10.01 Characteristics and Resource Utilization in Pediatric Blunt and Penetrating Trauma

Posted on December 22, 2014

J. W. Nielsen1, J. Shi2, K. Wheeler2, H. Xiang2, B. D. Kenney1  1Nationwide Children’s Hospital,Division Of Pediatric Surgery,Columbus, OH, USA 2Nationwide Children’s Hospital,Center For Injury Research And Policy At The Research Institute,Columbus, OH, USA

Introduction:  Trauma is a leading cause of pediatric morbidity and mortality.  Children suffer both from blunt and penetrating injuries but the differences in resource utilization based on cause is not well studied.

Methods:  The National Trauma Data Bank (NTDB) was analyzed for all patients 0-18 years of age with ICD-9 external-cause-of-injury codes for blunt and penetrating trauma from 2007-2012.  Demographics, causes, treatments, complications, and outcomes were assessed.   T-test for continuous variables, and Chi-square tests for categorical variables were performed with a significance level of p<0.05.

Results: A total of 748,347 pediatric trauma patients were assessed.  Blunt trauma was identified as the cause in 601,898 (80.43%) patients compared to 55,597 (7.4%) patients with penetrating trauma.  Blunt trauma patients were younger on average (10.2 years vs. 14.7 years, p<0.001) and more likely to be female (34.5% vs. 16.4%, p<0.001).   Despite having only a slightly higher mean ISS (injury severity score) (7.9 vs. 7.6, p<0.001), blunt trauma patients had shorter lengths of stay (LOS) in the hospital (2.9 vs. 4.3 days, p<0.001), fewer complications (34.8% vs. 38.6%, p<0.001), and a much lower mortality rate (1.3% vs. 7.1%, p<0.001).  Penetrating trauma patients were more likely to receive transfusions (5.5% vs. 1.8%, p<0.001) and to undergo exploratory laparotomy (9.4% vs. 0.9%, p<0.001) and thoracotomy (1.7% vs. 0.07%, p<0.001).  Blunt trauma patients were more likely to undergo CT scanning (23.4% vs. 13.0%, p<0.001).  African American mortality was higher than Caucasians for both penetrating (7.9% vs. 5.2%, p<0.001) and blunt (1.3% vs. 1.1%, p<0.001) trauma.

Conclusion:   Blunt trauma is much more common than penetrating trauma among pediatric patients. Blunt trauma patients have shorter LOS, less complications, and lower mortality than penetrating trauma patients.  Penetrating trauma patients are more likely to need operative intervention and blood transfusions.  Racial disparities in outcome exist.

 

10.02 Identification of risk factors for cervical spine injury from pediatric trauma registry

Posted on December 22, 2014

A. S. Chaudhry1, S. Bloom1, J. McGinn1, C. Fasanya1, J. Schulz1, M. Price1  1North Shore University And Long Island Jewish Medical Center,Staten Island University Hospital/ Surgery,Manhasset, NY, USA

Cervical spine injuries (CSI) are rare in children. A vast majority is related to blunt trauma, occurring in less than 1% of those evaluated. So far, there is no established standardized protocol in the pediatric population to clear the cervical spine. Exposing children to harmful radiations due to excessive CT scan runs a risk of malignancy, that is 25% higher in the exposed group. The Canadian C-Spine rule and National Emergency X-Radiography Utilization Study (NEXUS) criteria for adults are more than 99% sensitive for identifying cervical spine injuries in adults.  The purpose of this study is to evaluate certain risk stratification strategies for identification of cervical spine injury (CSI) in pediatric trauma patients. 

Methods

With IRB approval we retrospectively reviewed the records of Pediatric Trauma Registries from two state designated level 1 pediatric trauma centers for 11 years (January 2002 and June 2013),inclusive. Patients age 1 month to 17 years who had a CT of the C-spine and evaluated for Cervical Spine Injury (CSI). We identified variables associated with increasing incidence of CSI in the literature and evaluated all patients as per these variables. The Age, Gender, Injury severity score (ISS), Glasgow coma score (GCS), LOC (Loss of consciousness), neck tenderness, significant injuries, and mechanism of injuries were examined for differences based on the presence or absence of cervical spine Injuries (CSI).

Results

A total of 220 cases were reviewed 46 (21%) were positive for CSI and 174(79%) were negative for CSI. Patients with a positive CSI were male (p=0.0261) had ISS > 25 (p=0.00076) and presented with neck tenderness (p=0.0001). The most common mechanism of injury was motor vehicle crashes (39%). LOC unexpectadly was not associated with having CSI (p=0.0003). Upper CSI (C1-C4) were more prevalent inyounger age group (0-8yrs) i.e (82.35%), while lower CSI (C5-C8) were more common in older children (9-16yrs) i.e (44.83%). However this result was not statistically significant (p=0.0617). There was statistically no significant association between CSI and Age, GCS, other significant injuries, or mechanism of injury.

 

Conclusion:

In our study significant CSI is related to male gender, higher ISS and neck tenderness. Patients with significant ISS and those with neck tenderness require diagnostic imaging appropriate for patients who have a higher likelihood of CSI. We propose a protocol for cervical spine injury clearance in children based on this data. Those patients who do not need the above criteria may be saved from undergoing excessive CT scans, in an effort to lower children radiation exposuretion:

 

10.03 Predictors of Mortality Following Pediatric Burns: a 20-year Review of an ABA-verified Burn Center

Posted on December 22, 2014

J. P. Meizoso1, C. J. Allen1, J. J. Ray1, C. M. Thorson1, L. R. Pizano1, N. Namias1, K. G. Proctor1, J. E. Sola2, C. I. Schulman1  1University Of Miami,Trauma, Surgical Critical Care, And Burns,Miami, FL, USA 2University Of Miami,Pediatric And Adolescent Surgery,Miami, FL, USA

Introduction:  Although trauma is the leading cause of death and morbidity in children in the US, pediatric burns continue to represent a large source of morbidity with an estimated 30,000 children requiring inpatient admission every year for treatment. In addition, children account for approximately 25% of burn deaths each year. The objective of this study is to identify major predictors of mortality in the pediatric burn population at a large American Burn Association verified burn center.

