75.19 Study of the Relationship between Outcomes of Severe Traumatic Brain Injury and Coagulopathy

Posted on January 18, 2016

P. Chang1, W. Chong1 1First Affiliated Hospital Of China Medical University,Emergency Department,Shenyang, LIAONING, China

Introduction: Traumatic coagulopathy usually follows severe traumatic brain injury (sTBI).The present study aimed to assess the relationship between coagulation parameters and outcomes in sTBI.

Methods: A total of 58 sTBI patients with Glasgow Coma Scale (GCS) <9, head Abbreviated Injury Scale (AIS)≥3 and all other body regions AIS<3 were recruited in this retrospective study. The age, gender, GCS score, pupil reaction, median line shifting and biochemical parameters including blood platelet (PLT), prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen (Fg) and blood glucose of sTBI patients on admission were retrieved from the medical record database. The patients were divided into good outcome group whose Glasgow Outcome Scale (GOS) was between 3 and 5 and poor outcome group whose GOS was between 1 to 2.In single-factor analysis, P≤0.15 was defined as statistical significance. The significance of parameters was determined with non-conditional multivariate Logistic regression analysis and those with P≤0.10 were used to generate receiver operating characteristic curves (ROCs).

Results: There were 41 males and 17 females ranging from 12 to 88 years old. The occurrence of TBI-associated coagulopathy is 31.03%. Compared with good outcome group, poor outcome group had significantly increased occurrence of abnormal pupil reaction[24(77.4%) vs 10(37.0%),P=0.002], occurrence of median line shifting[21(67.7%) vs 7(25.9%),P=0.001], blood glucose[mmol/L: 9.1(6.53-12.85)vs6.9(4.90-7.88),P=0.000], PT[second:14.5(13.18-16.53) vs 13.8(12.45-15.18),P=0.004],and aPTT[second:37.56(6.06) vs 34.32(7.98),P=0.087],lower GCS[6(1.75-3.32) vs 5(1.82-5.24),P=0.000], PLT[×109/L:167.33(48.8) vs 191.45(75.247),P=0.149]and Fg[g/L:2.55(1.75-3.32)vs2.98(1.82-5.24),P=0.021]. In addition, there was no significant difference of GCS between patients with coagulapothy and non-coagulopathy. The multivariate Logistic regression analysis demonstrated that pupil reaction (β=-3.650,OR=0.026,P=0.068), median line shifting (β=-1.990,OR=0.137,P=0.082), GCS (β=0.716,OR=0.195,P=0.081), PT (β=-1.200,OR=0.031,P=0.082), aPTT (β=0.293,OR=1.340,P=0.073), and blood glucose (β=-1.636,OR=0.195,P=0.078) were the independent risk factors for unfavorable outcome in patients with sTBI. Pairwise comparisons of the AUC were as follows: GCS versus PT, p = 0.516, blood glucose versus PT, p=0.227, GCS versus blood glucose, p=0.579, GCS versus aPTT, p=0.033?blood glucose versus aPTT?p=0.006, PT versus aPTT, p=0.142.

Conclusion: Prolonged PT and aPTT are the independent risk factors for unfavorable outcome in patients with sTBI. It suggests that there is a strong association between coagulopathy and an unfavorable outcome of sTBI.

75.20 Size Matters: Defining the Size tor Neurosurgical Intervention With Isolated Intra-Cranial Injury

Posted on January 18, 2016

V. Pandit1, P. Rhee1, N. Kulvatunyou1, A. Tang1, T. O’Keeffe1, L. Gries1, G. Vercruysse1, R. Latifi1, R. S. Friese1, B. Joseph1 1University Of Arizona,Trauma Surgery,Tucson, AZ, USA

Introduction: The size of the intracranial hemorrhage (ICH) in patients with traumatic brain injury is an important determinant for neurosurgical intervention (NI). However; the optimum size for NI remains unclear. The aim of this study was to define the optimum size of isolated ICH (epidural [EDH] or SDH [SDH]) for NI in patients with TBI.

Methods: We performed a 5 year retrospective analysis of a prospectively collected database of all patients with an isolated EDH or SDH to our level 1 trauma center. The outcome measure was need for neurosurgical intervention. . Neurosurgical intervention was defined as craniotomy and/or craniectomy. Receiver operating characteristic (ROC) curves were plotted to identify the optimal ICH size for EDH and SDH for need for neurosurgical intervention. Sub-analysis was performed for patient on antiplatelet/anti-coagulation therapy (AP/AC).

Results: A total of 905 patients (isolated SDH: 729, isolated EDH: 176) were included of which; 21.2% (n=192) patients underwent NI. In patients with SDH, size of 6 mm was the optimum threshold for NI (AUC: 0.80, p=0.01) while in patient with EDH, size of 6.5 mm optimum threshold for NI (AUC: 0.78, p=0.01).

On multivariate regression analysis after adjusting for demographics, neurological examination, AP/AC therapy, injury severity, patient with SDH≥6 were 3.9 times (OR: 3.9, CI: 2.5-5.2) more likely while patient with EDH ≥ 6.5 were 3 times (OR: 3, CI: 1.7-4.9) more likely to have neurosurgical intervention

On sub-analysis of patients on AC/AP therapy, size of 4.5 mm was the optimum threshold for NI for both patients with SDH (AUC: 0.79, p=0.001) and EDH (AUC: 0.77, p=0.02).

Conclusion:Our study defines the optimal size of ICH in patients with isolated SDH and EDH for the need for NI. In patient with SDH/EDH 6mm is the optimal threshold determining the need for NI while it is lower at 4.5mm in patient on AP/AC therapy. This will help establish guidelines based on the size of ICH for better defining the criteria for NI in patients with TBI and isolated ICH.

75.15 Age Predicts Discharge Disposition but Not Adjusted Mortality After Nonoperative Management of TBI

Posted on January 18, 2016

Q. Dang1,2, S. Moradian1,2, J. Catino1, L. Zucker1, I. Puente1, F. Habib1, M. Bukur1 1Delray Medical Center,Department Of Trauma And Surgical Critical Care,Delray Beach, FL, USA 2Larkin Community Hospital,Department Of Surgery,Miami, FL, USA

Introduction: Traumatic Brain Injury (TBI) continues to be a leading cause of death and disability particularly in the elderly population. Age is generally considered to be a risk factor for adverse outcomes after TBI. We sought to examine the impact of age on outcomes in TBI patients who do not require neurosurgical operative intervention.

Methods: This was a retrospective review of all patients with survivable head injuries undergoing nonoperative management at a Level I trauma center from 2008-2013. Patients were stratified by age into young and elderly groups using the age of 40 as a reference group based upon the current Brain Trauma Foundation guidelines. Logistic regression was used to adjust for baseline differences in demographic and injury variables to determine the effect of age on outcomes. The primary outcomes were in-hospital mortality, worsening discharge GCS, and discharge disposition.

