Session 4 Poster # 1 POST-OPERATIVE NEUROMUSCULAR BLOCKER USE IS ASSOCIATED WITH HIGHER PRIMARY FASCIAL CLOSURE RATES FOLLOWING DAMAGE CONTROL LAPAROTOMY Chadi T Abouassaly, MD, William D Dutton, MD, Victor Zaydfudim, MD, MPH, Lesly A Dossett, MD, MPH, Timothy C Nunez, MD, Sloan B Fleming, PharmD, Bryan A Cotton,* MD, MPH. Vanderbilt University. Background: Failure to achieve fascial primary closure following damage control laparotomy (DCL) is associated with increased morbidity, higher health care expenditures, and a reduction in quality of life. The use of neuromuscular blockers (NMB) to facilitate closure remains controversial and poorly studied. The purpose of this study was to determine if exposure to NMB is associated a higher likelihood of primary fascial closure. Methods: All adult trauma patients admitted between 01/02-05/08 who (1) went directly to the operating room, (2) were managed initially by DCL, and (3) survived to undergo a second laparotomy. Study group (NMB+): those receiving NMB in the first 24 hours after DCL. Comparison group (NMB-): those not receiving NMB in the first 24 hours after DCL. Primary fascial closure defined as fascia-to-fascia approximation by hospital day 7. Results: 191 patients met inclusion (92 in NMB+ group, 99 in NMB- group). While the NMB+ patients were younger (31 yrs vs. 37 yrs, p=0.009), there were no other differences in demographics, severity of injury, or lengths of stay between the groups. However, NMB+ patients achieved primary closure faster (5.1 vs. 3.5 days, p=0.046) and were more likely to achieve closure by day 7 (93% vs. 83%, p=0.023). Logistic regression identified NMB use as an independent predictor of achieving primary fascial closure by day 7. Odds Ratio 95% C.I. p-value Exposure to NMB 3.24 1.15-9.16 0.026 Age (years) 0.99 0.96-1.02 0.882 Male gender 0.29 0.06-1.35 0.117 White race 2.81 0.98-8.06 0.055 Penetrating mechanism 0.25 0.07-0.92 0.037 Injury severity score 0.99 0.95-1.02 0.707 Conclusions: Early NMB use is associated with faster and more frequent achievement of primary fascial closure in patients initially managed with damage control laparotomy. Patients exposed to NMB had a 3-times higher likelihood of achieving primary fascial closure by hospital day seven. Session 4 Poster # 2 CT IDENTIFICATION OF LATENT PSEUDOANEURYSM FOLLOWING BLUNT SPLENIC INJURY: PATHOLOGY OR TECHNOLOGY? Jordan A Weinberg*, MD, Mark E Lockhart, MD, Abhishek D Parmar, MD, Russell L Griffin*, MPH, Sherry M Melton*, MD, Gerald McGwin, Jr, PhD, Loring W Rue, III*, MD. University of Alabama at Birmingham. Background: Serial CT imaging of blunt splenic injury (BSI) can identify the latent formation of splenic artery pseudoaneurysms (PSAs), potentially contributing to improved success in nonoperative management (NOM). It remains unclear, however, whether the delayed appearance of such PSAs is truly pathophysiologic or attributable to imaging quality and timing. The objective of this study was to evaluate the influence of recent advancements in imaging technology on the incidence of the latent PSA. Methods: Consecutive BSI patients over 4.5 years were identified from our trauma registry. Follow-up CT was performed for all but low-grade BSI 24 to 48 hours following initial CT. Incidences of both early and latent PSA formation were reviewed and compared with respect to imaging technology (4-slice vs. 16-slice or greater). Results: 411 BSI patients underwent NOM. PSAs were detected as follows: CT Type Patients (n) Early PSA (%) Latent PSA (%) 4-slice 135 6.2 3.8 ? 16-slice 276 6.6 4.1 Comparing 4-slice to ? 16-slice, there were no significant differences in the incidence of early PSA (p = 0.91) or latent PSA (p = 0.90). Splenic injury grade on initial CT was not associated with latent PSA (p = 0.44). PSAs were managed by embolization (14), splenectomy (13), and observation (2). 18 patients (4%) underwent unplanned splenectomy (i.e. dropping hematocrit or hemodynamic instability). 88% of patients had follow-up > 7 days. Overall, NOM was successful in 92% of patients. Conclusions: The incidences of both early and latent PSA have remained remarkably stable despite advances in CT technology. This suggests that latent PSA is not a result of imaging technique, but rather a true pathophysiologic phenomenon. While the natural history of latent vs. early PSA remains unclear, adherence to a NOM protocol guided by serial CT results in a high nonoperative success rate with a limited incidence of unplanned splenectomies. Injury grade is unhelpful concerning the prediction of latent PSA formation. Session 4 Poster # 3 A MULTI-CENTER STUDY EXAMINING THE ROLE OF IMAGING AND CLINICAL FINDINGS AS INDICATIONS TO OPERATE FOR PEDIATRIC BLUNT INTESTINAL INJURY Kaveer Chatoorgoon, MD, Richard Falcone, MD MPH, Randall Burd*, MD PHD, APSA Committee on Trauma: Blunt Intestinal Injury Study