 

Methods:  A retrospective review of all pediatric burn patients (≤ 17y) from January 1993 to December 2013 were surveyed. Demographics, laboratory studies, total body surface area (TBSA) burn, need for emergent procedures, length of stay (LOS), and survival were obtained. Univariate analysis was performed to identify factors significantly associated with mortality. A multiple logistic regression model was used to identify independent predictors of mortality. Data are expressed as M±SD if normally distributed or median (interquartile range) if not.

 

Results: 943 patients evaluated at our center were average age 4.9±5 years, 63% male, 44% black, 33% white, and 21% Hispanic, TBSA 8%(28), base deficit -2 mEq/L(8), Glasgow Coma Scale (GCS) 15(0), scene GCS 15(0), and hospital LOS 3(30) days. The vast majority of burns occurred at home (95%). Only 14% of patients had a TBSA burn >20%. Intubation was required in 6.7% of patients. Overall mortality was 2.3%. Initial base deficit [-8(11) vs -2(8), p<0.001], bicarbonate level (18±5 vs 23±3, p<0.001), hematocrit (46±11 vs 34±12, p=0.012), pCO2 (49±21 vs 41±10, p=0.013), pH (7.24±0.15 vs 7.36±0.09, p<0.001), scene GCS [3(12) vs 15(0), p<0.001], hospital GCS [3(12) vs 15(0), p<0.001], TBSA [50(55) vs 7(25), p<0.001], and the need for intubation (67% vs 5.4%, p<0.001) were significantly associated with mortality on univariate analysis. The logistic regression model identified TBSA burn [odds ratio (OR): 1.09, confidence interval (CI): 1.03-1.15] and scene GCS (OR: 0.83, CI: 0.68-0.99) as significant independent predictors for mortality (area under receiver operator characteristic curve: 0.979).

 

Conclusion: Pediatric burn patients are typically young and male with predominantly small burns (<20% TBSA) that occur in the home. Overall mortality over a 20-year period in our burn center was 2.3%. Independent risk factors for mortality included TBSA burn and Glasgow Coma Scale at the scene of the incident. This suggests pre-hospital determinants such as GCS might serve as an indicator for poor outcome in the pediatric burn patient.

 

10.04 Outcomes in Pediatric Trauma Patients: ‘Alerted’ vs. 'Non- Alerted’

Posted on December 22, 2014

C. G. Dessaigne1, K. J. Caldwell1, S. D. Larson1, J. A. Taylor1, D. W. Kays1, S. Islam1  1University Of Florida,Gainesville, FL, USA

Introduction:  Trauma centers and the triage or ‘alert’ system has been shown to save lives. There remain issues with both over and under triage however, and that may result in significant expense to the hospital, or potentially increased morbidity to the patient. The purpose of this study was to compare the presentation and outcomes in children with trauma that presented after an alert or not. 

Methods:  IRB approval was obtained and data collected for a retrospective cohort analysis of all pediatric trauma patients (less than 16 years of age) between May 2010 and August 2013. Data regarding demographics, trauma details, ED and hospital course, and outcomes were collected. Patients were in either the ‘alerted’ or ‘non alerted’ groups, and an age and ISS matched cohort was selected for comparison. 

Results: We found 359 ‘alerted’ and 1004 ‘non-alerted’ patients during the study period. Overall, the mean ISS, median GCS was higher in the ‘alerts’.  After selecting an age and ISS matched cohort of ‘non alerts’, we performed Univariate analyses. Physiologic parameters of heart rate and systolic/diastolic BP, and respiratory rate were statistically higher in the alerted patients, but clinically not different.  Median GCS was equivalent. The mortality rate was not different (3.6 vs. 1.6%), and there were no missed injuries in the non-alerted group. The ICU and overall hospital LOS was slightly greater in the alerted group, with an equivalent number of procedures and consults being done (table). In addition, we noted that 26% of the ‘alerts’ were based on the criteria of paramedic discretion. Separate analysis of this group noted that 62% were admitted to the floor, 6% were discharged home after being downgraded from an alert, and there was only one patient with a GCS less than 13. This reduced the discriminating power of a trauma 'alert'.

Conclusion: We noted a 25% rate of trauma alerts during the study period. The alerted patients presented with minimal physiologic change compared to the non alerts, and the outcomes were not significantly different including mortality. This suggests that the triage system may need to be adjusted. Education of paramedics would be helpful in reducing the number of unnecessary alerts and improve the cost efficiency of the system. 

 

10.05 Epidemiology and Cause-Specific Outcome of Facial Fracture in Hospitalized Children in the US.

Posted on December 22, 2014

T. Soleimani1, T. M. Bell2, Y. Tahiri1, R. Sood1, R. L. Flores1, N. Nosrati1, S. S. Tholpady1  1Indiana University School Of Medicine,Plastic Surgery,Indianapolis, IN, USA 2Indiana University School Of Medicine,Surgery,Indianapolis, IN, USA

Introduction:
Facial fractures in the pediatric population, although less common than in adults, have a significant impact on public health and the US economy. Although some demographic data exists regarding the overall epidemiology of facial fractures in adults and children, little attention has been paid to the patterns of facial fractures based on the etiology of the trauma. This study was designed to provide a more thorough analysis via a large dataset.

Methods:
The KID (Kid Inpatient Database) was used to analyze pediatric facial fractures. Data from years 2000-2009 was studied. 21,533 patients aged 0-17 were identified using ICD-9 diagnosis codes for facial fractures. National estimates of incidence and distribution of pediatric facial fracture by mechanism were obtained. Association of demographics with mortality and length of stay (LOS) as the outcomes of interest was assessed by bivariate analysis using SAS.

