16.18 Is it Cool to Cool Post Cardiac Arrest Trauma Patients?

Posted on January 18, 2016

S. H. Asfaw1, N. D. Martin1, M. J. Seamon1, J. L. Pascual1, C. A. Sims1, P. M. Reilly1, D. N. Holena1 1University Of Pennsylvania,Traumatology, Surgical Critical Care And Emergency General Surgery,Philadelphia, PA, USA

Introduction: Therapeutic Hypothermia (TH) is a widely accepted mechanism for neuroprotection and has been shown to improve neurologic outcomes in post cardiac arrest (PCA) medical patients. One theoretical drawback to TH is an increased bleeding risk. For this reason, its use has been limited in many surgical and trauma populations. We hypothesized that bleeding risk would be low in trauma patients while still realizing similar neurologic benefits to the medical population.

Methods: A retrospective chart review of our cardiac arrest registry at our level one trauma center from May 10, 2005 to June 18, 2014 was performed. Patients with a traumatic diagnosis or mechanism, who sustained and in-hospital or out of hospital arrest, had return of spontaneous circulation (ROSC), and had a post arrest GCS (Glasgow Coma Scale) score of less than 6 were included. Targeted temperature management of 32-34°C was performed in accordance with our institutional protocol. Data collection included age, sex, race, Injury Severity Score (ISS), location of arrest, cause of arrest, initial rhythm at arrest, initial GCS, GCS at discharge, GCS and survival at follow up intervals of 6 months and 1 year, hemoglobin and coagulation profile on admission and during TH and if a surgical intervention was performed during hospitalization.

Results: A total of 3380 patients sustained a cardiac arrest at our institution during the time period reviewed of which 301 were admitted to the trauma service. Return Of Spontaneous Circulation (ROSC) occurred in 134 patients, of which 14 (10%) with a GCS of less than 6 underwent TH. Five were excluded from analysis for minimal injury (ISS <5). Of 9 trauma patients undergoing TH, 4 died in the hospital (mean age 74, mean ISS 24.5). Five trauma patients undergoing TH survived to discharge (mean age 42, mean ISS 17.6) of which 4 were alive at both 6 months and 1 year all with good neurologic outcomes (1 with a GCS of 11T and 3 with a GCS of 15). None of the cooled patients had bleeding complications during their initial hospitalization.

Conclusion: Only a small fraction of trauma patients with ROSC after cardiac arrest underwent TH, but we found no bleeding complications in those patients who were cooled. Although small, our series demonstrates neurologic and survival outcomes consistent with larger medical studies previously published. Therapeutic Hypothermia should be considered for trauma patients with ROSC after cardiac arrest.

16.19 Is Routine Continous Electroencephalography for Traumatic Brain Injury Beneficial?

Posted on January 18, 2016

L. Aquino1, C. Y. Kang1, M. Y. Harada1, A. Ko1, E. J. Ley1, D. R. Margulies1, R. F. Alban1 1Cedars-Sinai Medical Center,Division Of Trauma And Critical Care,Los Angeles, CA, USA

Introduction: Severe traumatic brain injury (TBI) has been associated with potential increased risk for early clinical and subclinical seizures. The use of continuous electroencephalography monitoring (cEEG) in TBI patients allows for potential identification and subsequent treatment of seizures that may otherwise occur undetected. The benefits of ‘routine’ cEEG after TBI remains controversial. This test is time consuming, utilizes a significant amount of resources and is expensive. To evaluate the benefit of cEEG, we examined the rate of clinical and subclinical seizures identified by cEEG in a cohort of moderate to severe TBI patients admitted to a Level I urban trauma center.

Methods: We analyzed a cohort of trauma patients with moderate to severe TBI (head AIS ≥ 3) who received cEEG within 7 days of admission at our Level I trauma center between October 2011 and May 2015. Demographics, clinical data, injury severity, and costs were recorded. Rate of seizure activity based on cEEG result was analyzed and clinical characteristics were compared between those with and without seizures.

Results: A total of 106 TBI patients with moderate to severe TBI received a routine cEEG during the study period. Most were male (74%) with a mean age of 55.1 ± 23.5 years. Subclinical seizures were identified by cEEG in only 4 (3.8%) of these patients. Of all patients, 93% were on anti-seizure prophylaxis at the time of cEEG. Patients who had subclinical seizures were significantly older than their counterparts (80 v. 54 years, p=0.01) and had a higher mean head AIS (5.0 v. 4.0, p=0.01) and ISS (27 v. 22, p=0.03). Mortality and ICU stay was similar for both groups. In addition, the estimated total direct cost for cEEGs on all patients was $68,488.

Conclusion: Of all TBI patients who were monitored with cEEG, only 3.8% were identified to have seizures. These neurological events were more likely to occur in older patients with severe head injury. Given the high cost of cEEG and the low incidence of subclinical seizures, we do not recommend ‘routine’ cEEG in patients with TBI. Rather, cEEG monitoring in TBI patients should be conducted only when clinically indicated.

16.14 Subdural Hematoma may be a Risk Factor for Hemorrhage Expansion after Initiation of Antithrombotics

Posted on January 18, 2016

J. Pattison2, U. Pandya1 1Grant Medical Center,Trauma Services,Columbus, OH, USA 2Ohio University College Of Osteopathic Medicine,Heritage College Of Medicine,Athens, OH, USA

Introduction: Common indications for anticoagulant and/or antiplatelet medication use after injury include venous thromboembolism, blunt cerebrovascular injury, and atrial fibrillation to name a few. Patients with traumatic intracranial hemorrhage with a clinical indication for antiplatelet and/or anticoagulant medication present a significant clinical dilemma, burdened by the task of weighing the potential risks of hemorrhage expansion against the risk of withholding antithrombotic therapy. We speculate that specific types of intracranial hemorrhage may be more susceptible to hemorrhage expansion after post injury administration of antithrombotics. In this study, we sought to determine the effect of subdural hemorrhage on the risk of hemorrhage expansion after administration of antiplatelet and/or anticoagulant medication.

