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Papers by Bellal Joseph

JAMA surgery, Jan 24, 2015

The role of acute care surgeons is evolving; however, no guidelines exist for the selective treat... more The role of acute care surgeons is evolving; however, no guidelines exist for the selective treatment of patients with traumatic brain injury (TBI) exclusively by acute care surgeons. We implemented the Brain Injury Guidelines (BIG) for managing TBI at our institution on March 1, 2012. To compare the outcomes in patients with TBI before and after implementation of the BIG protocol. We conducted a 2-year analysis of our prospectively maintained database of all patients with TBI (findings of skull fracture and/or intracranial hemorrhage on an initial computed tomographic scan of the head) who presented to our level I trauma center. The pre-BIG group included patients with TBI from March 1, 2011, through February 29, 2012, and the post-BIG group included patients from July 1, 2012, through June 30, 2013. The primary outcome measures were patients with repeated computed tomography of the head and neurosurgical consultations. Secondary outcome measures were findings of progression of int...

The American Journal of Surgery, 2015

Over 1 million healthcare providers have participated in the Advanced Trauma Life Support course.... more Over 1 million healthcare providers have participated in the Advanced Trauma Life Support course. No studies have evaluated factors that predict course performance. This study aims to identify these predictors. All participants taking the course at 2 centers over a 4-year period were identified. Demographics, background, and performance data were extracted. Participants who failed were compared with those who did not. Stepwise logistic regression analysis was used to identify independent risk factors for failure. Seven hundred forty-four healthcare providers participated in the course; 89.5% passed and 10.5% failed. Failure rates were lowest (.0%) among Trauma/Surgical Critical Care (SCC) providers and highest among pediatric providers (28.6%). Stepwise logistic regression identified age greater than 55, English as a second language, pretest score less than 75, and non-Trauma/SCC and non-Emergency Medicine background as predictors of failure. A failure rate of 10.5% was demonstrated among the course participants. Age greater than 55, English as second language, pretest score less than 75, and non-Trauma/SCC and non-Emergency Medicine backgrounds were associated with failure. These subgroups may benefit from performance improvement measures.

Journal of the American Geriatrics Society, Jan 6, 2015

To determine whether frail elderly adults are at greater risk of fracture after a ground-level fa... more To determine whether frail elderly adults are at greater risk of fracture after a ground-level fall (GLF) than those who are not frail. Prospective observational study. Level 1 trauma center. All elderly (≥65) adults presenting after a GLF over 1 year (N = 110; mean age ± SD 79.5 ± 8.3, 54% male). A Frailty Index (FI) was calculated using 50 preadmission frailty variables. Participants with a FI of 0.25 or greater were considered to be frail. The primary outcome measure was a new fracture; 40.1% (n = 45) of participants presented with a new fracture. The secondary outcome was discharge to an institutional facility (rehabilitation center or skilled nursing facility). Multivariate logistic regression was performed. Forty-three (38.2%) participants were frail. The median Injury Severity Score was 14 (range 9-17), and the mean FI was 0.20 ± 0.12. Frail participants were more likely than those who were not frail to have fractures (odds ratio (OR) = 1.8, 95% confidence interval (CI) = 1.2...

BACKGROUND: The aim of this study was to compare the safety of early (%48 hours), intermediate (4... more BACKGROUND: The aim of this study was to compare the safety of early (%48 hours), intermediate (48 to 72 hours), and late (R72 hours) venous thromboembolism prophylaxis in patients with blunt abdominal solid organ injury managed nonoperatively.

The journal of trauma and acute care surgery, 2013

Platelet transfusion is increasingly used in patients with traumatic intracranial hemorrhage (ICH... more Platelet transfusion is increasingly used in patients with traumatic intracranial hemorrhage (ICH) on aspirin therapy to minimize the progression of ICH. We hypothesized (null) that platelet transfusion in this cohort of patients does not improve platelet function. We performed a prospective interventional trail on patients with traumatic ICH on daily high-dose (325 mg) aspirin therapy. All patients received one pack of apheresis platelets. Blood samples were collected before and 1 hour after platelet transfusion. Platelet function was assessed using Verify Now Platelet Function Assay, and a cutoff of greater than 550 aspirin reaction units was used to define functioning platelets (FP). Twenty-eight patients were enrolled in the study. On presentation, 79% (22 of 28) of the patients had nonfunctioning platelets (NFPs), and transfusion of platelets did not improve platelet function as 81% (18 of 22) still had NFP. Of the 22 patients, 4 converted from NFP to FP after transfusion. Ther...

