Randall S Friese

Tucson Medical Center, Tucson, Arizona, United States

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Publications (197)487.85 Total impact

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    ABSTRACT: Blunt diaphragmatic rupture (BDR) is uncommon with a reported incidence range of 1%–2%. The true incidence is not known. Bilateral BDR is particularly rare. We presented a case of bilateral BDR and we think that the incidence is under-recognised thanks to an easily missed and difficult to diagnose right sided injury.
    Full-text · Article · Nov 2015
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    ABSTRACT: Background: The standard approach to vascular trauma involves arterial exposure and reconstruction using either a vein or polytetrafluoroethylene graft. We have developed a novel technique to repairing arterial injuries by deploying commercially available vascular stents through an open approach, thus eliminating the need for suture anastomosis. The objective of this study was to evaluate the feasibility, stent deployment time (SDT), and stent patency of this technique in a ewe vascular injury model. Methods: After proximal and distal control, a 2-cm superficial femoral arterial segment was resected in 8 Dorper ewes to simulate an arterial injury. Two stay sutures were placed in the 3- and 9-o'clock positions of the transected arterial ends to prevent further retraction. Ten milliliters of 10-IU/mL heparinized saline was flushed proximally and distally. An arteriotomy was then created 2.5 cm from the transected distal end through which we deployed Gore Viabahn stents with a 20% oversize and at least 1-cm overlap with the native vessel on either end. The arteriotomy was then closed with 3 (1) interrupted 6-0 Prolene sutures. The ewes were fed acetylsalicylic acid 325 mg daily. Duplex was performed at 2 months postoperatively to evaluate stent patency. SDT was defined as time from stay suture placement to arteriotomy closure. Results: The 8 ewes weighed a mean (SD) of 34.4 (4.3) kg. The mean (SD) superficial femoral arterial was 4.3 (0.6) mm. Six 5 mm × 5 cm and two 6 mm × 5 cm Gore Viabahn stents were deployed. The mean (SD) SDT was 34 (19) minutes, with a trend toward less time with increasing experience (SDTmax, 60 minutes; SDTmin, 10 minutes). Duplex performed at 2 months postoperatively showed stent patency in five of eight stents. There was an association between increasing SDT and stent thrombosis. Conclusion: Open deployment of commercially available vascular stents to treat vascular injuries is a conceptually sound and technically feasible alternative to standard open repair. Larger studies are needed to refine this technique and minimize stent complications, which are likely technical in nature.
    No preview · Article · Oct 2015
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    ABSTRACT: Background: Nonoperative management of hemodynamically stable children with Solid Organ Injury (SOI) has become standard of care. The aim of this study is to identify differences in management of children with SOI treated at Adult Trauma Centers (ATC) versus Pediatric Trauma Centers (PTC). We hypothesized that patients treated at ATC would undergo more procedures than PTC. Methods: Patients younger than 18 years old with isolated SOI (spleen, liver, kidney) who were treated at level I-II ATC or PTC were identified from the 2011-2012 National Trauma Data Bank. The primary outcome measure was the incidence of operative management. Data was analyzed using multivariate logistic regression analysis. Procedures were defined as surgery or transarterial embolization (TAE). Results: 6799 children with SOI (spleen: 2375, liver: 2867, kidney: 1557) were included. Spleen surgery was performed more frequently at ATC than PTC {101 (7.7%) vs. 52 (4.9%); P=0.007}. After adjusting for potential confounders (grade of injury, age, gender and injury severity score), admission at ATC was associated with higher odds of splenic surgery (OR: 1.5, 95% CI: 1.02-2.25; p=0.03). 11 and 8 children underwent kidney and liver operations respectively. TAE was performed in 17 patients with splenic, 34 with liver and 14 with kidney trauma. There was no practice variation between ATC and PTC regarding kidney and liver operations or TAE incidence. Conclusions: Operative management for SOI was more often performed at ATC. The presence of significant disparity in the management of children with splenic injuries justifies efforts to use these surgeries as a reported national quality indicator for trauma programs.
