102.20 Atraumatic Splenic Rupture Does it Mandate Intervention? A Case Series and Review of the Literature

Posted on January 31, 2019

A. Rogers1, L. Sadri1, V. Eddy2, O. Kirton1, T. Vu1  1Abington Jefferson Health,Department Of Surgery,Abington, PA, USA 2Maine Medical Center,Department Of Surgery,Portland, ME, USA

Introduction:
Management of acute splenic trauma and injury has been well studied. National trauma societies have published guidelines to support clinical decision making. Meanwhile, splenic “injury” not associated with trauma is confined to the realm of case reports and antidote. Most cases discussing the management of “atraumatic splenic injury” focus on an underlying diseased spleen and advocate for aggressive management. We aim to better define the literature and propose a guideline for management of splenic injury in non-trauma patients.

Methods:
We reviewed a series of 5 cases between two institutions over the period of two years focusing on patient presentation, hemodynamic stability, underlying disease, choice of management, and ultimate outcome. We then conducted a review of the available literature regarding the management of atraumatic splenic rupture and injury. We focused on operative (splenectomy) compared non-operative (embolization or expectant management) treatment strategies.

Results:
Each case we reviewed was handled differently and showed significant variation at the discretion of the attending surgeon. Treatment ranged from ICU admission with serial exams and laboratory studies to splenectomy. There appeared to be a mild correlation between initial presentation and imaging results and aggressive management, variations did not appear to alter ultimate patient outcome.

Conclusion:
The management of splenic injury in the absence of trauma or on the diseased spleen is poorly studied and lacks any standardization or existing guidelines. Based on our review of cases at our two institutions we would propose that conservative management of splenic injury in the diseased spleen with minimal to no preceding trauma can be safely managed in a similar manner to that of an acute injury associated with a traumatic event. 
 

102.19 The Hazards of Ingesting Wire Grill-Brush Bristles: Optimizing Prevention, Diagnosis and Management.

Posted on January 31, 2019

K. A. Calabro1,2, J. Y. Zhao2, E. A. Bowdish1,2, C. M. Harmon1,2, K. Vali1,2  1John R. Oishei Children’s Hospital,Department Of Pediatric Surgery,Buffalo, NY, USA 2University at Buffalo Jacobs School of Medicine and Biomedical Sciences,Department Of Surgery,Buffalo, NY, USA

Intro:
Accidental wire grill-brush ingestion is a largely unidentified threat to children. Injuries affect multiple organ systems, resulting in morbidity and even mortality. We sought to review available literature to characterize wire grill-brush injury.

Methods:
A review of Ovid MEDLINE ®, PubMed, Google Scholar, and two injury databases National Electronic Injury Surveillance System (NEISS), and Safer Products (SP) government database was conducted by two independent auditors. The literature search was performed using the terms “bristle brush,” “grill brush,” and “wire brush.” The injury database search required that all events had one of the following codes linked with it: (41) ingestion, or (56) foreign body, (0) internal, (88) mouth, or (89) neck, (480) household cleaning products, (837) wire unspecified, (3218) charcoal or wood-burning grills, (3229) electric grills, (3248) gas or LP grills or stoves, (3230) kerosene grills or stoves, (3233) other grills or stoves, (3249) grills not specified. Variables of interest included common symptomatology, associated foods, time to presentation, and treatment course.

Results:
A total of 92 cases of wire grill-brush injury were identified; 43 from literature review, 35 from NEISS, and 14 from SP. The combined case list was reviewed and data was extracted. Complete case information was missing in a majority of patients, but in general, genders were affected equally and 10% of patients were under 19 years of age. The most common foods were hamburgers and grilled chicken. The main diagnostic imaging tests were CT scan (38%), and XR (29.3%). Of the known 58 cases 22.4% required intervention using a combination of laryngoscopy, endoscopy and surgery. Operative management alone was used in 23 (39.7%), whereas 6 (10.3%) were treated by laryngoscopy alone and 6 (10.3%), endoscopy alone. The majority of known cases (18, 58.0%) presented over 24 hours after suspected ingestion; of those, 7 (22.6%) presented over 1 week after suspected ingestion. Injuries involving the head and neck were more frequent (53.2%) than abdominal injuries (23.9%), and a significant amount of the injuries were unknown/unlisted (22.8%). Neck exploration occurred in 6.8%, abdominal surgery (laparoscopy or laparotomy) in 29.3%, laryngoscopy or endoscopy in 27.5%, and 3.4% required multiple operative procedures that resulted in failed retrieval.

Conclusions:
Wire grill-brush associated injuries are variable, and often present with a significant delay after presumed ingestion. Diagnostic imaging modalities are quite variable, and significant proportions of patients treated for ingestion require operative intervention. More information is needed to better characterize rare but perhaps underappreciated injuries stemming from wire grill-brush ingestion, and to better inform prevention strategies.

102.18 Follow the Guidelines: Overtriage of Blunt Trauma Patients Does Not Capture More Injured Patients

Posted on January 31, 2019

A. Fulginiti4, A. Jambhekar1, Z. Nasrawi2, V. Chan3, B. Fahoum2, J. Rucinski2  1Columbia University College Of Physicians And Surgeons,Breast Surgery Division,New York, NY, USA 2New York Presbyterian Brooklyn Methodist Hospital,Department Of Surgery,Brooklyn, NY, USA 3Abington Memorial Hospital,Department Of Medicine,Abington, PA, USA 4Monmouth Medical Center,Department Of Obstetrics/Gynecology,Long Branch, NJ, USA

Introduction:  The American College of Surgeons (ACS) provides guidelines for the triage of patients at Trauma Centers.  Several studies have shown that activations based on mechanism have been ineffective at predicting patient outcome.  The objective of our study is to evaluate injury severity in overtriaged blunt trauma activations based on mechanism.

Methods:  Data was prospectively gathered on 1,298 blunt trauma patients from April 1st 2015 to December 31st 2016.  Patients over 14 years old who were overtriaged as a level one or two activation (n=153) were compared to trauma consults (n=1145) by age, injury severity score (ISS), length of stay (LOS), time to evaluation and mechanism of injury using the unpaired Student T Test and Chi Square analysis.

Results: Overall, 11.79% of patients were overtriaged, most involving motor vehicle or bicycle related trauma (Table 1). The age (years), LOS (days), and time to evaluation (hours) of overtriaged patients were significantly decreased compared to consults.  The ISS scores were similar. There were no missed injuries.

Conclusion: Patients who were overtriaged by mechanism of injury underwent earlier evaluation although the ISS was similar and hospital stay was shorter than trauma consult patients. Based on these results, mechanism of injury is not an accurate predictor of outcome in blunt trauma patients. More stringent application of the ACS trauma triage guidelines may lead to optimal use of trauma team resources.