Results: 1,869 patients met inclusion criteria with 77% of patients being older than 40 years. Elderly patients were more likely to be victims of falls and presented with a higher GCS despite having a higher Head AIS. Immediate need for non-intracranial operative intervention was greater in younger patients. After adjusting for differences in characteristics, there was no significant difference in overall mortality (Elderly 3.6% vs. young 5%, p=0.209) or worsening discharge GCS (14% vs. 11%, p=0.926). However, younger patients were more likely to be discharged to a rehabilitation facility or home (91% vs. 70%, AOR=2.4, p=0.001). Stratification of mortality by decade revealed similar results, with adjusted mortality being lower in the sixth and ninth decades of life (Figure).

Conclusion: Survival of patients sustaining TBI not requiring neurosurgical operative intervention may not be age dependent. However, age is associated with a less favorable discharge disposition that is independent of discharge GCS.

75.17 Secondary Overtriage in Level 3 and 4 Trauma Centers: Are These Transfers Necessary?

Posted on January 18, 2016

R. M. Essig1, K. T. Lynch1, D. M. Long2, U. Khan1, G. Schaefer1, J. C. Knight1, A. Wilson1, J. Con1 1West Virginia University,Surgery,Morgantown, WV, USA 2West Virginia University,Biostatistics,Morgantown, WV, USA

Introduction:
‘Secondary overtriage’ refers patients discharged home shortly after being transferred to another hospital. Although minimally injured patients could potentially be discharged home, a recent regional study showed that 9.8% of these seemingly uninjured patients seen at level 3 and 4 trauma centers were transferred to a higher level of care prior to being discharged. We analyze these occurrences at the national level to identify patient characteristics and injury patterns which may facilitate the development of strategies to reduce overtriage rates.

Methods:
Data from the National Trauma Data Bank was obtained from 2008-2012 to isolate those who were: 1) discharged home within 48h of arrival, and 2) did not undergo a surgical procedure. We then identified those who arrived as a transfer to a Level 1 or 2 Trauma Center prior to being discharged (secondary overtriage) from those who were discharged directly from a Level 3 or 4 Trauma Center. Factors associated with transfer were analyzed using a logistic regression. Injuries were classified based on the need for a specific consultant. Co-morbidities examined included: smoking status, functionally dependent status, diabetes, and history of cerebrovascular accidents.

Results:
Descriptive analysis showed a number of differences between transfers and non-transfers due to our large sample size. Those who were not transferred tended to be older than 65 years (21.3% vs. 15.5%) and female (35.3% vs. 26.9%). Rates of hypotension (SBP<90mmHg) were low (0.6% vs. 1.3%) and those with ISS>15 were more likely to be transferred (10.5% vs. 3.7%). No clinically significant differences in co-morbidities were found between groups. We examined the more siginificant variables using a logistic regression controlling for age, gender, ISS, SBP<90, and injury pattern (Table 1). Neurosurgical injuries, vertebral injuries, and facial injuries were associated to an increased risk of transfer, while orthopedic injuries were protective.

Conclusion:
Secondary overtriage results from a combination of limited hospital resources, patient characteristics, and injury pattern. Although some injuries such as mild traumatic brain injuries and stable spine fractures are managed expectantly, it seems that they may be the underlying reason behind many of these transfers. A fear of an underdiagnosed or a progressing central nervous system injury may prompt a referral to a specialist for evaluation. Orthopedic injuries may involve a mechanism isolated to a single limb and therefore be considered more stable. Further studies into how these types of injuries are treated at Level 3 and 4 trauma centers may help reduce inefficiencies stemming from unnecessary transfers.

75.13 Discharge Destination as an Independent Risk Factor for Readmission of the Older Trauma Patient

Posted on January 18, 2016

D. S. Strosberg2, B. C. Housley3, D. Vazquez1, A. Rushing1, C. Jones1 1Ohio State University,Department Of Surgery, Division Of Trauma, Critical Care, And Burn,Columbus, OH, USA 2Ohio State University,Department Of Surgery,Columbus, OH, USA 3Ohio State University,College Of Medicine,Columbus, OH, USA

Introduction: Unplanned readmissions are a major quality measure used to evaluate hospital care. Readmissions after traumatic injury are frequent, and older trauma patients are at increased risk for poor outcomes in both morbidity and mortality. Determining an appropriate destination after discharge in this population is difficult, and may impact readmission rates. Prior literature evaluating discharge destination’s impact on patient outcome is limited and conflicting; no prior study has evaluated this relationship in older trauma patients. The objective of this study was to explore the association between the discharge destination and rate of 30-day readmission in older trauma patients.

Methods: A database of all patients age 45 years or older undergoing trauma evaluation at our American College of Surgeons verified level 1 trauma center over a 1-year period was used to retrospectively compare frequency of 30-day readmission to the center between patients discharged to home, to inpatient rehabilitation facilities, and to other extended care facilities (ECFs, including long term acute care hospitals, skilled nursing facilities, and nursing homes). Further abstracted potentially confounding factors were trauma activation level, injury severity score, comorbidity-polypharmacy score, age, hospital length of stay (LOS), ICU LOS, Glasgow coma score, gender, pre-trauma functional status (independent, partially dependent, or dependent), and pre-trauma residence (home, rehab, or ECF). Inmates, patients who died during their hospitalizations, and patients who were discharged to hospice were excluded from analysis. Univariate analysis was undertaken using chi-square testing. Multiple logistic regression was performed with all the above variables to evaluate for independent contribution to readmission risk.

Results: 960 patients age 45 and older were evaluated over the study period; 81 (8.4%) were excluded and 879 patients age 45-103 were included in the analysis. Seventy-six patients (8.6%) were readmitted within 30 days of discharge, including 6% of patients discharged to home, 14% discharged to ECF, and 19% discharged to rehab (p=0.00009 on univariate analysis). 557 (63%) patients had data recorded for all variables analyzed using multiple logistic regression; among these, only discharge destination was independently associated with the rate of readmission (p=0.019).

Conclusion: Unplanned hospital readmission following traumatic injury is common in older patients and is used as a marker of hospital quality. In this first study of outcomes based on discharge destination of older trauma patients, discharge to inpatient rehabilitation or other extended care facilities was a strong independent risk factor for hospital readmissions. Though causes of this association are likely multifactorial, recognition of this risk factor may aid in the disposition planning of these patients and suggests the need for further evaluation of this correlation at other centers.

