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Papers by Michael Lekawa

Research paper thumbnail of Successful Management of Occult Pneumothorax without Tube Thoracostomy despite Positive Pressure Ventilation

American Surgeon, Oct 1, 2008

The objective of this study was to determine whether tube thoracostomy can be safely avoided in a... more The objective of this study was to determine whether tube thoracostomy can be safely avoided in a subset of patients with blunt occult pneumothorax. A retrospective review was performed. Management without tube thoracostomy was attempted for 59 occult pneumothoraces and was successful in 51 (86%). Observation was successful in 16 of 20 occult pneumothoraces (80%) exposed to positive pressure ventilation within 72 hours of admission. Eight delayed tube thoracostomies were required an average of 19.7 hours post admission. Patients who failed observant management had more significant physiologic derangement on admission (revised trauma score 6.96 vs 7.66, P = 0.04), were more likely to have significant multisystem trauma (88% vs 37%, P = 0.007), but were not more likely to require positive pressure ventilation (PPV) (50% vs 31%, P = 0.31). This study demonstrates that a subset of patients with blunt occult pneumothorax requiring positive pressure ventilation may be safely managed without tube thoracostomy.

Research paper thumbnail of Implementation of a Cost-Saving Algorithm for Pelvic Radiographs in Blunt Trauma Patients

Journal of Trauma-injury Infection and Critical Care, Sep 1, 2011

Background: In a previous retrospective study, we demonstrated that pelvic radiographs (PXRs) in ... more Background: In a previous retrospective study, we demonstrated that pelvic radiographs (PXRs) in the evaluation of blunt trauma patients undergoing abdominal computed tomographic (CT) scanning have limited utility in the absence of hemodynamic instability and significant physical findings. The purpose of this study was to prospectively validate an algorithm defining indications for PXR in blunt trauma patients in the emergency department. Methods: We performed a prospective observational study of consecutive blunt trauma patients over 6 months at a single Level 1 trauma center. The trauma faculty agreed to implement an algorithm of obtaining PXRs in patients undergoing abdominal CT scanning only if a specific set of criteria were met: systolic blood pressure Ͻ90 mm Hg, hemoglobin Ͻ8 mg/dL, a drop in Hgb of more than 3 mg/dL while in the trauma bay, or significant physical examination findings. The algorithm could be overridden at the discretion of the attending physician. Results: Nine hundred ninety-five consecutive blunt trauma patients whose evaluation was to include an abdominal CT scan were included in the study. Only 54 patients (6%) received a PXR. Fifty-six indications for PXR were provided: 35 (63%) severe pelvic pain, 14 (25%) proximal fractures, 3 (5%) hip dislocations, and only 4 (7%) had unexplained hypotension. No adverse events or delays in care occurred such as hypotension in the CT scanner or a delay in contacting interventional radiology, blood transfusion, or application of a pelvic binder. The algorithm selected PXR for patients who were more likely to have a pelvic fracture (33% vs. 4.5%, p Ͻ 0.001), hip dislocation (7.4% vs. 0.1%, p Ͻ 0.001), femur fracture (22.2% vs. 2.7%, p Ͻ 0.001), and to require blood transfusion (11.1% vs. 1.9%, p Ͻ 0.001). Implementation of this algorithm resulted in a decrease in charges of Ͼ$226, 000 in 6 months. Conclusion: When objective evaluation of the abdomen is to be obtained via CT scanning, PXR in the emergency department is obsolete in the absence of hemodynamic instability and significant physical examination findings. Implementation of a selective algorithm in this patient population can result in significant cost savings without adverse patient outcomes.

Research paper thumbnail of Risk factors for venous thromboembolism in critically ill nontrauma surgical patients who cannot receive chemical prophylaxis

American Journal of Surgery, Sep 1, 2013

BACKGROUND: We sought to identify independent predictors of venous thromboembolism in critically ... more BACKGROUND: We sought to identify independent predictors of venous thromboembolism in critically ill general surgery patients who cannot receive chemical prophylaxis in order to identify those who may benefit from aggressive screening and/or prophylactic inferior vena cava filter placement. METHODS: Nontrauma patients in the surgical intensive care unit were prospectively followed for 2 years. Patients who had contraindications to prophylactic anticoagulation and received routine screening duplex examinations were included. Data regarding lower-extremity deep venous thrombosis or pulmonary embolism (PE) rates, past medical history (PMH), surgeries, and transfusions were collected. Logistic regression was used to identify independent predictors of lower-extremity deep venous thrombosis or PE (venous thromboembolism) with a P , .05. RESULTS: Data were complete for 204 patients. Twenty (9.8%) patients developed venous thromboembolism. Independent predictors of venous thromboembolism included postoperative blood product requirements (odds ratio 5 1.04 per unit), a PMH of PE (OR 5 10.1), and a PMH of renal insufficiency (odds ratio 5 5.1). CONCLUSIONS: Aggressive screening and/or prophylactic inferior vena cava filter may be considered when prophylactic anticoagulation is prohibited in patients with increased postoperative transfusion requirements or a PMH of either PE or renal insufficiency.

Research paper thumbnail of University Teaching Trauma Centers: Decreased Mortality but Increased Complications

Journal of Surgical Research

Research paper thumbnail of Utility of Thoracic Computed Tomography after Blunt Trauma: When is Chest Radiograph Enough?

American Surgeon, Oct 1, 2009

Research paper thumbnail of The Clinical Significance of Occult Thoracic Injury in Blunt Trauma Patients

American Surgeon, Oct 1, 2010

Increased use of thoracic CT (TCT) in diagnosis of blunt traumatic injury has identified many inj... more Increased use of thoracic CT (TCT) in diagnosis of blunt traumatic injury has identified many injuries previously undetected on screening chest x-ray (CXR), termed ''occult injury.'' The optimal management of occult rib fractures, pneumothoraces (PTX), hemothoraces (HTX), and pulmonary contusions is uncertain. Our objective was to determine the current management and clinical outcome of these occult blunt thoracic injuries. A retrospective review identified patients with blunt thoracic trauma who underwent both CXR and TCT over a 2-year period at a Level I urban trauma center. Patients with acute rib fractures, PTX, HTX, or pulmonary contusion on TCT were included. Patient groups analyzed included: 1) no injury (normal CXR, normal TCT, n 5 1337); 2) occult injury (normal CXR, abnormal TCT, n 5 205); and 3) overt injury (abnormal CXR, abnormal TCT, n 5 227). Patients with overt injury required significantly more mechanical ventilation and had greater mortality than either occult or no injury patients. Occult and no injury patients had similar ventilator needs and mortality, but occult injury patients remained hospitalized longer. No patient with isolated occult thoracic injury required intubation or tube thoracostomy. Occult injuries, diagnosed by TCT only, have minimal clinical consequences but attract increased hospital resources.

