Publications by authors named "Demetrios Demetriades"

526 Publications

Left subclavian artery coverage during endovascular repair of thoracic aorta injury in trauma and non-trauma patients.

Eur J Trauma Emerg Surg 2022 Jun 17. Epub 2022 Jun 17.

Division of Trauma and Surgical Critical Care, University of Southern California, 2051 Marengo Street, Los Angeles, CA, 90033, USA.

Purpose: In thoracic endovascular aortic repair (TEVAR), the left subclavian artery (LSA) is often occluded. Although most patients tolerate this, some develop ischemic symptoms to the brain or left upper extremity (LUE). A revascularization procedure may be associated with significant complications. The purpose of this review was to assess the incidence of LSA occlusion, resulting ischemic symptoms, and complications related to revascularization operations in trauma patients compared to non-trauma patients.

Methods: Studies from 2010 to 2020 were fully reviewed if they discussed incidence of LSA coverage, LUE ischemia, carotid-subclavian bypass, or complications associated with carotid-subclavian bypass.

Results: Seventeen articles were included in this analysis. A total of 167 patients were identified as trauma cases. Incidence of LSA occlusion in trauma was 91/167 (54%) compared to 281/1446 (19%) in the population exclusive of trauma (p < 0.001). Following LSA occlusion, the rate of LUE claudication/ischemia was 21/56 (38%) for trauma, compared to 12/193 (6%) in non-trauma cases (p < 0.001). The overall complication rate after carotid-subclavian rescue bypass was 29.2% (33/112), with phrenic nerve palsy (24%), recurrent laryngeal nerve palsy (5%), and pseudoaneurysm (1.7%) being the most common.

Conclusion: LSA coverage following TEVAR is common and associated with significant complications, often requiring operative management. The incidence of ischemic complications after occlusion of the LSA is significantly higher in the trauma population. Revascularization procedures to correct the occlusion have a high rate of complications.
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http://dx.doi.org/10.1007/s00068-022-02027-5DOI Listing
June 2022

Falls from Ladders: Injury Patterns and Outcomes.

J Trauma Acute Care Surg 2022 May 25. Epub 2022 May 25.

Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County and University of Southern California Medical Center, University of Southern California, Los Angeles, CA, USA.

Background: Our contemporary understanding of the impact of falls from ladders remains limited. The purpose of this study was to examine the injury patterns and outcomes of falls from ladders. Our hypothesis was that age affects both injury type and outcomes.

Methods: The NTDB was queried for all patients who fell from a ladder (01/2007-12/2017). Participants were stratified into 4 groups according to age: ≤15, 16-50, 51-65, and > 65 years. Univariate and multivariate analyses were performed to compare the injury patterns and outcomes between the groups.

Results: A total of 168,227 patients were included for analysis. Median age was 56 years (IQR: 45-66), 86.1% were male, and median ISS was 9 (IQR: 4-13). Increasing age was associated with a higher risk of severe trauma (ISS > 15: 8.8% vs 13.7% vs 17.5% vs 22.0%, p < 0.001). Head injuries followed a U-shaped distribution with pediatric and elderly patients representing the most vulnerable groups. Overall, fractures were the most common type of injury, in the following order: lower extremity 27.3%, spine 24.9%, rib 23.1%, upper extremity 20.1%, and pelvis 10.3%. The overall ICU admission rate was 21.5%; however, it was significantly higher in the elderly (29.1%). In-hospital mortality was 1.8%. The risk of death progressively increased with age with a mortality rate of 0.3%, 0.9%, 1.5%, and 3.6%, respectively (p < 0.001). Strong predictors of mortality were GCS ≤8 on admission (OR 29.80, 95% CI 26.66-33.31, p < 0.001) and age > 65 years (OR 4.07, 95% CI 3.535-4.692, p < 0.001). Only 50.8% of elderly patients were discharged home without health services, 16.5% were discharged to nursing homes and 15.2% to rehabilitation centers.

Conclusion: Falls from ladders are associated with considerable morbidity and mortality, especially in the elderly. Head injuries and fractures are common and often severe. An intensified approach to safe ladder use in the community is warranted.

Level Of Evidence: IV.
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http://dx.doi.org/10.1097/TA.0000000000003696DOI Listing
May 2022

Early pharmacologic thromboprophylaxis after splenectomy is associated with better outcomes: A matched cohort study.

Am J Surg 2022 Jul 1;224(1 Pt B):535-538. Epub 2022 Feb 1.

Division of Trauma, Emergency Surgery and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA, 90033, USA. Electronic address:

Background: This study aimed to explore the timing of pharmacologic prophylaxis initiation after trauma splenectomy and the development of venous thromboembolism (VTE).

Methods: Retrospective review of American College of Surgeons Trauma Quality Improvement Program (TQIP) database 2013-2017. Adults (>16 years) with isolated splenic injuries who underwent splenectomy and received pharmacologic VTE prophylaxis were stratified based on timing of initiation of prophylaxis: ≤48 h (EARLY) or > 48 h (LATE) from admission. Patients were matched for demographic and clinical characteristics and outcomes compared.

Results: 3631 patients were included. On logistic regression, LATE prophylaxis was associated with DVT (OR 2.317, p < 0.001) and VTE (OR 2.064, p < 0.001). Low molecular weight heparin (LMWH) was protective for DVT (OR 0.621, p = 0.014) and VTE (OR 0.667, p = 0.015). 1196 patients with EARLY prophylaxis were matched with 1196 patients with LATE prophylaxis. VTE and overall complications were significantly higher in the LATE group (7.4% vs. 4.3%, p = 0.001 and 25.8% vs 16.6%, p < 0.001).

Conclusions: Late initiation of VTE prophylaxis is associated with DVT and VTE in post-splenectomy patients, while LMWH is protective.
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http://dx.doi.org/10.1016/j.amjsurg.2022.01.030DOI Listing
July 2022

The trauma pelvic X-ray: Not all pelvic fractures are created equally.

Am J Surg 2022 Jul 31;224(1 Pt B):489-493. Epub 2022 Jan 31.

Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County + University of Southern California Medical Center, University of Southern California, Los Angeles, CA, 90033, USA. Electronic address:

Background: The primary aim of this study was to evaluate the role of the initial pelvic X-ray in identifying significant pelvic fractures, which could result in changes in the management of the patient.

Methods: Patients admitted to a level I trauma center (2010-2019) with a severe blunt pelvic fracture (AIS ≥3) were identified. Included in the analysis were patients who underwent emergency department pelvic X-ray followed by CT scan. A control group of patients without pelvic fractures was also included in the study. All investigations were reviewed by a blinded attending trauma radiologist. Pelvic X-ray findings and CT scan reports were compared according to the specific pelvic fracture location, and severity.

Results: Overall, pelvic X-ray was diagnosed 252 of the 285 pelvic fractures (sensitivity 88.4%) and wrongly diagnosed a facture in 3 of 97 patients without a fracture (specificity 96.9%). In 29/184 (15.8%) of patients with pelvic fracture AIS 3, the pelvic X-ray was read as normal, missing the fracture, compared with 4/101 (4.0%) in the AIS 4/5 group (p = 0.003). Pelvic X-ray had the lowest sensitivity in ischial (10.7%), iliac (28.7%), acetabular (42.4%), and sacral fractures (49.1%) and was best for detecting symphysis diastasis (89.8%).