75.14 Time to Pelvic Embolization ts Increased in Those Presenting After Business Hours and on Weekends

Posted on January 18, 2016

R. J. Miskimins1, L. R. Webb1, S. D. West1, A. N. Delu2, S. W. Lu1 1University Of New Mexico HSC,Department Of Surgery,Albuquerque, NM, USA 2University Of New Mexico HSC,Department Of Radiology,Albuquerque, NM, USA

Introduction:
Multiple methods of hemorrhage control associated with pelvic fractures have been described. At our Level 1 Trauma center, the primary method used is placement of a pelvic binder followed by angioembolization. Angioembolization is performed by a interventional radiology (IR) team which is not in house at night or on weekends. We hypothesized that individuals with pelvic hemorrhage requiring embolization who present to the emergency department (ED) after business hours have an increased time to angioembolization, require more blood products, and have a higher mortality compared to those presenting during business hours.

Methods:
The IR database was used to identify individuals who underwent emergent pelvic angioembolization secondary to blunt trauma from January 2008 to December 2013. These were divided into, the business hours (BH) group, defined as those presenting to the ED between 7:30 AM and 5:30 PM Monday to Friday and the after business hours group (ABH) defined as those presenting to the ED on weekends, holidays or between the hours of 5:30 PM and 7:30 AM. A chart review was used to obtain the time of ED presentation, presence of contrast extravasation on CT, start time of angioembolization, units of packed red blood cells (PRBC) transfused and if the patient went to the operating room prior to IR. The trauma database was used to obtain initial vitals, demographics, ISS and mortality. Continuous variables were analyzed with the Mann Whitney U test and categorical data was analyzed using the Fisher exact test.

Results:
Ninety nine patients meet inclusion criteria (64 ABH vs 35 BH). There was no difference in initial vitals or demographics. The ISS was similar between the groups (median, 27 ABH vs 26 minutes BH). A blush was present on CT in 63% of the ABH vs 57% in the BH (p=0.67). 25% of the ABH went to the OR prior to IR vs 17% in the BH (p=0.45). There was no difference in PRBCs transfused (median, 6.5 ABH vs 5 BH, p=0.27). There was a significant difference in the time to IR (median, 304 minutes ABH vs 219 minutes BH). Ten patients died within 30 days in the ABH vs 6 in the BH group (p=0.78). There were five deaths from hemorrhage in the first 24 hours in the ABH compared to one in the BH group (p=0.32).

Conclusion:
Individuals who arrive after hours, on weekends, or holidays who require angioembolization to control pelvic hemorrhage, require more time to arrive in the IR suite for management. Although they require more time to arrive in the IR suite, our data does not demonstrate an increase in 30 day mortality, the number of PRBCs transfused, or the number of patients who died from hemorrhage in the ABH group. A limitation of our study is the ability to determine the number of patients who died in both groups while waiting for IR. We have demonstrated there is an increased time to pelvic angioembolization in those presenting outside of business hours, however, there is no difference in mortality if the patient is able to arrive in IR.

75.10 Lactate Clearance as a Predictor of Mortality in Trauma Patients with and without TBI

Posted on January 18, 2016

S. E. Dekker1, H. M. de Vries1, W. D. Lubbers1, P. M. Van De Ven2, A. Toor3, F. W. Bloemers4, L. M. Geeraedts4, P. Schober1, C. Boer1 1VU University Medical Center,Anesthesiology,Amsterdam, NH, Netherlands 2VU University Medical Center,Epidemiology And Biostatistics,Amsterdam, NH, Netherlands 3VU University Medical Center,Center For Acute Care, VU Medical Center Region,Amsterdam, NH, Netherlands 4VU University Medical Center,Surgery,Amsterdam, NH, Netherlands

Introduction: Impaired lactate clearance is predictive of mortality in general trauma patients. The relationship between this biomarker and outcome in traumatic brain injury (TBI) patients, however, is still unknown. This retrospective study examined the association between lactate clearance and mortality in trauma patients with and without TBI.

Methods: Lactate values of trauma patients admitted to the emergency department between 2010-2014 were retrieved from patient files. Patients without initial lactate drawn within 30 minutes after admission, or without a second lactate measurement within 8 hours after admission, were excluded. Lactate clearance was calculated based on modified methods described by Odom et al. (2013) [(Lactateinitial – Lactatedelayed) / Lactateinitial × 100%]; Régnier et al. (2012) [(Lactateinitial – Lactatedelayed) / Lactateinitial × 100% × Delay−1]; and Billeter et al. (2009) [four groups: (1) always below 2.5mmol/L, (2) decreasing below 2.5mmol/L, (3) increasing above 2.5mmol/L, and (4) always above 2.5mmol/L]. We studied the association between lactate clearance and in-hospital mortality in patients with isolated TBI, TBI combined with extracerebral injuries, and trauma patients without TBI.

Results: Of the 3000 admitted trauma patients, 818 (27.2%) had an initial lactate measurement. 367 patients (12.2%) were eligible for lactate clearance calculations. A high initial lactate was associated with a higher in-hospital mortality [OR = 1.20, 95% CI: (1.13 – 1.27), P<0.001]. We found a significant relationship between the lactate clearance method of Billeter et al. and in-hospital mortality (Wald chi-square = 14.614, P=0.002). Post-hoc pairwise comparisons only revealed a significant difference between groups 1 and 4 [Bonferroni corrected P=0.002, OR = 3.59, 95% CI: (1.86 – 6.93)]. There was no association between lactate clearance and in-hospital mortality using the methods of Odom et al. and Régnier et al. Initial lactate value and Billeter’s lactate clearance method did not differ in their ability to predict in-hospital mortality [AUC 0.64, 95% CI: (0.56 – 0.71) vs. AUC 0.64, 95% CI: (0.57 – 0.71), P=0.71]. Neither initial lactate nor lactate clearance differed between isolated TBI, polytrauma + TBI, and general trauma without TBI patients.

Conclusion: This is the first study to investigate the relationship between lactate clearance and outcome in TBI patients, and the first to compare three previously described lactate clearance metrics. In contrast to the available literature for the general trauma patient, only lactate clearance using the method of Billeter et al. predicted mortality in trauma patients with and without TBI. However, in our patient population we found no clinical advantage of using Billeter’s lactate clearance method, as the initial lactate value was equally effective in its ability to predict in-hospital mortality.

