60.12 A Body Of Evidence: Barriers To Family Viewing After Death By Gun Violence

Posted on January 31, 2019

D. Reny1, S. Root1, K. Chreiman1, R. Browning1, C. Sims1  1University Of Pennsylvania,Trauma, Surgical Critical Care And Emergency Surgery,Philadelphia, PA, USA

Introduction: Gun violence remains a staggering public healthcare crisis in the United States with over 11,000 deaths annually. Although viewing of the body after violent crime is an essential component of the grieving process, this practice is not universally practiced in the trauma bay and may not be supported by nursing. This study investigates how trauma nurses perceive bereavement and the potential barriers to family viewing following death by gun violence.

Methods: A survey designed to assess demographics, current practices, knowledge of policies, and personal beliefs regarding family viewing after violent crime was sent electronically to the 3,000 members of the Society of Trauma Nurses. In addition to demographic questions, participants were asked to rank the importance of 14 barriers to viewing on a scale of 1 (least important) to 6 (most important). Descriptive analysis and perception of barriers between those who did and did not permit viewing were compared using Mann Whitney tests. *p<00.5=significant.

Results: Of the 232 participants, the majority were white, female nurses (86%) between the ages of 30 and 60 years who worked at a Level 1 or 2 trauma center (83%) in an urban or suburban setting (58% and 30%). Only 14% had a written hospital policy surrounding viewing; and the majority did not know if the police (64%) or medical examiner (69%) had written policies. Despite lack of clear guidelines, 68% reported that viewing did routinely occur, but only 36.7% permitted touching. Race of the victim did not correlate with viewing. Primary barriers included legal concerns, safety, and a perception that the trauma bay was not designed for viewing. These were ranked significantly higher by nurses who did not permit viewing.

Conclusion:  Although family viewing after gun violence frequently occurs in the trauma bay, there are significant legal concerns despite the lack of formal policies. Collaboration with police and medical examiners could mitigate these fears while promoting a safe and more family-centered experience. 

 

 

60.11 Thromboembolic Prophylaxis in Nonoperatively Managed Patients with Blunt Spleen Injuries

Posted on January 31, 2019

J. Owens1,2, A. A. Fokin2, J. Wycech2,3, M. Crawford2, A. Tymchak1,2,3, M. Gomez3, I. Puente1,2,3,4  1Florida Atlantic University,College Of Medicine,Boca Raton, FL, USA 2Delray Medical Center,Trauma Services,Delray Beach, FL, USA 3Broward Health Medical Center,Trauma Services,Fort Lauderdale, FL, USA 4Florida International University,College Of Medicine,Miami, FL, USA

Introduction:
Nonoperative management (NOM) is the standard of care for blunt splenic injuries (BSI) in hemodynamically stable patients. Low-Molecular-Weight Heparin (LMWH) has been shown to be effective in prevention of thromboembolic complications in trauma patients. Reports are scarce regarding safety of early administration of LMWH in patients with BSI. The goal of this study was to investigate safety of early LMWH use in NOM patients with BSI.

Methods:
This IRB approved retrospective cohort study included 135 adult patients with BSI who were delivered to a level 1 trauma center over a 6 year period (2012 to 2017) with attempted NOM. Patients were divided into three groups: Early LMWH (n=12) who received LMWH within 72 hours of admission; Late LMWH (n=21) who received LMWH after 72 hours; and No LMWH (n=102) who did not receive LMWH or received it only after failed NOM and laparotomy. Injury Severity Score (ISS), Spleen organ injury scale (OIS) grade, rate of hemoperitoneum, units of blood transfused, occurrence of Deep Venous Thrombosis/Pulmonary Embolism (DVT/PE) and mortality were compared between the groups. Failure of NOM (FNOM) was defined as undergoing laparotomy after initially attempting NOM. To compare variability between the three groups one way ANOVA was used, followed by Tukey’s post-hoc comparison within the groups. Categorical variables were analyzed using the Kurskall Wallis test.

Results:

Mean ISS was significantly higher in the Late LMWH group compared to the No LMWH group, (19.4 vs 13.5; p=0.02). Mean spleen OIS grade was not different between the three groups (1.7 vs 2.5 vs 2.4; p=0.1). The percent of high grade spleen injuries (OIS 3+) was not statistically different between three groups (16.7% vs 47.6% vs 46.1%; p=0.1). In the Early LMWH group 7 patients (58.3%) had BSI injuries with other abdominal trauma, in the Late LMWH it was 15 patients (71.4%), and in No LMWH group it was 11 patients (10.8%).

Percent of patients with hemoperitoneum diagnosed on computed tomography CT scan was similar in the three groups (49.2% vs 48.3% vs 48.3%; p=0.9). In 135 patients, 17 (12.6%) had FNOM, and all but two failures occurred either before LMWH administration or in patients who never received LMWH. Mean units of blood transfused during hospital stay were statistically different between the three groups (1.2 vs 3.0 vs 1.6 units; p<0.001), with more units transfused in Late LMWH than in Early LMWH (p=0.005), and than in No LMWH (p<0.001). DVT/PE occurred in 4 patients (1 in Early and No LMWH and in 2 patients in Late LMWH) and was not statistically different between the groups (p=0.06). There were no mortalities in any of the groups that received LMWH.

Conclusion:
In patients undergoing NOM for blunt splenic injuries, early administration of LMWH did not increase the failure rate of NOM, units of blood transfused, or mortality and therefore, is safe and recommended. 

60.10 The Effects of Combined Solid Organ Injuries on Management of Blunt Kidney Injuries

Posted on January 31, 2019

J. Wycech1,2, J. Saluck1,3, A. Tymchak1,3, M. Crawford1,2, M. Gomez2, I. Puente1,2,3,4, A. A. Fokin1  1Delray Medical Center,Trauma Services,Delray Beach, FL, USA 2Broward Health Medical Center,Trauma Services,Fort Lauderdale, FL, USA 3Florida Atlantic University,College Of Medicine,Boca Raton, FL, USA 4Florida International University,College Of Medicine,Miami, FL, USA

Introduction:
In hemodynamically stable patients, nonoperative management (NOM) of blunt kidney injuries (BKI) has become the standard of care. However, the efficacy of NOM in patients with BKI combined with other solid organ injuries (SOI) remains unclear. The aim of this study was to assess the efficacy of NOM in isolated BKI as compared to combined BKI.