Conclusion: Pelvic X-ray is useful in identifying pubic symphysis diastasis. However, it misses or underestimates a significant number of fractures. CT scan evaluation should be performed in patients with a suspicious mechanism or clinical suspicion of pelvic fracture.
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http://dx.doi.org/10.1016/j.amjsurg.2022.01.009DOI Listing
July 2022

Destructive colon injuries requiring resection: Is colostomy ever indicated?

J Trauma Acute Care Surg 2022 Jun 25;92(6):1039-1046. Epub 2022 Jan 25.

From the Division of Acute Care Surgery (D.P.M., M.R.L., M.D.W., D.D.), LAC+USC Medical Center, University of Southern California, Edmonton, Alberta, Canada; Trauma Surgery and General Surgery (M.S.), Royal Alexandra Hospital, Edmonton, Alberta, Canada; and Grady Memorial Hospital (E.R.B.), Emory University, Atlanta, Georgia.

Background: The management of destructive colon injuries requiring resection has shifted from mandatory diverting stoma to liberal use of primary anastomosis. Various risk criteria have been suggested for the selection of patients for primary anastomosis or ostomy. At our center, we have been practicing a policy of liberal primary anastomosis irrespective of risk factors. The purpose of this study was to evaluate the colon-related outcomes in patients managed with this policy.

Methods: This retrospective study included all colon injuries requiring resection. Data collected included patient demographics, injury characteristics, blood transfusions, operative findings, operations performed, complications, and mortality.

Results: A total of 287 colon injuries were identified, 101 of whom required resection, forming the study population. The majority (63.4%) were penetrating injuries. Furthermore, 16.8% were hypotensive on admission, 40.6% had moderate or severe fecal spillage, 35.6% received blood transfusion of >4 U, and 41.6% had Injury Severity Score of >15. At index operation, 88% were managed with primary anastomosis and 12% with colon discontinuity, and one patient had stoma. Damage-control laparotomy (DCL) with temporary abdominal closure was performed in 39.6% of patients. Of these patients with DCL, 67.5% underwent primary anastomosis, 30.0% were left with colon discontinuity, and 2.5% had stoma. Overall, after the definitive management of the colon, including those patients who were initially left in colon discontinuity, only six patients (5.9%) had a stoma. The incidence of anastomotic leaks in patients with primary anastomosis at the index operation was 8.0%, and there was no colon-related mortality. The incidence of colon anastomotic leaks in the 27 patients with DCL and primary anastomosis was 11.1%, and there was no colon-related mortality. Multivariate analysis evaluating possible risk factors identified discontinuity of the colon as independent risk factor for mortality.

Conclusion: Liberal primary anastomosis should be considered in almost all patients with destructive colon injuries requiring resection, irrespective of risk factors.

Level Of Evidence: Therapeutic/Care Management; Level IV.
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http://dx.doi.org/10.1097/TA.0000000000003513DOI Listing
June 2022

Skateboard head injuries: Are we making progress?

Injury 2022 May 15;53(5):1658-1661. Epub 2021 Dec 15.

Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, U.S.

Background: Skateboarding is a popular sport and U.S. trauma centers care for a significant number of skateboard-related injuries (SRIs). However, injury prevention strategies are still underdeveloped. This study was designed to compare the epidemiology, type, and location of skateboard injury as well as the use and influence of protective gear over two time periods.

Methods: This is a retrospective National Trauma Data Bank study including all patients with SRIs between 2007and 2016. Study groups were divided into two 5-year periods: 2007-2011 and 2012-2016. The incidence and severity of traumatic brain injury (TBI), as well as the compliance and effectiveness of protective gear and skate parks, was assessed in various age groups in the two study periods using univariable and multivariable analyses. Univariable analysis was used to compare the two study periods, logistic regression analysis was performed to identify independent predictors of head injury and severe TBI.

Results: 24,903 patients presented with SRIs: 10,594 from 2007 to 2011 and 14,309 from 2012 to 2016. Helmet use was low in both periods (5.7% and 5.4% respectively). The incidence of severe TBI (head AIS≥3) did not change significantly during the two periods (31.6% vs. 30.8%, p = 0.162). In children with severe TBI, there was no significant difference in helmet use across all ages, (10.4% vs. 11.5%, p = 0.467; 6.4% vs. 6.5%, p = 0.753; 4.2% vs. 3.7%, p = 0.201, respectively) with the lowest usage in the older than 16 years age group. On logistic regression, male gender (OR 1.526, 95% CI 1.372-1.698, p<0.001) was associated with increased odds of severe TBI, while helmet use (OR 0.534, 95% CI 0.455-0.627, p<0.001) and injuries at skate parks (OR 0.584, 95% CI 0.541-0.630, p<0.001), near home (OR 0.465, 95% CI 0.418-0.518, p<0.001), and public buildings (OR 0.386, 95% CI 0.440-0.541, p<0.001) were associated with reduced odds of severe TBI.

Conclusions: Helmet use in patients with SRIs is low in all pediatric age groups. Helmet use and skate parks are protective against severe TBI. Older age children and male gender are at increased risk of severe TBI after skateboard-related injuries, and more targeted preventive education and legislation are needed.
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http://dx.doi.org/10.1016/j.injury.2021.12.023DOI Listing
May 2022

Intra-abdominal hypertension and abdominal compartment syndrome.

Curr Probl Surg 2021 Nov 13;58(11):100971. Epub 2021 Feb 13.

Emergency Surgery and Surgical Intensive Care Unit, University of Southern California, Los Angeles, California. Electronic address:

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http://dx.doi.org/10.1016/j.cpsurg.2021.100971DOI Listing
November 2021

Timing of venous thromboembolic pharmacological prophylaxis in traumatic combined subdural and subarachnoid hemorrhage.

Am J Surg 2022 Jun 18;223(6):1194-1199. Epub 2021 Nov 18.

Division of Trauma and Surgical Critical Care, Department of Surgery, University of Southern California Medical Center, University of Southern California Los Angeles, Los Angeles, CA, 90033, USA. Electronic address:

Background: The combination of subdural and subarachnoid hemorrhage is the most common intracranial bleeding. The present study evaluated the timing and type of venous thromboembolic chemoprophylaxis (VTEp) for efficacy and safety in patients with blunt head trauma with combined acute subdural and subarachnoid hemorrhage.

Methods: Patients with isolated combined acute subdural and subarachnoid hemorrhage were extracted from the ACS-TQIP database (2013-2017). After 1:1 cohort matching of patients receiving early prophylaxis (EP, ≤48 h) versus late prophylaxis (LP, >48 h) outcomes were compared with univariable and multivariable regression analysis.

Results: Multivariable regression analysis identified EP as an independent protective factor for VTE complications (OR 0.468, CI 0.293-0.748) but not mortality (p = 0.485). The adjusted risk for delayed craniectomy was not associated with EP compared to LP (p = 0.283). The type of VTEp was not associated with VTE complications (p = 0.301), mortality (p = 0.391) or delayed craniectomy (p = 0.126).