Results:
The incidence of facial fractures increased with age and 49% of patients were 15 to 17 years old. 70% of the patients were male. 59% of patients were white, 18% were African-American, and 15.6% were Hispanic. The most frequent primary payer was private insurance (54%) followed by Medicaid (25%). Most of the patients were admitted at large (68%), urban (94%), teaching (75%) hospitals. The top 4 trauma mechanisms were motor vehicle accident (MVA) (43%), intentional trauma (IT) (17%), falls (11%) and non-intentional trauma (NIT) (9%). Compared to other trauma mechanism groups, patients in the IT group were more likely to be older, male, African-American, low income, covered by Medicaid, and treated in northeastern hospitals. 47% of patients had concomitant injuries including skull fracture, intracranial injuries, and cervical spine injuries. The overall mortality rate was 2.0%. Mortality was highest in the MVA group (3.4%) followed by IT group (0.6%). Having concomitant injury was associated with a higher mortality. In MVA, IT, and NIT groups, younger age was associated with higher rate of concomitant injury. Compared to male patients, female patients were more likely to have concomitant injury and mortality in IT and NIT groups. They were less likely to have concomitant injury in MVA group. In all four groups, mortality rate decreased by age and longer LOS was associated with African-American race, Medicaid payer, and receiving treatment at urban, teaching, and public hospitals.

Conclusion:
This study shows that the epidemiology and pattern of pediatric facial fracture differs based on the etiology of the trauma. Increasing incidence of facial trauma by age suggests increased vulnerability of the face in older children and higher risk-taking behavior in this group. The analysis demonstrated young female victims have a greater risk of mortality and that LOS increases with African-American race. Because poor outcomes are more likely in vulnerable populations, further analysis of the causes of increased mortality and LOS is warranted.
 

10.06 Predictors of Mortality in Pediatric Urban Firearm Injuries.

Posted on December 22, 2014

J. Tashiro1, C. J. Allen2, E. A. Perez1, H. L. Neville1, C. I. Schulman2, J. E. Sola1  1University Of Miami,Division Of Pediatric Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA 2University Of Miami,Division Of Trauma And Critical Care, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA

Introduction:
Although firearms account for less than 5% of all pediatric injuries, they have the highest associated case fatality rate. In the U.S., pediatric hospitalizations and deaths from firearms have continued to increase with most of these injuries occurring in metropolitan settings. We sought to examine factors associated with mortality due to firearm injuries in pediatric patients treated at an urban trauma center.

Methods:
We queried the trauma registry at a large, urban, Level 1 trauma center for all patients aged <18 years evaluated for firearm injuries from 1991-2011. Descriptive statistics and risk-adjusted multivariate analyses (MVA) were used.

Results:
Overall, 1085 patients were identified. The cohort had a median (IQR) age of 16 (2) years, LOS 2.4 (4.3) days, and most were male (86%), black (74%), sustained intentional injuries (93%) and were admitted to hospital (68%). The most commonly injured locations were abdomen (20%), extremities (19%), and chest (15%). Immediate operations were performed in 33% (n=358) of patients with most having abdominal surgery (n=214). Survival was 86% (7% expired in emergency department), but higher for blacks (OR=1.92) than for Hispanics (p=0.006). Blacks were more likely to sustain extremity (OR=2.26) and less head (OR=0.36) injuries than Hispanics (p<0.001), see Table. Analysis by injury location showed that head (OR=14.1) had the highest associated mortality followed by multiple major by Abbreviated Injury Scale (AIS) with central nervous system (7.30), chest (OR=2.68), and multiple major by AIS (OR=2.52) compared to abdomen (p<0.02). Most deaths occurred in patients with head (43%) or chest (21%) gunshot wounds. No fatalities occurred following scalp, face, or extremity injuries. MVA demonstrated that white children were 8.06 times more likely to die from a firearm injury than Hispanics (p=0.013). Children admitted with initial pH ≤ 7.15 (OR=21.8), initial hematocrit ≤ 30 (OR=4.69), or Injury Severity Score (ISS) > 15 (OR=7.73) had higher mortality rates (p<0.006).

Conclusion:
Analysis of pediatric firearm injuries treated at an urban trauma center demonstrates that most patients are male, black, teenagers who are more likely to sustain extremity rather than higher mortality head injuries seen more frequently in whites and Hispanics. On risk-adjusted MVA, white children are more likely to die than Hispanics. Initial pH, hematocrit, and ISS are significant independent predictors of mortality following firearm injury in children.

 

10.08 Dysphagia: An Underappreciated Complication in Cervical Spine Injury

Posted on December 22, 2014

J. C. Lee1, A. Vellucci1, B. W. Gross1, K. J. Rittenhouse1, C. Morrison1, F. B. Rogers1  1Lancaster General Hospital,Trauma,Lancaster, PENNSYLVANIA, USA

Introduction: Severe cervical spine (c-spine) injuries requiring rigid immobilization are associated with high rates of dysphagia and complications. Research suggests a geriatric predisposition to this complication. We sought to compare the incidence of dysphagia in the geriatric and general population for patients with c-spine injuries and propose an aggressive screening program that aims to decrease morbidity.

Methods: All trauma admissions to a level II trauma center from January 2010 to April 2014 with c-spine injuries were retrospectively reviewed. C-spine injury was classified as any ligamentous or vertebral body fracture. Patients were considered to have signs of dysphagia if a speech evaluation and/or a barium swallow (VFSS) was conducted, indicating a failure of preliminary bedside nursing assessment. The relationship between dysphagia development and age was assessed using X2 analysis (significance p<0.05). Development of pneumonia was considered a complication.

Results: Over the four-year study period, 537 c-spine injured patients were admitted. Of this, 144 total patients (26.8%) exhibited signs of dysphagia, 105 (72.9%) of which were geriatric and 39 (27.1%) general. Geriatric patients were found to be associated with higher rates of speech evaluation (p<0.001) and barium swallow (p=0.022), while the general population was associated with higher rates of pneumonia (p=0.021) (Table 1).

Conclusion: The high rate of speech evaluation and even higher incidence of formal contrast swallow studies in the geriatric population suggests a significant presence of dysphagic symptoms following c-spine injury. The low prevalence of pneumonia in the geriatric population may reflect the preventative measures taken due to heightened awareness of this susceptible population. Therefore, a formal speech therapy evaluation for dysphagia should be strongly considered in all trauma patients with c-spine injuries, and mandatory for those over the age of 65. 
 
