50.05 The utility of pre-sacral drainage in penetrating rectal injuries in adult and pediatric patients

Posted on January 26, 2017

K. B. Savoie1,5, T. M. Beazley3, B. Cleveland2, S. Khaneki4, T. Markel4, P. Hammer6, S. Savage6, R. F. Williams5  1University Of Tennessee Health Science Center,Department Of Surgery,Memphis, TN, USA 2Indiana University,School Of Medicine,Indianapolis, IN, USA 3University of Tennessee Health Science Center,School Of Medicine,Memphis, TN, USA 4Indiana University Health, Riley Hospital For Children,Division Of Pediatric Surgery,Indianapolis, IN, USA 5University Of Tennessee Health Science Center, Le Bonheur Children’s Hospital,Division Of Surgery And Pediatrics,Memphis, TN, USA 6Indiana University Health, Methodist Hospital,Division Of Trauma Surgery,Indianapolis, IN, USA

Introduction:

The historical tenets of treating penetrating rectal injuries (PRI) developed out of military trauma and often included presacral drainage to decrease risk of pelvic sepsis. With different weaponry associated with injuries in civilian trauma, there is equipoise on the utility of pre-sacral drainage (PSD), particularly in pediatric patients.

Methods:

IRB approval was obtained at two free-standing children’s hospital and two adult level 1-trauma hospitals. Data was retrospectively collected from July 2004-June 2014 and compared by age (pediatric patients <16 years) and PSD. A stratified analysis was performed based on age. The primary outcome was pelvic or presacral abscess.

Results:

We identified 92 patients with PRI; 23 pediatric and 69 adult. Forty-one patients had PSD; only 3 pediatric patients.  Time from injury to presentation was longer in pediatric patients (284 vs 46 minutes, p<0.01) and they were more tachycardic on arrival (110 vs 89, p<0.01). There was no difference in the proportion of patients presenting in shock. Adult patients had higher estimated blood loss (250 vs 10 mL, p<0.01). However, in a stratified analysis there was no difference in either adult or pediatric patients in preoperative, operative, or postoperative transfusion requirements between those with PSD and those without PSD. Adult patients were more likely to have sustained gunshot wounds (GSW; 84%). There was no significant difference in work-up between the two age cohorts with regard to rectal exam or proctoscopy.  

Adult patients were more likely to have AAST grade 3 injuries (57%) and pediatric patients were more likely to have AAST grade 2 injuries (83%; p<0.01); there was no association between AAST grade and PSD placement.  Pediatric patients were more likely to have distal extraperitoneal injuries (52% vs 27% in adults, p=0.03). Overall, PSD was more common in adult patients (59% vs 14%, p<0.01), African-American patients (68% vs 2% Caucasian, p<0.01) and those sustaining GSWs (62% vs 17% impalement, p<0.01); in a stratified analysis only race remained significant for both adult and pediatric patients.

There were 3 cases of pelvic or presacral abscess, all in the adult patients (p=0.31); 1 patient with PSD and 2 without PSD (p=0.58). In a stratified analysis there were no differences in any infectious complication: In adult PSD patients there were 2 wound infections; there was 1 intraabdominal abscess in those without PSD. There were 2 mortalities, both in patients without PSD. In children, there was 1 wound infection, 1 urinary tract infection, and 1 case of pneumonia, all in children without PSD.

Conclusion:

Pelvic or presacral abscess is a rare complication of PRI, especially in pediatric patients. Presacral drainage is not associated with decreased rates of infectious complications and may not be necessary in the treatment of PRI. Further prospective studies are needed in both adult and pediatric patients to determine utility.

50.04 Role of Computed Tomography as Screening in Pediatric Head Trauma by Hospital Type

Posted on January 26, 2017

H. Naseem1, A. Train1, S. Baek2, T. Zhuang3, K. Bass1,4  1Women And Children’s Hospital Of Buffalo,Department Of Pediatric Surgery,Buffalo, NY, USA 2State University Of New York At Buffalo,Department Of Urban And Regional Planning, School Of Architecture And Planning,Buffalo, NY, USA 3State University Of New York At Buffalo,Department Of Biostatistics,Buffalo, NY, USA 4State University Of New York At Buffalo,Department Of Surgery, Jacobs School Of Medicine And Biomedical Sciences,Buffalo, NY, USA

Introduction: Trauma systems encourage expedited transfer of patients requiring specialty trauma services. Initial management and use of imaging is variable among hospital types. Our purpose was to compare the use of head computed tomography (CT) by hospital type for management of pediatric head injury in our region. Our hypothesis is that community hospitals have a higher rate of head CT's for evaluation of pediatric head trauma compared to a Pediatric Trauma Center (PTC).

 

Methods: Retrospective study using the state discharge database including patients <18 years old presenting with a diagnosis of head injury from January 2010 to December 2014. Exclusions were incomplete data, hospitals with <10 patients and disposition of death or left against medical advice. The exposure variable of interest was hospital type and main outcome variable of interest was head CT scan. Secondary exposure variable was age and secondary outcome variable was disposition.  A p-value of <0.05 was considered significant.

 

Results: A total of 22,129 patients were included in analysis of which 52% received a head CT. 32% of patients were evaluated at a PTC, 2% at an adult trauma center (ATC), 25% at an adult community hospital (ACH), 33% at an adult/pediatric community hospital (APCH), and 8% at an urgent care center (UC). On univariate analysis, patients presenting with a head injury to the PTC were more likely to receive a head CT in their evaluation than patients presenting to an ACH, APCH, ATC, or UC (p<0.0001). Patients between ages 4-13 (OR: 1.629, 95% CI: 1.525 to 1.741) and 14-17 (OR: 2.917, 95% CI: 2.718 to 3.131) were more likely to receive a head CT compared to patients who were 0-3 years old (Table 1). On multivariate analysis, patients with a head CT were more likely to be admitted (OR: 1.929, 95% CI: 1.668 to 2.230) as well as transferred from the community hospital to the PTC (OR: 2.320, 95% CI: 1.891 to 2.847).