Methods:
This IRB approved retrospective cohort study included 74 adult patients, admitted to a level 1 trauma center between 2012 and 2017 with a kidney injury confirmed by computed tomography scan. 49 patients had an isolated BKI (Group I) and 25 patients had BKI combined with additional SOI (Group II). The most common additional SOI in Group II were equally distributed between the spleen and liver (56.0% each), followed by pancreas and adrenal glands (8.0% each). Injury Severity Score (ISS), mechanism of injury (MOI), kidney Organ Injury Scale (KOIS) grade, packed red blood cells transfused within 24 hours of admission (PRBC24), rates of hemoperitoneum, angiography, embolization, Intensive Care Unit length of stay (ICULOS), hospital LOS (HLOS) and mortality were compared.

Results:

Group I compared to Group II had statistically lower mean ISS (17.5 vs 24.0; p=0.02), also having less high impact MOI (61.2% vs 92.0%; p=0.02). Mean KOIS for both groups was similar, grade 2.2 for Group I and 2.3 for Group II (p=0.5). NOM was attempted in 98.0% of patients in Group I and in 80.0% of Group II (p=0.007). Attempted NOM was successful in 100% of Group I and in 85.0% of Group II (p=0.01). Of the 3 patients that failed NOM in Group II, 2 patients failed due to a liver injury and 1 due to a spleen injury. In Group I, 1 patient underwent an early exploratory laparotomy and surgical intervention on the kidney. Early exploratory laparotomy was performed less often in Group I compared to Group II (2.0% vs 20.0%; p<0.001), with 40.0% undergoing surgery of the kidney and 60.0% surgery of other organs only.

Rate of PRBC24 was statistically lower in Group I than in Group II (16.0% vs 24.0%; p=0.004). Hemoperitoneum was detected statistically less often in Group I than in Group II (45.0% vs 72.0%; p=0.003). Angiography was performed statistically less often in Group I than in Group II (8.2% vs 36.0%; p=0.003), as was embolization (0.0% vs 12.0%; p=0.01). ICULOS was similar for the two groups (6.5 vs 6.7 days, p=0.3), however HLOS was statistically shorter in Group I than in Group II (8.2 vs 10.9 days; p=0.04). Mortality rate was not statistically different between two groups (12.2% vs 8.0%; p=0.6) and none of it was attributed to the kidney injury.

Conclusion:
In Group I, attempted NOM was always successful, regardless of severity of kidney injury. However, in Group II, attempted NOM was statistically less successful, due to the other organ injuries. In patients with combined BKI, the consideration of NOM should not be based on the severity of the kidney injury but instead should be based on the severity of other SOI.

60.09 Sternotomy for Hemorrhage Control in Trauma

Posted on January 31, 2019

L. Al-Khouja1, A. Grigorian1, S. Schubl1, K. Galvin1, A. Kong1, M. Lekawa1, T. Chin1, J. Nahmias1  1University Of California – Irvine,Department Of Trauma And Critical Care Surgery,Orange, CA, USA

Introduction: Thoracic trauma accounts for 20-25% of trauma deaths. Little is known about the injuries, mechanisms, and outcomes in trauma patients undergoing sternotomy for hemorrhage control. The purpose of this study is to perform a descriptive analysis of trauma patients undergoing sternotomy for hemorrhage control and identify which thoracic injuries and other factors are predictors of mortality. We hypothesize blunt trauma is associated with higher risk of death compared to penetrating trauma within this population.

Methods: The Trauma Quality Improvement Program (2010-2016) database was queried for patients undergoing sternotomy for hemorrhage control within 24-hours of admission. Patients with blunt and penetrating trauma were compared using chi-square and Mann-Whitney U test. A multivariable logistic regression model was used to determine risk of mortality.

Results: Of the 584 patients undergoing sternotomy for hemorrhage control, 322 (55.1%) were involved in penetrating trauma, 69 (11.8%) in blunt trauma and 193 (33.3%) involved in “other/unknown” mechanism. The median injury severity score (ISS) was 25.0 and the most common known mechanism was a stab wound (49.9%) followed by gunshot wound (19.2%). The overall time to hemorrhage control was 52.8 minutes and was longer in those with blunt compared to penetrating trauma (84.6 vs. 49.8 minutes, p <0.001). Open-cardiac injury (26.4%) and hemothorax (23.5%) were the most common thoracic injuries. The most common procedures involved cardiac repair (44.7%) followed by lung repair (15.8%). The overall mortality rate was 18.2% and was higher in patients with blunt compared to penetrating trauma (29.0% vs. 12.7%, p<0.001). However, after adjusting for covariates there was no difference in risk of mortality between blunt and penetrating trauma (p=0.49). We did not find any independent predictors of mortality in patients with blunt trauma. The strongest independent predictor of mortality in patients with penetrating trauma was ISS≥25 (OR=6.24, CI=2.04-19.11, p=0.001).

Conclusion: Trauma patients who undergo sternotomy for bleeding often achieve hemorrhage control in less than one hour. Nearly half the patients present after a stab wound and require cardiac repair. Trauma patients requiring sternotomy for hemorrhage control after blunt trauma had a higher mortality rate, compared to those involved in penetrating trauma. However, after adjusting for known predictors of mortality in trauma, there was no difference in risk of mortality despite nearly double the time to hemorrhage control in patients presenting after blunt trauma.

60.08 Use of Indirect Calorimetry in a Cohort of Patients with Enterocutaneous Fistula

Posted on January 31, 2019

S. Bou Zein Eddine1, A. Kamien1, Z. Yin1, C. Trevino1, R. Fritzshall1, A. Stachowiak1, A. Szabo1, J. S. Juern1, J. R. Peschman1, M. A. De Moya1, P. A. Codner1  1Medical College Of Wisconsin,Surgery/ Trauma And Acute Care Surgery,Milwaukee, WI, USA

Introduction:
Nutrition is key in Enterocutaneous Fistula (ECF) management.  Predictive Equations (PE) and Indirect Calorimetry (IC) are used to calculate nutritional needs but do not correlate well to each other. We hypothesize that even though IC is the gold standard, it is difficult to implement logistically and has a weak concordance with PE.

Methods:
The study included a retrospective cohort of all patients aged ≥18 with ECF admitted between January 2011 and April 2016 and a prospective cohort admitted between April 2016 and February 2017. Demographics, comorbidities, surgeries, and fistula output were determined.  A dietitian determined nutritional therapy and caloric requirements at initial consult, hospital discharge, and outpatient using the Mifflin St Jeor (MSJ) equation. The baseline Resting Energy Expenditure from PE (REEPE) and REE from IC (REEIC) was evaluated for both cohorts, the difference was calculated, and the concordance were plotted in a Bland-Altman plot.

