# Publications by authors named "Fredric M Pieracci"

102 Publications

### Basic Introduction to Statistics in Medicine, Part 2: Comparing Data.

##### Authors:
Wyatt P Bensken Vanessa P Ho Fredric M Pieracci

Surg Infect (Larchmt) 2021 Aug;22(6):597-603

Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA.

Comparison of parameters between two or more groups forms the basis of hypothesis testing. Statistical tests (and statistical significance) are designed to report the likelihood the observed results are caused by chance alone, given that the null hypothesis is true. To demonstrate the concepts described, we utilized the Nationwide Inpatient Sample for patients admitted for emergency general surgery (EGS) and those admitted with non-EGS diagnoses. Depending on the type and distribution of individual variables, appropriate statistical tests were applied. Comparison of numerical variables between two groups is begun with a simple correlation, depicted graphically in a scatterplot, and assessed statistically with either a Pearson or Spearman correlation coefficient. Normality of numerical variables is then assessed and in the case of normality, a t-test is applied when comparing two groups, and an analysis of variance (ANOVA) when comparing three or more groups. For data that are not distributed normally, a Wilcoxon rank sum (Mann-Whitney U) test may be used. For categorical variables, the χ test is used, unless cell counts are less than five, in which case the Fisher exact test is used. Importantly, both the ANOVA and χ test are used to assess for overall differences between two or more groups. Individual pair comparison tests, as well as adjusting for multiple comparisons must be used to identify differences between two specific groups when there are more than two groups. A basic understanding of statistical significance, and the type and distribution of variables is necessary to select the appropriate statistical test to compare data. Failure to understand these concepts may result in spurious conclusions.

Source
http://dx.doi.org/10.1089/sur.2020.430DOI Listing
August 2021

### Basic Introduction to Statistics in Medicine, Part 1: Describing Data.

##### Authors:
Wyatt P Bensken Fredric M Pieracci Vanessa P Ho

Surg Infect (Larchmt) 2021 Aug;22(6):590-596

Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.

Standardized and concise data presentation forms the base for subsequent analysis and interpretation. This article reviews types of data, data properties and distributions, and both numerical and graphical methods of data presentation. For the purposes of illustration, the National Inpatient Sample was queried to categorize patients as having either emergency general surgery or non-emergency general surgery admissions. Variables are categorized as either categorical or numerical. Within the former, there are ordinal and or nominal subtypes; within the latter, there are ratio and interval subtypes. Categorical data are typically displayed as number (%). Numerical data must be assessed for normality as normally distributed data behave in certain patterns that allow for specific statistical tests to be used. Several properties exist for numerical data, including measurements of central tendency (mean, median, and mode), as well as standard deviation, range, and interquartile range. The best initial assessment of the distribution of numerical data is graphical with both histograms and box plots. Knowledge of the types, distribution, and properties of data is essential to move forward with hypothesis testing.

Source
http://dx.doi.org/10.1089/sur.2020.429DOI Listing
August 2021

### The financial burden of rib fractures: National estimates 2007 to 2016.

Injury 2021 May 19. Epub 2021 May 19.

Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, United States.

Background: The aim of this study is to define the cost of rib fracture hospitalization by single, multiple, and flail type using a nationally representative sample.

Methods: The national inpatient sample (NIS) was used to identify patients with a primary diagnosis of rib fracture hospitalization 2007-2016. International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) codes were used to characterize patients as having single, multiple, or flail chest rib fractures. Patients with only trauma related diagnosis groups (DRG) at the time discharge were included in the final sample. The cost of hospitalization was obtained by converting reported charges into cost using the all-payer inpatient cost-to-charge ratio (CCR) for all hospitals in the NIS data. The log of cost was modeled using multivariate linear regression. The rib fracture type was the primary predictor in the model.

Results: There were 373,053 rib fracture admissions during 2007-2016. The average cost per hospitalization was \$10,169 (95%Confidence Interval [CI]: 9,942-10,395), which translated into a national expenditure of \$3.64 billion over 10 years. The cost of rib fracture hospitalization increased from \$209 million in 2007 to \$469 million in 2016. Compared to single rib fracture patients, the cost of hospitalization for multiple rib fractures and flail chest was 3% (p = 0.001) and 5% (p=0.02) higher, respectively. Higher injury severity score, total number of body regions injured and longer length of stay were associated with higher rib fracture hospitalization cost.

Conclusions: Rib fractures affect ~22,000-45,000 people per year in the United States. The cost of rib fractures is over \$469 million per year and is increasing over time. Multiple rib fractures and flail chest rib fractures are associated with increased cost. Pathways to improve care in patients with rib fractures should consider the cost of treatment.

Source
http://dx.doi.org/10.1016/j.injury.2021.05.027DOI Listing
May 2021

### Surgical stabilization of rib fractures in octogenarians and beyond-what are the outcomes?

J Trauma Acute Care Surg 2021 Jun;90(6):1014-1021

From the Department of Surgery (F.M.P., K.L.), Denver Health Medical Center, Denver, Colorado; Department of Surgery (M.C.H., B.K.), Mayo Clinic, Rochester, Minnesota; Department of Surgery (E.C., Z.B.), University of Nebraska Medical Center, Omaha, Nebraska; Department of Surgery (S.G., S.M., T.W.), Intermountain Medical Center, Murray, Utah; Department of Surgery (S.D., E.E.), Medical University of South Carolina, Charleston, South Carolina; Department of Surgery (M.B., D.B.C.), The Medical Center, Navicent Health, Macon, Georgia; Department of Surgery (E.T.L., S.S.), University of California, Irvine, California; Department of Surgery (A.S.), University of Colorado School of Medicine, Aurora, Colorado; and Department of Surgery (A.R.D.), St. Francis Medical Center, Hartford, Connecticut.

Background: Prospective studies of surgical stabilization of rib fractures (SSRF) have excluded elderly patients, and no study has exclusively addressed the ≥80-year-old subgroup. We hypothesized that SSRF is associated with decreased mortality in trauma patients 80 years or older.

Methods: Multicenter retrospective cohort study involving eight centers. Patients who underwent SSRF from 2015 to 2020 were matched to controls by study center, age, injury severity score, and presence of intracranial hemorrhage. Patients with chest Abbreviated Injury Scale score less than 3, head Abbreviated Injury Scale score greater than 2, death within 24 hours, and desire for no escalation of care were excluded. A subgroup analysis compared early (0-2 days postinjury) to late (3-7 days postinjury) SSRF. Poisson regression accounting for clustered data by center calculated the relative risk (RR) of the primary outcome of mortality for SSRF versus nonoperative management.