 

Conclusion: Community hospitals are evaluating the majority of pediatric head injuries in our region without exceeding the rate of head CT utilization at the PTC. Patients receiving a head CT are more likely to be admitted or transferred to a PTC, suggesting that the head CT is not being used as a primary screening tool. Patients evaluated for head injury in our region are more likely to receive a head CT and undergo admission when presenting to the PTC compared to an ATC, ACH, APCH or UC. Further outcomes research is needed to delineate appropriate utilization of head CT based on current standards.

50.03 Complications of Operative vs Non-Operative Management of Blunt AAST IV-V Liver Injuries

Posted on January 26, 2017

R. J. Miskimins1, A. Greenbaum1, P. Kilen2, S. D. West1, S. W. Lu1  1University Of New Mexico HSC,Department Of Surgery,Albuquerque, NM, USA 2University Of New Mexico HSC,School Of Medicine,Albuquerque, NM, USA

Introduction: The initial treatment of high grade liver injuries is primarily determined by the patient’s hemodynamic status. Non-Operative management has become the standard in hemodynamically stable patients with high grade blunt liver injuries.   We sought to evaluate the differences in high grade blunt liver injuries managed non-operatively vs. those requiring laparotomy.

Methods: The records of patients with blunt high grade liver injuries defined as AAST grade 4 and 5 from Jan 2008 to July 2015 at an ACS verified Level I trauma center were retrospectively reviewed.  Charts were reviewed to identify liver-directed interventions and liver-related complications. The trauma database was used to obtain demographics, initial vitals, ISS, length of stay, and mortality.  Statistical analysis was performed with the Mann Whitney U and Fisher exact tests.

Results:  Eighty-six patients met inclusion criteria, with blunt high grade liver injuries, 20 grade 5 and 66 grade 4.  Fifty-one (59%) patients were initally managed non-operatively and 35 (41%) initally required laparotomy. Of those initally managed non-operatively, 7 (14%) failed and required laparotomy (5 abdominal compartment syndrome (ACS), 2 peritonitis). Those who failed non-operative management were more likely to have undergone angioembolization (57% vs 16%, p=0.03).  In the operative group, 12 patients (35%) died, 7 (20%) in the first 24 hours from hemorrhagic shock and 3 (9%) from multi-organ system failure. No patients initially managed non-operatively and subsequently requiring laparotomy died.  When comparing the two groups, the operative groups had higher ISS (38 vs 27, p <0.01), lower initial SBP (87 vs 113 mmHG, p <0.01), higher transfusion of PRBC (11 vs 1 units, p<0.01) and FFP (9 vs 1 units, p <0.01), and longer ICU stays 12 vs 4 days (p <0.01). Bile leak was more prevalent in the operative group (33% vs 9%, p<0.01), as was ischemic gallbladder injury 24% vs 2% (p<0.01). When comparing patients that underwent embolization in both groups to patients not receiving embolization, the embolization group experienced higher rates of liver abscess (35% vs 3%, p=<0.01) and bile leak (50 % vs 12%).

Conclusions:  Blunt AAST Grade IV-V liver trauma patients requiring laparotomy had significantly higher mortality, transfusion requirements and ICU length of stay when compared to patients managed non-operatively in our institution.  Non-Operative management augmented with hepatic embolization has higher rates of failure compared to those not receiving hepatic embolization; however, these failures resulted from ACS and peritonitis as opposed to hemorhage.

50.02 The Title Matters: Trauma Center Designation Improves Outcomes For Patients With Hip Fractures

Posted on January 26, 2017

A. V. Jambhekar1, R. Lindborg1, V. Chan1, B. Fahoum1, J. Rucinski1  1New York Methodist Hospital,Brooklyn, NY, USA

Introduction:

Hip fractures often result from low energy mechanisms of injury and seldom present with other traumatic injuries. One large retrospective cohort study has recently shown that patients with isolated hip fractures may not necessitate care at higher level trauma centers. The objective of this study was to determine if hip fracture patients have improved hospitalization outcomes since designation of the study hospital as a level II trauma center.

Methods:

Data was collected on 375 patients with hip fractures evaluated between April 1, 2014 and February 20, 2016. Patients were included if they presented to the Emergency Department with a traumatic mechanism of injury which manifested with a hip fracture. Patients less than 15 years of age were excluded from the study.  Data was retrospectively collected using ICD 9 codes for the pre designation group from April 1, 2014 to March 30, 2015 (n = 234). Data was prospectively collected for the post designation group, or patients evaluated after the study hospital was designated as a level II trauma center on April 1, 2015 (n = 141). Analysis was conducted using the unpaired student’s T tests and chi square test.

Results:

Patients in the pre and post designation groups were of similar age (77.19 +/- 9.90 vs. 80.10 +/- 13.49; p = 0.076). Complication and mortality rates also remained similar between the two groups (8.1% vs. 8.5%; p = 0.89; 4.7% vs. 4.3%; p = 0.84). Length of stay was significantly shorter in the post designation group (20.23 +/- 2.60 vs. 6.52 +/- 1.10; p <0.0001). More patients were discharged to subacute rehabilitation facilities and fewer patients were discharged directly home in the post designation group (50% vs. 63.8%; p = 0.009; 9.8% vs. 2.1%; p = 0.004).

Conclusion:

Hip fracture management is multidisciplinary and requires optimizing systems of care. Trauma center designation at the study hospital appears to lead to a decreased length of inpatient hospitalization with an increased percentage of patients being discharged to skilled rehabilitation facilities. Management of patients with hip fractures at a designated higher level trauma center may lead to improved hospitalization outcomes and more cost effective care.
 

50.01 Early Brain Death Results In Greater Organ Donor Potential?

Posted on January 26, 2017

S. Resnick1, M. J. Seamon1, D. Holena1, J. L. Pascual1, P. M. Reilly1, N. D. Martin1  1University Of Pennsylvania,Philadelphia, PA, USA

Introduction:  

Aggressive management of patients prior to and after determination of death by neurologic criteria (DDNC) is necessary to optimize organ recovery, transplantation and increase the number of organs transplanted per donor (OTPD). The effects of time management is an understudied but potentially pivotal component. The objective of this study was to analyze specific timepoints (time to DDNC, time to procurement) and the time intervals between them to better characterize the optimal timeline of organ donation.