Group. Cincinnati Childrens Hospital Medical Center. Purpose: Although CT scans are accurate in diagnosing solid organ injuries, their ability to diagnose a blunt intestinal injury (BII) is limited, occasionally requiring repeat imaging. The purpose of this study was to evaluate the role of clinical findings, as well as, original and repeat CT imaging in the ultimate decision to operate for BII. Methods: An 18 institution record review of children (< 15 yrs) diagnosed with a BII confirmed during surgery or autopsy between 2002 and 2007 was conducted by the APSA Trauma Committee. The incidence of imaging, repeat imaging, and final reported indications for operative exploration were evaluated. Results: Among 353 patients identified with a BII, 313 (89%) underwent at least one abdominal CT scan. Sixty-six (21%) underwent at least one repeat scan before operation. Most children who underwent a CT scan (129, 47%) were taken to the operating room based only on clinical indications (fever, abdominal pain, shock or elevated WBC), while 31% were operated on based on both a clinical and CT indication and 22% based on a CT indication alone (p<0.001). Although free air was the most common radiographic indication for surgery, 17% of patients with a repeat scan had free air diagnosed on their first CT. Most children undergoing a repeat CT (56 children, 85%) had findings on the original scan suggesting a BII. Among the 10 patients whose first CT scan was normal, only one went to the OR based only on radiographic findings. Children who had their first CT scan at a referring hospital were more likely to have a repeat study than those imaged at a trauma center (33% vs. 13%, p<0.001). Conclusions: Although abdominal CT imaging may contribute to diagnosing intestinal injury following blunt trauma, most children undergo operation based on clinical findings. Repeat imaging should be limited to select patients with diagnostic uncertainty to avoid unneeded delay and radiation exposure. Session 4 Poster # 4 DIAGNOSTIC LAPAROSCOPY VERSUS NON-THERAPEUTIC LAPAROTOMY IN THE EVALUATION OF ACUTE ABDOMINAL TRAUMA Jay N Collins*,MD, Michael Lofgren, MD, Leonard J Weireter*, MD, Timothy J Novosel,MD, Scott F Reed, MD, Rebecca C Britt,MD, LD Britt*,MD. EVMS. Objective: To evaluate the safety and efficacy of diagnostic laparoscopy (DL) versus non-therapeutic laparotomy (NTL) in the setting of acute abdominal trauma. Methods: A retrospective analysis of prospectively collected data on trauma patients older than 16 years admitted from September 1, 2005 to January 31, 2009 was performed. Hemodynamically normal patients with suspicion for intraabdominal injury after physical exam and/or CT scan underwent either diagnostic laparoscopy or exploratory laparotomy based on the attending surgeon’s preference. Patient demographics, hospital length of stay (LOS) and hospital complications were analyzed. Univariate statistical analysis was performed to identify statistically significant differences defined as a p value <0.05 Results: 3665 patients, 2895 blunt and 767 penetrating, were seen during the study period. Thirty underwent NTL and 27 underwent DL. Fourteen DL patients had negative explorations (NDL) and all were discharged within 3 days. Five DL patients underwent laparoscopic repair of stomach, bowel or diaphragm injuries. Eight DL patients required conversion to open laparotomy for injury repair. Age (31.3 v. 32), male gender (87% v. 78%) and ISS (8.4 v. 9.5) were similar. Blunt and penetrating injuries were seen in 6 and 24 of NTL and in 10 and 17 of DL patients. Mean hospital LOS was 1.4 days in NDL and 5.1 days in NTL patients (p<0.05). NDL patients had one complication (cutaneous abscess) and NTL patients had 19 complications including wound infections, C. difficile colitis, pneumonia, urinary tract infections, reintubation, splenectomy, atrial fibrillation and ileus. No NDL patient had missed injuries achieving a negative predictive value of 100%. Fifty-two percent of DL patients safely avoided NTL. Conclusion: Diagnostic laparoscopy in the evaluation of acute abdominal trauma is safe and allows for earlier discharge and return to normal activities when negative. Significantly more complications and longer LOS are associated with NTL. Session 4 Poster # 5 PROSPECTIVE VALIDATION OF AN ALGORITHM DEFINING INDICATIONS FOR PELVIC RADIOGRAPHS IN THE EVALUATION OF BLUNT TRAUMA PATIENTS Andrew R Barleben MD MPH , Fariba Jafari BS, Darren Malinoski MD, Cristobal Barrios MD, Michael Lekawa* MD , Matthew Dolich MD, David Hoyt* MD , Marianne Cinat* MD. University of California Irvine. Introduction: In a previous retrospective study, we demonstrated that plain film pelvic radiographs (PXR) in the evaluation of blunt trauma patients undergoing abdominal CT scan 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 six months at a single Level 1 trauma center.