk. Injury characteristics of patients suffering from opioid poisoning are demonstrated in Figure 1. Trauma patients who suffer from opioid poisonings are hospitalized longer (Mean=6.6, SD=6.6 vs. Mean=5.2, SD=6.8 p<0.001) and have more costly hospitalizations (Mean=$19,202, SD=$22,687 vs. Mean=$16,248, SD=$22,572 p<0.001).

Conclusion: Despite focused efforts to raise awareness and reduce opioid misuse, inpatient opioid poisonings occurred in approximately 3,000 trauma patients over the study period. These risks are higher in female patients, those with minor injuries, and those with non-extremity injuries, which is a group likely at risk of discharge with opioids. This suggests that a pattern of opioid misuse may begin with a patient’s initial inpatient hospitalization for trauma. Opioid stewardship for trauma patients is more than just an outpatient responsibility, and likely begins during the initial inpatient hospitalization. 

 

14.17 Disaster Response In The Operative Suite

Posted on January 18, 2018

R. Frazee1, H. Papaconstantinou1, R. Frazee1  1Scott & White Healthcare,Surgery,Temple, Texas, USA

Introduction:  Physical disasters to the operative suite can occur through severe weather, power outages, fires, and structural failure.  Advanced planning permits a coordinated response to physical disasters, and should be a part of hospitals’ emergency response planning.  Loss of services can severely impact patient care and produce financial shortfalls.

Methods:  A retrospective review of a flood in at a 25-room hospital operative suite was performed.  Patient safety, operative volume, disaster team response, and overall impact to patient care were analyzed.

Results:  

On May 10, 2017, during the night shift cleaning of the operative suite, a ceiling fire sprinkler was dislodged.  One hundred gallons of stored water/minute was released for 48 minutes before the shut off valve was located and closed.  Eleven operating rooms sustained flood damage and were deemed unsafe for usage.  The disaster plan was activated and the “command center” opened. Physician, nursing, administrative, and physical plant leadership joined in the command center to coordinate the response as follows:

Containment:  Physical barriers were placed between involved and uninvolved operating rooms to contain water, humidity, and potential infectious contaminants.  Ongoing monitoring of rooms occurred to assure patient safety.

Communication:  Patients scheduled for elective surgery and their surgeons were contacted before their report time to inform them of the situation.  They were given the option to reschedule for another day or proceed with a revised report time. 

Cooperation:  A revised schedule utilizing the 14 remaining functional rooms was developed.  When possible, hospital outpatient procedures were moved to our on-campus outpatient surgery center.  A second shift of scheduled cases was developed to accommodate the volume of cases with fewer operating rooms.  An elective Saturday schedule was added to address unmet surgical volume.

Clean-up:  Water removal and drying devices were immediately implemented.  Assistance from a commercial restoration company and consultants was utilized.  Damaged structural elements were removed and reconstructed.  Infectious disease experts performed culture analysis to assure patient safety.

After six days of round the clock clean-up, the damaged rooms were repaired and met monitoring standards for patient use.  All postponed cases had been accommodated with the expanded hours and weekend schedule.

Conclusion:  Prior planning is essential to meet the challenges of physical disaster in the operative suite.  A command center with defined leadership roles permits a rapid response to minimize the impact of these events.  
 

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