J Trauma Acute Care Surg Volume 76, Number 5
Letters to the Editor
emergency department codes into one code. This proposal, given the highly complex nature of trauma care relative to emergency department services generally, would disproportionately impair trauma centers’ ability to provide an appropriate level of care to patients with traumatic injury and would significantly impact trauma centers financially. The challenges facing trauma centers, physicians, nurses, and the entire trauma team are profound. Federal funding and an adequate reimbursement are necessary to ensure access to lifesaving trauma care for all Americans. *The author declares no conflict of interest.
Blaine L. Enderson, MD Division of Trauma and Critical Care University of Tennessee Knoxville, TN
REFERENCE 1. Khoury AL, Charles AG, Sheldon GF, et al. The trauma safety-net hospital under the Affordable Care Act: will it survive? J Trauma Acute Care Surg. 2013;75(3):512Y5.
Nonoperative management of splenic trauma should be approached with caution in the setting of traumatic brain injury To the Editor: e read with great interest the recent publication by Teixeira et al.1 The current article describes a retrospective study performed on a cohort extracted from the National Trauma Data Bank. The authors sought to characterize the mortality outcome of splenectomy in patients with concomitant traumatic brain injury (TBI). Patients with moderate-to-severe blunt head injury and those with splenic injury were included in the study. Careful scrutiny of the cohort characteristics reveals important differences between the two populations1 (Tables 1 and 2). Those that underwent splenectomy were more likely to be hemodynamically unstable on arrival. Absence of a base deficit from the analysis limits the reader’s ability to appreciate the degree and persistence of hypotension as well as estimated mortality. Moreover, those who underwent splenectomy were more likely to have concomitant severe lifethreatening intra-abdominal injuries.
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1334
In the unadjusted outcome measures, patients with severe TBI seemed to fair better when nonoperative splenic management (NOM) was pursued (16.9% vs. 10.1% mortality, p G 0.001). Given the previously discussed cohort differences, the observed increased risk of death in the splenectomy group with severe TBI is not unanticipated. Furthermore, despite the purported mortality benefit, hospital and intensive care unit (ICU) lengths of stay as well as ventilator days seemed to be negatively corelated with NOM. Although the adjusted outcome measures seem to support a mortality benefit in both the moderate and severe TBI group when NOM was elected (odds ratio, 2.43 and 1.49; p = 0.008 and p = 0.036 respectively), different logistic regression models were used to reach these conclusions. It is unclear why different models should be used to investigate subgroups within each arm. Unchanged is the apparent negative correlation with hospital and ICU lengths of stay as well as ventilator days. Of particular interest in the present study given the inability to readily interpret the increased mortality rate in the splenectomy group is the neurologic outcome of patients in these two groups. In a recent systematic review of the literature, Injury Severity Score (ISS) greater than 25 and splenic injury grade of 3 or higher were associated with failure of NOM.2 It is reasonable to hypothesize that this subpopulation of critically injured patients will exhibit increased hemodynamic instability and need for blood transfusion. Recent studies investigating the role of intermittent hypotension and blood transfusion in those with isolated TBI have demonstrated an increased morbidity and mortality.3,4 Together, these data suggest that the very population proposed to have a decreased mortality rate may in fact have a poorer neurologic outcome. Limitations of the National Trauma Data Bank preclude further investigation needed to determine if the increased hospital or ICU lengths of stay are reflective of this possibility. Finally, several groups have found that TBI may independently predict the failure of NOM,5 further complicating interpretation of the results put forth by Teixeira et al.1 In summary, given the significant differences between the two study arms, we question the validity of the authors’ conclusion that ‘‘splenectomy was independently associated with increased mortality in patients with moderate or severe TBI.’’ Furthermore, the neurologic outcome in these survivors remains unknown. While the current findings are provocative, further study is needed to clarify the impact of the interdependent variables of hemodynamics, injury severity, as well as splenic injury and TBI. Given the preponderance of evidence, the routine implementation of aggressive attempts of splenic preservation with concomitant TBI
should be deferred until additional investigation is undertaken. *The authors declare no conflicts of interest.
