Eric J Ley

Cedars-Sinai Medical Center, Los Ángeles, California, United States

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Publications (147)335.03 Total impact

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    ABSTRACT: Background: Beta adrenergic receptor blockers (BB) administered after trauma blunt the cascade of immune and inflammatory changes associated with injury. BBs are associated with improved outcomes after traumatic brain injury (TBI). Propranolol may be an ideal BB due to its nonselective inhibition and ability to cross the blood brain barrier. We determined if early administration of propranolol after TBI is associated with lower mortality. Methods: All adults (age ≥ 18) with moderate to severe TBI (head AIS = 3-5) requiring intensive care unit (ICU) admission at a Level I trauma center from January 1, 2013 to May 31, 2015 were prospectively entered into a database. Administration of early propranolol was dosed within 24 hours of admission at 1 mg IV every 6 hours. Patients who received early propranolol after TBI (EPAT) were compared to those who did not (non-EPAT). Data including demographics, hospital length of stay (LOS), ICU LOS, and mortality were collected. Results: Over 29 months, 440 patients with moderate to severe TBI met inclusion criteria. Early propranolol was administered to 25% (109/440) of patients. The EPAT cohort was younger (49.6 vs. 60.4 years, p < 0.001), had lower GCS (11.7 vs. 12.4, p = 0.003), lower head AIS (3.6 vs. 3.9, p = 0.001), higher admission HR (95.8 vs. 88.4 bpm, p = 0.002), and required more days on the ventilator (5.9 vs. 2.6 days, p < 0.001). Similarities were noted in gender, ISS, admission SBP, hospital LOS, ICU LOS and mortality rate. Multivariate regression showed EPAT was independently associated with lower mortality (AOR 0.25, p = 0.012). Conclusions: After adjusting for predictors of mortality, early administration of propranolol after TBI was associated with improved survival. Future studies are needed to identify additional benefits as well as optimal dosing regimens. Level of evidence: Therapeutic Level IV.
    No preview · Article · Jan 2016 · Journal of Trauma and Acute Care Surgery
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    ABSTRACT: Background: The obese state has been linked to various immune-mediated conditions. Our objective was to examine the association of body mass index (BMI) with the diagnosis of heparin-induced thrombocytopenia (HIT). Methods: Prospectively collected data on patients in the surgical and cardiac ICU suspected of having HIT between January 2007 and August 2014 were analyzed. Patients were categorized into 5 discreet BMI (kg/m) groups and compared. Data collected included Warkentin 4-T scores, anti-platelet factor 4 (anti-PF4OD), Serotonin Release Assay (SRA), and thromboembolic diseases. HIT positivity was defined as SRA>20%. Results: Of 304 patients meeting inclusion criteria, mean age was 62.1 ± 16.5 years, 59% were male, and mean BMI was 27 ± 6 kg/m. Thirty-six (12%) were positive for HIT. Incidence of HIT increased progressively with BMI [0%, 8%, 11%, 19%, 36%; p < 0.001]. Compared to patients with normal BMI, patients with BMI 30-39.9 had a 200% increase in the odds for HIT [OR = 2.94, 95% CI = 1.20-7.54, p = 0.019], while patients with BMI ≥40 had a 600% increase [OR = 6.98, 95% CI = 1.59-28.2, p = 0.012]. After regression analysis, BMI remained an independent predictor of the development of HIT (AOR per kg/m [95% CI], 1.08 [1.02 1.14]; p=0.010). Anti-PF4OD ≥2.0 also increased with BMI (p<0.001). In-hospital mortality increased significantly with BMI above normal (p = 0.026). Warkentin 4-T scores, DVT, PE, and stroke incidence did not correlate with changes in BMI. Conclusion: Increasing BMI appears to be strongly associated with increased rates of HIT in ICU patients. Obesity is an important new clinical variable for estimating the pre-test probability of HIT, and patient "Thickness" could be considered a 5th "T" of the 4-T scoring. Additional biochemical work is indicated to decipher the role of obesity in this immune-mediated condition. Level of evidence: III, prospective, observational.