Methods: Medical records of 1,626 trauma patients admitted with traumatic intracranial hemorrhage between March 1, 2008 and March 31, 2013 to an adult level 1 trauma center were retrospectively reviewed. The pharmacy database was queried to determine which patients were administered anticoagulant (warfarin, therapeutic intravenous heparin, therapeutic weight based lovenox) or antiplatelet (clopidogrel, aspirin) medication during their hospitalization, leaving a sample of 97 patients that met inclusion criteria. Patients presenting with subdural hemorrhage were compared to patients without subdural hemorrhage. Demographic data, clinically significant expansion of hematoma (defined as the need to stop therapy due to worsening intracranial hemorrhage), post injury day of initiation, and mortality were analyzed. P values < 0.05 were considered statistically significant

Results: A total of 97 patients met inclusion criteria with 55 patients in the subdural hemorrhage group and 42 in the other intracranial hemorrhage group. There were no significant differences in age, gender, injury severity score, admission Glasgow coma score, or mean hospital day of antithrombotic administration between the 2 groups. Patients with subdural hemorrhage did have a significantly higher rate of intracranial hemorrhage expansion (9.1% vs 0%, p=0.045). There was no difference in overall hospital mortality between the 2 groups.

Conclusion: Incidence of intracranial hemorrhage expansion was higher in patients with subdural hemorrhage. It may be prudent to use special caution when administering antiplatelet or anticoagulant medication in this group of patients after injury. Further study could help better define which types of intracranial hemorrhage are most susceptible to expansion after antithrombotic administration.

16.15 Cervical Spine Injury and Mandibular Fractures: When is the Lifesaver Broken in Two Spots?

Posted on January 18, 2016

T. Soleimani1, T. A. Evans1, S. I. Fernandez1, L. Spera2, R. Sood1, C. Klene1, B. L. Zarzaur2, S. S. Tholpady1 2Indiana University School Of Medicine,Department Of Surgery,Indianapolis, IN, USA 1Indiana University School Of Medicine,Division Of Plastic Surgery,Indianapolis, IN, USA

Introduction: The rate of cervical spine injury (CSI) among trauma patients with mandibular fractures has been reported to be between 0.8 and 11%. They are anatomically related as forces on the mandible have the ability to damage the posterior portion of the ring, or the cervical spine. Recognition of CSI is critical in the management of mandibular fractures as manipulation of the neck during fracture fixation has the potential to cause spinal cord damage. The current study was designed to identify risk factors associated with CSI in patients with mandibular fractures using the largest US trauma database.

Methods: The National Trauma Databank (NTDB) 2007-2010 was reviewed for patients with the ICD-9 diagnosis code for mandibular fractures. Due to anatomic differences, patients were divided into two groups: children (<18 years) and adults (≥18 years). In each age group, the association between demographics, mechanism of injury, and injury characteristics with CSI was evaluated using bivariate analysis and logistic regression.

Results: A total of 8,317 children (14%) and 50,711 adults (86%) were identified. The rate of CSI in children was significantly lower than adults (3.5% vs 7.3%). In both age groups, the most frequent type of mandibular fracture was comminuted fractures (35.4% and 34.5% of children and adults respectively) followed by symphyseal (18.1%, 15.7%), body (13.2%, 15.3%), and condylar (16.6%, 11.3%) fractures. Using logistic regression different predictors of CSI were determined for adults and children; however, increased age, lower Glasgow Coma Score (GCS), thoracic injury (OR= children: 2.5, adults: 2.3), and motor vehicle accident (OR=3.0 and 4.0) or firearm (OR=9.5 and 3.0) mechanisms were predictive of CSI in both groups. In children, condylar (OR=0.5) or multiple mandibular (OR=0.7) fractures were inversely correlated with CSI. In adults, female gender (OR=1.1), mandibular body fracture (OR=1.2), and concomitant upper extremity injury (OR=1.4) predicted higher probability of CSI; multiple mandibular fracture (OR=0.8), concomitant abdominopelvic injury (OR=0.9), and concomitant lower extremity injury (0.8) were inversely correlated with CSI.

Conclusion: The results of this study demonstrate the demographics, mechanistic, and injury patterns most significantly associated with CSI in the adult and pediatric populations. Increased age, lower GCS, thoracic injury, and MVA or firearm mechanisms were associated with CSI in both groups. In adults, CSI was associated with female gender, mandibular body fracture, and concomitant upper extremity injury. The inverse correlation between multiple mandibular fracture with CSI could indicate that in multiple fractures the energy gets dissipated in the mandible instead of getting transmitted into the cervical spine. In order to prevent morbidity from CSI, these factors should be considered while evaluating patients with mandibular fractures.

16.16 meld score is associated with mortality in non-cirrhotic patients following hemorrhagic shock

Posted on January 18, 2016

J. O. Hwabejire1, C. Nembhard1, E. Cornwell1, W. Greene1 1Howard University College Of Medicine,Washington, DC, USA

Introduction: The Model for End-Stage Liver Disease (MELD) score has been shown to predict mortality in cirrhotic trauma patients. We examined the association of the MELD score in patients without liver disease who sustained traumatic hemorrhagic shock.

Methods: The Inflammation and the Host Response to Injury database was analyzed. Patients with complete parameters for calculating the MELD score were included, while those with pre-existing liver disease were excluded. Subjects were stratified into 3 groups: MELD I (MELD score ≤10), MELD II (MELD score >10 and ≤20) and MELD III (MELD score >20). Logistic regression analysis was used to evaluate the association between mortality and the MELD score.

Results: A total of 183 patients were included, with a mean age of 43 years, and males making 68% of the study group. The mean MELD score and in-hospital mortality of the study cohort were 12.5 ± 5.9 and 18.0%, respectively. MELD I had a mortality of 9.4%, with 6.3% and

15.6% of them developing abdominal compartment syndrome (ACS) and acute respiratory distress syndrome (ARDS), respectively. The mortality for MELD II was 22.0%, with 11.0% and 38.0% of subjects developing ACS and ARDS respectively. MELD III had a mortality of 26.3%, with 15.8% and 31.6% of subjects ACS and ARDS, respectively. The MELD score was associated with mortality (OR: 1.073, CI: 1.010-1.140, p=0.021), with a 7.3% increase in mortality for every unit increase in MELD score.

Conclusion: In non-cirrhotic patients who sustained traumatic hemorrhagic shock, increased MELD score is associated with increased mortality. Whether optimization of liver function following hemorrhagic shock would improve outcome deserves further investigations

16.11 Determinants of Mortality in Post-traumatic Sepsis: An Analysis of the National Trauma Data Bank

Posted on January 18, 2016

J. O. Hwabejire1, C. E. Nembhard1, T. A. Oyetunji2, T. Seyoum1, S. M. Siram1, E. E. Cornwell1, W. R. Greene1 1Howard University College Of Medicine,Surgery,Washington, DC, USA 2Children’s Mercy Hospital,Surgery,Kansas City, MO, USA

Introduction: Post-traumatic sepsis is a potentially lethal condition. While ‘multiple organ failure’ is often the labeled culprit for the cause of death, it is important to identify specific factors that may increase mortality in this setting. We hypothesize that pre-injury variables contribute significantly to mortality after post-traumatic sepsis.

