A Leg to Stand on: Trauma Center Designation and Association with Rate of Limb Salvage in Patients Suffering Severe Lower Extremity Injury. Bunn C, Kulshrestha S, Di Chiaro B, Maduekwe U, Abdelsattar ZM, Baker MS, Luchette FA, Agnew S. J Am Coll Surg. 2021 Jul;233(1):120-129.
Management of a mangled extremity is complex and influenced by a multitude of factors. Despite the existence of mangled extremity scores to guide decision making, the decision to perform a reconstruction versus primary amputation remains controversial and varies by center. This study aimed to determine whether salvage rates for limb-threatening lower extremity injuries varied by trauma center designation. The Trauma Quality Improvement Program (TQIP) database was queried for all adult patients with limb-threatening lower extremity injury, defined as an open, displaced tibia/fibula fracture with concurrent popliteal, tibial and/or peroneal artery injury (2007-2017). Individuals were grouped by whether they had limb salvage (LS) or primary amputation at their index admission. Multivariate and 1:1 nearest neighbor propensity matching was performed using demographic and clinical variables, including teaching status, transfer status and presence of concurrent deep vein and/or motor nerve injury.
Out of 8 million records, 2,035 had limb-threatening injury and 712 fit the inclusion criteria (LS=391, amputation=321). On univariate analysis, there were no differences between groups in clinical characteristics including body region AIS or presence of concurrent motor nerve injury, deep vein injury, or soft-tissue defect. However, those with penetrating injury, treated at a Level I center, and with tibial/peroneal artery over popliteal artery injury had higher rates of LS. On multivariable analysis, individuals treated at a Level I center and with tibial and/or peroneal artery injury over popliteal artery injury were significantly more likely to get LS. Patients at a Level I center had a 3x higher odds of getting LS. Propensity matched analysis demonstrated patients treated at Level I centers had significantly higher rates of LS (53% v 34.8%, p=0.004). A time-based analysis during the entire study period found that differences in LS to amputation rates between Level I and Level II centers diverged in the past 5 years, with more LS being conducted at Level I centers. The limitations of this study include the challenges of extrapolating data from a large database using ICD9 and ICD10 codes. The authors conclude that despite ACS COT criteria designating Level I and II centers as having equivalent resources to provide care for mangled extremities, disparities in management continue to exist.
Not so FAST—Chest Ultrasound Underdiagnoses Traumatic Pneumothorax. Santorelli JE, Chau H, Godat L, Casola G, Doucet JJ, Costantini TW. J Trauma Acute Care Surg. 2022 Jan 1;92(1):44-48.
Traumatic pneumothorax can be a life-threatening condition that requires prompt diagnosis and treatment. Traditionally, chest x-ray has been the primary diagnostic tool to detect pneumothorax, but trauma centers are increasingly relying on ultrasound as a diagnostic modality. Small studies have indicated that ultrasound may be better at detecting pneumothorax than chest x-ray. This study is a retrospective, single-center evaluation of all patients with pneumothorax from 2018-2020 at a Level I trauma center. The authors hypothesized that Complete Ultrasonography of Trauma (CUST) would be superior to CXR in detecting pneumothorax. At this institution, all ultrasounds are performed by trained sonographers and the thoracic views include four views in each hemithorax (two anterior views and two lateral views). These images are entered into PACS and reviewed by an attending radiologist in real time.
The authors reviewed the electronic health record as well as all available imaging studies (CXR, ultrasound, CT C-spine and Chest CT). Patients who did not get CUST, or who had a tube thoracostomy before CUST were excluded. 362 out of 568 patients with pneumothorax as a diagnosis had a CXR, CUST and confirmatory CT and were in the final study population. CUST had a sensitivity of 35% and false-negative rate of 65%; CXR had a sensitivity of 43% and false-negative rate of 57%. After removal of 191 patients with occult PTX, sensitivity of CUST was 65% and false negative rate was 36% compared to CXR sensitivity of 78% and false-negative rate of 22% (p<0.01). 31 patients (50%) with false-negative CUST underwent tube thoracostomy placement, 85% of which were performed within 8 hours of admission. Aside from younger age, there were no differences between those with false negative and true positive CUST. It must be noted that since only patients with diagnosis of pneumothorax were included, specificity or false positive rates could not be calculated. The limitations of this study stem from its retrospective design. The authors conclude by cautioning against the use of ultrasound as a sole modality to diagnose traumatic pneumothorax.