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High velocity penetrating wounds to the neck: Lessons learned from the battlefields in Afghanistan and Iraq
QUALITY, OUTCOMES, AND COSTS I Expedited treatment of lower extremity gunshot wounds
admission, ICU LOS, the need for invasive procedures, total hospital charges, discharge disposition, and payer information.
Javid Sadjadi, MD, Kelley Bullard, MD, Patrick Twomey, MD, Terrence Liu, MD, Alden Harken, MD, Greg Victorino, MD University of California-San Francisco-East Bay, Oakland, CA
RESULTS: The use of methamphetamines rose steadily from 2000 (1.6%) to 2006 (6.3%), and was associated with a higher frequency of penetrating injuries (24% vs. 7%;P⬍0.0001) and legal interventions (4% vs. 0%; P⬍0.01). Despite similar ICU LOS, total hospital LOS, and operative interventions, patients using methamphetamines required a higher number of intubations (P⬍0.005) and ICU admissions (P⬍0.0001). Subsequently, the hospitalization charges were markedly higher for the methamphetamine group (53056⫾3656 vs. 43792⫾1923; P⬍0.03), and a greater percentage of charges were billed directly to the patient or county (P⬍0.005).
INTRODUCTION: Conventional wisdom asserts that non-operative management of lower extremity gun shot wounds (GSWs) obligates admission for observation and adds angiography for trajectories close to major vessels. We hypothesized that many patients with these wounds can be simply identified as safe for early discharge from the Emergency Department (ED) without admission. METHODS: For five years we evaluated the following protocol. Patients with lower extremity GSWs were discharged within 6 hours if they: were hemodynamically stable, had no bony injury, had an ankle-brachial index ⬎ 0.9, and understood the need for early return if needed. Followup was deemed adequate because our urban trauma center was the sole available provider of care for more than 90% of the patients.
CONCLUSIONS: Despite controlling for injury severity, methamphetamine positive patients required higher levels of care resulting in significantly higher hospital charges and consumption of valuable hospital resources.
High velocity penetrating wounds to the neck: Lessons learned from the battlefields in Afghanistan and Iraq
RESULTS: During the study period we saw 362 patients with isolated lower extremity GSWs. Of these, 182 patients (50%) met criteria for early discharge directly from the ED. No patient subsequently developed ischemia, bleeding or limb loss. Three patients returned with complications: two wound infections and one delayed compartment syndrome secondary to pseudo-aneurysm. These all responded to standard care without late sequelae. The predictive accuracy of an evaluation of safe to discharge was 98%. This noninvasive outpatient strategy cost $180,600 annually whereas admit/ observation with duplex or arteriogram strategies would have cost $288,900 and $325,400 respectively.
Ian R Driscoll, MD, Paul F Hwang, MD, Michael M Fuenfer, MD, Craig D Shriver, MD, Alexander Stojadinovic, MD, Jayson D Aydelotte, MD Walter Reed Army Medical Center, Washington, DC INTRODUCTION: Soldiers in Afghanistan and Iraq are sustaining high-velocity penetrating cervical wounds from small arms, mortars, and improvised explosive devices (IED). This study examined the extent of these injuries, the use of surgical neck exploration at all echelons of care, and the incidence of complications.
CONCLUSIONS: This protocol identifies patients who can be safely discharged directly from the ED resulting in less hospital resource utilization and an acceptable complication rate.
METHODS: We examined fifty-two soldiers who sustained highvelocity penetrating cervical wounds in combat operations from 2003 to 2005. Injuries were organized by system and echelon of care at which they were treated. Complications were defined as permanent neurologic deficits, vascular repair failures, soft tissue defects requiring reconstruction, and in-hospital mortality.
Methamphetamine use by trauma patients: Current trends and consequences Jessica Deree, MD, Dale Fortlage, BA, Vishal Bansal, MD, Jeanne Lee, MD, Bruce Potenza, MD, Raul Coimbra, MD, PhD, FACS University of California, San Diego Medical Center, San Diego, CA INTRODUCTION: Methamphetamine use has become a major contributor to traumatic injury. The purpose of this study is to determine the current profile of methamphetamine positive trauma patients and to examine their utilization of hospital resources.
RESULTS: Injuries included esophageal (12%), tracheal (17%), neurological (17%), spinal (6%), vascular (42%), maxillo-facial (40%), and soft tissue (50%). Surgical neck exploration was performed on 65% at the first echelon of care (Combat Support Hospital, Forward Surgical Team), 19% at the second echelon (Landstuhl Regional Medical Center), and 2% at the third echelon (Walter Reed Army Medical Center). Permanent neurologic deficits occurred in 8%, vascular repair failure in 4%, complicated soft tissue defects in 6%, and death in 2%.
METHODS: In a retrospective review of the trauma registry from 2000 to 2006, patient demographics and injury mechanism were compared between patients testing positive and negative for methamphetamines. To accurately compare the effect on resources, a 4:1 cohort of toxicology negative patients matched by age, gender, mechanism of injury, and Abbreviated Injury Scale were compared to the methamphetamine positive group on length of stay (LOS), ICU
CONCLUSIONS: Soft tissue and vascular structures continue to be the most commonly injured after high-velocity penetrating cervical trauma. The high percentage of surgical neck explorations at the first and second echelons of care reflects the severity of injuries and imaging limitations in deployed settings. The low complication rates reflect the effectiveness of current algorithms in managing highvelocity penetrating neck wounds.