 

10.09 Timing Is Not Everything: National Survey of Emergency Department Thoracotomy Practice

Posted on December 22, 2014

B. M. Dennis1, A. J. Medvecz2, O. L. Gunter1, O. D. Guillamondegui1  1Vanderbilt University Medical Center,Division Of Trauma And Surgical Critical Care,Nashville, TN, USA 2Vanderbilt University Medical Center,Department Of General Surgery,Nashville, TN, USA

Introduction: There continues to be significant debate in the trauma community regarding the indications for emergency department thoracotomy (EDT). Numerous studies have focused on the timing of EDT, while few have examined other factors that influence surgeon decision-making. We hypothesize there is continued variability among surgeons in the use of EDT.

Methods: A 13-question web-based survey was distributed to the membership of a large, national trauma association, examining demographics, trauma fellowship completion, trauma center designation, professional organization membership, and annual EDTs performed. Consideration of patient’s age, comorbidities, total injury burden and the use of technological adjuncts, such as ultrasound, was assessed. Respondents were asked when they would perform the procedure after loss of vital signs for blunt and penetrating trauma. Logistic regression determined factors influencing consideration of EDT.

Results: 540 of 1485 surveys were completed (36.4%). Patient age, total injury burden and comorbidities are considered by 38.5%, 29.1% and 55.7% of respondents, respectively. Technological adjuncts are used always or most of the time by 64% of respondents. 78% of respondents perform EDT with no more than 10 minutes of pre-hospital arrest for both blunt and penetrating traumatic arrest. 20.6% would never perform EDT for blunt traumatic arrest. Odds of EDT increase with longer pre-hospital times in both blunt and penetrating traumatic injuries as annual thoracotomies performed rise respectively (1.07, 95% CI 1.04-1.11; 1.09, 95% CI 1.0-1.13). Odds of performing an EDT with longer pre-hospital time in penetrating trauma decreases with increased respondent age (0.95, 95% CI 0.91-0.98).

Conclusion: Emergency department thoracotomy decision-making is more nuanced than previously described.  Variation continues in the use of thoracotomy following loss of vital signs, in both blunt and penetrating trauma. For both mechanisms, there remains little consensus on the appropriate timing for performing EDT despite published guidelines.  A large proportion of surgeons consider other factors such as patient age, total injury burden, and comorbidities in addition to vital signs when deciding to perform an EDT. Technological adjuncts are frequently used by surgeons to determine the need for EDT.
 

10.10 Does Hyperthermia On Admission Predict Poor Outcomes After Trauma?

Posted on December 22, 2014

A. Batool1, X. Tang2, F. Toy1, N. Becker1  1Geisinger Wyoming Valley Hospital,Department Of Trauma Surgery,Wilkes Barre, PA, USA 2Geisinger Medical Center,Department Of Biostatistics,Danville, PA, USA

Introduction:

The aim of this study is to determine whether hyperthermia in trauma patients predicts poor outcomes including increased mortality and longer hospital length of stay (LOS), ICU LOS, and ventilator dependence (VD).  A secondary aim was to assess if this effect remained significant in patients without severe head injury.

Methods:

The National Trauma Data Bank registry for the years 2010-2011 was obtained. All patients with age > 13 yrs with traumatic injury and admission temperature > 36 oC were stratified into normothermic (36-38oC) and hyperthermic (> 38oC) groups. Outcomes including mortality, LOS, ICU LOS, and VD were compared. A multivariate regression analysis was utilized to adjust for variables previously shown to effect outcomes. Subgroup analysis to assess the effect of hyperthermia on patients with and without significant head injury (GCS> 8) was performed.

Results:

The study included 857,178 patients. Of these, 7879 were hyperthermic.  Overall, patients with hyperthermia were found to have higher ISS, lower GCS, and were more likely to be hypotensive. Hyperthermic patients had higher mortality (6.7%) compared to normothermic patients (2.1%, p< 0.001).  In addition, hyperthermic patients had longer LOS, ICU LOS, and VD (all p values < 0.001 – table 1). After adjustment, hyperthermia remained an independent predictor of mortality [OR = 1.37 (95% CI 1.21-1.54)]. In subgroup analysis, irrespective of GCS score, patients with hyperthermia had increased mortality.

Conclusion:

Hyperthermia on admission is an independent predictor of mortality in trauma patients. In addition, it predicts longer LOS, ICU LOS, and VD.  These results are applicable to patients with and without head injury.  Further studies need to be done to determine the cause of these poor outcomes and to determine if hyperthermia prevention protocols need to be developed and implemented.

10.11 Investigating the relationship between weather and violence in Baltimore, Maryland, USA

Posted on December 22, 2014

S. J. Michel1, H. Wang1, S. Selvarajah1, M. Murrill1, A. Chi1, D. T. Efron1, E. B. Schneider1  1Johns Hopkins University School Of Medicine,Baltimore, MD, USA

Introduction:

It is a common refrain at major urban trauma centers that caseloads increase in the heat of the summer. Several previous studies supported this assertion, finding trauma admissions and crime to correlate positively with temperature. We examined links between weather and violence in Baltimore, MD, through trauma presentation to Johns Hopkins Hospital and crime reports filed with the Baltimore Police Department.

Methods:

Trauma data were obtained from a prospectively collected registry of all trauma patients presenting to Johns Hopkins Hospital from January 1, 2007 to March 31, 2013. Crime data were obtained from the Baltimore City Police Department from January 1, 2008 to March 31, 2013. Weather data were obtained from the National Climatic Data Center. Correlation coefficients were calculated and negative binomial regression was used to elucidate the independent associations of weather and temporal variables with the trauma and crime data.

Results:

When adjusting for temporal and meteorological factors, maximum daily temperature was positively associated with total trauma, intentional injury, and gunshot wounds presenting to Johns Hopkins Hospital along with total crime, violent crime, and homicides in Baltimore City (all p≤0.0001). Associations of average wind speed, daily precipitation, and daily snowfall with trauma and crime were far weaker and, when significant, nearly universally negative.

Conclusion:

Maximum daily temperature is the most important weather factor associated with violence and trauma in our study period and location. Our findings suggest implications for optimizing hospital staffing and also for the targeting of violence prevention and community policing initiatives.