The journal of trauma and acute care surgery, 2014

Hypothermia is a known predictor of mortality in trauma patients; however, its impact on organ pr... more Hypothermia is a known predictor of mortality in trauma patients; however, its impact on organ procurement has not been defined. The aim of this study was to assess the effect of hypothermia on organ procurement. We hypothesized that admission hypothermia impedes successful organ procurement. We performed a 5-year retrospective analysis of all trauma patients approached for organ donation. Hypothermia was defined as a core body temperature 36°C/97°F or less. The two groups (hypothermic [HT] vs. nonhypothermic [non-HT]) were matched in a 1:1 ratio using propensity score matching for age, sex, admission Glasgow Coma Scale (GCS) score, systolic blood pressure, international normalized ratio, and Injury Severity Score (ISS). Primary outcome measures were eligibility for organ donation and solid organ procurement. Secondary outcome measures were blood product and vasopressor requirements. This study was composed of 537 brain-dead patients, of whom 416 (HT, 208; non-HT, 208) were included...

American journal of surgery, 2014

We hypothesized that patients with acute mild gallstone pancreatitis (GSP) admitted to surgery (S... more We hypothesized that patients with acute mild gallstone pancreatitis (GSP) admitted to surgery (SUR; vs medicine [MED]) had a shorter time to surgery, shorter hospital length of stay (HLOS), and lower costs. We performed chart reviews of patients who underwent a cholecystectomy for acute mild GSP from October 1, 2009 to May 31, 2013. We excluded patients with moderate to severe and non-gallstone pancreatitis. We compared outcomes for time to surgery, HLOS, costs, and complications between the 2 groups. Fifty acute mild GSP patients were admitted to MED and 52 to SUR. MED patients were older and had more comorbidity. SUR patients had a shorter time to surgery (44 vs 80 hours; P < .001), a shorter HLOS (3 vs 5 days; P < .001), and lower hospital costs ($11,492 ± 6,480 vs $16,183 ± 12,145; P = .03). In our subgroup analysis on patients with an American Society of Anesthesiologists score between 1 and 2, the subgroups were well matched; all outcomes still favored SUR patients. Adm...

The journal of trauma and acute care surgery, Jan 4, 2015

Management of traumatic brain injury (TBI) is focused on preventing secondary brain injury. Remot... more Management of traumatic brain injury (TBI) is focused on preventing secondary brain injury. Remote ischemic conditioning (RIC) is an established treatment modality that has been shown to improve patient outcomes secondary to inflammatory insults. The aim of our study was to assess whether RIC in trauma patients with severe TBI could reduce secondary brain injury. This prospective consented interventional trial included all TBI patients admitted to our Level 1 trauma center with an intracranial hemorrhage and a Glasgow Coma Scale (GCS) score of 8 or lower on admission. In each patient, four cycles of RIC were performed within 1 hour of admission. Each cycle consisted of 5 minutes of controlled upper limb (arm) ischemia followed by 5 minutes of reperfusion using a blood pressure cuff. Serum biomarkers of acute brain injury, S-100B, and neuron-specific enolase (NSE) were measured at 0, 6, and 24 hours. Outcome measure was reduction in the level of serum biomarkers after RIC. A total of...

Neurosurgery, 2015

BACKGROUND: The use of prothrombin complex concentrate (PCC) to reverse acquired (coagulopathy of... more BACKGROUND: The use of prothrombin complex concentrate (PCC) to reverse acquired (coagulopathy of trauma) and induced coagulopathy (preinjury warfarin use) is well defined. OBJECTIVE: To compare outcomes in patients with traumatic brain injury without warfarin therapy receiving PCC as an adjunct to fresh frozen plasma (FFP) therapy compared with patients receiving FFP therapy alone. METHODS: All patients with traumatic brain injury coagulopathy without warfarin therapy who received PCC (25 IU/kg) in conjunction with FFP or FFP alone at our Level I trauma center were reviewed. Coagulopathy was defined as an international normalized ratio .1.5. The groups (PCC 1 FFP vs FFP alone) were matched using propensity score matching on a 1:2 ratio for age, sex, Glasgow Coma Scale score, Injury Severity Score, head Abbreviated Injury Scale score, and international normalized ratio (INR) on presentation. The primary outcome measure was time to craniotomy. Secondary outcome measures were blood product requirements, cost of therapy, and mortality. RESULTS: A total of 1641 patients were reviewed, 222 of whom were included (PCC 1 FFP, 74; FFP, 148). The mean 6 standard deviation age was 46.4 6 21.7 years, the median (range) Glasgow Coma Scale score was 8 (3-12), and the mean 6 standard deviation INR on presentation was 1.92 6 0.6. PCC 1 FFP therapy was associated with an accelerated correction of INR (P = .001) and decrease in overall pack red blood cell (P = .035) and FFP (P = .041) administration requirement. Craniotomy was performed in 26.1% of patients (n = 58). Patients who received PCC 1 FFP therapy had faster time to craniotomy (P = .028) compared with patients who received FFP therapy alone. CONCLUSION: PCC as an adjunct to FFP decreases the time to craniotomy with faster correction of INR and concomitant decrease in the need for blood product requirement in patients with traumatic brain injury exclusive of prehospital warfarin therapy.

