[Show abstract][Hide abstract] ABSTRACT: Mortality benefit has been demonstrated for trauma patients transported via helicopter but at great cost. This study identified patients who did not benefit from helicopter transport to our facility and demonstrates potential cost savings when transported instead by ground.
We performed a 6-year (2007-2013) retrospective analysis of all trauma patients presenting to our center. Patients with a known mode of transfer were included in the study. Patients with missing data and those who were dead on arrival were excluded from the study. Patients were then dichotomized into helicopter transfer and ground transfer groups. A subanalysis was performed between minimally injured patients (ISS < 5) in both the groups after propensity score matching for demographics, injury severity parameters, and admission vital parameters. Groups were then compared for hospital and emergency department length of stay, early discharge, and mortality.
Of 5,202 transferred patients, 18.9% (981) were transferred via helicopter and 76.7% (3,992) were transferred via ground transport. Helicopter-transferred patients had longer hospital (p = 0.001) and intensive care unit (p = 0.001) stays. There was no difference in mortality between the groups (p = 0.6).On subanalysis of minimally injured patients there was no difference in hospital length of stay (p = 0.1) and early discharge (p = 0.6) between the helicopter transfer and ground transfer group. Average helicopter transfer cost at our center was $18,000, totaling $4,860,000 for 270 minimally injured helicopter-transferred patients.
Nearly one third of patients transported by helicopter were minimally injured. Policies to identify patients who do not benefit from helicopter transport should be developed. Significant reduction in transport cost can be made by judicious selection of patients. Education to physicians calling for transport and identification of alternate means of transportation would be both safe and financially beneficial to our system.
Epidemiologic study, level III. Therapeutic study, level IV.
The Journal of Trauma and Acute Care Surgery 03/2015; 78(3). · 1.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Trauma centers often receive transfers from lower-level trauma centers or nontrauma hospitals. The aim of this study was to analyze the incidence and pattern of secondary overtriage to our Level I trauma center.
We performed a 2-year retrospective analysis of all trauma patients transferred to our Level I trauma center and discharged within 24 hours of admission. Reason for referral, referring specialty, mode of transport, and intervention details were collected. Outcomes measures were incidence of secondary overtriage as well as requirement of major or minor procedure. Major procedure was defined as surgical intervention in the operating room. Minor procedures were defined as procedures performed in the emergency department.
A total of 1,846 patients were transferred to our Level I trauma center, of whom 440 (24%) were discharged within 24 hours of admission. The mean (SD) age was 35 (21) years, 72% were male, and mean (SD) Injury Severity Score (ISS) 4 (4). The most common reasons for referral were extremity fractures (31%), followed by head injury (23%) and soft tissue injuries (13%).Of the 440 patients discharged within 24 hours, 380 (86%) required only observation (268 of 380) or minor procedure (112 of 380). Minor procedures were entirely consisted of fracture management (n = 47, 42%) and wound care (n = 65, 58%). The mean (SD) interfacility transfer distance was 45 (46) miles. Mean (SD) hospital charges per transfer were $12,549 ($5,863).
A significant number of patients transferred to our trauma center were discharged within 24 hours; most of them required observation and/or minor procedures. Appropriately increasing primary hospital resources, in addition to interhospital outreach in the form of education or telemedicine, should be considered to decrease the number of avoidable transfers.
Epidemiologic study, level III.
The Journal of Trauma and Acute Care Surgery 12/2014; 77(6):969-73. · 1.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To optimize neurosurgical resources, guidelines were developed at our institution, allowing the acute care surgeons to independently manage traumatic intracranial hemorrhage less than or equal to 4 mm. The aim of our study was to evaluate our established Brain Injury Guidelines (BIG 1 category) for managing patients with traumatic brain injury (TBI) without neurosurgical consultation.
