Publications by authors named "Joshua P Hazelton"

39 Publications

Medical Student Attitudes Toward Blood Donation in Times of Increased Need.

Am Surg 2021 Apr 20:31348211011083. Epub 2021 Apr 20.

Division of Trauma, Acute Care and Critical Care Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA.

Background: In situations of increased need, such as mass casualty incidents (MCIs) and COVID-19, donated blood products are in shortage across the United States. Medical students are a potential pool for blood donors. The aim of this study was to determine overall attitudes of medical students at a single academic institution toward blood donation during times of increased need.

Methods: Three anonymous REDCap surveys were administered to all medical students at a rural academic institution. Surveys 1 and 2 were administered preceding and after an institution-wide MCI drill, in September and November 2019, respectively. Survey 3 was administered following a student-organized COVID-19 blood drive in June 2020. Multivariable analysis was performed to determine if factors, ie, experience with MCI drills and emergency medical services (EMS) training, were associated with willingness to donate blood. Furthermore, barriers to donation among those not willing to donate were assessed.

Results: Overall response rate for MCI surveys (surveys 1 and 2) was 38% (mean age 25.2 years and 50% women). 91% (n = 210) of respondents were willing to donate blood. Previous participation in MCI drills and EMS training was not associated with higher willingness to donate blood. Response rate for survey 3 was 15.6% (59.4% women), and 30 (31.3%) respondents indicated they did not volunteer to donate blood during the COVID-19 drive. Most common reasons for not donating were "other," medical concerns, and being out-of-town.

Conclusions: Majority of medical students are willing to donate blood during times of increased need and offer a possible solution to increase blood donor pool.
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http://dx.doi.org/10.1177/00031348211011083DOI Listing
April 2021

Association of Acute Care Surgeon Experience With Emergency Surgery Patient Outcomes and Mortality.

JAMA Surg 2021 Mar 10. Epub 2021 Mar 10.

Department of Surgery, Yale School of Medicine, New Haven, Connecticut.

Importance: Previous studies comparing emergency surgery outcomes with surgeon experience have been small or used administrative databases without controlling for patient physiology or operative complexity.

Objective: To evaluate the association of acute care surgeon experience with patient morbidity and mortality after emergency surgical procedures.

Design, Setting, And Participants: This cohort study evaluated the association of surgeon experience with emergency surgery outcomes at 5 US academic level 1 trauma centers where the same surgeons provided emergency general surgical care. A total of 772 patients who presented with a traumatic injury and required an emergency surgical procedure or who presented with or developed a condition requiring an emergency general surgical intervention were operated on by 1 of 56 acute care surgeons. Surgeon groups were divided by experience of less than 6 years (early career), 6 to 10 years (early midcareer), 11 to 30 years (late midcareer), and 30 years or more (late career) from the end of training. Surgeons with less than 3 years of experience were also compared with the entire cohort. Hierarchical logistic regression models were constructed controlling for Emergency Surgery Score, case complexity, preoperative transfusion, and trauma or emergency general surgery. Data were collected from May 2015 to July 2017 and analyzed from February to May 2020.

Main Outcomes And Measures: Mortality, complications, length of stay, blood loss, and unplanned return to the operating room.

Results: Of 772 included patients, 469 (60.8%) were male, and the mean (SD) age was 50.1 (20.0) years. Of 772 operations, 618 were by surgeons with less than 10 years of experience. Early- and late-midcareer surgeons generally operated on older patients and patients with more septic shock, acute kidney failure, and higher Emergency Surgery Scores. Patient mortality, complications, postoperative transfusion, organ-space surgical site infection, and length of stay were similar between surgeon groups. Patients operated on by early-career surgeons had higher rates of unplanned return to the operating room compared with those operated on by early-midcareer surgeons (odds ratio [OR], 0.66; 95% CI, 0.40-1.09), late-midcareer surgeons (OR, 0.34; 95% CI, 0.13-0.90), and late-career surgeons (OR, 1.11; 95% CI, 0.45-2.75). Patients operated on by surgeons with less than 3 years of experience had similar mortality compared with the rest of the cohort (OR, 1.97; 95% CI, 0.85-4.57) but higher rates of complications (OR, 2.07; 95% CI, 1.05-4.07).

Conclusions And Relevance: In this study, experienced surgeons generally operated on older patients with more septic shock and kidney failure without affecting risk-adjusted mortality. Increased complications and unplanned return to the operating room may improve with experience. Early-career surgeons' outcomes may be improved if they are supported while experience is garnered.
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http://dx.doi.org/10.1001/jamasurg.2021.0041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7948108PMC
March 2021

Temporary intravascular shunts after civilian arterial injury: A prospective multicenter Eastern Association for the Surgery of Trauma study.

Injury 2021 May 3;52(5):1204-1209. Epub 2021 Jan 3.

Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, University of Pennsylvania, Penn Presbyterian Medical Center, 51 North 39th Street, Medical Office Building Suite 120, 19104 Philadelphia, Pennsylvania, USA. Electronic address:

Introduction: We sought to determine the impact of the indication for shunt placement on shunt-related outcomes after major arterial injuries. We hypothesized that a shunt placed for damage control indications would be associated with an increase in shunt-related complications including shunt dislodgement, thrombosis, or distal ischemia.

Patients & Methods: A prospective, multicenter study (eleven level one US trauma centers) of all adult trauma patients undergoing temporary intravascular shunts (TIVS) after arterial injury was undertaken (January 2017-May 2019). Exclusion criteria included age <15years, shunt placement distal to popliteal/brachial arteries, isolated venous shunts, and death before shunt removal. Clinical variables were compared by indication and shunt-related complications. The primary endpoint was TIVS complications (thrombosis, migration, distal ischemia).

Results: The 66 patients who underwent TIVS were primarily young (30years [IQR 22-36]) men (85%), severely injured (ISS 17 [10-25]) by penetrating mechanisms (59%), and had their shunts placed for damage control (41%). After a median SDT of 198min [89-622], 9% experienced shunt-related complications. Compared by shunt placement indication (damage control shunts [n=27] compared to non-damage control shunts [n=39]), there were no differences in gender, mechanism, extremity AIS, MESS score, fractures, or surgeon specialty between the two groups (all p>0.05). Patients with shunts placed for damage control indications had more severe injuries (ISS 23.5 compared to 13; SBP 100 compared to 129; GCS 11 compared to 15; lactate 11.5 compared to 3.6; all p<0.05), and had more frequent shunt complication predictors, but damage control shunts did not have significantly more TIVS complications (11.1% compared to 7.7%, p=0.658). Shunt complication patients were discharged home less often (33% vs 65%; p<0.05) but all survived.

Conclusion: Shunts placed for damage control indications were not associated with shunt complications in this prospective, multicenter study.
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http://dx.doi.org/10.1016/j.injury.2020.12.035DOI Listing
May 2021

The incidence of venous thromboembolic events in trauma patients after tranexamic acid administration: an EAST multicenter study.

Blood Coagul Fibrinolysis 2021 Jan;32(1):37-43

Department of Surgery, University of Colorado, Aurora, Colorado.

To determine if there is a significant association between administration of tranexamic acid (TXA) in severely bleeding, injured patients, and venous thromboembolism (VTE), myocardial infarction (MI), or cerebrovascular accident (CVA). A multicenter, retrospective study was performed. Inclusion criteria were: age 18-80 years old and need for 5 units or more of blood in the first 24 h after injury. Exclusion criteria included: death within 24 h, pregnancy, administration of TXA more than 3 h following injury, and routine ultrasound surveillance for deep venous thrombosis. Incidence of VTE was the primary outcome. Secondary outcomes included MI, CVA, and death. A power analysis found that a total of 830 patients were needed to detect a true difference in VTE risk. 1333 patients (TXA = 887, No-TXA = 446 patients) from 17 centers were enrolled. There were no differences in age, shock index, Glasgow coma score, pelvis/extremity abbreviated injury score, or paralysis. Injury severity score was higher in the No-TXA group. Incidence of VTE, MI, or CVA was similar between the groups. The TXA group required significantly less transfusion (P < 0.001 for all products) and had a lower mortality [adjusted odds ratio 0.67 (95% confidence interval 0.45-0.98)]. Despite having a higher extremity/pelvis abbreviated injury score, results did not change when evaluating only patients with blunt injury. Use of TXA in bleeding, injured patients is not associated with VTE, MI, or CVA but is associated with a lower transfusion need and mortality.
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http://dx.doi.org/10.1097/MBC.0000000000000983DOI Listing
January 2021

Low-density Isolated Intraperitoneal Free Fluid in Pediatric Blunt Trauma Is Not Associated With Abdominal Injury.