Results: Of 360 patients, 133 (36.9%) underwent SSRF. Compared with nonoperative patients, SSRF patients were more severely injured and more likely to receive locoregional analgesia. There were 31 hospital deaths among the entire sample (8.6%). Multivariable regression demonstrated a decreased risk of mortality for the SSRF group, as compared with the nonoperative group (RR, 0.41; 95% confidence interval, 0.24-0.69; p < 0.01). However, SSRF patients were more likely to develop pneumonia, and had an increased duration of both mechanical ventilation and intensive care unit stay. There were no differences in discharge destination, although the SSRF group was less likely to be discharged on narcotics (RR, 0.66; 95% confidence interval, 0.48-0.90; p = 0.01). There was no difference in adjusted mortality between the early and late SSRF subgroups.

Conclusion: Patients selected for SSRF were substantially more injured versus those managed nonoperatively. Despite this, SSRF was independently associated with decreased mortality. With careful patient selection, SSRF may be considered a viable treatment option in octogenarian/nonagenarians.

Level Of Evidence: Therapeutic, Level IV.

Source
http://dx.doi.org/10.1097/TA.0000000000003140DOI Listing
June 2021

### A randomized clinical trial of single dose liposomal bupivacaine versus indwelling analgesic catheter in patients undergoing surgical stabilization of rib fractures.

J Trauma Acute Care Surg 2021 May 5. Epub 2021 May 5.

Department of Surgery, Denver Health & Hospital Authority Department of Anesthesiology, Denver Health & Hospital Authority Department of Pharmacy, Denver Health & Hospital Authority.

Introduction: Loco-regional analgesia (LRA) remains underutilized in patients with chest wall injuries. Surgical stabilization of rib fractures (SSRF) offers an opportunity to deliver surgeon-directed LRA under direct visualization at the site of surgical intervention. We hypothesized that a single-dose liposomal bupivacaine (LB) intercostal nerve block provides comparable analgesia to an indwelling, peripheral nerve plane analgesic catheter with continuous bupivacaine infusion (IC), each placed during SSRF.

Methods: Non-inferiority, single center, randomized clinical trial (2017-2020). Patients were randomized to receive either IC or LB during SSRF. The IC was tunneled into the surgical field (subscapular space) and LB involved thoracoscopic intercostal blocks of ribs 3-8. The primary outcome was the Sequential Clinical Assessment of Respiratory Function (SCARF) score, measured daily for 5 days post-operatively. Secondary outcomes included daily narcotic equivalents and failure of primary LRA, defined as requiring a second LRA modality.

Results: Thirty-four patients were enrolled; 16 IC and 18 LB. Age, injury severity score, RibScore, Blunt Pulmonary Contusion Score, and use of non-narcotic analgesics was similar between groups. Duration of IC was 4.5 days. There were three failures in the IC group versus one in the LB group (p=0.23). There was no significant difference in SCARF score between the IC and LB groups. On post-operative days 2-4, narcotic requirements were less than half in the LB, as compared to the IC group; however, this difference was not statistically significant. Average wholesale price was \$605 for IC and \$434 for LB.

Conclusions: In this non-inferiority trial, LB provided at least comparable, and potentially superior LRA as compared to IC among patients undergoing SSRF.

Level Of Evidence: Level II, Therapeutic.

Source
http://dx.doi.org/10.1097/TA.0000000000003264DOI Listing
May 2021

### Beyond the tube: Can we reduce chest tube complications in trauma patients?

Am J Surg 2021 Apr 20. Epub 2021 Apr 20.

Denver Health and Hospital Authority, 777 Bannock Street, Denver, CO 80204, USA.

Background: We sought to identify opportunities for interventions to mitigate complications of tube thoracostomy (TT).

Methods: Retrospective review of all trauma patients undergoing TT from 6/30/2016-6/30/2019. Multivariable logistic regression identified independent predictors of complications.

Results: Out of 451 patients, 171 (37.9%) had at least one TT malpositioning or complication. Placement in the emergency department, placement by emergency medicine physicians, and body mass index >30 kg/m were independent predictors of complication. Malpositioning increased the likelihood of early complication (6.5%-53.5%), and early complication increased the likelihood of late complication (4.3%-13.6%). Patients with a late complication had, on average, a 7.56 day longer hospital stay than patients without a late complication.

Conclusion: TT complications were associated with placement in the emergency department, placement by emergency medicine physicians, and BMI>30 kg/m. We identified associations between malpositioning, early complications, and late complications, and demonstrated that TT complications impact patient outcomes.

Source
http://dx.doi.org/10.1016/j.amjsurg.2021.04.008DOI Listing
April 2021

### The Chest Wall Injury Society Recommendations for Reporting Studies of Surgical Stabilization of Rib Fractures.

Injury 2021 Jun 17;52(6):1241-1250. Epub 2021 Feb 17.

Department of Surgery, St. Francis Medical Center, Hartford, CT.

Background: Publications investigating the efficacy of surgical stabilization of rib fractures (SSRF) have increased exponentially. However, there is currently no standardized reporting structure for these studies, rendering both comparisons and extrapolation problematic.

Methods: A subject matter expert group was formed by the Chest Wall Injury Society. This group conducted a review of the SSRF investigational literature and identified variable reporting within several general categories of relevant parameters. A compliment of guidelines was then generated.

Results: The reporting guidelines consist of 26 recommendations in the categories of: (1) study type, (2) patient and injury characteristics, (3) patient treatments, (4) outcomes, and (5) statistical considerations.

Conclusion: Our review identified inconsistencies in reporting within the investigational SSRF literature. In response to these inconsistencies, we propose a set of recommendations to standardize reporting of original investigations into the efficacy of SSRF.

Source
http://dx.doi.org/10.1016/j.injury.2021.02.032DOI Listing
June 2021

### Strategies for successful implementation of resuscitative endovascular balloon occlusion of the aorta (REBOA) in an urban Level I trauma center.

J Trauma Acute Care Surg 2021 Mar 27. Epub 2021 Mar 27.

Background: The rationale for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is to control life-threatening sub-diaphragmatic bleeding and facilitate resuscitation, however, incorporating this into the resuscitative practices of a trauma service remains challenging. The objective of this study is to describe the process of successful implementation of REBOA use in an academic urban level I trauma center. All REBOA procedures from April 2014 through December 2019 were evaluated; REBOA was implemented after surgical faculty attended a required and internally developed Advanced Endovascular Strategies for Trauma Surgeons course (AESTS). Success was defined by sustained early adoption rates.

Methods: An institutional protocol was published, and a REBOA supply cart was placed in the emergency department(ED) with posters attached to depict technical and procedural details. A focused professional practice evaluation was utilized for the first three REBOA procedures performed by each faculty member, leading to internal privileging.