The journal of trauma and acute care surgery, 2013

The American surgeon, 2014

Anticoagulation agents are proven risk factors for intracranial hemorrhage (ICH) in traumatic bra... more Anticoagulation agents are proven risk factors for intracranial hemorrhage (ICH) in traumatic brain injury (TBI). The aim of our study is to describe the epidemiology of prehospital coumadin, aspirin, and Plavix (CAP) patients with ICH and evaluate the use of repeat head computed tomography (CT) in this group. We performed a retrospective study from our trauma registry. All patients with intracranial hemorrhage on initial CT with prehospital CAP therapy were included. Demographics, CT scan findings, number of repeat CT scans, progressive findings, and neurosurgical intervention were abstracted. A comparison between prehospital CAP and no-CAP patients was done using χ(2) and Mann-Whitney U test. A total of 1606 patients with blunt TBI charts were reviewed of whom 508 patients had intracranial bleeding on initial CT scan and 72 were on prehospital CAP therapy. CAP patients were older (P < 0.001), had higher Injury Severity Score and head Abbreviated Injury Scores on admission (P &l...

The journal of trauma and acute care surgery, 2014

Patients receiving antiplatelet medications are considered to be at an increased risk for traumat... more Patients receiving antiplatelet medications are considered to be at an increased risk for traumatic intracranial hemorrhage after blunt head trauma. However, most studies have categorized all antiplatelet drugs into one category. The aim of our study was to evaluate clinical outcomes and the requirement of a repeat head computed tomography (RHCT) in patients on preinjury clopidogrel therapy. Patients with traumatic brain injury with intracranial hemorrhage on initial head CT were prospectively enrolled. Patients on preinjury clopidogrel were matched with patients exclusive of antiplatelet and anticoagulation therapy using a propensity score in a 1:1 ratio for age, Glasgow Coma Scale (GCS), head Abbreviated Injury Scale (h-AIS), Injury Severity Score (ISS), neurologic examination, and platelet transfusion. Outcome measures were progression on RHCT scan and need for neurosurgical intervention. A total of 142 patients with intracranial hemorrhage on initial head CT scan (clopidogrel, 7...

The journal of trauma and acute care surgery, 2014

It is becoming a standard practice that any "positive" identification of a radiographic... more It is becoming a standard practice that any "positive" identification of a radiographic intracranial injury requires transfer of the patient to a trauma center for observation and repeat head computed tomography (RHCT). The purpose of this study was to define guidelines-based on each patient's history, physical examination, and initial head CT findings-regarding which patients require a period of observation, RHCT, or neurosurgical consultation. In our retrospective cohort analysis, we reviewed the records of 3,803 blunt traumatic brain injury patients during a 4-year period. We classified patients according to neurologic examination results, use of intoxicants, anticoagulation status, and initial head CT findings. We then developed brain injury guidelines (BIG) based on the individual patient's need for observation or hospitalization, RHCT, or neurosurgical consultation. A total of 1,232 patients had an abnormal head CT finding. In the BIG 1 category, no patients ...

The journal of trauma and acute care surgery, 2014

Protocols call for the start of hormonal therapy with levothyroxine after the declaration of brai... more Protocols call for the start of hormonal therapy with levothyroxine after the declaration of brain death. As the hormonal perturbations occur during the process of brain death, the role of the early initiation of levothyroxine therapy (LT) to salvage organs is not well defined. The aim of this study was to evaluate the impact of early LT (before the declaration of brain death) on the number of solid organs procured per donor. We performed an 8-year retrospective analysis of all trauma patients who progressed to brain death. Patients who consented for organ donation, received LT, and donated solid organs were included. Patients were dichotomized into two groups: early LT group, patients who received LT before the declaration of brain death, and late LT group, those who received LT after brain death. The two groups were compared for differences in demographics, clinical characteristics, need for vasopressor, and number of solid organ donation. A total of 100 solid organ donors were id...