© 2007 by the American College of Surgeons Published by Elsevier Inc.
ISSN 1072-7515/07/$32.00
S67
admission, ICU LOS, the need for invasive procedures, total hospital charges, discharge disposition, and payer information.
Javid Sadjadi, MD, Kelley Bullard, MD, Patrick Twomey, MD, Terrence Liu, MD, Alden Harken, MD, Greg Victorino, MD University of California-San Francisco-East Bay, Oakland, CA
RESULTS: The use of methamphetamines rose steadily from 2000 (1.6%) to 2006 (6.3%), and was associated with a higher frequency of penetrating injuries (24% vs. 7%;P⬍0.0001) and legal interventions (4% vs. 0%; P⬍0.01). Despite similar ICU LOS, total hospital LOS, and operative interventions, patients using methamphetamines required a higher number of intubations (P⬍0.005) and ICU admissions (P⬍0.0001). Subsequently, the hospitalization charges were markedly higher for the methamphetamine group (53056⫾3656 vs. 43792⫾1923; P⬍0.03), and a greater percentage of charges were billed directly to the patient or county (P⬍0.005).
INTRODUCTION: Conventional wisdom asserts that non-operative management of lower extremity gun shot wounds (GSWs) obligates admission for observation and adds angiography for trajectories close to major vessels. We hypothesized that many patients with these wounds can be simply identified as safe for early discharge from the Emergency Department (ED) without admission. METHODS: For five years we evaluated the following protocol. Patients with lower extremity GSWs were discharged within 6 hours if they: were hemodynamically stable, had no bony injury, had an ankle-brachial index ⬎ 0.9, and understood the need for early return if needed. Followup was deemed adequate because our urban trauma center was the sole available provider of care for more than 90% of the patients.
CONCLUSIONS: Despite controlling for injury severity, methamphetamine positive patients required higher levels of care resulting in significantly higher hospital charges and consumption of valuable hospital resources.
High velocity penetrating wounds to the neck: Lessons learned from the battlefields in Afghanistan and Iraq
RESULTS: During the study period we saw 362 patients with isolated lower extremity GSWs. Of these, 182 patients (50%) met criteria for early discharge directly from the ED. No patient subsequently developed ischemia, bleeding or limb loss. Three patients returned with complications: two wound infections and one delayed compartment syndrome secondary to pseudo-aneurysm. These all responded to standard care without late sequelae. The predictive accuracy of an evaluation of safe to discharge was 98%. This noninvasive outpatient strategy cost $180,600 annually whereas admit/ observation with duplex or arteriogram strategies would have cost $288,900 and $325,400 respectively.
Ian R Driscoll, MD, Paul F Hwang, MD, Michael M Fuenfer, MD, Craig D Shriver, MD, Alexander Stojadinovic, MD, Jayson D Aydelotte, MD Walter Reed Army Medical Center, Washington, DC INTRODUCTION: Soldiers in Afghanistan and Iraq are sustaining high-velocity penetrating cervical wounds from small arms, mortars, and improvised explosive devices (IED). This study examined the extent of these injuries, the use of surgical neck exploration at all echelons of care, and the incidence of complications.
CONCLUSIONS: This protocol identifies patients who can be safely discharged directly from the ED resulting in less hospital resource utilization and an acceptable complication rate.
METHODS: We examined fifty-two soldiers who sustained highvelocity penetrating cervical wounds in combat operations from 2003 to 2005. Injuries were organized by system and echelon of care at which they were treated. Complications were defined as permanent neurologic deficits, vascular repair failures, soft tissue defects requiring reconstruction, and in-hospital mortality.
Methamphetamine use by trauma patients: Current trends and consequences Jessica Deree, MD, Dale Fortlage, BA, Vishal Bansal, MD, Jeanne Lee, MD, Bruce Potenza, MD, Raul Coimbra, MD, PhD, FACS University of California, San Diego Medical Center, San Diego, CA INTRODUCTION: Methamphetamine use has become a major contributor to traumatic injury. The purpose of this study is to determine the current profile of methamphetamine positive trauma patients and to examine their utilization of hospital resources.
RESULTS: Injuries included esophageal (12%), tracheal (17%), neurological (17%), spinal (6%), vascular (42%), maxillo-facial (40%), and soft tissue (50%). Surgical neck exploration was performed on 65% at the first echelon of care (Combat Support Hospital, Forward Surgical Team), 19% at the second echelon (Landstuhl Regional Medical Center), and 2% at the third echelon (Walter Reed Army Medical Center). Permanent neurologic deficits occurred in 8%, vascular repair failure in 4%, complicated soft tissue defects in 6%, and death in 2%.
METHODS: In a retrospective review of the trauma registry from 2000 to 2006, patient demographics and injury mechanism were compared between patients testing positive and negative for methamphetamines. To accurately compare the effect on resources, a 4:1 cohort of toxicology negative patients matched by age, gender, mechanism of injury, and Abbreviated Injury Scale were compared to the methamphetamine positive group on length of stay (LOS), ICU
CONCLUSIONS: Soft tissue and vascular structures continue to be the most commonly injured after high-velocity penetrating cervical trauma. The high percentage of surgical neck explorations at the first and second echelons of care reflects the severity of injuries and imaging limitations in deployed settings. The low complication rates reflect the effectiveness of current algorithms in managing highvelocity penetrating neck wounds.
© 2007 by the American College of Surgeons Published by Elsevier Inc.
ISSN 1072-7515/07/$32.00
S67