Eastern Association for the Surgery of Trauma

The need for extensive surgical debridement with necrotizing soft tissue infections (NSTIs) may put patients at high risk for unplanned readmission. However, there is a paucity of data on the burden of readmission in patients afflicted with NSTI. We hypothesized that unplanned readmission would significantly contribute to the burden of disease after discharge from initial hospitalization. The Nationwide Readmission Database was used to identify adults undergoing debridement for NSTI hospitalizations from 2010 to 2017. Risk factors for 90-day readmission were assessed by Cox proportional hazards regression. There were a total of 82,738 NSTI admissions during the study period, of which 25,076 (30.3%) underwent 90-day readmissions. Median time to readmission was 25 days (interquartile range, 9-49 days). Fragmentation of care, longer length of index stay (>2 weeks), and Medicaid status were independent risk factors for readmission. Median cost of a readmission was US $10,543. Readmission added 174,640 hospital days to episodes of care over the study period, resulting in an estimated financial burden of US $1.4 billion. Unplanned readmission caused by NSTIs is common and costly. Interventions that target patients at risk for readmission may help decrease the burden of disease. Economic/Epidemiological, level IV.

The incidence of early cognitive impairment (ECI) after traumatic brain injury (TBI) is unknown. We hypothesized ECI is common and can be predicted based on Glasgow Coma Scale (GCS) and Brain Injury Guideline (BIG) category. A single-center, retrospective review of adult trauma patients (2014-2016) with intracranial hemorrhage (ICH) and mild TBI (GCS score, 13-15) was performed. The primary outcome was ECI, defined as a Rancho Los Amigos score less than 8. Routine cognitive evaluation is performed on all ICH patients at our institution. Comparisons between ECI and no-ECI groups regarding demographic, cognitive, and clinical outcomes were evaluated using bivariate statistics. The odds of ECI were evaluated using a multivariable logistic regression. There were 465 patients with mild TBI, 70.3% were male, and the average age was 53 ± 23 years. The most common mechanism of injury was fall (41.1%) followed by motor vehicle collision (15.9%). The incidence of ECI was 51.4% (n = 239). The incidence in patients with a GCS score of 15 was 42.9%, and BIG 1 category was 42.7%. There were no differences in demographics (age, sex, comorbidities), mechanism of injury, or imaging when comparing ECI patients with no-ECI patients. The GCS score was lower in the ECI group (14.4 vs. 14.7, p < 0.001). Patients with ECI were also less likely to be discharged home (58.2% vs. 78.3%, p < 0.001). Lower GCS-verbal, BIG category 3, and presence of pelvic/extremity fractures were strong risk factors for ECI in a logistic regression model adjusted for age, loss of consciousness, anticoagulants, narcotic administration, and Rotterdam score. Half of all patients with ICH and mild TBI had ECI. Both lower initial GCS score and BIG category 3 were associated with increased likelihood of ECI. Therefore, we recommend all patients with ICH and mild TBI undergo cognitive evaluation. Prognostic Study, Level III.

Postoperative prescribing following acute care surgery must be optimized to limit excess opioids in circulation as misuse and diversion are frequently preceded by a prescription for acute pain. This study aimed to identify patient characteristics associated with higher opioid prescribing following laparoscopic cholecystectomy (LC). Among patients aged 18 years or older who underwent LC at a single institution in 2014 to 2016, opioids prescribed at discharge were converted to oral morphine equivalents (OME) and compared with developing state guidelines (maximum, 200 OME). Preoperative opioid use was defined as any opioid prescription 1 month to 3 months before LC or a prescription unrelated to gallbladder disease less than 1 month before LC. Univariate and multivariable methods determined characteristics associated with top quartile opioid prescriptions among opioid-naive patients. Of 1,606 LC patients, 34% had emergent procedures, and 14% were preoperative opioid users. Nonemergent LC patients were more likely to use opioids preoperatively (16% vs. 11%, p = 0.006), but median OME did not differ by preoperative opioid use (225 vs. 219, p = 0.40). Among 1,376 opioid-naive patients, 96% received opioids at discharge. Median OME was 225 (interquartile range, 150-300), and 52% were prescribed greater than 200 OME. Top quartile prescriptions (≥300 OME) were associated with gallstone pancreatitis diagnosis, younger age, higher pain scores, and longer length of stay (all p < 0.05). While median OME did not differ by emergent status (median, 225; interquartile range, 150-300 for both, p = 0.15), emergent had more top quartile prescriptions (32% vs. 25%, p = 0.005). After adjusting for diagnosis, age, and sex, emergent status showed evidence of being associated with top quartile prescription (odds ratio, 1.3; 95% confidence interval, 1.0-1.8). Thirty-day refill rate was 5%. Over half of opioid-naive patients undergoing LC were prescribed opioids exceeding draft state guidelines. Variation in prescribing patterns was not fully explained by patient factors. Acute care surgeons have an opportunity to optimize prescribing practices with the ultimate goal of reducing opioid misuse. Therapeutic study, level IV; Epidemiologic study, level III.