Research paper thumbnail of Standard Prophylactic Enoxaparin Dosing Leads to Inadequate Anti-Xa Levels and Increased Deep Venous Thrombosis Rates in Critically Ill Trauma and Surgical Patients

Journal of Trauma-injury Infection and Critical Care, Apr 1, 2010

Background: Deep venous thromboses (DVT) continue to cause significant morbidity in critically il... more Background: Deep venous thromboses (DVT) continue to cause significant morbidity in critically ill patients. Standard prophylaxis for high risk patients includes twice-daily dosing with 30 mg enoxaparin. Despite prophylaxis, DVT rates still exceed 10% to 15%. Anti-Xa levels are used to measure the activity of enoxaparin and 12-hour trough levels Յ0.1 IU/mL have been associated with higher rates of DVT in orthopedic patients. We hypothesized that low Anti-Xa levels would be found in critically ill trauma and surgical patients and that low levels would be associated with higher rates of DVT. Methods: All patients on the surgical intensive care unit (ICU) service were prospectively followed. In the absence of contraindications, patients were given prophylactic enoxaparin and anti-Xa levels were drawn after the third dose. Trough levels Յ0.1 IU/mL were considered low. Screening duplex exams were obtained within 48 hours of admission and then weekly. Patients were excluded if they did not receive a duplex, if they had a prior DVT, or if they lacked correctly timed anti-Xa levels. DVT rates and demographic data were compared between patients with low and normal anti-Xa levels. Results: Data were complete for 54 patients. Eighty-five percent suffered trauma (Injury Severity Score of 25 Ϯ 12) and 74% were male. Overall, 27 patients (50%) had low anti-Xa levels. Patients with low anti-Xa levels had significantly more DVTs than those with normal levels (37% vs. 11%, p ϭ 0.026), despite similar age, body mass index, Injury Severity Score, creatinine clearance, high risk injuries, and ICU/ventilator days. Conclusion: Standard dosing of enoxaparin leads to low anti-Xa levels in half of surgical ICU patients. Low levels are associated with a significant increase in the risk of DVT. These data support future studies using adjusted-dose enoxaparin.

Research paper thumbnail of Injury and Mortality Profiles in Level II and III Trauma Centers

The American Surgeon

Background While the benefit of admission to trauma centers compared to non-trauma centers is wel... more Background While the benefit of admission to trauma centers compared to non-trauma centers is well-documented and differences in outcomes between Level-I and Level-II trauma centers are well-studied, data on the differences in outcomes between Level-II trauma centers (L2TCs) and Level-III trauma centers (L3TCs) are scarce. Objectives We sought to compare mortality risk between patients admitted to L2TCs and L3TCs, hypothesizing no difference in mortality risk for patients treated at L3TCs compared to L2TCs. Methods A retrospective analysis of the 2016 Trauma Quality Improvement Program (TQIP) database was performed. Patients aged 18+ years were divided into 2 groups, those treated at American College of Surgeons (ACS) verified L2TCs and L3TCs. Results From 74,486 patients included in this study, 74,187 (99.6%) were treated at L2TCs and 299 (.4%) at L3TCs. Both groups had similar median injury severity scores (ISSs) (10 vs 10, P < .001); however, L2TCs had a higher mean ISS (14.6 ...

Research paper thumbnail of Brachial Plexus Injury Significantly Increases Risk of Axillosubclavian Vessel Injury in Blunt Trauma Patients With Clavicle Fractures

The American Surgeon

Background A national analysis of clavicle fractures is lacking and the risk of concomitant axill... more Background A national analysis of clavicle fractures is lacking and the risk of concomitant axillosubclavian vessel injury (ASVI) in patients with clavicle fractures is unknown. A minority of patients may have a combined brachial plexus injury (BPI). We sought to describe risk factors for concomitant ASVI in patients with a clavicle fracture; hypothesizing patients with combined clavicle fracture and BPI has a higher risk of ASVI. Methods The Trauma Quality Improvement Program (2010-2016) was queried for blunt trauma patients with a clavicle fracture. A multivariable logistic regression model was used to determine risk factors for ASVI. A subset analysis on patients with isolated clavicle fractures was additionally performed. Results From 59 198 patients with clavicle fractures, 341 (.6%) had concomitant ASVI. Compared to patients without ASVI, patients with ASVI had a higher median injury severity score (24 vs. 17, P < .001) and rates of pulmonary contusions (43.4% vs. 37.7%, P ...

Research paper thumbnail of Isolated Thoracic Injury Patients With Rib Fractures Undergoing Rib Fixation Have Improved Mortality

Journal of Surgical Research, 2021

BACKGROUND Despite a lack of consensus recommendations for surgical stabilization of rib fracture... more BACKGROUND Despite a lack of consensus recommendations for surgical stabilization of rib fractures (SSRF), SSRF has increased over the past decade. Outcomes of patients with isolated thoracic injuries undergoing SSRF are unknown. We hypothesized adult trauma patients with isolated thoracic injuries and rib fractures undergoing SSRF would have a decreased risk of mortality and in-hospital respiratory complications compared with those not undergoing SSRF. MATERIALS AND METHODS The Trauma Quality Improvement Program (2010-2016) was queried for patients presenting with a rib fracture. Patients who died in the emergency department or within 24-h, as well as those with a grade>1 for abbreviated injury scale of the head, face, neck, spine, abdomen, and extremities, were excluded. A multivariable logistic regression analysis was performed. RESULTS From 60,000 patients with isolated thoracic injuries and rib fractures, 688 (1.1%) underwent SSRF. Compared with patients without SSRF, those undergoing SSRF had a similar median age (P = 0.83) and higher injury severity score (P < 0.001). Patients undergoing SSRF had a longer length of stay (P < 0.001), higher rate of acute respiratory distress syndrome (P < 0.001), unplanned intubation (P < 0.001), and pneumonia (P < 0.001) but lower rate of mortality (0.9% versus 1.7%, P = 0.084). After adjusting for confounding variables, patients undergoing SSRF had a decreased associated risk of mortality (OR 0.40, P = 0.036) compared with those not undergoing SSRF. CONCLUSIONS The risk of mortality in trauma patients with isolated thoracic injuries and rib fractures is lower when undergoing SSRF despite being associated with a higher rate of respiratory complications during their increased length of stay.