Conclusions: Early VTEp (≤48 h) was associated with fewer VTE complications in patients and did not increase the risk for craniectomies in patients with combined acute subdural and subarachnoid hemorrhage.
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http://dx.doi.org/10.1016/j.amjsurg.2021.11.021DOI Listing
June 2022

Diagnosing penetrating diaphragmatic injuries: CT scan is valuable but not reliable.

Injury 2022 Jan 17;53(1):116-121. Epub 2021 Sep 17.

Division of Trauma, Emergency Surgery and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA, 90033, USA. Electronic address:

Background: The diagnosis of penetrating isolated diaphragmatic injuries can be challenging because they are usually asymptomatic. Diagnosis by chest X-ray (CXR) is unreliable, while CT scan is reported to be more valuable. This study evaluated the diagnostic ability of CXR and CT in patients with proven DI.

Methods: Single center retrospective study (2009-2019), including all patients with penetrating diaphragmatic injuries (pDI) documented at laparotomy or laparoscopy with preoperative CXR and/or CT evaluation. Imaging findings included hemo/pneumothorax, hemoperitoneum, pneumoperitoneum, elevated diaphragm, definitive DI, diaphragmatic hernia, and associated abdominal injuries.

Results: 230 patients were included, 62 (27%) of which had isolated pDI, while 168 (73%) had associated abdominal or chest trauma. Of the 221 patients with proven DI and preoperative CXR, the CXR showed hemo/pneumothorax in 99 (45%), elevated diaphragm in 51 (23%), and diaphragmatic hernia in 4 (1.8%). In 86 (39%) patients, the CXR was normal. In 126 patients with pDI and preoperative CT, imaging showed hemo/pneumothorax in 95 (75%), hemoperitoneum in 66 (52%), pneumoperitoneum in 35 (28%), definitive DI in 56 (44%), suspected DI in 26 (21%), and no abnormality in 3 (2%). Of the 57 patients with isolated pDI the CXR showed a hemo/pneumothorax in 24 (42%), elevated diaphragm in 14 (25%) and was normal in 24 (42%).

Conclusions: Radiologic diagnosis of DI is unreliable. CT scan is much more sensitive than CXR. Laparoscopic evaluation should be considered liberally, irrespective of radiological findings.
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http://dx.doi.org/10.1016/j.injury.2021.09.014DOI Listing
January 2022

A pandemic recap: lessons we have learned.

World J Emerg Surg 2021 09 10;16(1):46. Epub 2021 Sep 10.

Division of Trauma, Emergency Surgery, and Surgical Critical Care, LAC+USC Medical Center, Los Angeles, USA.

On January 2020, the WHO Director General declared that the outbreak constitutes a Public Health Emergency of International Concern. The world has faced a worldwide spread crisis and is still dealing with it. The present paper represents a white paper concerning the tough lessons we have learned from the COVID-19 pandemic. Thus, an international and heterogenous multidisciplinary panel of very differentiated people would like to share global experiences and lessons with all interested and especially those responsible for future healthcare decision making. With the present paper, international and heterogenous multidisciplinary panel of very differentiated people would like to share global experiences and lessons with all interested and especially those responsible for future healthcare decision making.
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http://dx.doi.org/10.1186/s13017-021-00393-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8430288PMC
September 2021

Firearm injuries during legal interventions Nationwide analysis.

J Trauma Acute Care Surg 2021 09;91(3):465-472

From the Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County and University of Southern California Medical Center, University of Southern California, Los Angeles, California.

Introduction: There is limited literature on firearm injuries during legal interventions. The purpose of this study was to examine the epidemiology, injury characteristics, and outcomes of both civilians and law enforcement officials (LEOs) who sustained firearm injuries over the course of legal action.

Methods: Retrospective observational study using data from the National Trauma Data Bank (2015-2017) was performed. All patients who were injured by firearms during legal interventions were identified using the International Classification of Disease, Tenth Revision, external cause of injury codes. The study groups were injured civilian suspects and police officers. Demographics, injury characteristics, and outcomes were analyzed and compared between the groups. Primary outcomes were the clinical and injury characteristics among the victims.

Results: A total of 1,411 patients were included in the study, of which 1,091 (77.3%) were civilians, 289 officers (20.5%), and 31 bystanders (2.2%). Overall, 95.2% of patients were male. Compared with LEOs, civilians were younger (31 vs. 34 years, p = 0.007) and more severely injured (median Injury Severity Score, 13 vs. 10 [p = 0.005]; Injury Severity Score >15, 44.4% vs. 37.1% [p = 0.025]). Civilians were more likely to sustain severe (Abbreviated Injury Scale, ≥3) intra-abdominal injuries (26.8% vs. 16.1%, p < 0.001) and spinal fractures (13.0% vs. 6.9%, p = 0.004). In-hospital mortality and overall complication rate were similar between the groups (mortality: civilians, 24.7% vs. LEOs, 27.3% [p = 0.360]; overall complications: civilians, 10.3% vs. LEOs, 8.4% [p = 0.338]).

Conclusion: Firearm injuries during legal interventions are associated with significant injury burden and a higher mortality than the reported mortality in gunshot wounds among civilians. The mortality and overall complication rate were similar between civilian suspects and law enforcement officials.

Level Of Evidence: Epidemiologic, level IV.
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http://dx.doi.org/10.1097/TA.0000000000003146DOI Listing
September 2021

Nonoperative Management of Blunt Hepatic Trauma: Comparison of Level I and II Trauma Centers.

Am Surg 2021 Aug 16:31348211038558. Epub 2021 Aug 16.

Division of Trauma and Surgical Critical Care, 5116Lac+Usc Medical Center, University of Southern California, Los Angeles, CA, USA.

Introduction: Most blunt liver injuries are treated with nonoperative management (NOM), and angiointervention (AI) has become a common adjunct. This study evaluated the use of AI, blood product utilization, pharmacological venous thromboembolic prophylaxis (VTEp), and outcomes in severe blunt liver trauma managed nonoperatively at level I versus II trauma centers.

Methods: American College of Surgeons Trauma Quality Improvement Program (TQIP) study (2013-2016), including adult patients with severe blunt liver injuries (AIS score>/= 3) treated with NOM, was conducted. Epidemiological and clinical characteristics, severity of liver injury (AIS), use of AI, blood product utilization, and VTEp were collected. Outcomes included survival, complications, failure of NOM, blood product utilization, and length of stay (LOS).

Results: Study included 2825 patients: 2230(78.9%) in level I and 595(21.1%) in level II centers. There was no difference in demographics, clinical presentation, or injury severity between centers. Angiointervention was used in 6.4% in level I and 7.2% in level II centers (P=.452). Level II centers were less likely to use LMWH for VTEp (.003). There was no difference in mortality or failure of NOM. In level II centers, there was a significantly higher 24-hour blood product utilization (PRBC P = .015 and platelets P = .002), longer ventilator days (P = .012), and longer ICU (P< .001) and hospital LOS (P = .024). The incidence of ventilator-associated pneumonia was significantly higher in level II centers (P = .003).

Conclusion: Utilization of AI and NOM success rates is similar in level I and II centers. However, the early blood utilization, ventilator days, and VAP complications are significantly higher in level II centers.
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http://dx.doi.org/10.1177/00031348211038558DOI Listing
August 2021

Venous thromboembolic pharmacological prophylaxis in severe traumatic acute subdural hematomas: Early prophylaxis is effective and safe.

Am J Surg 2022 05 31;223(5):1004-1009. Epub 2021 Jul 31.

Division of Trauma and Critical Care, University of Southern California, Los Angeles, CA, USA. Electronic address:

Background: The purpose of this study was to evaluate the optimal timing and type of pharmacological venous thromboembolism prophylaxis (VTEp) in patients with severe blunt head trauma with acute subdural hematomas (ASDH).

Methods: Matched cohort study using ACS-TQIP database (2013-2016) including patients with isolated ASDH. Outcomes of matched patients receiving early prophylaxis (EP, ≤48 h) and late prophylaxis (LP, >48 h) were compared with univariable and multivariable regression analysis.

Results: In 1,660 matched cases VTE complications (3.1% vs 0.5%, p < 0.001) were more common in the LP compared to the EP group. Multivariable regression analysis identified EP as an independent protective factor for VTE complications (OR 0.169, p < 0.001) but not mortality (p = 0.260). The adjusted risk for delayed craniectomy was not associated with EP compared to LP (p = 0.095). LMWH was independently associated with a lower mortality (OR 0.480, p = 0.008) compared to UH.

Conclusions: Early VTEp (≤48 h) does not increase the risk for craniectomies and is independently associated with fewer VTE complications in patients with isolated ASDH. LMWH was independently associated with a lower mortality compared to UH.
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http://dx.doi.org/10.1016/j.amjsurg.2021.07.048DOI Listing
May 2022

Gunshot wounds sustained during legal intervention versus those inflicted by civilians: A comparative analysis.

J Trauma Acute Care Surg 2022 02;92(2):436-441

From the Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, California.

Background: Existing data demonstrate that injuries sustained during legal intervention (LI) differ from those incurred during civilian interpersonal violence (CIV), but gunshot wounds (GSWs) have not yet been specifically examined. This study was undertaken to provide an in-depth analysis of patients shot during LI versus CIV.

Methods: Patients injured by GSW and captured by the National Trauma Data Bank (2007-2017) were included. Exclusions were transfer from outside hospital or self-inflicted, accidental, or undetermined injury intent GSWs. Study groups were defined by injury circumstances: GSWs sustained during LI versus CIV. Univariable analysis compared demographics, clinical/injury data, and outcomes.

Results: In total, 248,726 patients met inclusion/exclusion criteria: 98% (n = 243,150) CIV versus 2% (n = 5,576) LI. Race varied significantly between study groups (p < 0.001). White patients were the most commonly injured race after LI (n = 2,176, 39%). Black patients were the most commonly injured race after CIV (n = 139,067, 57%). Psychiatric disease (9% vs. 2%, p < 0.001) was more common among LI GSWs. The LI patients were more frequently tachycardic (18% vs. 13%, p < 0.001), hypotensive (26% vs. 14%, p < 0.001), and comatose (34% vs. 15%, p < 0.001). The LI patients had higher Injury Severity Scores (13 vs. 9, p < 0.001), required emergent surgical intervention (39% vs. 28%, p < 0.001) and intensive care unit admission (47% vs. 32%, p < 0.001) more often, and had longer hospital stay (4 vs. 3 days, p < 0.001). Mortality was higher after LI (27% vs. 14%, p < 0.001).

Conclusion: Significant racial and injury severity differences exist between patients shot during LI and CIV. White patients were the most commonly injured race after LI, while Black patients were the most commonly injured race during CIV. In addition, Black patients were overrepresented in both groups when compared with their proportion in the US population. LI patients were more significantly injured, as quantified by clinical, injury, and outcomes variables including increased mortality. Further study of patients shot during LI is needed to better understand this increased burden of injury.

Level Of Evidence: Prognostic and epidemiological, level IV.
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http://dx.doi.org/10.1097/TA.0000000000003366DOI Listing
February 2022

Pelvic fracture-related hypotension: A review of contemporary adjuncts for hemorrhage control.

J Trauma Acute Care Surg 2021 10;91(4):e93-e103

From the R Adams Cowley Shock Trauma Center (J.J.D., M.K., M.H., J.M., C.J.F., R.O., G.S.), University of Maryland Medical System, Baltimore, Maryland; Department of Surgery (C.C.B., N.L.W.), Denver Health Medical Center, Denver, Colorado; Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery (B.J.), College of Medicine, University of Arizona, Tucson, Arizona; Baylor University Medical Center (J.M.), Dallas, Texas; Department of Orthopedic Surgery (L.S.M.), University of Utah, Salt Lake City, Utah; Division of Trauma and Surgical Critical Care (D.D., E.B.), LAC+USC Medical Center, University of Southern California, Los Angeles, California; Trauma/Surgical Critical Care (T.C.), Grady Memorial Hospital/Emory University School of Medicine, Atlanta, Georgia; and Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery (T.C.), University of California San Diego School of Medicine, San Diego, California.

Abstract: Major pelvic hemorrhage remains a considerable challenge of modern trauma care associated with mortality in over a third of patients. Efforts to improve outcomes demand continued research into the optimal employment of both traditional and newer hemostatic adjuncts across the full spectrum of emergent care environments. The purpose of this review is to provide a concise description of the rationale for and effective use of currently available adjuncts for the control of pelvic hemorrhage. In addition, the challenges of defining the optimal order and algorithm for employment of these adjuncts will be outlined.

Level Of Evidence: Review, level IV.
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http://dx.doi.org/10.1097/TA.0000000000003331DOI Listing
October 2021

Surgical Rib Fixation in Isolated Flail Chest Improves Survival.

Ann Thorac Surg 2022 06 29;113(6):1859-1865. Epub 2021 Jun 29.

Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, California. Electronic address:

Background: The presence of severe associated injuries in flail chest complicates the interpretation of outcomes and the role of rib fixation. This study examined the impact of fixation in patients with isolated flail chest.

Methods: All patients diagnosed with flail chest injuries were queried from the National Trauma Data Bank (2016-2017). Patients who died within 72 hours, transferred from an another hospital, or had associated thoracic aortic injuries or significant extrathoracic injuries were excluded. Patients with rib fixation were propensity score matched 1:3 with similar patients treated nonoperatively, and outcomes were evaluated. Multivariate analysis was used to identify independent predictors for mortality and prolonged mechanical ventilation.

Results: Of 287,947 patients with rib fractures, there were 12,110 patients (4.2%) with flail chest. After exclusion, 5293 patients with isolated blunt flail chest injuries were included in the analysis. Rib fixation was performed in 575 (10.9%), and 4718 (89.1%) were managed nonoperatively. After matching, the mortality rate was significantly lower in the fixation group (2.0% vs 5.5%, P = .001). On multivariate analysis, rib fixation was associated with improved mortality (odds ratio, 0.355; P = .002). The timing of the operation was not a significant independent risk factor for mortality. However, early fixation (≤72 hours) was associated with a significantly lower need for prolonged ventilation (>7 days).