    No preview · Article · Oct 2015 · Journal of Pediatric Surgery
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    ABSTRACT: REDEFINING THE ASSOCIATION BETWEEN OLD AGE AND POOR OUTCOMES AFTER TRAUMA: THE IMPACT OF FRAILTY SYNDROME INTRODUCTION: Frailty syndrome (FS) is a well-established measure of poor outcomes in geriatric patients. The aim of this study was to quantify the prevalence of FS in geriatric trauma patients and determine its association with trauma readmissions, repeat falls, and 6 month mortality. METHODS: We performed a 2-year prospective cohort analysis of all geriatric (age ≥ 65 yrs.) trauma patients. FS was assessed using a trauma specific frailty index (TSFI). Patients were stratified into: Non-frail: TSFI ≤ 0.12, Pre-frail: TSFI = 0.13-0.27, and Frail: TSFI > 0.27. Patients were contacted at six months to assess their outcomes. Regression analysis was performed after adjusting for age, gender, injury severity (ISS), and vital parameters to assess independent association between TSFI and outcomes. RESULTS: A total of 350 patients were enrolled of which, 38% were frail and 26% were pre-frail. Frail patients were more likely to develop in-hospital complications compared to non-frail and pre-frail (non-frail: 12% vs pre-frail: 17.4% vs frail: 33.4%, p=0.02). ). Frail patients were more likely to have adverse discharge disposition compared to non-frail and pre-frail (non-frail:8% vs. pre-frail:18% vs. frail: 47%, p=0.001). Six month follow up was recorded in 80% of the patients. On analysis of 6 month outcomes, frail patients were more likely to have trauma related readmission to the hospital (OR [95%CI], 1.4 [1.2-3.6]) and repeated falls (OR [95%CI], 1.6 [1.1-2.5]) compared to non-frail patients. Overall mortality at 6 months was 2.8% (n=10) and frail elderly patients were more likely to die (OR [95%CI], 1.1 [1.04-4.7]) compared to non-frail patients. CONCLUSION: Frailty syndrome is prevalent among geriatric trauma patients. Trauma specific frailty index is superior to age and ISS for predicting trauma related re-admissions, recurrent falls, and six-month mortality. Early focused intervention in frail geriatric patients is warranted to improve long-term outcomes.
    Full-text · Article · Oct 2015 · Journal of the American College of Surgeons
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    ABSTRACT: Impact of Admission Hypothermia on Outcomes in Severe Traumatic Brain Injury: Not So Cool! Introduction: The role of medically induced hypothermia in traumatic brain injury (TBI) has been well studied; however, the impact of non-therapeutic hypothermia on outcomes in TBI remains unknown. The aim of this study was to assess the association between admission hypothermia and mortality after severe TBI. Methods: We did a 2-year (2011-2012) retrospective analysis of National Trauma Data Bank. We enrolled all patients with severe TBI (head AIS≥3 and other body AIS<3). Patients who presented with no signs of life, died in ED, intoxicated, and missing data on presenting temperature were excluded from the study. Patients were divided into two groups based on admission temperature: Hypothermic (admission temperature < 35ºC) and Normothermic (admission temperature ≥ 35ºC). Our outcome measures were mortality, hospital, and ICU length of stay. We performed missing values analysis and multiple imputation technique to account for missing data. Propensity score matching was performed adjusting for age, gender, ISS, systolic blood pressure, heart rate, and oxygen saturation. Results: After propensity score matching we included 4,788 patients (Hypothermic: 2,394 and Normothermic: 2,394). Mean age of the population was 45±24 years, 62% were male, median [IQR] h-AIS was 3[3-4], and median [IQR] ISS was 25[16-30]. There was no difference in basic demographics between the groups. Overall mortality was higher in hypothermic patients compared to normothermic (14.7% vs 12.4%, p=<0.001). Hypothermic patients were more likely to develop in-hospital complications (55% vs 44%, p <0.001) and had longer ICU length of stay (Median [IQR]: 3[1-8] vs 2[1-8], p=0.03). On regression analysis for mortality, with every ºc drop in admission temperature, odds of mortality increased significantly. (Fig) Conclusion: Admission hypothermia appears to be detrimental in traumatic brain injury outcomes. Further understanding of the pathophysiologic changes secondary to admission hypothermia in traumatic brain injury will help define preventive and treatment strategies in this group of patients.