Methods: The National Trauma Data Bank data sets for 2008-2010 were retrospectively examined. ICD-9 diagnostic codes 995.91 and 995.92 were used to identify subjects aged ≥ 16 with sepsis. Survivors were compared with non-survivors using demographic, injury-related, co-morbid, and other clinical variables. The primary outcome was mortality. Univariate and multivariate analyses were done to determine predictors of mortality.

Results: A total of 1486 patients were included, with a mean age of 55, in a predominantly male population (72%). Whites made up 60% and Blacks 17%. Mortality was 15% in those who had sepsis without organ dysfunction and increased to 38% in those with sepsis plus organ dysfunction. There was no difference in Injury Severity Score, emergency room systolic BP, pulse rate, temperature, oxygen saturation, GCS, ICU days or ventilation days between survivors and non-survivors. Compared to survivors, non-survivors were older (62±21 vs. 52±21, p<0.001), had a lower respiratory rate (16±10 vs. 17±10, p=0.045), more likely to be female (33% vs. 25%, p=0.002), transferred from another facility (32% vs. 26%, p=0.021), and had pre-injury bleeding disorder (41% vs. 25%, p<0.001), congestive heart failure (40% vs. 26%, p<0.001), DNR status (71% vs. 26%, p<0.001), history of myocardial infarction (45% vs. 26%, p=0.002) or hypertension (30% vs. 25%, p=0.04). Independent predictors of mortality in patients with sepsis were age (OR:1.02, CI:1.01-1.03, p<0.001), bleeding disorder (OR:1.80, CI:1.27-2.55, p=0.001) and DNR status (OR:4.99, CI:2.01-12.44, p=0.001).

Conclusion: Age, pre-injury bleeding disorder and DNR status are independent determinants of mortality in post-traumatic sepsis. Prompt attention to correction of coagulopathy, especially in older patients may be life-saving in this condition.

16.12 Admission Lactate Predicts Massive Transfusions in Hemodynamically Normal Patients

Posted on January 18, 2016

M. A. Brooke1,2, L. Yeung1,2, E. Miraflor1,2, G. Arturo1,2, G. Victorino1,2 1University Of California – San Francisco,General Surgery,San Francisco, CA, USA 2Highland Hospital,General Surgery,Oakland, CA, USA

Introduction: Despite hemodynamic stability on arrival, trauma patients can have occult severe injuries and may deteriorate with little warning. Early identification of this subset of patients may improve care, especially for those who will require a massive transfusion (MT). Our hypothesis was that an elevated admission lactate predicts the need for MT in hemodynamically normal patients.

Methods: All trauma patients treated at our university-based urban trauma center over a 5 year period were reviewed. Inclusion criteria consisted of hemodynamically normal patients (systolic blood pressure >90 mmHg and heart rate between 60-100 bpm) who had an admission lactate. Demographics and outcomes were analyzed using Chi square and unpaired t-tests, a receiver-operating curve (ROC) and univariate and multivariate regressions.

Results: Out of 5951 hemodynamically normal trauma patients, 3468 (58%) had an admission lactate. Patients who received a MT (n=19) had a higher lactate than those who did not receive a MT (n=3449) (5.6 vs 2.6 mmol/L, p=<0.001). ROC curve analysis for admission lactate as a predictor of MT showed an area under the curve (AUC) of 0.71 and a threshold lactate value of 4 mmol/L. Patients with a lactate of >4mmol/L had increased mortality (8 vs 2%), longer hospital LOS (6 vs 3 days), longer ICU LOS (6 vs 3 days), greater need for MT (2.8 vs 0.3%) and greater amount of blood transfused (219vs 38 ml; all p-values <0.001). After controlling for confounding variables with univariate and multivariate regression, the predictive value of admission lactate>4 for MT remained strong (OR 5.2; 95% CI 1.87-14.2).

Conclusion: The admission lactate is a robust predictor of massive transfusions and is associated with poor outcomes even in hemodynamically normal trauma patients. An admission lactate >4 mmol/L may identify those patients at greater risk of clinical decompensation.

16.13 Prevalence and Outcomes of Pulmonary Contusions in a Suburban County Following Blunt Trauma

Posted on January 18, 2016

R. S. Jawa1, J. E. McCormack1, E. C. Huang1, M. J. Shapiro1, J. A. Vosswinkel1 1Stony Brook University Medical Center,Trauma,Stony Brook, NY, USA

Introduction: There is limited information regarding hospitalization and discharge characteristics of blunt trauma patients with pulmonary contusions, especially those with isolated pulmonary contusions (IP). We evaluated the prevalence and outcomes following pulmonary contusion in a suburban county of 1.5 million people.

Methods: A county-wide trauma registry for all admitted adult blunt trauma patients from 1999 to 2008 was examined. Emergency Room deaths were excluded. Three groups were analyzed: isolated pulmonary contusion (IP), pulmonary contusion + other chest injury (CH), and pulmonary contusion + chest injury + other body region injury (OT).

Results: There were 14,286 admissions. The major mechanisms of injury in the three groups were MVC/MCC (58.8% OT, 45.6% CH, and 72.1%IP*,^) followed by falls (42.6% OT, 31.4% CH, and 12.9% IP*,^). Pulmonary contusions were associated with rib fractures in 55.4% of OT#, 82.2% of CH, and 0% of IP*,^ patients. The median hospital length of stay was longer in OT patients (9 [IQR 5-19] days), as compared to CH (6 [IQR 4-10)) and IP patients (4 [IQR 2-6]) *,^. Mechanical ventilation was required more often in the OT (36.1%#) than CH (8.1%) or IP (5.9%^) groups. The most commonly severely injured regions (AIS≥3) in the OT group were chest (100%), head/neck (33.6%), and extremity (26.6%). Hemothorax/pneumothorax or a combination thereof was present in 45.6%OT#, 54.1%CH and 0%IP*,^ patients. Rib fractures were present in 55.4% OT#, 82.2% CH, and 0% IP patients*,^.Tracheostomy was required in 10.1% OT#, 2.2%CH, and 0%IP^ patients. A chest tube was placed in 28.1% OT#, 23.0% CH, and 2.0% IP*,^ patients; 1 IP likely had chest tube placement for presumed blood/air. The most common major surgical procedure in the OT group was orthopedic at 32.0%. Finally, 57.7% OT#, 84.4% CH, and 86.3% IP^ patients were discharged to home.