Research paper thumbnail of No Difference in Morbidity or Mortality Between Octogenarians and Other Geriatric Burn Trauma Patients

The American Surgeon, 2021

Background Geriatric burn trauma patients (age ≥65 years) have a 5-fold higher mortality rate tha... more Background Geriatric burn trauma patients (age ≥65 years) have a 5-fold higher mortality rate than younger adults. With the population of the US aging, the number of elderly burn and trauma patients is expected to increase. A past study using the National Burn Repository revealed a linear increase in mortality for those >65 years old. We hypothesized that octogenarians with burn and trauma injuries would have a higher rate of in-hospital complications and mortality, than patients aged 65-79 years old. Methods The Trauma Quality Improvement Program (2010-2016) was queried for burn trauma patients. To detect mortality risk a multivariable logistic regression model was used. Results From 282 patients, there were 73 (25.9%) octogenarians and 209 (74.1%) aged 65-79 years old. The two cohorts had similar median injury severity scores (16 vs. 15 in octogenarians, P = .81), total body surface area burned ( P = .30), and comorbidities apart from an increased smoking (12.9% vs. 4.1%, P = ....

Research paper thumbnail of Race, Age, and Lack of Insurance Increase Risk of Suicide Attempt in Trauma Patients

Archives of Suicide Research, 2020

Objective: The overall rate of suicide between 1999 and 2017 increased by 33% in the United State... more Objective: The overall rate of suicide between 1999 and 2017 increased by 33% in the United States. We sought to examine suicide attempts in the trauma patient population, hypothesizing that in adult trauma patients race and lack of insurance status would be predictors of suicide attempt. Method: The Trauma Quality Improvement Program (2010-2016) was queried for trauma patients !18 years old. The primary outcome was suicide attempt. A multivariable logistic regression model was performed including covariates that influence risk of suicide attempt. Results: From 1,403,466 adult trauma admissions, 16,263 (1.2%) patients attempted suicide. Death after suicide attempt occurred in 30.2% of patients. Independent predictors of suicide attempt were age < 40 years old (odds ratio [OR] ¼ 1.46, 95% confidence interval [CI] [1.41, 1.51], p < .001) and no insurance (OR ¼ 1.92, 95% CI [1.85, 2.00], p < .001). Black (vs. White) race was associated with decreased risk of suicide attempt (OR ¼ 0.63, 95% CI [0.60, 0.67], p < .001). Hispanic (versus non-Hispanic) patients demonstrated lower associated risk of suicide attempt by gun (OR ¼ 0.50, 95% CI [0.45, 0.54], p < .001), while Asian (vs. White) patients exhibited higher risk of suicide attempt overall (OR ¼ 1.25, 95% CI [1.12, 1.39], p < .001) and more specifically by knife (OR ¼ 2.55, 95% CI [2.16, 3.00], p < .001). Conclusions: Age younger than 40 years and lack of insurance were associated with higher risk of suicide attempt in adult trauma patients. Asian race was associated with the highest risk of suicide, with >2.5 times increased risk of attempt by knife. Awareness of these demographic-specific risk factors for suicide attempt, and in particular violent mechanisms of suicide attempt, is critical to implementation of effective suicide prevention efforts. HIGHLIGHTS Age younger than 40 and no insurance were associated with risk of suicide attempt. Black (vs. White) race was associated with decreased risk of suicide attempt. Asian race was associated with an increased risk of suicide attempt with a knife.

Research paper thumbnail of Regional, Racial, and Mortality Disparities Associated With Neurosurgeon Staffing at Level I Trauma Centers

The American Surgeon, 2020

Background Traumatic brain injury (TBI) occurs in approximately 30% of trauma patients. Because n... more Background Traumatic brain injury (TBI) occurs in approximately 30% of trauma patients. Because neurosurgeons hold expertise in treating TBI, increased neurosurgical staffing may improve patient outcomes. We hypothesized that TBI patients treated at level I trauma centers (L1TCs) with ≥3 neurosurgeons have a decreased risk of mortality vs. those treated at L1TCs with <3 neurosurgeons. Methods The Trauma Quality Improvement Program database (2010-2016) was queried for patients ≥18 years with TBI. Patient characteristics and mortality were compared between ≥3 and <3 neurosurgeon-staffed L1TCs. A multivariable logistic regression analysis was used to identify risk factors associated with mortality. Results Traumatic brain injury occurred in 243 438 patients with 5188 (2%) presenting to L1TCs with <3 neurosurgeons and 238 250 (98%) to L1TCs with ≥3 neurosurgeons. Median injury severity score (ISS) was similar between both groups (17, P = .09). There were more Black (37% vs. 12%...