    No preview · Article · Dec 2015
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    ABSTRACT: Background: The source of coagulopathy in traumatic brain injury (TBI) is multifactorial and may include adrenergic stimulation. The aim of this study was to assess coagulopathy after TBI using thromboelastography (TEG), and to investigate the implications of β-adrenergic receptor knockout. Methods: Adult male wild type c57/bl6 (WT) and β1/β2-adrenergic receptor knockout (BKO) mice were assigned to either TBI (WT-TBI, BKO-TBI) or sham injury (WT-sham, BKO-sham). Mice assigned to TBI were subject to controlled cortical impact (CCI). At 24 h post-injury, whole blood samples were obtained and taken immediately for TEG. Results: At 24 h after injury, a trend toward increased fibrinolysis was seen in WT-TBI compared to WT-sham although this did not reach significance (EPL 8.1 vs. 0 %, p = 0.18). No differences were noted in fibrinolysis in BKO-TBI compared to BKO-sham (LY30 2.6 vs. 2.5 %, p = 0.61; EPL 3.4 vs. 2.9 %, p = 0.61). In addition BKO-TBI demonstrated increased clot strength compared to BKO-sham (MA 76.6 vs. 68.6, p = 0.03; G 18.2 vs. 11.3, p = 0.03). Conclusions: In a mouse TBI model, WT mice sustaining TBI demonstrated a trend toward increased fibrinolysis at 24 h after injury while BKO mice did not. These findings suggest β-blockade may attenuate the coagulopathy of TBI and minimize progression of intracranial hemorrhage by reducing fibrinolysis and increasing clot strength.
    No preview · Article · Dec 2015 · Neurocritical Care
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    ABSTRACT: The optimal heart rate (HR) for children after trauma is based on values derived at rest for a given age. As the stages of shock are based in part on HR, a better understanding of how HR varies after trauma is necessary. Admission HRs of pediatric trauma patients were analyzed to determine which ranges were associated with lowest mortality.
    No preview · Article · Nov 2015
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    ABSTRACT: Objective: In the USA, organ donor shortage is especially pronounced among minority ethnic populations such as Hispanics, who are 60% less likely to donate compared to non-Hispanic Whites. Recent evidence suggests that US Hispanics may consent to organ donation via a registry within a doctor's office. The objective of this study was to investigate the effectiveness of using 'kiosks' to distribute organ donation educational material located within primary care clinics on US Hispanic donor registration rates. Design/setting: A prospective observational study was conducted at four clinics, located in Southern Californian neighbourhoods with a high percentage of Hispanics. Method: Kiosks containing organ donation educational material were set up at each clinic for a total of 7 weeks. The kiosks were unstaffed for 6 weeks, 3 weeks before and 3 weeks after a week that was staffed by individuals from OneLegacy, the local Organ Procurement Organisation (OPO). The number of patient encounters and the number of patients who registered were recorded and analysed. Registration rates per 1,000 patient encounters and 95% confidence interval (CI) were derived. Differences between the staffed and unstaffed kiosks were assessed. Results: During the 6-week unstaffed period, a total of 59,181 patient encounters occurred with a registration rate of 0.03 per 1,000 (95% CI: 0.0-0.1). During the 1-week staffed period, a total of 9,805 patient encounters occurred and 102 patients registered, which is a registration rate of 10 per 1,000 (95% CI: 8-13). Significance was reached when comparing staffed and unstaffed rates of registration (p < .0001). Conclusion: This study demonstrates that when compared with unstaffed kiosks, staffed kiosks are more effective in increasing organ donation registration among US Hispanics.
