January 2023 - Trauma
January 2023
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This issue was prepared by EAST Equity, Diversity and Inclusion in Trauma Surgery Practice Committee Member Jessica L. Weaver, MD, PhD, FACS.
Thank you to Haemonetics for supporting the EAST Monthly Literature Review.
In This Issue: Trauma
Scroll down to see summaries of these articles
Article 1 reviewed by Jessica L. Weaver, MD, PhD, FACS
Hyperglycemia in nondiabetic adult trauma patients is associated with worse outcomes than diabetic patients: An analysis of 95,764 patients. Fakhry SM, Morse JL, Wilson NY, Waswick WA, Garland JM, Chipko JM, Wyse RJ, Elkbuli A, Dunne J, Litow KJ, Duane TM, Fisher C, Shillinglaw WC, Banton KL, Biswas S, Plurad D, Watts DD. J Trauma Acute Care Surg. 2022 Sep 1;93(3):316-322.
Article 2 reviewed by Jessica L. Weaver, MD, PhD, FACS
Validating the Brain Injury Guidelines: Results of an American Association for the Surgery of Trauma prospective multi-institutional trial. Joseph B, Obaid O, Dultz L, Black G, Campbell M, Berndtson AE, Costantini T, Kerwin A, Skarupa D, Burruss S, Delgado L, Gomez M, Mederos DR, Winfield R, Cullinane D; AAST BIG Multi-Institutional Study Group. J Trauma Acute Care Surg. 2022 Aug 1;93(2):157-165.
| Article 1 Hyperglycemia in nondiabetic adult trauma patients is associated with worse outcomes than diabetic patients: An analysis of 95,764 patients. Fakhry SM, Morse JL, Wilson NY, Waswick WA, Garland JM, Chipko JM, Wyse RJ, Elkbuli A, Dunne J, Litow KJ, Duane TM, Fisher C, Shillinglaw WC, Banton KL, Biswas S, Plurad D, Watts DD. J Trauma Acute Care Surg. 2022 Sep 1;93(3):316-322. Transient hyperglycemia is a normal response in trauma patients, but when it persists, this can lead to vascular and immune deficiency. While numerous studies have examined the importance of glucose control in diabetic patients, this study evaluates the effects of hyperglycemia in non-diabetic trauma patients. This retrospective chart review of patients from 46 trauma centers defined patients as “diabetic” if they had a listed diagnosis of diabetes or a hemoglobin A1c greater than 6.5% during the admission, and all other patients were considered “non-diabetic.” Hyperglycemia was defined as a glucose measurement greater than 180 mg/dL at any time during the hospitalization. 95,764 patients were included in the study. Hyperglycemic non-diabetics (HND) were more likely to be white, male, and have a higher BMI. HND patients had a significantly higher mortality (14.6%) compared with all other groups, including hyperglycemic diabetics (3.9%), non-hyperglycemic diabetics (1.6%), and non-hyperglycemic non-diabetics (1.1%). They also had higher rates of sepsis, increased surgical site infections, and longer ICU and hospital stays. This study of almost 100,000 patients offers compelling evidence that hyperglycemia is associated with increased mortality in non-diabetic trauma patients. Unfortunately, this retrospective study cannot determine whether the hyperglycemia is a cause of the increased mortality, or merely a marker of injury severity. However, the fact that the increased morbidity and mortality remained despite adjusting for ISS, age, sex, or BMI suggests that these findings are significant. Prospective data collection will be necessary to determine whether treatment of this hyperglycemia can improve outcomes in trauma patients. Article 2 Validating the Brain Injury Guidelines: Results of an American Association for the Surgery of Trauma prospective multi-institutional trial. Joseph B, Obaid O, Dultz L, Black G, Campbell M, Berndtson AE, Costantini T, Kerwin A, Skarupa D, Burruss S, Delgado L, Gomez M, Mederos DR, Winfield R, Cullinane D; AAST BIG Multi-Institutional Study Group. J Trauma Acute Care Surg. 2022 Aug 1;93(2):157-165. Treatment for traumatic brain injury (TBI) frequently uses significant resources, including imaging, ICU admission, and neurosurgical consultation. Increasing quality and availability of imaging can lead to diagnosis of very small intracranial hemorrhages, and reflexive use of all these options for every TBI patient can consume a vast amount of time and resources. The Brain Injury Guidelines (BIG) were developed based on retrospective data to standardize management of TBI patients. The purpose of this study was to prospectively validate the application of the BIG. Patients were enrolled if they were over 15 and presented to one of 10 enrolled level 1 and 2 trauma centers between January 2018 and December 2020 with a TBI and positive head CT. Patients were divided into BIG 1, 2, and 3 categories. BIG 1 patients had isolated hemorrhages ≤4mm, a normal exam, and no anticoagulation, and their recommended treatment was 6 hours of observation in the emergency room without repeat head CT (RHCT) or neurosurgical consultation. BIG 2 patients had 5-7mm hemorrhages and could have loss of consciousness and/or be intoxicated, and their recommended treatment was hospital admission for 24 hours without RHCT or neurosurgical consultation. Patients with larger or more numerous hemorrhages, or an abnormal exam, were categorized as BIG 3 and they received hospital admission, repeat head CT, and neurosurgical consultation. A total of 2,033 patients were included in the final analysis. Only 1.3% of BIG 1 patients had progression of hemorrhage on RHCT and none required neurosurgical intervention. Of BIG 2 patients, 7.1% had progression on RHCT, 0.7% had clinical deterioration, and none required neurosurgical intervention. Of BIG 3 patients, 21.6% had progression on RHCT and 16.0% and clinical deterioration. All patients that received neurosurgical intervention, such as surgery or intracranial monitor placement, were categorized as BIG 3. If the BIG had been followed, 425 RHCTs, 401 prolonged hospitalizations, and 511 neurosurgical consultations would have been avoided. The strengths of this study include its prospective nature and the large patient cohort. One limitation of the study is that it is limited to level 1 and 2 trauma centers, which have access to neurosurgical services at all times. The implications of this study for smaller hospitals and non-trauma centers could be significant, as following these guidelines could also save the resources associated with transferring patients with small, low-risk intracranial hemorrhages solely due to the lack of neurosurgical capabilities at the smaller hospital, as neurosurgical consultation would no longer be recommended. However, this situation is not directly addressed by the current study. Other limitations of the study include a lack of long-term outcomes data and its observational, non-interventional nature. Despite these limitations, the study provides compelling data to support more patient-focused and less routine treatment strategies for treating patients with mild brain injuries. |