Practice Management Guidelines for the Diagnosis and Management of Injury in the Pregnant Patient: The EAST Practice Management Guidelines Work Group

Trauma during pregnancy has presented very unique challenges over the centuries. From the first report of Ambrose Pare of a gunshot wound to the uterus in the 1600s to the present, there have existed controversies and inconsistencies in diagnosis, management, prognostics, and outcome. Anxiety is heightened by the addition of another, smaller patient. Trauma affects 7% of all pregnancies and requires admission in 4 of 1000 pregnancies. The incidence increases with advancing gestational age. Just over half of trauma during pregnancy occurs in the third trimester. Motor vehicle crashes comprise 50% of these traumas, and falls and assaults account for 22% each. These data were considered to be underestimates because many injured pregnant patients are not seen at trauma centers. Trauma during pregnancy is the leading cause of nonobstetric death and has an overall 6% to 7% maternal mortality. Fetal mortality has been quoted as high as 61% in major trauma and 80% if maternal shock is present. The anatomy and physiology of pregnancy make diagnosis and treatment difficult

Reduced Lentivirus Susceptibility in Sheep with TMEM154 Mutations

Visna/Maedi, or ovine progressive pneumonia (OPP) as it is known in the United States, is an incurable slow-acting disease of sheep caused by persistent lentivirus infection. This disease affects multiple tissues, including those of the respiratory and central nervous systems. Our aim was to identify ovine genetic risk factors for lentivirus infection. Sixty-nine matched pairs of infected cases and uninfected controls were identified among 736 naturally exposed sheep older than five years of age. These pairs were used in a genome-wide association study with 50,614 markers. A single SNP was identified in the ovine transmembrane protein (TMEM154) that exceeded genome-wide significance (unadjusted p-value 3×10−9). Sanger sequencing of the ovine TMEM154 coding region identified six missense and two frameshift deletion mutations in the predicted signal peptide and extracellular domain. Two TMEM154 haplotypes encoding glutamate (E) at position 35 were associated with infection while a third haplotype with lysine (K) at position 35 was not. Haplotypes encoding full-length E35 isoforms were analyzed together as genetic risk factors in a multi-breed, matched case-control design, with 61 pairs of 4-year-old ewes. The odds of infection for ewes with one copy of a full-length TMEM154 E35 allele were 28 times greater than the odds for those without (p-value<0.0001, 95% CI 5–1,100). In a combined analysis of nine cohorts with 2,705 sheep from Nebraska, Idaho, and Iowa, the relative risk of infection was 2.85 times greater for sheep with a full-length TMEM154 E35 allele (p-value<0.0001, 95% CI 2.36–3.43). Although rare, some sheep were homozygous for TMEM154 deletion mutations and remained uninfected despite a lifetime of significant exposure. Together, these findings indicate that TMEM154 may play a central role in ovine lentivirus infection and removing sheep with the most susceptible genotypes may help eradicate OPP and protect flocks from reinfection

Impact of Minimal Injuries on a Level I Trauma Center.

Overtriage (i.e.; transport of patients with minimal injuries to a trauma center) has been accepted as necessary to avoid missing clinically significant injuries. We reviewed our experience with 344 patients (ISS less than or equal to 4) who were admitted to a level I trauma center during a 2-year period. The trauma team was activated for 209 patients (TA), and emergency department referrals accounted for 135 (ED). One hundred seventy-three patients (TA = 64%, ED = 36%) met American College of Surgeons\u27 Committee on Trauma (ACSCOT) field triage criteria (FTC). Mechanism of injury, especially ejection from a motor vehicle, was the most frequently utilized FTC indicator. We found no differences between the TA and ED groups relative to Trauma Score, Glasgow Coma Scale score, Injury Severity Score, length of stay, or ICU days. Mean total costs were higher for the TA group than for the ED group. The TA group had a higher nursing acuity level than the ED group. Compliance with FTC yields an inherent overtriage of minimally injured patients; however, noncompliance with FTC compounds the overtriage rate. Failure to comply with FTC is costly, labor intensive, and may represent misuse of the trauma system. We propose continual re-education of prehospital personnel, increased responsibility of all hospitals in the trauma center catchment area, and protocols for downstaging trauma resuscitation in minimally injured patients

Maternal Predictors of Fetal Demise in Trauma During Pregnancy.