    Full-text · Article · Nov 2015 · Health Education Journal
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    ABSTRACT: Introduction: As bicycling has become more popular, admissions after bicycle trauma are on the rise. The impact of alcohol use on bicycle trauma has not been well studied. The aim of this study was to examine the effect of alcohol intoxication on injury burden following bicycle-related crashes. Methods: A retrospective review of trauma patients presenting to a Level I trauma center after bicycle-related crashes from January 2002 to December 2011 was conducted. Demographics, injury data, alcohol intoxication, helmet use, and clinical outcomes were reviewed. Blood alcohol level (BAL) was considered positive if >0.01 g/dL. Variables were compared between patients based on BAL: negative, 0.01 to 0.16 g/dL, and > 0.16 g/dL. Results: During the 10 year study period, 563 patients met study criteria; mean age was 33.5 ± 16.5 years, 87% were male, and mortality was 1%. On average, bicycle crashes increased over the study period by 4.4 collisions per year. BAL was tested in 211 (38%) patients. Mean BAL was 0.24 g/dL, with 37% of these patients being intoxicated (BAL ≥ 0.010 g/dL). Intoxicated patients were significantly less likely to wear a helmet (4.7% vs. 22.2%, p=0.002) and to be involved in motor vehicle crash (59.0% vs. 81.2%, p<0.001). There was no difference noted in the injury burden including ISS ≥ 16 (14.3% vs. 19.5%, p=0.335) and AIS Head ≥ 3 (17.9% vs. 21.8%, p=0.502). When comparing patients according to their BAL, there was a decreasing risk of motor vehicle collision with increasing BAL (81.2% for undetected, 76.5% for BAL ≤ 0.16 g/dL and 54.1% for BAL > 0.16 g/dL, p<0.001). The risk for a severe head injury (AIS Head ≥ 3) was significantly lower in helmeted patients (8.4% vs. 15.8%, p=0.035). Conclusions: The incidence of bicycle-related crashes is increasing and more than a third of patients injured in bicycle-related crashes are found to be intoxicated. The injury burden in intoxicated patients, including head trauma, was not different compared to non-intoxicated patients. In addition, the risk for a collision with a motor vehicle was significantly lower. Nonetheless, these patients rarely utilize a helmet. The findings from this study can be used for the development and implementation of preventive strategies to minimize the injury burden associated with bicycle crashes and intoxicated cyclists.
    No preview · Article · Oct 2015 · International Journal of Surgery (London, England)
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    ABSTRACT: Background: Thrombocytosis following splenectomy is a common occurrence. Whether this thrombocytosis leads to a higher risk for venous thromboembolism (VTE) remains unclear. This investigation aimed to determine if splenectomy increases the risk for VTE. Methods: This was a prospective study conducted in the SICU between 1/2011 and 11/2013 investigating the VTE risk in patients undergoing a splenectomy compared with those undergoing any other abdominal procedure. Results: In total 2,503 patients were admitted to the SICU: 37 (2%) after a splenectomy and 638 (26%) after any other abdominal surgery. Splenectomy patients had a higher incidence of VTE compared to patients undergoing any other abdominal procedure (29.7% vs. 12.1%, p<0.01). After adjustment, splenectomy was associated with a higher adjusted risk for VTE compared to the no-splenectomy group (AOR [95% CI]: 2.6 [1.2, 5.9], p=0.02). Reactive thrombocytosis did not predict the development of VTE. Conclusion: Splenectomy increases the risk for VTE, however reactive thrombocytosis is not associated with this higher incidence. Further investigations are required to characterize the pathophysiologic mechanisms of VTE development following splenectomy.