Research paper thumbnail of 1336: Blunt Trauma Massive Transfusion (B-MaT) Score: A Novel Scoring Tool

Critical Care Medicine, 2020

Research paper thumbnail of Evolving Utility of Endovascular Treatment of Juxtarenal, Pararenal, and Suprarenal Abdominal Aortic Aneurysms Associated With Increased Risk of Mortality Over Time

Annals of Vascular Surgery, 2020

Research paper thumbnail of Seatbelt Sign as an Indication for Four-vessel Computed Tomography Angiogram of the Neck to Diagnose Blunt Carotid Artery and Other Cervical Vascular Injuries

The American Surgeon, 2013

Computed tomography angiography (CTA) of the neck has become the most common modality for diagnos... more Computed tomography angiography (CTA) of the neck has become the most common modality for diagnosing blunt carotid artery injury (BCAI). The protocol at our institution includes CTA on trauma patients with a seatbelt sign. The purpose of this study is to evaluate whether a solitary seatbelt sign is an indication for CTA of the neck to diagnose BCAI. We conducted a retrospective review of patients from 2000 to 2010 who received CTAs as a result of a seatbelt sign performed at our Level I trauma center. Four hundred eighteen patients received CTAs based on the presence of a seatbelt sign. Two hundred twenty-six had skeletal injuries, obvious soft tissue injuries, and/or positive findings on imaging, including 11 positive vascular findings with two BCAIs found. Patients with noncarotid vascular injuries on CTA had a higher Injury Severity Score than patients with solitary seatbelt signs (11.4 ± 7.6 vs 3.4 ± 4.2, P < 0.01). The correlation between seatbelt sign and positive finding o...

Research paper thumbnail of Racial Disparities in Access and Outcomes of Cholecystectomy in the United States

The American Surgeon, 2016

Disparities in access to health care between white and minority patients are well described. We a... more Disparities in access to health care between white and minority patients are well described. We aimed to analyze the trends and outcomes of cholecystectomy based on racial classification. The Nationwide Inpatient Sample database was reviewed for all patients undergoing cholecystectomy from 2009 to 2012. Patients were stratified as white or non-white. A total of 243,536 patients were analyzed: 159,901 white and 83,635 non-white. Non-white patients had significantly higher proportions of Medicaid (25% vs 9.3%), self-pay (14% vs 7.1%), and no-charge (1.8% vs 0.64%). Non-white patients had significantly higher rates of emergent admission (84% vs 78%) compared with the white patients. Multivariate analysis revealed that non-whites had a significantly longer length of stay [mean difference of 0.14 days, 95% confidence interval (CI) 0.08–0.20] and higher total hospital charges (mean difference of $6748.00, 95% CI 5994.19–7501.81) than whites, despite a lower morbidity (odds ratio 0.94, 95%...

Research paper thumbnail of Analysis of blunt cerebrovascular injury in pediatric trauma

Journal of Trauma and Acute Care Surgery, 2019

BACKGROUND Blunt cerebrovascular injury (BCVI) occurs in <1% of pediatric patients. The two pr... more BACKGROUND Blunt cerebrovascular injury (BCVI) occurs in <1% of pediatric patients. The two principal screening criteria for BCVI in children are the Utah and McGovern Score with motor vehicle accident (MVA) considered to be a predictor for BCVI. We sought to confirm previously reported risk factors and identify novel associations with BCVI in pediatric patients. METHODS The Pediatric Trauma Quality Improvement Program (2014–2016) was queried for patients younger than 16 years presenting after blunt trauma. A multivariable logistic regression was used to determine risk of BCVI. RESULTS From 69,149 pediatric patients, 109 (<0.2%) had BCVI. The median age was 13 years, and the median Injury Severity Score was 25. More than half the patients were involved in MVAs (53.2%) and had a skull base fracture (53.2%). Factors independently associated with BCVI include skull base fracture (odds ratio [OR], 3.84; 95% confidence interval [CI], 2.40–6.14; p < 0.001), cervical spine fractur...

Research paper thumbnail of Increased risk of head injury in pediatric patients with attention deficit hyperactivity disorder

Journal of Child and Adolescent Psychiatric Nursing, 2019

ObjectiveThe prevalence of attention deficit hyperactivity disorder (ADHD) in the general pediatr... more ObjectiveThe prevalence of attention deficit hyperactivity disorder (ADHD) in the general pediatric population is 7%, whereas the prevalence in trauma is unknown. We hypothesized pediatric patients with ADHD would have a higher risk of involvement in a mechanism of injury (MOI) requiring constant attention to surroundings, such as a bicycle collision.MethodsThe Pediatric Trauma Quality Improvement Program (2014–2016) was queried for patients with ADHD. Patients, less than 16 years of age, with ADHD were compared to those without ADHD.ResultsThe prevalence of ADHD was 2.5% (2,866). ADHD patients had higher risk for bicycle collision (odds ratio [OR], 1.85; 95% confidence interval [CI], 1.59–2.15; p < .001). ADHD bicyclists were less likely to wear a helmet (9.4% vs. 18.2%, p = .003) and had a higher rate of traumatic brain injury (TBI; 55.6% vs. 39.7%, p < .001), compared to non‐ADHD bicyclists.ConclusionsPediatric ADHD patients have a 60% higher risk of being involved in a bic...

Research paper thumbnail of Non-accidental trauma increases length of stay and mortality in pediatric trauma

Pediatric Surgery International, 2019

Purpose More than half a million children experience non-accidental trauma (NAT) annually. Histor... more Purpose More than half a million children experience non-accidental trauma (NAT) annually. Historically, NAT has been associated with an increased hospital length of stay (LOS). We hypothesized that in pediatric trauma patients, NAT is associated with longer hospital LOS, independent of injury severity, compared to accidental trauma (AT). Methods The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients aged 1-16 years. Patients were stratified into two groups: AT and NAT. The median LOS for the entire cohort was identified and used in a multivariable logistic regression analysis. Results From 93,089 pediatric trauma patients, 417 (< 0.1%) were involved in NAT. Patients with NAT had a lower median age (3 vs. 9 years, p < 0.001) and higher median injury severity score (10 vs. 5, p < 0.001), compared to patients with AT. After controlling for covariates, patients with NAT were associated with a longer hospital LOS (≥ 2 days), compared to those with AT (OR = 4.99 CI = 3.55-7.01, p < 0.001). In comparison to AT, NAT was also associated with a higher mortality rate (10.3% vs. 0.8%, p < 0.001). Conclusion Pediatric patients presenting after NAT have a prolonged hospital and ICU LOS, even after adjusting for injury severity. Furthermore, pediatric victims of NAT had a higher mortality rate compared to those presenting after AT.