Pediatr Emerg Care 2020 Jul 6. Epub 2020 Jul 6.

From the *Division of Trauma and Acute Care Surgery, Department of Surgery, Penn Medicine Lancaster General Hospital, Lancaster, PA †Division of Trauma, Department of Surgery ‡Cooper Research Institute §Department of Radiology, Cooper University Hospital, Camden, NJ ∥Division of Trauma, Acute Care and Critical Care Surgery, Department of Surgery, Pennsylvania State University College of Medicine, Hershey, PA.

Objectives: Isolated intraperitoneal free fluid (IIFF) is defined as intraperitoneal fluid seen on computed tomography (CT) without identifiable injury. In a hemodynamically stable patient, this finding creates a challenge for physicians regarding the next steps in management because the clinical significance of this fluid is not completely understood. We hypothesized that pediatric blunt trauma patients with a finding of simple IIFF on CT would not have clinically significant intraabdominal injury.

Methods: A retrospective review (2009-2018) was conducted of all pediatric blunt trauma patients who underwent CT scan of the abdomen/pelvis at our institution. All patients with scans performed at our institution with the finding of IIFF were included. Scans were reviewed to measure the Hounsfield Units (HU) of the intraabdominal fluid. Groups were stratified into HU > 25 and HU ≤ 25, below accepted cutoffs for acute blood, and clinical outcomes were reviewed.

Results: A total of 413 patients had free fluid on CT abdomen/pelvis with 279 (68%) having only the finding of IIFF. The HU was 25 or less in 236 (85%) patients. No patients in the HU ≤ 25 group required operative exploration or had examination findings to indicate they had intraabdominal injury. Four (9%) patients in the HU > 25 required laparotomy (P < 0.0001). No patients in the HU ≤ 25 group required further workup or hospital admission over concern for intraabdominal injury.

Conclusions: Pediatric blunt trauma patients with HU of 25 or less IIFF and a nonperitonitic physical examination did not require operative exploration or further workup for intraabdominal injury. In the absence of other injuries, it is safe to discharge these patients without further workup.
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http://dx.doi.org/10.1097/PEC.0000000000002189DOI Listing
July 2020

Patient Outcomes in Mesenteric Venous Thrombosis Treated With Empiric Antibiotics.

Am Surg 2021 Apr 6;87(4):658-663. Epub 2020 Nov 6.

12311Department of Surgery, Division of Trauma, Acute Care and Critical Care Surgery, Milton S. Hershey Medical Center.

Background: Mesenteric venous thrombosis (MVT) is typically associated with poor prognosis. Although prophylactic antibiotics are sometimes given with the intent of limiting bacterial luminal load and translocation in patients with MVT, this approach has not been universally adopted. The aim of this study is to analyze whether utilizing antibiotics empirically in those with MVT improves patient outcomes and survival when compared to those who do not receive empiric antibiotics.

Methods: A retrospective review of patients admitted with MVT between 2002 and 2019 at a single academic institution was performed. Demographics and rates of mortality need for bowel resection, readmission, and () infection were compared between patients treated with empiric antibiotics and patients not treated with antibiotics.

Results: Eighty-three patients (mean age 64.5 years and 55.4% male) who were admitted for MVT were included. Empiric antibiotics were utilized in 53% (n = 44) of MVT patients while 47% (n = 39) received supportive treatment without empiric antibiotics. Death occurred in 4 patients treated with antibiotics and 6 patients treated without antibiotics (9.1% vs. 15.3%, = .50). Readmissions occurred in 12 patients (27.3%) treated with antibiotics and 10 patients (25.6%) not treated with antibiotics (27.3% vs. 25.6%, = .87). infection occurred in 6 patients treated with antibiotics and in no patients not treated with antibiotics (13.6% vs. 0%, = .03).

Conclusions: Empiric antibiotic usage may not improve rates of mortality or hospital readmission in patients with MVT and may unnecessarily expose patients to an increased risk of infection.
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http://dx.doi.org/10.1177/0003134820954850DOI Listing
April 2021

Novel policing techniques decrease gun-violence and the cost to the healthcare system.

Prev Med Rep 2019 Dec 25;16:100995. Epub 2019 Oct 25.

Cooper Bone & Joint Institute, Cooper University Hospital, 3 Cooper Plaza, Camden, NJ 08103, United States.

The objective was to investigate the effects of novel policing techniques on hospital-observed incidence, healthcare utilization, mortality and costs associated with gun violence, from the perspective of a level-1 trauma center. An eight-year retrospective review evaluating the clinical and financial effects of gunshot wound (GSW) encounters between January 1st, 2010 and December 31st, 2017. Individuals who presented to the emergency department (Level-1 trauma center in Camden, NJ) between January 1, 2010 and December 31, 2017 with GSW (995 encounters) were included; however, patients with incomplete financial or medical record data were excluded (55 encounters). Patients were subdivided into two cohorts: before and after changes in policing tactics (May 1st, 2013). 940 total firearm-related encounters were included in the study. Following the policing changes, the hospital-observed quarterly incidence of GSW encounters decreased by 22% post-policing changes, 44.3 to 34.6 (p = 0.038). Average quarterly days spent in-house for GSW treatment decreased 220.7 to 151.3 (31%) days. Hospital observed mortality increased from 13.5% of presentations to 17.3% of presentations (p = 0.106). Total cost savings associated with the policing change was roughly $254,000 per quarter (p = 0.023). In areas susceptible to high rates of gun violence, similar novel policing tactics could significantly decrease hospital-observed incidence, costs and healthcare utilization demanded by firearm-related injury.
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http://dx.doi.org/10.1016/j.pmedr.2019.100995DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6861592PMC
December 2019

Incidence and significance of injuries on secondary CT imaging after initial selective imaging in blunt trauma patients.

Am J Emerg Med 2020 08 11;38(8):1588-1593. Epub 2019 Sep 11.

Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, Department of Emergency Medicine, United States of America.

Objective: It is unclear if additional computerized tomography (CT) imaging is warranted after injuries are identified on CT in blunt trauma patients. The objective of this study was to determine the incidence and significance of injuries identified on secondary CT imaging after identification of injuries on initial CTs in blunt trauma patients.

Methods: This was a retrospective cohort study at an academic Level 1 trauma center with a two-tiered trauma system.

Inclusion Criteria: age ≥ 18, level 2 trauma activation, injury identified on initial CT, and secondary CTs ordered. Secondary injuries were categorized as resulting in: no changes, minor changes, or major changes in management.

Results: 537 patients underwent 1179 initial CT scans which identified 744 injuries. There were 1094 secondary CTs which identified 143 additional injuries in 94 (18%) patients. 9 (1.7%) patients had at least one major management change and 64 (12%) had at least one minor management change. Rib fracture(s) was the most common injury on secondary scans [45/143 (32%)]. The major management changes were: tube thoracostomy for pneumothorax (4 patients), blood transfusion for hemoperitoneum (1 patient), surgery for acetabular fracture (1 patient), thoracolumbar brace for spine fracture (2 patients) and angiography for splenic injury (1 patient).

Conclusion: While a significant proportion of patients (18%) had injuries on secondary CT, only 1.7% of patients had a resultant major management change. Future research is warranted to determine the need for additional CT imaging after an initial selective imaging strategy in blunt trauma patients.
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http://dx.doi.org/10.1016/j.ajem.2019.158432DOI Listing
August 2020

Comparison of Urban Off-Road Vehicle and Motorcycle Injuries at a Level 1 Trauma Center.

J Surg Res 2020 01 16;245:373-376. Epub 2019 Aug 16.

Division of Trauma, Acute Care, and Critical Care Surgery, Department of Surgery, Penn State University College of Medicine, Hershey, Pennsylvania.