10.12 Radiologic Interpretation of Nutrition at Base of Spine (RIBS) – Reliability and Reproducibility

Posted on December 22, 2014

I. Shnaydman1, J. McLatchy1, R. Barrera1  1North Shore University And Long Island Jewish Medical Center,Manhasset, NY, USA

Introduction:

Critically ill patients suffer from nutritional deficiency, resulting in poor wound healing, prolonged ventilator dependence and poor outcomes. There is currently no objective method to accurately assess nutritional status and determine effectiveness of nutritional support. Albumin, Prealbumin and Transferrin have been used as nutritional markers, but are unreliable in the critically ill patient due to being acute phase reactants. Radiologic Interpretation at Base of Spine, RIBS, was created to objectively assess nutrition and correlate to postoperative outcomes. The purpose of this study is to evaluate the reproducibility, reliability and clinical potential of the RIBS application.

Methods:

The RIBS application, developed by one of the authors, allows users to determine the ratio of visceral fat to muscle tissue. The easy to use program guides users through a few steps involving uploading a scan of the sacral area obtained from a routine CTAP and selecting the boundaries of fat and muscle adjacent to the spine. The application calculates this ratio of fat to muscle to determine a RIBS score. The application is cross-platform compatible and may be used on desktop computers and handheld devices.

Twenty surgical residents were given a brief introduction, and then ran the application on the same series of images. Half of the subjects used a portable device and half used a desktop computer. Results were compared to determine average time to completion, intra and inter-user reliability and reproducibility.

Clinical use of the RIBS application was assessed using a case study that followed the hospital course of a critically ill patient over the course of a year.  RIBS scores were compared to albumin, prealbumin and BMI.

Results:

Preliminary results demonstrate the reliability and reproducibility of the RIBS application. Test subjects found the program practical with an average completion time of 8 and 12 seconds on desktop and mobile devices respectively.

The case study showed that RIBS scores can provide clinical  insight into the nutritional status of a patient.  The RIBS scores correlated positively with BMI, Albumin and Prealbumin.

Conclusion:

In critically ill patients, appropriate nutritional support is often based on caloric need with adjustments made for specific illnesses. During an inflammatory process such as sepsis, it is important to use an objective marker for nutrition to both assess a patient’s prognosis as well as to trend their response to nutritional support. The data suggests that RIBS could be used to accurately and easily assess nutritional status.  Further research is underway to determine the efficacy of RIBS as a nutritional marker and correlate it to outcome measures.

10.13 Low Level Falls In The Elderly: Think Spinal Column Fracture

Posted on December 22, 2014

N. Joseph1, J. A. Vosswinkel1, J. E. McCormack1, E. C. Huang1, D. N. Rutigliano1, M. J. Shapiro1, R. S. Jawa1  1Stony Brook University Medical Center,Trauma,Stony Brook, NY, USA

Introduction:  Low-level falls, under three feet, in geriatric patients account for a substantial proportion of admissions at trauma centers.  In the absence of significant head injury, spinal evaluation in these patients is often limited.  We hypothesized that low-level falls often result in cervical, thoracolumbar, or sacrococcygeal vertebral fractures, which contribute to significant morbidity. 

Methods:  A county-wide trauma registry for admitted adult trauma patients age ≥ 65 years sustaining a fall from less than 3 feet from 2004 to 2013 was reviewed.  Deaths in the emergency department were excluded.  Statistical analyses were performed using parametric and nonparametric tests, percentage or median values with interquartile range are presented; p≤ 0.05 was significant. 

Results: After a low level fall, 17.8% of elderly patients sustained a vertebral fracture, in the following distribution: cervical spine 42.8%, thoracic spine 5.6%, lumbar spine 4.9%, sacrococcygeal 36.3%, and multiple vertebral levels 9%.

In comparing demographics between elderly patients with vertebral fractures (EW) and those without vertebral fractures (EWO), significant differences were found in patient age (84, 79-89 vs. 82, 76-88 years), gender (26.1% male vs. 36.4% male), injury severity score (5, 4-9 vs. 10, 9-16), and GCS (15, 15-15 vs. 15, 15-15).  In evaluating comorbidities, the 2 groups had similar rates of HTN, DM, dementia, heart disease, or respiratory disease.  However, the EW group was significantly less frequently on anticoagulant or antiplatelet agents (19.6% vs. 24.3%).  

In comparing hospitalization characteristics, significantly less EW patients required ICU admission (20.5.1% vs. 34.9%) or mechanical ventilation (6.0% vs. 10.3%) than EWO patients.  However, hospital length of stay (LOS) (7, 4-10 vs. 7, 4-10 days), ICU LOS (4, 3-8 vs. 4, 2-7 days) and duration of mechanical ventilation (3.5, 2-13 vs. 4, 2-10 days) were similar.  In evaluating complications, EW patients had significantly different rates of deep venous thrombosis and pulmonary embolism (0.8% vs. 02.7%) and sepsis (3.7% vs. 2.4%) than EWO patients.  However, the groups had similar rates of pneumonia, myocardial infarction, and decubitus ulcers.  

In comparing discharge disposition, significantly more EW patients went to acute rehabilitation (46.8% vs. 34.0%) and less EW went home (21.0% vs. 34.4%).  Rate of discharge to a SNF were similar (23.2% vs 21.5%), as was the in-hospital mortality rate (8.6% vs. 9.4%) between EW and EWO patients.

Conclusion: Low level falls resulted in vertebral fracture in 17.8% of elderly patients.  While C-spine fractures were most common, 10.5% had thoracic or lumbar spine fractures.  None of the above comorbidities were associated with spinal fracture.  Surprisingly, vertebral fractures in the elderly are not morbid, as measured by LOS or most complication rates.  The data suggest the need for greater vigilance in spinal evaluation in the geriatric patient following a low level fall.

 

10.14 Factors Associated With Failure-to-rescue in Patients Undergoing Trauma Laparotomy

Posted on December 22, 2014

B. Zangbar1, B. Joseph1, V. Pandit1, N. Kulvatunyou1, T. O’keeffe1, M. Khalil1, A. Tang1, G. Vercruysse1, R. Latifi1, R. S. Friese1, P. Rhee1  1University Of Arizona,Trauma/Surgery/Medicine,Tucson, AZ, USA

Introduction:  Quality improvement initiatives have primarily focused on preventing in-hospital complications. Patients developing complications are at a higher risk of mortality however; factors associated with failure-to-rescue (death after major complication) in trauma patients remain undefined. The aim of this study was to identify risk factors associated with failure-to-rescue in patients undergoing trauma laparotomy.