Research paper thumbnail of Successful Management of Occult Pneumothorax without Tube Thoracostomy despite Positive Pressure Ventilation

American Surgeon, Oct 1, 2008

The objective of this study was to determine whether tube thoracostomy can be safely avoided in a... more The objective of this study was to determine whether tube thoracostomy can be safely avoided in a subset of patients with blunt occult pneumothorax. A retrospective review was performed. Management without tube thoracostomy was attempted for 59 occult pneumothoraces and was successful in 51 (86%). Observation was successful in 16 of 20 occult pneumothoraces (80%) exposed to positive pressure ventilation within 72 hours of admission. Eight delayed tube thoracostomies were required an average of 19.7 hours post admission. Patients who failed observant management had more significant physiologic derangement on admission (revised trauma score 6.96 vs 7.66, P = 0.04), were more likely to have significant multisystem trauma (88% vs 37%, P = 0.007), but were not more likely to require positive pressure ventilation (PPV) (50% vs 31%, P = 0.31). This study demonstrates that a subset of patients with blunt occult pneumothorax requiring positive pressure ventilation may be safely managed without tube thoracostomy.

Research paper thumbnail of Implementation of a Cost-Saving Algorithm for Pelvic Radiographs in Blunt Trauma Patients

Journal of Trauma-injury Infection and Critical Care, Sep 1, 2011

Background: In a previous retrospective study, we demonstrated that pelvic radiographs (PXRs) in ... more Background: In a previous retrospective study, we demonstrated that pelvic radiographs (PXRs) in the evaluation of blunt trauma patients undergoing abdominal computed tomographic (CT) scanning have limited utility in the absence of hemodynamic instability and significant physical findings. The purpose of this study was to prospectively validate an algorithm defining indications for PXR in blunt trauma patients in the emergency department. Methods: We performed a prospective observational study of consecutive blunt trauma patients over 6 months at a single Level 1 trauma center. The trauma faculty agreed to implement an algorithm of obtaining PXRs in patients undergoing abdominal CT scanning only if a specific set of criteria were met: systolic blood pressure Ͻ90 mm Hg, hemoglobin Ͻ8 mg/dL, a drop in Hgb of more than 3 mg/dL while in the trauma bay, or significant physical examination findings. The algorithm could be overridden at the discretion of the attending physician. Results: Nine hundred ninety-five consecutive blunt trauma patients whose evaluation was to include an abdominal CT scan were included in the study. Only 54 patients (6%) received a PXR. Fifty-six indications for PXR were provided: 35 (63%) severe pelvic pain, 14 (25%) proximal fractures, 3 (5%) hip dislocations, and only 4 (7%) had unexplained hypotension. No adverse events or delays in care occurred such as hypotension in the CT scanner or a delay in contacting interventional radiology, blood transfusion, or application of a pelvic binder. The algorithm selected PXR for patients who were more likely to have a pelvic fracture (33% vs. 4.5%, p Ͻ 0.001), hip dislocation (7.4% vs. 0.1%, p Ͻ 0.001), femur fracture (22.2% vs. 2.7%, p Ͻ 0.001), and to require blood transfusion (11.1% vs. 1.9%, p Ͻ 0.001). Implementation of this algorithm resulted in a decrease in charges of Ͼ$226, 000 in 6 months. Conclusion: When objective evaluation of the abdomen is to be obtained via CT scanning, PXR in the emergency department is obsolete in the absence of hemodynamic instability and significant physical examination findings. Implementation of a selective algorithm in this patient population can result in significant cost savings without adverse patient outcomes.

Research paper thumbnail of Risk factors for venous thromboembolism in critically ill nontrauma surgical patients who cannot receive chemical prophylaxis

American Journal of Surgery, Sep 1, 2013

BACKGROUND: We sought to identify independent predictors of venous thromboembolism in critically ... more BACKGROUND: We sought to identify independent predictors of venous thromboembolism in critically ill general surgery patients who cannot receive chemical prophylaxis in order to identify those who may benefit from aggressive screening and/or prophylactic inferior vena cava filter placement. METHODS: Nontrauma patients in the surgical intensive care unit were prospectively followed for 2 years. Patients who had contraindications to prophylactic anticoagulation and received routine screening duplex examinations were included. Data regarding lower-extremity deep venous thrombosis or pulmonary embolism (PE) rates, past medical history (PMH), surgeries, and transfusions were collected. Logistic regression was used to identify independent predictors of lower-extremity deep venous thrombosis or PE (venous thromboembolism) with a P , .05. RESULTS: Data were complete for 204 patients. Twenty (9.8%) patients developed venous thromboembolism. Independent predictors of venous thromboembolism included postoperative blood product requirements (odds ratio 5 1.04 per unit), a PMH of PE (OR 5 10.1), and a PMH of renal insufficiency (odds ratio 5 5.1). CONCLUSIONS: Aggressive screening and/or prophylactic inferior vena cava filter may be considered when prophylactic anticoagulation is prohibited in patients with increased postoperative transfusion requirements or a PMH of either PE or renal insufficiency.

Research paper thumbnail of University Teaching Trauma Centers: Decreased Mortality but Increased Complications

Journal of Surgical Research

Research paper thumbnail of Utility of Thoracic Computed Tomography after Blunt Trauma: When is Chest Radiograph Enough?

American Surgeon, Oct 1, 2009

Research paper thumbnail of The Clinical Significance of Occult Thoracic Injury in Blunt Trauma Patients

American Surgeon, Oct 1, 2010

Increased use of thoracic CT (TCT) in diagnosis of blunt traumatic injury has identified many inj... more Increased use of thoracic CT (TCT) in diagnosis of blunt traumatic injury has identified many injuries previously undetected on screening chest x-ray (CXR), termed ''occult injury.'' The optimal management of occult rib fractures, pneumothoraces (PTX), hemothoraces (HTX), and pulmonary contusions is uncertain. Our objective was to determine the current management and clinical outcome of these occult blunt thoracic injuries. A retrospective review identified patients with blunt thoracic trauma who underwent both CXR and TCT over a 2-year period at a Level I urban trauma center. Patients with acute rib fractures, PTX, HTX, or pulmonary contusion on TCT were included. Patient groups analyzed included: 1) no injury (normal CXR, normal TCT, n 5 1337); 2) occult injury (normal CXR, abnormal TCT, n 5 205); and 3) overt injury (abnormal CXR, abnormal TCT, n 5 227). Patients with overt injury required significantly more mechanical ventilation and had greater mortality than either occult or no injury patients. Occult and no injury patients had similar ventilator needs and mortality, but occult injury patients remained hospitalized longer. No patient with isolated occult thoracic injury required intubation or tube thoracostomy. Occult injuries, diagnosed by TCT only, have minimal clinical consequences but attract increased hospital resources.