Conclusion: Pulmonary contusions are not infrequent following blunt trauma, with a 13.0% incidence. They rarely (2.7%) occur in isolation; most frequently they are associated with rib fractures. However, 45.4% of blunt multi-system trauma patients will have pulmonary contusions in the absence of rib fractures, as compared to only 18.8% of patients with isolated chest injuries. Further, the presence of a pulmonary contusion warrants an aggressive search for additional injuries; 98.6% of multi-trauma patients had major non-thoracic injuries. The additional injuries will often require major surgical procedures, with orthopedic surgery being the most common. Pulmonary contusions in association with other injuries are associated with substantial mortality as well as morbidity, as measured by the need for ICU care, mechanical ventilation, and low discharge to home rate.

16.08 Patients with TBI-Related Coagulopathy have more Profound Disturbances in Tissue Perfusion Markers

Posted on January 18, 2016

S. E. Dekker1, H. M. De Vries1, A. Duvekot1, L. M. Geeraedts2, S. M. Peerdeman3, M. C. De Waard4, P. Schober1, C. Boer1 1VU University Medical Center,Anesthesiology,Amsterdam, NH, Netherlands 2VU University Medical Center,Surgery,Amsterdam, NH, Netherlands 3VU University Medical Center,Neurosurgery,Amsterdam, NH, Netherlands 4VU University Medical Center,Intensive Care,Amsterdam, NH, Netherlands

Introduction: A severe, frequently overlooked complication of traumatic brain injury (TBI) is the development of coagulopathy, which may contribute to poor outcome. It has been suggested that cerebral hypoperfusion might be one of the causes of coagulopathy. This study investigated the relationship between cerebral and somatic tissue oxygenation and hemostatic derangements in TBI patients.

Methods: Rotational thromboelastometry (ROTEM) and tissue oxygenation were simultaneously measured in 92 trauma patients with suspicion of TBI at ED admission. Overall, 52 patients were diagnosed with TBI (head AIS ≥ 3). The level of hypoperfusion was characterized by tissue hemoglobin oxygenation index (TOI) using noninvasive near infrared spectroscopy (NIRS) located at the forehead (cerebral) or arm (somatic), base excess, and lactate. Coagulopathy was defined as an INR >1.2 and/or activated partial thromboplastin time (aPTT) >40 seconds and/or thrombocytopenia (<120*10-9/L). Patients who used anticoagulant medication (vitamin K antagonists, clopidogrel and dabigatran) were excluded from the study.

Results: Trauma patients with acute coagulopathy had a higher head-AIS level compared to trauma patients without coagulopathy [5 (4 to 5) vs. 4 (4 to 5); P=0.038]. TBI-patients with coagulopathy (42%) had significantly lower levels of fibrinogen [1.8 (1.1 to 2.3) vs. 2.8 (2.4 to 3.2) g/L; P<0.001], and higher D-dimers [17.6 (9.0 to 67.1) vs. 6.4 (2.7 to 13.2) mg/L; P=0.032] compared to TBI-patients without coagulopathy. TBI patients with coagulopathy had more signs of tissue hypoperfusion as indicated by increased lactate levels [1.9 (1.1 to 3.2) vs. 1.2 (1.0 to 1.7) mmol/L; P=0.026] and base excess [-3.1 (-4.6 to -2.0) vs. -0.1 (-2.5 to 1.8) mmol/L; P<0.001] than patients without coagulopathy. There was no difference in NIRS cerebral or somatic TOI between TBI patients with or without coagulopathy. However, we found an inverse relationship between NIRS cerebral TOI and fibrinolysis as measured by D-dimers (P=0.038), fibrinogen (P=0.041), and maximum lysis in the aptem ROTEM test (P=0.016). The presence of coagulopathy was associated with both an increased in-hospital mortality (47.6 vs. 6.9%; P=0.002) and one-year mortality (65 vs. 16%; P=0.002) compared to patients without coagulopathy.

Conclusion: This is the first study to investigate the relationship between hemostatic derangements and cerebral and somatic tissue oxygenation using NIRS in TBI patients. This study showed that TBI-related coagulopathy is more profound in patients with metabolic acidosis and increased lactate levels. While there was no difference in NIRS cerebral or somatic tissue oxygenation between patients with or without coagulopathy, we found an inverse relationship between NIRS tissue oxygenation levels and fibrinolysis.

16.09 Using a Centrally Located Rotational Thromboelastometry (ROTEM) to Guide Trauma Resuscitations

Posted on January 18, 2016

M. W. Cripps1, C. T. Minshall1, B. Williams1, A. Eastman1, R. Sarode1 1University Of Texas Southwestern Medical Center,Burn/Trauma/Critical Care,Dallas, TX, USA

Introduction: Rotational Thromboelastometry (ROTEM) is a viscoelastic analyzer that identifies patient-specific coagulopathy thereby providing a patient directed transfusion strategy. In order to be effective, patients in hemorrhagic shock with associated coagulopathy need an expeditious return of ROTEM results as rapid correction of coagulopathy significantly improves patient outcomes. Although often used at bedside, ROTEM can be used to guide transfusions from a centrally located lab while results are viewed in real time from remote locations. Benefits include hospital wide availability and multi-disciplinary use. However, potential pitfalls in using a centrally located ROTEM include increased sample delivery and processing times. We performed a time efficiency study to identify work elements that could be streamlined to determine if we could improve the speed at which viscoelastic results are returned from a centrally located viscoelastic analyzer (ROTEM) in trauma patients.

Methods: A time efficiency study to evaluate work elements required in central lab ROTEM analyses on trauma patients was performed. Elements included time from sample collection to lab arrival and time to initial display on remote viewing monitor. These were measured for all ROTEM studies during January 2015 to calculate standard time per element and normal time to view results. We then implemented protocol changes to shorten the duration of each work element and prospectively measured them over the subsequent 3 months.