Methods:  

Using data over a 5-year time period (2011-2015) from the largest US organ procurement organization (OPO), all patients who died from head trauma, and donated transplantable organs were retrospectively reviewed. Active smokers were excluded. Maximum donor potential was 7 organs (heart, lungs (2), kidneys (2), liver, pancreas). Time from admission to DDNC and donation was calculated. Mean timepoints stratified by specific organ procurement rates and overall OTPD were compared using unpaired t-test.

Results: 

Of 1719 DDNC organ donors, 381 were secondary to head trauma. Smokers and organs recovered but not transplanted were excluded leaving 297 patients. Males comprised 78.8%, the mean age was 36.0 (±16.8) years, and 87.6% were treated at a trauma center. Higher donor potential (>4 OTPD) was associated with shorter average times from admission to brain death; 67 vs 82 hours, p=0.0042. Lung donors were also associated with shorter average times from admission to brain death; 62 vs 84 hours, p=0.004. The time interval from DDNC to donation varied minimally amongst groups and did not affect donation rates.

Conclusion: 

A shorter time interval between admission and DDNC was associated with an increased OTPD, especially lungs. Further research to identify what role timing plays in the management of the potential organ donor and how that relates to donor management goals is needed.  

 

49.20 Abdominal Heterotopic Ossification Following Damage Control Laparotomy: A 6-Year Experience

Posted on January 26, 2017

Y. Wang1, A. Stanek1, J. Grushka1, P. Fata1, A. Beckett1, K. Khwaja1, T. Razek1, D. Deckelbaum1  1McGill University,Trauma Surgery,Montreal, QC, Canada

Introduction:  The incidence of heterotopic ossification (HO) following damage control laparotomy is unclear. Abdominal wall reconstruction may prove more challenging in patients with HO. This study reviews the incidence of HO in patients who had an open abdomen post damage control laparotomy.

Methods:  A retrospective review of all patients who had an open abdomen post damage control laparotomy between 2009 – 2015 at a level 1 trauma centre was conducted. Patient demographics, mechanism of injury, duration of open abdomen and number of surgeries prior to abdominal closure were reviewed. Heterotopic ossification was detected on computed tomography images and characterized based on location, dimensions and distance from the xiphoid.

Results: Of the 117 patients reviewed, 49 patients were excluded because of death (n= 27), lack of imaging studies (n = 19) or missing chart information (n = 3). Of the 68 patients included in the study, 36 (53%, 29 male, 7 female) developed HO. There were no significant differences in age, sex or mechanism of trauma between the HO group and the non-HO group. The HO group had a significantly longer time to definitive closure (6.5 vs. 2.0 days, p = 0.013) and a greater number of abdominal surgeries prior to closure (2 vs. 1, p = 0.002). The median time to detection of HO was 41 days. The median size of HO was 4.8 cm (craniocaudal) by 2.2 cm (axial), with a distance of 1.5 cm from the xiphoid.

Conclusion: Trauma patients treated with open abdomens post damage control laparotomy have a high incidence of heterotopic ossification. Development of HO is associated with a longer duration of open abdomen and a greater number of surgeries prior to definitive closure. The impact of HO on functional status and abdominal reconstruction should be better quantified. Prevention strategies including the use of non-steroidal anti-inflammatories should be evaluated. 

49.18 Preoperative Decontamination to Reduce Infections in Elective and Emergent Lower Extremity Repairs

Posted on January 26, 2017

D. S. Urias1, S. Morrissey1, R. Dumire1  1Conemaugh Memorial Medical Center,Johnstown, PA, USA

Introduction:

Medical implant associated surgical site infections (SSIs) are a heavy burden on patients and the healthcare system, with increased costs and significant rise in morbidity and mortality. Previously, our practice had been either bathing patients with 2% chlorohexadine gluconate (CHG) wash cloth or 4% CHG solution shower the night before and morning of surgery. We implemented evidence based nasal painting with povidone-iodine to our protocol and sought to measure the effectiveness in reducing SSIs in patients who underwent elective or emergent repair of lower extremity fractures.

Methods:

A retrospective review of patients undergoing elective or emergent orthopedic operations will continue to be conducted at Duke Life Point-Conemaugh Memorial Medical Center in Johnstown, PA from 10/1/2012 through 9/30/2016. The intervention period will extend from 10/1/2014 to 9/30/2016 and included the addition of povidone-iodine nasal swabbing of each nares preoperatively. Per standard surveillance, all patients were followed for 30 days postoperatively for the development of a SSI. Patient demographics were collected including: injury, history of diabetes, chronic obstructive pulmonary disease, alcoholism, and smoking.

Results:

The pre-intervention group consisted of 933 cases over two years with a 1.2% infection rate (1.7% year one and 0.7% year two), 11 total SSIs, 10 after emergent procedures. The post-intervention group consisted of 484 cases over 1 year (10/1/2014 to 9/30/2015) with zero infections. Using the z-test for two independent proportions, a statistically significant difference was found overall pre vs. post (P = .0164). When pre was compared to post, a statistically significant difference was seen between post and pre year one (P = 0.00424) but not two (P = 0.0735) with a Bonferroni corrected alpha. Patients were well-matched on sex, age, ASA score, and surgical procedure duration.

Conclusion:

This retrospective review of an evidence based MRSA decontamination protocol with CHG wash cloths or solution shower and povidone iodine nasal painting successfully contributed to the decrease of the infection rate in patients undergoing elective and emergent repair of lower extremity fractures. Additional investigations into widespread use of decolonization of MRSA in the nares is necessary; however, based on published studies and our experience we recommend its use in patients without contraindications.

49.19 High Flow Nasal Cannula with Extubation of Critically Ill Surgical Patients

Posted on January 26, 2017

E. J. Smith1, N. K. Dhillon1, A. Ko1, M. Y. Harada1, T. Li1, R. Liang1, G. Barmparas1, E. J. Ley1  1Cedars-Sinai Medical Center,Los Angeles, CA, USA

Introduction:  High flow nasal cannula (HFNC) is increasingly used to avoid intubating patients with hypoxemic respiratory failure. Benefits include providing PEEP, reducing anatomical dead space, and decreasing work of breathing. We sought to compare outcomes of critically ill surgical patients extubated to HFNC versus conventional therapy.