    Full-text · Article · Oct 2015 · Journal of the American College of Surgeons
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    Full-text · Article · Oct 2015 · Journal of the American College of Surgeons

  • 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: Background: Multiple prior studies have suggested an association between survival and beta-blocker administration in patients with severe traumatic brain injury (TBI). However, it is unknown whether this benefit of beta-blockers is dependent on heart rate control. The aim of this study was to assess whether rate control affects survival in patients receiving metoprolol with severe TBI. Our hypothesis was that improved survival from beta-blockade would be associated with a reduction in heart rate. Methods: We performed a 7-y retrospective analysis of all blunt TBI patients at a level-1 trauma center. Patients aged >16 y with head abbreviated injury scale 4 or 5, admitted to the intensive care unit (ICU) from the operating room or emergency room (ER), were included. Patients were stratified into two groups: metoprolol and no beta-blockers. Using propensity score matching, we matched the patients in two groups in a 1:1 ratio controlling for age, gender, race, admission vital signs, Glasgow coma scale, injury severity score, mean heart rate monitored during ICU admission, and standard deviation of heart rate during the ICU admission. Our primary outcome measure was mortality. Results: A total of 914 patients met our inclusion criteria, of whom 189 received beta-blockers. A propensity-matched cohort of 356 patients (178: metoprolol and 178: no beta-blockers) was created. Patients receiving metoprolol had higher survival than those patients who did not receive beta-blockers (78% versus 68%; P = 0.04); however, there was no difference in the mean heart rate (89.9 ± 13.9 versus 89.9 ± 15; P = 0.99). Nor was there a difference in the mean of standard deviation of the heart rates (14.7 ± 6.3 versus 14.4 ± 6.5; P = 0.65) between the two groups. In Kaplan-Meier survival analysis, patients who received metoprolol had a survival advantage (P = 0.011) compared with patients who did not receive any beta-blockers. Conclusions: Our study shows an association with improved survival in patients with severe TBI receiving metoprolol, and this effect appears to be independent of any reduction in heart rate. We suggest that beta-blockers should be administered to all severe TBI patients irregardless of any perceived beta-blockade effect on heart rate.
    No preview · Article · Sep 2015 · Journal of Surgical Research
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    ABSTRACT: Importance: Domestic violence is an extremely underreported crime and a growing social problem in the United States. However, the true burden of the problem remains unknown. Objective: To assess the reported prevalence of domestic violence among trauma patients. Design, setting, and participants: A 6-year (2007-2012) retrospective analysis of the prospectively maintained National Trauma Data Bank. Trauma patients who experienced domestic violence and who presented to trauma centers participating in the National Trauma Data Bank were identified using International Classification of Diseases, Ninth Revision diagnosis codes (995.80-995.85, 995.50, 995.52-995.55, and 995.59) and E codes (E967.0-E967.9). Patients were stratified by age into 3 groups: children (≤18 years), adults (19-54 years), and elderly patients (≥55 years). Trend analysis was performed on April 10, 2014, to assess the reported prevalence of domestic violence over the years. Participants: Trauma patients presenting to trauma centers participating in the National Trauma Data Bank. Main outcomes and measures: To assess the reported prevalence of domestic violence among trauma patients. Results: A total of 16 575 trauma patients who experienced domestic violence were included. Of these trauma patients, 10 224 (61.7%) were children, 5503 (33.2%) were adults, and 848 (5.1%) were elderly patients. The mean (SD) age was 15.9 (20.6), the mean (SD) Injury Severity Score was 10.9 (9.6), and 8397 (50.7%) were male patients. Head injuries (46.8% of patients) and extremity fractures (31.2% of patients) were the most common injuries. A total of 12 515 patients (75.1%) were discharged home, and the overall mortality rate was 5.9% (n = 980). The overall reported prevalence of domestic violence among trauma patients was 5.7 cases per 1000 trauma center discharges. The prevalence of domestic violence increased among children (14.0 cases per 1000 trauma center discharges in 2007 to 18.5 case per 1000 trauma center discharges in 2012; P = .001) and adults (3.2 cases per 1000 discharges in 2007 to 4.5 cases per 1000 discharges in 2012; P = .001) over the 6-year period and remained unchanged for elderly patients (0.8 cases per 1000 discharges in 2007 to 0.96 cases per 1000 discharges in 2012; P = .09). On subanalysis of adults and elderly patients, the prevalence of domestic violence increased among both female (4.6 cases per 1000 discharges in 2007 to 5.3 cases per 1000 discharges in 2012; P = .001) and male patients (1.5 cases per 1000 discharges in 2007 to 2.8 cases per 1000 discharges in 2012; P = .001). Conclusions and relevance: Domestic violence is prevalent among trauma patients. Over the years, the reported prevalence of domestic violence has been increasing among children and adults, and continues to remain high among female trauma patients. A robust mandatory screening for evaluating domestic violence among trauma patients, along with a focused national intervention, is warranted.