Results:
A total of 33 patients were included. In the prospective arm (n=12) mean age was 54.3 (±18.9) and 66.7% were male. In the retrospective arm (n=21), mean age was 53.7 (±18.3) and 66.7% were male. The median equation difference of REEPE from REEIC, was 71.0 kcal/24 h (IQR, -203.0 – 173.5) in the prospective arm and 123.0 kcal/24 h (IQR, -97.0 – 177.0) in the retrospective arm. The concordance correlation coefficient between REEPE and REEIC was 0.541 (95%CI, 0.213, 0.785). The Bland-Altman plot for the concordance between the REEIC and REEPE (Figure 1) had wide limits of agreement.

Conclusion:
Assessing accurate nutritional requirements remains an increasingly challenging clinical problem. There’s a weak to moderate agreement between REEPE and REEIC and the standardization for IC measurements is logistically difficult to perform.
 

60.07 Is Hospital-Associated Venous Thromboembolism Preventable in Trauma Patients?

Posted on January 31, 2019

K. L. Florecki1, B. Lau1, O. Owodunni1, J. Sakran1, M. Streiff1, E. Haut1  1The Johns Hopkins University School Of Medicine,Baltimore, MD, USA

Introduction: Venous thromboembolism is a common complication associated with significant morbidity and mortality in the trauma population. We strived  to characterize the true preventability of venous thromboembolism (VTE) in the trauma patient population and the patients who receive “defect-free care” prophylaxis for VTE. 

Methods:  Retrospective review of trauma patients with hospital-acquired VTE (including deep vein thrombosis [DVT] and/or pulmonary embolism [PE]) identified at The Johns Hopkins Hospital from January 2008 – June 2016.  Data on patient risk assessment for VTE, prescription of risk-appropriate VTE prophylaxis and pharmacologic VTE prophylaxis medication administration were extracted from the electronic health record system. Patients were dichotomized into prophylaxis failure vs. defect-free care, defined as receiving all doses of risk-appropriate VTE prophylaxis recommended by our validated, mandatory computerized clinical decision support tool. Prophylaxis failure was divided into prescription failures or dose-administration failures (missed doses).

Results: 92 trauma patients had hospital-acquired VTE. All 92 (100%) were assessed using the VTE risk assessment mandatory computerized clinical decision support tool, however only 75 (81.5%) were prescribed risk-appropriate prophylaxis. Of the 92 patients, 33 (35.9%) received defect free-care. Of the 59 (64.1%) who received suboptimal care, 17 (28.8%) were not prescribed risk-appropriate prophylaxis and 42 (71.2%) missed at least one dose of pharmacologic VTE prophylaxis. 

Conclusion: Our study identifies the need to reevaluate outcome and process measures for VTE prevention after trauma. 33 VTE events occurred in patients who received best-practice defect-free care, showing not all VTE are truly preventable, and should not be included in outcome measures as “potentially preventable events.”  Our findings also identify specific targets and emphasize the importance of ongoing efforts to improve prescription and administration of risk appropriate VTE prophylaxis in trauma centers. 

 

60.06 Trauma Patients with Mangled Lower Extremities Experience a Higher Incidence of VTE

Posted on January 31, 2019

D. Freitas1, E. Warnack1, M. Kim1, C. DiMaggio1, S. Frangos1, M. Klein1, C. Berry1, M. Bukur1  1New York University School Of Medicine,New York, NY, USA

Introduction:
The mangled lower extremity (MLE) is a limb sustaining complex structural injuries (i.e. soft tissue, bone, nerves, and vessels) resulting from a high- energy mechanism. We hypothesized that trauma patients who present with MLE experience a higher rate of deep venous thrombosis (DVT) and pulmonary embolism (PE) when matched with trauma patients of similar injury burden without MLE.

Methods:
Data were abstracted from the Trauma Quality Improvement Program (TQIP) database from 2013- 2016. Characteristics of blunt trauma patients who presented with MLE versus all other patients were compared using Chi-squared, Student’s t-test, or Mann-U Whitney test where appropriate. Propensity score matching, using a 2:1 match of controls versus patients with MLE, was used to compare the occurrence of DVT and PE.

Results:
A total of 1,060 patients presented with MLE from 2013 through 2016. Patients with MLE were younger (median age 42 IQR [28,54] vs. 54 [32,72], p < .001) and were more likely to need immediate operative intervention when compared to other trauma patients (60.5% vs. 11%, p < .001). In controlled models, while patients with MLE had a higher odds of receiving VTE prophylaxis (86% vs. 58.8%, AOR = 3.23, p < .001) and filter placement (6% vs. 1.5%, AOR = 2.81; p < .001), they were over two times more likely to experience DVT (5.4% vs. 1.4%, AOR 2.5, p < .001) or PE (2.3% vs. 0.6%, AOR 2.07, p = .155), although the latter was not statistically significant. In a propensity score model, MLE conferred a significant absolute risk increase of 3.6% for DVT or PE with an odds ratio of 2.43 (7% MLE vs. 3.3% no MLE). Mortality was not significantly lower in MLE patients versus other trauma patients (4.5% vs. 5.5%, p = .157).

Conclusion:
Trauma patients with MLE have a 2.4 times higher odds of having a DVT or PE with an absolute risk increase of 3.6%. Early aggressive prophylactic measures are warranted in this high-risk population.
 

60.05 Nutritional Support Disparities in Trauma ICUs in the US: An Assessment of the AAST TRIPP Database

Posted on January 31, 2019

L. TUNG1, R. Dumas1, D. N. Holena1, M. J. Seamon1, L. J. Kaplan1, A. B. Newcomb2, C. P. Michetti2, N. D. Martin1  1University Of Pennsylvania,Philadelphia, PA, USA 2Inova Fairfax Hospital,Falls Church, VA, USA

Introduction:  Adequate nutritional support during critical illness has been shown to improve outcomes. Timely initiation of any nutrition can be variable by patient population. We hypothesize that all patient types in a trauma-designated ICU would receive a similar onset of nutritional support, and that pressors would not play a role in nutrition.