Joseph S. Hanna, MD, PhD Vicente H. Gracias, MD Division of Acute Care Surgery Department of Surgery Rutgers-Robert Wood Johnson Medical School New Brunswick, NJ
REFERENCES 1. Teixeira PG, Karamanos E, Okoye OT, et al. Splenectomy in patients with raumatic brain injury: protective or harmful? A National Trauma Data Bank analysis. J Trauma Acute Care Surg. 2013;75:596Y601. 2. Olthof DC, Joosse P, van der Vlies CH, et al. Prognostic factors for failure of nonoperative management in adults with blunt splenic injury: a systematic review. J Trauma Acute Care Surg. 2013;74:546Y557. 3. Brenner M, Stein DM, Hu PF, et al. Traditional systolic blood pressure targets underestimate hypotension-induced secondary brain injury. J Trauma Acute Care Surg. 2012;72:1135Y1139. 4. Elterman J, Brasel K, Brown S, et al. Transfusion of red blood cells in patients with a prehospital Glasgow Coma Scale score of 8 or less and no evidence of shock is associated with worse outcomes. J. Trauma Acute Care Surg. 2013;75:8Y14; discussion 14. 5. Velmahos GC, Zacharias N, Emhoff TA, et al. Management of the most severely injured spleen: a multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT). Arch Surg. 2010;145: 456Y460.
Spinal cord injury without radiologic abnormality in children imaged with magnetic resonance imaging To the Editor: e congratulate Dr. Mahajan and colleagues on their article comparing the clinical characteristics and outcomes of children with spinal cord injury without radiologic abnormality (SCIWORA) relative to the presence or absence of abnormalities on magnetic resonance imaging (MRI).1 In this retrospective multicenter study, 69 children presenting with a clinicoradiologic mismatch and treated at 17 contributing emergency departments in the United States were analyzed. One of the key findings is the predominance of normal MRI scan findings in
W
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Trauma Acute Care Surg Volume 76, Number 5
children with SCIWORA (78% normal vs. 22% abnormal). Interestingly, this is in stark contrast to the ratio between normal (7.1%) and abnormal (92.9%) MRI findings in adults, as shown by our recent systematic review.2 The correlation of neurologic outcome and imaging findings revealed a significantly better prognosis for children without MRI abnormalities compared with patients with abnormal findings, mirroring the findings in adults. The strength of the current report is the large number of children with cervical spine injuries and the availability of MRI data in 55% of the cases. Furthermore, clear inclusion and exclusion criteria were applied. While the highest level of spinal cord injury is given, the major limitation of the article is the lack of a detailed description of the detected MRI abnormalities or the application of a conclusive MRI classification system. Furthermore, there is no information regarding the follow-up time and the clinical course of individual patients with respect to their specific MRI findings and treatment. Finally, the description of neurologic impairment lacks a standardized classification system, further limiting the comparability of the data. In their discussion, the authors suggest a standardization of the taxonomy of spinal cord injuries and underline the disadvantages of using multiple diagnostic terms for SCIWORA and SCIWORA-like conditions. They recommend ‘‘Ithat the term SCIWORA be restricted to those patients with evidence of neurologic deficits attributable to the cervical spinal cord and who have normal cervical spine imaging results including MRI.’’ We do agree with Mahajan et al. on the need for a simplified and standardized nomenclature for patients with a clinico-radiological mismatch and without controversy, SCIWORA is excluded by the detection of fractures and dislocations on plain radiographs or computed tomography. However, we do not agree on the notion that any MRI abnormality should be recognized as an exclusion criterion for the diagnosis of SCIWORA per se. We are rather convinced that the meticulous analysis and description of the intraneural3 and extraneural2 MRI findings will eventually improve our understanding of the condition. Taken together, we believe that the presentation of the epidemiologic and clinical characteristics of one of the largest cohorts of children with SCIWORA and available MRI data is an important contribution to the field; however we strongly recommend the detailed description of MRI findings and the application of a MRI classification system for future studies. *The authors declare no conflicts of interest.