Methods:  An 8-year retrospective analysis of patients undergoing trauma laparotomy was performed. Patients who developed major in-hospital complications were included. Major complications were defined as respiratory, infectious, cardiac, renal, or development of compartment syndrome. Regression analysis was performed to identify independent factors associated with failure-to-rescue after adjusting for demographics, mechanism of injury, abbreviated injury scales (AIS), initial vital signs, performance of damage control laparotomy, and volume of crystalloids and blood products administered.

Results: A total of 1,029 patients were reviewed of which; 21% (n=217) patients who developed major complications were included. The mean age was 39 ± 18 years, 82% were male, 61% had blunt trauma, and median a-AIS was 25 [16-34]. Respiratory complications (35.4%, n=77) followed by infectious complications (45.1%, n=98) were the most common major complications. The mortality rate was 15.7% (n=34).  Blunt trauma, severe head injury, uninsured status, and blood products administered on the second day were independent predictors for failure-to-rescue. The overall failure-to-rescue rate was 3.3%.

Conclusion: The overall failure-to-rescue rate was low (3.3%) in patients undergoing trauma laparotomy. However, when major complications develop, uninsured status, severity and mechanism of injury, and blood product requirement are independently associated with failure-to-rescue.
 

10.15 Evidence-Based Transfusion Guidelines Markedly Decrease Inappropriate Transfusions in a Surgical ICU

Posted on December 22, 2014

M. Sethi1, C. T. Wilson1, P. R. Ayoung-Chee1, G. Marshall1, S. G. Frangos1, H. Diaz1, S. R. Todd1  1New York University School Of Medicine,Surgery,New York, NY, USA

Introduction:
Restrictive packed red blood cell (PRBC) transfusion practices (hemoglobin transfusion trigger < 7g/dl) are as effective if not superior to liberal transfusion practices in critically ill patients. A 2004 study noted compliance with this recommendation in less than 10% of ICU transfusions. Similarly, a 2012 prospective study performed at this Level 1 Trauma Center demonstrated that 52% of PRBC transfusions in SICU patients with hemoglobin > 7g/dl were clinically inappropriate. The objective of this study was to evaluate the efficacy of a PRBC Transfusion Guideline instituted in the SICU. We hypothesized that with the dissemination of this new guideline to clinical faculty and staff, the number of inappropriate PRBC transfusions would decrease.

Methods:
This was a prospective study of patients receiving PRBC transfusions in the SICU since the implementation of the PRBC Transfusion Guideline compared with the 2012 historic controls prior to its implementation. The PRBC Transfusion Guideline was developed based on best evidence and local expert opinion. Data evaluated included patient demographics, details surrounding the PRBC transfusions, and clinical outcomes. 

Results:

Over 3 months, 32 SICU patients received 63 distinct PRBC transfusions for a total of 81 units. The study patients compared to historic controls were similar in age (51±18 years vs. 55±18, p=0.05), gender (62% male vs. 64% male, p=0.30) and APACHE II score (17.1±8.7 vs. 15±8.7, p=0.05). Following implementation of the PRBC Transfusion Guideline, pre-transfusion hemoglobin decreased from 7.6 to 7.4 (p=0.34). PRBC transfusions for hemoglobin > 7g/dl decreased from 64% to 57% (p=0.38). The percentage of clinically inappropriate transfusions in all SICU patients decreased from 31% to 17% (p=0.05).

  

Conclusion:

The implementation of a PRBC Transfusion Guideline decreased clinically inappropriate PRBC transfusions in the SICU. However, at 17%, the rate remains high. Numerous clinical factors alter such practices, despite a lack of supporting evidence. Education is needed to further decrease this rate.

10.16 “Double check” Technique of Bedside Post Pyloric Feeding Tube Placement Using Transnasal Endoscopy

Posted on December 22, 2014

T. Nishimura1, H. Sakata1, T. Yamada1, A. Hashimoto1, K. Kohama1, J. Kotani1, A. Nakao1  1Hyogo College Of Medicine,Department Of Emergency And Critical Care Medicine,Mukogawacyo 1-1 ,Nishinomiya City, HYOGO PREFECTURE, Japan

Introduction:
Enteral feefing has become an important means of providing nutritional support to seriously ill patients.Placement of the feeding tube through the pyloric ring and past the ligament of Treitz into the proximal jejunum is critical to reduce the risk of gastroesophageal regurgitation and microaspiration.

Methods:
We started utilizing transnasal endoscopy for intestinal feeding tube placement, placing enteral tubes for 40 patients between March 2008 and February 2010. Although we achieved a high succes rate comparable to previous reports, we experienced several cases of failure, which was corrected with repeated endoscopy. Based on these experiences, we modified our method by adding a “double check” transnasal endoscopy through the other nasal passage. 

Results:
After April 2010, we have placed the feeding tube by “double check” method for all patients (more than 40 patients) who required transnasal endoscopic feeding tube placement. We have not experienced any misplacement in all these patients after 24 h later with 100% successful rate since the introduction of “double check” procedure.

Conclusion:
We describe our experience with “double check” transnasal endoscopic feeding tube placement, which we found to be a helpful adjunct, for patients in intensive care unit.
 