 

102.17 Pediatric Train Injuries: A 10 Year Review from the Pennsylvania Trauma Outcomes Study Database

Posted on January 31, 2019

C. Pennell1, E. Lindholm1, J. Latreille2, S. Kadakia2, A. D. Nanassy1, S. Ciullo1, L. Arthur1, H. Grewal1, R. Prasad1  1St. Christopher’s Hospital for Children,Department Of Pediatric General, Thoracic, And Minimally Invasive Surgery,Philadelphia, PA, USA 2Drexel University,College Of Medicine,Philadelphia, PA, USA

Introduction: Pediatric train trauma can result in severe injuries requiring significant resource utilization.  We sought to review train injuries in the state of Pennsylvania to determine the burden of these injuries on the pediatric trauma system.

Methods: We queried the Pennsylvania Trauma Outcomes Study Database to identify all patients <21 years of age suffering traumatic injuries resulting from a train accident between 2007-2016. Demographics, hospital course, outcomes, and health resource utilization was reviewed.

Results: Forty-eight patients suffered train-related injuries in the study period with an average age of 15.3 years (range 1-20). A majority of patients were male (77.1%), Caucasian (60.4%), and resided in urban environments (81.3%).  Injuries occurred most often in the spring (31.3%) and least often in the winter (16.7%). Alcohol screen was positive in 50% of patients.  Transfer from the initial hospital was required in 22.9% of cases and usually occurred within 24 hours of arrival (81.2%). The average length of stay was 12.4 days (range 0-121) and overall mortality of 10.4%. Over half of patients (56.3%) required ICU admission with an average ICU stay of 5.3 days. Injury Severity Score on arrival and Functional Independence Measure (FIM) Score on discharge averaged 17.3 and 16.4, respectively. On average, 7.1 services were consulted per patient with the most common being physical and occupational therapy (64.5%), social services (60.4%), and orthopedic surgery (52.1%). Among the 48 patients included, 41.7% experienced at least 1 long-bone or pelvic fracture. Intracranial hemorrhage occurred in 25.5% of patients, major traumatic amputation in 16.7%, concussion in 27.7%, and pneumothorax in 20.8%. Solid organ injuries occurred in 12.5% of patients with the most common being spleen (6.3%), kidney (6.3%), and liver (4.2%) injuries. Surgical management of injuries was common with 60.4% of patients requiring at least one operative intervention, most commonly internal fixation of a fracture (33.3%) or amputation (20.8%). Laparotomy was rare (6.3%) as was thoracotomy (4.2%). Overall, 75.0% of patients experienced a major injury, defined as one resulting in death, requiring surgical repair, or discharge to a rehabilitation or long-term care facility.

Conclusion: Injuries caused by trains can be severe, with a majority of admitted patients experiencing a major injury. Orthopedic injuries are the most common followed by traumatic brain injuries. Train traumas in children can be costly injuries that require a multi-disciplinary approach to care.

 

102.16 Femoral Vessel Injuries: A Review of Cases from the National Trauma Data Bank.

Posted on January 31, 2019

D. J. Keleny1, A. D. Person1, G. Mendoza-Barrera1, S. R. Brown1, D. Rigg1, M. Dale1, J. Dabestani1, D. K. Agrawal1, J. A. Asensio1  1Creighton University Medical Center,Trauma Surgery And Surgical Critical Care,Omaha, NE, USA

Introduction: Femoral vessel injuries are the most frequent vascular injuries seen at Trauma Centers accounting for 70% of all peripheral large blood vessel injuries treated in large volume hospitals. This makes it important to determine parameters contributory to morbidity and mortality with such injuries in an effort to optimize management and predict outcome. Our objective is to review the National Trauma Data Bank with respect to location of femoral vessel injuries with related mortality, to identify predictors of patient outcome, and to report the outcomes of these injuries based on the aforementioned predictive variables including mechanism of injury.

 

Methods: The National Trauma Data Bank was queried for pre-hospital and admission data for femoral vessel injuries. The primary outcome measured was survival. Statistical analysis included univariate and stepwise logistic regression.

 

Results: A total of 2,021 patients were identified with a total of 2,693 femoral vessel injuries from 1,466,887 patients in the National Trauma Data Bank. This is an incidence of 0.13%, with the number of survivors being 1,788 (89%). Mean age of patients was 34.1±17.34. The mean revised trauma score (RTS) for survivors was 7.2±1.67 ; for non-survivors 3.57±3.35. The mean GCS for survivors was 13±3.65 ; for non-survivors 6.59±5.11. The mean injury severity score (ISS) for survivors was 16.73±6.32 ; for non-survivors 28.0±13.88. Mechanism of injury was documented in 1,996 patients, with the majority due to penetrating injuries (1,419; 71%). The most commonly injured vessel was the superficial femoral artery (1,044; 39%). The next most commonly injured vessels were the femoral vein (817 ; 30%), the common femoral artery (645; 24%), and the femoral nerve (153; 5.7%). The highest mortality was 19%, in patients with injuries to the common femoral artery.

 

Conclusion: Although there is a relatively high survival rate for femoral vessel injuries, they incur high complication rates. Initial admission parameters correlate well with morbidity and mortality, including neurological status and hemodynamic stability. When comparing mortality rates by location of injury, common femoral vessel injuries had a significantly higher mortality rate although the most commonly injured vessel is by far the superficial femoral artery. Femoral vein injuries were also more lethal than superficial femoral artery injuries. These correlations should be looked to for optimization of management.

102.15 Demographics and Outcomes of the Acutely Intoxicated Trauma Patient

Posted on January 31, 2019

M. Fleury1, H. Hakmi1, J. Vosswinkel1, J. Mccormack1, E. Huang1, R. Jawa1  1Stony Brook University Medical Center,Trauma/Surgical Critical Care,Stony Brook, NY, USA

Introduction: A hsitory of alcohol use is often reported in injured patients.  We evaluated the association of elevated BAL with outcomes.

Methods: Retrospective analysis of a single ACS verified level 1 trauma center’s registry. Trauma patients >16yrs old, discharged between 1/1/16 and 12/31/17 were included. Emergency room deaths, isolated hip fracture patients, and injuries in nursing homes were excluded.  Patients with BAL values were separated into three groups consisting of negative BAL (NBAL <10mg/dl), low positive BAL (LBAL 11-79mg/dl), and high positive BAL (HBAL ≥80mg/dl).