Methods:  The TRIPP database is a 2-day, multicenter prevalence study of all patients present in a trauma-designated intensive care unit (ICU) on 11/2/17 and 4/10/2018. Patients were stratified as either trauma, general surgery, or medical ICU patients. The presence of any nutritional support was evaluated based on the current ICU length of stay (LOS). Differences in nutritional support over the first 7 days were determined by t-test. Differences in either enteral feeds or parenteral nutrition above or below a total pressor equivalence of norepinephrine (NE) of 0.11mcg/kg/min was determined by chi-square.

Results: 1216 patients from 49 trauma-designated ICUs contributed data. 562 (46.2%) patients were traumatically injured, 458 (37.7%) were general surgery, and 196 (16.1%) were medicine patients. On ICU day 1, 45.7%, 51.1%, 45.5% of trauma, general surgery, and medical ICU patients were receiving nutritional support, respectively. By ICU day 7, this increased to 89.3%, 78.9%, and 80.0%, respectively, with a trend toward statistical significance. There was also no significant difference between the number of patients who were receiving nutrition on NE ≥0.11 mcg/kg/min compared to those on NE ≤0.11mcg/kg/min (p=0.5).

Conclusion: After 7 days of critical illness, a significant percentage of Trauma ICU patients were not receiving nutritional support; further, disparities between ICU populations within trauma-designated ICUs also seemed to exist.  Vasopressors however, were not associated with decreased nutritional support.  Additional research into the etiologies of these findings is warranted.

 

60.04 Comparison Of Urban Off-road Vehicle And Motorcycle Injuries At A Level 1 Trauma Center

Posted on January 31, 2019

C. A. Butts1, R. Gonzalez2, J. P. Gaughan2, J. San Roman2, S. Ross2, J. Porter2, J. P. Hazelton2  1Rutgers-Robert Wood Johnson University Hospital,Acute Care Surgery,New Brunswick, NJ, USA 2Cooper University Hospital,Trauma, Surgical Critical Care, & Acute Care Surgery,Camden, NJ, USA

Introduction:
Recently, there has been an increase in the use of dirt bikes (DB) and all-terrain vehicles (ATV) in urban environments. Our previous work found that crashes involving urban off-road vehicles (UORV), defined as any ATV or DB accident which occurred on paved inner city/suburban/major roadways, resulted in different injury patterns than crashes which occurred in rural environments.  The aim of this study is to compare the injury patterns of patients involved in crashes while riding urban off-road vehicles with motorcycles (MC).

Methods:

A retrospective review (2005-2016) of patients who presented to our urban Level I trauma center as a result of any MC or UORV crash was performed. Patients who presented more than 48 hours from time of accident were excluded. A p<0.05 was considered significant.  

Results:

1556 patients were identified to have an MC or UORV crash resulting in injury [MC: n=1324 (85%); UORV: n=232 (15%)]. Patients involved in UORV accidents were younger (26.2 vs 39.6; p <0.05), less likely to be helmeted (39.6% vs 90.2%; p<0.05), but required fewer emergent trauma bay procedures (28.4% vs. 36.7%; p<0.05) and fewer operative interventions (45.9% vs 54.2%; p <0.05).  Both group of patients had a similar ISS (12.2 vs 12.6; p=0.54) and presenting GCS (13.8 vs 13.5; p=0.46). Interestingly, UORV patients had a lower mortality (0.9% vs 4.7%; p <0.05) when compared to MC crash patients despite injury patterns being similar between both groups.

Conclusion:
Our data demonstrates that UORV riders are younger and less likely to be helmeted, but have a lower mortality rate following a crash, despite having similar injury patterns to motorcyclists.  Even though our data suggests a lower mortality in this patient population, we feel that the fact that fewer than 50% of UORV patients were wearing helmets is unacceptable in this younger patient population.  This data may provide a framework for legislative intervention for helmet laws to be more strictly enforced in this population and facilitate a more aggressive community outreach focusing on increased helmet compliance.

60.03 CSF Cultures in Traumatic Brain Injury: Is It Worth It? A Two-Center Study

Posted on January 31, 2019

N. K. Dhillon1, S. Sahi2, G. Barmparas1, N. T. Linaval1, T. Lin1, S. Lahiri1, C. V. Brown2, E. J. Ley1  1Cedars-Sinai Medical Center,Los Angeles, CA, USA 2Dell Medical School, University of Texas at Austin,Austin, TEXAS, USA

Introduction:  Patients with traumatic brain injury (TBI) frequently develop leukocytosis, fever, and tachycardia which may lead to extensive medical investigations to rule out an infectious process. Cerebral spinal fluid (CSF) is often acquired during this work-up, however the utility of this practice has not been previously studied. We hypothesized that CSF cultures would unlikely yield positive results in patients with TBI.

Methods:  A retrospective review was conducted of all TBI patients admitted to two Level 1 trauma center at an urban, academic medical center from 01/2009 to 12/2016. Data collected included patient demographics, presenting GCS, injury profile, injury severity scores (ISS), regional abbreviated injury scale (AIS), hospital and ICU length of stay (LOS), ventilator days, and culture results. For purposes of the analysis, CSF cultures with Staphylcoccus epidermidis, Staphylococcus aureus, or Candida were considered contaminated and deemed negative.

Results: There were 148 patients who had CSF cultures obtained with a median age of 40 years and 77.7% being male. The majority of patients presented following blunt trauma with median GCS of 6, head AIS of 4, and ISS of 26. These patients had prolonged median ICU and hospital stay at 14 and 22 days, respectively. Seven (4.7%) CSF cultures demonstrated growth. Four (2.7%) were deemed to be contaminants, with two growing Staphylcoccus epidermidis only, one with both Staphylcoccus epidermidis and Staphylococcus aureus, and one with Candida. Three cultures (2.0%) were positive; two had Enterobacter Cloacae and one Klebsiella Pneumoniae. Of note, all three patients with positive cultures also had instrumentation with either an external ventricular drain or a lumbar drain.

Conclusion: Obtaining CSF cultures in TBI patients without instrumentation is of extremely low yield. Other sources of infectious etiologies should be considered in this patient population.

 

60.02 Time to Prothrombin Complex Conctretrate Administration Effect on Intracranial Hemorrhage Outcomes.

Posted on January 31, 2019

L. S. Kuzomunhu1, M. M. Fleming2, R. R. Jean2, K. Y. Pei2  1Yale University School Of Medicine,New Haven, CT, USA 2Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA

Introduction: Prothrombin complex concentrate (PCC) is indicated in patients sustaining traumatic intracranial hemorrhage (ICH) while taking warfarin, but the optimal timing is unknown. This study evaluates the effect of timing to PCC administration on outcomes including intracranial hemorrhage expansion and length of hospital stay.