The American surgeon, 2014

The American surgeon, 2014

Coagulopathy is a defined barrier for organ donation in patients with lethal traumatic brain inju... more Coagulopathy is a defined barrier for organ donation in patients with lethal traumatic brain injuries. The purpose of this study was to document our experience with the use of prothrombin complex concentrate (PCC) to facilitate organ donation in patients with lethal traumatic brain injuries. We performed a 4-year retrospective analysis of all patients with devastating gunshot wounds to the brain. The data were analyzed for demographics, change in international normalized ratio (INR), and subsequent organ donation. The primary end point was organ donation. Eighty-eight patients with lethal traumatic brain injury were identified from the trauma registry of whom 13 were coagulopathic at the time of admission (mean INR 2.2 ± 0.8). Of these 13 patients, 10 patients received PCC in an effort to reverse their coagulopathy. Mean INR before PCC administration was 2.01 ± 0.7 and 1.1 ± 0.7 after administration (P < 0.006). Correction of coagulopathy was attained in 70 per cent (seven of 10)...

The journal of trauma and acute care surgery, 2014

To optimize neurosurgical resources, guidelines were developed at our institution, allowing the a... more To optimize neurosurgical resources, guidelines were developed at our institution, allowing the acute care surgeons to independently manage traumatic intracranial hemorrhage less than or equal to 4 mm. The aim of our study was to evaluate our established Brain Injury Guidelines (BIG 1 category) for managing patients with traumatic brain injury (TBI) without neurosurgical consultation. We formulated the BIG based on a 4-year retrospective chart review of all TBI patients presenting at our Level 1 trauma center. We then prospectively implemented our BIG 1 category to identify TBI patients that were to be managed without neurosurgical consultation (No-NC). Propensity scoring matched patients with No-NC to a similar cohort of patients managed with NC before the implementation of our BIG in a 1:1 ratio for demographics, severity of injury, and type and size of intracranial hemorrhage. Primary outcome measure was need for neurosurgical intervention and 30-day readmission rates. A total of...

The journal of trauma and acute care surgery, 2015

Animal and human bite wounds represent a significant global health issue. In the United States, a... more Animal and human bite wounds represent a significant global health issue. In the United States, animal and human bites are a very common health issue, causing significant morbidity and even, in rare scenarios, mortality. Most animal bite wounds in the United States are caused by dogs, with cat bites being a distant second. Human bite wounds constitute a dominant subset of all bite wounds. Several studies of bite wounds have reported improved outcomes with early diagnosis and immediate treatment. However, the available literature on the initial treatment provides a plethora of conflicting opinions and results. In this review, our aim was to identify and assess the current evidence on the management of animal (dog, cat, insects, scorpions, and snakes) and human bite wounds. Review article, level III.

Journal of Trauma and Acute Care Surgery, 2014

Platelet dysfunction has been attributed to progression of initial intracranial hemorrhage (ICH) ... more Platelet dysfunction has been attributed to progression of initial intracranial hemorrhage (ICH) on repeat head computed tomographic (RHCT) scans in patients on prehospital antiplatelet therapy. However, there is little emphasis on the effect of platelet count and progression of ICH in patients with traumatic brain injury. The aim of this study was to determine the platelet count cutoff for progression on RHCT and neurosurgical intervention in patients on antiplatelet therapy.

The journal of trauma and acute care surgery, 2014

The frailty index (FI) has been shown to predict outcomes in geriatric patients. However, FI has ... more The frailty index (FI) has been shown to predict outcomes in geriatric patients. However, FI has never been applied as a prognostic measure after trauma. The aim of our study was to identify hospital admission factors predicting discharge disposition in geriatric trauma patients. We performed a 1-year prospective study at our Level 1 trauma center. All trauma patients 65 years or older were enrolled. FI was calculated using 50 preadmission variables. Patient's discharge disposition was dichotomized as favorable outcome (discharge home, rehabilitation) or unfavorable outcomes (discharge to skilled nursing facility, death). Multivariate logistic regression was performed to identify factors that predict unfavorable outcome. A total of 100 patients were enrolled, with a mean (SD) age of 76.51 (8.5) years, 59% being males, median Injury Severity Score (ISS) of 14 (range, 9-18), median head Abbreviated Injury Scale (h-AIS) score of 2 (2-3), and median Glasgow Coma Scale (GCS) score of...