Results: REBOA was performed in 97 patients by 9 trauma surgeons, which is 1% of the total trauma admissions during this time. Each surgeon performed a median of 12 REBOAs (IQR: 5,14). Blunt (77/97, 81%) or penetrating abdominopelvic injuries (15/97, 15%) comprised the main injury mechanisms; 4% were placed for other reasons (4/97) including ruptured abdominal aortic aneurysms (AAA, n=3) and pre-operatively for a surgical oncologic resection (n=1). Overall survival was 65% (63/97) with a steady early adoption trend that resulted in participation in a Department of Defense (DoD) multicenter trial.

Conclusions: Strategies for how departments adopt new procedures require clinical guidelines, a training program focused on competence, and a hospital education and privileging process for those acquiring new skills.

Level Of Evidence: Level V.

Study Type: Original Article, Diagnostic.

Source
http://dx.doi.org/10.1097/TA.0000000000003198DOI Listing
March 2021

### Surgical Infection Society Guidance for Restoration of Surgical Services during the Coronavirus Disease-2019 Pandemic.

Surg Infect (Larchmt) 2021 Feb 25. Epub 2021 Feb 25.

Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA.

As the coronavirus disease-2019 (COVID-19) pandemic continues globally, high numbers of new infections are developing nationwide, particularly in the U.S. Midwest and along both the Atlantic and Pacific coasts. The need to accommodate growing numbers of hospitalized patients has led facilities in affected areas to suspend anew or curtail normal hospital activities, including elective surgery, even as earlier-affected areas normalized surgical services. Backlogged surgical cases now number in the tens of millions globally. Facilities will be hard-pressed to address these backlogs, even absent the recrudescence of COVID-19. This document provides guidance for the safe and effective resumption of surgical services as circumstances permit. Review and synthesis of pertinent international peer-reviewed literature, with integration of expert opinion. The "second-wave" of serious infections is placing the healthcare system under renewed stress. Surgical teams likely will encounter persons harboring the virus, whether symptomatic or not. Continued vigilance and protection of patients and staff remain paramount. Reviewed are the impact of COVID-19 on the surgical workforce, considerations for operating on a COVID-19 patient and the outcomes of such operations, the size and nature of the surgical backlog, and the logistics of resumption, including organizational considerations, patient and staff safety, preparation of the surgical candidate, and the role of enhanced recovery programs to reduce morbidity, length of stay, and cost by rational, equitable resource utilization. Resumption of surgical services requires institutional commitment (including teams of surgeons, anesthesiologists, nurses, pharmacists, therapists, dieticians, and administrators). Structured protocols and equitable implementation programs, and iterative audit, planning, and integration will improve outcomes, enhance safety, preserve resources, and reduce cost, all of which will contribute to safe and successful reduction of the surgical backlog.

Source
http://dx.doi.org/10.1089/sur.2020.421DOI Listing
February 2021

### Providing access to affordable bariatric surgery for uninsured Denver County residents: description of a successful public health initiative.

Surg Obes Relat Dis 2021 May 11;17(5):994-999. Epub 2021 Jan 11.

Department of Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, Colorado.

Background: Severe obesity disproportionately affects medically underserved communities. However, patients from these communities are the least likely to have access to affordable bariatric surgery. Few studies have described successful initiatives to mitigate this disparity.

Objectives: To describe the implementation of a public health initiative that provided affordable bariatric surgery to uninsured patients at our hospital.

Setting: Denver Health Medical Center (DHMC), a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)-accredited safety-net hospital.

Methods: Context regarding Denver city and county, DHMC, and bariatric surgery accreditation are provided, followed by a detailed description of the intervention.

Results: Successful implementation of the initiative centered around: (1) MBSAQIP accreditation; (2) identification of existing institutional charity care programs, (3) enlistment of support/buy-in from key parties; (4) presentation of both general and institutional-specific outcome data following bariatric surgery to hospital administration; (5) framing of the argument as primarily financial, rather than moral; (6) delineation of initial volume and risk expectations; and (7) outcome monitoring.

Conclusion: We successfully provided access to affordable bariatric surgery for uninsured patients at our accredited safety-net hospital.

Source
http://dx.doi.org/10.1016/j.soard.2021.01.003DOI Listing
May 2021

##### Authors:
Kimberly S Hardin Fredric M Pieracci

J Trauma Acute Care Surg 2020 11;89(5):e152

Department of Surgery Division of Trauma & Surgical Critical Care Denver Health Medical Center Denver, Colorado.

Source
http://dx.doi.org/10.1097/TA.0000000000002856DOI Listing
November 2020

### Outcome after surgical stabilization of rib fractures versus nonoperative treatment in patients with multiple rib fractures and moderate to severe traumatic brain injury (CWIS-TBI).

J Trauma Acute Care Surg 2021 03;90(3):492-500

From the Trauma Research Unit, Department of Surgery (J.T.H.P., E.M.M.V.L., M.H.J.V., M.M.E.W.), Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Surgery (F.A.-O.), HonorHealth John C. Lincoln Medical Center, Phoenix, Arizona; Division of Trauma, Emergency General Surgery, Critical Care Surgery, Department of Surgery (Z.M.B.), University of Nebraska Medical Center, Nebraska Medical Center, Omaha, Nebraska; Department of Surgery (E.-C.C.), Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Section of Acute Care Surgery, Department of Surgery (J.C., J.D.F.), Stanford University, Stanford, California; Department of Trauma Surgery/Critical Care (D.B.C., T.N.), Mercer University School of Medicine, The Medical Center Navicent Health, Macon, Georgia; HealthPartners Orthopedics & Sports Medicine (P.A.C.), Bloomington; Department of Orthopaedic Surgery (P.A.C.), University of Minnesota, Minneapolis; Department of Orthopaedic Surgery (P.A.C.), Regions Hospital, St. Paul, Minnesota; Department of Surgery (W.B.D., D.G.H.), Riverside Methodist Hospital, Columbus, Ohio; Department of Surgery (A.R.D., B.G.), Saint Francis Hospital, Hartfort, Connecticut; Division of Trauma and Critical Care, Department of Surgery (E.A.E., S.L.), Medical University of South Carolina, Charleston, South Carolina; Department of Surgery (D.R.F., A.G.M.), UNLV School of Medicine, Las Vegas, Nevada; Division of Trauma, Department of Surgery (C.H., G.R.S.), Wright State University/Miami Valley Hospital, Dayton, Ohio; Department of Surgery (A.J.K., P.P.), Overland Park Regional Medical Center, Overland Park, Kansas; Division of Trauma Surgery, Department of Surgery (H.-J.K., Y.-H.S.), National Taiwan University Hospital, Hsinchu City, Taiwan; Department of Surgery (K.N.L.), Denver Health Medical Center, Denver, Colorado; CJOB Department of Cardiothoracic Surgery (S.F.M.), The Alfred, Melbourne; Department of Surgery (S.F.M.), Monash University, Clayton, Victoria, Australia; Department of Orthopaedic Surgery (T.D.O.), University of Minnesota, Minneapolis; Department of Orthopaedic Surgery (T.D.O.), Regions Hospital, St. Paul, Minnesota; Department of Surgery (A.P.R.), Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts; Department of Trauma/Burn (V.S.), John H Stronger Hospital of Cook County, Chicago, Illinois; Department of Surgery (J.W.), University of Texas Rio Grande Valley, Doctors Hospital at Renaissance, Edinburg, Texas; Department of Surgery (F.M.P.), Denver Health Medical Center, University of Colorado School of Medicine, Denver, Colorado.