75.11 Comparison of Average Pre-Transfusion Hemoglobin Trigger in the SICU

Posted on January 18, 2016

N. Provenzale1, M. Cripps1,2, T. Chung1, C. Townsend1, W. Huda1, C. T. Minshall1,2 1Parkland Health And Hospital System,Dallas, TX, USA 2University Of Texas Southwestern Medical Center,Division Of Burn, Trauma And Critical Care,Dallas, TX, USA

Introduction:
Adverse effects of blood transfusions on patient outcomes are well known; however, adherence to best practice by providers is often inconsistent. We assessed whether our transfusion practice varied respective of which primary service admitted the patient to the Surgical Intensive Care Unit (SICU). We hypothesized that average pre-transfusion hemoglobin levels for patients on elective surgery services, Otorhinolaryngology (ENT), Vascular, and general surgery, would be significantly higher than hemoglobin triggers for Emergency General Surgery (EGS) and Trauma services, despite the Surgical Intensive Care Unit (SICU) operating as a closed unit.

Methods:
The expected practice of the SICU team is to transfuse packed red blood cells (PRBCs) according to the standards established by the TRICC trial. We used a semantic layer construct to identify pre-transfusion hemoglobin levels for SICU patients between June 2014 and May 2015. Patients with uncontrolled hemorrhage were excluded. Self-service electronic health record (EHR) data reporting was used to aggregate patients by primary surgical service and retrieve medical history, BMI, and age for transfused patients. Independent samples T-tests and Fischer’s exact tests were used to assess differences between groups

Results:
403 surgical patients were transfused ≥ 1 units of PRBCs during the study period. Average pre-transfusion hemoglobin level was significantly lower for EGS compared to the ENT and Vascular services. The average pre-transfusion hemoglobin level for Trauma was also significantly lower compared to Vascular (see Table). Two or more units were transfused in 37% of transfusion instances. EGS was the only service found to have a significant difference in average pre-transfusion hemoglobin for patients that received one unit (7.19 ± 0.28) versus two units (6.72 ± 0.44; p=0.042). The prevalence of coronary artery disease was similar between all services. ENT patients were significantly older than EGS (p=0.016) and Trauma (p<0.01) patients, while Vascular patients were significantly older than Trauma patients (p<0.01). EGS patients were more likely to have a history of diabetes mellitus as compared to both Trauma and ENT patients (p=0.01, p=0.039) and more likely than Trauma patients to have hypertension (p=0.041).

Conclusion:
This review of the transfusion practice in our SICU demonstrates variability in transfusion practice for patients on ENT and Vascular services as compared to the other services and is not justified by an increased incidence of comorbid conditions. We also have a high incidence of multiple unit transfusions. The results of this review will allow us to focus our provider education and strive to improve our performance.

75.12 Injury Level Impacts Dysphagia Incidence in Elderly Patients with Non Operative C-Spine Fractures

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 Osteopathic Medicine,Athens, OH, USA

Introduction: Dysphagia is a common condition in the elderly with significant complications such as aspiration, pneumonia, and potentially increased mortality. This problem is even more magnified in elderly patients with cervical spine fractures as neck positioning and altered physiology may further predispose these patients to complications. Fractures of the cervical spine can span the entire length of the neck from C1 to C7. It stands to reason that injuries at different levels of the cervical spine could influence swallowing function in unique ways. This study seeks to investigate how the level of cervical fracture in elderly patients who are non-operatively managed impacts the incidence of dysphagia.

Methods: Medical records of all trauma patients age 65 and older admitted with cervical fractures between January 2008 and April 2014 to a level 1 trauma center were retrospectively reviewed. Patients with a past medical history of dysphagia or stroke or who had operatively managed fractures were excluded, leaving 123 patients for analysis. Bedside evaluation of swallowing function was performed and any patients with evidence of swallowing dysfunction had formal speech therapy consultation. Dysphagia was defined as any restriction or diet modification as a result of swallowing dysfunction after speech therapy assessment. Demographic data, hospital length of stay, intensive care unit days, ventilator days, injury severity score, mortality and level of cervical fracture were analyzed. P values < 0.05 were considered statistically significant. Multiple regression analysis was used to control for confounding variables.

Results: A total of 123 patients met inclusion criteria and 19 (15.4%) of those patients had dysphagia Patients with dysphagia were older (86.3 ± 8.01 vs. 80.6 ± 8.76, p = 0.007), had higher hospital length of stay (7.4 ±4.23 vs 4.3 ± 4.21, p = 0.016), and were more likely to have intensive care unit days (47.4% vs 20.2%, p=0.01).. Patients with C1 fractures were more likely to have dysphagia than patients with other cervical fractures (29.2% vs 7.1%, p = 0.0008). After using regression analysis to control for total length of stay, any intensive care unit days, and age, C1 fracture increased the likelihood of dysphagia by 4 times (OR = 4.0; 95% CI 1.2-13.0)

Conclusion: Incidence of dysphagia is significant in geriatric trauma patients with cervical spine fractures and has important ramifications for patient outcomes such as hospital length of stay. Patients with C1 fractures are at increased risk for dysphagia and these patients may benefit from more vigorous surveillance to prevent subsequent complications.

75.07 Extended Venous Thromboembolism Prophylaxis After Trauma: A Disparity of Beliefs and Practices

Posted on January 18, 2016

C. McCoy1, J. H. Lawson1, M. Shapiro1, C. Sommer1 1Duke University Medical Center,Durham, NC, USA

Introduction: Multiply injured trauma patients are at high risk for venous thromboembolism (VTE) and inpatient chemoprophylaxis is standard of care. However, the time period when a patient is at risk for VTE may extend beyond the inpatient stay. The indication for and utilization of extended VTE prophylaxis following discharge have not been previously described.

Methods: A survey regarding current use of inpatient and extended VTE prophylaxis was distributed to trauma surgeons at Level 1, 2 and 3 trauma centers nationwide with the assistance of the Trauma Center Association of America. Practice patterns including indications for prophylaxis, agents used, and duration of extended VTE prophylaxis were studied.

Results: 80 surgeons, the majority (80%) of whom staff Level 1 trauma centers, responded from 56 hospitals. Nearly all (98%) respondents believed the risk of VTE was elevated following traumatic injury. All respondents utilized VTE chemoprophylaxis for trauma inpatients. Although 72 (90%) responding surgeons believed certain trauma patients should receive chemoprophylaxis following discharge, only 50 (62%) routinely discharged these patients on extended prophylaxis. The most common indications for extended VTE prophylaxis identified by respondents were prolonged immobility and orthopedic trauma. The most common agents utilized were low molecular weight heparin and aspirin. Specific drug dosage and duration were highly variable.

Conclusion: Current practice patterns surrounding extended VTE prophylaxis in trauma patients are highly variable despite widespread belief that extended prophylaxis is warranted in certain patients. Indications, efficacy, and risk stratification of extended prophylaxis regimens should be a focus of additional prospective research in the trauma population.