Background: Recently, there has been an increase in the usage of dirt bikes and all-terrain vehicles in urban environments. Previously, it has been shown that crashes involving these urban off-road vehicles (UORVs) resulted in different injury patterns from crashes that occurred in rural environments. The aim of this study was to compare injury patterns of patients involved in crashes while riding UORVs versus motorcycles (MCs).

Methods: A retrospective review (2005-2016) of patients who presented to our urban level I trauma center as a result of any MC or UORV crash was performed. Patients who presented after 48 h from the time of accident were excluded. A P < 0.05 was considered significant.

Results: We identified 1556 patients who were involved in an MC or UORV crash resulting in injury (MC: n = 1324 [85%]; UORVs: n = 232 [15%]). Patients in UORV crashes were younger (26.2 y versus 39.6 y), less likely to be helmeted (39.6% versus 90.2%), required fewer emergent trauma bay procedures (28.4% versus 36.7%), and needed fewer operative interventions (45.9% versus 54.2%) (all P < 0.05). Both groups had a similar Injury Severity Score (12.2 versus 12.6; P = 0.54) and Glasgow Coma Score (13.8 versus 13.5; P = 0.46). UORV patients had a lower mortality (0.9% versus 4.7%; P < 0.05) compared to MC crash patients despite similar injury patterns.

Conclusions: Our data demonstrate that patients sustaining UORV injuries were younger and less likely to be helmeted but have a lower mortality rate after a crash, despite sustaining similar injuries as motorcyclists. This study provides an overview of how crashes involving UORV usage is a unique phenomenon and not entirely comparable to MC crashes.
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http://dx.doi.org/10.1016/j.jss.2019.07.069DOI Listing
January 2020

Use of ShotSpotter detection technology decreases prehospital time for patients sustaining gunshot wounds.

J Trauma Acute Care Surg 2019 12;87(6):1253-1259

From the Division of Trauma, Department of Surgery (A.G.), Department of Surgery (D.R.), Cooper University Hospital, Camden; Department of Surgery (M.D.), St. Barnabas Hospital, Livingston; Department of Medicine (J.P.G.), Cooper University Hospital; Camden County Police Department (J.S.T.); Division of Trauma, Department of Surgery (K.R.), Cooper University Hospital, Camden; Division of Acute Care Surgery, Department of Surgery (C.B.), Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; and Division of Trauma, Department of Surgery (J.P.H.), Acute Care and Critical Care Surgery, Penn State College of Medicine, Hershey, Pennsylvania.

Background: Shorter prehospital time in patients sustaining penetrating trauma has been shown to be associated with improved survival. Literature has also demonstrated that police transport (vs. Emergency Medical Services [EMS]) shortens transport times to a trauma center. The purpose of this study was to determine if ShotSpotter, which triangulates the location of gunshots and alerts police, expedited dispatch and transport of injured victims to the trauma center.

Methods: All shootings which occurred in Camden, NJ, from 2010 to 2018 were reviewed. Demographic, geographic, response time, transport time, and field intervention data were collected from medical and police records. We compared shootings where the ShotSpotter was activated versus shootings where ShotSpotter was not activated. Incidents, which did not occur in Camden or where complete data were not available, were excluded as were patients not transported by police or EMS.

Results: There were 627 shootings during the study period which met inclusion criteria with 190 (30%) activating the ShotSpotter system. Victims involved in shootings with ShotSpotter activation were more severely injured, more likely to be transported by police, less likely to undergo trauma bay resuscitative measures, and more likely to receive blood products. Mortality, when adjusted for distance, Trauma, and Injury Severity Score, Injury Severity Score, and shock index, was not significantly different between ShotSpotter and non-ShotSpotter incidents. ShotSpotter activation significantly reduced both the response time as well as transport time for both police and EMS (all p < 0.05).

Conclusion: The activation of the ShotSpotter technology increased the likelihood of police transport of gunshot victims. Furthermore, the use of this technology resulted in shorter response times as well as transport times for both police and EMS. This technology may be beneficial in enhancing the care of victims of penetrating trauma.

Level Of Evidence: Therapeutic/Care management, level III.
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http://dx.doi.org/10.1097/TA.0000000000002483DOI Listing
December 2019

Determining Trajectory to Predict Injury: The Use of X-Ray During Resuscitation in Gunshot Wounds.

J Surg Res 2019 08 9;240:201-205. Epub 2019 Apr 9.

Division of Trauma, Department of Surgery, Cooper University Hospital, Camden, New Jersey. Electronic address:

Background: The practice of marking gunshot wounds and obtaining X-rays (XRs) has been performed to determine the trajectory of missiles to help identify internal injuries. We hypothesized that surgeons would have poor accuracy in predicting injuries and that X-rays do not alter the clinical decision.

Methods: We developed a 50-patient (89 injury sites) PowerPoint survey based on cases seen at our level 1 trauma center from 2012 to 2014. Images of a silhouetted BodyMan (BM) with wounds marked, XRs, and vital signs (VSs) were shown in series for 20 s each. Surgeons were asked to record which organs they thought could be injured and to document their clinical decision. Data were analyzed to determine the inter-rater reliability (agreement, intraclass correlation coefficient [ICC]) for each mode of clinical information (BM, XR, VS). Predicted versus actual injuries were compared using absolute agreements.

Results: Ten surgeons completed the survey. We found that no single piece of information was helpful in allowing the surgeon to accurately predict injuries. Pulmonary injury had the highest agreement among all injuries (ICC = 0.727). VSs had the highest ICC in determining the clinical plan for the patient (ICC = 0.342), whereas both BM and XR had low ICCs (0.162 and 0.183, respectively).

Conclusions: We found that marking wounds and obtaining X-rays, other than a chest X-ray, did not result in accuracy in predicting injury nor alter the clinical decision. VSs were the only piece of information found significant in determining clinical management. We conclude that marking wounds for X-rays is an unnecessary step during the initial resuscitation of patients with gunshot wounds.
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http://dx.doi.org/10.1016/j.jss.2019.03.065DOI Listing
August 2019

Expeditious Diagnosis and Laparotomy for Patients with Acute Abdominal Compartment Syndrome May Improve Survival.

Am Surg 2018 Nov;84(11):1836-1840

Causes of abdominal compartment syndrome (ACS) are varied and can result from both medical and surgical diseases. Early recognition of ACS and prompt surgical treatment has been shown to improve mortality. We hypothesize that earlier recognition of ACS and earlier involvement by surgical specialists may improve mortality. A retrospective review between July 2010 and July 2015 was performed of adult patients who underwent decompressive laparotomy for ACS. Patients were divided into surgical and medical intensive care units (SICU and MICU) arms. Twenty patients were included (MICU = 12; SICU = 8) without significant difference between the groups. Median time from admission to suspicion for MICU patients was 60 hours 13 hours for SICU patients ( = 0.013). Time from suspicion to surgical consult was 60 minutes 0 minutes, respectively ( = 0.003), however, time from surgical consult to intervention was not different. Mortality rate in the MICU was 83 per cent 12.5 per cent in the SICU ( = 0.005). Patients in the SICU who developed ACS were more quickly diagnosed than those in the MICU. These patients had a shorter time from suspicion of ACS to surgical consultation and eventual surgical intervention, and was associated with improved survival. A multidisciplinary approach, including early surgical consultation, for patients in whom there is a suspicion of ACS may contribute to improved mortality.
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November 2018

Financial Impact of Minor Injury Transfers on a Level 1 Trauma Center.

J Surg Res 2019 01 18;233:403-407. Epub 2018 Sep 18.

Division of Trauma, Department of Surgery, Cooper University Hospital, Camden, New Jersey.

Background: Trauma centers frequently accept patients from other institutions who are being sent due to the need for a higher level of care. We hypothesized that patients with minor traumatic injuries who are transferred from outside institutions would impart a negative financial impact on the receiving trauma center.

Methods: We performed a retrospective review of all trauma patients admitted to our urban level I trauma center from October 1, 2011, through September 30, 2013. Patients were categorized as minor trauma if they did not require operation within 24 h of arrival, did not require ICU admission, did not die, and had a hospital length of stay <24 h. Transferred patients and nontransfers (those received directly from the field) were compared with respect to injury severity, insurance status, and hospital net margin. Student's t-test and z-test for proportions were performed for data analysis.