Background: Outcomes after surgical stabilization of rib fractures (SSRF) have not been studied in patients with multiple rib fractures and traumatic brain injury (TBI). We hypothesized that SSRF, as compared with nonoperative management, is associated with favorable outcomes in patients with TBI.

Methods: A multicenter, retrospective cohort study was performed in patients with rib fractures and TBI between January 2012 and July 2019. Patients who underwent SSRF were compared to those managed nonoperatively. The primary outcome was mechanical ventilation-free days. Secondary outcomes were intensive care unit length of stay and hospital length of stay, tracheostomy, occurrence of complications, neurologic outcome, and mortality. Patients were further stratified into moderate (GCS score, 9-12) and severe (GCS score, ≤8) TBI.

Results: The study cohort consisted of 456 patients of which 111 (24.3%) underwent SSRF. The SSRF was performed at a median of 3 days, and SSRF-related complication rate was 3.6%. In multivariable analyses, there was no difference in mechanical ventilation-free days between the SSRF and nonoperative groups. The odds of developing pneumonia (odds ratio [OR], 0.59; 95% confidence interval [95% CI], 0.38-0.98; p = 0.043) and 30-day mortality (OR, 0.32; 95% CI, 0.11-0.91; p = 0.032) were significantly lower in the SSRF group. Patients with moderate TBI had similar outcome in both groups. In patients with severe TBI, the odds of 30-day mortality was significantly lower after SSRF (OR, 0.19; 95% CI, 0.04-0.88; p = 0.034).

Conclusion: In patients with multiple rib fractures and TBI, the mechanical ventilation-free days did not differ between the two treatment groups. In addition, SSRF was associated with a significantly lower risk of pneumonia and 30-day mortality. In patients with moderate TBI, outcome was similar. In patients with severe TBI a lower 30-day mortality was observed. There was a low SSRF-related complication risk. These data suggest a potential role for SSRF in select patients with TBI.

Level Of Evidence: Therapeutic, level IV.

Source
http://dx.doi.org/10.1097/TA.0000000000002994DOI Listing
March 2021

### Use of the Internet to Facilitate an Annual Scientific Meeting: A Report of the First Virtual Chest Wall Injury Society Summit.

J Surg Educ 2021 May-Jun;78(3):889-895. Epub 2020 Sep 29.

Department of Surgery, St. Francis, Hartford, Connecticut.

Introduction: The COVID-19 pandemic has resulted in cancellation of medical peer meetings. The Chest Wall Injury Society Annual Summit was scheduled for April 2020. Due to safety concerns, the Society altered the meeting to an online format. The purpose of this paper is to describe how this was accomplished and also to highlight its outcomes.

Methods: An online survey of participants was carried out to assess their views on the educational yield and technical difficulties encountered as compared to in-person meetings.

Results: Sixty two of 275 (23%) registered participants filled out the survey. Eighty four percent felt that the educational quality was excellent/good. Seventy five percent and 95% felt in-person meetings are better for education and for networking, respectively. Eighty seven percent preferred in-person meetings in the future but would attend a virtual meeting again. Thirteen percent had technical difficulties accessing the meeting.

Conclusion: Online meetings are feasible but in-person meetings have more educational and networking value.

Source
http://dx.doi.org/10.1016/j.jsurg.2020.09.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7523529PMC
June 2021

### Trust the FAST: Confirmation that the FAST examination is highly specific for intra-abdominal hemorrhage in over 1,200 patients with pelvic fractures.

J Trauma Acute Care Surg 2021 01;90(1):137-142

From the Department of Surgery (A.C.S., A.V.G., F.M.P., K.B.P., R.A.L., E.M.C., J.J.C., E.E.M., C.C.B.), Denver Health Medical Center, Denver, Colorado; Department of Anesthesia (A.W.), Brigham and Women's Hospital, Harvard University, Boston, Massachussets; and Department of Surgery (A.E.R.), University of Colorado, Aurora, Colorado.

Background: Use of the focused assessment with sonography for trauma (FAST) examination in patients with pelvic fractures has been reported as unreliable. We hypothesized that FAST is a reliable method for detecting clinically significant intra-abdominal hemorrhage in patients with pelvic fractures.

Methods: All patients with pelvic fractures over a 10-year period were reviewed at a Level I trauma center. The predictive ability of FAST was assessed by calculating the sensitivity, specificity, positive predictive value and negative predictive value against the criterion standard of either computed tomography (CT) or laparotomy findings. The FAST examination was considered "false negative" if findings at laparotomy indicated traumatic intra-abdominal hemorrhage. Likewise, the FAST examination was considered "false positive" if either CT or findings at laparotomy indicated no intra-abdominal hemorrhage. Hemodynamic instability scores were calculated for all patients.

Results: There were 1,456 patients with pelvic fractures and an initial FAST reviewed; 1,219 (83.7%) underwent FAST and either CT or operative exploration. Median age was 43 years (interquartile range, 26-56 years) and mean Injury Severity Score was 18.5 ± 12.3. The sensitivity and specificity for FAST in this group of patients with pelvic fracture was 85.4% and 98.1%, respectively. The positive predictive value and negative predictive value were 78.4% and 98.8%, respectively. Of 21 patients with a false-positive FAST, 15 (71.4%) were confirmed with a negative CT scan, and 6 (28.6%) underwent laparotomy without findings of intra-abdominal hemorrhage. Of 13 patients with a false-negative FAST, all were identified with positive findings at the time of laparotomy. The specificity of the FAST examination remained high regardless of hemodynamic instability score grade.