    No preview · Article · Oct 2015 · International Journal of Surgery (London, England)
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    ABSTRACT: Background: Field intubation (FI) by Emergency Medical Services personnel on severely injured trauma patients remains a contentious practice. Clinical studies suggest an association between FI and adverse outcomes in patients with traumatic brain injury. Military tactical emergency casualty care recommends deferring intubation and providing supplemental oxygenation until reaching a more equipped destination. Additionally, animal models with penetrating hemorrhagic shock demonstrate increased acidosis with intubation prior to resuscitation. The purpose of this study was to evaluate the impact of FI on outcomes in trauma patients with hemorrhagic shock requiring massive transfusion. Methods: The Los Angeles County Trauma System Database was retrospectively queried for all trauma patients ≥ 16 years of age with hemorrhagic shock requiring massive transfusion (≥6 units PRBCs in the first 24 hours) between January 1, 2012 and June 30, 2014. Demographics, clinical and transfusion data, and outcomes were compared between patients who received FI and those who did not (NO-FI). Multivariate regression analysis was utilized to adjust for confounders. Results: Of 552 trauma patients meeting inclusion criteria, 63 (11%) received FI and the remaining 489 (89%) were NO-FI. Age, gender, and incidence of blunt injury were similar between FI and NO-FI. The FI cohort presented with a lower GCS median (3 v. 14, p<0.001), a lower SBP median (86 v. 104 mmHg, p<0.001), and a higher ISS median (41 v. 29, p<0.001). Mortality was significantly higher in FI patients (83% v. 43%, p<0.001). Transfusion patterns and total field times were similar in both groups. After adjusting for confounders, FI patients had increased odds of mortality (AOR 2.89; 95% CI 1.08-7.78, p=0.035). Additionally, FI was identified as an independent predictor of mortality (AOR 3.41; 95% CI 1.35-8.59, p=0.009). Conclusion: Field intubation may be associated with higher mortality in trauma patients with hemorrhagic shock requiring massive transfusion. Less invasive airway interventions and rapid transport might improve outcome for these patients. Level of evidence: Prognostic Study, Level III.
    No preview · Article · Oct 2015
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    ABSTRACT: Purpose: The purpose of the study is to determine if excessive fluid administration is associated with a prolonged hospital course and worse outcomes. Materials and methods: In July 2013, all normotensive trauma patients admitted to the surgical intensive care unit (ICU) were administered crystalloids at 30 mL/h ("to keep open [TKO]") and were compared to patients admitted during the preceding 6 months who were placed on a rate between 125 mL/h to 150 mL/h (non-TKO). The primary outcomes were ICU, hospital, and ventilator days. Results: A total of 101 trauma patients met inclusion criteria: 56 (55.4%) in the TKO and 45 (44.6%) in the non-TKO group. Overall, the 2 groups were similar in regard to age, Injury Severity Score, Acute Physiology and Chronic Health Evaluation IV scores, and the need for mechanical ventilation. TKO had no effect on renal function compared to non-TKO with similarities in maximum hospital creatinine. TKO patients had lower ICU stay (2.7 ± 1.5 vs 4.1 ± 4.6 days; P = .03) and ventilator days (1.4 ± 0.5 vs 5.5 ± 4.8 days; P < .01). Conclusions: A protocol that encourages admission basal fluid rate of TKO or 30 mL/h in normotensive trauma patients is safe, reduces fluid intake, and may be associated with a shorter intensive care unit course and fewer ventilator days.
    No preview · Article · Oct 2015 · Journal of critical care