Research paper thumbnail of Standard Prophylactic Enoxaparin Dosing Leads to Inadequate Anti-Xa Levels and Increased Deep Venous Thrombosis Rates in Critically Ill Trauma and Surgical Patients

Journal of Trauma-injury Infection and Critical Care, Apr 1, 2010

Background: Deep venous thromboses (DVT) continue to cause significant morbidity in critically il... more Background: Deep venous thromboses (DVT) continue to cause significant morbidity in critically ill patients. Standard prophylaxis for high risk patients includes twice-daily dosing with 30 mg enoxaparin. Despite prophylaxis, DVT rates still exceed 10% to 15%. Anti-Xa levels are used to measure the activity of enoxaparin and 12-hour trough levels Յ0.1 IU/mL have been associated with higher rates of DVT in orthopedic patients. We hypothesized that low Anti-Xa levels would be found in critically ill trauma and surgical patients and that low levels would be associated with higher rates of DVT. Methods: All patients on the surgical intensive care unit (ICU) service were prospectively followed. In the absence of contraindications, patients were given prophylactic enoxaparin and anti-Xa levels were drawn after the third dose. Trough levels Յ0.1 IU/mL were considered low. Screening duplex exams were obtained within 48 hours of admission and then weekly. Patients were excluded if they did not receive a duplex, if they had a prior DVT, or if they lacked correctly timed anti-Xa levels. DVT rates and demographic data were compared between patients with low and normal anti-Xa levels. Results: Data were complete for 54 patients. Eighty-five percent suffered trauma (Injury Severity Score of 25 Ϯ 12) and 74% were male. Overall, 27 patients (50%) had low anti-Xa levels. Patients with low anti-Xa levels had significantly more DVTs than those with normal levels (37% vs. 11%, p ϭ 0.026), despite similar age, body mass index, Injury Severity Score, creatinine clearance, high risk injuries, and ICU/ventilator days. Conclusion: Standard dosing of enoxaparin leads to low anti-Xa levels in half of surgical ICU patients. Low levels are associated with a significant increase in the risk of DVT. These data support future studies using adjusted-dose enoxaparin.

Research paper thumbnail of Injury and Mortality Profiles in Level II and III Trauma Centers

The American Surgeon

Background While the benefit of admission to trauma centers compared to non-trauma centers is wel... more Background While the benefit of admission to trauma centers compared to non-trauma centers is well-documented and differences in outcomes between Level-I and Level-II trauma centers are well-studied, data on the differences in outcomes between Level-II trauma centers (L2TCs) and Level-III trauma centers (L3TCs) are scarce. Objectives We sought to compare mortality risk between patients admitted to L2TCs and L3TCs, hypothesizing no difference in mortality risk for patients treated at L3TCs compared to L2TCs. Methods A retrospective analysis of the 2016 Trauma Quality Improvement Program (TQIP) database was performed. Patients aged 18+ years were divided into 2 groups, those treated at American College of Surgeons (ACS) verified L2TCs and L3TCs. Results From 74,486 patients included in this study, 74,187 (99.6%) were treated at L2TCs and 299 (.4%) at L3TCs. Both groups had similar median injury severity scores (ISSs) (10 vs 10, P < .001); however, L2TCs had a higher mean ISS (14.6 ...

Research paper thumbnail of Brachial Plexus Injury Significantly Increases Risk of Axillosubclavian Vessel Injury in Blunt Trauma Patients With Clavicle Fractures

The American Surgeon

Background A national analysis of clavicle fractures is lacking and the risk of concomitant axill... more Background A national analysis of clavicle fractures is lacking and the risk of concomitant axillosubclavian vessel injury (ASVI) in patients with clavicle fractures is unknown. A minority of patients may have a combined brachial plexus injury (BPI). We sought to describe risk factors for concomitant ASVI in patients with a clavicle fracture; hypothesizing patients with combined clavicle fracture and BPI has a higher risk of ASVI. Methods The Trauma Quality Improvement Program (2010-2016) was queried for blunt trauma patients with a clavicle fracture. A multivariable logistic regression model was used to determine risk factors for ASVI. A subset analysis on patients with isolated clavicle fractures was additionally performed. Results From 59 198 patients with clavicle fractures, 341 (.6%) had concomitant ASVI. Compared to patients without ASVI, patients with ASVI had a higher median injury severity score (24 vs. 17, P < .001) and rates of pulmonary contusions (43.4% vs. 37.7%, P ...

Research paper thumbnail of Isolated Thoracic Injury Patients With Rib Fractures Undergoing Rib Fixation Have Improved Mortality

Journal of Surgical Research, 2021

BACKGROUND Despite a lack of consensus recommendations for surgical stabilization of rib fracture... more BACKGROUND Despite a lack of consensus recommendations for surgical stabilization of rib fractures (SSRF), SSRF has increased over the past decade. Outcomes of patients with isolated thoracic injuries undergoing SSRF are unknown. We hypothesized adult trauma patients with isolated thoracic injuries and rib fractures undergoing SSRF would have a decreased risk of mortality and in-hospital respiratory complications compared with those not undergoing SSRF. MATERIALS AND METHODS The Trauma Quality Improvement Program (2010-2016) was queried for patients presenting with a rib fracture. Patients who died in the emergency department or within 24-h, as well as those with a grade>1 for abbreviated injury scale of the head, face, neck, spine, abdomen, and extremities, were excluded. A multivariable logistic regression analysis was performed. RESULTS From 60,000 patients with isolated thoracic injuries and rib fractures, 688 (1.1%) underwent SSRF. Compared with patients without SSRF, those undergoing SSRF had a similar median age (P = 0.83) and higher injury severity score (P < 0.001). Patients undergoing SSRF had a longer length of stay (P < 0.001), higher rate of acute respiratory distress syndrome (P < 0.001), unplanned intubation (P < 0.001), and pneumonia (P < 0.001) but lower rate of mortality (0.9% versus 1.7%, P = 0.084). After adjusting for confounding variables, patients undergoing SSRF had a decreased associated risk of mortality (OR 0.40, P = 0.036) compared with those not undergoing SSRF. CONCLUSIONS The risk of mortality in trauma patients with isolated thoracic injuries and rib fractures is lower when undergoing SSRF despite being associated with a higher rate of respiratory complications during their increased length of stay.