Conclusion: The false positive rate of FAST examination for intra-abdominal hemorrhage is 1.1%. These data suggest that a positive FAST in this clinical scenario should be considered to represent intra-abdominal fluid. This series contradicts prior reports that FAST is unreliable in patients with pelvic fracture.

Level Of Evidence: Diagnostic, level III.

Source
http://dx.doi.org/10.1097/TA.0000000000002947DOI Listing
January 2021

### Worth looking! venous thromboembolism in patients who undergo preperitoneal pelvic packing warrants screening duplex.

Am J Surg 2020 12 31;220(6):1395-1399. Epub 2020 Aug 31.

Department of Surgery, Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO, 80204, USA. Electronic address:

Background: Venous thromboembolism (VTE) in patients with major pelvic fractures who undergo preperitoneal pelvic packing (PPP) has not been investigated. We hypothesized that patients who undergo PPP are at high risk for VTE, thus early prophylactic anticoagulation and screening duplex are warranted.

Study Design: All patients requiring PPP from 2015 to 2019 were reviewed. Management and outcomes were analyzed.

Results: During the study period, 79 patients underwent PPP. Excluding the early deaths, 17 patients had deep venous thrombosis (DVT) and 6 had pulmonary emboli (PE); 4 patients had both DVT/PE. Overall mortality was 15%. Thirty-two patients underwent screening duplex within 72 h of admission and 10 were positive for DVT.

Conclusion: Patients with complex pelvic trauma undergoing PPP have a 23% incidence of DVT and an additional 8% incidence of PE. 31% of screening ultrasounds are positive. The overall mortality was 15%. With a high incidence of VTE in this patient population, we recommend screening duplex ultrasounds.

Source
http://dx.doi.org/10.1016/j.amjsurg.2020.08.043DOI Listing
December 2020

### Characterization and influence of ipsilateral scapula fractures among patients who undergo surgical stabilization of sub-scapular rib fractures.

Eur J Orthop Surg Traumatol 2021 Apr 9;31(3):429-434. Epub 2020 Sep 9.

Department of Surgery, Denver Health Medical Center, Denver, CO, USA.

Background: Current decision algorithms involving surgical stabilization of rib fractures (SSRF) do not consider either specific fracture locations or other chest wall bony injuries. Our objective was to characterize the impact of scapula fractures on morbidity among patients who underwent fixation of sub-scapular rib fractures. We hypothesized that an ipsilateral scapula fracture was associated with poor acute and long-term outcomes.

Methods: Retrospective review of two institutions' prospectively maintained SSRF databases (October 2010 to January 2019). Patients who underwent repair of ≥ 1 sub-scapular rib fracture were included. Patients were grouped by the presence of an ipsilateral scapula fracture. Outcomes were acute SSRF complications, long-term rib implant removal, and quality of life via phone survey.

Results: A total of 144 patients were analyzed; 53 (36.8%) had an ipsilateral scapula fracture. Patients with a scapula fracture had a higher injury severity score (p = 0.02), degree of pulmonary contusion (p < 0.01), and RibScore (p < 0.01). The overall incidence of both acute re-operation (n = 4, 2.8%) and long-term implant removal (n = 5, 3.8%) following SSRF was low and did not vary by the presence of a scapula fracture. Only twenty-one patients completed phone questionnaires a median of 38 months after SSRF; both shoulder and rib outcomes were excellent and did not vary by the presence of a scapula fracture.

Conclusion: Ipsilateral scapula fractures are common in patients who undergo surgical stabilization of sub-scapular rib fractures. Despite higher injury severity, patients with an ipsilateral scapula fracture did not incur worse outcomes.

Source
http://dx.doi.org/10.1007/s00590-020-02789-xDOI Listing
April 2021

### Authors' Response to letter by Elkbuli et al.

J Trauma Acute Care Surg 2020 10;89(4):e123-e124

Source
http://dx.doi.org/10.1097/TA.0000000000002844DOI Listing
October 2020

### Prehospital end-tidal carbon dioxide predicts massive transfusion and death following trauma.

J Trauma Acute Care Surg 2020 10;89(4):703-707

From the Department of Surgery (E.M.C., A.C., C.R., F.M.P., R.A.L., B.P., E.E.M., M.J.C., J.J.C., C.F., C.C.B.), and Department of Emergency Medicine (K.M.), Denver Health Medical Center, University of Colorado School of Medicine; Denver Paramedics (J.R., D.E.); and School of Public Health (A.S.), University of Colorado, Boulder, Colorado.

Background: The lack of an accurate marker of prehospital hemorrhagic shock limits our ability to triage patients to the correct level of care, delays treatment in the emergency department, and inhibits our ability to perform prehospital interventional research in trauma. End-tidal carbon dioxide (ETCO2) is the measurement of alveolar carbon dioxide concentration at end expiration and is measured noninvasively in the ventilator circuit for intubated patients in continuous manner. Several hospital-based studies have been able to demonstrate that either low or decreasing levels of ETCO2 as well as disparities between ETCO2 and plasma carbon dioxide correlate with increasing mortality in trauma. We hypothesized that prehospital ETCO2 values will be predictive of mortality and need for massive transfusion following injury.

Methods: This is a single-center retrospective study from an urban level 1 trauma center. We reviewed all intubated adult patients transported for injury who had prehospital ETCO2 values available. Unadjusted comparisons of continuous variables were done with the Wilcoxon two-sample test. The predictive performance of prehospital ETCO2, the prehospital shock index, and prehospital systolic blood pressure were assessed and compared using areas under the receiver operating characteristic curves. Optimal cutoffs were estimated by maximizing the Youden index. Massive transfusion was defined as >10 U of blood or death in 24 hours.

Results: A total of 173 patients were identified with prehospital ETCO2 values during the 2-year study period. Population was 78.5% male with a median age of 37.5 years (interquartile range, 23.5-53.5 years). Injury mechanism was penetrating in 22.8%. This cohort had a median Injury Severity Score of 26 (interquartile range, 17-36), massive transfusion rate of 34.7%, and mortality of 42.1%. In the evaluation of prediction of postinjury mortality and massive transfusion, ETCO2 outperformed systolic blood pressure and shock index, but these differences did not reach statistical significance.

Conclusion: End-tidal carbon dioxide is a novel prehospital predictor of mortality and massive transfusion after injury.

Level Of Evidence: Prognostic/Epidemiologic, level III.

Source
http://dx.doi.org/10.1097/TA.0000000000002846DOI Listing
October 2020

### Tube thoracostomy during the COVID-19 pandemic: guidance and recommendations from the AAST Acute Care Surgery and Critical Care Committees.