The incidence and severity of civilian public mass shootings (CPMS) continue to rise. Initiatives predicated on lessons learned from military woundings have placed strong emphasis on hemorrhage control, especially via use of tourniquets, as means to improve survival. We hypothesize that both the overall wounding pattern and the specific fatal wounds in CPMS events are different from those in military combat fatalities and thus may require a new management strategy. A retrospective study of autopsy reports for all victims involved in 12 CPMS events was performed. Civilian public mass shootings was defined using the FBI and the Congressional Research Service definition. The site of injury, probable site of fatal injury, and presence of potentially survivable injury (defined as survival if prehospital care is provided within 10 minutes and trauma center care within 60 minutes of injury) was determined independently by each author. A total 139 fatalities consisting of 371 wounds from 12 CPMS events were reviewed. All wounds were due to gunshots. Victims had an average of 2.7 gunshots. Relative to military reports, the case fatality rate was significantly higher, and incidence of potentially survivable injuries was significantly lower. Overall, 58% of victims had gunshots to the head and chest, and only 20% had extremity wounds. The probable site of fatal wounding was the head or chest in 77% of cases. Only 7% of victims had potentially survivable wounds. The most common site of potentially survivable injury was the chest (89%). No head injury was potentially survivable. There were no deaths due to exsanguination from an extremity. The overall and fatal wounding patterns following CPMS are different from those resulting from combat operations. Given that no deaths were due to extremity hemorrhage, a treatment strategy that goes beyond use of tourniquets is needed to rescue the few victims with potentially survivable injuries. Prognostic/epidemiologic study, level IV; therapeutic/care management study, level V.

Plasma infusion with or without red blood cells is the current military standard of care for prehospital resuscitation of combat casualties. We examined possible advantages of early and limited resuscitation with fresh plasma compared with a single plasma protein or crystalloid solutions in an uncontrolled hemorrhage model in rabbits. Anesthetized spontaneously breathing rabbits (3.3 ± 0.1 kg) were instrumented and subjected to a splenic uncontrolled hemorrhage. Rabbits in shock were resuscitated at 15 minutes with Plasma-Lyte (PAL; 30 mL/kg), PAL + fibrinogen (PAL + F; 30 mL + 100 mg/kg), fresh rabbit plasma (15 mL/kg), or 25% albumin (ALB; 5 mL/kg) solution, all given in two bolus intravenous injections (15 minutes apart) to achieve a mean arterial pressure of 65 mm Hg, n = 8 to 9/group. Animals were monitored for 2 hours or until death, and blood loss was measured. Blood samples and tissues were collected and analyzed. There were no differences among groups in baseline measures and their initial bleeding volume at 15 minutes. At 60 minutes after injury, mean arterial pressure was higher with ALB than with crystalloids (PAL or PAL + F), but shock indices were not different despite the large differences in resuscitation volumes. Fibrinogen addition to PAL only increased clot strength. Plasma resuscitation increased survival rate (75%) without significant improvement in coagulation measures. Albumin administration replenished total plasma protein and increased survival rate to 100% (p < .05 vs. crystalloids). No histological adverse events were identified in the vital organs. Fibrinogen administration added to a compatible crystalloid did not improve hemostatic outcomes. Plasma resuscitation increased survival rate; however, its effects did not differ from those obtained with 25% ALB at one-third of the volume. The ALB advantage was consistent with our previous findings in which 5% ALB was used at a volume equal to plasma. The benefit of plasma for resuscitation may be mostly due to its ALB content rather than its coagulation proteins.