Results: 33 consecutive ROTEM studies performed during a 1 month period determined standard time per element and the normal time per study. The median time from sample collection to lab arrival was 11 min [8, 18]. Time from lab arrival to remote display of results was 10 min [6, 12.5]. The normal time per study was 22.9 min [18.7, 28]. 196 consecutive ROTEM studies were performed after protocol changes and there was no difference in the time from sample drawn to lab arrival, 9min [6.7, 13] p=0.11, but time from lab arrival to initial display was significantly reduced to 5.6 min [3, 7.8], p<0.0001. Modifications in work-flow resulted in a reduction in normal time per study to 14.8 min [10.7, 20.1]; p<0.0001.

Conclusion: Using a centrally located ROTEM to guide trauma transfusions requires optimized processes to obtain rapid return of results. We were able to modify performance and effectively shorten the standard time per work element resulting in a significant reduction in the normal time to view results. This study validates that a centrally located ROTEM can rapidly return results for any hospitalized patient with hemorrhagic shock.

16.10 Not All Failure-to-Rescue Events in Trauma Are Preventable

Posted on January 18, 2016

L. Kuo1, E. Kaufman2, J. Pascual1, P. Reilly1, N. Martin1, P. Kim1, D. N. Holena1 1Hospital Of The University Of Pennsylvania,Surgery,Philadelphia, PA, USA 2Cornell University,Ithaca, NY, USA

Introduction: The Failure to Rescue (FTR) rate is defined as the conditional probability of death after complications and is felt to reflect a center’s ability to ‘rescue’ patients after complications occur. Implicit in this terminology is that rescue is possible and death therefore represents a failure. We sought to evaluate the relationship between preventability and FTR with the hypothesis that many deaths meeting the definition for FTR in trauma would be judged non-preventable by structured explicit review and expert panel consensus.

Methods: We merged registry data from 2009-2013 at an academic level I trauma center with the results of all adjudications from morality review panels for the same time period. Explicit review of charts by the mortality panel included attention to the timing and appropriateness of care rendered. The preventability of each death was determined by consensus of panel of trauma surgeons as part of peer review. FTR events were defined as deaths occurring after any registry-defined complication. Characteristics of patients sustaining FTR events were compared between groups using chi-squared and Mann-Whitney test as appropriate.

Results: 1,339/12,295 (10.9%) of patients had a complication. Of these, 146/1339 died, for a FTR rate of 10.9%. Of FTR deaths, 118 (81%) were judged to be Non-Preventable (NP), 19 (13%) were judged Potentially Preventable (PP), and 9 (6%) were judged to be preventable (P) by peer review. Deaths judged to be preventable were more likely to have occurred in patients sustaining penetrating trauma, those with high GCS component scores, and with higher predicted survival by TRISS methodology (Table 1).

Conclusion: In the trauma setting, only 20% of deaths meeting the definition of failure to rescue were judged to be preventable or potentially preventable by mortality review panels. The current definition of the FTR metric may not be a valid measurement of the quality of care in the trauma population and revision prior to use for benchmarking of care in this setting is warranted.

16.05 Increasing Incidence of Multiple Drug Resistant Gram Negative Bacteria in a Pediatric Burn Population

Posted on January 18, 2016

P. H. Chang1,2,3, P. H. Chang1,2,3 1Shriners Hospitals For Children-Boston,Boston, MA, USA 2Massachusetts General Hospital,Boston, MA, USA 3Harvard Medical School,Boston, MA, USA

Introduction:

The proliferation of multiple drug resistant gram negative bacteria (MDR-GNB) species is a concern in the pediatric burn patient population. Sepsis continues to be the leading cause of death in this population. The consequences of cross-infection across patients by these organisms can be dire.

Methods:
A retrospective review of a single pediatric burn institution's experience with MDR-GNB colonization and infection in children with burns was performed. The definition of multiple drug resistance was set as resistance to three or more antimicrobial classes of medications. The definition of pan drug resistance was set as resistance to all antimicrobial classes of medications except for colistimethate. Data collected on patents by the infection control coordinator included demographics, burn clinical data, MDR-GNB speciation, source of positive culture, hospital length of stay, and survival.

Results:
3,359 children were admitted from January 1994 to December 2013 for management of acute burns or open wounds to the single pediatric burn institution. 220 of the 3,359 patients (6.5%) had MDR-GNB identified in cultures collected from wounds, sputum, urine, or blood during their admission. MDR-GNB incidence significantly increased over the 2 decade period of the study from 2.5% of admission in the first decade to 8.6% of admissions in the second decade.

Demographics of the patients included an average age of 8.8 years (+/- 5.3 years) and an average burn size of 42.9% TBSA (+/- 22.8%).

MDR-GNB infections included bacteremia in 80 (36.4%) patients, invasive wound infection in 46 (20.9%) patients, pneumonia in 19 (8.6%) patients, and UTI in 46 (20.9%) patients. The 3 most common bacterial species identified included Pseudomonas aeruginosa (116 total, 33 PAN), Acinetobacter baumannii (127 total, 41 PAN), and Klebsiella pneumoniae (84 total, 2 PAN). 14 patients died (6.4%) with the cause of death in all 14 children attributable to MDR-GNB sepsis. Cross-contamination was suspected in 22 (10%) patients. No statistically significant effect was noted on rates of graft loss or number of operations needed per patient.

Conclusions:

Pediatric burn patients face the risk of MDR-GNB infections which can lead to life-threatening sepsis. The incidence of MDR-GNB identification in this institution has increased over 2 decades. This may be due to inappropriate common use of broad-spectrum antibiotics. Fortunately, most MDR-GNB isolates were still susceptible to colistimethate. Stringent infection control adherence is even more important than ever to prevent cross-contamination of MDR-GNB across patients.

16.06 Litigation Following Injury And The Effects On Quality Of Life

Posted on January 18, 2016

F. R. Rutigliano1, T. M. Bell1, B. L. Zarzaur1 1Indiana University School Of Medicine,Department Of Surgery, Center For Outcomes Research In Surgery,Indianapolis, IN, USA

Introduction: Injured patients are often involved in civil litigation as a result of the circumstances of their injury. Injury, already a stressful time for patients, may be exacerbated by the stress involved in litigation. The purpose of this study was to compare the quality of life of injured patients engaging in compensation litigation to those not engaged in compensation litigation.

Methods: Patients 18 and older admitted with an injury severity score of 10 or greater, but, without a traumatic brain injury or spinal cord injury were prospectively followed for 1 year. A comprehensive survey was administered at baseline and at 1, 4, 6, and 12 months after injury. The survey included questions about litigation involvement and quality of life (RAND Short Form-36 (SF-36)). Those involved in litigation were compared to those not involved in litigation.