Trauma Surg Acute Care Open 2020 30;5(1):e000498. Epub 2020 Apr 30.

Department of Surgery, Inova Fairfax Medical Center, Falls Church, Virginia, USA.

This document provides guidance for trauma and acute care surgeons surrounding the placement, management and removal of chest tubes during the COVID-19 pandemic.

Source
http://dx.doi.org/10.1136/tsaco-2020-000498DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7213907PMC
April 2020

### Pro-Con Perspectives on Ethics in Surgical Research: Update from the 39th Annual Surgical Infection Society Meeting.

Surg Infect (Larchmt) 2020 May;21(4):332-343

Department of Surgery, Denver Health Medical Center/University of Colorado School of Medicine, Denver, Colorado, USA.

Surgical research is potentially invasive, high-risk, and costly. Research that advances medical dogma must justify both its ends and its means. Although ethical questions do not always have simple answers, it is critically important for the clinician, researcher, and patient to approach these dilemmas and surgical research in a thoughtful, conscientious manner. We present four ethical issues in surgical research and discuss the opposing viewpoints. These topics were presented and discussed at the 39th Annual Meeting of the Surgical Infection Society as pro-con debates. The presenters of each opinion developed a succinct summary of their respective reviews for this publication. The key subjects for these pro-con debates were: (1) Should patients be enrolled for time-sensitive surgical infection research using an opt-out or an opt-in strategy? (2) Should patients who are being enrolled in a randomized controlled trial (RCT) comparing surgery with a non-operative intervention pay the costs of their treatment arm? (3) Should the scientific community embrace open access journals as the future of scientific publishing? (4) Should the majority of funding go to clinical or basic science research? Important points were illustrated in each of the pro-con presentations and illustrated the difficulties that are facing the performance and payment of infection research in the future. Surgical research is ethically complex, with conflicting demands between individual patients, society, and healthcare economics. At present, there are no clear answers to these and the many other ethical issues facing research in the future. Answers will only come from continued robust dialogue among all stakeholders in surgical research.

Source
http://dx.doi.org/10.1089/sur.2020.098DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7232654PMC
May 2020

### Surgical stabilization of rib fractures during the COVID-19 pandemic.

##### Authors:

J Trauma Acute Care Surg 2020 08;89(2):272

Source
http://dx.doi.org/10.1097/TA.0000000000002751DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7202116PMC
August 2020

### Trends in hematologic markers after blunt splenic trauma: Risk factor or Epiphenomenon?

Am J Surg 2020 08 20;220(2):489-494. Epub 2019 Dec 20.

Department of Surgery, Denver Health Medical Center, Denver, CO, USA. Electronic address:

Background: Most blunt splenic injuries (BSI) are treated with nonoperative management (NOM) or embolization (EMBO). Little is known about the hematologic changes associated with these treatments. We aim to assess the temporal changes of hematologic markers in trauma patients who undergo splenectomy (SPL), packing and splenorrhaphy (P/S), EMBO, or NOM. We hypothesize that differences in trends of hematologic markers exist in patients undergoing EMBO or SPL, compared to NOM.

Methods: An 8-year review of adult patients with BSI and underwent SPL, EMBO, P/S, or NOM. White blood cell count (WBC), hematocrit (HCT) and platelet count (PLT) at presentation to 14 days post-admission were analyzed; post-procedural complications were reviewed. Temporal trends were compared using linear mixed-effects models.

Results: 478 patients sustained BSI, 298 (62.3%) underwent NOM, 100 (29.2%) SPL, 42 (8.8%) EMBO, and 38 (8.0%) P/S. After adjustment for age, ISS and splenic injury grade, SPL patients had a significantly higher upward trend compared to other management strategies (p < 0.05). Infection further increased this trend. Starting on day 6, SPL patients with infections had significantly higher WBC than those without infection. SPL and P/S were more likely than NOM to develop infections after adjustment for confounders (HR = 3.64; 95%CI: 1.79-7.39 and HR = 2.59; 95%CI: 1.21-5.55, respectively). Day 6 WBC>16,000 cells/ml post-SPL had a positive predictive value (PPV) of 65.2% and negative predictive value (NPV) of 76.9% for infections. Among P/S, Day 6 WBC >10,200 cells/ml had a PPV = 50% and NPV = 86.7% for infections.

Conclusions: We observed distinct patterns of hematologic markers following BSI managed with SPL, EMBO, P/S, and NOM. Day 6 WBC increases after SPL or P/S should raise suspicion of infections and trigger a diagnostic investigation.

Source
http://dx.doi.org/10.1016/j.amjsurg.2019.12.016DOI Listing
August 2020

### A multicenter, prospective, controlled clinical trial of surgical stabilization of rib fractures in patients with severe, nonflail fracture patterns (Chest Wall Injury Society NONFLAIL).

J Trauma Acute Care Surg 2020 Feb;88(2):249-257

From the Department of Surgery, Division of Trauma, Denver Health Medical Center (F.M.P., K.L.), Denver Colorado; Department of Surgery, Division of Trauma, University of Nebraska Medical Center (Z.B.), Omaha, Nebraska; Department of Surgery, Division of Trauma, Medical University of South Carolina (E.A.E.), Charleston, South Carolina; Department of Surgery, Division of Trauma, St. Mary's Medical Center (L.L.), West Palm Beach, Florida; Department of Surgery, Division of Trauma, Intermountain Medical Center (S.M.), Murray, Utah; Department of Surgery, Division of CT Surgery, St. Joseph Health (L.P.), Mission Hospital, Mission Viejo, California; Department of Surgery, Division of Trauma, George Washington University (B.S.), Washington, District of Columbia; Department of Surgery, Division of Trauma, Wright State University/Miami Valley Hospital (G.S.), Dayton, Ohio; Department of Surgery, Division of Trauma, Carolinas Medical Center (B.T.), Charlotte, North Carolina; Department of Surgery, Division of Trauma, The Queens Medical Center (F.Z.), Honolulu, Hawaii; Department of Surgery, Division of Trauma, Sanford Health (C.D.), Fargo, North Dakota; Department of Surgery, Division of Trauma, Baystate Medical Center (A.R.D.), Springfield, Massachusetts.

Background: The efficacy of surgical stabilization of rib fracture (SSRF) in patients without flail chest has not been studied specifically. We hypothesized that SSRF improves outcomes among patients with displaced rib fractures in the absence of flail chest.