Results: 1797 patients met the study criteria: 17.3% HBAL, 4.6% LBAL, and 78% NBAL. Median [IQR] BAL level was 200.5 [142-265] mg/dL in HBAL and 40 [27-58] in LBAL. The most common mechanisms of injury were: MVC/MCC in the hBAL group (35.3%), MVC/MCC in LBAL (44.6%), and falls in the nBAL group (47.4%). The HBAL group more often had pedestrians struck (12.8% vs 7.2% LBAL, 8.2% NBAL, p=0.03). The elevated BAL groups more often sustained penetrating trauma (7.0% HBAL, 6.0% LBAL, 3.4% NBAL p=0.01) or were assaulted (6.7% HBAL, 4.8% LBAL, 2.14% LBAL, p<0.001).  The median Injury Severity Score (ISS) was 10 in all 3 groups, p=0.68. There were no significant differences in major injury patterns (Abbreviated Injury Score>3) amongst the groups, except for a difference in major face injuries (0.1% NBAL vs 1.2% LBAL vs 1.6% HBAL).  The groups had a similar frequency of comorbidities (70.0% NBAL, 69.9% LBAL, 73.1% LBAL, p=0.56). The overall (major and minor) complication rate was higher in the HBAL group (14.4% vs 7.2% LBAL, 0.3% NBAL, p<0.001). However, there was no significant difference in hospital length of stay (7 [4-14] hBAL, 7 [3-11] LBAL, 6[4-11] NBAL, p=0.67), major complications (8.0% HBAL, 6.0% LBAL, 7.5% NBAL, p=0.83), or mortality (2.2% HBAL, 2.4% LBAL, 3.3% NBAL, p=0.55) amongst groups.  In multivariate analysis, an elevated BAL level was also not associated with mortality.  Additional demographics and outcomes are presented in Table 1.

Conclusion: Principal findings of this study were: 22% of admitted patients were intoxicated; over 79% of those were highly intoxicated. The data suggest that alcohol intoxication is hazardous even when not driving: patients with elevated BALs were more often assaulted, sustained penetrating trauma, or were struck by motor vehicles,  Elevated BAL patients had a higher overall complication rate and more frequently experienced alcohol/drug withdrawal.  However, a negative admission BAL did not preclude the presence of alcoholism or the development of withdrawal.

102.14 Pattern of Vascular Injuries From The Colombian Military Conflict

Posted on January 31, 2019

G. E. Mendoza-Barrera1, W. Sanchez2, S. R. Brown1, A. Person1, D. Keleny1, D. Rigg1, M. Dale1, J. Dabestani1, D. K. Agrawal1, J. A. Asensio1  1Creighton University Medical Center,Surgery,Omaha, NE, USA 2Colombian Military Hospital,Nueva Granada Military School Of Medicine,Bogota, BOGOTA, Colombia

Introduction:  Recent military conflicts have changed from more conventional to guerrilla and counter insurgency warfare with the subsequent refinement of newer antipersonnel devices such as improvised explosive devices (IEDs). The Iraq and Afghanistan conflicts have shown newer injury patterns with a subsequent decrease in definitive extremity vascular injury repairs, along with a significant increase in single and multiple limb amputations. Objectives of this study are to analyze the Colombian military experience with combat related extremity vascular injuries. Describe distribution of wounds, mechanisms of injury related to vascular injuries incurred in combat. Identify predictors of outcomes and validate conventional  wounding patterns.

Methods: Retrospective review of 13 year prospective data base. Statistical analysis: Chi square, T test, ANOVA and stepwise logistic regression which included mode of injury (MOI), MOI over time, ISS, RTS, type of vascular injury, time to definitive surgical care, procedures performed, incidence of amputation and mortality.

Results: 204 patients sustained 390 vascular injuries 159 (40.8%) arterial and 231(59.2%) . Weapons: Automatic Rifles (RIF) n=124 (60.7%), Improvised Explosive Devices (IEDs) n=42 (20.7%) and Land Mines (LMs) n=38 (18.6%). 70 patients (36.8%) were directly transferred from the field and 134 (63.2%) from MASH units. Mode of injury (MOI) remained unchanged. Extremity vascular injuries accounted for 86%: – 61% upper and 25% lower.  Neck 10% , abdominal injuries 4%. 20 patients (9.8%) required amputation (19 LE and 1 UE). Amputation was independent of MOI – RIF 9.7%, IEDs 13.1% and LM 9.8%, – p < 0.05. Amputation was dependent on presence of combined arterial-venous injuries (AVI), ligation of a named vein and performance of fasciotomy. 11/20 (55%) with lower extremity amputations sustained arterial-venous (AV) injuries, popliteal vessel injury managed with arterial interposition vein graft and popliteal vein ligation. Overall mortality 3.9% (8/204).

Conclusion: For combatants sustaining vascular injuries automatic rifles remain responsible for majority of these injuries. Extremity vascular injuries are as in other wars most prevalent. Strategies to decrease the rate of amputation for popliteal artery injuries: avoid ligation of popliteal vein  and perform complete fasciotomy. Trauma surgeons must remain adept at vascular injuries management.

102.13 Causes of Death and Wounding Patterns in Firearm-Related Violence in Washington DC

Posted on January 31, 2019

C. S. Hendrix1, M. Matecki1, S. Maghami1, K. Mahendran1, R. Mitchell2, F. Diaz2, J. Estroff1, E. R. Smith3, G. Shapiro3, B. Sarani1  1George Washington University School Of Medicine And Health Sciences,Surgery,Washington, DC, USA 2George Washington University School Of Medicine And Health Sciences,Pathology,Washington, DC, USA 3George Washington University School Of Medicine And Health Sciences,Emergency Medicine,Washington, DC, USA

Introduction:  Approximately 30,000 people die from gunshot wounds (GSW) annually in the United States. However, there are no reports of the injury patterns and exact causes of death in this cohort. The purpose of this study is to elucidate cause of death due to gun-related violence. We hypothesize that the mechanism of death following urban GSW is the same as has been reported following civilian public mass shooting events (CPMS).

Methods:  The autopsy reports of all gun related deaths in Washington, DC were reviewed from January 1, 2016 to December 31, 2017. Demographic data including age, gender, race, manner of death, type of firearm used, number and anatomic location of GSWs, and organ(s) injured were abstracted. Each GSW was catalogued by body region: head, neck, chest/upper back, abdomen/lower back and extremity. The organ injury resulting in death was noted. 

Results:182 autopsy reports were reviewed. The median age was 28 years old and 91% were male. There were 167 (92%) homicides, 13 (7%) suicides, and 0.5% accidental or unknown deaths. Handguns were implicated in 180 (98.9%) events. The median number of GSW per victim was 3 (25, 75 IQR 2, 7). Of 367 total GSW, 109 (30%) were to the chest/upper back, 85 (23%) to the head, 77 (21%) to an extremity, 70 (19%) to the abdomen/lower back, and 26 (7%) to the neck. The leading 5 mechanisms of death were injury to the brain (39%), lung parenchyma (37%), heart (27%), thoracic aorta (19%), and liver (19%) (Figure 1). 59% were transported to a trauma center. Patients with head wounds were significantly less likely (45% v 55%, p=0.003) and patients with abdominal wounds were significantly more likely (45% v 29%, p=0.03) to be transported to a trauma center. Transported patients were younger (26 v 31 years, p=0.011). There were 39 thoracotomies, 15 laparotomies, 7 vascular repairs, and 5 craniectomies performed.

