Venous thromboembolism after penetrating femoral and popliteal artery injuries: an opportunity for increased prevention

Background: Trauma patients with penetrating vascular injuries have a higher rate of venous thromboembolism (VTE). The objective of this study was to determine the risk of VTE formation in penetrating femoral and popliteal vascular injuries and the effects of endovascular management of these injuries. Methods: A retrospective study of Pennsylvania Trauma Outcome Study registry was conducted during a 5-year period (2013-2017). All adult patients with a penetrating mechanism with femoral/popliteal vascular injuries were studied. Primary outcome was incidence of VTE in patients with isolated arterial injuries versus combined arterial/venous injuries. Secondary endpoints were intensive care unit (ICU) length of stay (LOS), hospital LOS and mortality. Statistical comparisons were accomplished using Fisher\u27s exact tests, and parametric two-sample t-tests or non-parametric Wilcoxon rank-sum tests for categorical and continuous variables, respectively. Results: Of the 865 patients with penetrating extremity vascular injuries, 207 had femoral or popliteal artery injuries. Patients with isolated arterial injuries (n=131) had a significantly lower deep venous thrombosis (DVT) rate compared with those with concurrent venous injuries (n=76) (3.1% vs. 13.2%, p=0.008). There were 14 patients in the study who developed DVTs. Among the four patients with isolated femoral or popliteal arterial injuries who had developed DVTs, three had an open repair. Among patients with isolated arterial injuries, those with DVT spend significantly more time on the ventilator (median=2 vs. 0, p=0.0020) compared with patients without DVT. Patients with DVT also had longer stay in the hospital (median=17.5 vs. 8, p=0.0664) and in the ICU (median=3 vs. 1, p=0.0585). Conclusions: Risk of DVT exists in patients with penetrating isolated femoral and popliteal artery trauma. Open repair was associated with significantly higher DVT rates in isolated arterial injuries. Level of evidence: Level IV therapeutic care/management

A Statewide Analysis of Pediatric Liver Injuries Treated at Adult Versus Pediatric Trauma Centers.

INTRODUCTION: Hemodynamically normal pediatric trauma patients with solid organ injury receive nonoperative management. Prior research supports that pediatric patients have higher rates of nonoperative management at pediatric trauma centers (PTCs). We sought to evaluate differences in outcomes of pediatric trauma patients with liver injuries. We hypothesized that the type of trauma center (PTC versus adult trauma center [ATC]) would not be associated with any difference in mortality. METHODS: The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003 to 2018 for all patients (y) with liver injuries by International Classification of Disease 9 and 10 codes. Patients were categorized based on admission to the PTC or ATC. The primary endpoint was mortality with secondary endpoints being operative intervention and length of stay. Multivariate logistic regressions assessed the adjusted impact on mortality and surgical intervention. RESULTS: Of the 1600 patients with liver trauma, 607 met inclusion criteria. A total of 78.4% were treated at PTCs. Patients underwent hepatobiliary surgery more frequently at ATCs (11.5% [n = 15] versus 2.74% [n = 13], P \u3c 0.001). Adjusted analysis showed lower odds of surgical intervention for hepatobiliary injuries at PTCs (adjusted odds ratio: 0.17, P = 0.001). There was a decrease in mortality at PTCs versus ATCs (adjusted odds ratio: 0.38, P = 0.032). CONCLUSIONS: Our statewide analysis showed that pediatric trauma patients with liver injuries treated at ATCs were associated with having higher odds of mortality and higher incidence of operative management for hepatobiliary injuries than those treated at PTCs. In addition, between centers, patients had similar functional status at discharge