10.17 Initial Screening Test For Blunt Cerebrovascular Injury: Validity Assessment Of Whole-Body CT

Posted on December 22, 2014

A. Laser1, B. R. Bruns1,3, J. A. Kufera3,4, R. Tesoriero1,3, C. W. Sliker2,3, T. M. Scalea1,3, D. M. Stein1,3  1University Of Maryland,Department Of Surgery,Baltimore, MD, USA 2University Of Maryland,Department Of Diagnostic Radiology & Nuclear Medicine,Baltimore, MD, USA 3University Of Maryland,R Adams Cowley Shock Trauma Center,Baltimore, MD, USA 4National Study Center For Trauma & EMS,Baltimore, MD, USA

Introduction: Our Whole-body CT protocol (WBCT) used to image polytrauma patients consists of a non-contrast head CT followed by a MDCT [40- or 64- slice] that includes an IV contrast-enhanced scan from the face through the pelvis. WBCT is used to screen for blunt cerebrovascular injury (BCVI) during initial CT imaging of the poly-trauma patient, and allow for early initiation of therapy with the goal of avoiding stroke. WBCT has not been directly compared to CT angiography (CTA) of the neck as a screening tool for BCVI. We hypothesize that WBCT is a valid modality to diagnose BCVI when compared to neck CTA, thus screening polytrauma patients for BCVI and limiting the need for subsequent CTA.

Methods:  Retrospective review of the trauma registry for all patients diagnosed with BCVI from June 2009 to June 2013 at our institution was performed. All injuries identified by grade on initial WBCT and grading was compared to neck CTA imaging performed within the first 72 hours. Sensitivity was calculated for WBCT using CTA as the reference standard. Proportions of agreement were also calculated between the grades of injury for each imaging modality.  

Results: 319 injured vessels were identified in 226 patients. On initial WBCT 80 (25%) of the injuries were grade I, 75 (24%) grade II, 45 (14%) grade III, 41 (13%) grade IV, and 58 (18%) were classified as indeterminate: 27 vertebral and 31 carotid lesions. Twenty (6%) of the 319 injuries were not detected on WBCT but identified on subsequent CTA (9 grade I, 7 grade 2, 4 grade III); 6 vertebral and 14 carotid. For each vessel type and for all vessels combined, WBCT demonstrated sensitivity rates of over 90% to detect BCVI among the population of patients with at least one vessel injured.

There was concordant grading of injuries between WBCT and initial diagnostic CTA in 149 (47% of all injuries). Lower grade injures were more discordant than higher grades (58% vs. 26%, respectively; p <0.001). Grading was upgraded 11% of the time and downgraded 32%.

Conclusion: WBCT holds promise as a rapid screening test for BCVI in the polytrauma patient and to identify injuries in the early stage of the trauma evaluation, thus allowing more rapid initiation of treatment. In patients at high-risk for BCVI, we continue to recommend dedicated neck CTA for better characterization of the injury, regardless of WBCT findings.
 

10.18 Pyoderma Gangrenosum: An Analysis of 2273 Cases – Demographics, Treatments and Outcomes

Posted on December 22, 2014

S. E. Sasor1, T. Soleimani1, R. L. Flores1, R. Sood1, J. Socas1, Y. Tahiri1, W. Wooden1, I. A. Munshi1, S. S. Tholpady1  1Indiana University School Of Medicine,Plastic Surgery,Indianapolis, IN, USA

Introduction:
Pyoderma gangrenosum (PG) is a rare skin condition within the spectrum of neutrophilic and auto-inflammatory dermatoses. Diagnosis is difficult and treatment is often delayed due to confusion with other skin conditions, including wound infection in the surgical patient population. To date, data on this disease is limited to case series and small cohort studies. In this study, the authors characterize clinically relevant features associated with PG based on a large inpatient cohort.

Methods:
The National Inpatient Sample Database (NIS) was used to identify patients with the diagnosis of pyoderma gangrenosum over a three year period from 2008 to 2010. Data was collected on demographics, associated diagnoses, treatments and outcomes.

Results:
A total of 2273 patients were identified with PG during the study period. Mean age was 56 years. 66.3% of patients were female.  Prevalence was highest in Caucasians (71.1%), followed by black (17.6%), Hispanic (7.1%), and Asian (1.3%) races. The disease was evenly distributed across socioeconomic groups based on median household income (25%, 27%, 24.6%, and 23.6% in 1st-4th quartiles, respectively) and Medicare was the most common primary expected payer (48%). PG was most often treated in large (69%), urban (91.6%), teaching (54.8%) hospitals located in southern states (39%). Pyoderma gangrenosum was the primary diagnosis in 22.6% of patients. Other primary diagnoses included cellulitis (9.44%), inflammatory bowel disease (6.9%), wound/ulcer (5.4%), sepsis (4.7%), post-operative infection/complication (2.7%), and pneumonia (2.2%). The most common procedures performed on patients with PG were wound debridement (10.8%), skin biopsy (10.3%), large bowel biopsy (3.6%), incision and drainage (2.4%), EGD (1.8%) and skin grafting (1.6%). 74 patients (3.2%) died during hospitalization.

Conclusion:
Pyoderma gangrenosum is a rare but serious skin condition, most common in females and Caucasians, frequently associated with systemic disease, and often confused with other skin disorders.  PG should be considered in the differential diagnosis when evaluating patients with ulcers, wounds and post-operative complications. A heightened awareness of the disease and multi-disciplinary approach is needed for proper diagnosis and management.
 

10.19 Prognosticating Abdominal Gunshot Wounds – A Comparative Assessment of Severity Measures

Posted on December 22, 2014

A. A. Shah1,2, A. Rehman2, S. Shah2, H. Zafar2, C. K. Zogg1, S. Zafar3, Z. Rehman2, Y. Bashir2, A. H. Haider1  1Johns Hopkins University School Of Medicine,Center For Surgical Trials And Outcomes Research, Department Of Surgery,Baltimore, MD, USA 2Aga Khan University Medical College,Department Of Surgery,Karachi, Sindh, Pakistan 3Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA

Introduction:  Penetrating abdominal trauma is a common feature of trauma treated in low- and middle-income countries (LMICs). Two measures: the Penetrating Abdominal Trauma Index (PATI) and the Injury Severity Score (ISS), are often utilized by hospitals in LMICs to measure the injury severity of penetrating abdominal wounds. However, it remains unclear which measure better accounts for the severity of injuries that a patient sustains. The purpose of this study was to compare the efficacy of both injury severity measures at predicting outcomes in patients presenting to a low-middle income healthcare facility in Pakistan.  