Results: A total of 6951 trauma patients were identified (transfer n = 2228, nontransfer n = 4724). Minor injury transfers (n = 440) were compared to nontransfers (n = 689). Hospital net margin of transferred patients and nontransferred patients were $2227 and $2569, respectively (P = 0.22). Percentages of uninsured/underinsured for transfers and nontransfers were 27.3% and 36.1%, respectively (P = 0.002).

Conclusions: During our study period, 19.7% of transfers and 14.6% of nontransfers can be categorized as having minor trauma. Minor trauma transfer patients are associated with a positive hospital net margin for the trauma center that is similar to that of the nontransfer group. The data also demonstrate a lower percentage of uninsured/underinsured in the transferred group.
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http://dx.doi.org/10.1016/j.jss.2018.08.036DOI Listing
January 2019

Twelve-Year Review of Urban Versus Rural Off-road Vehicle Injuries at a Level 1 Trauma Center.

J Surg Res 2019 01 5;233:331-334. Epub 2018 Sep 5.

Department of Trauma, Surgical Critical Care, & Acute Care Surgery, Cooper University Hospital, Camden, New Jersey. Electronic address:

Objective: Traditionally, all-terrain vehicles (ATVs) and dirt bikes (DBs) have been used in rural locations for recreation and work. Recently, there has been an increase in the use of these vehicles in an urban environment. The aim of this study is to compare the injury patterns of patients involved in crashes while riding off-road vehicles in both urban (UORV) and rural (RORV) environment.

Methods: A retrospective review (2005-2016) of patients who presented to an urban level 1 trauma center as a result of any ATV or DB crash was performed. UORV was defined as any ATV or DB accident that occurred on paved inner city, suburban, or major roadways. RORV was defined as those accidents that occurred on secondary roadways or off-road. Patients who presented more than 48 h from time of accident were excluded. A P < 0.05 was considered significant.

Results: Five hundred and twenty-eight patients were identified to have an ATV or DB injury (RORV n = 296 [56%]; UORV n = 232 [44%]). UORV accidents had a higher Injury Severity Score (12.2 versus 9.7; P < 0.05), lower presenting Glasgow Coma Scale (13.8 versus 14.3; P < 0.05), more likely to need emergent trauma bay procedures (28.5% versus 17.9%; P < 0.05), were less likely to have been helmeted (39.6% versus 71.2%; P < 0.05) with a higher unhelmeted Abbreviated Injury Scale head of ≥3 (13.5% versus 5%; <0.05), and more likely to have extremity injuries (53.5% versus 41.2%; P < 0.05). There were no significant differences in additional injury patterns or hospital outcomes including mortality for the two groups.

Conclusions: Our data suggest that UORV use was associated with decreased helmet use, higher mean Injury Severity Score, lower presenting Glasgow Coma Scale, an increased need for emergent trauma bay procedures, higher unhelmeted Abbreviated Injury Scale head scores, and higher rates of extremity injuries.
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http://dx.doi.org/10.1016/j.jss.2018.07.061DOI Listing
January 2019

The expedited discharge of patients with multiple traumatic rib fractures is cost-effective.

Injury 2019 Jan 13;50(1):109-112. Epub 2018 Oct 13.

Division of Trauma, Department of Surgery, Cooper University Hospital, 1 Cooper Plaza, Camden, NJ 08103, United States. Electronic address:

Introduction: Rib fractures are a cause of significant morbidity and mortality in trauma patients. It is well documented that optimizing pain control, mobilization, and respiratory care decreases complications. However, the impact of these interventions on hospital costs and length of stay is not well defined. We hypothesized patients with multiple rib fractures can be discharged within three hospital days resulting in decreased hospital costs.

Methods: A retrospective review of adult patients (≥18yrs) admitted to our Level 1 trauma center (2011-2013) with ≥2 rib fractures was performed. Patients were excluded if they were intubated, admitted to the ICU, required chest tube placement, or sustained significant multi-system trauma. (n = 202) Demographics, clinical characteristics, hospital costs, and outcome data were analyzed. Patients discharged within three hospital days of admission were considered to have achieved expedited discharge (ED). Univariate and multivariate analyses determined predictors of failure to achieve ED. A p value of <0.05 was considered significant.

Results: Study patients (n = 202) were 60 (SD = 19) years of age with an injury severity score (ISS) of 10 (SD = 5), and 4 (SD = 2) rib fractures. Of 202 patients, 127 (63%) achieved ED while 75 (37%) did not. No differences in chest AIS, ISS, smoking status or history of pulmonary disease were identified between the two groups (all p > 0.05). Average LOS (2 (SD = 1) vs. 7 (SD = 4) days; p < 0.001) and hospital costs ($2865 (SD = 1200) vs. $6085 (SD = 3033)); p < 0.001). were lower in the ED group A lower percentage of ED patients required placement in rehabilitation facilities (6% vs. 48%; p < 0.001). There were no readmissions within 30 days in either group. After controlling for potential confounding variables, multiple variable logistic regression analysis revealed that advancing age (OR 1.05 per year, 1.02-1.07) independently predicted failure to achieve ED.

Conclusion: The majority of patients admitted to the hospital with multiple rib fractures can be discharged within three days. This expedited discharge results in significant cost savings to the hospital. Early identification of patients who cannot meet the goal of expedited discharge can facilitate improvement in management strategies.
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http://dx.doi.org/10.1016/j.injury.2018.10.014DOI Listing
January 2019

Pediatric Major Vascular Injuries: A 16-Year Institutional Experience From a Combined Adult and Pediatric Trauma Center.

Pediatr Emerg Care 2018 Oct 17. Epub 2018 Oct 17.

From the Division of Trauma, Department of Surgery, and.

Objectives: Vascular injury in pediatric trauma patients is uncommon but associated with a reported mortality greater than 19% in some series. The purpose of this study was to characterize pediatric major vascular injuries (MVIs) and analyze mortality at a high-volume combined adult and pediatric trauma center.

Methods: A retrospective review (January 2000 to May 2016) was conducted of all pediatric (<18 years old) trauma patients who presented with a vascular injury. A total of 177 patients were identified, with 60 (34%) having an MVI, defined as injury in the neck, torso, or proximal extremity. Patients were then further analyzed based on location of injury, mechanism, age, and race. P ≤ 0.05 was deemed significant.

Results: Of the 60 patients with MVI, the mean age was 14.3 years (range, 4-17 years). Mean intensive care unit length of stay (LOS) was 5.4 days, and mean hospital LOS was 12.5 days. Blunt mechanism was more common in patients 14 years or younger; penetrating trauma was more common amongst patients older than 14 years. Overall, blunt injuries had a longer intensive care unit LOS compared with penetrating trauma (7.8 vs 3.1 days; P = 0.016). A total of 33% (n = 20) of MVIs occurred in the torso, with 50% (n = 10) of these from blunt trauma. Location of injury did correlate with mortality; 45% (n = 9) of torso MVIs resulted in death (penetrating n = 7, blunt n = 2). Overall mortality from an MVI was 15.3% (n = 9); all were torso MVIs. Higher Injury Severity Score and Glasgow Coma Scale score were found to be independently associated with mortality.

Conclusions: Our experience demonstrates that MVIs are associated with a significant mortality (15.3%), with a majority of those resulting from gunshot wounds, more than 9-fold greater than the overall mortality of pediatric trauma patients at our institution (1.6%). Further research should be aimed at improving management strategies specific for MVIs in the pediatric trauma patient as gun violence continues to afflict youth in the United States.
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http://dx.doi.org/10.1097/PEC.0000000000001642DOI Listing
October 2018

Added Value of Dedicated Spine CT to Detect Fracture in Patients with CT Chest, Abdomen, and Pelvis in the Trauma Setting.

Curr Probl Diagn Radiol 2019 Nov - Dec;48(6):554-557. Epub 2018 Aug 13.

Department of Radiology, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ. Electronic address:

Purpose: Fractures of the thoracolumbar spine account for up to 90% of spinal fractures, and are associated with significant disability. The advantage of acquiring dedicated spine CT imaging in addition to visceral CT studies of the chest, abdomen and pelvis for detection of spinal fractures has not been definitively established. This retrospective study seeks to determine the contribution of dedicated spine CT in the acute clinical setting.