Methods: We retrospectively reviewed patients presenting with ICH who received PCC at our tertiary care hospital between March 2013 to November 2017. Only patients on warfarin and with repeat computed tomography of head were included. Time to PCC was defined as the time from order entry to patient administration as documented contemporaneously in the electronic health record. Time was stratified as early (≤30 minutes) or late (>30 minutes). Multivariable logistic regression with stepwise selection was used to predict ICH expansion between initial and repeat cross sectional imaging. Linear regression identified predictors for increased hospital and intensive care unit length of stay.

Results: In total, 127 patients with ICH on warfarin were included for analysis. Mean time to PCC administration was 82.3 ± 43.7 minutes. The majority of patients who demonstrated expansion of ICH (31.5% of patients) had admission motor Glasgow Coma Score (GCS) less than 6 (p<0.05), a higher Charlson Comorbidity Index (CCI) (p<0.05) and higher inpatient mortality (p<0.01). On multivariable analysis, only admission motor GCS<6 was independently associated with ICH expansion (OR 3.016, 95% CI 1.158-7.858). Time to PCC (early versus late), admission INR and anticoagulation indication were not associated with ICH expansion. On linear regression admission motor GCS<6 was associated with increased length of ICU stay (β=8.261, SE 2.070, p=0.0001); however no other patient characteristics or PCC administration time was associated with hospital length of stay.

Conclusion: Timing to PCC administration was not associated with ICH expansion or mortality after traumatic ICH. Further multi-institutional studies are needed to evaluate clinical and process measures to streamline PCC administration.

60.01 Axillary Vessel Injuries: What have we Learned From an Analysis of the National Trauma Data Bank

Posted on January 31, 2019

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

Introduction: Axillary vessel injuries remain uncommon even in busy urban trauma centers. Most trauma surgeon possess limited experience with these injuries. The proximity of the surrounding anatomic structures account for a large number of associated injuries and mobidity associated with such injuries.

Methods: The National Trauma Data bank was queried for pre-hospital admission data for axillary vessel injuries. Data extracted included demographics, physiologic conditioins, surgical interventions and Functional Independent Measure Score (FIM). Univariate and stepwise logistic regression analysis were used.

Results: 590 cases were identified from 1,466,887 patients in NTDB from 2001-2005. Incidence = 0.004%. Mean age 33 ±  16, mean RTS 6.8 ±  2.3, mean Glasgow Coma Score 13 ±  4.4, mean ISS 14.9 ± 10.3. Mechanism of inury: penetrating n=329 (55.6%), blunt n=259 (43.9%), and non-specified n=2 (0.34%). Mean initial SBP 119.7 ±  37.7, mean in survivors 122.8 ± 24.8, mean in non-survivors 79.7 ±  56.1. Base deficit mean -3.7 ±  10.7, in survivors -3.3 ±  8.5, non-survivors -7.3 ± 19.2. Total number of injuries n=681, of these axillary artery n=455 (67%), axillary vein n=144 (21%), axillary nerve n=68 (9.98%), unspecified n=14 (2%). Sugical procedures for axillary injuries were documented in 238 patients, these included n=54 (15.4%) suture of the artery, n=38 (8.91%) vascular shunt or bypass. Complications n=2637 associated with axillary vessel injuries: pneumonia n=22 (16.05%), wound infection n=16 (11.67%), compartment syndrome n=14 (10.21%), ARDS n=12 (8.76%). Fuctional Independent Measures: dependent n=11 (1.86%), partial help required n=13 (2.2%), independent with device n=28 (4.75%), independent n=210 (35%), not applicable (7.3%), and not documented n=285 (48.3%). Survivors n=548 (92.88%), non-survivors n=42 (7.12%).

Conclusion: Axillary vessel injuries remain an uncommon occurence in the United States as denoted by their low incidence as reported in the NTDB and literature. Initial admitting systolic blood pressure has a higher correlation with morbidity based on mechanism of inury. However, when using stepwise logitistic models, ISS, TRISS, and LOS had the highest correlation with survival. Axillary vessel repairs require complex surgical interventions. Most injuries carry an associated high morbidity, good functional outcomes, and relative low mortality.

 

59.20 Efficacy of Endovascular Approach for Pediatric Traumatic Thoracic Aorta Injuries

Posted on January 31, 2019

M. Moore1, M. B. LaPlant1, B. J. Segura1, D. J. Hess1, D. A. Saltzman1  1University Of Minnesota,Pediatric Surgery/Pediatric Surgery/Medical School,Minneapolis, MN, USA

Introduction:  Traumatic thoracic aortic injuries are relatively rare within the pediatric population, occurring in only 0.06% to 0.1% of patients. Though infrequent, these injuries contribute to 2.1% of pediatric trauma related deaths. Thoracic aortic injuries are most frequently due to high energy, blunt trauma, with motor vehicle accidents and falls being the most common mechanisms. Endovascular repair of traumatic aortic injuries has become more common in the adult population where it has demonstrated a survival benefit and decreased morbidities in comparison to an open approach. In a previous study of all types of arterial injuries in pediatric trauma patients, there was no mortality difference between endovascular and open approaches. We aim to compare outcomes between endovascular and open management of traumatic thoracic aortic injuries in pediatric patients.

Methods:  We selected records from the National Trauma Databank, years 2010 – 2016. Included in analysis were all patients, aged 1 to 18 years, with a thoracic aorta injury who had endovascular repair (n = 92) or open repair (n = 93). We compared hospital mortality by treatment approach using fisher’s exact test and logistic regression, adjusting for patient demographics, injury severity, injury type, facility type, and facility clustering.  

Results: Patients ranged in age from three to 17 years (mean 15; SD 2.8). Injury severity scores ranged from 16 to 75 (mean 37; SD 15.0), and 85% of injuries were blunt. The mortality rate for patients who underwent endovascular repair was 6.5%, compared to 30.1% for patients that underwent open repair (p < .001). The mortality odds remained significantly higher for open approach patients after adjusting for patient and facility characteristics (AOR 5.89; 95% CI 1.32 – 26.28; p .021). 

Conclusion: Endovascular interventions are increasingly common in the management of trauma, but require further evaluation in pediatric patients. Mortality was significantly higher for pediatric patients who underwent open repair of thoracic aortic injuries, as compared to endovascular repair. After adjusting for patient and facility characteristics, the mortality odds remained significantly higher for patients undergoing an open approach. The use of endovascular approach for thoracic aorta repair may be efficacious and beneficial in pediatric patients.  As endovascular therapy becomes widely available, it is important to characterize further the populations and types of injuries that will benefit from this approach.