75.08 Management of Major Hepatic Trauma in The Era of Damage Control Resuscitation

Posted on January 18, 2016

K. M. Ibraheem1, P. Rhee1, A. A. Haider1, N. Kulvatunyou1, T. O’Keeffe1, A. Tang1, R. Latifi1, G. Vercruysse1, L. Gries1, R. Friese1, B. Joseph1 1University Of Arizona,Trauma Surgery,Tucson, AZ, USA

Introduction: Major hepatic trauma (AAST grade ≥4) classically has been associated with mortality as high as 80%. With improvements in resuscitation, increased utilization of angioembolization, and non-operative management, morality associated with these injuries is expected to change. The aim of this study was to assess our experience with the management of major hepatic injuries, to determine if there is a difference in mortality with the use of different techniques for hemorrhage control, and to determine factors associated with mortality.

Methods: We performed a 4 year (2009-2012) retrospective analysis of all patients with major hepatic injuries (AAST grade ≥4) who presented to our trauma center and abstracted information regarding patient injuries, physiological parameters, resuscitation details, radiological findings, and operative details. Our outcome measures were mortality. Multivariate regression and ROC curve analysis were performed.

Results: A total of 98 (Grade 4, 73; Grade 5, 25) patients with a mean age of 30.6 ±19.1 years and mean ISS of 26 [18 – 34] were included. 27.6% (n=27) had other solid organ injuries and 12.2% (n=12) had juxtahepatic vascular injuries. 26.5% (n=26) patients required massive transfusion; and mean pRBC and FFP packs transfused were 8±11 and 5±8 units respectively. 66.3% (n=65) patients required operative intervention and mean estimated blood loss was 2500 mL. The most common hemorrhage control techniques performed were packing (36.7%, n=36) and hepatorraphy (34.7%, n=34) followed by Pringle’s (18.4%, n=18), hepatotomy (8.2%, n=8), non-anatomical resection (4.1%, n=4), omental packing (3.1%, n=3), total hepatic isolation (3.1%, n=3), atriocaval shunt (1.0%, n=1), and lobectomy (1.0%, n=1). Angioembolization was performed in (8.2%, n=8) patients. Overall mortality rate was 28.6% (n=28). Mortality rate with packing (70.6%) was significantly higher as compared to hepatorraphy (18.8%) and angioembolization (0.0%; p<0.001). The strongest predictor of mortality was 24hours pRBC transfusion (OR [CI]: 1.8 [1.3-2.6]; p=001). ROC curve analysis revealed >4.5units of pRBC transfusion as the most sensitive cutoff associated with mortality.

Conclusion: The use of angioembolization and hepatorraphy for hemorrhage control are associated with significantly lower mortality compared to packing after major hepatic trauma. Greater than 4.5 units of pRBC requirement is the most sensitive cutoff associated with mortality in these patients.

75.09 A Nursing Team Trained in Ultrasound-Guided IV Placement Improves Infection Rates in the SICU

Posted on January 18, 2016

J. R. MacDermott1, C. H. Cook3, J. Flaherty1, C. Jones2 1Ohio State University,Wexner Medical Center,Columbus, OH, USA 2Ohio State University,Department Of Surgery, Division Of Trauma, Critical Care, And Burn,Columbus, OH, USA 3Beth Israel Deaconess Medical Center,Department Of Surgery,Boston, MA, USA

Introduction: Central venous catheters (CVCs) are often necessary during critical illness, but are associated with higher rates of blood stream infections than peripheral intravenous catheters (PIVs). To augment ongoing efforts to reduce central line-associated bloodstream infections (CLABSIs), we sought to limit durations that CVCs are in place by placing PIVs and removing CVC as quickly as possible. Because PIV placement in critically ill patients is often difficult, we developed a team of surgical intensive care unit (SICU) nurses trained to use ultrasound (US) to place PIVs in SICU patients. We hypothesized that training SICU nurses to use US guidance for PIV placement in critically ill patients would reduce CVC catheter days and thereby reduce the rate of CLABSI.

Methods: We retrospectively reviewed data gathered prospectively from 2011 through 2014 regarding individual attempts by the nursing team at US-guided PIV (US-PIV) placement and further evaluated pre-existing SICU quality databases of central line usage, patient census, and incidence of CLABSI from 2009 to 2014. Monthly rates of central line usage were calculated from central line days and patient days. Rates of CLABSI were evaluated quarterly as infections per 1000 central line days. Differences between rates before and after implementation of the US-PIV team were analyzed via Kruskal-Wallis testing.

Results: From 2011 to 2014, 2748 attempts at US-PIV placement were recorded, with placement of 2440 PIVs in 1646 patients (success rate 89%). Rates of central line usage trended down from 61.8 central line days per 100 patient days before US-PIV team implementation (monthly range 49.6-76.0) to 58.7 central line days per 100 patient days after its implementation (38.6-81.5, p=0.208). CLABSI incidence decreased substantially from a rate of 2.40 per 1000 patient days prior to US-PIV team creation (quarterly range 1.48-3.46) to 0.85 per 1000 patient days thereafter (0-2.43, p=0.0009).

Conclusion: Properly trained SICU nurses can be highly successful at US guided PIV placement. Implementation of this technology was associated with decreased central line usage and CLABSI when used in conjunction with other infection-reducing efforts. Effective CLABSI prevention requires a multifaceted approach; creation of a nursing team trained to place PIVs using ultrasound may be a useful adjunct to standard practices in improving these quality measures.

75.04 Implementation of a Trauma Activation Checklist at an Academic Trauma Center

Posted on January 18, 2016

D. Ruter1, J. Um1, D. Evans1, C. Boulger2, C. Jones1 1The Ohio State University College Of Medicine,Department Of Surgery, Division Of Trauma, Critical Care And Burn,Columbus, OH, USA 2The Ohio State University College Of Medicine,Department Of Emergency Medicine,Columbus, OH, USA

Introduction: The unpredictable nature of trauma evaluation makes it vulnerable to human error, often communication related and occurring at times of handoff. In 2014, our university-based American College of Surgeons verified Level 1 trauma center developed a ‘Trauma Activation Checklist’ as a joint project between the Departments of Emergency Medicine and Surgery. The checklist included three sections: ‘sign in’ for introductions and preparation prior to patient arrival; ‘EMS timeout’ for attention to handoff by prehospital providers; and ‘sign out’ for planning imaging, consults, and patient disposition upon leaving the trauma bay. The checklist was posted prominently in each trauma bay and discussed during annual and monthly trauma team orientations. We sought to evaluate checklist use during the transition to new teams in July 2015.

Methods: During July 2015, trained observers monitored arrivals and evaluations of a convenience sample of patients seen as Level 1 (severely injured) and Level 2 (moderately injured) trauma activations. For each patient, they recorded the level of activation, time of day, and use of each checklist component as ‘checked’ or ‘not checked’. Failure to verbally acknowledge a checklist component led to its recording as ‘not checked’. No personally identifying data regarding patients were recorded. Descriptive statistics were performed to analyze use of the checklist.