Trauma complicates 6 to 7 per cent of all pregnancies, but fetal demise secondary to maternal trauma occurs much less frequently. This study was done to analyze the incidence of fetal demise as a function of 21 maternal characteristics determined within the first 24 hours after trauma. Nine instances of fetal demise were identified from 73 pregnant patients with trauma admitted to four Level I trauma centers from a combined data base of 30,000 patients. Maternal factors examined by logistic regression were Injury Severity Score (ISS), Trauma Score (TS), Abbreviated Injury Scale (AIS), fluid requirements in the initial 24 hours, systolic blood pressure (SBP), heart rate (HR), hemoglobin, hematocrit and arterial blood gas analysis. Fetal demise was found to be associated with increasing ISS, increasing face and abdominal AIS, increasing fluid requirements, maternal acidosis and maternal hypoxia. Standard maternal laboratory and physiologic parameters, such as hemoglobin and hematocrit, oxygen and hemoglobin saturation, partial pressure of carbon dioxide, SBP and HR were not predictive. The TS was also found to be nonpredictive

Prognostication of traumatic brain injury outcomes in older trauma patients: A novel risk assessment tool based on initial cranial CT findings.

INTRODUCTION: Advanced age has been traditionally associated with worse traumatic brain injury (TBI) outcomes. Although prompt neurosurgical intervention (NSI, craniotomy or craniectomy) may be life-saving in the older trauma patient, it does not guarantee survival and/or return to preinjury functional status. The aim of this study was to determine whether a simple score, based entirely on the initial cranial computed tomography (CCT) is predictive of the need for NSI and key outcome measures (e.g., morbidity and mortality) in the older (age 45+ years) TBI patient subset. We hypothesized that increasing number of categorical CCT findings is independently associated with NSI, morbidity, and mortality in older patients with severe TBI. METHODS: After IRB approval, a retrospective study of patients 45 years and older was performed using our Regional Level 1 Trauma Center registry data between June 2003 and December 2013. Collected variables included patient demographics, Injury Severity Score (ISS), Abbreviated Injury Scale Head (AISh), brain injury characteristics on CCT, Glasgow Coma Scale (GCS), Intensive Care Unit (ICU) and hospital length of stay (LOS), all-cause morbidity and mortality, functional independence scores, as well as discharge disposition. A novel CCT scoring tool (CCTST, scored from 1 to 8+) was devised, with one point given for each of the following findings: subdural hematoma, epidural hematoma, subarachnoid blood, intraventricular blood, cerebral contusion/intraparenchymal blood, skull fracture, pneumocephalus, brain edema/herniation, midline shift, and external (skin/face) trauma. Descriptive statistics and univariate analyses were conducted with 30-day mortality, in-hospital morbidity, and need for NSI as primary end-points. Secondary end-points included the length of stay in the ICU (ICULOS), step-down unit (SDLOS), and the hospital (HLOS) as well as patient functional outcomes, and postdischarge destination. Factors associated with the need for NSI were determined using matched NSI ( RESULTS: A total of 620 patients were analyzed, including 310 patients who underwent NSI and 310 age- and ISS-matched non-NSI controls. Average patient age was 72.8 ± 13.4 years (64.1% male, 99% blunt trauma, mean ISS 25.1 ± 8.68, and mean AISh/GCS of 4.63/10.9). CCTST was the only variable independently associated with NSI (AOR 1.23, 95% CI 1.06-1.42) and was inversely proportional to initial GCS and functional outcome scores on discharge. Increasing CCTST was associated with greater mortality, morbidity, HLOS, SDLOS, ICULOS, and ventilator days. On multivariate analysis, factors independently associated with mortality included AISh (AOR 2.70, 95% CI 1.21-6.00), initial GCS (AOR 1.14, 1.07-1.22), and CCTST (AOR 1.31, 1.09-1.58). Variables independently associated with in-hospital morbidity included CCTST (AOR 1.16, 1.02-1.34), GCS (AOR 1.05, 1.01-1.09), and NSI (AOR 2.62, 1.69-4.06). Multivariate models incorporating factors independently associated with each respective outcome displayed good overall predictive characteristics for mortality (AUC 0.787) and in-hospital morbidity (AUC 0.651). Finally, modified CCTST demonstrated good overall predictive ability for NSI (AUC 0.755). CONCLUSION: This study found that the number of discrete findings on CCT is independently associated with major TBI outcome measures, including 30-day mortality, in-hospital morbidity, and NSI. Of note, multivariate models with best predictive characteristics incorporate both CCTST and GCS. CCTST is easy to calculate, and this preliminary investigation of its predictive utility in older patients with TBI warrants further validation, focusing on exploring prognostic synergies between CCTST, GCS, and AISh. If independently confirmed to be predictive of clinical outcomes and the need for NSI, the approach described herein could lead to a shift in both operative and nonoperative management of patients with TBI