Geriatric Motorcycle-Related Outcomes: A Pennsylvania Multicenter Study

Introduction: Geriatric patients (GP) often experience increased morbidity and mortality following traumatic insult and as a result, require more specialized care due to lower physiologic reserve and underlying medical comorbidities. Motorcycle injuries (MCC) occur across all age groups, however, no large-scale studies evaluating outcomes of GP exist with data thus far limited to recreational based studies. We hypothesized that geriatric MCC will face worse outcomes and utilize more hospital resources despite greater helmet usage compared with their younger counterparts. Methods: We performed multicenter retrospective review of MCC patients at three Pennsylvania level I trauma centers from January 2016 to December 2020. Data was extracted from each institution’s electronic medical records and trauma registry. GP were defined as patients greater than or equal to 65 years of age. The primary outcome was mortality. Secondary outcomes included ventilator days (VD) and hospital (HLOS), intensive care unit (ICU LOS), and intermediate unit (IMU LOS) length of stays. 3:1 [(nongeriatric patients (NGP) to GP] propensity score matching (PSM) was based on sex, abbreviated injury scale (AIS) and injury severity score (ISS). p≤0.05 was considered significant. Results: 1538 (GP:7%[n=113]; NGP:93%[n=1425]) patients were included. Median ISS (GP:10 vs NG:6), median Charleston Comorbidity Index (GP:3 vs NGP:0), and helmet usage (GP:76.9% vs NGP:58.8%) were higher in GP (p≤0.05), however, mortality rates were similar (GP:1.7% vs NGP:2.6%; p=0.99). Following PSM (n=488), GP had significantly more comorbidities (p≤0.05). There was no difference in trauma bay interventions or complications between cohorts. Mortality remained similar between cohorts post-PSM (GP:1.8% vs NGP:3.2%; p=0.417). Differences in ventilator days as well as ICU LOS, IMU LOS and HLOS were negligible. Helmet usage (GP:64.5% vs NGP:66.8%; p=0.649) and insurance status (GP:87.4% vs NGP:91.5%; p=0.189) between groups were similar. Helmet use was more prevalent among insured NGP compared with those without insurance (69.1% vs 46.2%; p≤0.05). Conclusion: When matched for sex, ISS and AIS, age was not associated with interventions, complications, ventilator days, length of stay or mortality. There was no significant difference in helmet usage or insurance status between groups. Based on our study, there is no strong evidence for altering initial management of motorcycle-related trauma in geriatric patients

Outcomes among trauma patients with duodenal leak following primary versus complex repair of duodenal injuries: An Eastern Association for the Surgery of Trauma multicenter trial

BACKGROUND: Duodenal leak is a feared complication of repair, and innovative complex repairs with adjunctive measures (CRAM) were developed to decrease both leak occurrence and severity when leaks occur. Data on the association of CRAM and duodenal leak are sparse, and its impact on duodenal leak outcomes is nonexistent. We hypothesized that primary repair alone (PRA) would be associated with decreased duodenal leak rates; however, CRAM would be associated with improved recovery and outcomes when leaks do occur. METHODS: A retrospective, multicenter analysis from 35 Level 1 trauma centers included patients older than 14 years with operative, traumatic duodenal injuries (January 2010 to December 2020). The study sample compared duodenal operative repair strategy: PRA versus CRAM (any repair plus pyloric exclusion, gastrojejunostomy, triple tube drainage, duodenectomy). RESULTS: The sample (N = 861) was primarily young (33 years) men (84%) with penetrating injuries (77%); 523 underwent PRA and 338 underwent CRAM. Complex repairs with adjunctive measures were more critically injured than PRA and had higher leak rates (CRAM 21% vs. PRA 8%, p \u3c 0.001). Adverse outcomes were more common after CRAM with more interventional radiology drains, prolonged nothing by mouth and length of stay, greater mortality, and more readmissions than PRA (all p \u3c 0.05). Importantly, CRAM had no positive impact on leak recovery; there was no difference in number of operations, drain duration, nothing by mouth duration, need for interventional radiology drainage, hospital length of stay, or mortality between PRA leak versus CRAM leak patients (all p \u3e 0.05). Furthermore, CRAM leaks had longer antibiotic duration, more gastrointestinal complications, and longer duration until leak resolution (all p \u3c 0.05). Primary repair alone was associated with 60% lower odds of leak, whereas injury grades II to IV, damage control, and body mass index had higher odds of leak (all p \u3c 0.05). There were no leaks among patients with grades IV and V injuries repaired by PRA. CONCLUSION: Complex repairs with adjunctive measures did not prevent duodenal leaks and, moreover, did not reduce adverse sequelae when leaks did occur. Our results suggest that CRAM is not a protective operative duodenal repair strategy, and PRA should be pursued for all injury grades when feasible. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV