Comparison Of Emergent And Late V. Urgent Spinal Fixation Outcomes

244

ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS

normal patients with penetrating chest trauma. It can successfully exclude the absence of significant thoracic injury with a NPV of 99%. Even in patients with high clinical suspicion of thoracic injury with negative chest CT, initial non-operative management is still appropriate with exploration based on clinical deterioration.

27.6. Predicting Six-Month Posttraumatic Stress Disorder Symptoms And Quality Of Life In An Injured Trauma Population. J. L. Anderson, K. J. Brasel, T. DeRoon-Cassini; Medical College of Wisconsin, Milwaukee, WI Introduction: This study investigated the incidence of PTSD in a civilian trauma population following hospitalization and at six months. We hypothesized that trauma mechanism impacts a patient’s risk for developing PTSD, which negatively impacts quality of life. Factors present during initial hospitalization can predict PTSD at six months. Methods: A screening program was implemented at a Level I trauma center. Patients were administered the SF-36 Health Survey and the PTSD civilian checklist. Patients met criteria for PTSD with a score of
45. Individual SF-36 domain scores, physical component scores (PCS), and mental component scores (MCS) were calculated. PTSD symptom severity in assaultive vs. non-assaultive injury was analyzed using the independent samples t-test. Two-way analysis of variance was used to assess main and interaction effects of PTSD symptom severity and trauma type on quality of life. Spearman’s rank order correlation and hierarchical regression investigated predictive power of age, gender, injury mechanism, heart rate, perceived injury severity score (ISS), and perceived life threat on development of PTSD at six months. Results: 22.5% of admitted patients met criteria for PTSD and 18.6% met criteria at six months. Patients suffering from assaultive injury had greater PTSD symptom severity scores compared to patients with non-assaultive injuries. PCS and MCS did not differ based on interaction between PTSD symptom severity and trauma type after injury or at six months. PCS and MCS negatively correlated with increasing PTSD symptom severity scores. Assaultive mechanism, perceived ISS and perceived life threat were predictive of PTSD at six months. Conclusions: Greater than one in five trauma patients meet criteria for PTSD immediately following injury and remains significant at six months. Early PTSD screening programs may impact quality of life.

Spearman’s Rank Order Correlation and Hierarchical Multiple Regression between PTSD Symptom Severity Scores at Six-months with Selected Variables Variable

b

Step 1 Assaultive mechanism -12.58 Scene heart rate .08 Step 2 Perceived injury severity score 6.18 Perceived life threat 1.51

SE ß

ß

5.33 .06

-.27 .16

1.82 .46

.34 .33

R2

delta R2

.11

.35

.24

27.7. Clinical Predictors Of Cervical Spine Injury In Patients. G. Dulan,1 A. Raniere,2 R. Huang,2 N. Garcia,3 A. Fischer2; 1 University of Texas, Southwestern, Dallas, Tx; 2Children’s Medical Center, Dallas, Tx; 3Dell Children’s Medical Center, Austin, Tx Introduction: Clearance of a cervical spine in the young pediatric population (3 years old) can be difficult for many reasons. This

age is often non-cooperative and there is no clear paradigm for age appropriate clearance of the cervical spine in the literature. Several studies have suggested an increased prevalence of cervical spine injury (CSI) in children who are in a motor vehicle accident. Motor vehicle accidents (MVC) are the most common high velocity trauma for this population. The purpose of this study was to characterize pre-hospital and hospital clinical predictors of CSI in young children involved in MVC. Methods: An IRB approved, retrospective chart review was performed on patients 3 years old who were involved in a MVC from January 2005 to December 2009 and evaluated at a Level 1 Trauma Center. Data collected included mechanism of injury (rollover, t-bone, ejection, speed), Glasgow coma score (GCS), neurologic exam, and radiologic modalities used to clear the cervical spine, radiologic findings, and clinical outcomes. Statistical significance was set at p<0.05 for all comparisons. Results: For the period of review, 204 children,  3 years old involved in a MVC, were evaluated for CSI. 32 (15.7%) children were identified with CSI. Demographics (gender, age and race) were similar in both injured and uninjured patients. GCS, ISS and a mechanism of ejection all were significantly different in those with a CSI (p<0.02). A GCS of  8 increased the odds of having CSI by 3.5 times (p ¼ 0.002). The three mechanisms, ejection (95% [CI] ¼ 1.18-6.64, p ¼ 0.02), ejection & roll over (95% CI ¼1.604-15.59, p ¼ 0.003) and ejection & high speed (95%CI ¼ 2.026-24.53, p ¼ 0.001) were found to increase the odds ratio of having a CSI 2.8, 5 and 7 fold respectively. No missed injuries were identified. Conclusions: MVC is known to be the most common high velocity trauma to children. Our study showed that this is a subset of trauma with a uniquely higher percentage of CSI injury than previously reported. GCS  8, ejection, ejection & high speed, and ejection & roll over should increase clinical suspicion for CSI in the youngest patients in motor vehicle accidents. The higher incidence of CSI in MVC demonstrates that MVC may be the preferred model to analyze the best clinical protocol for cervical spine clearance.

27.8. Comparison Of Emergent And Late V. Urgent Spinal Fixation Outcomes. C. V. Villegas,1 A. H. Haider,1 P. R. Neubauer,3 D. T. Efron,1 E. B. Schneider,1 B. L. Zarzaur2; 1 Center for Surgical Trials and Outcomes, Johns Hopkins School of Medicine, Baltimore, MD; 2Department of Surgery, University of Tennessee Health Science Center, Memphis, TN; 3Orthopedic and Spine Surgery, Johns Hopkins School of Medicine, Baltimore, MD Introduction: Recent studies indicate that early fixation of spinal fractures after blunt injury (<72 hours) is associated with improved outcomes and less resource utilization, leading some to advocate for rapid operative intervention. However, as has been demonstrated with other fractures, very early intervention may be associated with deleterious outcomes. The purpose of this study is to explore the relation between timing of operative spinal fixation in blunt trauma patients and outcomes. Methods: Patients (>14 years old) in the National Trauma Data Bank (2007-8) who underwent spinal fixation were included and grouped by time to spinal fixation: Emergent (0-6 h), Urgent (24-72 h), and Late (109-240 h). Primary outcome was mortality, and secondary outcomes were presence of complications [pneumonia (PNA), ARDS, acute renal failure, sepsis, or decubitus ulcer] and resource utilization (days in the ICU and on a ventilator). Logistic or Poisson regression was used to determine the effect of fixation time on outcomes, controlling for patient (age, gender, minority, insurance status) and injury [hypotension and GCS motor on presentation, spinal cord injury (SCI), Injury Severity Score, severe head injury, Abbreviated Injury Scale for spine, and injury mechanism] characteristics. Cluster analysis controlled for intra-hospital variation. Results: Of the 11,102 patients who met

ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS study criteria, there were 6,540 Emergent, 3,344 Urgent, and 1,218 Late cases. Overall, 4.7% of the patients were hypotensive on presentation, and 39.4% of them had a concomitant SCI. Adjusted analysis revealed an increased odds of PNA [Odds Ratio (OR) 1.51, 95% Confidence Interval (95% CI) 1.13-2.02]and decubiti (OR 1.56, 95% CI 1.04-2.35) for Emergent relative to Urgent cases while no differences were seen between Late and Urgent fixations. None of the groups showed differences in mortality, ARDS, or sepsis rates. Similarly, adjusted analysis indicated no difference in days on a ventilator, but Late fixation cases showed a 22% increase in their ICU stay compared to those fixed Urgently. Conclusions: Timing of spinal fixation after blunt injury does not significantly impact mortality. However, Emergent fixation is associated with an increased rate of post-operative complications. Patients undergoing spinal fracture fixation early after injury should be adequately resuscitated, and it may be appropriate to delay fixation at least 24 hours after injury so that patients are physiologically optimized, especially for neurologically stable patients.

245

intensity (using the Injury Severity Score), hypotension on arrival to ED, mechanism of injury, insurance status and year of admission. Results: Of the approximately 1.8 million patients in the databank, 83,566 patients met the inclusion criteria. Of these, 29.2% patients had a positive head CT scan and 4.2% underwent a NSP. After adjusting for patient and injury severity factors: increasing age (figure), Hispanic ethnicity and injury mechanism significantly predicted a positive finding on head CT scan. Whereas, males, African Americans and those injured due to a fall were more likely to require a NSP (table). Older patients (age>65) were less likely to receive a NSP. Hypotension and insurance status did not significantly predict outcomes. Conclusions: Approximately 1/3rd patients had a positive head CT and a remarkable 4% of patients who presented with a normal GCS required a neurosurgical procedure. Older age, male gender, non-Caucasian ethnicity and mechanism of injury are significant predictors of positive finding on head CT scans or of neurosurgical procedures in patients with minor head injury. This study highlights patient and injury specific characteristics that may help in identifying patients with supposedly minor head injury who will benefit from a head CT scan.

Adjusted Outcomes of Emergent (0-6 h) and Late (109-240 h) v. Urgent (25-72 h) Spinal Fixation Total n¼11,102 Logistic Regression Mortality PNA ARDS ARF Sepsis Decubitus Ulcer Poisson Regression Days in ICU Days on Ventilator

Emergent, 0-6h* (n¼6,540)

Late, 109-240h* (n¼1,218)

OR (95% CI) 1.42 (0.87-2.33) 1.25 (0.63-2.48) 1.51 (1.13-2.02) 1.15 (0.83-1.59) 1.18 (0.81-1.74) 0.94 (0.60-1.47) 0.68 (0.37-1.25) 0.65 (0.28-1.54) 1.44 (0.89-2.33) 0.69 (0.39-1.20) 1.56 (1.04-2.35) 1.10 (0.72-1.70) Incidence Rate Ratio (95% CI) 0.92 (0.84-1.01) 1.22 (1.08-1.37) 0.98 (0.83-1.16) 1.17 (0.97-1.41)

Significant Predictors of Positive Head CT or Neurosurgical Procedures (NSP) in Patients with Minor Head Injury Total n¼ 83,566

Positive CT (n¼ 24,414)

Co-Variates

Adjusted Odds (95% CI)

NSP (n¼3,476)

Male gender Race Caucasian (Ref) African American Hispanic Mechanism of injury Falls (Ref) MVC

0.97 (0.92-1.03)

1.27 (1.16-1.39)

1 0.96 (0.89-1.04) 1.11(1.01-1.22)

1 1.21 (1.08-1.36)

1 0.64 (0.59-0.68)

1 0.68 (0.62-0.76)

*Reference group is the Urgently (25-72h) fixated patients.

27.9. Predictors Of Positive Head CT Scan And Neurosurgical Procedure Among Patients With A Normal GCS: An Analysis Of The National Trauma Data Bank. M. T. Kisat,2 S. Zafar,2 C. V. Villegas,1 E. B. Schneider,1 A. Latif,1 E. R. Haut,1 K. A. Stevens,1 D. T. Efron,1 A. H. Haider1; 1Johns Hopkins Center for Surgery Trials and Outcomes Research, Baltimore, Maryland; 2Aga Khan University Medical College, Karachi, Sindh Introduction: Several prediction rules and clinical pathways have been established that recommend obtaining a Head CT for trauma patients with a Glasgow Coma Score (GCS) less than 15. However, among patients who present to the Emergency Department (ED) with a normal GCS of 15 and reported minor head injury, there is considerable debate as to which patients require a Head CT scan. The objective of this study is to determine patient and injury characteristics that predict a positive head CT scan or a Neurosurgical Procedure (NSP) among patients with blunt head injury and a normal GCS. Methods: Retrospective analysis of the National Trauma Data Bank v 7.1 (2002-2006) was performed. Patients aged 16 years or older who presented to the ED with a history of blunt head injury and GCS of 15 were included. A positive head CT scan was the primary outcome while a NSP (for diagnostic purposes e.g. placement of intracranial pressure monitor or for therapeutic purposes such as a hemicraniectomy) was the secondary outcome. Multivariate logistic regression was used to determine predictors of each outcome after adjusting for the following covariates: age, gender, ethnicity, severity of head injury (using Abbreviated Injury Scale, head region), overall injury

27.10. 11-Year Longitudinal Study Of 19,169 Trauma Patients: Implications For An Aging United States Population. J. M. Huston, L. J. Hydo, J. E. McCormack, E. Huang, D. Wolbrom, A. Haleem, L. T. Merriam, M. J. Shapiro; Stony Brook University Medical Center, Stony Brook, New York