Conclusion:Compared to previous reports regarding CPMS, there was little difference noted in the mechanism of death between urban GSW and CPMS events in this single city study. Over 50% of urban GSW are to the head/chest. Whereas gunshots to the extremity are common, they are rarely fatal. Based on the organs injured, rapid transport to a trauma center remains the best option for mitigating death following all GSW events. 

 

102.11 Effect of Temporary Shunts on Neurologic Outcomes in Repair of Penetrating Carotid Artery Injuries

Posted on January 31, 2019

S. R. Brown1, A. D. Person1, G. E. Mendoza1, M. Dale1, D. Rigg1, D. Keleny1, J. Dabestani1, D. K. Agrawal1, J. A. Asensio1  1Creighton University Medical Center,Surgery,Omaha, NE, USA

Introduction:  The management of penetrating carotid artery injuries continues to evolve. Early questions regarding repair versus ligation have largely been settled in favor of repair for all but the most devastating injuries. To date, the use of temporary shunts to maintain cerebral perfusion in the repair of carotid artery injuries has not been well studied. Thus far, no single study has had the power to state whether the use of shunts makes any difference in neurological outcomes in the setting of penetrating carotid artery injuries.

Methods: A focused literature search was performed with PubMed, Scopus, and Ovid. PRISMA guidelines were followed. Inclusion criteria were those series reporting surgical repair for penetrating carotid artery injuries. Exclusion criteria were endovascular repair, neurosurgical techniques involving craniotomy, and studies with no reports on preoperative or postoperative neurologic status. Further relevant studies found as references in these papers were also evaluated. A total of 28 papers were identified that met these criteria, ranging from 1970 to 2012. Studies were systematically analyzed to extract cases of surgical repair for which both the utilization of temporary shunts and perioperative neurologic outcome data was reported. Non-parametric data was analyzed with Fisher Exact or Chi-Square tests as applicable. Statistical significance was set to a p-value less than 0.05.

Results: There were a total of 717 carotid artery injuries. 592 were repaired without shunts. 125 were repaired with shunts. There was a trend towards lower overall mortality in repairs with shunts vs. those without shunts (5.6% vs. 9.8%; p=0.17). There was a trend towards increased rates of neurological improvement in repairs with shunts vs. those without shunts (13.6% vs. 10%, p=0.34). Patients undergoing repairs with shunts were more likely to have improved or unchanged neurologic outcomes in comparison to those without shunts (92% vs. 84%, p=0.018).

Conclusion: This focused analysis offers the first large scale evidence that the use of temporary shunts in the surgical repair of penetrating carotid artery injuries results in better neurologic outcomes in comparison to repair without the use of shunts. Based on this evidence, we recommend the routine use of temporary shunts during complex repair of penetrating carotid artery injuries.

 

102.10 Fibrinolysis Spectrum in the Burn Population

Posted on January 31, 2019

H. B. Cunningham1, L. R. Taveras1, M. L. Pickett1, J. B. Imran1, T. D. Madni1, S. Park1, M. Zhou1, F. M. Adeyemi1, H. A. Phelan1, M. W. Cripps1  1University Of Texas Southwestern Medical Center,Surgery,Dallas, TX, USA

Introduction: Viscoelastic testing is regarded as superior to conventional clotting assays in detecting coagulation dysfunction after burn injury. A hypercoagulable state has been observed by rotational thromboelastography (ROTEM) in these patients. Moreover, close to a third of patients with severe burns develop disseminated intravascular coagulation. A mortality difference has been found within the fibrinolysis spectrum for trauma patients. The distribution, and associated mortality, of burn patients within this range is unknown. Our aim is to describe the distribution of fibrinolysis, as measured by ROTEM, and identify associated mortality rates.

Methods: All the patients that underwent ROTEM assays were screened at an urban, Level 1 burn center from July 2014 to December 2017. Clinical and ROTEM data were analyzed on burn patients. Data from the initial ROTEM at time of admission was included for evaluation. Hyperfibrinolysis (HF) was defined as maximum lysis on EXTEM >15%. Hypofibrinolysis was defined as maximum lysis on EXTEM <3%.

Descriptive statistics were compared using Fischer’s exact test and the Kruskal-Wallis test for categorical and continuous variables, respectively.

Results: ROTEM results from 1162 patients were reviewed and 116 corresponded to burn patients. Five patients were excluded due to incomplete ROTEM data. A total of 111 patients were included in our study. Median age was 45 years (IQR 33.5 – 58), 79% were male and median TBSA% was 16 (IQR 32.5 – 44). No differences were found in gender, age, ethnicity, race, admission weight, burn type, presence of inhalation injury or presence of concomitant trauma between the groups.

Distribution of fibrinolysis was: hypofibrinolysis, 26 (23.4%); physiologic, 83 (74.8%); and hyperfibrinolysis, 2 (1.8%). Mortality during admission was significantly different between the above-mentioned groups: 42.3%, 10.8% and 0.0%, respectively (p = 0.005).

Conclusion: Hypofibrinolysis, physiologic fibrinolysis and hyperfibrinolysis can be differentiated as separate entities using ROTEM. Different rates of mortality are found across the fibrinolysis spectrum in the burn population. Hyperfibrinolysis is not a common expression of coagulation dysfunction in traumatic burn injury. Different distributions in the trauma and the burn population imply different mechanisms of dysfunction and limit generalizability of treatment standards across populations.      

102.09 Layperson Perception of and Ability to Apply an Improvised Tourniquet after B-Con Training

Posted on January 31, 2019

J. C. McCarty1,2, J. P. Herrera-Escobar1, Z. G. Hashmi1, M. A. Chaudhary1, E. De Jager1, C. J. Ezeibe1, R. M. Nunez1, A. H. Haider1, E. Goralnick1,3, E. J. Caterson1,2  1Brigham And Women’s Hospital,Center For Surgery And Public Health, Department Of Surgery,Boston, MA, USA 2Brigham And Women’s Hospital,Division Of Plastic Surgery,Boston, MA, USA 3Brigham And Women’s Hospital,Department Of Emergency Medicine,Boston, MA, USA

Introduction: The American College of Surgeons Bleeding Control Basic (B-Con) course is the most common hemorrhage control training for laypeople; teaching participants skills on how to pack a wound, apply pressure, and apply a commercial tourniquet. In most scenarios in the civilian sector, however, a tourniquet would not be immediately available in the event of a trauma. The Hartford Consensus states improvised tourniquets are an option if a commercial tourniquet is not available, but with minimal supporting data. The objective of this study was to evaluate laypeople’s 1) ability to improvise a tourniquet after B-Con training and 2) evaluate what participant’s perceived actions before and after the training if a commercial tourniquet were not available.

Methods: B-Con course participants were evaluated on their ability to fashion and apply an improvised tourniquet to a high-fidelity Hapmed trainer, which simulates bleeding and provides an estimated blood loss (EBL), immediately after B-Con training. Participants were provided gauze, shoestring, a belt, and a rod to act as a windlass. No feedback was given to participants about which materials to use. Participants were administered questionnaires before and after the B-Con course, but before testing, assessing what participants would do if presented with life-threatening extremity bleeding in the absence of a commercial tourniquet. Descriptive statistics were used to describe the primary and secondary outcomes.

Results: 61 laypeople were evaluated. 32.8% (n=20) participants correctly fashioned and applied an improvised tourniquet. Of the available materials, 82.0% (n=50) used the windlass, 62.3% (n=38) used the shoelace, 47.5% (n=29) used gauze, and 18.0% (n=11) used the belt.  The leather belt broke in 45.5% (n=5/11) of cases. 11 participants did not use a windlass and had a 0% success rate. When a commercial tourniquet was not available, pre-training 27.9% would apply an improvised tourniquet and 72.1%(n=44) would apply pressure. Post-training, 26.2% (n=16) would apply an improvised tourniquet and 72.1% (n=44) would apply pressure. Of those that would place an improvised tourniquet post-training, 8 (50%) applied the tourniquet correctly. 66.7% (n=40) reported the tourniquet was the most important skill taught in the course and 23.3% (n=14) thought it was how to apply pressure with your hands.

Conclusion: Civilian laypeople are unlikely to have a tourniquet when called upon to respond to a bleeding victim and, even with ideal supplies, can improvise a tourniquet less than a third of the time. The emphasis on tourniquet training for laypeople, rather than teaching pressure and packing alone, should be re-evaluated to align with the scenarios laypeople are likely to face.

102.08 Morning Report Decreases Length of Stay in Emergency General Surgery Patients

Posted on January 31, 2019

J. R. Gardner1, J. D. Wolfe1, W. Beck1, A. Bhavaraju1, M. K. Kimbrough1, B. Davis1, A. Privratsky1, M. Jupin1, J. Jensen1, R. Roberston1, K. Sexton1, J. R. Taylor1  1University of Arkansas for Medical Sciences,Department Of Surgery,Little Rock, AR, USA

Introduction:
Reduction of errors, as the result of inefficient patient hand-offs, has been a focus of interest in the Emergency General Surgery (EGS) field. High patient loads, and limited time to thoroughly conduct patient hand-offs during shift changes can result in errors in patient care. UAMS, a state-wide tertiary care center, changed its hand-off method from an email- based approach to a Morning Report (MR) model.

Methods:
Prior to MR, there was a lack of attending physician supervision during hand-offs between resident teams. The MR model instituted meetings between resident teams and 3 attending surgeons (night call, trauma day call, and EGS day call). The enterprise data warehouse was queried for all patients admitted to the Emergency General Surgery service from May 2014 until January 2018. Bivariate frequency statistics and linear regression analysis were performed using JMP Pro Version 13.2.1. Elixhauser categories were used for risk stratification.

Results:
2592 patients were analyzed in this study (pre-MR, n= 608; post-MR, n= 1984). The majority of patients were white males. The pre-MR cohort had an average age of 47.8 years compared to the post-MR cohort, 49.6 years (p= 0.253). 1484 patients had an operation, while 1108 did not. No significant difference in the number of comorbidities was found between pre and post-MR cohorts (p= 0.686). The LOS (days) for pre and post cohorts were (4.87 ± 7.9 and 4.13 ± 6.7, p= 0.019). Linear Regression showed procedures, Elixhauser Categories, Morning Report, age > 65, race, and gender were predictive of LOS.

Conclusion:
Attending supervised EGS MR is associated with a decreases length of stay. Further work needs to be done to quantify the effects of a MR system.
 

102.07 What’s Behind the Widened Mediastinum on CXR?

Posted on January 31, 2019

G. Vasileiou1, S. Qian1, H. Al-ghamdi1, D. Pace1, R. Rattan1, G. D. Pust1, M. Mulder1, N. Namias1, D. D. Yeh1  1University Of Miami,Surgery,Miami, FL, USA

Introduction:  It is commonly taught that a widened mediastinum (WM) on CXR is a marker for aortic injury (AI). We sought to describe the epidemiology of injuries for all patients with WM and compare their CXR to those of patients with confirmed AI. 

Methods:  Adults (age≥ 18) sustaining blunt traumatic injuries from 1/17-6/17 with both CXR (supine, anterior-posterior [AP]) and chest CT were included. We excluded those whose CT preceded CXR and those with missing data. Basic demographic information, injury characteristics, mediastinal width (MW), mediastinal-to-thoracic width ratio (MTR), and all thoracic imaging findings were analyzed. MW >8cm was considered “widened”.  We also queried our registry for all AI patients over a 4 yr period. The sensitivity (Sn), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), and accuracy of WM on CXR for AI were calculated for the 6-month period. Mann-Whitney U test was used as appropriate to compare patients with WM, and patients with confirmed AI. Multivariate logistic regression was performed to identify factors associated with positive traumatic findings. 

Results: Of 749 included subjects, 502 (67%) had a MW > 8 cm: mean age was 48 ±20 yrs, 381 (76%) were men, and mean BMI was 28 ± 5 kg/m2. Mechanism of injury was: motor vehicle crash (MVC) in 335 (67%); fall in 113 (23%); assault in 31 (6%), other (jet-ski accidents, etc.) in 17 (3%), and unknown in 6 (1%). Only 128 (26%) of WM patients had positive findings on CT, with the most common [80 (16%)] being non-traumatic findings (thymic tissue, lymph nodes, etc.), followed by hemo/pneumomediastinum [32 (6%)], sternal fractures [18 (4%)], multiple findings [15 (3%)], and vertebral fractures [6 (1%)]. Only 2 (1%) had AI. The Sn was 100%, Sp was 33%, PPV was 0.4%, NPV was 100%, and accuracy was 33%. From 2013-2017, 38 patients had AI: mean age was 46 ± 19 yrs, 26 (68%) were men, and mean BMI was 28 ±4 kg/m2. MVC was the most common mechanism (n=34 (89%)), followed by ‘other’ trauma mechanism in 2 (5%), fall in 1 (3%), and assault in 1 (3%). On univariate analysis, compared to all patients with WM, AI patients had significantly greater MW (9.5 [8.8-10.4] vs 10.2 [9.1-11.1]; p= 0.042) and MTR (0.31 [0.28-0.34] vs 0.32 [0.31-0.37]; p=0.001), though the actual differences were not clinically significant. Regression analysis did not identify any factors associated with traumatic CXR findings (Table).