Methods: Patients who were diagnosed with fractures of the thoracic or lumbar spine at our institution between January 1, 2010 and June 30, 2014 were identified. Additional inclusion criteria included having a CT of the chest and/or abdomen and pelvis followed by a dedicated thoracic or lumbar spine CT within 30 days. Reports were reviewed for accuracy of fracture detection, and missed fractures were retrospectively analyzed on images for detectability.

Results: A total of 102 patients met our inclusion criteria for a total of 312 fractures. Of the 312 fractures, 31 (10%) were missed on the initial visceral CT in 18 of the 102 patients. In all but two cases, at least one fracture was identified on the visceral spine CT. There were no cases in which the newly identified fractures changed patient management.

Conclusion: All fractures requiring surgical intervention were identified on the visceral CT. A dedicated spine CT does detect additional spine fractures but does not clearly alter patient management.
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http://dx.doi.org/10.1067/j.cpradiol.2018.08.002DOI Listing
February 2020

Time to stroke: A Western Trauma Association multicenter study of blunt cerebrovascular injuries.

J Trauma Acute Care Surg 2018 11;85(5):858-866

From the Department of Surgery (C.C.B., J.J.S., C.D.B., M.J.C.), Denver Health Medical Center, Denver, Colorado; Department of Surgery (M.K.M., J.M.), McGovern Medical School, University of Texas Health Science Center, Houston, Texas; Department of Surgery (J.P.S., M.A.C.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.B., J.K.), Hadassah Hebrew University Medical Center, Jerusalem, Israel; Department of Surgery (M.B., J.K.), Assia Medical Group/Tel Aviv University School of Medicine, Tel Aviv, Israel; Department of Surgery (M.C.S., P.R.B.), Grant Medical Center, Columbus, Ohio; Department of Surgery (S.J., D.J.H.), Erlanger Health System, Chattanooga, Utah; Department of Surgery (L.H., D.M.S.), R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery (R.C., C.W.), University of California, San Francisco, San Francisco, California; Department of Surgery (J.S., V.A.), University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery (J.D.), University of Colorado Health North Medical Center of the Rockies, Loveland, Colorado; Department of Surgery (J.P.V., C.V.R.B.), Dell Medical School, University of Texas at Austin, Austin, Texas; Department of Surgery (A.C., T.L.Z.), Oklahoma University Health Science Center, Oklahoma City, Oklahoma; Department of Surgery (R.C., A.E.B.), University of California, San Diego, La Jolla, California; Department of Surgery (T.Z.M., A.K.M.), University of Vermont Medical Center, Burlington, Vermont; Department of Surgery (J.P.H., K.L.), Cooper University Hospital, Camden, New Jersey; Department of Surgery (M.W.), North Memorial Health, Robbinsdale, Minnesota; Department of Surgery (H.B.A., A.M.W.), University of Michigan, Ann Arbor, Michigan; Department of Surgery (J.K., K.I.), University of Southern California, Los Angeles, California; Department of Surgery (S.M., Y.M.C.), Children's Hospital Colorado, Aurora, Colorado; Department of Surgery (H.L.W., B.C.), Virginia Tech Carilion School of Medicine, Roanoke, Virginia; Department of Surgery (C.G.D.), University of Calgary, Calgary, Alberta, Canada; Department of Surgery (S.S., J.L.H.), Indiana University School of Medicine, Indianapolis, Indiana; Department of Surgery (D.C.C.), Marshfield Clinic, University of Wisconsin School of Medicine, Madison, Wisconsin; Department of Surgery (M.D.Z., M.D.R.-Z.), Mayo Clinic, Rochester, Minnesota; Department of Surgery (B.C.M.), Grady Memorial Hospital, Chickasha Oklahoma; Department of Surgery (E.J.R., P.U.), WakeMed Health & Hospitals, Raleigh, North Carolina; Department of Surgery (C.R., E.T.), East Carolina University, Greenville, North Carolina; Department of Surgery (S.G., T.J.), George Washington University Hospital, Washington, District of Columbia; Department of Surgery (J.M.H., K.L.L.), Via Christi Hospital, Wichita, Kansas; Department of Surgery (N.K., B.C.), Banner-University of Arizona Tucson, Tucson, Arizona; Department of Surgery (A.F.K., S.R.T.), Baylor College of Medicine/Ben Taub Hospital, Houston, Texas; Department of Surgery (B.Z.), Eskenazi Health, Indianapolis, Indiana; Department of Surgery (C.J.W., K.J.K.), Gundersen Health System, La Crosse, Wisconsin; Department of Surgery (T.N., S.B.Z.E.), Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Surgery (K.A.P., C.E.D.), Scripps Mercy Hospital, San Diego, California; Department of Surgery (K.K., F.B.), John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois; Department of Surgery (T.S.D., J.M.G.), and University of California, Davis, Davis, California.

Background: Screening for blunt cerebrovascular injuries (BCVIs) in asymptomatic high-risk patients has become routine. To date, the length of this asymptomatic period has not been defined. Determining the time to stroke could impact therapy including earlier initiation of antithrombotics in multiply injured patients. The purpose of this study was to determine the time to stroke in patients with a BCVI-related stroke. We hypothesized that the majority of patients suffer stroke between 24 hours and 72 hours after injury.

Methods: Patients with a BCVI-related stroke from January 2007 to January 2017 from 37 trauma centers were reviewed.

Results: During the 10-year study, 492 patients had a BCVI-related stroke; the majority were men (61%), with a median age of 39 years and ISS of 29. Stroke was present at admission in 182 patients (37%) and occurred during an Interventional Radiology procedure in six patients. In the remaining 304 patients, stroke was identified a median of 48 hours after admission: 53 hours in the 144 patients identified by neurologic symptoms and 42 hours in the 160 patients without a neurologic examination and an incidental stroke identified on imaging. Of those patients with neurologic symptoms, 88 (61%) had a stroke within 72 hours, whereas 56 had a stroke after 72 hours; there was a sequential decline in stroke occurrence over the first week. Of the 304 patients who had a stroke after admission, 64 patients (22%) were being treated with antithrombotics when the stroke occurred.

Conclusions: The majority of patients suffer BCVI-related stroke in the first 72 hours after injury. Time to stroke can help inform clinicians about initiation of treatment in the multiply injured patient.

Level Of Evidence: Prognostic/Epidemiologic, level III.
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November 2018

Can acute care surgeons perform while fatigued? An EAST multicenter study.

J Trauma Acute Care Surg 2018 09;85(3):476-484

From the Department of Surgery, Yale School of Medicine, New Haven, Connecticut (K.M.S., C.H., B.B.); Division of Trauma, Cooper University Hospital, Camden, New Jersey (J.P.H., D.R., L.N.); Department of Surgery, Harbor UCLA Medical Center, Torrance, California (D.K., L.H.S.); Department of Surgery, Loma Linda Medical Center, Loma Linda, California (D.T., X.L-O.); and Hackensack University Medical Center Department of Surgery, Hackensack, New Jersey (J.M.P., S.D., M.B.).

Background: Fatigued surgeon performance has only been assessed in simulated sessions or retrospectively after a night on call. We hypothesized that objectively assessed fatigue of acute care surgeons affects patient outcome.

Methods: Five acute care surgery services prospectively identified emergency cases over 27 months. Emergency cases were defined by the surgeon identifying the patient as requiring immediate operation upon consultation or admission. Within 48 hours, surgeons reported sleep time accumulated before operation, if nonclinical delays to operation occurred, and patient volume during the shift. To maximize differences, fatigued surgeons were defined as performing a case after midnight without having slept in the prior 18 hours. Rested surgeons performed cases at or before 8 PM or after at least 3 hours of sleep before operation. A four-level ordinal scale was used to assign case complexity. Hierarchical logistic regression models were constructed to assess the impact of fatigue on mortality and major morbidity while controlling for center and patient level factors.

Results: Of 882 cases collected, 611 met criteria for fatigue or rested. Of these cases, 370 were performed at night and 182 by a fatigued surgeon. Rested surgeons were more likely to be operating on an older or female patient; other characteristics were similar. Mortality and major morbidity were similar between fatigued and rested surgeons (12.1% vs 12.1% and 46.9% vs 48.9%), respectively. After controlling for center and patient factors, surgeon fatigue did not affect mortality or major morbidity. Mortality variance was 6.30% and morbidity variance was 7.02% among centers.