JAMA surgery, Jan 24, 2015

The role of acute care surgeons is evolving; however, no guidelines exist for the selective treat... more The role of acute care surgeons is evolving; however, no guidelines exist for the selective treatment of patients with traumatic brain injury (TBI) exclusively by acute care surgeons. We implemented the Brain Injury Guidelines (BIG) for managing TBI at our institution on March 1, 2012. To compare the outcomes in patients with TBI before and after implementation of the BIG protocol. We conducted a 2-year analysis of our prospectively maintained database of all patients with TBI (findings of skull fracture and/or intracranial hemorrhage on an initial computed tomographic scan of the head) who presented to our level I trauma center. The pre-BIG group included patients with TBI from March 1, 2011, through February 29, 2012, and the post-BIG group included patients from July 1, 2012, through June 30, 2013. The primary outcome measures were patients with repeated computed tomography of the head and neurosurgical consultations. Secondary outcome measures were findings of progression of int...

The American Journal of Surgery, 2015

Over 1 million healthcare providers have participated in the Advanced Trauma Life Support course.... more Over 1 million healthcare providers have participated in the Advanced Trauma Life Support course. No studies have evaluated factors that predict course performance. This study aims to identify these predictors. All participants taking the course at 2 centers over a 4-year period were identified. Demographics, background, and performance data were extracted. Participants who failed were compared with those who did not. Stepwise logistic regression analysis was used to identify independent risk factors for failure. Seven hundred forty-four healthcare providers participated in the course; 89.5% passed and 10.5% failed. Failure rates were lowest (.0%) among Trauma/Surgical Critical Care (SCC) providers and highest among pediatric providers (28.6%). Stepwise logistic regression identified age greater than 55, English as a second language, pretest score less than 75, and non-Trauma/SCC and non-Emergency Medicine background as predictors of failure. A failure rate of 10.5% was demonstrated among the course participants. Age greater than 55, English as second language, pretest score less than 75, and non-Trauma/SCC and non-Emergency Medicine backgrounds were associated with failure. These subgroups may benefit from performance improvement measures.

Journal of the American Geriatrics Society, Jan 6, 2015

To determine whether frail elderly adults are at greater risk of fracture after a ground-level fa... more To determine whether frail elderly adults are at greater risk of fracture after a ground-level fall (GLF) than those who are not frail. Prospective observational study. Level 1 trauma center. All elderly (≥65) adults presenting after a GLF over 1 year (N = 110; mean age ± SD 79.5 ± 8.3, 54% male). A Frailty Index (FI) was calculated using 50 preadmission frailty variables. Participants with a FI of 0.25 or greater were considered to be frail. The primary outcome measure was a new fracture; 40.1% (n = 45) of participants presented with a new fracture. The secondary outcome was discharge to an institutional facility (rehabilitation center or skilled nursing facility). Multivariate logistic regression was performed. Forty-three (38.2%) participants were frail. The median Injury Severity Score was 14 (range 9-17), and the mean FI was 0.20 ± 0.12. Frail participants were more likely than those who were not frail to have fractures (odds ratio (OR) = 1.8, 95% confidence interval (CI) = 1.2...

BACKGROUND: The aim of this study was to compare the safety of early (%48 hours), intermediate (4... more BACKGROUND: The aim of this study was to compare the safety of early (%48 hours), intermediate (48 to 72 hours), and late (R72 hours) venous thromboembolism prophylaxis in patients with blunt abdominal solid organ injury managed nonoperatively.

The journal of trauma and acute care surgery, 2013

Platelet transfusion is increasingly used in patients with traumatic intracranial hemorrhage (ICH... more Platelet transfusion is increasingly used in patients with traumatic intracranial hemorrhage (ICH) on aspirin therapy to minimize the progression of ICH. We hypothesized (null) that platelet transfusion in this cohort of patients does not improve platelet function. We performed a prospective interventional trail on patients with traumatic ICH on daily high-dose (325 mg) aspirin therapy. All patients received one pack of apheresis platelets. Blood samples were collected before and 1 hour after platelet transfusion. Platelet function was assessed using Verify Now Platelet Function Assay, and a cutoff of greater than 550 aspirin reaction units was used to define functioning platelets (FP). Twenty-eight patients were enrolled in the study. On presentation, 79% (22 of 28) of the patients had nonfunctioning platelets (NFPs), and transfusion of platelets did not improve platelet function as 81% (18 of 22) still had NFP. Of the 22 patients, 4 converted from NFP to FP after transfusion. Ther...