Methods:  A retrospective review was conducted in the surgical intensive care unit (SICU) of an academic hospital during August 2015 to February 2016. HFNC use depended upon the rounding surgical intensivist.  Demographics, ventilator days, oxygen therapy post-extubation, re-intubation rates, SICU length of stay (LOS), hospital LOS, and mortality were collected. Self and palliatively extubated patients were excluded. Characteristics and outcomes were compared between those who extubated to HFNC versus cool mist/nasal cannula (CM/NC).

Results: Of the 184 critically ill patients analyzed, 46 were extubated to HFNC and 138 to CM/NC. Mean age and days on ventilation prior to extubation were 57.8 years and 4.3 days, respectively. Both cohorts were similar in age, gender, and pre-existing pulmonary history. Although HFNC had lengthier intubation (7.1 vs. 3.4 days, p<0.001) and SICU stays prior to extubation (7.1 vs. 3.4 days, p<0.001), rate of reintubation trended lower compared to CM/NC (6.5% vs. 13.8%, p=0.19). Multivariate analysis demonstrated HFNC was associated with lower reintubation rates (AOR 0.049, p=0.032). HFNC had a similar mortality rate compared to CM/NC.

Conclusion: Ventilated patients at risk for respiratory failure have reduced reintubation rates when extubated to HFNC. Patient with prolonged intubation, the elderly or high-risk comorbidities may benefit from extubation to HFNC.

49.16 Polypharmacy Among Elderly Drivers: An Epidemic Exacerbated By Trauma

Posted on January 26, 2017

A. Lauria1, S. Armen1, K. Fitzgerald1, J. Chandler1, R. Staszak1, S. Allen1  1Penn State Hershey Medical Center,Hershey, PA, USA

Introduction: Elderly drivers are frequently prescribed multiple medications to treat an increasing number of medical co-morbidities. Polypharmacy (>5 medications) lead to an increased risk of collisions and higher morbidity and mortality than those on fewer medications. The purpose of the current study was to describe the incidence of polypharmacy among elderly drivers prior to a motor vehicle collision. We hypothesized that polypharmacy before an MVC is common and directly related to the number of co-morbidities and is exacerbated by injuries sustained in the MVC.

Methods: A retrospective chart review was performed over a 3-year study period at our urban Level 1 trauma center. IRB approval was obtained. Elderly drivers (>65 years) involved in an MVC were studied. Demographic information, ISS, pre-existing conditions (PEC) as well as the number and types of pre-MVC and post-MVC discharge medications were collected. 

Results:Polypharmacy is very common among elderly drivers (55.5%) who present to our urban trauma center and is often unassociated with the number of PEC’s (mean 0.98 PEC’s with median 1 PEC, range 0-5) at the time of admission. The incidence of polypharmacy significantly worsens upon hospital discharge especially in those patients discharged home (Pre-MVC 55.5% vs. Post-MVC: 79.0%, P=0.001). Many elderly drivers were noted to be on several medications prior to the MVC and were discharged home on significantly more medications following their hospitalization (Pre-MVC: 5.8 + 3.9 medications (range 0-16) vs. Post-MVC: 8.1 + 4.4 medications (range 0-20), P=0.001).

Conclusion:Polypharmacy exists in epidemic proportions, is often out of proportion to a patient’s PEC’s and exacerbated after hospitalization. Polypharmacy may place elderly patients at increased risk for future injury. Interventions to minimize polypharmacy are necessary to ensure that all unnecessary medications are discontinued in a timely fashion to mitigate the risk of future injury.

 

49.15 Effect of Prehospital Time on Trauma Team Activation and Patient Outcomes in Severe Blunt Trauma

Posted on January 26, 2017

T. W. Clements1, K. Vogt3, M. Hameed2, N. Parry3, A. Kirkpatrick1, S. Grondin1, E. Dixon1, J. Mckee1, C. Ball1  1University Of Calgary,Division Of General Surgery,Calgary, AB, Canada 2University Of British Columbia,Vancouver, British Columbia, Canada 3Western University,London, ONTARIO, Canada 4University Of Calgary – Cumming School Of Medicine,Calgary, AB – ALBERTA, Canada

Introduction:  Emergency medical services (EMS) prehospital times vary substantially between different regions. The impact of these times on trauma team activation (TTA) and patient survival is unknown. The aim of this study was to identify the impact of EMS prehospital time on resource utilization (TTA) and patient outcomes.

 

Methods: A multi-institutional study from 3 geographically distinct regions (level 1 trauma centers) reviewed all severely blunt injured patients (ISS>12) to determine the relationship between prehospital times (30 minute increments), hemodynamic instability(sBP<100), TTA, and patient outcomes. Standard statistical methodology was employed.

Results:From January 2011 to January 2016, 6881 severely blunt injured patients (mean ISS = 24.6; LOS = 16.3 days) were evaluated (Calgary 3376; Vancouver 2401; London 1104). As the prehospital time interval increased, the overall mortality rate decreased (0-30min: = 24.1%; 31-60min = 14.7%; 61-90min = 10.3%; 91-120min = 10.4%;121-150min = 10.2%; 151-180min = 12.1%; p<0.05). Although centers varied in overall injury severity (ISS) and prehospital system formats, this pattern of decreasing mortality with longer prehospital time was consistent across all 3 regions (p>0.05). TTA was variable across time intervals (0-30min: = 51.9%; 31-60min = 25.4%; 61-90min = 17.1%; 91-120min = 26.3%; 121-150min = 27.1%; 151-180min = 29.9%; p<0.05) and only variably related to ISS. Hemodynamic instability was predictive of mortality in all prehospital intervals (p<0.05).

Conclusion: TTA criteria must improve to select appropriate patients who have a prehospital transport time less than 30 minutes and a high mortality. Patients with prehospital times more than 60 minutes and hemodynamic stability rarely require life-saving interventions and TTA. Longer prehospital times lead to a ‘trial of life’ preselection scenario with decreasing overall mortality regardless of the regional trauma system structure.

49.14 Is It Safe to Transport Penetrating Trauma Via Helicopter in a Rural State?

Posted on January 26, 2017

J. W. Greer1, K. W. Sexton1  1University Of Arkansas For Medical Sciences,Little Rock, AR, USA

Introduction:
Patients with penetrating trauma often have significant blood loss and may need temporizing measures before definitive care is delivered.  This raised the question of whether or not these patients should be taken to a local emergency department or flown to the states only Level I trauma center for definitive care.  Since distance traveled can be significant for some patients in a rural state, we sought to evaluate the safety of helicopter transport of penetrating trauma in a rural state with a single Level I trauma center.  