Conclusions: Operative fixation in patients with isolated flail chest is associated with improved survival and should be considered liberally. The timing of fixation did not affect mortality, but early fixation was associated with a reduced need for prolonged mechanical ventilation.
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http://dx.doi.org/10.1016/j.athoracsur.2021.05.085DOI Listing
June 2022

Nationwide Analysis of Dog Bite Injuries: Different Age Groups, Different Injury Patterns.

Am Surg 2021 Dec 15;87(10):1612-1615. Epub 2021 Jun 15.

Division of Acute Care Surgery, 5116University of Southern California, Los Angeles, CA, USA.

Background: As the number of households with dogs in the United States has increased, so has the incidence of dog bites. Contemporary analysis of nationwide epidemiological data regarding such injuries is scarce. The purpose of this study is to describe dog bite injury patterns and related surgical interventions with a focus on differences between pediatric and adult age groups.

Study Design: This is a retrospective study (2015-2017) using the National Trauma Data Bank. 10 569 patients were included.

Results: Of these, 4729 (44.7%) qualified as pediatric (age ≤ 12 years) and 5840 (55.3%) qualified as adults (age ≥ 13 years). Pediatric patients were more frequently admitted with facial injuries (78.1% vs. 29.3%, < .01) and facial fractures (4.8% vs. 2.5%, < .01), and had a higher incidence of facial bone surgical procedures (1.3% vs. .5%, < .01). Adult patients were more frequently admitted with upper extremity injuries (65.8% vs. 21.2%, < .01) and upper extremity vascular arterial injuries (2.3% vs. .2%, < .01) with a higher incidence of upper extremity arterial procedures (1.3% vs. .2%, < .01).

Conclusion: This study demonstrates the contrast in injury patterns from dog bite between adults and children. These findings can dictate injury prevention policies and prepare clinicians to treat dog bite victims.
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http://dx.doi.org/10.1177/00031348211024657DOI Listing
December 2021

Epidemiology and management of isolated blunt renal artery injuries.

J Trauma Acute Care Surg 2021 06;90(6):1003-1008

From the Division of Trauma and Surgical Critical Care (N.O., E.B., M.L., D.D.), LAC+USC Medical Center, University of Southern California, Los Angeles, California; and Department of Critical Care Medicine (C.J.), Huazhong University of Science and Technology Union Shenzhen Hospital (Nanshan Hospital), China.

Background: Isolated blunt renal artery injury (BRAI) is uncommon. Treatment options include observation, nephrectomy, surgical reconstruction and endovascular stenting. Over the last decade, there has been an increasing use of angiointervention techniques in vascular trauma. Previous studies reported underutilization of endovascular stenting in BRAI, in favor of observation. The aim of this study was to examine the epidemiology and assess changes in the management of isolated BRAI over the last decade.

Methods: Patients with BRAI identified from the National Trauma Data Bank (2016-2017). Deaths in the emergency department, transferral from outside hospital, and those with associated high-grade kidney injuries were excluded. Demographics, type of renal artery injury, and renal artery management were analyzed. Multivariate analysis was used to identify independent factors associated with isolated BRAI.

Results: During the study period, there were 1,708,076 patients with blunt trauma and 873 (0.05%) of them had BRAI. After exclusions, 563 patients with isolated BRAI who met the criteria for inclusion in the analysis. Auto versus pedestrian mechanism and male sex were associated with the highest risk for isolated BRAI. Comorbidities, such as hypertension or diabetes, were not associated with an increased risk of BRAI. Seatbelt use had a protective effect against BRAI. In the majority of patients (534, 95%), the renal artery injury was treated with observation, 23 (4%) with nephrectomy, 5 (0.9%) with endovascular stent and 1 (0.2%) with open renal artery repair. Among the 103 patients with isolated major renal artery laceration, 91.2% were treated with observation, 7.8% with nephrectomy and 1% with stenting.

Conclusion: Isolated blunt renal artery trauma is rare. The vast majority of patients with BRAI is managed with observation with only a small number undergoing endovascular intervention. Endovascular stenting utilization has remained very low and has not changed in the last decade.
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http://dx.doi.org/10.1097/TA.0000000000003153DOI Listing
June 2021

The impact of delayed time to first CT head on functional outcomes after blunt head trauma with moderately depressed GCS.

Eur J Trauma Emerg Surg 2021 May 14. Epub 2021 May 14.

Division of Trauma and Surgical Critical Care, LAC + USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA.

Purpose: Recent work suggests patients with moderately depressed Glasgow Coma Scale (GCS) score in the Emergency Department (ED) who do not undergo immediate head CT (CTH) have delayed neurosurgical intervention and longer ED stay. The present study objective was to determine the impact of time to first CTH on functional neurologic outcomes in this patient population.

Methods: Blunt trauma patients presenting to our Level I trauma center (11/2015-10/2019) with first ED GCS 9-12 were retrospectively identified and included. Transfers and those with extracranial AIS ≥ 3 were excluded. The study population was stratified into Immediate (≤ 1 h) and Delayed (1-6 h) CTH groups based on time from ED arrival to first CTH. Outcomes included functional outcomes at hospital discharge based on the Modified Rankin Scale (mRS).

Results: After exclusions, 564 patients were included: 414 (73%) with Immediate CTH and 150 (27%) Delayed CTH. Both groups arrived with median GCS 11 and alcohol/drug intoxication did not differ (p > 0.05). AIS Head/Neck was comparable (3[3-4] vs. 3[3-3], p = 0.349). Time to ED disposition decision and ED exit were significantly shorter after Immediate CTH (2.8[1.5-5.3] vs. 5.2[3.6-7.5]h, p < 0.001 and 5.5[3.3-8.9] vs. 8.1[5.2-11.7]h, p < 0.001). Functional outcomes were slightly worse after Immediate CTH (mRS 2[1-4] vs. 2[1-3], p = 0.002). Subgroup analysis of patients requiring neurosurgical intervention demonstrated a greater proportion of moderately disabled patients with a lower proportion of severely disabled or dead patients after Immediate CTH as compared to Delayed CTH (51 vs. 20%, p = 0.063 and 35 vs. 60%, p = 0.122).

Conclusions: Immediate CTH shortened time to disposition decision out of the ED and ED exit. Patients requiring neurosurgical intervention after Immediate CTH had improved functional outcomes when compared to those undergoing Delayed CTH. These differences did not reach statistical significance in this single-center study and, therefore, a large, multicenter study is the next step in demonstrating the potential functional outcomes benefit of Immediate CTH after blunt head trauma.
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http://dx.doi.org/10.1007/s00068-021-01677-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8121018PMC
May 2021

Increased Incidence of COVID-19 Infections Amongst Interpersonal Violence Patients.

J Surg Res 2021 10 30;266:62-68. Epub 2021 Apr 30.