The journal of trauma and acute care surgery, 2014

Hypothermia is a known predictor of mortality in trauma patients; however, its impact on organ pr... more Hypothermia is a known predictor of mortality in trauma patients; however, its impact on organ procurement has not been defined. The aim of this study was to assess the effect of hypothermia on organ procurement. We hypothesized that admission hypothermia impedes successful organ procurement. We performed a 5-year retrospective analysis of all trauma patients approached for organ donation. Hypothermia was defined as a core body temperature 36°C/97°F or less. The two groups (hypothermic [HT] vs. nonhypothermic [non-HT]) were matched in a 1:1 ratio using propensity score matching for age, sex, admission Glasgow Coma Scale (GCS) score, systolic blood pressure, international normalized ratio, and Injury Severity Score (ISS). Primary outcome measures were eligibility for organ donation and solid organ procurement. Secondary outcome measures were blood product and vasopressor requirements. This study was composed of 537 brain-dead patients, of whom 416 (HT, 208; non-HT, 208) were included...

American journal of surgery, 2014

We hypothesized that patients with acute mild gallstone pancreatitis (GSP) admitted to surgery (S... more We hypothesized that patients with acute mild gallstone pancreatitis (GSP) admitted to surgery (SUR; vs medicine [MED]) had a shorter time to surgery, shorter hospital length of stay (HLOS), and lower costs. We performed chart reviews of patients who underwent a cholecystectomy for acute mild GSP from October 1, 2009 to May 31, 2013. We excluded patients with moderate to severe and non-gallstone pancreatitis. We compared outcomes for time to surgery, HLOS, costs, and complications between the 2 groups. Fifty acute mild GSP patients were admitted to MED and 52 to SUR. MED patients were older and had more comorbidity. SUR patients had a shorter time to surgery (44 vs 80 hours; P < .001), a shorter HLOS (3 vs 5 days; P < .001), and lower hospital costs ($11,492 ± 6,480 vs $16,183 ± 12,145; P = .03). In our subgroup analysis on patients with an American Society of Anesthesiologists score between 1 and 2, the subgroups were well matched; all outcomes still favored SUR patients. Adm...

The journal of trauma and acute care surgery, Jan 4, 2015

Management of traumatic brain injury (TBI) is focused on preventing secondary brain injury. Remot... more Management of traumatic brain injury (TBI) is focused on preventing secondary brain injury. Remote ischemic conditioning (RIC) is an established treatment modality that has been shown to improve patient outcomes secondary to inflammatory insults. The aim of our study was to assess whether RIC in trauma patients with severe TBI could reduce secondary brain injury. This prospective consented interventional trial included all TBI patients admitted to our Level 1 trauma center with an intracranial hemorrhage and a Glasgow Coma Scale (GCS) score of 8 or lower on admission. In each patient, four cycles of RIC were performed within 1 hour of admission. Each cycle consisted of 5 minutes of controlled upper limb (arm) ischemia followed by 5 minutes of reperfusion using a blood pressure cuff. Serum biomarkers of acute brain injury, S-100B, and neuron-specific enolase (NSE) were measured at 0, 6, and 24 hours. Outcome measure was reduction in the level of serum biomarkers after RIC. A total of...

Neurosurgery, 2015

BACKGROUND: The use of prothrombin complex concentrate (PCC) to reverse acquired (coagulopathy of... more BACKGROUND: The use of prothrombin complex concentrate (PCC) to reverse acquired (coagulopathy of trauma) and induced coagulopathy (preinjury warfarin use) is well defined. OBJECTIVE: To compare outcomes in patients with traumatic brain injury without warfarin therapy receiving PCC as an adjunct to fresh frozen plasma (FFP) therapy compared with patients receiving FFP therapy alone. METHODS: All patients with traumatic brain injury coagulopathy without warfarin therapy who received PCC (25 IU/kg) in conjunction with FFP or FFP alone at our Level I trauma center were reviewed. Coagulopathy was defined as an international normalized ratio .1.5. The groups (PCC 1 FFP vs FFP alone) were matched using propensity score matching on a 1:2 ratio for age, sex, Glasgow Coma Scale score, Injury Severity Score, head Abbreviated Injury Scale score, and international normalized ratio (INR) on presentation. The primary outcome measure was time to craniotomy. Secondary outcome measures were blood product requirements, cost of therapy, and mortality. RESULTS: A total of 1641 patients were reviewed, 222 of whom were included (PCC 1 FFP, 74; FFP, 148). The mean 6 standard deviation age was 46.4 6 21.7 years, the median (range) Glasgow Coma Scale score was 8 (3-12), and the mean 6 standard deviation INR on presentation was 1.92 6 0.6. PCC 1 FFP therapy was associated with an accelerated correction of INR (P = .001) and decrease in overall pack red blood cell (P = .035) and FFP (P = .041) administration requirement. Craniotomy was performed in 26.1% of patients (n = 58). Patients who received PCC 1 FFP therapy had faster time to craniotomy (P = .028) compared with patients who received FFP therapy alone. CONCLUSION: PCC as an adjunct to FFP decreases the time to craniotomy with faster correction of INR and concomitant decrease in the need for blood product requirement in patients with traumatic brain injury exclusive of prehospital warfarin therapy.

