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NYC-RTAC NEWSLETTER�

SEPTEMBER 2014�

VOLUME 1 ISSUE 5�

PREFACE�

ANNOUNCEMENTS�
Greater NY ACS-COT Resident Paper Competition
October 6th
Bellevue Hospital Center

We recently had a patient with penetrating colon injury present to our
institution. I had the opportunity to review current EAST guidelines for
the management of penetrating colonic injury, and felt that this would
be useful to share with our RTAC community.

ACS-COT Region 2 Resident Paper Competition
Puerto Rico
December 11-14th

Please contact me if you have specific practice management
guidelines you would like to see covered. EAST and AAST do provide
excellent evidence-based guidelines that I would be happy to
summarize in upcoming editions of the newsletter.

PRACTICE MANAGEMENT GUIDELINES�
Summary of Guidelines for the Management of Penetrating Colon
Injuries:

The member directory is available on our website. If anyone wishes to
contribute editorials, current research, or articles please forward them
to me. The submission deadline for inclusion in the next edition of the
newsletter is the 25th day of each month.
It has come to my attention that certain individuals in the RTAC
community feel that this newsletter is Richmond University Medical
Center propaganda. This could not be further from the truth. I once
again invite all members to please send me material which they wish
put into our newsletter. In fact, we have delayed the publication of this
month’s edition to accommodate any further content. If anyone has
suggestions on how we can improve this newsletter, I am available for
discussion. However characterizing this newsletter, which has taken
up a significant amount of time from my staff and me, as RUMC
propaganda is inappropriate and detrimental to the goals of our RTAC.
Akella Chendrasekhar, MD FACS
Trauma Director
Richmond University Medical Center
Staten Island, NY

UPCOMING MEETINGS�
New York State Trauma Advisory Committee
Thursday, January 8th, 2015
Hilton Garden Inn
Troy, NY
NYC-RTAC
Monday, October 6th, 2014
Bellevue Hospital Center
New York, NY
28th

Patients with penetrating intraperitoneal colon wounds
which are destructive (involvement of > 50% of the
bowel wall or devascularization of a bowel segment) can
undergo resection and primary anastomosis if they are:
a) 

Hemodynamically stable without evidence of shock
(sustained pre- or intraoperative hypotension as
defined by SBP < 90 mm Hg)

b) 

Have no significant underlying disease

c) 

Have minimal associated injuries (PATI < 25, ISS <
25, Flint grade < 11)

d) 

Have no peritonitis

3. 

Patients with shock, underlying disease, significant
associated injuries, or peritonitis should have destructive
colon wounds managed by resection and colostomy.

4. 

Colostomies performed following colon and rectal
trauma can be closed within two weeks if contrast
enema is performed to confirm distal colon healing. This
recommendation pertains to patients who do not have
non-healing bowel injury, unresolved wound sepsis, or
are unstable.

5. 

A barium enema should not be performed to rule out
colon cancer or polyps prior to colostomy closure for
trauma in patients who otherwise have no indications for
being at risk for colon cancer and/or polyps.

A significant percentage of trauma patients are often admitted
to the medical service, even in dedicated trauma centers. At
our institution, a level-I urban teaching hospital, 10-20% of
trauma admissions are placed on non-trauma services. The
objective of this paper is to examine the ability of internal
medicine residents to appropriately triage trauma patients in
multicasualty scenarios.

Akella Chendrasekhar, MD FACS
Richmond University Medical Center
355 Bard Ave
Staten Island, NY
AChendrasekhar@rumcsi.org

2. 

Richmond University Medical Center has provided previously
presented abstracts and abstracts currently under review.
Trauma scenarios and internal medicine residents:
education needed to build triage ability
Pate A, Bhamidipati A, Adams D, Chendrasekhar A

EDITORIAL CONTACT�

NYC-RTAC News �

There is sufficient class I and class II data to support a
standard of (involvement of < 50% of the bowel wall
without devascularization) colon peritonitis.

CURRENT RESEARCH �

Annual Scientific Assembly
January 13th-17th, 2015
Disney's Contemporary Resort
Lake Buena Vista, FL

EAST

1. 