Results:312 patients were recruited and followed for 1 year. Mean age was 39 years, 58% were male, and 63.2% were self employed or employed for wages at the time of injury. 47% engaged in compensation litigation. Patients engaged in litigation were significantly younger than those not engaged in litigation (41 vs 36; p<0.05) and they were significantly less likely to be employed for wages (16.5% vs 6.5% p<0.05) at 4 months after injury. Those involved in litigation had lower SF-36 mental component scores at 1 month, 2 month, and 4 month follow-up (Table). SF-36 Physical component scores were not significantly different between patients involved in litigation and those not involved.

Conclusion:Litigation after injury is associated with worse mental health and unemployment in the first few months after injury. However, litigation was not associated with overall physical health nor injury severity, location, or mechanism. Providers caring for injured patients involved in litigation should be aware of this potential stress and screen for the development of more severe emotional symptoms in these patients.

16.07 Risk Factors for Colonic Suture Line Failure in Patients Undergoing Emergent Trauma Laparotomy

Posted on January 18, 2016

R. W. Beach1, R. A. Lawless1, M. K. McNutt1, L. J. Moore1, B. A. Cotton1, C. E. Wade1, J. B. Holcomb1, J. A. Harvin1 1University Of Texas Health Science Center At Houston,Acute Care Surgery,Houston, TX, USA

Introduction:
Enteric suture line failure (SLF) following colon resection in patient undergoing emergent trauma laparotomy is a morbid complication. Reported risk factors for SLF include the amount of red blood cells (RBCs) transfused, but vary in their inclusion of damage control laparotomy (DCL) patients. This report aims to determine risk factors associated with SLF that are available to the surgeon prior to the performance of anastomosis or stoma creation in patients undergoing both definitive laparotomy (DEF) and DCL.

Methods:
A retrospective review was performed of all patients ≥16 years of age admitted between 1/1/2011 and 3/31/2015 who underwent colon resection during emergent trauma laparotomy – defined as ED directly to OR or ED to IR to OR. Data was obtained from an institutional trauma registry and patient medical records. Patients who had stoma formation or died in intestinal discontinuity were excluded. On univariate analysis, patients undergoing DEF and DCL were analyzed separately comparing those who did and did not have SLF. A multiple logistic regression model was then created use variables determined a priori (age, post-operative vasopressor use, and RBCs) and those found to be clinically and significantly different.

Results:
A total of 19,506 patients were admitted during the study period, of which 871 underwent emergent laparotomy and 16% (142/871) had a colon resection. 29 had stoma placement and 6 died in intestinal discontinuity, leaving 107 patients having undergone anastomosis, 54 (50%) DEF and 53 (50%) DCL. In DEF group, 4 (7%) had SLF. Comparing those with and without SLF, no differences in demographics, Injury Severity Score (ISS), ED vital signs and resuscitation, or technique of anastomosis were seen. The patients with SLF had a lower final OR BE (median -9, IQR [-9, -4] versus -3, IQR [-4, -2], p=0.03) and a higher rate of postoperative vasopressor use (50% versus 4%, p=0.02). In the 53 DCL patients with an anastomosis, 8 (15%) patients had SLF. Comparing those with and without SLF, there were no differences in demographics, ISS, ED vital signs and resuscitation, OR vital signs and resuscitation, or postoperative vasopressor use. There was also no difference in indication for DCL, the use of intestinal discontinuity, or anastomotic technique. After adjusting for age, post-operative vasopressor use, OR RBCs, arrival SBP, arrival BE, ISS, and intestinal discontinuity, increasing age (OR 1.06, 95% CI 1.01-1.12, p=0.03) and intestinal discontinuity (OR 8.29, 95% CI 1.30-52.76, p=0.03) were independently associated with SLF.

Conclusion:
In patients undergoing definitive emergent trauma laparotomy with colectomy, SLF is an uncommon event, but appears associated with increased age and the degree of shock upon admission the OR. In patients undergoing damage control laparotomy with colectomy, SLF is associated with increased age and the utilization of intestinal discontinuity.

15.21 Description of Orthopedic Injuries Following Urban Bicycle Trauma

Posted on January 18, 2016

R. 7. Beyene1, S. M. Kettyle1, R. Golden1, D. Milzman1, J. A. Sava1 1MedStar Washington Hospital Center,Washington, DC, USA

Introduction:
Bicycle use has increased in urban areas, both as transportation and recreation. This increased popularity has lead to more bicycle accidents and bicycle-related orthopedic injuries and procedures. Previous studies have focused on head trauma, but operative orthopedic trauma in bicycle crashes remains poorly described. This study was designed to characterize injury patterns in urban cyclists presenting to a large metropolitan care system.

Methods:
Retrospective four-year review of University HealthSystem Consortium database for all patients admitted after bicycle injury to 8 member hospitals in the MedStar system, serving the Baltimore-Washington metropolitan area. Patient demographics were recorded, as were admission status, injury site and type, and type of intervention.

Results:
3594 patients were included in this study. Of those, 268 (7.5%) required operative management, 476 (13.2%) required non-operative intervention (such as splinting), and 2850 (79.3%) required no orthopedic intervention. Among the 1941 patients with orthopedic injures, 1197 (61.7%) required no orthopedic interventions. Patients who required an operation were older than those who had non-operative or no intervention. Open reduction internal fixation (ORIF) was the most commonly performed procedure (Fig.1). Patients who did no require a procedure primarily had contusions, sprain, open wounds, and fractures.

Conclusion:
In this large review, bicycle related orthopedic injuries were rarely operative. Those that required operation were fractures in an older subset. Further study into bicycle and rider characteristics should be studied to help predict need for orthopedic intervention.

16.01 Socioeconomic Status Effects Outcome of Traumatic Brain Injury

Posted on January 18, 2016

K. McQuistion1, H. Jung1, T. Zens1, M. Beems1, G. Leverson1, A. O’Rourke1, A. Liepert1, J. Scarborouh1, S. Agarwal1 1University Of Wisconsin,Surgery,Madison, WI, USA

Introduction:
There is increasing evidence that socioeconomic factors affect patient outcomes after traumatic brain injury. However, these factors are often considered in isolation. The goal of the present study was to assess the effect of race/ethnicity and method of payment on hospital length of stay, mortality, and discharge disposition after traumatic brain injury.