Results: Our center evaluated 130 patients via trauma activation in July 2015. 46 evaluations (35%) were observed for checklist adherence, divided between daytime (7am-5pm, 16 patients, 35%), evening (5-10pm, 23, 50%) and nighttime (10p-7a, 7, 15%). The least frequently completed section was the sign out; only 7 (15%) of the trauma activations completed this section in its entirety. All sections of the checklist were more commonly completed in Level 1 trauma activations than in Level 2 trauma activations (sign in: 41% vs 24%; EMS timeout: 65% vs 38%; sign out: 24% vs 14%).The most commonly missed individual components in the sign in section were placing pre-arrival orders and obtaining equipment access. In the EMS timeout section, obtaining referring institution records was most commonly missed, while assuring intensive care unit handoff was the component most overlooked in the sign out section.

Conclusions: Despite prominent incorporation into trauma team training and its highly visible position in the trauma bay, a trauma activation checklist is used suboptimally in organizing the arrival and initial evaluation of injured patients at our academic medical center. Teams are particularly deficient in completing the sign out section and verbalizing forthcoming plans for patient care, especially for patients deemed less critically injured. Improvements to the checklist itself and to checklist adherence and its effects on information exchange and patient care are ongoing.

75.05 Changing Lives, Changing Lanes – A New Role for Vehicle Deformity and GCS in Trauma Triage?

Posted on January 18, 2016

M. Subrize1, B. A. Asif1, M. Mukit1, H. C. Thode1, M. C. Henry1 1Stony Brook University Medical Center,Department Of Emergency Medicine,Stony Brook, NY, USA

Introduction:
In 2001, Suffolk County, New York implemented the use of the trauma prehospital care report (TPCR), which included the current American College of Surgeons (ACS) trauma triage criteria, a vehicle diagram to identify the location of damage, body diagrams to identify the location and type of bodily injury and the use of safety equipment. We sought to use the TPCR in conjunction with Trauma Registry data to examine which criteria were predictive of patient outcomes and resource use.

Methods:
We conducted a retrospective study of adult TPCR cases matched with the County’s regional Trauma Registry. All patients with a TPCR from 2003 to 2007 were eligible for inclusion. Outcomes included severe injury (Injury Severity Score > 16), need for major OR procedure (MOR), and death. Univariate analysis of triage criteria vs. outcomes was shown as relative risks. Multivariate analysis was performed using stepwise logistic regression analysis. Predictors were included if they were significant at the 0.05 level. Stepwise receiver operating characteristic (ROC) curves were also made using triage criteria as discrete (binary) predictors. At each step the sensitivity and specificity of each remaining criterion was calculated, and the criterion with the largest YI was accepted as the next predictor. This method was repeated until all remaining predictors had a YI of < 5.

Results:

17001 TPCR’s were analyzed. The most common cause of injury was due to motor vehicle collision. Nearly every trauma triage criterion was significantly associated with need for MOR, severe injury, and death. GCS <14 and flail chest were the most related to mortality (OR=12.4 CI 5.8-25.6; 11.4, 2.3-57.3 respectively).

GCS <14 and vehicle deformity were associated with every outcome and often the first criteria accepted into an outcome model. Mechanism criteria were included in 3 of the 6 outcome models. Speed over 40 mph was a useful indicator for ISS>15 or Major OR, but not death. The model with the highest sensitivity and specificity used mortality as the outcome (81% / 85%). Vehicle rollover, vehicle ejection, death of same vehicle occupant and pulse were not accepted into any models. Only death as an outcome had high sensitivity; all models had adequate specificity (78-85%).

Conclusion:
The current study explored different triage criteria and found vehicle deformity >20” and GCS <14 had the best predictive value in traumas causing death and were significant predictors in all other models as well. Vehicle rollover, vehicle ejection, death of same vehicle occupant and pulse had little impact on outcomes. The findings were discordant with other studies evaluating the 2011 trauma triage guidelines, and offer a glimpse into a unique environment, which includes a high percentage of automobile collisions.

75.06 Injury Type Predicts Extubation Failure Despite Successful Spontaneous Breathing Trials

Posted on January 18, 2016

A. Adkins2, U. Pandya1 1Grant Medical Center,Trauma Services,Columbus, OH, USA 2The Ohio State University,College Of Medicine,Columbus, OH, USA

Introduction: Extubation failure and subsequent reintubation is associated with longer intensive care unit and hospital stay and worse outcomes when compared to successfully extubated patients. For many institutions, a successful spontaneous breathing trial is the primary criteria to determine readiness for extubation. Patients with traumatic injury, however, represent a unique population that requires special consideration. It seems reasonable that injury types such as rib fractures and cervical fractures could influence success of extubation. Relatively few studies on this topic have focused on the trauma patient population and their specific injury types. The purpose of this investigation is to determine if specific types of traumatic injury predispose patients to extubation failure. We hypothesize that rib fractures and cervical spine fractures are risk factors for failed extubation despite having a successful spontaneous breathing trial.

Methods: This study was a retrospective chart review of all trauma patients admitted to Grant Medical Center over a 6 year period from January 2009 to December 2014. All injured patients on mechanical ventilation over the age of 15 were considered for the study. Patients that were endotracheally intubated and subsequently passed a spontaneous breathing trial were included. Exclusion criteria were self-extubation, tracheostomy placement prior to attempted extubation, palliative withdrawal of life support, or death prior to an extubation attempt. Patients requiring re-intubation within 72 hours of extubation were determined to have failed extubation and were compared to patients who had successful extubation. Differences between the two groups were analyzed with a p value < 0.05 signifying statistical significance. Multiple regression analysis was used to control for age, injury severity score, and vent days prior to extubation.

Results: A total of 1,613 patients met inclusion criteria with 103 (6.4%) of those in the failed extubation group. Patients who failed extubation were older, had higher injury severity score, more ventilator days prior to extubation, and more intensive care unit and hospital days. Patients who failed extubation were more likely to have cervical spine fractures (21.4% versus 8.2%, p = <0.0001) and more likely to have rib fractures (39.8% versus 23.4%, p = 0.0002).

Conclusion: Cervical spine fractures and rib fractures are risk factors predictive of failed extubation despite successful spontaneous breathing trial. These patients may require additional weaning criteria to better determine chances of successful liberation from mechanical ventilation.