We formulated the BIG based on a 4-year retrospective chart review of all TBI patients presenting at our Level 1 trauma center. We then prospectively implemented our BIG 1 category to identify TBI patients that were to be managed without neurosurgical consultation (No-NC). Propensity scoring matched patients with No-NC to a similar cohort of patients managed with NC before the implementation of our BIG in a 1:1 ratio for demographics, severity of injury, and type and size of intracranial hemorrhage. Primary outcome measure was need for neurosurgical intervention and 30-day readmission rates.
A total of 254 TBI patients (127 of NC and 127 of No-NC patients) were included in the analysis. The mean (SD) age was 40.8 (22.7) years, 63.4% (n = 161) were male, median Glasgow Coma Scale (GCS) score was 15 (range, 13-15), and median head Abbreviated Injury Scale (AIS) score was 2 (range, 2-3). There was no neurosurgical intervention or 30-day readmission in both the groups. In the No-NC group, 3.9% of the patients had postdischarge emergency department visits compared with 4.7% of the NC group (p = 0.5). All patients were discharged home from the emergency department.
We validated our BIG and demonstrated that acute care surgeons can effectively care for minimally injured TBI patients with good outcomes. A national multi-institutional prospective evaluation is warranted.
Therapeutic/care management, level IV.
The Journal of Trauma and Acute Care Surgery 12/2014; 77(6):984-8. · 1.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Direct laryngoscopy (DL) has long been the gold standard for tracheal intubation in emergency and trauma patients. Video laryngoscopy (VL) is increasingly used in many settings and the purpose of this study was to compare its effectiveness to direct laryngoscopy in trauma patients. Our hypothesis was that the success rate of VL would be higher than that of DL.
World Journal of Surgery 10/2014; 39(3). · 2.35 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Introduction
Splenic abscesses associated with leukemia are rare. Most reported cases of splenic abscesses occur after chemotherapy and are related to the immunosuppressive effects of the chemotherapy. Their etiology is most frequently fungal.
Presentation Of Case
A 58-year-old male presented with splenomegaly and scrotal swelling secondary to a multibacterial splenic abscess which required a splenectomy. Upon investigation he was found to suffer from chronic myeloid leukemia (CML) and epididymitis.
Splenic abscesses are rarely found in leukemic patients. Reported cases are fungal and commonly occur after chemotherapy due to immunosuppression. Scrotal swelling with concurrent splenomegaly can be found in other pathologies including Brucellosis, Lyme disease and even non-Hodgkin primary testicular lymphoma. Scrotal swelling in our case was likely secondary to epididymitis and exacerbated by the effects of splenomegaly upon the systemic circulation promoting venous congestion.
This case illustrated an unusual presentation of CML because the patient presented with splenomegaly, a multibacterial splenic abscess, and scrotal swelling.
International Journal of Surgery Case Reports. 10/2014; 5(12).
[Show abstract][Hide abstract] ABSTRACT: Hypothermia is a known predictor of mortality in trauma patients; however, its impact on organ procurement has not been defined. The aim of this study was to assess the effect of hypothermia on organ procurement. We hypothesized that admission hypothermia impedes successful organ procurement.
The Journal of Trauma and Acute Care Surgery 10/2014; 77(4):559-563. · 1.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
We hypothesized that acute mild gallstone pancreatitis (GSP) patients admitted to surgery (SUR) (vs. medicine [MED]) had a shorter time to surgery, shorter hospital length of stay (HLOS), and lower costs.
We performed chart reviews of patients who underwent a cholecystectomy for acute mild GSP during 10/1/2009-5/31/2013. We excluded patients with moderate-to-severe and non-gallstone pancreatitis. We compared outcomes for time to surgery, HLOS, costs and complications between the 2 groups.
Fifty acute mild GSP patients were admitted to MED and 52 to SUR. MED patients were older and had more comorbidity. SUR patients had a shorter time to surgery (44 vs. 80 hours, P<0.001), a shorter HLOS (3 vs. 5 days, P<0.001), and lower hospital costs ($11,492 + 6,480 vs. $16,183 + 12,145; P=0.03). In our subgroup analysis on patients with an American Society of Anesthesiologists (ASA) score between1-2, the subgroups were well-matched; all outcomes still favored SUR patients.