    Full-text · Article · Sep 2015 · JAMA SURGERY
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    ABSTRACT: Differences in outcomes among trauma centers (TCs) and non-TCs (NTCs) in patients undergoing emergency general surgery (EGS) are well established. However; the impact of development of certified acute care surgery (ACS) programs on patient outcomes remains unknown. The aim of this study was to evaluate outcomes in patients undergoing EGS across TCs, NTCs, and TCs with ACS (ACS-TC). National estimates for EGS procedures were abstracted from the National Inpatient Sample database. Patients undergoing emergent procedures (appendectomy, cholecystectomy, hernia repair, as well as small and large bowel resections) were included. TCs were identified based on American College of Surgeons' verification. ACS-TC programs were recorded from the American Association for the Surgery of Trauma. Outcome measures were hospital length of stay, complications, and mortality. Regression analysis was performed after adjusting for age, sex, race, Charlson comorbidity index, and type of procedure. A total of 131,410 patients undergoing EGS were analyzed. Patients managed in ACS-TCs had shorter hospital stay (p = 0.045) and lower complication rate (p = 0.041) compared with patients managed in both TCs and NTCs. There was no difference in mortality in patients managed across the groups; however, there was a trend toward lower mortality in patients managed in ACS-TCs in comparison with TCs (p = 0.064) and NTCs (p = 0.089). The overall hospital costs were lower for patients managed in ACS-TCs compared with TCs (p = 0.036). TCs with ACS have improved outcomes in EGS procedures compared with both TCs and non-TCs. ACS training with the associated infrastructure standards may contribute to these improved outcomes. Therapeutic/care management study, level IV.
    No preview · Article · Jul 2015
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    ABSTRACT: BACKGROUND: Obesity measured by body mass index (BMI) is known to be associated with worse outcomes in trauma patients. Recent studies have assessed the impact of distribution of body fat measured by waist-hip ratio (WHR) on outcomes in nontrauma patients. The aim of this study was to assess the impact of distribution of body fat (WHR) on outcomes in trauma patients. METHODS: A 6-month (June to November 2013) prospective cohort analysis of all admitted trauma patients was performed at our Level 1 trauma center. WHR was measured in each patient on the first day of hospital admission. Patients were stratified into two groups: patients with WHR of 1 or greater and patients with WHR of less than 1. Outcome measures were complications and in-hospital mortality. Complications were defined as infectious, pulmonary, and renal complications. Regression and correlation analyses were performed. RESULTS: A total of 240 patients were enrolled, of which 28.8% patients (n = 69) had WHR of 1 or greater. WHR had a weak correlation with BMI (R2 = 0.231, R = 0.481). Eighteen percent (n = 43) of the patients developed complications, and the mortality rate was 10% (n = 24). Patients with a WHR of 1 or greater were more likely to develop in-hospital complications (32% vs. 13%, p = 0.001) and had a higher mortality rate (24% vs. 4%, p = 0.001) compared with the patients with a WHR of less than 1. In multivariate analysis, a WHR of 1 or greater was an independent predictor for the development of complications (odds ratio, 3.1; 95% confidence interval 1.08–9.2; p = 0.03) and mortality (odds ratio, 13.1; 95% confidence interval, 1.1–70; p = 0.04). CONCLUSION: Distribution of body fat as measured by WHR independently predicts mortality and complications in trauma patients. WHR is better than BMI in predicting adverse outcomes in trauma patients. Assessing the fat distribution pattern in trauma patients may help improve patient outcomes through focused targeted intervention. LEVEL OF EVIDENCE: Prognostic study, level II.