75.02 Do Transferred Patients Increase the Risk of Venous Thromboembolism in Trauma Centers?

Posted on January 18, 2016

B. K. Yorkgitis1, O. Olufajo1, G. Reznor1, J. M. Havens1, D. Metcalfe1, Z. Cooper1, A. Salim1 1Brigham And Women’s Hospital,Trauma, Burns And Surgical Critical Care,Boston, MA, USA

Introduction: It is well known that trauma patients are at increased risk for venous thromboembolism (VTE). Because many patients require initial stabilization followed by transfer to a higher level of care, administration of VTE prophylaxis may often be delayed. It is unclear if these patients are actually at increased risk for VTE. As VTE has become a quality metric for trauma centers, it is important to know if there is an actual increased risk for patients transferred.

Methods: The National Trauma Database (NTDB) v6.2 (2007-2012) was used to identify patients admitted to Level I and II trauma centers. Patients receiving anticoagulants, <18 years, or pregnant were excluded. Patients transferred <24 hours were compared to non-transferred patients with respect to age, sex, race, patient-level risk factors for VTE, and VTE rates. Multivariable logistic regression models were used to identify risk factors for deep venous thrombosis (DVT), pulmonary embolism (PE), and VTE. All calculations were done with SAS 9.3 SURVEYLOGISTIC and SURVEYFREQ procedures to include NTDB weights, strata and clustering to create nationally representative estimates. Alpha was set on P= 0.05.

Results:There were 736,374 trauma patients identified for analysis during with 189,166 (25.7%) patients transferred to a level I or II trauma center within 24 hours of injury. A total of 11,619 (1.5%) developed VTE including 9,149 (78.8%) with DVT and 3,167 (21.2%) with PE. The VTE rate was significantly higher in the transferred group compared to the non-transferred group (1.73% vs. 1.42%, p=0.002). Significant differences exist with respect to DVT (1.39% vs. 1.14%, p=0.004) and PE (0.45% vs. 0.37%, p=0.003) between transferred and non-transferred patients respectively. Multivariable analyses adjusting for patient-level risk factors demonstrated that transferred patients were independently associated with a higher likelihood of VTE (OR 1.15; 95% CI: 1.06 – 1.25, P=0.001 ), PE (OR 1.18; 95% CI: 1.08 – 1.30, p<0.001), and DVT (OR 1.13; 95% CI: 1.04 – 1.25, p=0.007).

Conclusion: Adult trauma patients transferred to a level I or II center that initially presented to another facility are at increased risk for VTE. Further studies are necessary to determine the causes for this increased risk. Accepting a transferred trauma patient results in an increased VTE risk and may not be reflective of the quality of trauma care at the receiving facility.

75.03 Loss of Health Insurance after Traumatic Spinal Cord Injury

Posted on January 18, 2016

J. K. Canner1, E. R. Hammond5, E. B. Schnieder1,3,4, A. Asemota1, S. Selvarajah2 1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA 2Kennedy Krieger Institute,International Center For Spinal Cord Injury,Baltimore, MD, USA 3Harvard School Of Medicine,Brookline, MA, USA 4Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 5Johns Hopkins University School Of Medicine,Psychiatry And Behavioral Sciences,Baltimore, MD, USA

Introduction: Individuals are at risk of losing their insurance if they are severely injured or have a disabling illness, such as following a traumatic spinal cord injury (TSCI). A factor that may affect patients’ ability to address all their healthcare needs following a TSCI, particularly the potential life-long need for neuro-rehabilitation to improve neurological and functional outcomes, is their insurance status. We sought to describe time to insurance loss after TSCI in a population with employer-sponsored insurance.

Methods: We used the 2010-2012 Truven Health Systems MarketScan® database which includes approximately 45 million patients under the age of 65 years who are covered through an employer-sponsored insurance plan. All hospitalized patients with a primary diagnosis of TSCI or a secondary diagnosis of TSCI accompanied by a primary diagnosis of other major trauma were included in the sample. Patients were followed in the database until discontinuation of enrollment in a MarketScan-affiliated insurance plan or until December 31, 2012, and the duration of insurance coverage was calculated. Log-rank tests and univariable Cox proportional hazards regression were used to compare TSCI patients with the general population and to compare the time to coverage loss for patients with and without spinal fracture and traumatic brain injury (TBI). Multivariable Cox proportional hazards regression was used to adjust for age, sex, and injury beneficiary status (e.g., employee, spouse, or child).

Results: A total of 5,231 patients were hospitalized for a TSCI during the study period. Of these, 44.8% had a primary diagnosis of TSCI, 70.5% had an associated vertebral fracture, and 21.0% had a complete TSCI. Two-thirds of the patients (67.1%) were male and the median age was 41 years (IQR: 23-54). An estimated 43.8% of the population with TSCI lost their insurance before the end of the study period, compared to 33.9% in the general population (HR=1.18, p<0.001). After adjusting for potential confounders, the hazard ratio was 1.23 (95% CI: 1.17-1.29, p<0.001). Among patients with a TSCI, there was no difference in the risk of insurance loss between those with and without a concomitant spinal fracture (HR=1.03, p=0.61), but there was a significant difference between those with and without a concomitant TBI (HR=1.17, p=0.026).

Conclusion: Approximately 4 in 10 patients with TSCI lost their employer-sponsored health insurance during the study period, a proportion significantly higher than that seen in the general population. Further research is needed to identify modifiable factors that could mitigate the extent of, and rate of loss of insurance among patients with TSCI.

74.18 Validation Of A Checklist For Postoperative Wounds In Vascular Surgery

Posted on January 18, 2016

R. Gunter1,3, J. Wiseman1, S. Fernandes-Taylor1, Y. Ma2, S. Saha2, S. Clarkson3, D. Yamanouchi4, K. C. Kent1,3 1University Of Wisconsin,Wisconsin Institute Of Surgical Outcomes Research,Madison, WI, USA 2University Of Wisconsin,Department Of Biostatistics,Madison, WI, USA 3University Of Wisconsin,Department Of Surgery,Madison, WI, USA 4University Of Wisconsin,Department Of Surgery, Division Of Vascular Surgery,Madison, WI, USA

Introduction

Surgical site infection (SSI) is the most common nosocomial infection and reason for readmission in surgical patients, particularly in vascular surgery patients who experience the highest readmission rate for surgical populations. Technology-based transitional care that allows digital image-based wound monitoring has the potential to detect and facilitate treatment of SSI at an early stage. We undertake a study to validate the use of smartphone digital photography to evaluate postoperative vascular surgery wounds.