Conclusion: Acute care surgeons have similar outcomes in a fatigued or rested state. Work schedules for acute care surgeons should not be adjusted to shifts less than 24 hours for the sole purpose of improving patient outcomes.

Level Of Evidence: Prognostic study, level IV.
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September 2018

Occupational exposure during emergency department thoracotomy: A prospective, multi-institution study.

J Trauma Acute Care Surg 2018 07;85(1):78-84

From the Wake Forest Baptist Health (A.N.), Winston-Salem, North Carolina; University of Chicago (P.P.), Chicago, Illinois; University of Southern California (K.I., A.E.), Los Angeles, California; Temple University (Z.M., S.Y.), Philadelphia, Pennsylvania; University of California Los Angeles (D.Y.K., J.M.), Los Angeles, California; University of Maryland (W.C.C., B.D.), Baltimore, Maryland; Cooper University Health Care (J.P.H.), Camden, New Jersey; Loma Linda University (K.M., X.L.-O.), Loma Linda, California; Hennepin County Medical Center (R.M.N., A.P.M.), Minneapolis, Minnesota; Emory University (B.C.M., C.A.F.), Atlanta, Georgia; University of Alabama at Birmingham (P.L.B.), Birmingham, Alabama; Stony Brook University (R.S.J.), Stony Brook, New York; Oregon Health & Science University (S.E.R.), Portland, Oregon; University of Tennessee Health Science Center (L.J.M.), Memphis, Tennessee; Reading Hospital (A.W.O.), Reading, Pennsylvania; Boston Medical Center (T.S.B.), Boston, Massachusetts; Southside Hospital (M.D.G.), Bay Shore, New York; and University of Pennsylvania (M.J.S.), Philadelphia, Pennsylvania.

Background: Occupational exposure is an important consideration during emergency department thoracotomy (EDT). While human immunodeficiency virus/hepatitis prevalence in trauma patients (0-16.8%) and occupational exposure rates during operative trauma procedures (1.9-18.0%) have been reported, exposure risk during EDT is unknown. We hypothesized that occupational exposure risk during EDT would be greater than other operative trauma procedures.

Methods: A prospective, observational study at 16 US trauma centers was performed (2015-2016). All bedside EDT resuscitation providers were surveyed with a standardized data collection tool and risk factors analyzed with respect to the primary end point, EDT occupational exposure (percutaneous injury, mucous membrane, open wound, or eye splash). Provider and patient variables and outcomes were evaluated with single and multivariable logistic regression analyses.

Results: One thousand three hundred sixty participants (23% attending, 59% trainee, 11% nurse, 7% other) were surveyed after 305 EDTs (gunshot wound, 68%; prehospital cardiopulmonary resuscitation, 57%; emergency department signs of life, 37%), of which 15 patients survived (13 neurologically intact) their hospitalization. Overall, 22 occupational exposures were documented, resulting in an exposure rate of 7.2% (95% confidence interval [CI], 4.7-10.5%) per EDT and 1.6% (95% CI, 1.0-2.4%) per participant. No differences in trauma center level, number of participants, or hours worked were identified. Providers with exposures were primarily trainees (68%) with percutaneous injuries (86%) during the thoracotomy (73%). Full precautions were utilized in only 46% of exposed providers, while multiple variable logistic regression determined that each personal protective equipment item utilized during EDT correlated with a 34% decreased risk of occupational exposure (odds ratio, 0.66; 95% CI, 0.48-0.91; p = 0.010).

Conclusions: Our results suggest that the risk of occupational exposure should not deter providers from performing EDT. Despite the small risk of viral transmission, our data revealed practices that may place health care providers at unnecessary risk of occupational exposure. Regardless of the lifesaving nature of the procedure, improved universal precaution compliance with personal protective equipment is paramount and would further minimize occupational exposure risks during EDT.

Level Of Evidence: Therapeutic/care management study, level III.
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July 2018

A selective placement strategy for surgical feeding tubes benefits trauma patients.

J Trauma Acute Care Surg 2018 07;85(1):135-139

From the Department of Surgery (J.M., J.P.H., J.G., J.P., N.F.), Cooper University Hospital, Camden, New Jersey; Rowan University (C.A.), Glassboro, New Jersey; Department of Surgery (M.D.), St. Barnabas Medical Center, Livingston, NJ; Department of Surgery (A.P), Lancaster General Hospital, Lancaster, Pennsylvania; Jefferson Medical School (L.N.), Philadelphia.

Background: The indications for surgical feeding tube (SFT) placement in trauma patients are poorly defined. Patient selection is critical as complications from SFTs have been reported in up to 70% of patients. A previous analysis by our group determined that 25% of the SFTs we placed were unnecessary and that older patients, patients with head and spinal cord injuries, and patients who needed a tracheostomy were more likely to require long-term SFTs. Following this study, we modified our institutional guidelines for SFT placement. We hypothesized that a more selective placement strategy would result in fewer unnecessary SFTs.

Methods: A retrospective review of all adult patients from 2012 to 2016 with an intensive care unit length of stay longer than 4 days and an SFT placed during admission was conducted. This group was compared to data collected prior to our change in practice (2007-2010). Data from 2011 were excluded as a washout period. "Necessary" SFT use was defined per established guidelines as either daily use of the SFT through discharge or for 28 days or longer and "unnecessary" SFT use as all others.

Results: Two hundred fifty-seven SFTs were placed from 2007 to 2010 and 244 from 2012 to 2016. Following implementation of our selective SFT placement strategy, unnecessary SFT placement decreased from 25% in 2007 to 2010 to 8% in 2012 to 2016 (p < 0.0001). Significant predictors of necessary SFT placement by univariate regression were as follows: increasing age (odds ratio [OR] 1.03/year; 95% confidence interval [CI], 1.01-1.04), head injury (OR, 2.80; 95% CI, 1.71-4.60), cervical spinal cord injury (OR, 4.42; 95% CI, 1.34-14.50), and need for tracheostomy (OR, 1.41; 95% CI, 2.21-7.67). The overall complication rate was 11% (9% in the selective group vs. 13% in the preselective group, p = 0.2574) and was highest following open SFT placement (22%).

Conclusion: A selective placement strategy for SFTs in our trauma population resulted in fewer unnecessary SFTs and a trend toward fewer complications. Surgical feeding tubes should be placed through a percutaneous approach whenever possible.

Level Of Evidence: Therapeutic study, level IV.
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http://dx.doi.org/10.1097/TA.0000000000001867DOI Listing
July 2018

Spectral analysis of heart rate variability predicts mortality and instability from vascular injury.

J Surg Res 2018 04 22;224:64-71. Epub 2017 Dec 22.

Cooper University Hospital, Camden, New Jersey.

Background: Spectral analysis of continuous blood pressure and heart rate variability provides a quantitative assessment of autonomic response to hemorrhage. This may reveal markers of mortality as well as endpoints of resuscitation.

Methods: Fourteen male Yorkshire pigs, ranging in weight from 33 to 36 kg, were included in the analysis. All pigs underwent laparotomy and then sustained a standardized retrohepatic inferior vena cava injury. Animals were then allowed to progress to class 3 hemorrhagic shock and where then treated with abdominal sponge packing followed by 6 h of crystalloid resuscitation. If the pigs survived the 6 h resuscitation, they were in the survival (S) group, otherwise they were placed in the nonsurvival (NS) group. Fast Fourier transformation calculations were used to convert the components of blood pressure and heart rate variability into corresponding frequency classifications. Autonomic tones are represented as the following: high frequency (HF) = parasympathetic tone, low frequency (LF) = sympathetic, and very low frequency (VLF) = renin-angiotensin aldosterone system. The relative sympathetic to parasympathetic tone was expressed as LF/HF ratio.

Results: Baseline hemodynamic parameters were equal for the S (n = 11) and NS groups. LF/HF was lower at baseline for the NS group but was higher after hemorrhage and the resuscitation period indicative of a predominately parasympathetic response during hemorrhagic shock before mortality. HF signal was lower in the NS group during the resuscitation indicating a relatively lower sympathetic tone during hemorrhagic shock, which may have contributed to mortality. Finally, the NS group had a lower VLF signal at baseline (e.g., [S] 16.3 ± 2.5 versus [NS] 4.6 ± 2.9 P < 0.05,) which was predictive of mortality and hemodynamic instability in response to a similar hemorrhagic injury.

Conclusions: An increased LF/HF ratio, indicative of parasympathetic predominance following injury and during resuscitation of hemorrhagic shock was a marker of impending death. Spectral analysis of heart rate variability can also identify autonomic lability following hemorrhagic injuries with implications for first responder triage. Furthermore, a decreased VLF signal at baseline indicates an additional marker of hemodynamic instability and marker of mortality following a hemorrhagic injury. These data indicate that continuous quantitative assessment of autonomic response can be a predictor of mortality and potentially guide resuscitation of patients in hemorrhagic shock.
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April 2018

Human adipose-derived stem cell treatment modulates cellular protection in both in vitro and in vivo traumatic brain injury models.

J Trauma Acute Care Surg 2018 05;84(5):745-751

From the Department of Surgery (N.S.K., S.C., W.M.H., M.P., T.O., P.Z., J.P.C., S.A.B.), Cooper University Hospital, Camden, NJ; and Division of Trauma (J.P.H.), Cooper University Hospital, Camden, NJ.

Background: Traumatic brain injury (TBI) is a common cause of morbidity and mortality in the civilian population. The purpose of this study was to examine the effect(s) of adipose-derived stem cell (ASC) treatment on cellular and functional recovery in TBI via both in vitro and in vivo methods.

Methods: Cultured neuroblastoma cells, SH-SY5Y, were scratched to mimic TBI in an in vitro model. The effect of ASC-conditioned medium (CM) on cell death, mitochondrial function, and expression of inflammatory cytokines (tumor necrosis factor α [TNF-α], interleukin 1β [IL-1β], and IL-6), as well as apoptosis marker FAS, was measured. In our in vivo model, Sprague-Dawley rats underwent TBI via a frontal, closed-head injury model. Animals randomly received either intravenous human-derived ASCs or intravenous saline within 3 hours of injury and were compared with a sham group. Functional recovery was evaluated via accelerating Rotarod method. On post-TBI Day 3, brain tissue was harvested and assessed for cellular damage via enzyme-linked immunosorbent assay for TNF-α, as well as immunohistochemical staining for β-amyloid precursor protein (β-APP).

Results: Our in vitro data show that ASC treatment imparted reduced cell death (ratio to control: 1.21 ± 0.066 vs. 1.01 ± 0.056, p = 0.017), increased cell viability (ratio to control: 0.86 ± 0.009 vs. 1.09 ± 0.01, p = 0.0001), increased mitochondrial function (percentage of control: 78 ± 6% vs. 68 ± 3%), and significantly decreased levels of inflammatory cytokine IL-1β. In our in vivo study, compared with TBI alone, ASC-treated animals showed no difference in functional recovery, lower levels of expressed TNF-α (ratio to total protein, 0.47 ± 0.01 vs. 0.67 ± 0.04; p < 0.01), and lower levels of β-amyloid precursor protein (fluorescence ratio, 0.43 ± 0.05 vs. 0.69 ± 0.03; p < 0.01).

Conclusions: Adipose-derived stem cell treatment results in improved cell survival, decreased inflammatory marker release, and decreased evidence of neural injury. No difference in functional recovery was seen. These data suggest the potential for ASC treatment to aid in cellular protection and recovery in neural cells following TBI.
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May 2018

Outpatient follow-up does not prevent emergency department utilization by trauma patients.

J Surg Res 2017 10 15;218:92-98. Epub 2017 Jun 15.

Division of Trauma, Department of Surgery, Cooper University Hospital, Camden, New Jersey.

Background: Although most trauma centers have a regularly scheduled trauma clinic, research demonstrates that trauma patients do not consistently attend follow-up appointments and often use the emergency department (ED) for outpatient care.

Methods: A retrospective review of outpatient follow-up of adult patients admitted to the trauma service (January 2014-December 2014) at an urban level I trauma center was conducted (n = 2134).

Results: A total of 219 patients (10%) were evaluated in trauma clinic after discharge from the hospital. Twenty-one percent of patients seen in trauma clinic visited the ED within 30 d compared with 12% of those not seen in clinic (P < 0.001). A total of 104 patients were readmitted within 30 d of discharge; no difference existed in the rate of hospital readmission between patients seen in clinic and those not seen in clinic (P = 0.25). Stepwise logistic regression showed that clinic follow-up was not a significant predictor of decreased ED utilization (adjusted odds ratio [OR] 1.16 [95% confidence interval 0.78-1.72], P = 0.461) and also showed that while ED use was a significant predictor of readmission (adjusted OR 216 [93-500], P < 0.001), clinic visits were not (adjusted OR 0.74 [0.33-1.69], P = 0.48).

Conclusions: Outpatient follow-up in the trauma clinic does not decrease ED utilization or hospital readmissions indicating that interventions aimed at improving access to a conventional outpatient clinic will not impact ED utilization rates. Further study is necessary to determine the best system for providing clinically appropriate and cost-effective outpatient follow-up for trauma patients.
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October 2017

Cervical spine evaluation and clearance in the intoxicated patient: A prospective Western Trauma Association Multi-Institutional Trial and Survey.

J Trauma Acute Care Surg 2017 12;83(6):1032-1040

From the Legacy Emanuel Medical Center (M.J.M., L.D.B., W.L.), Portland, Oregon; LAC+USC Medical Center (K.I., S.B. D.D.), Los Angeles, California; Oregon Health and Science University (M.S.), Portland, Oregon; Scripps Mercy Hospital (K.A.P.), San Diego; Cedars-Sinai Medical Center (G.B.), Los Angeles, California; R Adams Cowley Shock Trauma Center (J.M.), Baltimore, Maryland; Cooper University Hospital (J.H.), Camden, New Jersey; University of California-San Diego (R.C.), La Jolla, California; Mayo Clinic (M.D.Z.), Rochester, Minnesota; University Medical Center at Brackenridge (C.V.R.B.), Austin, Texas; University of Calgary-Foothills Medical Center (C.G.B.), Calgary, Alberta, Canada; University of Michigan (J.R.C-B.), Ann Arbor, Michigan; Denver Health Medical Center (C.C.B.), Denver, Colorado; University of Colorado Health-Medical Center of the Rockies (J.D.), Loveland, Colorado; University of Texas Southwestern Medical Center Parkland Memorial Hospital (C.T.M.), Dallas; Medical Center of Plano (M.M.C.), Plano, Texas; and Wesley Medical Center (G.M.B.), Wichita, Kansas.

Background: Intoxication often prevents clinical clearance of the cervical spine (Csp) after trauma leading to prolonged immobilization even with a normal computed tomography (CT) scan. We evaluated the accuracy of CT at detecting clinically significant Csp injury, and surveyed participants on related opinions and practice.

Methods: A prospective multicenter study (2013-2015) at 17 centers. All adult blunt trauma patients underwent structured clinical examination and imaging including a Csp CT, with follow-up thru discharge. alcohol- and drug-intoxicated patients (TOX+) were identified by serum and/or urine testing. Primary outcomes included the incidence and type of Csp injuries, the accuracy of CT scan, and the impact of TOX+ on the time to Csp clearance. A 36-item survey querying local protocols, practices, and opinions in the TOX+ population was administered.

Results: Ten thousand one hundred ninety-one patients were prospectively enrolled and underwent CT Csp during the initial trauma evaluation. The majority were men (67%), had vehicular trauma or falls (83%), with mean age of 48 years, and mean Injury Severity Score (ISS) of 11. The overall incidence of Csp injury was 10.6%. TOX+ comprised 30% of the cohort (19% EtOH only, 6% drug only, and 5% both). TOX+ were significantly younger (41 years vs. 51 years; p < 0.01) but with similar mean Injury Severity Score (11) and Glasgow Coma Scale score (13). The TOX+ cohort had a lower incidence of Csp injury versus nonintoxicated (8.4% vs. 11.5%; p < 0.01). In the TOX+ group, CT had a sensitivity of 94%, specificity of 99.5%, and negative predictive value (NPV) of 99.5% for all Csp injuries. For clinically significant injuries, the NPV was 99.9%, and there were no unstable Csp injuries missed by CT (NPV, 100%). When CT Csp was negative, TOX+ led to longer immobilization versus sober patients (mean, 8 hours vs. 2 hours; p < 0.01), and prolonged immobilization (>12 hrs) in 25%. The survey showed marked variations in protocols, definitions, and Csp clearance practices among participating centers, although 100% indicated willingness to change practice based on these data.