    No preview · Article · Jun 2015 · Journal of Trauma and Acute Care Surgery
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    ABSTRACT: Quality improvement initiatives have focused primarily on preventing in-hospital complications. Patients developing complications are at a greater 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. 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 we adjusted for demographics, mechanism of injury, abdominal abbreviated injury scale, initial vital signs, damage control laparotomy, and volume of crystalloids and blood products administered. 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 abdominal abbreviated injury scale was 25 [16-34, interquartile range]. Respiratory complications (n = 77) followed by infectious complications (n = 75) were the most common complications. The failure-to-rescue rate was 15.7% (n = 34/217). Age, blunt trauma, severe head injury, uninsured status, and blood products administered on the second day were independent predictor for failure-to-rescue. When major complications develop, age, uninsured status, severity of head injury, and prolonged resuscitation are associated independently with failure-to-rescue, whereas initial resuscitation, coagulopathy, and acidosis did not predict failure to rescue. Quality-of-care programs focus in patient level should be on improving the patient's insurance status, preventing secondary brain injury, and further development of resuscitation guidelines. Copyright © 2015 Elsevier Inc. All rights reserved.
    Full-text · Article · May 2015 · Surgery
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    ABSTRACT: Organ donation after cardiac death (DCD) is not optimal but still remains a valuable source of organ donation in trauma donors. The aim of this study was to assess national trends in DCD from trauma patients. A 12-year (2002 to 2013) retrospective analysis of the United Network for Organ Sharing database was performed. Outcome measures were the following: proportion of DCD donors over the years and number and type of solid organs donated. DCD resulted in procurement of 16,248 solid organs from 8,724 donors. The number of organs donated per donor remained unchanged over the study period (P = .1). DCD increased significantly from 3.1% in 2002 to 14.6% in 2013 (P = .001). There was a significant increase in the proportion of kidney (2002: 3.4% vs 2013: 16.3%, P = .001) and liver (2002: 1.6% vs 2013: 5%, P = .041) donation among DCD donors over the study period. DCD from trauma donors provides a significant source of solid organs. The proportion of DCD donors increased significantly over the last 12 years. Copyright © 2015 Elsevier Inc. All rights reserved.
    Full-text · Article · May 2015 · The American Journal of Surgery
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    ABSTRACT: Background: The use of prothrombin complex concentrate (PCC) to reverse acquired (coagulopathy of trauma) and induced coagulopathy (preinjury warfarin use) is well defined. Objective: To compare outcomes in patients with traumatic brain injury without warfarin therapy receiving PCC as an adjunct to fresh frozen plasma (FFP) therapy compared with patients receiving FFP therapy alone. Methods: All patients with traumatic brain injury coagulopathy without warfarin therapy who received PCC (25 IU/kg) in conjunction with FFP or FFP alone at our Level I trauma center were reviewed. Coagulopathy was defined as an international normalized ratio >1.5. The groups (PCC + FFP vs FFP alone) were matched using propensity score matching on a 1:2 ratio for age, sex, Glasgow Coma Scale score, Injury Severity Score, head Abbreviated Injury Scale score, and international normalized ratio (INR) on presentation. The primary outcome measure was time to craniotomy. Secondary outcome measures were blood product requirements, cost of therapy, and mortality. Results: A total of 1641 patients were reviewed, 222 of whom were included (PCC + FFP, 74; FFP, 148). The mean ± standard deviation age was 46.4 ± 21.7 years, the median (range) Glasgow Coma Scale score was 8 (3-12), and the mean ± standard deviation INR on presentation was 1.92 ± 0.6. PCC + FFP therapy was associated with an accelerated correction of INR (P = .001) and decrease in overall pack red blood cell (P = .035) and FFP (P = .041) administration requirement. Craniotomy was performed in 26.1% of patients (n = 58). Patients who received PCC + FFP therapy had faster time to craniotomy (P = .028) compared with patients who received FFP therapy alone. Conclusion: PCC as an adjunct to FFP decreases the time to craniotomy with faster correction of INR and concomitant decrease in the need for blood product requirement in patients with traumatic brain injury exclusive of prehospital warfarin therapy.
    Full-text · Article · May 2015 · Neurosurgery
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    ABSTRACT: To determine whether frail elderly adults are at greater risk of fracture after a ground-level fall (GLF) than those who are not frail. Prospective observational study. Level 1 trauma center. All elderly (≥65) adults presenting after a GLF over 1 year (N = 110; mean age ± SD 79.5 ± 8.3, 54% male). A Frailty Index (FI) was calculated using 50 preadmission frailty variables. Participants with a FI of 0.25 or greater were considered to be frail. The primary outcome measure was a new fracture; 40.1% (n = 45) of participants presented with a new fracture. The secondary outcome was discharge to an institutional facility (rehabilitation center or skilled nursing facility). Multivariate logistic regression was performed. Forty-three (38.2%) participants were frail. The median Injury Severity Score was 14 (range 9-17), and the mean FI was 0.20 ± 0.12. Frail participants were more likely than those who were not frail to have fractures (odds ratio (OR) = 1.8, 95% confidence interval (CI) = 1.2-2.3, P = .01). Thirty-six (32.7%) participants were discharged to an institutional facility. Frail participants were more likely to be discharged to an institutional facility (OR = 1.42, 95% CI = 1.08-3.09, P = .03) after a GLF. Frail individuals have a higher likelihood of fractures and discharge to an institutional facility after a GLF than those who are not frail. The FI may be used as an adjunct for decision-making when developing a discharge plan for an elderly adult after a GLF. © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.
    Full-text · Article · Apr 2015 · Journal of the American Geriatrics Society
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    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.
    Full-text · Article · Mar 2015 · Journal of Trauma and Acute Care Surgery
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    ABSTRACT: Computed Tomography Angiography (CTA) is being used to identify traumatic intracranial aneurysms (TICA) in patients with findings such as skull fracture and intracranial haemorrhage on initial Computed Tomography (CT) scans after blunt traumatic brain injury (TBI). However, the incidence of TICA in patients with blunt TBI is unknown. The aim of this study is to report the incidence of TICA in patients with blunt TBI and to assess the utility of CTA in detecting these lesions. A 10-year retrospective study (2003-2012) was performed at a Level 1 trauma centre. All patients with blunt TBI who had an initial non-contrasted head CT scan and a follow-up head CTA were included. Head CTAs were then reviewed by a single investigator and TICAs were identified. The primary outcome measure was incidence of TICA in blunt TBI. A total of 10 257 patients with blunt TBI were identified, out of which 459 patients were included in the analysis. Mean age was 47.3 ± 22.5, the majority were male (65.1%) and median ISS was 16 [9-25]. Thirty-six patients (7.8%) had intracranial aneurysm, of which three patients (0.65%) had TICAs. The incidence of traumatic intracranial aneurysm was exceedingly low (0.65%) over 10-years. This study adds to the growing literature questioning the empiric use of CTA for detecting vascular injuries in patients with blunt TBI.
    Full-text · Article · Mar 2015 · Brain Injury
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    ABSTRACT: Hypopituitarism after hypovolemic shock is well established in certain patient cohorts. However; the effects of hemorrhagic shock on pituitary function in trauma patients remains unknown. The aim of this study was to assess pituitary hormone variations in trauma patients with hemorrhagic shock. Patients with acute traumatic hemorrhagic shock presenting to our level 1 trauma center were prospectively enrolled. Hemorrhagic shock was defined as systolic blood pressure (SBP) ≤ 90 mmHg on arrival or within 10 minutes of arrival in the emergency department, and requirement of ≥2 units of packed red blood cell transfusion. Serum cortisol and serum pituitary hormones (vasopressin [ADH], adrenocorticotrophic hormone [ACTH], thyroid stimulating hormone [TSH], follicular stimulating hormone [FSH], and luteinizing hormone [LH]) were measured in each patient on admission and at 24, 48, 72, and 96 hours after admission. Outcome measure was variation in pituitary hormones. A total of 42 patients were prospectively enrolled; mean age was 37 ± 12 years, mean SBP 85.4 ± 64.5 mmHg, and median Injury Severity Score was 26 (range 18 to 38). There was an increase in the levels of cortisol (p < 0.001), a decrease in the levels of ACTH (p < 0.001) and ADH (p < 0.001), but no change in the levels of LH (p = 0.30), FSH (p = 0.07), and TSH (p = 0.89) over 96 hours. Ten patients died during their hospital stay. Patients who died had higher mean admission ADH levels (p = 0.03), higher mean admission ACTH levels (p < 0.001), and lower mean admission cortisol levels (p = 0.04) compared with patients who survived. Acute hypopituitarism does not occur in trauma patients with acute hemorrhagic shock. In patients who died, there was a decrease in cortisol levels, which appears to be adrenal in origin. Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
    Full-text · Article · Mar 2015 · Journal of the American College of Surgeons
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    ABSTRACT: Management of traumatic brain injury (TBI) is focused on preventing secondary brain injury. Remote ischemic conditioning (RIC) is an established treatment modality that has been shown to improve patient outcomes secondary to inflammatory insults. The aim of our study was to assess whether RIC in trauma patients with severe TBI could reduce secondary brain injury. This prospective consented interventional trial included all TBI patients admitted to our Level 1 trauma center with an intracranial hemorrhage and a Glasgow Coma Scale (GCS) score of 8 or lower on admission. In each patient, four cycles of RIC were performed within 1 hour of admission. Each cycle consisted of 5 minutes of controlled upper limb (arm) ischemia followed by 5 minutes of reperfusion using a blood pressure cuff. Serum biomarkers of acute brain injury, S-100B, and neuron-specific enolase (NSE) were measured at 0, 6, and 24 hours. Outcome measure was reduction in the level of serum biomarkers after RIC. A total of 40 patients (RIC, 20; control, 20) were enrolled. The mean (SD) age was 46.15 (18.64) years, the median GCS score was 8 (interquartile range, 3-8), and the median head Abbreviated Injury Scale (AIS) score was 3 (interquartile range, 3-5), and there was no difference between the RIC and control groups in any of the baseline demographics or injury characteristics including the type and size of intracranial bleed or skull fracture patterns. There was no difference in the 0-hour S-100B (p = 0.9) and NSE (p = 0.72) level between the RIC and the control group. There was a significant reduction in the mean levels of S-100B (p = 0.01) and NSE (p = 0.04) at 6 hours and 24 hours in comparison with the 0-hour level in the RIC group. This study showed that RIC significantly decreased the standard biomarkers of acute brain injury in patients with severe TBI. Our study highlights the novel therapeutic role of RIC for preventing secondary brain insults in TBI patients. Prospective interventional study, level II.
    Full-text · Article · Mar 2015 · Journal of Trauma and Acute Care Surgery

Publication Stats

2k Citations
487.85 Total Impact Points

Institutions

  • 2015
    • Tucson Medical Center
      Tucson, Arizona, United States
  • 2009-2015
    • The University of Arizona
      • Department of Surgery
      Tucson, Arizona, United States
    • Southern Adventist University
      Collegedale, Tennessee, United States
  • 2014
    • Johns Hopkins University
      Baltimore, Maryland, United States
  • 2005-2010
    • University of Texas Southwestern Medical Center
      • • Division of Burn/Trauma/Critical Care
      • • Department of Surgery
      Dallas, Texas, United States
  • 2005-2009
    • University of Texas at Dallas
      Richardson, Texas, United States
  • 1995-2006
    • University of Colorado
      • Department of Surgery
      Denver, Colorado, United States