Conclusion: Most blunt mechanism injured adults have a WM and the majority of those have either no findings or non-traumatic findings. The PPV of a WM for AI is <1%.  WM on supine AP CXR is non-specific and inaccurate for diagnosing traumatic injuries, especially AI.

 

102.06 Vices-Paradox in Trauma: Positive Alcohol and Drug Screens Associated with Decreased Mortality

Posted on January 31, 2019

J. Covarrubias1, A. Grigorian1, J. Nahmias1, T. Chin1, S. Schubl1, V. Joe1, M. Lekawa1  1University Of California – Irvine,Department Of Surgery,Orange, CA, USA

Introduction: There is a previously established association between trauma and alcohol, illegal drugs, as well as prescription drugs, all of which can lead to impaired judgement and reaction time resulting in injury. Improved survival in trauma patients with acute alcohol intoxication has been previously reported. The effect of illegal and prescription drugs on mortality is less clear. We hypothesized that alcohol, illegal and prescription drugs are each independently associated with decreased risk of mortality in adult trauma patients.

Methods: The Trauma Quality Improvement Program (2010-2016) was queried for patients screening positive for alcohol, illegal or prescription drugs on admission. These do not include prescription drugs for medical treatment. A multivariable logistic regression model was used to determine risk of mortality.

Results: From 1,299,705 adult patients, 227,995 (17.5%) screened positive for alcohol, 155,437 (12.0%) for illegal drugs and 90,259 (6.9%) for prescription drugs. The alcohol cohort had the highest mortality rate (6.2%), followed by prescription drugs (5.7%) and illegal drugs (5.1%) (p<0.001). After controlling for covariates in an analysis of all adult trauma patients, all three groups had lower risk for mortality: alcohol (OR=0.88, CI=0.84-0.92, p<0.001), illegal drugs (OR=0.80, CI=0.74-0.86, p<0.001), prescription drugs (OR=0.70, CI=0.65-0.76, p<0.001). When stratified by injury severity score (ISS), those screening positive for alcohol or illegal drugs continued to have decreased mortality until an ISS of 50. Patients screening positive for prescription drugs were associated with decreased mortality when ISS>16.

Conclusion: Compared to all trauma patients, those screening positive for alcohol on admission have more than a 10% decreased risk of mortality, those screening positive for illegal drugs have a 20% decreased risk of mortality, and those screening positive for prescription drugs have a 30% decreased risk of mortality. The effect of alcohol and illegal drugs on risk for mortality ceases only when ISS>50. This paradoxical association should be confirmed with future clinical studies, as well as merits basic science research to help identify biochemical or physiologic components conferring a protective effect on survival in trauma patients.

102.05 Fat Embolism – a Serious Complication after Trauma: An Analysis of the National Trauma Data Bank

Posted on January 31, 2019

G. Vasileiou1, J. Parks1, D. D. Yeh1, R. Rattan1, T. Zakrison1, N. Namias1, G. D. Pust1  1University Of Miami,Surgery,Miami, FL, USA

Introduction: Fat embolism (FE) is a rare complication after trauma that may have devastating consequences. Our objective was to describe the incidence of and clinical outcomes after FE.

Methods:  The 2008- 2014 National Trauma Data Bank (NTDB) were queried for FE, using ICD9 958.1. Descriptive analysis of demographics, injury, and hospitalization characteristics was carried out. Multivariate logistic regression analysis for mortality was performed controlling for age, gender, ISS score, and intensive care unit (ICU) admission. 

Results: Out of 4,495,935 patients, we identified 418 (0.01%) diagnosed with FE. Median age was 32 [21-62], and 275 (66%) were male. Of those, 393 (94%) had blunt mechanism, and 407 (97%) had fractures; femur fractures were the most common 286 (68%); followed by multiple bone fractures 225 (54%); other (ribs, vertebra, radius, ulna, etc) bone fractures 200 (48%); tibia and/or fibula 130 (31%); pelvis 78 (19%); and humerus 31 (7%) fractures. Median time to OR was 15 [6 – 34] hours.Internal fixation was performed in 248 (59%), followed by procedures without internal fixation in 47 (12%), and removal of implants in 35 (9%) patients. ICU admission was required in 291 (70%) patients, and 152 (36%) needed mechanical ventilation for 6 [2-11] days. Median hospital length of stay (LOS) and ICU LOS were 10 [6-16] and 5 [2-12] days, respectively. Median Injury Severity Score (ISS) was 10 [9-18], yet in-hospital mortality was 13% (n=54). There were 169 (40%) patients that were discharged home with or without additional services while 184 (44%) were transferred to other facilities. Multivariate logistic regression analysis showed that mortality was associated with ventilation (OR: 4.05; 95% CI [2.01-8.13]; p<0.001), age (OR: 1.02; 95% CI [1.01-1.03]; p=0.006), and ISS (OR: 1.04; 95% CI [1.01-1.07]; p=0.018), (Table 1).

Conclusion: Fat embolism is an extremely rare complication that occurs almost exclusively in trauma patients with fractures.  FE is associated with higher-than-expected mortality based on ISS and most patients require ICU admission and usually with concomitant mechanical ventilation. Formal diagnostic criteria and severity grading is the next step required for improving diagnostic accuracy and treatment of this entity.

 

102.04 The Impact of Obesity on Severity and Outcomes in Penetrating Abdominal Trauma

Posted on January 31, 2019

E. De La Cruz1, O. A. Olufajo1, A. Zeineddin1, E. Cornwell1  1Howard University College Of Medicine,Surgery,Washington, DC, USA

Introduction:
Obesity is widely acknowledged to be a predictor of increased morbidity and mortality. Multiple studies investigating the association between body mass index (BMI) and blunt abdominal trauma have shown a protective effect of increasing BMI on the severity of injury presumably owing to a “cushion effect”. However, the number of studies exploring the association of BMI and the severity of abdominal penetrating trauma patients is rather limited. The aim of our study is to evaluate that association using a nationwide sample.