Methods:
A retrospective cohort study using the National Trauma Data Bank years 2002-2012 was performed. Patients aged 14-89 with ICD-9 codes for one of six closed head injuries (Concussion, Cerebral Contusion, Cerebellar or Brainstem Contusion, Subarachnoid Hemorrhage, Subdural Hemorrhage, and Extradural Hemorrhage) were analyzed. Univariate logistic and linear regression was used to assess the effect of demographic and injury characteristics on each outcome variable. All significant predictors were included in the multivariate models for hospital length of stay, mortality, and discharge disposition.

Results:
The analytical sample consisted of 201,553 TBI patients, including 2.5% Asian, 12.0% Black, 10.1% Hispanic, 0.7% Native American, and 74.7% White patients. Of these, 9.0% had Medicaid, 25.2% had Medicare, 12.3% had other insurance, 37.9% were privately insured, and 15.6% were uninsured. Compared to White patients, Black and Hispanic patients were less likely to die in the hospital (Black OR=.792, p<.001; Hispanic OR=.840, p=.002), had longer hospital lengths of stay (Black coeff=.451, p<.001; Hispanic coeff=.249, p<.001), and were less likely to be discharged to inpatient rehabilitation (Black OR=.885, p<.001; Hispanic OR=.703, p<.001). Hispanics were also less likely to receive any continuing care after discharge than Whites (OR=.762, p<.001). Compared to the Privately Insured, the Uninsured were more likely to die in the hospital (OR=1.487, p<.001), less likely to receive any continuing care after discharge (OR=.564, p<.001) including inpatient rehabilitation (OR=.516, p<.001), and had shorter lengths of stay (coeff=-.095, p=.042). Patients with Medicaid were more likely to die in the hospital (OR=1.166, p=.019), had longer lengths of stay (coeff=1.493, p<.001), and were more likely to receive continuing care after discharge (OR=1.396, p<.001) including inpatient rehabilitation (OR=1.141, p<.001) than the Privately Insured.

Conclusion:
Race/ethnicity and insurance status both significantly effect patient’s outcomes after TBI, even after controlling for other demographic and injury characteristics. The strongest disparities can be seen for uninsured patients who are more likely to die in the hospital, less likely to receive any continuing care after discharge, particularly any inpatient rehabilitation, and have shorter lengths of stay than any other group. These socioeconomic outcome differences warrant further investigation into their root cause.

16.03 Understanding Large Database Research: Comparison of Trauma Injuries Captured in NTDB, NIS and NEDS

Posted on January 18, 2016

C. K. Zogg1, J. W. Scott1, L. L. Wolf1, O. A. Olufajo1, A. J. Rios Diaz1, D. Metcalfe1, M. Chaudhary1, A. A. Shah1,2, J. M. Havens1, S. L. Nitzschke1, Z. Cooper1, A. Salim1, A. H. Haider1 2Division Of General Surgery, Mayo Clinic,Scottsdale, AZ, USA 1Center For Surgery And Public Health, Harvard Medical School & Harvard School Of Public Health, Department Of Surgery, Brigham And Women’s Hospital,Boston, MA, USA

Introduction: Efforts to benchmark/improve trauma outcomes frequently rely on data obtained from the National Trauma Data Bank (NTDB), Nationwide Inpatient Sample (NIS), and Nationwide Emergency Department Sample (NEDS). Despite their widespread use, limited understanding is available of how these large databases compare. The objective of the study was to present a direct comparison and stratified, risk-adjusted assessment of trauma patients captured in NTDB, NIS, and NEDS.

Methods: Data (2007-2011) were abstracted for adult (18-64y) patients with primary trauma diagnoses (800-959). Patients with late effects of injury (905-909), superficial injuries (910-924), and foreign bodies (930-939) were excluded, as were those with non-blunt/penetrating injuries. Differences in patient (primary payer, sex, race/ethnicity, age, ISS, intent, mechanism, head AIS, CCI, year) and hospital (teaching status, trauma center level, annual trauma volume, region) factors were compared using descriptive statistics. Database-stratified, multilevel-logistic models assessed risk-adjusted differences in mortality, major morbidity, and extended LOS (>75th percentile) for trauma patients overall and among cohorts restricted to TBI, pneumothorax/hemothorax, blunt splenic injury, and pelvic fractures. In an effort to test the similarity of conclusions among the most comparable groups of patients, differences in trauma outcomes were further compared between ED/inpatients in NTDB and NEDS using coarsened-exact matching techniques.

Results: ED/inpatient combined totals of 1,578,487 (NTDB), 539,200 (NIS), and 5,069,811 (NEDS) patients were extracted. Patient encounters in NTDB were predominately managed at high-volume (86.7% in the top two trauma volume quintiles), teaching (87.3%), L1-L2 trauma (62.2%) centers. Encounters in NIS and NEDS were more varied: 1.5% (effect dominated by ED presentations) and 31.9% high trauma volume, 62.5% and 33.4% teaching, and 18.0% L1-L2 (only reported in NEDS) centers. Differences in patient factors, while present, were less pronounced. Risk-adjusted regression demonstrated qualitatively similar conclusions for most variables albeit notably stronger associations related to lack of insurance, Black race, age, and ISS in NTDB. Associations with self-inflicted injury, severe head injury (AIS>3), and teaching status were more pronounced in NIS and NEDS.

Conclusion: This methodological assessment of large trauma databases points to important differences underlying trauma populations used in outcomes research. While largely comparable for predictions related to demographic factors, discrepancies at the hospital level need to be carefully weighed. Researchers are encouraged to make use of the wealth of information provided by these large population resources while remaining cognizant of the generalizability and limitations of each.

16.04 Non-Operative Management of Splenic Injuries: ICU Utilization and Mortality in a State Trauma System

Posted on January 18, 2016

E. J. Kaufman1,2, D. N. Holena1 1University Of Pennsylvania,Perelman School Of Medicine,Philadelphia, PA, USA 2New York Presbyterian Hospital,Department Of Surgery,New York, NY, USA

Introduction: Non-operative management of abdominal trauma has gained acceptance in recent decades, but while ICU monitoring is a common component of this approach, there is little evidence to guide this practice. To evaluate the role of ICU admission in patients undergoing initial non-operative management of splenic injuries, we conducted a retrospective cohort study of prospectively-collected data from the Pennsylvania Trauma Outcomes Study. We hypothesized that ICU utilization would vary significantly among centers; that centers with higher-than-expected ICU utilization would have correspondingly lower mortality; and that patients admitted to the ICU would have lower risk-adjusted mortality than those admitted elsewhere.