  • No preview · Article · Oct 2015 · Journal of the American College of Surgeons
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    ABSTRACT: Stab wounds (SW) to the abdomen traditionally require urgent exploration when associated with shock, evisceration, or peritonitis. Hemodynamically stable patients without evisceration may benefit from serial exams even with peritonitis. We compared patients taken directly to the operating room with abdominal SWs (EDOR) to those admitted for serial exams (ADMIT). We retrospectively reviewed hemodynamically stable patients presenting with any abdominal SW between January 2000 and December 2012. Exclusions included evidence of evisceration, systolic blood pressure .110 mm Hg, or blood transfusion. NONTHER was defined as abdominal exploration without identification of intraabdominal injury requiring repair. Of 142 patients included, 104 were EDOR and 38 were ADMIT. When EDOR was compared with ADMIT, abdominal Abbreviated Injury Score was higher (2.4 vs 2.1. P = 0.01) and hospital length of stay was longer (4.8 vs 3.3 days. P = 0.04). Incidence of NONTHER was higher in EDOR cohort (71% vs 13%. P . 0.001). In a regression model, EDOR was a predictor of NONTHER (adjusted odds ratio 16.6. P < 0.001). One patient from EDOR expired after complications from NONTHER. There were no deaths in the ADMIT group. For those patients with abdominal SWs who present with systolic blood pressure .110 mm Hg, no blood product transfusion in the emergency department and lacking evisceration, admission for serial abdominal exams may be preferred regardless of abdominal exam.
    Full-text · Article · Oct 2015 · The American surgeon
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    ABSTRACT: Blunt aortic injury (BAI) after chest trauma is a potentially lethal condition that requires rapid diagnosis for appropriate treatment. We compared CT with IV contrast (CTI) with CT with angiography (CTA) during the initial phase of care at an urban Level I trauma center from January 1, 2010 to December 31, 2013. Overall, 281 patients met inclusion criteria with 167 (59%) CTI and 114 (41%) CTA. There were no differences between cohorts in age, gender, initial heart rate, systolic blood pressure, and Glasgow Coma Scale. Mortality rates were similar for CTI and CTA (4% vs 8%, P = 0.20). CTI identified any chest injury in 54 per cent of patients compared with 46 per cent with CTA (P = 0.05). The rate of BAI was similar with CTI and CTA (2% vs 2%, P = 0.80), and neither modality was falsely negative. We conclude that CTI and CTA are similar at evaluating trauma patients for BAI, although CTI may be preferable during the initial assessment phase because the contrast injection may be combined with abdominal scanning and image time is reduced when whole-body CT is required.
    No preview · Article · Oct 2015 · The American surgeon

