Predicting the Need for Damage Control Surgery in Penetrating Trauma by Using Shock Index

Vol. 223, No. 4S2, October 2016

discharge disposition to facility (p¼0.26), and mortality (p¼0.38) between patients managed in AC and PC.

Scientific Poster Presentations: 2016 Clinical Congress

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was significant. Plasma was associated with improved survival in MIH patients (OR 2.86; 95% CI 1.08e7.56). CONCLUSIONS: Use of plasma was associated with improved survival in a subset of iTBI patients.

CONCLUSIONS: Our data demonstrates variability in use of head CT scan among pediatric TBI patient across adult and pediatric trauma centers without differences in patient outcomes. Further understanding the differences in practices in management of TBI across pediatric and adult centers is required. Plasma Transfusion Is Associated with Improved Survival after Isolated Traumatic Brain Injury in Patients with Multifocal Intracranial Hemorrhage Ronald Chang, MD, Lindley E Folkerson, MD, Duncan Sloan, Jeffrey S Tomasek, MD, Ryan S Kitagawa, MD, Huimahn A Choi, MD, Charles E Wade, PhD, John B Holcomb, MD, FACS University of Texas Health Science Center at Houston, Houston, TX INTRODUCTION: Observational data and high quality large animal models suggest that resuscitation with plasma improves survival and neurologic outcomes after concomitant hemorrhagic shock and traumatic brain injury (TBI). We hypothesized that plasma was associated with improved survival to hospital discharge in adult trauma patients presenting with isolated TBI (iTBI). METHODS: Retrospective review of adult trauma patients from 2011 to 2015 with iTBI defined as head Abbreviated Injury Scale (AIS) 3 and AIS of all other body regions <3. Patients were dichotomized into “plasma” or “no plasma” groups based on transfusion of plasma within 4 hours of presentation. A purposeful multivariate logistic regression model was constructed. After testing for interaction, sub-group analysis was performed based on pattern of brain injury on initial head CT. RESULTS: Of the 656 patients included for analysis, 197 (30%) received plasma. These patients were older, more severely injured, more coagulopathic, more hypotensive, and less likely to survive (all p<0.03). After adjustment for covariates, plasma was not associated with improved survival in all patients (OR 1.06; 95% CI 0.66 e 1.71). The largest subgroup was multifocal intracranial hemorrhage (MIH) (defined as at least 2 different types of brain lesions without a dominant lesion on initial head CT) with 259 (39%) patients. Sixty-seven (26%) MIH patients received plasma. Test for interaction between use of plasma and presence of MIH

Predicting the Need for Damage Control Surgery in Penetrating Trauma by Using Shock Index Carlos A Ordonez, MD, Alberto Garcia, MD, Viviana Orozco, MD, MIchael W Parra, MD, Marisol Badiel, MD, PhD, Monica Morales, Juan P Herrera-Escobar, MD, Sara Escobar, MD, Cecibel Cevallos, MD, Juan C Puyana, MD, FACS Fundacion Valle del Lili, Cali, Colombia INTRODUCTION: The objective of our study was to identify a possible shock index (SI) cutoff number that could reliable predicts the need for damage control surgery (DCS) in penetrating trauma patients. METHODS: A retrospective 10-year study (2005e2015) which included all adult patients that suffered penetrating torso trauma at a level I trauma center. The SI was calculated upon admission and patients were divided into two groups: those that required DCS and those that did not (No-DCS). A 95% confidence interval for the area under a receiver operating characteristic curve (AUROC) was used to determine the accuracy of SI in detecting patients that would require DCS. RESULTS: A total of 747 patients were included, 92.3% were male and 80% suffered gunshot wounds. The DCS group had a total of 331 (44%) patients and the No-DCS group had 416 (56%). Mean SI values were higher in the DCS group (1.01 [0.76-1.5]) compare to the No-DCS (0.79[0.64-1.00]) (p¼0.0001). The AUROC was 0.69 [95% CI 0.69-0.77]. When a 0.9 SI cutoff point was used, it accurately classified 64.7% of patients who required DCS with sensitivity (Se) of 63.3%, specificity (Sp) of 65.8% and a false negative rate of 36.7%; thus not accurately differentiating the need for DCS. Table. Characteristic Laparotomies, n (%) Thoracotomies, n (%) Laparotomy and thoracotomy, n (%) Hollow viscera injuries, n (%) Solid viscera injuries, n (%) Major vessels injuries, n (%) ISS, median (IQR) NISS, median (IQR) Shock index, median (IQR)

DCS (n¼316) 212 (67) 31 (10) 73 (23)

No-DCS (n¼418) 300 (72) 94 (22) 24 (6)

p Value 0.1984 <0.0001 <0.0001

217 (69)

199 (48)

<0.0001

172 (54)

124 (30)

<0.0001

91 (29)

50 (12)

<0.0001

25(16-29) 34(25-50) 1.05(0.79-1.55)

16(9-22) 25(11-34) 0.78(0.64-1.00)