Division of Acute Care Surgery, University of Southern California, Los Angeles, California.

Objective: To investigate whether any specific acute care surgery patient populations are associated with a higher incidence of COVID-19 infection.

Background: Acute care providers may be exposed to an increased risk of contracting the COVID-19 infection since many patients present to the emergency department without complete screening measures. However, it is not known which patients present with the highest incidence.

Methods: All acute care surgery (ACS) patients who presented to our level I trauma center between March 19, 2020, and September 20, 2020 and were tested for COVID-19 were included in the study. The patients were divided into two cohorts: COVID positive (+) and COVID negative (-). Patient demographics, type of consultation (emergency general surgery consults [EGS], interpersonal violence trauma consults [IPV], and non-interpersonal violence trauma consults [NIPV]), clinical data and outcomes were analyzed. Univariate and multivariate analyses were used to compare differences between the groups.

Results: In total, 2177 patients met inclusion criteria. Of these, 116 were COVID+ (5.3%) and 2061 were COVID- (94.7%). COVID+ patients were more frequently Latinos (64.7% versus 61.7%, P = 0.043) and African Americans (18.1% versus 11.2%, P < 0.001) and less frequently Caucasian (6.0% versus 14.1%, P < 0.001). Asian/Filipino/Pacific Islander (7.8% versus 7.2%, P = 0.059) and Native American/Other/Unknown (3.4% versus 5.8%, P = 0.078) groups showed no statistical difference in COVID incidence. Mortality, hospital and ICU lengths of stay were similar between the groups and across patient populations stratified by the type of consultation. Logistic regression demonstrated higher odds of COVID+ infection amongst IPV patients (OR 2.33, 95% CI 1.62-7.56, P < 0.001) compared to other ACS consultation types.

Conclusion: Our findings demonstrate that victims of interpersonal violence were more likely positive for COVID-19, while in hospital outcomes were similar between COVID-19 positive and negative patients.
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http://dx.doi.org/10.1016/j.jss.2021.04.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8086826PMC
October 2021

Current practices and challenges in assessing traumatic hemorrhage: An international survey of trauma care providers.

J Trauma Acute Care Surg 2021 05;90(5):e95-e100

From the Department of Surgery (A.T., T.L., J.L.), The Ottawa Hospital, School of Epidemiology and Public Health (A.T., T.L., M.T.), and Division of Critical Care, Department of Medicine (A.T., S.M.F.), University of Ottawa; Clinical Epidemiology Program (M.T., C.V.), Ottawa Hospital Research Institute; Department of Emergency Medicine (S.M.F., C.V.), University of Ottawa, Ottawa, ON, Canada; Department of Surgery (K.I., D.D.), University of Southern California, Los Angeles, California; Department of Surgery (E.E.M.), University of Denver, Denver, Colorado; Division of Acute Care Surgery, Department of Surgery (E.R.H.), and Department of Anesthesiology and Critical Care, Department of Emergency Medicine (E.R.H.), The Johns Hopkins University School of Medicine; Department of Health Policy and Management (E.R.H.), The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.

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http://dx.doi.org/10.1097/TA.0000000000003081DOI Listing
May 2021

Hangings: Lessons Learned from the Coroner's Office.

J Surg Res 2021 08 5;264:158-162. Epub 2021 Apr 5.

Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, California.

Background: Hangings are an infrequent wounding mechanism among patients arriving alive to hospital but are frequently encountered by the Coroner's Office. It is unclear if classically described hanging injuries, such as the Hangman's fracture, are common among contemporary hangings patients who typically do not suspend from height. This study was undertaken to define patient and injury characteristics after hangings causing death.

Methods: All patients presenting to the Los Angeles County Medical Examiner/Coroner's Office (January 2016 - May 2020) who died by hanging were included. Demographics, psychiatric history, hanging details, autopsy type, and sustained injuries were collected. Data variables were summarized with descriptive statistics and the diagnostic yield of a ligature mark in the diagnosis/exclusion of cervical injuries was calculated.

Results: Over the study, 1,401 patients died by hanging. Patients underwent external exam alone (n = 1,282, 92%), traditional neck autopsy (n = 114, 8%), or traditional neck autopsy plus postmortem computed tomography scan (n = 5, <1%). Home was the most frequent hanging setting (n = 1,028, 73%) followed by public spaces (n = 80, 6%) and jail (n = 28, 2%). The manner of death was almost exclusively suicide (n = 1,395, >99%) and psychiatric disease was common (n = 968, 69%). Of the patients undergoing traditional autopsy, most had a ligature mark (n = 109, 92%) and only 9 (8%) had a cervical injury (hyoid fractures, n = 6, 5%; thyroid cartilage fractures, n = 4, 3%). None had a vertebral fracture/dislocation. Sensitivity, specificity, positive predictive value, and negative predictive value of a ligature mark were 100%, 5%, 8%, and 100%.

Conclusions: Hangings are a frequent cause of death in Los Angeles County. Patients typically have a psychiatric history and die almost exclusively from suicide. Hangings commonly occur at home, in public places, and in jail. Injuries were exceedingly rare and no patient sustained a Hangman's fracture, which may be related to the lack of significant suspension with modern hangings.
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http://dx.doi.org/10.1016/j.jss.2021.02.021DOI Listing
August 2021

Practical assessment of different saw types for field amputation: A cadaver-based study.

Am J Emerg Med 2021 07 21;45:11-16. Epub 2021 Feb 21.

Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County + University of Southern California Medical Center, University of Southern California, Los Angeles, CA 90033, USA. Electronic address:

Introduction: Field amputation can be life-saving for entrapped patients requiring surgical extrication. Under these austere conditions, the procedure must be performed as rapidly as possible with limited equipment, often in a confined space, while minimizing provider risk. The aim of this study was to determine the ideal saw, and optimal approach, through bone or joint, for a field amputation.

Methods: This was a prospective cadaver-based study. Four saws (Gigli, manual pruning, electric oscillating and electric reciprocating) were tested in human cadavers. Each saw was used to transect four separate long bones (humerus, ulna/radius, femur and tibia/fibula), previously exposed at a standardized location. The time required for each saw to cut through the bone, the number of attempts required to seat the saw when transecting the bone, slippage, quality of proximal bone cut and extent of body fluid splatter as well as the physical space required by each device during the amputation were recorded. Additionally, the most effective saw in the through bone assessment was compared to limb amputation using scalpel and scissors for a through joint amputation at the elbow, wrist, knee and ankle. Univariate analysis was used to compare the outcomes between the different saws.

Results: The fastest saw for the through bone amputation was the reciprocating followed by oscillating (2.1 [1.4-3.7] seconds vs 3.0 [1.6-4.9] seconds). The manual pruning (58.8 [25-121] seconds) was the slowest (p = 0.007). Overall, the oscillating saw was superior or equivalent to the other devices in number of attempts (1), slippage (0), quality of bone cut (100% good) and physical space requirements (4500 cm), and was the second fastest. In comparison, a through joint amputation (125.0 [50-147] seconds for scalpel and scissor; 125.5 [86-217] seconds for the oscillating saw) was significantly slower than through bone with the Gigli (p = 0.029), the oscillating (p = 0.029) and the reciprocal saw (p = 0.029).