Methods

We developed a wound assessment checklist using previously validated criteria. All patients 18 and older who underwent a vascular surgery procedure involving a surgical incision at least 3cm in size between May and December 2014 were recruited from a high-volume tertiary-care academic vascular surgery service. Vascular surgery attending surgeons, physician assistants, nurse practitioners, and registered nurses evaluated wounds using the assessment checklist in-person; a different group of providers evaluated the wound via a Smartphone digital photograph. Inter-rater reliability for (1) wound assessment and (2) treatment plan was measured using Gwet’s Agreement Coefficient (AC) for the in-person group, the photograph group, and between groups. We used 1000 bootstrap samples with replacement to calculate 95% CI of Gwet’s AC; the samples were drawn by wound.

Results

We assessed 80 wounds (23 lower extremity wounds, 20 groin wounds, 18 abdominal wounds, 10 neck wounds, 5 upper extremity wounds, and 4 amputation stumps) in-person with a median 2 raters per wound (minimum of 1 rater and maximum of 4 raters), and via photograph with 9 raters per wound. Agreement between in-person and image-based assessments was high with respect to course of treatment with substantial agreement for antibiotics (AC=0.76) and need for debridement (AC=0.89). Relative to in-person raters, raters evaluating high-quality images were more likely to detect redness (OR=2.23, p<0.001), drainage (OR=2.1, p<0.01), and indicate the need for an ED visit (OR=6.42, p<0.001). Raters evaluating low-quality images were more likely to indicate the need for an ED visit (OR=5.69, p<0.001), but less likely to detect drainage (OR 0.13, p=0.005), than in-person raters. Less experienced clinicians were more likely to indicate the presence of ecchymosis (OR=1.47, p=0.03), more likely to indicate a need for wound drainage (OR=1.89, p=0.03), and less likely to suggest surgical debridement (OR=0.51, p=0.03).

Conclusions

Smartphone digital photography is a valid method for evaluating postoperative vascular surgery wounds that is comparable to in-person evaluation across most domains of wound abnormality. The inter-rater reliability for determining treatment recommendations was universally high. Remote wound monitoring and assessment may play an integral role in future transitional care models to decrease readmission for SSI in vascular surgery patients.

74.19 Primary Fascial Closure After Damage Control Laparotomy: Factors Affecting Outcome

Posted on January 18, 2016

M. A. Khasawneh1, D. H. Jenkins1, H. J. Schiller1, D. J. Dries2, M. D. Zielinski1 1Mayo Clinic,Trauma, Critical Care, General Surgery,Rochester, MN, USA 2University Of Minnesota,General Surgery,St. Paul, MN, USA

Introduction: Our recently completed prospective, randomized, placebo controlled clinical trial studying the effects of flaccid paralysis of the lateral abdominal wall muscles after damage control laparotomy had unexpectedly high rates of primary fascial closure (PFC) whether botulinum toxin or placebo was injected (98% vs 96%). In order to ensure patient safety, numerous exclusion criteria were applied. We aim to compare PFC rates between enrolled and excluded patients, and identify factors associated with lack of PFC.

Methods: A retrospective review of all patients who were screened for enrollment into the prospective trial was performed. The principal exclusion criterion for each excluded patient was utilized for analysis. Patients who died before an attempt at fascial closure were excluded from the current analysis. Data is presented as means [standard deviation] for continuous variables and as rates for discrete variables.

Results: 153 patients were included in the current analysis, 46 of who were enrolled in the trial and 107 were excluded. Excluded patients were older, more likely to have cardiac disease, hypertension, peripheral vascular disease, and use corticosteroids. There were no differences in sex, BMI, diabetes mellitus, renal disease, connective tissue disorder, anticoagulation, malignancy, and smoking status between the groups. The rates of PFC were significantly greater in included patients (93.5% vs 76.5%, p=0.007). 30 day mortality was significantly different between the two groups (4.4 vs 27.9%, p=0.0003). Multivariate analysis demonstrated that COPD, BMI >50 and cirrhosis were independent predictors of lack of PFC.

Conclusion: The study identifies factors associated with lack of PFC. Future trials examining the effect of botulinum toxin injection in high risk patients are needed.

74.20 Alkaline Ocular Burns in the United States

Posted on January 18, 2016

R. S. Haring1,2,3,4, I. D. Sheffield5, J. K. Canner3, A. H. Haider1,2, E. B. Schneider1,2,3,4 1Harvard School Of Medicine,Brookline, MA, USA 2Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 3Johns Hopkins University School Of Medicine,Johns Hopkins Surgery Center For Outcomes Research,Baltimore, MD, USA 4Johns Hopkins Bloomberg School Of Public Health,Dept. Of Health Systems And Policy,Baltimore, MD, USA 5Brigham Young University,Provo, UT, USA

Introduction: Ocular chemical burns are a severe form of injury, often leading to long-term morbidity, including reduced visual acuity and quality of life. A review of the current literature on ocular burns found that chemical burns are most common among working-age men, suggesting that these types of injuries can have a substantial impact on quality-adjusted life years. Alkaline burns, which penetrate deeper and faster into the cornea, are the most severe form of chemical burn, and are associated with significantly poorer outcomes than acid burns. Currently, there are no large-scale epidemiologic studies that describe the incidence and burden of alkaline ocular burns in the United States. We sought identify and characterize trends, incidence, and characteristics related to patients presenting to Emergency Departments (EDs) in the US from 2006-2012 with alkaline ocular burns.

Methods: Using the Nationwide Emergency Department Sample (NEDS), we identified all patients who presented with an ICD-9-CM diagnosis of alkaline ocular burn from 2006-2012. We examined burden and trends related to age and sex to determine which populations were at highest risk of alkaline ocular burn injury. Age-specific population-based rates were calculated using the US Census Bureau’s intercensal and postcensal estimates. Chi square tests were used to compare subsets across time and between age and sex groupings.

Results: Patient age at ED presentation for treatment of alkaline ocular burns followed a bimodal distribution, with the highest population-based injury rates occurring among 1-year old infants (1.29 per 100,000), with a lower rate among two-year-olds (0.811 per 100,000). The second-highest injury-rates were found among adults in their twenties (e.g., 1.28 per 100,000 among 28-year olds). Overall, 55.2% of alkaline burn injuries occur among 20-45 year olds, and among this group, 67.9% of patients were male. Mean patient age at presentation was 35.5 years (95% CI: 34.7-36.3), and did not vary by sex (p=0.991).

Conclusion: Alkaline ocular burns are among the most critical and severe forms of ocular injury. Earlier studies and reviews in the literature identified working-age men as a high-risk cohort; however, we discovered that the single highest-risk age-based rate of ED presentation with alkaline ocular burns is found among one-year-old children. These findings may be used to aid in the design and implementation of appropriate prevention efforts, which may range from appropriate storage of chemicals in the home to policies on protective eyewear in the workplace. Special attention must be paid to preventing access to alkaline agents among the youngest of children and educating parents on the need for rapid appropriate response when alkaline ocular burn is suspected in an infant.

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