Letters to the Editor
Christoph Kolja Boese, MD Department of Orthopaedic and Trauma Surgery University Hospital of Cologne Cologne, Germany
Philipp Lechler, MD Department of Trauma, Hand and Reconstructive Surgery University of Giessen and Marburg Marburg, Germany
REFERENCES 1. Mahajan P, Jaffe DM, Olsen CS, et al. Spinal cord injury without radiologic abnormality in children imaged with magnetic resonance imaging. J Trauma Acute Care Surg. 2013; 75:843Y847. 2. Boese CK, Lechler P. Spinal cord injury without radiologic abnormalities in adults: a systematic review. J Trauma Acute Care Surg. 2013;75: 320Y330. 3. Ramo´n S, Domı´nguez R, Ramı´rez L, et al. Clinical and magnetic resonance imaging correlation in acute spinal cord injury. Spinal Cord. 1997;35(10):664Y673.
Driving intoxicated: Is hospital admission protective against legal ramifications? To the Editor: he problem of intoxicated driving is significant; however, progress has been made. Cheek et al.1 are commended for providing warning as to how the hospital may serve as a sanctuary for the intoxicated injured driver from the ‘‘long arm of the law.’’ By retrospectively examining records, they found that only 18% of intoxicated drivers (Blood Alcohol Level Q 0.08 g/dL) received a charge of driving while intoxicated (DWI). The authors state that ‘‘deterrents that prevent law enforcement agencies from being able to obtain evidence needed for prosecution should be eliminated. Health care providers and law enforcement agencies should work as a team to help mitigate the incidence of drunk driving and its burden on society.’’ In this argument for the prosecution of drunk drivers, the authors state that the ‘‘rate limiting step’’ is the law that ‘‘the police have to be present while the nurses draw blood at the hospital to keep the chain of evidence intact.’’ However, the liberties that we, as American citizens, enjoy are due to such pestering ‘‘rate limiting steps.’’ Procedural protocol should not be taken so lightly. The authors claim that more widespread mandatory reporting could help with the
conviction rate of these patients and, in turn, reduce the recidivism rate. Their own data do not support this statement. The group charged with a DWI or related crime had 12.5% subsequent DWI rate, while the group not charged with a DWI had a 1% subsequent DWI during the study period. Let us also remember that DWI may have negative effects on the patient and society, such as loss of a job, increased government cost, and even foster care for the children of an incarcerated parent. A scientific discourse needs to balance these harms with the benefits of a charge of DWI. In summary, our responsibility to the patient is to be their physician, not to act as an adjunct to law enforcement. Our focus should be on providing optimal trauma care, first and foremost; consequently, at times, that may mean limiting law enforcement access to the patient to provide necessary lifesaving procedures. Our mandate is simple: take the best possible care of the trauma patient within the legislative exigencies mandated to us. To do more is a slippery slope for trauma surgeons, and it invites a conflict of interest in our relationship with our patients. *The authors declare no conflicts of interest.
Mathew Edavettal, MD, PhD Frederick Rogers, MD, MS Katelyn Rittenhouse, BS Trauma Service Lancaster General Health Lancaster, PA
T
REFERENCE 1. Cheek SM, Murry JS, Truit MS, et al. Driving intoxicated: is hospital admission protective against legal ramifications? J Trauma Acute Care Surg. 2013;75(6):1081Y1084.