Research paper thumbnail of No Difference in Morbidity or Mortality Between Octogenarians and Other Geriatric Burn Trauma Patients

The American Surgeon, 2021

Background Geriatric burn trauma patients (age ≥65 years) have a 5-fold higher mortality rate tha... more Background Geriatric burn trauma patients (age ≥65 years) have a 5-fold higher mortality rate than younger adults. With the population of the US aging, the number of elderly burn and trauma patients is expected to increase. A past study using the National Burn Repository revealed a linear increase in mortality for those >65 years old. We hypothesized that octogenarians with burn and trauma injuries would have a higher rate of in-hospital complications and mortality, than patients aged 65-79 years old. Methods The Trauma Quality Improvement Program (2010-2016) was queried for burn trauma patients. To detect mortality risk a multivariable logistic regression model was used. Results From 282 patients, there were 73 (25.9%) octogenarians and 209 (74.1%) aged 65-79 years old. The two cohorts had similar median injury severity scores (16 vs. 15 in octogenarians, P = .81), total body surface area burned ( P = .30), and comorbidities apart from an increased smoking (12.9% vs. 4.1%, P = ....

Research paper thumbnail of Race, Age, and Lack of Insurance Increase Risk of Suicide Attempt in Trauma Patients

Archives of Suicide Research, 2020

Objective: The overall rate of suicide between 1999 and 2017 increased by 33% in the United State... more Objective: The overall rate of suicide between 1999 and 2017 increased by 33% in the United States. We sought to examine suicide attempts in the trauma patient population, hypothesizing that in adult trauma patients race and lack of insurance status would be predictors of suicide attempt. Method: The Trauma Quality Improvement Program (2010-2016) was queried for trauma patients !18 years old. The primary outcome was suicide attempt. A multivariable logistic regression model was performed including covariates that influence risk of suicide attempt. Results: From 1,403,466 adult trauma admissions, 16,263 (1.2%) patients attempted suicide. Death after suicide attempt occurred in 30.2% of patients. Independent predictors of suicide attempt were age < 40 years old (odds ratio [OR] ¼ 1.46, 95% confidence interval [CI] [1.41, 1.51], p < .001) and no insurance (OR ¼ 1.92, 95% CI [1.85, 2.00], p < .001). Black (vs. White) race was associated with decreased risk of suicide attempt (OR ¼ 0.63, 95% CI [0.60, 0.67], p < .001). Hispanic (versus non-Hispanic) patients demonstrated lower associated risk of suicide attempt by gun (OR ¼ 0.50, 95% CI [0.45, 0.54], p < .001), while Asian (vs. White) patients exhibited higher risk of suicide attempt overall (OR ¼ 1.25, 95% CI [1.12, 1.39], p < .001) and more specifically by knife (OR ¼ 2.55, 95% CI [2.16, 3.00], p < .001). Conclusions: Age younger than 40 years and lack of insurance were associated with higher risk of suicide attempt in adult trauma patients. Asian race was associated with the highest risk of suicide, with >2.5 times increased risk of attempt by knife. Awareness of these demographic-specific risk factors for suicide attempt, and in particular violent mechanisms of suicide attempt, is critical to implementation of effective suicide prevention efforts. HIGHLIGHTS Age younger than 40 and no insurance were associated with risk of suicide attempt. Black (vs. White) race was associated with decreased risk of suicide attempt. Asian race was associated with an increased risk of suicide attempt with a knife.

Research paper thumbnail of Regional, Racial, and Mortality Disparities Associated With Neurosurgeon Staffing at Level I Trauma Centers

The American Surgeon, 2020

Background Traumatic brain injury (TBI) occurs in approximately 30% of trauma patients. Because n... more Background Traumatic brain injury (TBI) occurs in approximately 30% of trauma patients. Because neurosurgeons hold expertise in treating TBI, increased neurosurgical staffing may improve patient outcomes. We hypothesized that TBI patients treated at level I trauma centers (L1TCs) with ≥3 neurosurgeons have a decreased risk of mortality vs. those treated at L1TCs with <3 neurosurgeons. Methods The Trauma Quality Improvement Program database (2010-2016) was queried for patients ≥18 years with TBI. Patient characteristics and mortality were compared between ≥3 and <3 neurosurgeon-staffed L1TCs. A multivariable logistic regression analysis was used to identify risk factors associated with mortality. Results Traumatic brain injury occurred in 243 438 patients with 5188 (2%) presenting to L1TCs with <3 neurosurgeons and 238 250 (98%) to L1TCs with ≥3 neurosurgeons. Median injury severity score (ISS) was similar between both groups (17, P = .09). There were more Black (37% vs. 12%...