Methods:
Data was retrieved from the National Trauma Data Bank (2013-2015). Patients included were those with penetrating abdominal trauma. Patients were stratified by BMI status (<18.5, 18.5-24.9, 25-29.9, 30-39.9, >40). Patients without information on BMI were excluded from the analyses. We defined injury severity using two methods. First, we used the abdomen abbreviated injury scale (AIS) ranging from 1 to 6. Second, we categorized patients as having an abdominal operation vs. no abdominal operation. We evaluated differences in injury severity and mortality across BMI groups using Chi-square tests. Logistic regression multivariate regression models were used to identify independent associations between BMI and the outcomes measured.    

Results:
We included 22,110 patients with abdominal penetrating trauma: 10,856 stab wounds, (SW) and 11,254 gunshot wounds (GSW). With increasing BMI, there was a decrease in AIS>2 in SW (26.4%, 27.2%, 26.9%, 23.1%, 20.9%) (P<0.001) and in GSW (60.4%, 51.7%, 52.7%, 50.4%, 48.1%) (P=0.016). The rate of operative management across BMI groups in SW was 43.6%, 43.7%, 43.3%, 44.8%, 46.1% (P<0.655), and in GSW was 59.2%, 58.9%, 59.8%, 60.9%, 54.9% (P=0.084). On multivariate analysis, patients with BMI 30-39.9 had increased odds of undergoing surgical procedures compared to patients with normal BMI [Odds Ratio, OR (95% Confidence Interval, CI)]: 1.15 (1.01-1.30) among those with GSW, but there was no difference in SW. The unadjusted analysis showed an increase in mortality with increasing BMI among patients with GSW (5.8%, 5.9%, 5,2%, 6.9%, 7.8%) (P=0.024), but no difference in mortality with increasing BMI in SW (1.4%, 1.3%, 1.2%, 0.9%, 2.5%) (P= 0.096). However, on multivariate analysis of patients with SW, patients with BMI >40 had increased odds of mortality compared with patients with normal BMI [OR(95% CI): 2.35 (1.08 – 5.06)]. This was also true for patients with BMI >40 among patients with GSW [OR(95% CI): 1.89 (1.26 – 2.86)].

Conclusion:
Increased BMI seems to have a protective effect against penetrating abdominal trauma, as it was associated with lower incidence of severe injury. However, there is increased mortality in morbidly obese patients who were victims of penetrating abdominal trauma. This study suggests that the protective effect of obesity in injury severity may be countered by other factors inherent to the morbidly obese population.

102.03 Regional Survey of Chest Tube Management Practices by Trauma Surgeons

Posted on January 31, 2019

M. H. Parker1, A. Newcomb1, C. Liu1, C. Michetti1  1Inova Fairfax Hospital,Falls Church, VA, USA

Introduction:
Evidence to guide CT management in trauma patients is limited and tends toward thoracic surgery patients. The goal of this study was to identify current practices among trauma providers regarding trauma CT management in trauma patients.

Methods:
We designed a web-based survey (Survey Monkey) to assess CT management practices of trauma providers who were active, senior, or provisional members (N=1890) of the Eastern Association for the Surgery of Trauma via email. The survey contained multiple choice and write-in questions. Descriptive statistics were used.

Results:

The response rate was 39% (N=734). 91% of respondents were attending surgeons, the remainder fellows or residents. Attendings were more likely than trainees to place pigtail catheters for stable patients with pneumothorax (PTX). Attendings with <5 years’ experience were more likely to choose a pigtail than more experienced surgeons for elderly patients with PTX. Respondents preferred standard size CT for hemothorax (HTX) and unstable patients with PTX, and larger tubes for unstable patients with HTX (Figure 1).

97.3% (PTX) and 97.5% (HTX) would place a CT to suction following placement.  Most respondents (58.9%) selected transitioning to water seal after resolution of any air leak, but not before 24 hours.  25.7% would use water seal after resolution of air leak regardless of timing.  For hemothorax, 41.9% of respondents would place to water seal based on a specific fluid output, 27.7% after 24 hours and 19% based on CXR findings.  While CT was on suction, the majority of respondents would allow water seal for ambulation for PTX (85.0%) and HTX (93.4%).  The median output at which respondents would remove a chest tube was 150cc for serosanguinous fluid and 100cc for bloody fluid.  After CT removal for PTX, CXR was preferred at 4 hours (39.7%), 6 hours (21.0%) 1 hour (13.8%); 12.9% did not get a CXR.

For non-ventilated patients, most attendings chose to get CXR after placement (96.7%), prior to removal at the end of a water seal trial (69.4%) and after removal (66.1%).  Some preferred CXR prior to placement to water seal (45.3%) or daily CXR (38.9%).  At outpatient follow-up, only 27.4% would get a CXR for PTX.  The majority (53%) perceived the quality of evidence for trauma CT management to be low and cited personal experience and training as the main factors driving their practice.

Conclusion:

Trauma CT management is variable and non-standardized, and depends mostly on clinician training and personal experience.  Few surgeons identify their practice as evidence based. We offer compelling justification for the need for trauma CT management research to determine best practices.

102.02 The Revolving Door, Readmissions after Traumatic Brain Injury

Posted on January 31, 2019

A. Brito1, L. N. Godat2, A. E. Berndtson2, J. Doucet2, A. M. Smith2, T. W. Costantini2  1University Of California – San Diego,General Surgery,San Diego, CA, USA, 2University Of California – San Diego,Division Of Trauma, Surgical Critical Care, Burns And Acute Care Surgery – Department Of Surgery,San Diego, CA, USA

Introduction: Traumatic brain injury (TBI) is associated with functional deficits, impaired cognition and medical comorbidities that continue well after the initial injury.  Many patients seek medical care at other healthcare facilities following discharge, rather than returning to the admitting trauma center, making assessment of readmission rates difficult to determine.  The objective of this study was to determine the incidence and factors associated with readmission to any acute care hospital after an index admission for TBI.

Methods: The Nationwide Readmission Database was queried for all patients admitted with a TBI during the first 3 months of 2015.  Readmissions for this population were then collected for the remainder of 2015.  Patients that died during the index admission were excluded. Demographic data, injury mechanism, type of TBI, the number of readmissions, days from discharge to readmission, readmission diagnosis and mortality were studied.

Results: Of the 15,277 patients with an index admission for TBI, 5,296 patients (35%) required at least 1 readmission. The number of readmissions ranged from 1 to 14.  Twenty six percent of readmissions occurred within the first 2 weeks after discharge from the index trauma admission (see Figure).  Patients with subdural hematoma (SDH) were more likely to require readmission compared to other types of TBI (RR 1.21, p<0.001).  The most common primary diagnosis on readmission was SDH, followed by septicemia, urinary tract infection, and aspiration.  The 3 most frequent injury mechanisms associated with readmission were fall (86%), motor vehicle crashes (7%) and assaults (4%).  Readmission rates increased with age, with 94% occurring in patients over the age of 45 and 75% in patients >65 years.  Mortality ranged from 6-14% on depending on the number of subsequent readmissions after TBI.