<0.0001 <0.0001 <0.0001

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J Am Coll Surg

Scientific Poster Presentations: 2016 Clinical Congress

CONCLUSIONS: We have shown that SI can be indicative to some degree of the need for DCS in patients suffering penetrating torso trauma but a specific cutoff point that can precisely predict this need is statically unobtainable. Preventing Another Near Miss: Use of a Trauma Checklist to Document Incidental Findings in Trauma Patients Amani Jambhekar, MD, Amy Maselli, MD, Vincent Chan, Ryan Lindborg, MD, Daniel Laskey, MD, James C Rucinski, MD, FACS, Bashar Fahoum, MD New York Methodist Hospital Brooklyn, NY INTRODUCTION: Incidental findings are frequently detected during the initial evaluation of trauma patients. Prior retrospective studies have shown that such incidental findings are not effectively communicated to patients either in the acute setting or at discharge. We present a prospectively designed study in which a standardized checklist was used to document incidental findings and to establish follow up care. METHODS: Five hundred sixty-three patients were evaluated by trauma surgery between August 1, 2015 and February 20, 2016 using a standardized checklist to document clinical and radiologic findings. Patients less than 15 years of age and patients evaluated exclusively by the emergency department were excluded from the study. An incidental finding was defined as any discovery which was unrelated to the mechanism of injury which required further diagnostic workup or treatment. RESULTS: Of the 563 patients evaluated during the study period, 49 had clinically significant incidental findings identified on their trauma checklists and 19 of these had findings which warranted urgent follow-up such as a new arrhythmia, undiagnosed lung disease, or possible malignancy. All patients were verbally informed of their findings by the trauma surgery team and appropriate follow-up information was documented in their discharge summaries. CONCLUSIONS: The initial trauma workup may represent a missed opportunity for improving medical care for an underserved population as trauma patients with incidental findings often do not receive the appropriate recommended follow up. The use of a structured checklist to document clinically relevant findings may assist in increasing patient awareness and coordinating further care.

Profile Evaluation of Brain Traumatic Injuries Victims Associated with the Brain Injury Guidelines Protocol Sarah Wong Hui, Jose Cruvinel Neto, Stephanie Santin, Marcelo Ribeiro, Jr., MD, FACS University of Santo Amaro, Hospital Geral do Grajau, Sao Paulo, Brazil INTRODUCTION: Neurosurgery teams are not available in secondary-complexity public hospitals for evaluation of victims of traumatic brain injury (TBI), a common condition seen in emergency

departments. Therefore, roles of acute care surgeons are essential, and the protocols for the treatment of these patients indispensable. METHODS: A retrospective analysis of the hospital records of patients with TBI, admitted in a a secondary-complexity hospital, from 2013 to 2015. The patients’ profiles were associated with Brain Injury Guidelines (BIG). The BIG protocol consists of the classification of patients into three categories: BIG 1, BIG 2 and BIG 3, based on their history, physcica examination and CT findings. BIG 1 patients do not require neurosurgical assessment nor cranium CT control, requiring only neurological observation for 6 hours followed by hospital discharge and outpatient follow-up. For BIG 2 patients, hospitalization is recommended, but without the need for neurosurgical assessment or cranium CT control. However, BIG 3 patients require hospitalization, neurosurgical assessment and CT monitoring. RESULTS: Ninety-five patients satisfied the inclusion criteria. Most of them were male (79%), presenting normal initial neurological examination findings (87.4%), with mild TBI (84.2%) due to high-energy traumas (53.7%). Of those who were consulted by a neurosurgeon (73.7%), 62 (92.8%) patients returned to our hospital for clinical treatment. As for BIG classification, BIG 3 (72.6%) was the most common category, followed by BIG 2 (23.2%) and then BIG 1 (4.2%). Table. Distribution of Casuistry According to BIG (95 Cases) BIG Measures / Freq. (%)

p Measures / 1 2 3 Value Category N 4 22 69 0.443 Variation 23 e 63 15 e 96 14 e 92 Median 49.5 40.5 48 Mean (SD) 46.2 (19.6) 41.9 (22.2) 47.9 (18.3) Neurosurgical Yes 3 (75.0) 16 (72.7) 51 (73.9) NSM Assessment No 1 (25.0) 6 (27.3) 18 (26.1) Conservative Yes 4 (100.0) 20 (90.9) 66 (95.6) NSM Treatment No 0 (0.0) 2 (9.1) 3 (4.4) Death Yes 0 (0.0) 1 (4.6) 8 (11.6) NSM No 4 (100.0) 21 (95.4) 61 (88.4) Variable Age (years)

NSM, not statistically measurable

CONCLUSIONS: The BIG protocol is applicable to TBI victims and presents a safe and effective method for the general and trauma surgery teams to utilize in managing such cases. Qualitative Study Assessing Rural Practitioners’ Comfort Level Managing Mild Traumatic Brain, Spine, and Hand Injuries Jorge Con, MD, Peter Zmijewski, MD, Cara A Lyle, MD, Rachel Warner, Amanda Palmer, MD, Wilson Alison, MD, David Borgstrom, MD, FACS West Virginia University, Morgantown, WV INTRODUCTION: Rural hospitals’ involvement in trauma care varies because of differences in resources and operational goals.