Admitting acute mild GSP patients directly to SUR shortened the time to surgery, shortened HLOS, and lowered hospital costs.
The American Journal of Surgery 09/2014; · 2.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Platelet dysfunction has been attributed to progression of initial intracranial hemorrhage (ICH) on repeat head computed tomographic (RHCT) scans in patients on prehospital antiplatelet therapy. However, there is little emphasis on the effect of platelet count and progression of ICH in patients with traumatic brain injury. The aim of this study was to determine the platelet count cutoff for progression on RHCT and neurosurgical intervention in patients on antiplatelet therapy.
The Journal of Trauma and Acute Care Surgery 09/2014; 77(3):417-421. · 1.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Abstract Introduction: Conventionally, a Glasgow Coma Scale (GCS) score of 13-15 defines mild traumatic brain injury (mTBI). The aim of this study was to identify the factors that predict progression on repeat head computed tomography (RHCT) and neurosurgical intervention (NSI) in patients categorized as mild TBI with intracranial injury (intracranial haemorrhage and/or skull fracture). Methods: This study performed a retrospective chart review of all patients with traumatic brain injury who presented to a level 1 trauma centre. Patients with blunt TBI, an intracranial injury and admission GCS of 13-15 without anti-platelet and anti-coagulation therapy were included. The outcome measures were: progression on RHCT and need for neurosurgical intervention (craniotomy and/or craniectomy). Results: A total of 1800 patients were reviewed, of which 876 patients were included. One hundred and fifteen (13.1%) patients had progression on RHCT scan. Progression on RHCT was 8-times more likely in patients with subdural haemorrhage ≥10 mm, 5-times more likely with epidural haemorrhage ≥10 mm and 3-times more likely with base deficit ≥4. Forty-seven patients underwent a neurosurgical intervention. Patients with displaced skull fracture were 10-times more likely and patients with base deficit >4 were 21-times more likely to have a neurosurgical intervention. Conclusion: In patients with intracranial injury, a mild GCS score (GCS 13-15) in patients with an intracranial injury does not preclude progression on repeat head CT and the need for a neurosurgical intervention. Base deficit greater than four and displaced skull fracture are the greatest predictors for neurosurgical intervention in patients with mild TBI and an intracranial injury.
[Show abstract][Hide abstract] ABSTRACT: Background
The aim of our study was to evaluate the clinical outcomes in patients on pre-injury Ibuprofen with traumatic brain injury (TBI).
We performed a 2-year analysis of all patients on pre-hospital Ibuprofen with TBI and intracranial hemorrhage (ICH). Patients on pre-injury Ibuprofen were matched using propensity score matching to patients not on Ibuprofen in a 1:2 ratio for age, GCS, head-AIS, ISS, INR, and neurologic exam. Outcome measures were: progression on repeat head CT (RHCT) and neurosurgical intervention.
A total of 195 matched [65: Ibuprofen, 130: No-Ibuprofen] patients were included. There was no difference in progression on RHCT (18%: Ibuprofen vs. 24%: No-Ibuprofen; p=0.50). The neurosurgical intervention rate was 18.9% (n=37). There was no difference for need for neurosurgical intervention (26% vs. 16%; p=0.10) between the two groups.
In a matched cohort of trauma patients, pre-injury Ibuprofen use was not associated with progression of initial ICH and the need for neurosurgical intervention. Pre-injury use of Ibuprofen as an independent variable should not warrant the need for a routine RHCT scan.
The American Journal of Surgery 08/2014; · 2.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The significance of posttraumatic stress disorder (PTSD) in trauma patients is well recognized. The impact trauma surgeons endure in managing critical trauma cases is unknown. The aim of our study was to assess the incidence of PTSD among trauma surgeons and identify risk factors associated with the development of PTSD.