Methods: Multicenter, prospective, controlled, clinical trial (12 centers) comparing SSRF within 72 hours to medical management. Inclusion criteria were three or more ipsilateral, severely displaced rib fractures without flail chest. The trial involved both randomized and observational arms at patient discretion. The primary outcome was the numeric pain score (NPS) at 2-week follow-up. Narcotic consumption, spirometry, pulmonary function tests, pleural space complications (tube thoracostomy or surgery for retained hemothorax or empyema >24 hours from admission) and both overall and respiratory disability-related quality of life (RD-QoL) were also compared.

Results: One hundred ten subjects were enrolled. There were no significant differences between subjects who selected randomization (n = 23) versus observation (n = 87); these groups were combined for all analyses. Of the 110 subjects, 51 (46.4%) underwent SSRF. There were no significant baseline differences between the operative and nonoperative groups. At 2-week follow-up, the NPS was significantly lower in the operative, as compared with the nonoperative group (2.9 vs. 4.5, p < 0.01), and RD-QoL was significantly improved (disability score, 21 vs. 25, p = 0.03). Narcotic consumption also trended toward being lower in the operative, as compared with the nonoperative group (0.5 vs. 1.2 narcotic equivalents, p = 0.05). During the index admission, pleural space complications were significantly lower in the operative, as compared with the nonoperative group (0% vs. 10.2%, p = 0.02).

Conclusion: In this clinical trial, SSRF performed within 72 hours improved the primary outcome of NPS at 2-week follow-up among patients with three or more displaced fractures in the absence of flail chest. These data support the role of SSRF in patients without flail chest.

Level Of Evidence: Therapeutic, level II.

Source
http://dx.doi.org/10.1097/TA.0000000000002559DOI Listing
February 2020

### Multiple Impacted Colonic Foreign Bodies Presenting Months After Ingestion.

##### Authors:
Calliandra Hintzen Fredric M Pieracci Amy Storfa

J Trauma Acute Care Surg 2019 Oct 29. Epub 2019 Oct 29.

St. Joseph Hospital, Denver CO Trauma, Acute Care Surgery, and Surgical Critical Care, The Ernest E. Moore Shock Trauma Center, Director of Bariatric Surgery, Denver Health Medical Center, Associate Professor of Surgery, University of Colorado School of Medicine, 777 Bannock Street. (O): 303-436-4029 (F): 303-436-6572. Denver Health Medical Center Department of Pathology and Laboratory Medicine, Associate Professor, University of Colorado School of Medicine, 777 Bannock St, Denver CO 80204. (O): 303-602-5209.

Source
http://dx.doi.org/10.1097/TA.0000000000002526DOI Listing
October 2019

### Taxonomy of multiple rib fractures: Results of the chest wall injury society international consensus survey.

J Trauma Acute Care Surg 2020 Feb;88(2):e40-e45

From the Department of Cardiothoracic Surgery, Sheffield Teaching Hospitals NHS Foundation Trust (J.G.E., P.C.), University of Sheffield (J.G.E., P.C.), Sheffield, United Kingdom; Department of Surgery, Denver Health Medical Center (F.M.P.), Denver, Colorado; Department of Surgery and Trauma, St Elisabeth Hospital (M.B.), Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands; Department of Surgery, Tawam Hospital (E.A.B.), Abu Dhabi, United Arab Emirates; Department of Trauma and Acute Care Surgery, Saint Francis Hospital and Medical Center Baystate Medical Center (A.B., R.G.), Hartford, Connecticut; Division of Cardiothoracic Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin (M.G.), Milwaukee, Wisconsin; Department of Thoracic and Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Beijing Luhe Hospital (W.J.), Capital Medical University Beijing, China; Trauma and General Surgery Service, Legacy Emmanuel Medical Centre (W.L.), Portland, Oregon; Department of Trauma and Acute Care Surgery, St. Mary's Medical Center (L.L.), West Palm Beach, Florida; Intermountain Trauma & General Surgery, Intermountain Medical Center (S.M., D.V.B.), Salt Lake City, Utah; Department of Cardiothoracic Surgery, Alfred Hospital (S.M.), Melbourne, Australia; General Surgery, St Lukes Wood River Medical Center (J.M.), Ketchum, ID; Trauma and Acute Care Surgery, George Washington University (B.S.), Washington, District of Columbia; Universitätsklinikum Erlangen (S.S-D.), Germany; and Chest Wall Injury Society (S.W.), Lake City, Utah.

Source
http://dx.doi.org/10.1097/TA.0000000000002282DOI Listing
February 2020

### It's sooner than you think: Blunt solid organ injury patients are already hypercoagulable upon hospital admission - Results of a bi-institutional, prospective study.

Am J Surg 2019 12 10;218(6):1065-1073. Epub 2019 Sep 10.

University of Colorado-Denver, Department of Surgery, 12631 E 17th Ave, Aurora, CO, 80045, USA; Ernest E Moore Shock Trauma Center at Denver Health, Department of Surgery, 777 Bannock St, Denver, CO, 80204, USA. Electronic address:

Introduction: The optimal time to initiate venous thromboembolism (VTE) chemoprophylaxis in blunt solid organ injury (BSOI) patients is debated. We hypothesize that 1) BSOI patients are hypercoagulable within 12 h of injury and 2) hypercoagulability dominates in patients who develop clot complications (CC).

Material And Methods: This is a prospective study of BSOI patients admitted to two Level-1 Trauma Centers' trauma intensive care units (ICU). Serial kaolin thrombelastography (TEG) and tissue plasminogen activator (tPA)-challenge TEGs were performed. CC included VTE and cerebrovascular accidents.

Results: On ICU admission, all patients (n = 95) were hypercoagulable, 58% were in fibrinolysis shutdown, and 50% of patients were tPA-resistant. Twelve patients (13%) developed CC. Compared to those without CC, they demonstrated decreased fibrinolysis at 12 h and higher clot strength at 48 h CONCLUSIONS: BSOI patients are universally hypercoagulable upon ICU admission. VTE chemoprophylaxis should be started immediately in BSOI patients with hypercoagulability on TEG.

Source
http://dx.doi.org/10.1016/j.amjsurg.2019.08.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6878200PMC
December 2019

### Not all in your head (and neck): Stroke after blunt cerebrovascular injury is associated with systemic hypercoagulability.

J Trauma Acute Care Surg 2019 11;87(5):1082-1087

From the Department of Surgery (J.J.S., H.B.M., E.E.M., M.L.S., F.M.P., C.J.F., E.M.C., R.A.L., K.B.P., A.S., M.J.C., C.C.B.), Denver Health Medical Center, University of Colorado School of Medicine, Denver, Colorado.