Methods: Data from 2011-2014 for all 30 level I and II trauma centers in Pennsylvania were evaluated. Patients were excluded if they were age <17; died or were discharged in the trauma bay; or had immediate abdominal operation or angiography. Centers with ≥20 eligible patients were included. Patients transferred from the trauma bay were included at the destination center. ICU utilization was defined as ICU admission from the trauma bay or after an immediate operation. We used multivariable logistic regression to model ICU admission and mortality. We calculated observed-to-expected (O:E) center-level ICU utilization and mortality ratios with 95% confidence intervals and evaluated correlations between ICU utilization and mortality with Spearman’s rho.

Results: A total of 2,048 patients at 26 trauma centers were included (median age 41; 90.1% white; 62.9% male). Overall, 67.3% were admitted to the ICU; 63.4% of patients with grade 1-2 splenic injuries and 78.1% of those with grade 3 and above. Median injury severity score (ISS) was 16 overall; 17 for ICU patients and 12 for non-ICU patients. The final regression model for ICU utilization incorporated patient characteristics, admission physiology, and injury characteristics (grade, mechanism, and presence of concomitant abdominal, thoracic or head injuries). Model fit was good (AUC 0.74). Risk-adjusted ICU utilization rates varied from 26.8% to 95.5% among centers. Crude mortality was 4.5%; 5.8% in ICU patients and 1.9% in non-ICU patients. The final regression model for mortality incorporated surgical interventions along with the above factors, with excellent fit (AUC 0.95). ICU admission was not associated with any significant difference in mortality (4.5% vs. 4.3%, p=0.893). Significant predictors of mortality included age, ISS, operation, and admission physiology. At the center level, there was no correlation between ICU utilization and mortality O:E ratios (rs= -0.09, p=0.6645 ) or rank order (rs=- 0.10, p=0.6311).

Conclusions: Risk-adjusted ICU utilization rates for splenic trauma vary widely among trauma centers, but there is no clear relationship with mortality. Standardizing ICU admission criteria could improve resource utilization without increasing mortality.

15.18 Factors Affecting On-Field Triage Decisions and Resource Utilization

Posted on January 18, 2016

P. P. Parikh1, B. Zoll1, P. Parikh1, K. Hendershot1, M. Whitmill1, T. Erskine2, S. Schmidt2, R. Woods1, J. Saxe1 1Wright State University,Dayton, OH, USA 2Emergency Medical Services,Ohio Department Of Public Safety,Columbus, OH, USA

Introduction: The trauma system has not produced the expected impact on patient safety and resource utilization in the state of Ohio. We, therefore, undertook a study with the Ohio Department of Public Safety (ODPS) to identify the contributing clinical and system-level factors affecting the four outcomes; overtriage, undertriage, mortality, and transfers.

Methods: All trauma and emergency medical services (EMS) data for 2008-2012 were obtained from the ODPS, which included 35,631 unique patient records. Overtriage (OT) rate was defined as the proportion of patients with ISS≤15 transported to a Level I/II trauma center; undertriage (UT) referred to patients ISS>15 transported to a non-trauma center. Statistical analysis was used to compare proportions of patients experiencing OT and UT, and subsequent mortality and transfers, across several factors where OT and transfers indicate resource utilization, and UT and mortality directly impact patient care.

Results:OT and UT rates were 43.03% and 3.06%, respectively. We confirm a previous finding that patient/family choice (41.24%) was the top reason for triage decisions; most appropriate closest facility (34.28%) and protocol (14.92%) followed. With increasing patient age triage decisions based on patient/family choice nearly doubled (from 26% to 51%), and OT and transfer rates decreased substantially. Interestingly, the UT rates remained fairly stable unlike a recent study suggesting an increase. The highest inter-facility transfers (21.83%; p<0.05) were observed when the triage decision was based on the most appropriate closest facility, which likely resulted from resuscitating the patient at a nearby non-trauma center first before transferring them to a trauma facility. However, when triage decisions were based on protocol, the OT rates (46.5%; p<0.05) and mortality rates (7.02%; p<0.05) were among the highest (Table 1), the reasons for which were unclear.

Conclusion:This work addresses several concerns related to on-field trauma triage currently under review within the state of Ohio. The findings in this study serve as building blocks to further our understanding of reasons for high mortality and transfer rates in an effort to potentially develop a new on-field triage model.

15.19 Prospective Observational Study of Point-of-care Creatinine in Trauma

Posted on January 18, 2016

A. J. Carden1, E. Salcedo1, N. Tran1, E. Gross1, J. Mattice1, J. Shepard1, J. Galante1 1University Of California – Davis,Sacramento, CA, USA

Introduction:

Trauma patients are at risk for renal dysfunction from hypovolemia or urologic injury. Contrast-induced nephropathy risk increases in those with pre-existing renal dysfunction. Laboratory plasma creatinine levels are often available only after contrast administration for imaging. Stable patients with low-energy trauma mechanisms may benefit from an algorithm for pre-contrast hydration or reduction in contrast load. Rapid point-of-care (POC) creatinine measurements may minimize delays to imaging. The purpose of this study is to determine the potential clinical impact of a new POC creatinine device in the trauma setting.

Methods:

Forty trauma patients were enrolled in a prospective observational study. One drop of blood was used for creatinine determination on a POC device (StatSensor Creatinine, Nova Biomedical, Waltham, MA). POC creatinine results were compared to the laboratory. Turnaround time (TAT) for POC and lab methods were calculated as well as time elapsed to CT scan if applicable.

Results:

Patients (n = 40) were enrolled between December 2014 and March 2015. POC creatinine values were similar to laboratory methods with a mean bias of 0.075±0.27 (p=0.08). Mean analytical TAT’s for the POC measurements were significantly faster than the laboratory method (11.6±10.0 mins vs. 78.1±27.9 mins, n = 40, p<0.0001). Mean elapsed time before arrival at the CT scanner was 52.9±34.2 mins.

Conclusion:

The POC device reported similar creatinine values to the hospital laboratory and provided significantly faster results. During this study POC testing has been successfully implemented into the standard trauma workflow. Most patients received POC creatinine values in time to affect decision-making on contrast imaging. The POC creatinine device can be implemented into the trauma algorithm to guide pre-contrast hydration or contrast load reduction in stable patients with low energy trauma mechanisms and increased risk for underlying renal dysfunction.

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