 

59.19 Training Local Law Enforcement to Stop the Bleed Improved Survival from Penetrating Trauma

Posted on January 31, 2019

A. Maitland1, K. W. Sexton1, A. Bhavaraju1, W. C. Beck1, B. Davis1, M. K. Kimbrough1, R. Robertson1, K. Buckner1, J. R. Taylor1  1University Of Arkansas for Medical Sciences,Trauma Surgery,Little Rock, AR, USA

Introduction: Hemorrhage continues to be the leading cause of early death after traumatic injury. To prevent death from hemorrhage, local law enforcement officers and first responders are being trained to "Stop the Bleed". In the year 2015, and going forward, each individual was trained using these bleeding control techniques and were equipped with CAT tourniquets. We hypothesized that this would improve early survival for victims of penetrating trauma.

Methods:  Registry data were used from a level 1 trauma center for all penetrating ballistic injuries. Exclusion criteria included patients from outside the center's county, patients not arriving directly from the scene of injury, suicide or self-injury, an event of pre-hospital cardiac arrest, a maximum AIS for the Head and Neck body regions =3, and a maximum AIS for the extremity body region =2. Univariate and bivariate statistics were performed using JMP Pro 13.2.0 (SAS: Cary, NC)

Results: In a final study population of 455 patients, overall ED mortality was 4.84%. The ED mortality rate in the pre-training group was 7.00% (21/300), and 0.65% (1/155) in the post-training group, which was a significant difference (p=0.0005). A nominal logistic regression model was performed. In this model, ED systolic blood pressure >90mmHg (p<0.0001), ED pulse rate <120bpm (p=0.000329), and injury occurrence after law enforcement training (p=0.00498) were significant predictors of survival

Conclusion: Local Law Enforcement Officer and First responder hemorrhage training can improve the early survival rate of patients with a penetrating injury. Further work needs to be done to determine the full impact of this training.

 

59.18 Does Surveillance Bias Impact the Incidence of Deep Vein Thrombosis and Pulmonary Embolism?

Posted on January 31, 2019

V. Morris1, M. K. McNutt1, L. S. Kao1, B. A. Cotton1  1McGovern Medical School at UTHealth,Acute Care Surgery,Houston, TEXAS, USA

Introduction: Venous thromboembolic events (VTE), which include deep vein thrombosis (DVT) and pulmonary embolism (PE), are used by many public and private agencies as a marker for quality of care. However, studies show rates may be affected by variability in screening practices; increased screening yields higher incidence. Reported incidence rates of VTE range from 4% to 16% in US trauma centers, suggesting a surveillance bias. The purpose of this study was to evaluate the incidence of both DVT and PE at our hospital, taking into account variability in aggressiveness in screening practices for the two distinct events.   

Methods: Retrospective cohort study, examining VTE events, screening Duplex ultrasound, and screening chest CT-angiograms (CTA) in patients admitted to the trauma service. Inclusion: Highest level-trauma activations, >15 years old, and admitted 1/16-12/16. Exclusions: patients dying in the first 24 hours, those who were pregnant, and those with >20% TBSA burns. Statistical analysis was performed with continuous data presented as medians (25th-75th interquartile range, IQR) and categorical data as proportions.

Results: 1314 patients met inclusion; 60 patients deveoped a VTE, 27 (2.1%) were diagnosed with a DVT and 37 (2.8%) were diagnosed with a PE.  A total of 141 patients had a Duplex scan and there was a total of 190 Duplex scans performed. 14.2% of Duplex scans were positive. Median Duplexes in DVT patients 1 (1, 2) vs 0 (0, 0) in those without DVT; p<0.05. 100% of DVT patients had at least one Duplex vs 9% of those without DVT, while 30% of DVT patients had at least two Duplexes vs 2% of those without DVT; both p<0.001. A total of 201 patients had a CTA and a total of 451 CTAs were performed. 8.2% of CTAs were positive. The median number of CTAs in PE patients 2 (1, 3) vs 0 (0, 0) in those without; p<0.001. 100% of PE patients had at least one CTA vs 13% of those without PE, while 80% of PE patients had at least two CTAs versus 11% of those without; both p<0.001. Of the PEs, 13% main pulmonary, 36% lobar, 24%segmental, and 27% were subsegmental. The rate of DVT per Duplex obtained was 1.8%, while the rate of PE per CTA was 2.6%. Controlling for age, gender, and injury severity, each Duplex obtained increased likelihood of DVT diagnosis 4-fold, while each CTA increased PE diagnosis almost 3-fold (TABLE).

Conclusion: The rate of VTE events in trauma centers is likely dependent on the intensity of screening for these events. An adjustment should be made for intensity of screening for these significant events when assigning scores for hospital performance and for reimbursement, least government, insurance, and quality organization discourage physicians and their hospitals from searching for these morbid and sometimes fatal events.

59.17 Aortic Injuries in Pediatric Blunt Trauma Patients

Posted on January 31, 2019

G. Bergman1, J. Hassoun1, L. S. Burkhalter3, G. P. Wools3, J. Tweed4, L. S. Hynan2, F. G. Qureshi1,3  1University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA 2University Of Texas Southwestern Medical Center,Department Of Clinical Sciences,Dallas, TX, USA 3Children’s Medical Center,Pediatric Surgery,Dallas, Tx, USA 4Children’s Medical Center,Trauma Services,Dallas, TX, USA

Introduction: Blunt traumatic aortic injuries are rare in children and management strategies are not well defined. These injuries can be managed expectantly, via open operation, or with endovascular techniques. We evaluated pediatric blunt aortic injuries at a level I pediatric trauma center over a ten-year period, focusing on management and outcomes between intervention and nonintervention groups.

Methods: After IRB approval, a retrospective chart review occurred. Demographics, injury mechanisms, associated injuries, injury severity score (ISS), management, and outcome data were collected and analyzed with SPSS.  Data is presented as counts and percentage, or mean and standard deviation as appropriate.  Fisher’s Exact Test was employed to test difference between groups.