Obesity is associated with a hypercoagulable state at baseline and following injury. The anatomic location of adipose deposition may influence the type of thrombotic event, with visceral adipose tissue (VAT) associated with arterial thrombosis and subcutaneous adipose tissue (SAT) predisposing to venous thrombosis. We sought to determine whether adipose tissue amount and location correlated with measures of coagulation. All adult Level I trauma activations at our institution between January 2013 and August 2014 who underwent admission abdominal computed tomography scan and had admission rotational thromboelastometry measurements were included. Patients were excluded for history of anticoagulant use and known coagulopathy/hypercoagulable state. Admission computed tomography was used to obtain cross-sectional VAT and SAT areas at the umbilicus utilizing a novel software system; VAT and SAT measurements were associated with markers of coagulation utilizing Spearman correlation and stepwise linear regression with significance set at p < 0.05. Two hundred forty-two patients met inclusion and exclusion criteria. Sixty-nine percent of patients sustained blunt injury, 79% were male, mean age was 40 years, 25% were obese or morbidly obese, and mean Injury Severity Scale score was 17. Seventeen percent of patients had acute deep venous thrombosis or pulmonary embolism during hospitalization. Neither SAT nor VAT correlated with prothrombin time, international normalized ratio, or partial thromboplastin time. Subcutaneous adipose tissue correlated positively with platelet count. Visceral adipose tissue and SAT correlated negatively with clot formation time and positively with TEM fibrinogen, α angle, maximum clot firmness, and lysis at 30 minutes; stronger correlations and greater significance were seen between SAT and these measures except for lysis at 30 minutes. Stepwise linear regression confirmed significant relationships between SAT and clot formation time, AA, and maximum clot firmness; VAT showed a significant relationship with TEM fibrinogen. Increased adipose tissue correlates with relative hypercoagulability following trauma. Subcutaneous adipose tissue shows a stronger relationship with functional measures of coagulation, suggesting that SAT may be associated with hemorrhage resistance and hypercoagulability after injury. Prognostic study, level IV.

Damage-control laparotomy (DCL) is a lifesaving operation used in critically ill patients; however, interval primary fascial closure remains a challenge. We hypothesized that flaccid paralysis of the lateral abdominal wall musculature induced by botulinum toxin A (BTX) would improve rates of primary fascial closure, decrease duration of hospital stay, and enhance pain control. Consenting adults who had undergone a DCL at two institutions were prospectively randomized to receive ultrasound-guided injections of their external oblique, internal oblique, and transversus abdominus muscles with either BTX (150 mL, 2 U/mL) or placebo (150-mL 0.9% NaCl). Patients were excluded if they had a body mass index of greater than 50, remained unstable or coagulopathic, were home O2 dependent, or had an existing neuromuscular disorder. Outcomes were assessed in a double-blinded manner. Univariate and Kaplan-Meier estimates of cumulative probability of abdominal closure were performed. We randomized 46 patients (24 BTX, 22 placebo). There were no significant differences in demographics, comorbidities, and physiologic status. Injections were performed on average 1.8 ± 2.8 days (range, 0-14 days) after DCL. The 10-day cumulative probability of primary fascial closure was similar between groups: 96% for BTX (95% confidence interval [CI], 72-99%) and 93% for placebo (95% CI, 61-99%) (HR, 1.0; 95% CI, 0.5-1.8). No difference between BTX and placebo groups was observed for hospital length of stay (37 days vs. 26 days, p = 0.30) or intensive care unit length of stay (17 days vs. 11 days, p = 0.27). There was no difference in median morphine equivalents following DCL. The overall complication rate was similar (63% vs. 68%, p = 0.69), with two deaths in the placebo group and none in the BTX group. No BTX or injection procedure complications were observed. The use of BTX after DCL was safe but did not seem to affect primary fascial closure, hospital length of stay, or pain modulation after DCL. Given higher-than-expected rates of primary fascial closure, Type II error may have occurred. Therapeutic study, level III.

Steel cleanliness is very important for the quality of final products. Stirring ladles have been widely used to ensure the good quality steel produced from liquid iron in steelmaking industry. Proper stirring is crucial for obtaining clean steel. In this study, three-dimensional computational fluid dynamics (CFD) technique is used to study the transient multiphase flow inside a working ladle at a steel plant. The study presents a comparison of three different methods to model multiphase flow, i.e. the volume of fluid (VOF) method, the Eulerian-Eulerian method, and the Eulerian-Lagrangian method. The simulation results are compared with experimental data obtained from a working ladle. The best simulation method, which gives the most accurate results within a reasonable amount of computational time, will be applied to optimize operating parameters under various conditions.