Re: Driving intoxicated: Is hospital admission protective against legal ramifications? In Reply: e would like to thank Dr. Edavettal for his thoughts on the issue of drunk driving as it relates to patients at trauma centers. While we agree with the points that he has made, we feel that drunk driving is a societal problem. As health care providers,
W
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1335
Letters to the Editor
emergency department codes into one code. This proposal, given the highly complex nature of trauma care relative to emergency department services generally, would disproportionately impair trauma centers’ ability to provide an appropriate level of care to patients with traumatic injury and would significantly impact trauma centers financially. The challenges facing trauma centers, physicians, nurses, and the entire trauma team are profound. Federal funding and an adequate reimbursement are necessary to ensure access to lifesaving trauma care for all Americans. *The author declares no conflict of interest.
Blaine L. Enderson, MD Division of Trauma and Critical Care University of Tennessee Knoxville, TN
REFERENCE 1. Khoury AL, Charles AG, Sheldon GF, et al. The trauma safety-net hospital under the Affordable Care Act: will it survive? J Trauma Acute Care Surg. 2013;75(3):512Y5.
Nonoperative management of splenic trauma should be approached with caution in the setting of traumatic brain injury To the Editor: e read with great interest the recent publication by Teixeira et al.1 The current article describes a retrospective study performed on a cohort extracted from the National Trauma Data Bank. The authors sought to characterize the mortality outcome of splenectomy in patients with concomitant traumatic brain injury (TBI). Patients with moderate-to-severe blunt head injury and those with splenic injury were included in the study. Careful scrutiny of the cohort characteristics reveals important differences between the two populations1 (Tables 1 and 2). Those that underwent splenectomy were more likely to be hemodynamically unstable on arrival. Absence of a base deficit from the analysis limits the reader’s ability to appreciate the degree and persistence of hypotension as well as estimated mortality. Moreover, those who underwent splenectomy were more likely to have concomitant severe lifethreatening intra-abdominal injuries.
W
1334
In the unadjusted outcome measures, patients with severe TBI seemed to fair better when nonoperative splenic management (NOM) was pursued (16.9% vs. 10.1% mortality, p G 0.001). Given the previously discussed cohort differences, the observed increased risk of death in the splenectomy group with severe TBI is not unanticipated. Furthermore, despite the purported mortality benefit, hospital and intensive care unit (ICU) lengths of stay as well as ventilator days seemed to be negatively corelated with NOM. Although the adjusted outcome measures seem to support a mortality benefit in both the moderate and severe TBI group when NOM was elected (odds ratio, 2.43 and 1.49; p = 0.008 and p = 0.036 respectively), different logistic regression models were used to reach these conclusions. It is unclear why different models should be used to investigate subgroups within each arm. Unchanged is the apparent negative correlation with hospital and ICU lengths of stay as well as ventilator days. Of particular interest in the present study given the inability to readily interpret the increased mortality rate in the splenectomy group is the neurologic outcome of patients in these two groups. In a recent systematic review of the literature, Injury Severity Score (ISS) greater than 25 and splenic injury grade of 3 or higher were associated with failure of NOM.2 It is reasonable to hypothesize that this subpopulation of critically injured patients will exhibit increased hemodynamic instability and need for blood transfusion. Recent studies investigating the role of intermittent hypotension and blood transfusion in those with isolated TBI have demonstrated an increased morbidity and mortality.3,4 Together, these data suggest that the very population proposed to have a decreased mortality rate may in fact have a poorer neurologic outcome. Limitations of the National Trauma Data Bank preclude further investigation needed to determine if the increased hospital or ICU lengths of stay are reflective of this possibility. Finally, several groups have found that TBI may independently predict the failure of NOM,5 further complicating interpretation of the results put forth by Teixeira et al.1 In summary, given the significant differences between the two study arms, we question the validity of the authors’ conclusion that ‘‘splenectomy was independently associated with increased mortality in patients with moderate or severe TBI.’’ Furthermore, the neurologic outcome in these survivors remains unknown. While the current findings are provocative, further study is needed to clarify the impact of the interdependent variables of hemodynamics, injury severity, as well as splenic injury and TBI. Given the preponderance of evidence, the routine implementation of aggressive attempts of splenic preservation with concomitant TBI
should be deferred until additional investigation is undertaken. *The authors declare no conflicts of interest.