Methods:
We conducted a retrospective review of prospectively collected data from 2009-2015 of all patients in the Arkansas Trauma Database.  Variables included: age, gender, mechanism of injury, time to scene, scene time, transport time, dispatch to hospital arrival time, discharge status, ISS (Injury Severity Score), NISS (New Injury Severity Score), TRISS (Trauma and Injury Severity Score), scene GCS (Glasgow Coma Scale), and scene hemodynamics.  Descriptive statistics were performed using t-tests and chi-square tests.  The data was also analyzed using a multivariate logistic regression with discharge status as the outcome variable.

Results:
During the study period 945 patients were transported by helicopter. Survivors were younger (42  + 16 years vs  51 + 22 years, p<0.001), had a higher TRISS (0.921  + 0.17 vs 0.5  + 0.33, p<0.001), and a GCS ≥ 12 (0.78 vs 0.32, p<0.001).  There was no difference in time from helicopter dispatch to hospital arrival (53 + 22 minutes vs 49 + 20 minutes, p =0.08) in these groups.  The results of the multivariate logistic regression indicate that mechanism of injury has no significant effect on patient discharge status.  Age was found to significantly increase the likelihood of mortality, while TRISS and mild GCS was found to have a significant decrease in the likelihood of mortality, when controlled for other characteristics.

Conclusion:
When controlling for age, gender, TRISS, year of injury, time of hospital arrival (day shift vs night shift), and GCS, penetrating trauma did not impact risk of death.  It is safe to fly penetrating trauma in a rural state.  Further work needs to be done to determine risk factors of mortality as related to mechanism of injury during helicopter transport.

49.13 The Aftermath of Firearm Injury: A National Survey of Current Management of Retained Bullets

Posted on January 26, 2017

R. N. Smith1, S. Smith1, S. Jacoby1, S. Johnson1, N. Martin1, M. J. Seamon1  1University Of Pennsylvania,Traumatology, Surgical Critical Care And Emergency General Surgery,Philadelphia, PA, USA

Introduction:  Retained bullets are common after the 70,000 firearm injuries that occur in the United States annually, yet their prevalence, impact on patient recovery, and ideal management strategy remain poorly understood.  We sought to determine the practice patterns of US surgeons regarding their decision-making and management of retained bullets.

Methods: Surgeon members of a large, national trauma society were surveyed using an anonymous, web-based survey from April to May 2016.  Data were collected on the demographic, institutional and professional background of respondents, along with current bullet removal practice patterns and psychological and procedural factors linked to bullet removal practices.  These data were analyzed descriptively using STATA 14.

Results: Four hundred seventy-two surveys were returned (27.6% response rate) of which 45 (9.5%) with incomplete data were excluded.  Of the final study sample of 427 surveys, the majority of respondents were male (n=327, 76.6%), and practicing Trauma Surgery (n=421, 98.6%) in urban (n=405, 94.8%), academic (n=377, 88.3%), Level I (n=311, 72.8%) trauma centers without a retained bullet management policy or guideline at their institution (n=365, 85%).  Although 38% of respondents stated that their patients requested bullet removal either “always” or “almost always”, only 1% of surgeons performed bulletectomies either “always” or “almost always.” Conversely, only 3% of surveyed surgeons reported that their patients requested retained bullet removal either “almost never” or “never”, yet, 48% of surgeons reported that they remove bullets either “almost never” or “never” (Figure). Respondents identified potential pain relief (n=376, 88.1%) and superficial location (n=304, 71.2%) as the factors most influential to their bullet removal decision, but surgeons seldom considered the potential psychological impact (PTSD n=17, 4.0%; stress n=22, 5.1%; anxiety n=55, 12.9%) that retained bullets may have on their patients. 

Conclusion: Despite frequent patient requests, our results suggest that most surgeons do not routinely remove retained bullets, nor do they consider the psychological impact of retained bullets when determining management strategies.  Consideration of patient wishes along with the physiologic and the psychological impact of retained bullets is warranted.

49.12 Geriatric Fracture Patterns and Risk Factors after Falls in the United States

Posted on January 26, 2017

D. Ang1,3,4, H. Liu1, M. Ziglar2, A. Garcia1,3,4, J. Hagan1,3,4, J. Farrah1,3,4, J. Clark1,3,4, J. Hurst3  1Ocala Health,Surgery,Ocala, FL, USA 2HCA,Nashville, TENNESSEE, USA 3University Of South Florida,Surgery,Tampa, FL, USA 4University Of Central Florida,Medicine,Orlando, FL, USA

Introduction: Falls are a leading cause of morbidity and mortality among the geriatric population. The purpose of this study is to investigate the epidemiology of fractures after falls among geriatric patients without trauma brain or spinal cord injury.

Methods: This is a retrospective cohort study using CMS data from 2011 to 2013 of all patients > 64 who fell. Patients with traumatic brain or spinal cord injuries were excluded. Both univariate and multivariate regression methods were used to compare the most common fracture types to those without these fractures. Subset analyses examined stratification by age and injury type. The multivariate regression adjusted for age, gender, injury severity (ICISS), comorbidity index, and race. 

Results:A total of 790,591 patients met study criteria and were included in the study. Of all patients who fell, rib fractures were the most common fracture pattern 8.5%), followed by humerus (7.3%) and pubic rami fractures (5.9%).  Patients over the age of 84 were more likely to have hip and facial fractures compared to other age cohorts. After the age of 75, the prevalence of falling was higher but did not change from one decade to the next (75-84 vs. >84).  Femoral shaft and hip fractures had the strongest association with mortality even after adjustment aOR 1.42 (95% CI 1.20, 1.69) and aOR 1.31 (95% CI 1.23, 1.40).

Conclusion: Fracture patterns and risks of adverse outcomes are unique to decade of life.  Ground level falls resulting in hip and femur fractures provides an opportunity for intervention.