Conclusion: Hospital readmission is common for patients discharged following TBI.  Elderly patients who fall with resultant SDH are at especially high risk for complications and readmission. Understanding potentially preventable causes for readmission can be used to guide discharge planning pathways to decrease morbidity in this patient population.

102.01 Development and Generalization of a Score to Predict Trauma Patient Discharge Disposition using NTDB

Posted on January 31, 2019

M. Graham1, P. Parikh1,2, S. Hirpara2, M. McCarthy1, P. P. Parikh1  1Wright State University,Department Of Surgery,Dayton, OH, USA 2Wright State University,Department Of Biomedical, Industrial, And Human Factors Engineering,Dayton, OH, USA

Introduction: Delay in discharge planning could result in extended length of stay leading to increased hospital costs, ineffective utilization of resources, and delays in rehabilitation treatment in trauma patients. Limited work has been done in developing models predicting discharge disposition in trauma patients. These models are developed using a single institution data and have not be demonstrated to be generalizable. The objective of this study is to develop a predictive model using the National Trauma Data Bank (NTDB) and evaluate its generalizability on data from a Level I trauma center.  

Methods:  NTDB data from 2015 were used to build and validate a binary logistic regression model using derivation-validation (i.e., train-test) approach to predict patient disposition location (home vs nonhome) upon admission. Patient demographics and clinical variables available at the time of admission were considered in the analysis. A Mann-Whiney U-test was used to compare patient parameters. The regression model was then converted into a 20-point score using an optimization-based approach. An appropriate threshold was selected to achieve a score with a sensitivity of >0.80 and specificity of >0.50. The generalizability of this score was then evaluated on the trauma registry data at our Level I trauma center in Midwest US.

Results:A total of 558,599 cases in the NTDB were included in the study, out of which, 178,666 (31.98%) went to a nonhome location and 379,933 (68.02%) patients went home. The average age of patients with a nonhome disposition compared to home disposition was significantly higher (68.11 ± 20.69 years vs. 43.23 ± 23.09 years; p<0.001) and had more severe injuries measured using the ISS (11.26 ± 8.25 vs 8.04 ± 6.28; p<0.001). Increased age, female sex, higher ISS, and the comorbidities of cancer, cardiovascular, coagulopathy, hepatic, neurological, psychiatric, renal, substance abuse, and diabetes were independent predictors of nonhome discharge. The logistic regression model’s AUC was 0.83; the score achieved a correlation of 0.94 with the predicted probabilities from the regression model. A threshold value of 4 or higher indicated higher likelihood of nonhome discharge; this threshold resulted in a sensitivity of 0.86 and specificity of 0.62 on NTDB validation data (n=167,580). The score generalized well on the insitutional data (n=3,384) obtained from trauma registry of our Level I Trauma Center; sensitivity of 0.85 and specificity of 0.60.

Conclusion:A model and a score developed using NTDB could be implemented at a Level I trauma center to predict upon admission a trauma patient’s discharge disposition location, home or nonhome. This score can aid in early hospital preparation for patients predicted to be discharged to a nonhome location yielding a smoother transition, increased satisfaction, effective utilization of hospital resources, and potentially decrease total operating costs.

101.20 Is Advanced Age Is a Contradiction for Non-Operative Management of Liver Injuries?

Posted on January 31, 2019

O. A. Vazquez1, M. Gomez3, A. A. Fokin2, M. Crawford2, J. Wycech2,3, A. Tymchak1,2,3, I. Puente1,2,3,4  1Florida Atlantic University,College Of Medicine,Boca Raton, FL, USA 2Delray Medical Center,Trauma Services,Delray Beach, FL, USA 3Broward Health Medical Center,Trauma Services,Fort Lauderdale, FL, USA 4Florida International University,College Of Medicine,Miami, FL, USA

Introduction:
Nonoperative management (NOM) of blunt liver injuries (BLI) has become the standard of care in hemodynamically stable patients without indications for laparotomy. However, controversy remains regarding the contraindications for NOM in the geriatric population. The goal of this study was to assess the efficacy of NOM in geriatric as compared to non-geriatric patients with liver injuries.

Methods:
This IRB approved retrospective cohort study included 108 adult patients with BLI who were admitted to a level I trauma center from 2012 to 2017. Of these 108 patients, 19.4% (n=21) were ≥65 years old (Geriatric Group) and 80.6% (n=87) were <65 (Non-Geriatric Group). Analyzed variables included injury severity score (ISS), liver organ injury scale (LOIS) grade, Glasgow Coma Scale (GCS), incidences of packed red blood cells transfused within 24 hours (PRBC24), angiography, embolization, repeat abdominal computed tomography (CT), hemoperitoneum, anticoagulation or antiplatelet therapy prior to trauma, spine co-injuries, management approach, intensive care unit length of stay (ICULOS), hospital LOS (HLOS), and mortality.

Results:

Geriatric Group was significantly older (76.8 vs 36.9 years, p<0.001). The two groups showed no statistical difference between mean ISS (19.9 vs 22.1), LOIS grade (2.1 vs 2.4), GCS (13.6 vs 11.8), rates of PRBC24 (42.9% vs 34.5%), angiography (19.0% vs 23.0%), embolization (4.8% vs 10.3%), repeat CT (42.9% vs 23.0%) and hemoperitoneum (47.6% vs 47.1%), with all p>0.06.

Geriatric Group had a higher rate of pre-injury anticoagulation therapy (38.1% vs 6.9%, p<0.001), and of spinal co-injuries (57.1% vs 29.5%, p=0.02) than Non-Geriatrics.

NOM was attempted in 75.0% of Geriatric versus 71.3% of Non-Geriatric patients (p=0.7). Failure of NOM rate between the two Groups was also not significantly different (13.3% vs 9.7%, p=0.7). In the Geriatric Group 2 out of the 2 and in the Non-Geriatric Group 3 out of the 6 failed NOM were due to the liver injury, with the rest in the Non-Geriatric Group due to other abdominal organ injury.

Geriatric and Non-Geriatric Groups did not have statistically different ICULOS (10.9 vs 7.2 days), HLOS (12.6 vs 10.3 days), and mortality (19.0% vs 10.3%), with all p>0.2. Three out of 4 Geriatric and 5 out of 9 Non-Geriatric patients died due to their abdominal trauma, including BLI, whereas the remainder of deaths were due to pulmonary insufficiency or TBI.

Conclusion:
Age was not a contraindication for non-operative management of abdominal trauma with liver injuries, as all outcomes in Geriatric and Non-Geriatric patients were comparable. Non-operative management should still be attempted in the Geriatric population despite their advanced age.

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