The journal of trauma and acute care surgery, 2013

The American surgeon, 2014

Anticoagulation agents are proven risk factors for intracranial hemorrhage (ICH) in traumatic bra... more Anticoagulation agents are proven risk factors for intracranial hemorrhage (ICH) in traumatic brain injury (TBI). The aim of our study is to describe the epidemiology of prehospital coumadin, aspirin, and Plavix (CAP) patients with ICH and evaluate the use of repeat head computed tomography (CT) in this group. We performed a retrospective study from our trauma registry. All patients with intracranial hemorrhage on initial CT with prehospital CAP therapy were included. Demographics, CT scan findings, number of repeat CT scans, progressive findings, and neurosurgical intervention were abstracted. A comparison between prehospital CAP and no-CAP patients was done using χ(2) and Mann-Whitney U test. A total of 1606 patients with blunt TBI charts were reviewed of whom 508 patients had intracranial bleeding on initial CT scan and 72 were on prehospital CAP therapy. CAP patients were older (P < 0.001), had higher Injury Severity Score and head Abbreviated Injury Scores on admission (P &l...

The journal of trauma and acute care surgery, 2014

Patients receiving antiplatelet medications are considered to be at an increased risk for traumat... more Patients receiving antiplatelet medications are considered to be at an increased risk for traumatic intracranial hemorrhage after blunt head trauma. However, most studies have categorized all antiplatelet drugs into one category. The aim of our study was to evaluate clinical outcomes and the requirement of a repeat head computed tomography (RHCT) in patients on preinjury clopidogrel therapy. Patients with traumatic brain injury with intracranial hemorrhage on initial head CT were prospectively enrolled. Patients on preinjury clopidogrel were matched with patients exclusive of antiplatelet and anticoagulation therapy using a propensity score in a 1:1 ratio for age, Glasgow Coma Scale (GCS), head Abbreviated Injury Scale (h-AIS), Injury Severity Score (ISS), neurologic examination, and platelet transfusion. Outcome measures were progression on RHCT scan and need for neurosurgical intervention. A total of 142 patients with intracranial hemorrhage on initial head CT scan (clopidogrel, 7...

The journal of trauma and acute care surgery, 2014

It is becoming a standard practice that any "positive" identification of a radiographic... more It is becoming a standard practice that any "positive" identification of a radiographic intracranial injury requires transfer of the patient to a trauma center for observation and repeat head computed tomography (RHCT). The purpose of this study was to define guidelines-based on each patient's history, physical examination, and initial head CT findings-regarding which patients require a period of observation, RHCT, or neurosurgical consultation. In our retrospective cohort analysis, we reviewed the records of 3,803 blunt traumatic brain injury patients during a 4-year period. We classified patients according to neurologic examination results, use of intoxicants, anticoagulation status, and initial head CT findings. We then developed brain injury guidelines (BIG) based on the individual patient's need for observation or hospitalization, RHCT, or neurosurgical consultation. A total of 1,232 patients had an abnormal head CT finding. In the BIG 1 category, no patients ...

The journal of trauma and acute care surgery, 2014

Protocols call for the start of hormonal therapy with levothyroxine after the declaration of brai... more Protocols call for the start of hormonal therapy with levothyroxine after the declaration of brain death. As the hormonal perturbations occur during the process of brain death, the role of the early initiation of levothyroxine therapy (LT) to salvage organs is not well defined. The aim of this study was to evaluate the impact of early LT (before the declaration of brain death) on the number of solid organs procured per donor. We performed an 8-year retrospective analysis of all trauma patients who progressed to brain death. Patients who consented for organ donation, received LT, and donated solid organs were included. Patients were dichotomized into two groups: early LT group, patients who received LT before the declaration of brain death, and late LT group, those who received LT after brain death. The two groups were compared for differences in demographics, clinical characteristics, need for vasopressor, and number of solid organ donation. A total of 100 solid organ donors were id...