Joseph S. Hanna, MD, PhD Vicente H. Gracias, MD Division of Acute Care Surgery Department of Surgery Rutgers-Robert Wood Johnson Medical School New Brunswick, NJ
REFERENCES 1. Teixeira PG, Karamanos E, Okoye OT, et al. Splenectomy in patients with raumatic brain injury: protective or harmful? A National Trauma Data Bank analysis. J Trauma Acute Care Surg. 2013;75:596Y601. 2. Olthof DC, Joosse P, van der Vlies CH, et al. Prognostic factors for failure of nonoperative management in adults with blunt splenic injury: a systematic review. J Trauma Acute Care Surg. 2013;74:546Y557. 3. Brenner M, Stein DM, Hu PF, et al. Traditional systolic blood pressure targets underestimate hypotension-induced secondary brain injury. J Trauma Acute Care Surg. 2012;72:1135Y1139. 4. Elterman J, Brasel K, Brown S, et al. Transfusion of red blood cells in patients with a prehospital Glasgow Coma Scale score of 8 or less and no evidence of shock is associated with worse outcomes. J. Trauma Acute Care Surg. 2013;75:8Y14; discussion 14. 5. Velmahos GC, Zacharias N, Emhoff TA, et al. Management of the most severely injured spleen: a multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT). Arch Surg. 2010;145: 456Y460.
Spinal cord injury without radiologic abnormality in children imaged with magnetic resonance imaging To the Editor: e congratulate Dr. Mahajan and colleagues on their article comparing the clinical characteristics and outcomes of children with spinal cord injury without radiologic abnormality (SCIWORA) relative to the presence or absence of abnormalities on magnetic resonance imaging (MRI).1 In this retrospective multicenter study, 69 children presenting with a clinicoradiologic mismatch and treated at 17 contributing emergency departments in the United States were analyzed. One of the key findings is the predominance of normal MRI scan findings in
W
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Trauma Acute Care Surg Volume 76, Number 5
children with SCIWORA (78% normal vs. 22% abnormal). Interestingly, this is in stark contrast to the ratio between normal (7.1%) and abnormal (92.9%) MRI findings in adults, as shown by our recent systematic review.2 The correlation of neurologic outcome and imaging findings revealed a significantly better prognosis for children without MRI abnormalities compared with patients with abnormal findings, mirroring the findings in adults. The strength of the current report is the large number of children with cervical spine injuries and the availability of MRI data in 55% of the cases. Furthermore, clear inclusion and exclusion criteria were applied. While the highest level of spinal cord injury is given, the major limitation of the article is the lack of a detailed description of the detected MRI abnormalities or the application of a conclusive MRI classification system. Furthermore, there is no information regarding the follow-up time and the clinical course of individual patients with respect to their specific MRI findings and treatment. Finally, the description of neurologic impairment lacks a standardized classification system, further limiting the comparability of the data. In their discussion, the authors suggest a standardization of the taxonomy of spinal cord injuries and underline the disadvantages of using multiple diagnostic terms for SCIWORA and SCIWORA-like conditions. They recommend ‘‘Ithat the term SCIWORA be restricted to those patients with evidence of neurologic deficits attributable to the cervical spinal cord and who have normal cervical spine imaging results including MRI.’’ We do agree with Mahajan et al. on the need for a simplified and standardized nomenclature for patients with a clinico-radiological mismatch and without controversy, SCIWORA is excluded by the detection of fractures and dislocations on plain radiographs or computed tomography. However, we do not agree on the notion that any MRI abnormality should be recognized as an exclusion criterion for the diagnosis of SCIWORA per se. We are rather convinced that the meticulous analysis and description of the intraneural3 and extraneural2 MRI findings will eventually improve our understanding of the condition. Taken together, we believe that the presentation of the epidemiologic and clinical characteristics of one of the largest cohorts of children with SCIWORA and available MRI data is an important contribution to the field; however we strongly recommend the detailed description of MRI findings and the application of a MRI classification system for future studies. *The authors declare no conflicts of interest.