 

49.11 Detection of Blunt Bowel and Mesenteric Injury Using Multidetector CT – Are We Getting Better?

Posted on January 26, 2017

R. Tayim1, E. Szymanski1, A. Gans1, A. Ekeh1  1Wright State University,Surgery,Dayton, OH, USA

Introduction:
The accurate detection of Blunt Bowel and Mesenteric Injuries (BBMI) remains a challenge, resulting in occasional delayed diagnosis.  CT imaging is the standard diagnostic modality used for the detection of BBMI. In many of the prior BBMI studies addressing missed injuries, lower resolution scanners were utilized. We sought to assess if our ability to diagnose BBMI and consequential missed injuries has improved with higher resolution CT.  

Methods:

All patients with small and large intestinal injuries as well as mesenteric injuries arising from blunt mechanisms, that were recognized in the operating room between January 2007 and January 2015, were identified utilizing the trauma registry at our ACS verified Level 1 Trauma Center. A 16-slice,multidetector, CT scanner was used exclusively during this time period. Patients under the age of 18, rectal injuries and simple serosal tears were excluded.

Results:
There were 116 patients identified with BBMI. Of these, 42 patients (36.2%) went directly to the Operating Room without CT imaging. Of the 74 patients who had CT imaging, definitive evidence ofBBMI was observed in 38 patients (51.4%) and evidence strongly indicating possible BBMI was seen in 31 patients (41.9%) – totalling 69 patients (93.2%). Evidence of BBMI on CT included free fluid without solid organ injury (40.6%), active mesenteric hemorrhage (24.6%), free intraperitoneal gas (20.3%), other mesenteric injury (18.9%), bowel swelling(14.5%), bowel hematoma (11.6%) and occult bowel injury (5.8%). 14 patients (18.9%) had delayed recognition of BBMI.

Conclusion:
The accurate diagnosis of BBMI remains a conundrum even in the era of higher resolution CT imaging. While the detection rate appears to have improved compared with prior studies, there is still a high rate of missed injuries. Free fluid without solid organ injuries continues to be the most prevalent finding. The search for the optimal diagnostic modality for BBMI continues.

49.10 End Stage Renal Disease is Associated with Increased Mortality in Perforated Gastroduodenal Ulcers

Posted on January 26, 2017

D. J. Gross1, P. J. Chung1, M. C. Smith1, V. Roudnitsky2, A. E. Alfonso1, G. Sugiyama1  1SUNY Downstate Medical Center,Department Of Surgery,Brooklyn, NY, USA 2Kings County Hospital Center,Brooklyn, NY, USA

Introduction:  Despite numerous advances in medical and surgical therapy, perforated gastroduodenal ulcers carry a high mortality rate. Patients with end stage renal disease (ESRD) represent a growing subset of surgical candidates, given their increasing life expectancy and prevalence in the general population. Furthermore, ESRD has been shown to be an independent predictor of morbidity and mortality in other emergency and elective operations. Using a large national database, we examined outcomes and risk factors for patients presenting with perforated gastroduodenal ulcers undergoing omentopexy.

Methods:  Data was obtained from the Nationwide Inpatient Sample (NIS) from 2005 – 2012. We identified patients that had duodenal and gastroduodenal ulcers with perforation (532.10, 532.20, 532.50, 532.60, 533.10, 533.20, 533.50, 533.60) that underwent omentopexy (44.42, 54.74). We included only adults (≥18 years) and non-elective cases. We excluded patients that had diagnoses of gastric cancer (151), patients with acute kidney injury (584.5, 584.6, 584.7, 584.8, 584.9), those undergoing peritoneal dialysis (V56.2, V56.8, 54.98, 585.9), and patients with missing gender and race information. We identified patients with a diagnosis of end stage renal disease (585.6) and computed the Elixhauser-Van Walraven score to assess global comorbidity status. We then performed multiple imputation for remaining missing data. Multivariable logistic regression was performed using inpatient mortality as our primary outcome while adjusting for demographics, comorbidity status, hospital size, urban vs rural status, and geographical location, weekend status, and month of year, as well as ESRD status.

Results:  A total of 6,521 patients were identified. Median age was 59.0 years. The majority were male (55.56%). There were 79 (1.21%) patients with ESRD, and 367 (5.63%) patients died during the same admission. Multivariable logistic regression showed that age (OR 2.71 [1.98-3.69 95% CI], p<0.0001), Elixhauser-Van Walraven score (OR 2.69 [2.37-3.05 95% CI], p<0.0001), and ESRD status (OR 3.88 [2.21-6.83 95% CI], p<0.0001) were independent risk factors for mortality. However, female gender (OR 0.77 [0.61-0.98 95% CI], p=0.0305), and obtaining care in the Midwest compared to the South, were independent predictors of decreased mortality (OR 0.58 [0.40-0.84 95% CI], p=0.0064).

Conclusion:  In this large observational study, ESRD was strongly associated with mortality in patients undergoing omentopexy for perforated gastroduodenal ulcers. These results highlight the observation that patients with ESRD are an especially vulnerable population and require extra consideration and careful preoperative planning. Future studies are necessary to identify mitigating factors in these patients, and identify methods to help improve survival.

49.09 The Golden Hour: When Does the Clock Stop? Emergency Department Length of Stay in Critical Trauma.

Posted on January 26, 2017

A. Siletz1, H. Cryer1, A. Cheaito1  1University Of California – Los Angeles,General Surgery,Los Angeles, CA, USA

Background: Despite advances in critical care medicine and surgical interventions the prognosis of peritonitis and intraabdominal sepsis remains poor. Many scoring systems have evolved to evaluate patients for surgical or medical interventions; However, none have looked at the time it takes to initiate the intervention; The purpose of this study is assess if time for aggressive intervention impacts outcome for this patient population.

Method: Retrospective chart review was performed for patients that required surgical intervention for intra-abdominal sepsis during a two year period. Demographic data including sex, age, and presenting disease was collected. Time of antibiotics administration was also noted; APACHE scores were extrapolated on these patients. Time the disease started (Ts), time the diagnosis was made (Td), and time of surgical intervention (Ti) were recorded based on careful chart review. Outcome measures included mortality, multi organ failure, ICU stay, and hospital stay.