Background: Stroke secondary to blunt cerebrovascular injury (BCVI) most often occurs before initiation of antithrombotic therapy. Earlier treatment, especially in multiply injured patients with relative contraindications to antithrombotic agents, could be facilitated with improved risk stratification; furthermore, the relationship between BCVI-attributed stroke and hypercoagulability remains unknown. We hypothesized that patients who suffer BCVI-related stroke are hypercoagulable compared with those with BCVI who do not stroke.

Methods: Rapid thromboelastography (TEG) was evaluated for patients with BCVI-attributed stroke at an urban Level I trauma center from 2011 to 2018. Contemporary controls who had BCVI but did not stroke were selected for comparison using propensity-score matching with 20% caliper that accounted for age, sex, injury severity, and BCVI location and grade.

Results: During the study period, 15,347 patients were admitted following blunt trauma. Blunt cerebrovascular injury was identified in 435 (3%) patients, of whom 28 experienced associated stroke and had a TEG within 24 hours of arrival. Forty-nine patients who had BCVI but did not suffer stroke served as matched controls. Stroke patients formed clots faster as evident in their larger angle (77.5 degrees vs. 74.6 degrees, p = 0.03) and had greater clot strength as indicated by their higher maximum amplitude (MA) (66.9 mm vs. 61.9 mm, p < 0.01). Activated clotting time was shorter among stroke patients but not significantly (113 seconds vs. 121 seconds, p > 0.05). Increased angle and elevated MA were significant predictors of stroke with odds ratios of 2.97 for angle greater than 77.3 degrees and 4.30 for MA greater than 63.0 mm.

Conclusion: Patients who suffer BCVI-related stroke are hypercoagulable compared with those with BCVI who remain asymptomatic. Increased angle or MA should be considered when assessing the risk of thrombosis and determining the optimal time to initiate antithrombotic therapy in patients with BCVI.

Level Of Evidence: Prognostic, Level III.

Source
http://dx.doi.org/10.1097/TA.0000000000002443DOI Listing
November 2019

### The Sequential Clinical Assessment of Respiratory Function (SCARF) score: A dynamic pulmonary physiologic score that predicts adverse outcomes in critically ill rib fracture patients.

J Trauma Acute Care Surg 2019 12;87(6):1260-1268

From Department of Surgery (K.S.H., K.N.L., J.H. E.E.M., C.C.B., F.M.P), Division of Trauma & Surgical Critical Care, Denver Health Medical Center, Denver, Colorado.

Background: Rib fracture scoring systems are limited by a lack of serial pulmonary physiologic variables. We created the Sequential Clinical Assessment of Respiratory Function (SCARF) score and hypothesized that admission, maximum, and rising scores predict adverse outcomes among critically ill rib fracture patients.

Methods: Prospective cohort study of rib fracture patients admitted to the surgical intensive care unit (ICU) at a Level I trauma center from August 2017 to June 2018. The SCARF score was developed a priori and validated using the cohort. One point was assigned for: <50% predicted, respiratory rate >20, numeric pain score ≥5, and inadequate cough. Demographics, injury patterns, analgesics, and adverse pulmonary outcomes were abstracted. Performance characteristics of the score were assessed using the receiver operator curve area under the curve.

Results: Three hundred forty scores were available from 100 patients. Median admission and maximum SCARF score was 2 (range 0-4). Likelihood of pneumonia (p = 0.04), high oxygen requirement (p < 0.01), and prolonged ICU length of stay (p < 0.01) were significantly associated with admission and maximum scores. The receiver operator curve area under the curve for the maximum SCARF score for these outcomes were 0.86, 0.76, and 0.79, respectively. In 10 patients, the SCARF score worsened from admission to day 2; these patients demonstrated increased likelihood of pneumonia (p = 0.04) and prolonged ICU length of stay (p = 0.07). Patients who developed complications maintained a SCARF score one point higher throughout ICU stay compared with patients who did not (p = 0.04). The SCARF score was significantly associated with both narcotic (p = 0.03) and locoregional anesthesia (p = 0.03) usage.

Conclusion: Admission, maximum, daily, and rising scores were associated with utilization of pain control therapies and development of adverse outcomes. The SCARF score may be used to guide therapies for critically ill rib fracture patients, with a proposed threshold greater than 2.

Level Of Evidence: Prognostic study, level II.

Source
http://dx.doi.org/10.1097/TA.0000000000002480DOI Listing
December 2019

### Preperitoneal Pelvic Packing Is Not Associated With an Increased Risk of Surgical Site Infections After Internal Anterior Pelvic Ring Fixation.

J Orthop Trauma 2019 Dec;33(12):601-607

Department of Surgery, Denver Health Medical Center, School of Medicine, University of Colorado, Denver, CO.

Objective: To investigate the risk of postoperative surgical site infections after plate fixation of the anterior pelvic ring subsequent to preperitoneal pelvic packing (PPP).

Design: Retrospective observational cohort study.

Setting: Level I academic trauma center.

Patients: Adult trauma patients with unstable pelvic ring injuries requiring surgical fixation of the anterior pelvic ring.

Intervention: Pelvic plate fixation was performed as a staged procedure after external fixation and PPP/depacking (PPP group; n = 25) or as a single-stage primary internal fixation (control group; n = 87).

Main Outcome Measure: Incidence of postoperative surgical site infections of the pelvic space.

Results: Anterior pelvic plate fixation was performed in 112 patients during a 5-year study period. The PPP group had higher injury severity scores and transfused packed red blood cells than the control group (injury severity score: 46 ± 12.2 vs. 29 ± 1.5; packed red blood cells: 13 ± 10 vs. 5 ± 2; P < 0.05). The mean time until pelvic depacking was 1.7 ± 0.6 days (range: 1-3 days) and 3.4 ± 3.7 days (range: 0-15 days) from depacking until pelvic fracture fixation. Two patients in the PPP group and 8 patients in the control group developed a postoperative infection requiring a surgical revision (8.0% vs. 9.2%; n.s.). Both PPP patients with a pelvic space infection had undergone anterior plate fixation for associated acetabular fractures.

Conclusions: These data support the safety of the PPP protocol for bleeding pelvic ring injuries due to the lack of increased infection rates after fracture fixation. Caution should be applied when considering PPP in patients with associated acetabular fractures.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Source
http://dx.doi.org/10.1097/BOT.0000000000001583DOI Listing
December 2019

### Challenges in acute care surgery: Zone III neck stab wound.

J Trauma Acute Care Surg 2019 Aug;87(2):508-509

From the Division of Gastrointestinal, Trauma and Endocrine Surgery (F.M.P., C.C.B), Department of Surgery, Division of Otorhinolaryngology (M.E.), Department of Surgery, and Department of Emergency Medicine (B.S., R.B.), University of Colorado School of Medicine/Denver Health Medical Center, Denver, Colorado.