Research paper thumbnail of 1336: Blunt Trauma Massive Transfusion (B-MaT) Score: A Novel Scoring Tool

Critical Care Medicine, 2020

Research paper thumbnail of Evolving Utility of Endovascular Treatment of Juxtarenal, Pararenal, and Suprarenal Abdominal Aortic Aneurysms Associated With Increased Risk of Mortality Over Time

Annals of Vascular Surgery, 2020

Research paper thumbnail of Seatbelt Sign as an Indication for Four-vessel Computed Tomography Angiogram of the Neck to Diagnose Blunt Carotid Artery and Other Cervical Vascular Injuries

The American Surgeon, 2013

Computed tomography angiography (CTA) of the neck has become the most common modality for diagnos... more Computed tomography angiography (CTA) of the neck has become the most common modality for diagnosing blunt carotid artery injury (BCAI). The protocol at our institution includes CTA on trauma patients with a seatbelt sign. The purpose of this study is to evaluate whether a solitary seatbelt sign is an indication for CTA of the neck to diagnose BCAI. We conducted a retrospective review of patients from 2000 to 2010 who received CTAs as a result of a seatbelt sign performed at our Level I trauma center. Four hundred eighteen patients received CTAs based on the presence of a seatbelt sign. Two hundred twenty-six had skeletal injuries, obvious soft tissue injuries, and/or positive findings on imaging, including 11 positive vascular findings with two BCAIs found. Patients with noncarotid vascular injuries on CTA had a higher Injury Severity Score than patients with solitary seatbelt signs (11.4 ± 7.6 vs 3.4 ± 4.2, P < 0.01). The correlation between seatbelt sign and positive finding o...

Research paper thumbnail of Racial Disparities in Access and Outcomes of Cholecystectomy in the United States

The American Surgeon, 2016

Disparities in access to health care between white and minority patients are well described. We a... more Disparities in access to health care between white and minority patients are well described. We aimed to analyze the trends and outcomes of cholecystectomy based on racial classification. The Nationwide Inpatient Sample database was reviewed for all patients undergoing cholecystectomy from 2009 to 2012. Patients were stratified as white or non-white. A total of 243,536 patients were analyzed: 159,901 white and 83,635 non-white. Non-white patients had significantly higher proportions of Medicaid (25% vs 9.3%), self-pay (14% vs 7.1%), and no-charge (1.8% vs 0.64%). Non-white patients had significantly higher rates of emergent admission (84% vs 78%) compared with the white patients. Multivariate analysis revealed that non-whites had a significantly longer length of stay [mean difference of 0.14 days, 95% confidence interval (CI) 0.08–0.20] and higher total hospital charges (mean difference of $6748.00, 95% CI 5994.19–7501.81) than whites, despite a lower morbidity (odds ratio 0.94, 95%...

Research paper thumbnail of Analysis of blunt cerebrovascular injury in pediatric trauma

Journal of Trauma and Acute Care Surgery, 2019

BACKGROUND Blunt cerebrovascular injury (BCVI) occurs in <1% of pediatric patients. The two pr... more BACKGROUND Blunt cerebrovascular injury (BCVI) occurs in <1% of pediatric patients. The two principal screening criteria for BCVI in children are the Utah and McGovern Score with motor vehicle accident (MVA) considered to be a predictor for BCVI. We sought to confirm previously reported risk factors and identify novel associations with BCVI in pediatric patients. METHODS The Pediatric Trauma Quality Improvement Program (2014–2016) was queried for patients younger than 16 years presenting after blunt trauma. A multivariable logistic regression was used to determine risk of BCVI. RESULTS From 69,149 pediatric patients, 109 (<0.2%) had BCVI. The median age was 13 years, and the median Injury Severity Score was 25. More than half the patients were involved in MVAs (53.2%) and had a skull base fracture (53.2%). Factors independently associated with BCVI include skull base fracture (odds ratio [OR], 3.84; 95% confidence interval [CI], 2.40–6.14; p < 0.001), cervical spine fractur...

Research paper thumbnail of Increased risk of head injury in pediatric patients with attention deficit hyperactivity disorder

Journal of Child and Adolescent Psychiatric Nursing, 2019

ObjectiveThe prevalence of attention deficit hyperactivity disorder (ADHD) in the general pediatr... more ObjectiveThe prevalence of attention deficit hyperactivity disorder (ADHD) in the general pediatric population is 7%, whereas the prevalence in trauma is unknown. We hypothesized pediatric patients with ADHD would have a higher risk of involvement in a mechanism of injury (MOI) requiring constant attention to surroundings, such as a bicycle collision.MethodsThe Pediatric Trauma Quality Improvement Program (2014–2016) was queried for patients with ADHD. Patients, less than 16 years of age, with ADHD were compared to those without ADHD.ResultsThe prevalence of ADHD was 2.5% (2,866). ADHD patients had higher risk for bicycle collision (odds ratio [OR], 1.85; 95% confidence interval [CI], 1.59–2.15; p < .001). ADHD bicyclists were less likely to wear a helmet (9.4% vs. 18.2%, p = .003) and had a higher rate of traumatic brain injury (TBI; 55.6% vs. 39.7%, p < .001), compared to non‐ADHD bicyclists.ConclusionsPediatric ADHD patients have a 60% higher risk of being involved in a bic...

Research paper thumbnail of Non-accidental trauma increases length of stay and mortality in pediatric trauma

Pediatric Surgery International, 2019

Purpose More than half a million children experience non-accidental trauma (NAT) annually. Histor... more Purpose More than half a million children experience non-accidental trauma (NAT) annually. Historically, NAT has been associated with an increased hospital length of stay (LOS). We hypothesized that in pediatric trauma patients, NAT is associated with longer hospital LOS, independent of injury severity, compared to accidental trauma (AT). Methods The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients aged 1-16 years. Patients were stratified into two groups: AT and NAT. The median LOS for the entire cohort was identified and used in a multivariable logistic regression analysis. Results From 93,089 pediatric trauma patients, 417 (< 0.1%) were involved in NAT. Patients with NAT had a lower median age (3 vs. 9 years, p < 0.001) and higher median injury severity score (10 vs. 5, p < 0.001), compared to patients with AT. After controlling for covariates, patients with NAT were associated with a longer hospital LOS (≥ 2 days), compared to those with AT (OR = 4.99 CI = 3.55-7.01, p < 0.001). In comparison to AT, NAT was also associated with a higher mortality rate (10.3% vs. 0.8%, p < 0.001). Conclusion Pediatric patients presenting after NAT have a prolonged hospital and ICU LOS, even after adjusting for injury severity. Furthermore, pediatric victims of NAT had a higher mortality rate compared to those presenting after AT.