Methods:  All isolated gunshot wounds to the abdomen presenting to a university hospital between 2011-2012 were included. Information was retrieved on patient demographics, injury type and mechanism, complications, mortality and length of stay. ISS and PATI were calculated for each case. Primary outcome measures included all-cause mortality and complications. Multivariate analysis adjusting for age, gender, referral status, hypotension, tachycardia, and injury severity measures was performed. Areas under receiver operating curves (AUROC) were further calculated to compare the respective abilities of ISS and PATI to predict death and complications.

Results: A total of 70 patients were included. Average age was 34.5 (±11.4) years, with a male predominance (n=68, 97.1%). The majority of gunshot wounds were intentionally inflicted (n=67, 95.7%). Crude rates of death and complications were 34.3% and 15.7%, respectively. Mean patient ISS was 17.2 (±8.0), and mean PATI was 18.8 (±11.1). AUROC analyses revealed ISS to be comparable to PATI at predicting mortality (AUROC [95%CI]: 0.952 [0.902-1.00] vs. 0.934 [0.860-1.00]). PATI was found to be as good as the ISS at predicting complications relative (AUROC [95% CI]: 0.895 [0.815-0.975] vs. 0.868 [0.778-0.959]).

Conclusion: The predictive ability of ISS and PATI severity measures was found to be comparable in patients with abdominal gunshot wounds treated at a university hospitals in a LMIC. ISS is regularly employed to quantify injury severity around the globe. We recommend its use as the standard injury severity measure, even for penetrating abdominal trauma given its widespread recognition and comparable utility to a lesser-known abdomen-specific measure.

 

10.20 Changes in Blast Trauma Patterns among Colombian Soldiers

Posted on December 22, 2014

J. C. Gomez-Rodriquez1, M. Swaroop3, D. A. Annaya2, C. A. FRANCO CORREDOR5, C. E. VELEZ1, W. Sanchez Maldonado4  1Hospital Militar De Oriente,General Surgery And Trauma,Villavicencio, , Colombia 2Baylor College Of Medicine,Surgical Oncology,Houston, TX, USA 3Northwestern University,Trauma And Critical Care,Chicago, IL, USA 4Hospital Militar Central,Bogota, , Colombia 5Jefatura De Sanidad Del Ejército De Colombia,Bogota, , Colombia

Introduction:
Terrorist groups have used a wide variety of improvised explosive devices (IED) in warfare in Colombia since the 1960s. There have been recent changes in governmental military tactics leading to decreased number of terrorist attacks, but the impact on IED use patterns has not been studied. We aimed to examine the change in blast injury patterns over the last five years to refine future military medical resource utilization planning.

Methods:
Data regarding blast injuries affecting military personnel in Colombia were collected from the Colombian Army Health Authority from 2009 to 2013.  

Results:
The annual number of blast injuries has decreased over the past four years (222 affected in 2009 vs 131 in 2013). Blast injury patterns have changed as well, with more recent injuries comprising primarily lower extremity wounds rather than lethal torso injuries seen in earlier years.

Conclusion:

With changes in military tactics in Colombia’s war on terrorism there has been a marked decrease in IED-associated blast injuries, with changes in blast injury patterns. The higher rate of mangled extremities has likely resulted in decreased blast lethality, but demands more health-care resources. With the likelihood of protracted military operations, military medical providers will need to continue planning for and optimizing treatment of complex lower extremity injuries.

 

11.01 Per Oral Endoscopic Myotomy (POEM) Improves Patient Symptoms and Quality of Life

Posted on December 22, 2014

J. S. Schwartz1, M. P. Meara1, J. W. Hazey1, K. A. Perry1  1Ohio State University,Division Of General And Gastrointestinal Surgery,Columbus, OH, USA

Introduction: Laparoscopic Heller myotomy is the gold standard therapy for achalasia in the United States due to its ability to produce effective and durable dysphagia relief. There is evidence that endoscopic pneumatic dilation can provide similar outcomes without the need for invasive surgical therapy; however, this approach has failed to gain widespread acceptance due to the need for repeated treatments and the increasing risk of esophageal perforation. Per Oral Endoscopic Myotomy (POEM) is emerging as an approach that combines the advantages of the currently available laparoscopic and endoscopic therapies. The objective of this study was to assess the impact of POEM on patient symptoms and quality of life.

Methods:  POEM was introduced in August of 2012 under an IRB approved protocol. The first 10 cases were performed in patients without a prior history of endoscopic or surgical treatment. All patients remained in the hospital overnight and underwent an esophagram on post-operative day one to evaluate for esophageal leak. The primary outcome measure was dysphagia relief as measured on a 5 point Likert scale. Secondary outcomes included operative data, complications, and length of stay. Dysphagia score, GERD symptom scores (GERSS), disease specific quality of life assessment (GERD-HRQL), and global quality of life assessment (SF-36) were assessed at baseline, 6 weeks, and 6 months post-operatively.

Results: Between August 2012 and October 2013, 26 patients underwent POEM, 25 for management of achalasia and 1 long myotomy for treatment of diffuse esophageal spasm. Patients averaged 54 ± 18 years of age with a mean BMI of 28.4 ± 5.1 kg/m2. Fourteen (54%) patents were male, and the median baseline dysphagia score was 4 (2-5). POEM was successfully completed in all cases. There were no intraoperative complications or post-operative esophageal leaks. The mean operative time was 105 ± 30 minutes, and blood loss was minimal in all cases. Median hospital stay was 1 (1-2) day. Dysphagia score (4 versus 0, p<0.01); GERD symptom score (32.5 versus 9.3, p<0.01); GERD-HRQL (19.7 versus 6.1, p<0.01); and SF-36 social functioning (56.5 v 82.6, p<0.01) and general health (56.2 versus 65.4, p<0.01) significantly improved at 6 weeks compared to baseline. At 6 month follow-up, median dysphagia score was 1 (0-4), and 40% of patients were taking a daily PPI for reflux control. GERD symptom scores (12.2, p<0.01) and GERD-HRQL (6.1, p<0.01) remained significantly improved compared to baseline.

Conclusion: POEM represents a safe and effective treatment strategy for achalasia which yields excellent dysphagia relief and improved disease specific and global quality of life. Although associated with post-procedure reflux symptoms in some cases, these are typically well controlled with medical therapy. Long-term studies are required to assess the durability of symptom relief in these patients.

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