Conclusion: For intoxicated patients undergoing Csp imaging, CT scan was highly accurate and reliable for identifying clinically significant spine injuries, and had a 100% NPV for identifying unstable injuries. CT-based clearance in TOX+ patients appears safe and may avoid unnecessary prolonged immobilization. There was wide disparity in practices, definitions, and opinions among the participating centers.

Level Of Evidence: Diagnostic tests or criteria, level II.
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December 2017

Venous thromboembolism after major venous injuries: Competing priorities.

J Trauma Acute Care Surg 2017 12;83(6):1095-1101

From the Department of Surgery, Geisinger Health System (B.F.), Danville; Division of Trauma and Surgical Critical Care, Department of Surgery (Z.M.) and Department of Surgery (E.D., A.L.L.), Temple University School of Medicine, Philadelphia, Pennsylvania; Division of Trauma and Surgical Critical Care, Department of Surgery, Cooper Medical School of Rowan University (J.P.H., A.G.), Camden, New Jersey; Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania (S.R., B.P.S., P.M.R., M.J.S.), Philadelphia, Pennsylvania; and Massachusetts General Hospital (N.N.S.), Boston, Massachusetts.

Background: Venous thromboembolism (VTE) after major vascular injury (MVI) is particularly challenging because the competing risk of thrombosis and embolization after direct vessel injury must be balanced with risk of bleeding after surgical repair. We hypothesized that venous injuries, repair type, and intraoperative anticoagulation would influence VTE formation after MVI.

Methods: A multi-institution, retrospective cohort study of consecutive MVI patients was conducted at three urban, Level I centers (2005-2013). Patients with MVI of the neck, torso, or proximal extremities (to elbows/knees) were included. Our primary study endpoint was the development of VTE (DVT or pulmonary embolism [PE]).

Results: The 435 major vascular injury patients were primarily young (27 years) men (89%) with penetrating (84%) injuries. When patients with (n = 108) and without (n = 327) VTE were compared, we observed no difference in age, mechanism, extremity injury, tourniquet use, orthopedic and spine injuries, damage control, local heparinized saline, or vascular surgery consultation (all p > 0.05). VTE patients had greater Injury Severity Score (ISS) (17 vs. 12), shock indices (1 vs. 0.9), and more torso (58% vs. 35%) and venous (73% vs. 48%) injuries, but less often received systemic intraoperative anticoagulation (39% vs. 53%) or postoperative enoxaparin (47% vs. 61%) prophylaxis (all p < 0.05). After controlling for ISS, hemodynamics, injured vessel, intraoperative anticoagulation, and postoperative prophylaxis, multivariable analysis revealed venous injury was independently predictive of VTE (odds ratio, 2.7; p = 0.002). Multivariable analysis of the venous injuries subset (n = 237) then determined that only delay in starting VTE chemoprophylaxis (odds ratio, 1.3/day; p = 0.013) independently predicted VTE after controlling for ISS, hemodynamics, injured vessel, surgical subspecialty, intraoperative anticoagulation, and postoperative prophylaxis. Overall, 3.4% of venous injury patients developed PE, but PE rates were not related to their operative management (p = 0.72).

Conclusion: Patients with major venous injuries are at high risk for VTE, regardless of intraoperative management. Our results support the immediate initiation of postoperative chemoprophylaxis in patients with major venous injuries.

Level Of Evidence: Therapeutic/care management, level IV.
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December 2017

Evaluation of a Device Combining an Inferior Vena Cava Filter and a Central Venous Catheter for Preventing Pulmonary Embolism Among Critically Ill Trauma Patients.

J Vasc Interv Radiol 2017 Sep 20;28(9):1248-1254. Epub 2017 Jun 20.

Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Purpose: To evaluate efficacy and safety of a novel device that combines an inferior vena cava (IVC) filter and central venous catheter (CVC) for prevention of pulmonary embolism (PE) in critically ill patients.

Materials And Methods: In a multicenter, prospective, single-arm clinical trial, the device was inserted at the bedside without fluoroscopy and subsequently retrieved before transfer from the intensive care unit (ICU). The primary efficacy endpoint was freedom from clinically significant PE or fatal PE 72 hours after device removal or discharge, whichever occurred first. Secondary endpoints were incidence of acute proximal deep venous thrombosis (DVT), catheter-related thrombosis, catheter-related bloodstream infections, major bleeding events, and clinically significant thrombus (occupying > 25% of volume of filter) detected by cavography before retrieval.

Results: The device was placed in 163 critically ill patients with contraindications to anticoagulation; 151 (93%) were critically ill trauma patients, 129 (85%) had head or spine trauma, and 102 (79%) had intracranial bleeding. The primary efficacy endpoint was achieved for all 163 (100%) patients (95% confidence interval [CI], 97.8%-100%, P < .01). Diagnosis of new or worsening acute proximal DVT was time dependent with 11 (7%) occurring during the first 7 days. There were no (0%) catheter-related bloodstream infections. There were 5 (3.1%) major bleeding events. Significant thrombus in the IVC filter occurred in 14 (8.6%) patients. Prophylactic anticoagulation was not initiated for a mean of 5.5 days ± 4.3 after ICU admission.

Conclusions: This novel device prevented clinically significant and fatal PE among critically ill trauma patients with low risk of complications.
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http://dx.doi.org/10.1016/j.jvir.2017.05.001DOI Listing
September 2017

Kaolin-based hemostatic dressing improves hemorrhage control from a penetrating inferior vena cava injury in coagulopathic swine.

J Trauma Acute Care Surg 2017 07;83(1):71-76

From the Cooper University Hospital (K.R.K., B.M.M., J.P.G., R.S.N., M.W.F., A.L., R.H., R.L.C., S.A.B., J.P.H.), Camden, New Jersey.

Background: Retrohepatic inferior vena cava (RIVC) injuries are often lethal due to challenges in obtaining hemorrhage control. We hypothesized that packing with a new kaolin-based hemostatic dressing (Control+; Z-Medica, Wallingford, CT) would improve hemorrhage control from a penetrating RIVC injury compared with packing with standard laparotomy sponges alone.

Methods: Twelve male Yorkshire pigs received a 25% exchange transfusion of blood for refrigerated normal saline to induce a hypothermic coagulopathy. A laparotomy was performed and a standardized 1.5 cm injury to the RIVC was created which was followed by temporary abdominal closure and a period of uncontrolled hemorrhage. When the mean arterial pressure reached 70% of baseline, demonstrating hemorrhagic shock, the abdomen was re-entered, and the injury was treated with perihepatic packing using standard laparotomy sponges (L; n = 6) or a new kaolin-based hemostatic dressing (K; n = 6). Animals were then resuscitated for 6 hours with crystalloid solution. The two groups were compared using the Wilcoxon rank sum test and Fisher exact test. A p value of 0.05 or less was considered statistically significant.

Results: There was no difference in the animal's temperature, heart rate, mean arterial pressure, cardiac output, and blood loss at baseline or before packing was performed (all p > 0.05). In the laparotomy sponge group, five of six pigs survived the entire study period, whereas all six pigs treated with kaolin-based D2 hemostatic dressings survived. Importantly, there was significantly less blood loss after packing with the new hemostatic kaolin-based dressing compared with packing with laparotomy sponge (651 ± 180 mL vs. 1073 ± 342 mL; p ≤ 0.05).

Conclusion: These results demonstrate that the use of this new hemostatic kaolin-based dressing improved hemorrhage control and significantly decreased blood loss in this penetrating RIVC model.

Level Of Evidence: This is basic science research based on a large animal model, level V.
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http://dx.doi.org/10.1097/TA.0000000000001492DOI Listing
July 2017