Results: One hundred thirty eight patients were operated on for intra-abdominal sepsis from 2011-2013. Overall mortality for patients who required intervention was 32%; ICU stay and total hospital stay were 9±2 days and 21 ±3 days respectively. Accounting for APACHE score mortality was different among patients with Ti-Td > or <150 minutes (48.7% vs. 22%); ICU stay also differed among the same group (14 vs. 6 days).  Ti-Ts > 2 days was also associated with longer hospital stay. Multivariate analysis showed that APACHE score (p<0.01), administration of antibiotic (p<0.01), and Ti-Td <150 minutes (p<0.01) independtly predicted survival and ICU stay.

Conclusion: Intra-abdominal sepsis is a time related and dynamic process. As times passes patient physiology, and ultimately prognosis changes. Among patients with intra-abdominal source time from diagnosis to time of intervention is critical for survival and outcome. Time of administering antibiotics is also important in predicting outcome. Better triaging of patients requiring surgical intervention is needed.

49.08 Self-Inflicted Penetrating Injuries: Challenges To Definitive Psychiatric Care

Posted on January 26, 2017

E. Wagreich1, S. Armen1, J. Chandler1, R. Staszak1, K. Fitzgerald1, S. Allen1  1Penn State Hershey Medical Center,Hershey, PA, USA

Introduction: Suicide represents over 60% of all violent deaths annually, with a significant number of attempts being unsuccessful. The cost of self-inflicted violent injury related to suicide attempts is not well studied to know the impact these injuries have on the modern healthcare system. We hypothesized that self-inflicted injuries from failed suicide attempts represent a unique demographic pattern with a significant burden on the current healthcare system as evidenced by longer hospital stays.

Methods: The institutional trauma registry from an academic level 1 trauma center was queried over a 5-year period. Institutional Review Board approval was obtained prior to initiation of the study. Those patients (>18 years of age) who sustained self-inflicted (SI) penetrating injuries to the head, chest and abdomen were included in the study and matched by injury pattern and injury severity score (ISS) to a separate cohort of subjects who sustained penetrating injuries from non-self inflicted (NSI) violent injury. Variables studied included age, gender, race, ISS, whether a psychiatric consult was obtained, hospital length of stay (LOS) and discharge destination. 

Results: Those who suffered SI (n=120) wounds were significantly older (46.0 years) than those from NSI (n=200) injuries (mean 32.5 years), P<0.001. Nearly 85% of those injured were male in both groups. There were significant racial differences among the SI and NSI groups (SI: 10% black, 84% Caucasian, 6% other vs. NSI: 47.4% black, 37.2% Caucasian and 15.4% other, P<0.05). The mechanisms of injury were evenly split between gunshot wounds (GSW) (51%) vs. stab wounds (SW) (49%), P=ns. Female SI injuries were most often due to stab wounds (64.7%) while men sustained more firearm injuries (57.3%) in the SI group, although this difference was not statistically significant. Mortality was significantly higher in those with SI wounds (30.8%) vs. those with NSI injuries (9.5%), P<0.001; with the majority of those deaths within the first 24 hours.  Within the SI group, those discharged home had a significantly longer stay (12.1 days) than those discharged to another facility (5.8 days), P = 0.02; with the vast majority discharged to a psychiatric facility (65.1%). Discharge to psychiatric facilities was often delayed or prevented altogether due to management of open wounds, presence of surgical staples and surgical drains. There were no differences in overall LOS between SI and NSI groups (8.1 days vs. 8.2 days, P=ns).

Conclusion:SI injuries for those who survive suicide attempts represent a unique challenge to the healthcare system due to relatively long hospital stays. Inpatient psychiatric care may be delayed or even prevented due to placement difficulties from the presence of surgical drains or closure techniques. These patients may no longer meet criteria required for inpatient psychiatric care thus not allowing them to receive the definitive psychiatric care they require. Techniques as simple as wound closure with sutures rather than staples and even delayed primary closure of open wounds may prevent unnecessary delays to definitive psychiatric care. Further inquiry of institutional practices across hospitals, and encouragement of communication between psychiatric and non-psychiatric units may yield valuable information by which to guide future practice.

 

49.07 Self-Inflicted Penetrating Neck Injuries: a Necessary Trip to the Operating Room

Posted on January 26, 2017

T. Swartz1, A. Azim1, K. Ibraheem1, A. Tang1, T. O’keeffe1, G. Vercruysse1, N. Kulvatunyou1, B. Joseph1  1University Of Arizona,Trauma-Department Of Surgery,Tucson, AZ, USA

Introduction:
Management of penetrating neck injuries remains a challenge to acute care surgeons. Self-inflicted injuries to the neck are a special entity that is extremely complex and difficult to manage, however literature is scarce about the seriousness and implications of these injuries. We sought to compare outcomes in patients with and without self-inflicted penetrating neck injuries. 

Methods:
8-year retrospective analysis of all adult trauma patients with penetrating neck injury at a Level I trauma center. We included all patients in whom the platysma was violated. Patients were classified into two groups; self-inflicted and non-self-inflicted. Age, mechanism of injury, zone of injury, hard and soft signs, computed tomography angiography (CTA) use and operative findings were analyzed. Our outcomes were need for operative intervention and therapeutic neck exploration (defined by repair of vascular or aero digestive injuries). Univariate and multivariate regression analyses were performed. We controlled for patient and injury-related risk factors, zone of injury and hard signs.

Results:
A total of 337 patients with penetrating neck injuries met the inclusion criteria. 60 patients (17.8%) had self-inflicted injuries. 97.6% had stab/slash wounds. Patients with self-inflicted injuries had less CTA (26.7% vs. 78.0%, p<0.001), more jugular venous injuries (35.0% vs. 10.1%, p<0.001) and more laryngeal injuries (13.3% vs. 2.5%, p=0.002) when compared to patients without self-inflicted injuries. More patients in the self-inflicted group went to the operating room (78.3% vs. 33.2%, p<0.001) and had therapeutic neck exploration (72.3% vs. 54.3%, p=0.031) Table. There was no difference in the incidence of arterial, esophageal, tracheal injuries or mortality. Sustaining self-inflicted injuries was an independent predictor of need for operative intervention (OR=5.1, 95% CI 2.2-12.1, p<0.001) and therapeutic neck exploration (OR=2.8, 95% CI 1.2-6.6, p=0.018).