  • No preview · Article · Oct 2015 · Journal of the American College of Surgeons

  • No preview · Article · Oct 2015 · Journal of the American College of Surgeons
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    ABSTRACT: Massive transfusion protocol (MTP) is used to resuscitate patients in hemorrhagic shock. Our goal was to review MTP use in the elderly. All trauma patients who required activation of MTP at an urban Level I trauma center from January 1, 2011 to December 31, 2013 were reviewed retrospectively. Elderly was defined as age ≥ 60 years. Sixty-six patients had MTP activated: 52 nonelderly (NE) and 14 elderly (E). There were no statistically significant differences between the two cohorts for gender, injury severity score, head abbreviated injury scale, emergency department Glasgow Coma Scale, initial hematocrit, intensive care unit length of stay, or hospital length of stay. Mean age for NE was 35 years and 73 years for E (P P = 0.07). Mortality rates were similar in the NE and the E (53%vs 50%, P = 0.80). After multivariate analysis with Glasgow Coma Scale, injury severity score, and blunt versus penetrating trauma, elderly age was not a predictor of mortality after MTP (P = 0.35). When MTP is activated, survival to discharge in elderly trauma patients is comparable to younger patients.
    No preview · Article · Oct 2015 · The American surgeon

  • No preview · Article · Oct 2015 · Journal of the American College of Surgeons

  • No preview · Article · Oct 2015 · Journal of the American College of Surgeons
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    ABSTRACT: Pain associated with rib fractures impairs respiratory function and increases pulmonary morbidity. The purpose of this study was to determine how epidural catheters alter mortality and complications in trauma patients. We performed a retrospective study involving adult blunt trauma patients with moderatetosevere injuries from January 1, 2004 to December 31, 2013. During the 10year period, 526 patients met the inclusion criteria; 43/526 (8%) patients had a catheter placed. Mean age of patients with epidural catheter (CATH) was higher compared with patients without epidural catheter (NOCATH) (54 vs 48 years, P = 0.021), Injury Severity Score was similar (26 CATH vs 27 NOCATH, P = 0.84), and CATH had higher mean rib fractures (7.4 vs 4.1, P < 0.001). Mortality was lower in CATH (0% vs 13%, P = 0.006). Deep vein thrombosis (DVT) rate was higher in CATH (12% vs. 5%, P = 0.036). After regression analysis, we found catheter placement to be a predictor for DVT (adjusted odds ratios 2.80, P = 0.036). Our center noted increased use of epidural catheters in patients who present with moderatetosevere injuries. Patients with catheters were older and had a mean of 7.4 ribs fractured. The epidural cohort had longer hospital LOS and decreased mortality. In contrast to other studies, DVT rates were increased in patients who received epidural catheters.
    Full-text · Article · Oct 2015 · The American surgeon
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    ABSTRACT: The effect of resident duty hour restrictions continues to yield conflicting results on patient outcomes. Failure to rescue (FTR), or death after a major complication, has become a topic of increasing quality assessment. The aim of this study is to evaluate the effect of duty hour restrictions on in-hospital mortality, complication rates, and FTR in patients suffering traumatic injuries. Data from the National Trauma Data Bank (NTDB) were retrospectively reviewed (Research Data Set 2007-2008 and version 7.2). Patients admitted to Level I or II teaching institutions were dichotomized into pre-duty hour restriction (2002-2003) and post-duty hour restriction (2007-2008) time periods. Patients who had nonsurvivable injuries (any region Abbreviated Injury Scale score = 6), died within 48 hours, or had missing data were excluded. Multivariate logistic regression was used to adjust for differences in patient characteristics and derive adjusted outcomes. Level I and II teaching institutions in the NTDB. All patients with trauma admitted to a Level I or II teaching institution between January 1, 2002 and June 30, 2003 and between January 1, 2007 and December 31, 2008. Although overall adjusted in-hospital mortality was decreased (adjusted odds ratio [AOR] = 0.7, p < 0.001) in the post-duty hour restriction era, overall complications (AOR = 2.0, p < 0.001) and FTR (AOR = 2.0, p < 0.001) were significantly higher. Although there may be some benefit to resident duty hour restrictions, there is still room for improvement in patient care. Individual institutions should carefully review their own complication data to identify preventable systems issues, such as poor handoffs, and opportunities for increased resident supervision. Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
    No preview · Article · Aug 2015 · Journal of Surgical Education
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    ABSTRACT: Trauma patients with diabetes mellitus (DM) represent a unique population as the acute injury and the underlying disease may both cause hyperglycemia that leads to poor outcomes. We investigated how insulin-dependent DM (IDDM) and noninsulin-dependent DM (NIDDM) impact mortality after serious trauma without brain injury. The National Trauma Data Bank (NTDB) version 7.0 was queried for all patients with moderate to severe traumatic injury [injury severity score (ISS) >9]. Patients were excluded if missing data, age <10 years, severe brain injury [head abbreviated injury scale (AIS) >3], dead on arrival or any AIS = 6. Logistic regression modeled the association between DM and mortality as well as IDDM, NIDDM and mortality. Overall 166,103 trauma patients without brain injury were analyzed. Mortality was 7.6 and 4.4 % in patients with and without DM, respectively (p < 0.01). Mortality was 9.9 % for patients with IDDM and 6.7 % for NIDDM (p < 0.01). The increased mortality associated with DM was only significantly higher for DM patients in their forties (5.6 vs. 3.3 %, p < 0.01). Regression analyses demonstrated that DM (AOR 1.14, p = 0.04) and IDDM (AOR 1.46, p < 0.01) were predictors of mortality compared to no DM, but NIDDM was not (AOR 1.02, p = 0.83). While DM was a predictor for higher mortality after serious trauma, this increase was only observed in IDDM and not NIDDM. Our findings suggest IDDM patients who present after serious trauma are unique and attention to their hyperglycemia and related insulin therapy may play a critical role in recovery.
    No preview · Article · Aug 2015 · European Journal of Trauma and Emergency Surgery

Publication Stats

1k Citations
335.03 Total Impact Points

Institutions

  • 2009-2015
    • Cedars-Sinai Medical Center
      • • Cedars Sinai Medical Center
      • • Department of Surgery
      Los Ángeles, California, United States
  • 2006-2010
    • University of Southern California
      • • Division of Colorectal Surgery
      • • Department of Pathology
      Los Angeles, California, United States
  • 2007-2009
    • University of California, Los Angeles
      Los Ángeles, California, United States