Letters to the Editor
Christoph Kolja Boese, MD Department of Orthopaedic and Trauma Surgery University Hospital of Cologne Cologne, Germany
Philipp Lechler, MD Department of Trauma, Hand and Reconstructive Surgery University of Giessen and Marburg Marburg, Germany
REFERENCES 1. Mahajan P, Jaffe DM, Olsen CS, et al. Spinal cord injury without radiologic abnormality in children imaged with magnetic resonance imaging. J Trauma Acute Care Surg. 2013; 75:843Y847. 2. Boese CK, Lechler P. Spinal cord injury without radiologic abnormalities in adults: a systematic review. J Trauma Acute Care Surg. 2013;75: 320Y330. 3. Ramo´n S, Domı´nguez R, Ramı´rez L, et al. Clinical and magnetic resonance imaging correlation in acute spinal cord injury. Spinal Cord. 1997;35(10):664Y673.
Driving intoxicated: Is hospital admission protective against legal ramifications? To the Editor: he problem of intoxicated driving is significant; however, progress has been made. Cheek et al.1 are commended for providing warning as to how the hospital may serve as a sanctuary for the intoxicated injured driver from the ‘‘long arm of the law.’’ By retrospectively examining records, they found that only 18% of intoxicated drivers (Blood Alcohol Level Q 0.08 g/dL) received a charge of driving while intoxicated (DWI). The authors state that ‘‘deterrents that prevent law enforcement agencies from being able to obtain evidence needed for prosecution should be eliminated. Health care providers and law enforcement agencies should work as a team to help mitigate the incidence of drunk driving and its burden on society.’’ In this argument for the prosecution of drunk drivers, the authors state that the ‘‘rate limiting step’’ is the law that ‘‘the police have to be present while the nurses draw blood at the hospital to keep the chain of evidence intact.’’ However, the liberties that we, as American citizens, enjoy are due to such pestering ‘‘rate limiting steps.’’ Procedural protocol should not be taken so lightly. The authors claim that more widespread mandatory reporting could help with the
conviction rate of these patients and, in turn, reduce the recidivism rate. Their own data do not support this statement. The group charged with a DWI or related crime had 12.5% subsequent DWI rate, while the group not charged with a DWI had a 1% subsequent DWI during the study period. Let us also remember that DWI may have negative effects on the patient and society, such as loss of a job, increased government cost, and even foster care for the children of an incarcerated parent. A scientific discourse needs to balance these harms with the benefits of a charge of DWI. In summary, our responsibility to the patient is to be their physician, not to act as an adjunct to law enforcement. Our focus should be on providing optimal trauma care, first and foremost; consequently, at times, that may mean limiting law enforcement access to the patient to provide necessary lifesaving procedures. Our mandate is simple: take the best possible care of the trauma patient within the legislative exigencies mandated to us. To do more is a slippery slope for trauma surgeons, and it invites a conflict of interest in our relationship with our patients. *The authors declare no conflicts of interest.
Mathew Edavettal, MD, PhD Frederick Rogers, MD, MS Katelyn Rittenhouse, BS Trauma Service Lancaster General Health Lancaster, PA
T
REFERENCE 1. Cheek SM, Murry JS, Truit MS, et al. Driving intoxicated: is hospital admission protective against legal ramifications? J Trauma Acute Care Surg. 2013;75(6):1081Y1084.
Re: Driving intoxicated: Is hospital admission protective against legal ramifications? In Reply: e would like to thank Dr. Edavettal for his thoughts on the issue of drunk driving as it relates to patients at trauma centers. While we agree with the points that he has made, we feel that drunk driving is a societal problem. As health care providers,
W
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1335