Conclusion:
Patients sustaining self-inflicted penetrating neck injuries have higher rates of operative intervention and therapeutic neck exploration. As we move towards an era of CTA and conservative management, a low threshold for operative intervention is advised in the approach to these challenging patients. 
 

49.06 Risk and Consequences of Acute Kidney Injury in Emergency General Surgery

Posted on January 26, 2017

A. Briggs1, J. M. Havens1,2, A. Salim1,2, K. B. Christopher3  1Brigham And Women’s Hospital,Division Of Trauma, Burn, And Surgical Critical Care,Boston, MA, USA 2Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 3Brigham And Women’s Hospital,The Nathan E. Hellman Memorial Laboratory, Renal Division,Boston, MA, USA

Introduction:   Patients undergoing Emergency General Surgery (EGS) have increased risk of complications and death when compared to those undergoing non-emergency general surgery. Acute Kidney Injury (AKI) is a known risk factor for death in critically ill patients. The risk of acute kidney injury in patients undergoing EGS, along with associated outcomes, is unknown.

Methods: We performed a two center observational study of patients treated in medical and surgical intensive care units in Boston between 1997 and 2012.  Emergency General Surgery (EGS) was defined by the seven procedures previously shown to account for the majority of the EGS specific operations, complications and mortality in the United States, occurring within 48 hours of ICU admission. The primary end point of AKI was defined as a Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease (RIFLE) criteria classification of Injury or Failure occurring up to 5 days after EGS.  The designation of ‘AKI requiring renal replacement’ was defined as AKI with subsequent need for renal replacement therapy.  We excluded patients with End Stage Renal Disease and those with advanced Chronic Kidney Disease (stages 4 and 5). Adjusted odds ratios were estimated by multi-variable logistic regression models with inclusion of covariate terms thought to plausibly associate with both EGS and AKI.  Estimates were adjusted for age, race, Deyo-Charlson comorbidity index, Chronic Kidney Disease stage, sepsis, patient type (medical vs surgical) and hospital.

Results:  We studied 59,604 patients who received critical care.  The study cohort was 58.8% male, 77.5% white, 46.6% surgical, had a mean age of 57.1 years, and 1,758 (2.9%) of these patients underwent EGS within 48 hours of ICU admission.  3,554 (6.0%) of the cohort patients developed AKI and 757 patients (1.3%) developed severe AKI. For the entire cohort, the 90-day all cause mortality was 13.7%. The adjusted odds of AKI for patients with EGS was 1.65 (95% CI 1.40-1.95; P< 0.001) relative to patients without EGS.  The adjusted odds of AKI requiring renal replacement for patients with EGS was 1.83 (95% CI 1.37-2.46; P< 0.001) relative to patients without EGS.  Patients who undergo EGS (n=1,758) have an increase in the adjusted odds of 90-day mortality depending on the severity of AKI, with an AKI OR of 3.04 (95%CI 2.15-4.30, p<0.001), and an OR for AKI requiring renal replacement of 4.72 (95%CI 2.67-8.33, p<0.001) relative to the absence of AKI.

Conclusions: ICU patients who undergo EGS have a significant increase in the risk of AKI.  The development of AKI in EGS patients is strongly predictive of increased 90 day mortality.  The risk and consequences of AKI should be considered when counseling EGS patients prior to operative intervention.

 

49.05 It’s Never Who You Think: Outcomes of Self-Inflicted Gunshot Wounds

Posted on January 26, 2017

M. C. Smith1,2, P. J. Chung1,2, V. Roudnitsky1,2, G. Sugiyama1  1SUNY Downstate Medical Center,Surgery,Brooklyn, NY, USA 2Kings County Hospital Center,Surgery,Brooklyn, NY, USA

Introduction:  Suicide is a large public health crisis in the United States, with over 400,000 people treated in emergency departments in 2013 with self-inflicted injuries, and it was responsible for over 41,000 deaths. This makes it the tenth leading cause of death in the country, and the second leading cause of death in the 15 to 35-year-old age group. Using a large, nationwide database, we sought to examine the outcomes of patients who present with self-inflicted gunshot wounds, and to determine risk factors for mortality.

Methods:  Data was collected from the Nationwide Inpatient Sample (NIS) from 2005-2012 using ICD 9 E-codes for self-inflicted gunshot wounds (E955, E955.0-E955.4). Patients age <18 years and with missing gender data were excluded. We then calculated the Trauma Mortality Prediction Model (TMPM) scores for each patient to provide an estimated assessment of trauma severity. We also calculated the Elixhauser-Van Walraven score to assess comorbidity status of each patient. We then performed multiple imputation for missing data. Using inpatient mortality as our primary outcome, we then performed multivariable logistic regression to adjust for age, gender, race, insurance status, income status, elective procedure, hospital size, rural vs urban hospital, geographic region, private vs government facility, TMPM score, Elixhauser-Van Walraven score, psychiatric history, and history of depression.

Results: A total of 3,349 patients sustained self-inflicted gunshot wounds. The majority of these patients were male (80.56%) and White (80.53%). The mortality rate was 33.17%. Variables associated with mortality on multivariable logistic regression analysis included age (OR 1.93 [1.61 – 2.32 95% CI], p <0.0001), lack of medical insurance (OR 1.49 [1.12 – 1.98 95% CI], p =0.0185), and TMPM score (OR 6.10 [5.26 – 7.07 95% CI], p <0.0001). Variables associated with decreased risk of mortality included female gender (OR 0.63 [0.47 – 0.84 95% CI], p=0.0014), admission to medium vs large hospital (OR 0.65 [0.50 – 0.86 95% CI], p=0.0057), admission to a rural vs urban teaching hospital (OR 0.27 [0.14 – 0.53 95% CI], p=0.0006), history of psychosis (OR 0.09 [0.06 – 0.13 95% CI], p <0.0001), and history of depression (OR 0.32 [0.25 – 0.42 95% CI], p <0.0001).

Conclusion: In this large, retrospective analysis of the NIS database, we found that among patients with self-inflicted gunshot wounds, age, lack of medical insurance, and increased TMPM score were associated with significantly greater risk of mortality. Factors which decreased mortality were female gender, admission to medium sized hospitals or those in rural areas, and history of psychosis or depression. Further studies should examine these cases on a prospective basis to help mitigate these risks, as well as work towards prevention.

 

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