The Journal of Trauma and Acute Care Surgery 07/2014; 77(1):148-154. · 1.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Introduction
A definitive consensus on the standardization of practice of a routine repeat head computed tomography (RHCT) scan in patients with traumatic intracranial hemorrhage is lacking. We hypothesized that, in examinable patients without neurological deterioration, RHCT scan does not lead to neurosurgical intervention (craniotomy/ craniectomy).
Methods: This was a 3-year prospective cohort analysis of patients with age > 18 years without antiplatelet or anticoagulation therapy presenting to our level 1 trauma center with ICH on initial head CT and a follow-up RHCT. Neurosurgical intervention (NSI) was defined by craniotomy/craniectomy. Neurologic deterioration was defined as altered mental status, focal neurological deficits and/or pupillary changes.
A total of 1,129 patients were included. Routine RHCT was performed in 1,099 patients. The progression rate was 19.7% (216/1099), with subsequent NSI in four patients. The four patients had an abnormal neurological examination with a Glasgow Coma Scale (GCS) of ≤ 8 requiring intubation. Thirty patients had a RHCT secondary to neurological deterioration. 53% (16/30) had progression on RHCT of which, 75% (12/16) required NSI. There was an association between deterioration in neurological exam and need for NSI (odds ratio: 3.98; 95% CI: 1.7–9.1). The negative predictive value (NPV) of a deteriorating neurological exam in predicting the need for NSI was 100% in patients with GCS > 8.
Routine repeat head CT scan is not warranted in patients with normal neurological exam. Routine repeat head CT scan does not supplement the need for neurological examination for determining the management in patients with traumatic brain injury.
Journal of the American College of Surgeons 07/2014; · 4.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The Frailty Index has been shown to predict discharge disposition in geriatric patients. The aim of this study was to validate the modified 15-variable Trauma-Specific Frailty Index (TSFI) to predict discharge disposition in geriatric trauma patients. We hypothesized that TSFI can predict discharge disposition in geriatric trauma patients.
Journal of the American College of Surgeons 07/2014; 219(1):10-17.e1. · 4.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: IMPORTANCE The Frailty Index (FI) is a known predictor of adverse outcomes in geriatric patients. The usefulness of the FI as an outcome measure in geriatric trauma patients is unknown. OBJECTIVE To assess the usefulness of the FI as an effective assessment tool in predicting adverse outcomes in geriatric trauma patients. DESIGN, SETTING, AND PARTICIPANTS A 2-year (June 2011 to February 2013) prospective cohort study at a level I trauma center at the University of Arizona. We prospectively measured frailty in all geriatric trauma patients. Geriatric patients were defined as those 65 years or older. The FI was calculated using 50 preadmission frailty variables. Frailty in patients was defined by an FI of 0.25 or higher. MAIN OUTCOMES AND MEASURES The primary outcome measure was in-hospital complications. The secondary outcome measure was adverse discharge disposition. In-hospital complications were defined as cardiac, pulmonary, infectious, hematologic, renal, and reoperation. Adverse discharge disposition was defined as discharge to a skilled nursing facility or in-hospital mortality. Multivariate logistic regression was used to assess the relationship between the FI and outcomes. RESULTS In total, 250 patients were enrolled, with a mean (SD) age of 77.9 (8.1) years, median Injury Severity Score of 15 (range, 9-18), median Glasgow Coma Scale score of 15 (range, 12-15), and mean (SD) FI of 0.21 (0.10). Forty-four percent (n = 110) of patients had frailty. Patients with frailty were more likely to have in-hospital complications (odds ratio, 2.5; 95% CI, 1.5-6.0; P = .001) and adverse discharge disposition (odds ratio, 1.6; 95% CI, 1.1-2.4; P = .001). The mortality rate was 2.0% (n = 5), and all patients who died had frailty. CONCLUSIONS AND RELEVANCE The FI is an independent predictor of in-hospital complications and adverse discharge disposition in geriatric trauma patients. This index should be used as a clinical tool for risk stratification in this patient group.