Results: In a facility with an average of 1,200 trauma admission annually, 14 suffered blunt aortic injuries, 9 (65%) were males, average 9.6 (±3.2) years of age, there were 12 abdominal and two thoracic aortic injuries.  Average ISS of 30 (±12.3), in which all patients survived to hospital discharge.  All were passengers in a vehicle with restraint status including lap and shoulder belt (n=6, 43%), lap belt alone (n=5, 36%), or restrained but unspecified (n=3, 21%). Thirteen (93%) patients had documented seatbelt signs. Aortic injuries included three (21%) intimal tears, three (21%) pseudo aneurysms, three (21%) dissections, two (14%) transections, and three (21%) with a combination of injuries.  All patients had at least one associated injuries including bowel (79%), chance fractures (50%), and solid organ (36%).  Exploratory laparotomy was required in 12 (86%) patients with 10 being immediate operations.  A total of five patients required open abdominal aortic repair, three performed immediately, one on second-look laparotomy, and one in conjunction with a delayed laparotomy. Open repair methods included thrombectomy with patch (3/5, 60%) and PTFE graft (2/5, 40%). Two patients underwent endovascular repair.  The remaining seven were managed conservatively. Surgical intervention and non-surgical intervention patients were similar in demographics and ISS.  As seen in table 1, the groups did not significantly differ terms of presentation or associated injuries.

Conclusions: Blunt aortic injuries are rare in the pediatric population, but have excellent survival outcomes.  Vascular management is varied and determined by type of aortic injury and clinical findings. While sample size is small, there are no apparent differences apart from severity of aortic injury between those requiring intervention and those that do not.

59.16 Even in Death, Women Are Better at Planning Ahead

Posted on January 31, 2019

E. W. Tindal1, C. A. Adams1, S. F. Monaghan1, D. S. Heffernan1, A. H. Stephen1, W. G. Cioffi1, S. N. Lueckel1  1Rhode Island Hospital,General Surgery,Providence, RI, USA

Introduction:  As the population ages, there has been a change in focus from curing disease to improving end of life care. Patients who receive early palliative care report increased quality of life, less depression and had longer survival compared to patients with more aggressive care. Additionally, Do-Not-Resuscitate (DNR) orders have been associated with higher quality of life. In the setting of trauma, devastating injuries and an aging population with a reduced capacity to recover make the incorporation of these practices increasingly important. Here we aim to determine predictors of having an advanced directive (AD) at the time of presentation in trauma patients.

Methods:  This is a retrospective analysis of our trauma registry from 2015 to 2017. We queried our registry for adult (≥ 18 years) patients with “Advanced directive limiting care” listed as a comorbidity on admission. We performed a multivariate logistic regression including a case-matching analysis to control for age to identify significant predictors of a pre-existing AD following univariate analysis.

Results: We identified 7561 patients, 822 with an AD on admission. Those with an AD were older (80 vs 55 years, p<.001), more likely to be female (64.8 vs 39.5%, p<.001) and white (93.3 vs 82.2%, p<.001). Patients with an AD were more likely to arrive from a nursing home (NH) (23.8 vs 0.1%, p<.001), and have multiple co-morbidities including a functionally-dependent health status (FDHS) (63.0 vs 35.7%, p<.001). Regression analysis demonstrated that a pre-existing AD was independently associated with age over 65 (odds ratio (OR) 3.8, p<.001), female gender (OR 1.5, p<.001), arrival from NH (OR 178, p<.001) as well as comorbidities which include dementia (OR 2, p<.001), congestive heart failure (CHF) (OR 1.6, p<.05), hypertension (HTN) (OR 2.7, p<.001), FDHS (OR 1.2, p<.05) and chronic obstructive pulmonary disorder (COPD) (OR 2.6, p<.001). Case-control matching for age was performed given the large age discrepancy between the two groups and showed that these factors remained significant with the exception of CHF and FDHS.

Conclusion: Our findings demonstrate that, in addition to age and comorbidities, gender plays a significant role in end-of-life planning even prior to arrival at the hospital. As a result of this, those without an AD in place may experience more physical and emotional discomfort following a traumatic injury than those who present with an AD at the time of admission. Additional analysis is warranted to determine what personal and systemic factors may be driving this relationship.

 

59.15 Full Trauma Team Activation versus Partial Trauma Team Activation- Does it Really Matter?

Posted on January 31, 2019

L. M. Maloney1, E. C. Huang1, A. J. Singer1, R. C. Jawa1  1Stony Brook University Medical Center,Stony Brook, NY, USA

Introduction: Most trauma centers have two levels of trauma team activation based on physiologic, anatomic, or mechanistic criteria: full activation (Code T), and partial activation (Trauma Alert).

Methods: A query was performed on a pre-existing, ACS verified level 1 trauma center registry for Code T or Trauma Alert patients. Inclusion criteria included: presentation between 1/1/2015 and 12/31/2017, hospital admission, age >16 years. Exclusion criteria included death in the ED and isolated burns. Univariate statistical analyses were performed to compare baseline characteristics and outcomes in patients in these two groups.

Results: Of 5023 trauma admissions, 314 were after a Code T, and 571 after a Trauma Alert. No large differences existed in sex (75% vs 73% male), median age (41[IQR 25-58] vs 45[IQR 26-73] years), or percentage of patients with ?1 comorbidity (59% vs 60%, p=.769). Trauma Alerts most often had ?5 comorbidities (3% vs 0%, p=.003), and were more likely to have diabetes (9% vs 3%, p=.003), dementia (4% vs 0.6%, p=.009), and a pre-admission DNR (2% vs 0%, p=.009). The most common mechanism of injury was motor vehicle/motorcycle collisions in both groups (43% Code T vs 48% Trauma Alert, p=0.15). Code T patients were more likely to sustain penetrating injuries (16% vs 2%, p<0.001), while Trauma Alert patients were more likely to sustain a fall (25% vs 16%, p=.004). Code T patients more often had major injuries (AIS>3) to the head (31% vs 16%, P<0.001), c-spine (7% vs 3%, p=.008), chest (45% vs 22%, p<0.001), and abdomen (17% vs 8%, p<0.001). Code T patients had a median ISS of 19 (IQR 9-33), compared to a median ISS of Trauma Alert patients of 10 (IQR 5-17, p<.001). The median ED GCS was 14 (IQR 3-15) for Code T patients and 15 (IQR 15-15, p<.001) for Trauma Alert patients. Disposition following evaluation in the ED was more often to the ICU in Code T patients (35% vs 25%, p=.003), and to the Operating Room (46% vs 25%, p<.001). Code T patients more often received blood within 4 hours of arrival (34% vs 7%, p<.001). Code T patients more often had complications (20% vs 10%, p<.001), with the most likely being a PE/DVT (5% vs 2%, p=.042) or ulcers (3% vs 0.7%, p=.01), with similar percentages of pneumonia, AMI, sepsis, respiratory or failure, stroke, and unplanned ICU time. The final disposition at hospital discharge of Trauma Alert patient was more frequently home than Code T patients (66% vs 48%, p<.001). Code T patients had a higher mortality rate (14% vs 2%, p<.001).