Conclusions: The speed, precision, safety, space required, as well as the adjustable blade of the oscillating saw make it ideal for a field amputation. A Gigli saw is an excellent backup for when electrical tools cannot be used. Through bone amputation is faster than a through joint amputation.
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http://dx.doi.org/10.1016/j.ajem.2021.02.034DOI Listing
July 2021

Damage Control Laparotomy in the Cirrhotic Trauma Patient is Highly Lethal: A Matched Cohort Study.

Am Surg 2022 Jul 26;88(7):1657-1662. Epub 2021 Feb 26.

Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County + University of Southern California Medical Center, University of Southern California Los Angeles, USA.

Introduction: Damage control laparotomy (DCL) has revolutionized trauma care and is considered the standard of care for severely injured patients requiring laparotomy. The role of DCL in cirrhotic patients has not been investigated.

Methods: A matched cohort study using American College of Surgeons Trauma Quality Improvement Program database including patients undergoing DCL within 24 hours of admission. A 1:2 cohort matching of cirrhotic vs. non-cirrhotic patients was matched for the following criteria: age (>55, ≤55 years), gender, mechanism of injury (blunt and penetrating), injury severity score (ISS) (≤25, >25), head/face/neck Abbreviated Injury Scale (AIS) (<3, ≥3), chest AIS (<3, ≥3), abdominal AIS (<3, ≥3), and overall comorbidities. Outcomes between the 2 cohorts were subsequently compared with univariable analysis.

Results: Overall, 1151 patients with DCL within 24 hours were identified, 29 (2.5%) with liver cirrhosis. Six cirrhotic patients were excluded because there were no suitable matching controls. The remaining 23 cirrhotic patients were matched with 46 non-cirrhotic patients. Overall mortality in the cirrhotic group was 65% vs. 26% in the non-cirrhotic group ( = .002). The higher mortality rate in cirrhotic vs. non-cirrhotic patients was accentuated in the group with ISS >25 (83% vs. 33%; = .005). 40% of the deaths in cirrhotic patients occurred after 10 days of admission, compared to only 8% in non-cirrhotic patients ( = .091). The total blood product use within 24 hours was significantly higher in cirrhotic than non-cirrhotic patients [33 (14-46) units vs. 19.9 (4-32) units; = .044].

Conclusion: Cirrhotic trauma patients undergoing DCL have a very high mortality. A significant number of deaths occur late and alternative methods of physiological support should be considered.
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http://dx.doi.org/10.1177/0003134821998673DOI Listing
July 2022

Isolated traumatic brain injury: Routine intubation for Glasgow Coma Scale 7 or 8 may be harmful!

J Trauma Acute Care Surg 2021 05;90(5):874-879

From the Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County-University of Southern California Medical Center, University of Southern California, Los Angeles, California.

Introduction: Despite strong recommendations, there is no direct evidence supporting routine intubation of trauma patients with Glasgow Coma Scale (GCS) score of 7 or 8. We hypothesized that routine intubation may not be beneficial in isolated blunt head injury.

Methods: A retrospective Trauma Quality Improvement Program study, including adult blunt trauma patients with GCS score of 7 or 8 and isolated head injury, was performed. Epidemiological and clinical characteristics, neurosurgical procedures, timing of intubation, and outcome variables were collected. The study population was stratified by the intubation procedure: immediate intubation (≤1 hour of admission), delayed intubation (>1 hour of admission), and no intubation. Multivariable regression analysis was used to determine risk factors for mortality and complications, as well as factors predictive of the decision to intubate.

Results: Of 2,727 patients with GCS score of 7 or 8 and isolated blunt head trauma, 1,866 patients (68.4%) were intubated within 1 hour of admission (immediate intubation), 223 (8.2%) had an intubation >1 hour of admission (delayed intubation), and 638 patients (23.4%) were not intubated at all. After correcting for age, sex, overall comorbidities, tachycardia, GCS, alcohol, illegal drug use, and head injury severity, immediate intubation was independently associated with higher mortality (odds ratio, 1.79; 95% confidence interval, 1.31-2.44; p < 0.001) and more overall complications (odds ratio, 2.46; 95% confidence interval, 1.62-3.73; p < 0.001). Increasing head Abbreviated Injury Scale (AIS) score, GCS score of 7, and tachycardia were identified as independent clinical factors associated with the decision to intubate. A policy of intubating all isolated blunt head injury patients 45 years or younger with head AIS score of 5 and GCS score of 7 would have improved intubation management, with seven immediate instead of delayed intubations and only three potentially unnecessary intubations.

Conclusion: In patients with GCS score of 7 or 8 and isolated head injury, immediate intubation was associated with higher mortality and more overall complications. Intubation management could have been improved by intubating all patients younger than 45 years with head AIS score of 5 and a GCS score of 7 on admission.

Level Of Evidence: Therapeutic, level III.
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http://dx.doi.org/10.1097/TA.0000000000003123DOI Listing
May 2021

Motor vehicle crashes in pregnancy: Maternal and fetal outcomes.

J Trauma Acute Care Surg 2021 05;90(5):861-865

From the Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, California.

Background: Motor vehicle crashes (MVCs) are a leading cause of death in pregnant women. Even after minor trauma, there is risk of fetal complications. The purpose of this study was to compare injuries and outcomes in pregnant with matched nonpregnant women after MVC and evaluate the incidence and type of pregnancy-related complications.

Methods: Retrospective study at a Level I trauma center included pregnant MVC patients, admitted 2009 to 2019. Pregnant patients were matched for age, seatbelt use, and airbag deployment with nonpregnant women (1:3). Gestation-related complications included uterine contractions, vaginal bleeding, emergency delivery, and fetal loss.

Results: During the study period, there were 6,930 MVC female admissions. One hundred forty-five (2%) were pregnant, matched with 387 nonpregnant. The seat belt use (71% in nonpregnant vs. 73% in pregnant, p = 0.495) and airbag deployment (10% vs. 6%, p = 0.098) were similar in both groups. Nonpregnant women had higher Injury Severity Score (4 vs. 1, p < 0.0001) and abdominal Abbreviated Injury Scale (2 vs. 1, p < 0.001), but a smaller proportion sustained abdominal injury (18% vs. 53%, p < 0.0001). Mortality (1% vs. 0.7%, p = 0.722), need for emergency operation (6% vs. 3%, p = 0.295) or angiointervention (0.3% vs. 0%, p = 0.540), ventilator days (3 vs. 8, p = 0.907), and intensive care unit (4 vs. 4, p = 0.502) and hospital length of stay (2 vs. 2, p = 0.122) were all similar. Overall, 13 (11.1%) patients developed gestation-related complications, most commonly uterine contractions (6.3%), need for emergency delivery (3.5%), and vaginal bleeding (1.4%).

Conclusion: Most pregnant patients hospitalized for MVC suffered minor injuries. Pregnant women had lower Injury Severity Score and abdominal Abbreviated Injury Scale than matched nonpregnant women. However, there was still a considerable incidence of gestation-related complications. It is imperative that pregnant patients be closely monitored even after minor trauma.