[Show abstract][Hide abstract] ABSTRACT: Falls from ladders account for a significant number of hospital visits. However, the epidemiology, injury pattern, and how age affects such falls are poorly described in the literature.
Journal of Surgical Research 06/2014; · 2.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Introduction
The current literature regarding hemorrhagic complications in patients on long-term antiplatelet therapy undergoing emergent laparoscopic cholecystectomy is limited. The aim of our study was to describe hemorrhagic complications in patients on pre-hospital aspirin (ASP) therapy undergoing emergent cholecystectomy.
We performed a one-year retrospective analysis of our prospectively maintained acute care surgery database. The two groups (ASP group vs. No-ASP group) were matched in a 1:1ratio for age, gender, previous abdominal surgeries, and co-morbidities. Primary outcome measures were: intra-operative hemorrhage, post-operative anemia, need for blood transfusion, conversion to open cholecystectomy. Intraoperative hemorrhage was defined as intraoperative blood loss of > 100 ml; post-op anemia was defined by > 2 g/dL drop in hemoglobin.
A total of 112 [ASP: 56, No-ASP: 56] patients were included in the analysis. The mean age was 65.9±10 years, 50% were male. There was no difference in age (p=0.9), gender (p=0.9), and co-morbidities (p=0.7) between the two groups. There was no difference in intra-operative blood loss>100ml (p=0.5), post-operative anemia (p=0.8), blood transfusion requirement (p=0.9), and conversion to open surgery (p=0.7) between patients on ASA therapy and patients not on ASA therapy.
Emergent laparoscopic cholecystectomy is a safe procedure in patients on long term aspirin therapy. Pre-hospital use of aspirin therapy as an independent factor should not be used to delay emergent cholecystectomy.
Level of Evidence
Level III, Therapeutic Study, Retrospective Comparative Study.
The American Journal of Surgery 06/2014; · 2.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The development of coagulopathy of trauma is multifactorial associated with hypoperfusion and consumption of coagulation factors. Previous studies have compared the role of factor replacement versus FPP for reversal of trauma coagulopathy. The purpose of our study was to determine the time to correction of coagulopathy and blood product requirement in patients who received PCC+FFP compared with patients who received FFP alone.
We performed a retrospective analysis of a prospectively maintained database of all coagulopathic (INR ≥ 1.5) trauma patients presenting to our level I trauma center during a 2-years period (2011-2012). Patients were stratified into two groups: patients who received PCC+FFP and patients who received FFP alone. Patients in the two groups were matched in a 1:3 (PCC+FFP:FFP) ratio using propensity score matching for demographics, injury severity, vital parameters, and initial INR. The two groups were then compared for: correction of INR, time to correction of INR, thromboembolic complications, mortality, and cost of therapy.
A total of 252 were included in the analysis [PCC+FFP:63; FFP:189]. The mean age was 44 ± 20 years; 70 % were male, with a median ISS score of 27 [16-38]. PCC use was associated with an accelerated correction of INR (394 vs. 1,050 min; p 0.001), reduction in requirement of pack red blood cell (6.6 vs. 10 units; p 0.001) and FFP (2.8 vs. 3.9 units; p 0.01), and decline in mortality (23 vs. 28 %; p 0.04). PCC+FFP use was associated with a higher cost of therapy ($1,470 ± 845 vs. 1,171 ± 949; p 0.01) but lower overall cost of transfusion ($7,110 ± 1,068 vs. 9,571 ± 1,524; p 0.01) compared with FFP therapy alone.
PCC in conjunction with FFP rapidly corrects INR in a matched cohort of trauma patients not on warfarin therapy compared with FFP therapy alone. The use of PCC as an adjunct to FFP therapy is associated with reduction of blood product requirement and also lowers overall cost.
World Journal of Surgery 05/2014; · 2.35 Impact Factor