Conclusions: The data demonstrate the principles of trauma triage recommended by the ACS effectively identified high-risk patients at the only level 1 trauma center in a large suburban county

59.14 Diagnosis of Pancreatic Injuries in Abdominal Trauma Patients with Negative Initial CT Scans

Posted on January 31, 2019

S. Rabinowitz1,2, J. Wycech2,3, A. Tymchak1,2,3,4, M. Crawford2, M. Gomez3, A. A. Fokin2, I. Puente1,2,3,4  1Florida Atlantic University,College Of Medicine,Boca Raton, FL, USA 2Delray Medical Center,Trauma Services,Delray Beach, FL, USA 3Broward Health Medical Center,Trauma Services,Fort Lauderdale, FL, USA 4Florida International University,College Of Medicine,Miami, FL, USA

Introduction:
There are several challenges of detecting pancreatic injury within the first hours post trauma, as clinical presentation is often delayed, imaging may be obscured, and enzyme analysis is unreliable. The aim of this study was to evaluate characteristics of patients with pancreatic injuries who had a negative initial computed tomography (CT) scan to determine indicators that can be used in detecting pancreatic injury.

Methods:
This IRB approved retrospective cohort study included 23 patients, ages 17-94, diagnosed with pancreatic injuries at a Level 1 trauma center between 01/2012 and 06/2018. Studied variables included: injury severity score (ISS), incidence of hemoperitoneum, contrast CT imaging, operative vs. non-operative management (NOM), enzyme levels, organ injury score (OIS), co-injuries, intensive care unit length of stay (ICULOS), hospital LOS (HLOS), complications and mortality.

Results:
Of the 23 patients, 9 (39.1%) had negative initial CT for pancreatic injury within the first 12 hours post trauma and were the subject of analysis. In this cohort, the mean ISS was 29.4. CT scans for all 9 patients were positive for hemoperitoneum.  Although initial contrast CT scans were negative for pancreatic injuries, they showed other abdominal organ trauma. As a result, 8 patients underwent urgent laparotomy during which injuries to the pancreas were diagnosed, and in 4 patients (44.4%) pancreas was immediately operated on. Only 1 of the 9 patients had attempted NOM, which failed, and pancreatic injury was discovered during laparotomy. Elevated amylase and lipase levels were seen in only 1 patient. Pancreas injuries categorized by region were: 7 patients had injuries to the pancreatic tail and 2 to the pancreatic head/neck. There were no injuries to the pancreatic duct. The mean pancreas OIS was 1.6. All 9 patients had additional solid organ injuries (SOI) and/or hollow viscus injuries (HVI):  4 patients had other SOI without HVI, 3 had other SOI with HVI, and 2 had pancreas injuries with HVI only. The most common SOI in association with pancreas was spleen (66.7%, n=6). All spleen injuries were categorized as severe (mean spleen OIS 4.3) and resulted in splenectomy. In patients with pancreatic injuries with two other SOI, the most common combination was spleen and left kidney injuries (33.3%, n=3). There was also incidence of lumbar trauma involving L1-L2 fractures in 2 patients: one had spleen and kidney co-injuries, while the other had spleen and left colon trauma. Mean ICULOS was 9.5 days and HLOS was 17.3 days. Complications, such as peritonitis and blood loss anemia developed in 4 patients, however no mortality was recorded.

Conclusion:
Early CT scans can be less sensitive for the detection of pancreatic injuries in patients with multiple abdominal organ injuries. High grade spleen injuries, especially when combined with left kidney, left colon or lumbar vertebrae trauma, should be considered risk factors for possible pancreatic damage.
 

59.13 Non Therapeutic Laparotomy Challenges the Conventional Indications for Laparotomy in Abdominal Trauma.

Posted on January 31, 2019

R. R. Chakraborty1, A. A. Maruf1, T. Benzir1, R. R. Chakraborty1  1Chittagong Medical College Hospital,Department Of Casualty,Chittagong, Bangladesh

Introduction:  

Trauma is the leading cause of death in the active people under the age 45 years. There is definite protocol for conservative management of Blunt Abdominal Trauma (BAT) but much lower threshold for exploratory laparotomy in Penetrating Abdominal Trauma (PAT). Though some specific presenting features and investigation findings are crucial in decision making, still the rate of Non Therapeutic Laparotomy (NTL) varies center to center from 12% – 40% in both blunt and penetrating abdominal trauma.

Methods:
A prospective study was conducted from July 2017 to June 2018 to evaluate the characteristics of cases that lead to NTL. The study was conducted in casualty department of a tertiary level hospital in Bangladesh. All patients with abdominal injury underwent exploratory laparotomy were included in this study. Only those cases which were found NTL were analyzed to see the presenting features that lead to exploratory laparotomy. 

Results:
During the study period 114 patients with abdominal trauma underwent exploratory laparotomy of which 42(36.8%) for blunt injury and 72(63.2%) for penetrating injury. Total NTL cases were 38 (33.33%). Analysis of NTL cases reveals that NTL for BAT were 8 (21.1%) and NTL in case of PAT were 30(78.9%). Indications for laparotomy in NTL cases of BAT were peritonitis 6(15.8%), Hemodynamic instability 4(10.5%), abdominal distension with significant peritoneal collection 8(21.1%)and average peritoneal collection was 2075 ml. Indications for laparotomy of NTL in PAT were peritonitis 20(52.6%), Evisceration of gut and omentum 8(21.1%), Hemodynamic instability 12(31.6%), dangerous mechanism of injury 6(15.8%), abdominal distension with significant peritoneal collection 14(36.8%) and average peritoneal collection was 226ml.

Conclusion:
In this study we found a high rate of NTL where we made the decision of exploratory laparotomy in abdominal trauma cases based on certain clinical features, abdominal Ultrasonography and in some cases on abdominal CT-Scan. More over higher rate of NTL in penetrating Abdominal trauma was due to very low threshold for exploratory laparotomy in these cases due to protocol obligation and medico-legal issue. So it seems that traditional way of decision making for exploratory laparotomy should be challenged and much scope to think in this issue.
 

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