The American surgeon, 2014

The American surgeon, 2014

Coagulopathy is a defined barrier for organ donation in patients with lethal traumatic brain inju... more Coagulopathy is a defined barrier for organ donation in patients with lethal traumatic brain injuries. The purpose of this study was to document our experience with the use of prothrombin complex concentrate (PCC) to facilitate organ donation in patients with lethal traumatic brain injuries. We performed a 4-year retrospective analysis of all patients with devastating gunshot wounds to the brain. The data were analyzed for demographics, change in international normalized ratio (INR), and subsequent organ donation. The primary end point was organ donation. Eighty-eight patients with lethal traumatic brain injury were identified from the trauma registry of whom 13 were coagulopathic at the time of admission (mean INR 2.2 ± 0.8). Of these 13 patients, 10 patients received PCC in an effort to reverse their coagulopathy. Mean INR before PCC administration was 2.01 ± 0.7 and 1.1 ± 0.7 after administration (P < 0.006). Correction of coagulopathy was attained in 70 per cent (seven of 10)...

The journal of trauma and acute care surgery, 2014

To optimize neurosurgical resources, guidelines were developed at our institution, allowing the a... more To optimize neurosurgical resources, guidelines were developed at our institution, allowing the acute care surgeons to independently manage traumatic intracranial hemorrhage less than or equal to 4 mm. The aim of our study was to evaluate our established Brain Injury Guidelines (BIG 1 category) for managing patients with traumatic brain injury (TBI) without neurosurgical consultation. We formulated the BIG based on a 4-year retrospective chart review of all TBI patients presenting at our Level 1 trauma center. We then prospectively implemented our BIG 1 category to identify TBI patients that were to be managed without neurosurgical consultation (No-NC). Propensity scoring matched patients with No-NC to a similar cohort of patients managed with NC before the implementation of our BIG in a 1:1 ratio for demographics, severity of injury, and type and size of intracranial hemorrhage. Primary outcome measure was need for neurosurgical intervention and 30-day readmission rates. A total of...

The journal of trauma and acute care surgery, 2015

Animal and human bite wounds represent a significant global health issue. In the United States, a... more Animal and human bite wounds represent a significant global health issue. In the United States, animal and human bites are a very common health issue, causing significant morbidity and even, in rare scenarios, mortality. Most animal bite wounds in the United States are caused by dogs, with cat bites being a distant second. Human bite wounds constitute a dominant subset of all bite wounds. Several studies of bite wounds have reported improved outcomes with early diagnosis and immediate treatment. However, the available literature on the initial treatment provides a plethora of conflicting opinions and results. In this review, our aim was to identify and assess the current evidence on the management of animal (dog, cat, insects, scorpions, and snakes) and human bite wounds. Review article, level III.

Journal of Trauma and Acute Care Surgery, 2014

Platelet dysfunction has been attributed to progression of initial intracranial hemorrhage (ICH) ... more Platelet dysfunction has been attributed to progression of initial intracranial hemorrhage (ICH) on repeat head computed tomographic (RHCT) scans in patients on prehospital antiplatelet therapy. However, there is little emphasis on the effect of platelet count and progression of ICH in patients with traumatic brain injury. The aim of this study was to determine the platelet count cutoff for progression on RHCT and neurosurgical intervention in patients on antiplatelet therapy.

The journal of trauma and acute care surgery, 2014

The frailty index (FI) has been shown to predict outcomes in geriatric patients. However, FI has ... more The frailty index (FI) has been shown to predict outcomes in geriatric patients. However, FI has never been applied as a prognostic measure after trauma. The aim of our study was to identify hospital admission factors predicting discharge disposition in geriatric trauma patients. We performed a 1-year prospective study at our Level 1 trauma center. All trauma patients 65 years or older were enrolled. FI was calculated using 50 preadmission variables. Patient's discharge disposition was dichotomized as favorable outcome (discharge home, rehabilitation) or unfavorable outcomes (discharge to skilled nursing facility, death). Multivariate logistic regression was performed to identify factors that predict unfavorable outcome. A total of 100 patients were enrolled, with a mean (SD) age of 76.51 (8.5) years, 59% being males, median Injury Severity Score (ISS) of 14 (range, 9-18), median head Abbreviated Injury Scale (h-AIS) score of 2 (2-3), and median Glasgow Coma Scale (GCS) score of...