Level Of Evidence: Prognostic and epidemiological, level III.
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http://dx.doi.org/10.1097/TA.0000000000003093DOI Listing
May 2021

Retained bullet fragments after nonfatal gunshot wounds: epidemiology and outcomes.

J Trauma Acute Care Surg 2021 06;90(6):973-979

From the Division of Trauma and Critical Care, LAC + USC Medical Center, Los Angeles, California.

Background: With no consensus on the optimal management strategy for asymptomatic retained bullet fragments (RBF), the emerging data on RBF lead toxicity have become an increasingly important issue. There are, however, a paucity of data on the magnitude of this problem. The aim of this study was to address this by characterizing the incidence and distribution of RBF.

Methods: A trauma registry was used to identify all patients sustaining a gunshot wound (GSW) from July 1, 2015, to June 31, 2016. After excluding deaths during the index admission, clinical demographics, injury characteristics, presence and location of RBF, management, and outcomes, were analyzed.

Results: Overall, 344 patients were admitted for a GSW; of which 298 (86.6%) of these were nonfatal. Of these, 225 (75.5%) had an RBF. During the index admission, 23 (10.2%) had complete RBF removal, 35 (15.6%) had partial, and 167 (74.2%) had no removal. Overall, 202 (89.8%) patients with nonfatal GSW were discharged with an RBF. The primary indication for RBF removal was immediate intraoperative accessibility (n = 39, 67.2%). The most common location for an RBF was in the soft tissue (n = 132, 58.7%). Of the patients discharged with an RBF, mean age was 29.5 years (range, 6.1-62.1 years), 187 (92.6%) were me, with a mean Injury Severity Score of 8.6 (range, 1-75). One hundred sixteen (57.4%) received follow-up, and of these, 13 (11.2%) returned with an RBF-related complication [infection (n = 4), pain (n = 7), fracture nonunion (n = 1), and bone erosion (n = 1)], with a mean time to complication of 130.2 days (range, 11-528 days). Four (3.4%) required RBF removal with a mean time to removal of 146.0 days (range, 10-534 days).

Conclusion: Retained bullet fragments are very common after a nonfatal GSW. During the index admission, only a minority are removed. Only a fraction of these are removed during follow-up for complications. As lead toxicity data accumulates, further follow-up studies are warranted.

Level Of Evidence: Prognostic and epidemiological, level III.
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June 2021

Intra-Abdominal Hemorrhage Control: The Need for Routine Four-Quadrant Packing Explored.

World J Surg 2021 Apr 16;45(4):1014-1020. Epub 2021 Jan 16.

Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County + University of Southern California Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower (C), 5th Floor, C5L100, Los Angeles, CA, 90033, USA.

Background: Routine four-quadrant packing (4QP) for hemorrhage control immediately upon opening is a standard practice for acute trauma laparotomy. The aim of this study was to evaluate the utility of 4QP for bleeding control in acutely injured patients undergoing trauma laparotomy.

Methods: Retrospective single-center study (01/2015-07/2019), including adult patients who underwent trauma laparotomy within 4 h of admission. Only patients with active intra-abdominal hemorrhage, defined as bleeding within the peritoneal cavity or expanding retroperitoneal hematoma, were considered for analysis. Bleeding sources were categorized anatomically: liver/retrohepatic inferior vena cava (RIVC), spleen, retroperitoneal zones 1, 2 and 3, mesentery and others. Hemorrhage was further categorized as originating from a single bleeding site (SBS) or from multiple bleeding sites (MBS). The effectiveness of directed versus 4QP was evaluated for bleeding from the liver/RIVC, spleen and retroperitoneal zone 3, areas that are potentially compressible. Directed packing was defined as indicated if the bleeding was restricted to one of the anatomic sites suitable for packing, 4QP was defined as indicated if ≥ 2 of the anatomic sites suitable for packing were bleeding.

Results: During the study time frame, 924 patients underwent trauma laparotomy, of which 148 (16%) had active intra-abdominal hemorrhage. Of these, 47% had a SBS and 53% had MBS. The liver/RIVC was the most common bleeding source in both patients with SBS (42%) and in patients with MBS (54%). According to our predefined indications, 22 of 148 patients (15%) would have benefitted from initial 4QP, 90 of 148 patients (61%) from directed packing and 36 of 148 patients (24%) packing would not have been of any value.

Conclusion: Routine four-quadrant packing is frequently practiced. However, this is only required in a small proportion of patients undergoing trauma laparotomy. Directed packing can be equally effective, saves time and decreases the risk of iatrogenic injury from unnecessary packing.
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http://dx.doi.org/10.1007/s00268-020-05906-3DOI Listing
April 2021

Impact of obesity on outcomes after abdominal gunshot injury.

J Trauma Acute Care Surg 2021 04;90(4):680-684

From the Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA.

Background: The impact of obesity, on outcomes after a gunshot wound, remains unclear. We hypothesized that patients with obesity have a higher burden of intraabdominal injuries after gunshot injury when compared with the nonobese population.

Methods: The Trauma Quality Improvement Program database (2013-2017) was queried for all patients age ≥16 with abdominal gunshot injuries. Patients who died in the emergency department (ED), arrived without signs of life, had Abbreviated Injury Scale score ≥ 3 in any other region, or transferred from an outside hospital were excluded. The patient with obesity was defined by a body mass index ≥ 30. Demographics, injury data, and outcomes were abstracted and analyzed. Patients with obesity were compared to those with a body mass index < 30. Multivariate logistical regression was used to compare mortality between groups.

Results: Of 34,138 patients with gunshot injuries, there were 2,616 (7.7%) with isolated abdominal injuries. Median age is 29 years (22-39 years), 86.7% men. Eight hundred twenty-seven (31.6%) were obese. The obese group was significantly older (32 [25-42] vs. 27 [22-37]; p < 0.001) with a higher incidence of hypertension (16.8% vs. 6.3%, p < 0.001) and diabetes mellitus (7.1% vs. 2.3%, p < 0.001). There was no difference in presenting vital signs, abdominal Abbreviated Injury Scale or Injury Severity Score between groups. The rate of superficial injuries and intraabdominal organ injuries were comparable between groups. Patients with obesity had significantly higher mortality (6.5% vs. 4.2%, p = 0.010), hospital length of stay (9 [7-16] vs. 9[6-14], p < 0.001), ventilator days (3 [2-5] vs. 3 [2-4], p = 0.015), and hospital-acquired pneumonia (3.5% vs. 1.7%, p = 0.005). On multivariate analysis, in addition to older age (odds ratio [OR], 1.050; p < 0.001), ED hypotension (OR, 3.192; p < 0.001), and ED tachycardia (OR, 3.714; p < 0.001), obesity was significantly associated with mortality (OR, 1.636; p = 0.021).

Conclusion: Patients with obesity are at a high risk of mortality after abdominal gunshot injury. Further prospective evaluation is warranted.

Level Of Evidence: Prognostic study, Level III.
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April 2021
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