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Vol 1 Iss 5�

CURRENT RESEARCH (CONTʼD) �
An average hemoglobin of 12 gm/dl or greater and sustained
management by a designated trauma service is associated with
improved survival in patients with severe closed head injury

Five multicasualty scenarios consisting of five patients each were
developed in keeping with ATLS primary survey guidelines. Two
scenarios incorporated a pregnant woman and a child. Our
hospital’s internal medicine residents were tasked with ranking
patients by need for urgent intervention from 1 to 5, with “1” being
the highest priority and “5” being the lowest. We also collected
data on level of postgraduate training (PGY) and prior medical
experience.

Resuscitation of a patient with severe head injury to a hemoglobin
level of greater than 12 grams/dl and keeping the patient on a
dedicated trauma service at a designated trauma center improves
survival.

MEETING UPDATES�

50 internal medicine residents participated: 23 PGY-1 (46%), 16
PGY-2 (32%), and 11 PGY-3 (22%). Mean experience including
medical school was 7 ± 0.6 years. Six residents (12%) had one to
two years of prior emergency medical service experience. 80% of
residents correctly identified the number one patient in at least
one scenario correctly. 40% ranked the first two patients in at
least one scenario correctly. Only 34% ranked the top three
patients in at least one scenario correctly. Level of training or prior
clinical experience was not correlated with ability to triage
scenarios appropriately.

American Trauma Society – New York State Division
The New York State Division of the American Trauma Society held
their most recent meeting in Albany on September 18, 2014. Seventy
eight participants attended. Ian Weston, Executive Director of the
American Trauma Society, attended the meeting and gave a
presentation highlighting the new activities and changes that have
taken place since his arrival two years ago. Please refer to their
website at www.amtrauma.org to see the programs they have to offer
and to become a member.

Trauma triage is not standard curriculum in undergraduate
medical education. Internal medicine residents were unable to
consistently identify the patient in need of urgent intervention
across five scenarios. Considering the volume of trauma patients
cared for by internists, intensive education on trauma patient
management and triage principles would be appropriate.

At the meeting, Injury Prevention and Educational grants were
awarded to the following RTAC institutions:

Higher Hemoglobin Concentration and Dedicated Trauma
Team Management Is Associated with Improved Survival in
Patients with Severe Closed Head Injury
Panigrahi B, Sharp A, Smith M, Chendrasekhar A

Injury Prevention Grants-to be used to promote unique &
comprehensive injury prevention activities at trauma
centers:

Staten Island University Hospital

 

Bellevue Medical Center

 

Elmhurst Hospital

 

Jamaica Hospital Medical Center

 

New York Hospital of Queens

This year 10 NY State trauma centers applied for injury prevention
grants. Seven centers were awarded grants totaling $3500.
Within the next several weeks we will begin to accept nomination
forms our annual NY State American Trauma Society distinction
awards. Distinction awards recognize outstanding individual
contributors within the NY State trauma community who have been
nominated/selected by their peers. A total of four awards will be
handed out this year. Distinction award winners will be announced at
the next NY State American Trauma Society dinner scheduled to be
held on January 7, 2015. Nomination forms and instructions will be
posted on our website at www.nyats.org soon. Award categories
include:

158 patients were evaluated for the study. 135 patients [85.4%]
survived to discharge and 23 patients [14.6%] died. The average
Hgb of survivors was 12.8 ± 0.2 gm/dl versus 10.7 ± 0.4 for nonsurvivors [p=0.0001]. Conversely patients with an average Hgb of
12 gm/dl or greater had an improved survival [ 91.3 ± 3.6% versus
76.9 ± 4.3% for Hgb less than 12, p=0.01] As expected the age,
AIS, and injury severity score [ISS] were higher for non-survivors.
The hospital length of stay [HLOS] as well as the ICU length of
stay [ICU-LOS] was equivalent. When we assessed the data by
discharge service, we found that a greater percentage of patients
who remained on the trauma service went on to survive as
compared to being transferred to the medical service [89.5 ± 3.6%
versus 69.0 ± 5.2%, respectively, p=0.008]. We also found that
trauma service had a shorter HLOS as compared to medical
service [6.6 ± 1.1 days versus 11.1 ± 1.5 days respectively,
p=0.01], while ICU-LOS , AIS and ISS were equivalent.

 

This year 6 NY State trauma centers applied for educational grants.
Four centers were awarded grants totaling $3,000.

We performed a retrospective data analysis on 251 severe head
injured trauma patients [abbreviated injury score (AIS) ≥ 3]seen at
our level 1 trauma center. Patients with length of stay ≤ 1 day and
pediatric patients with age < 16 years were excluded. We
assessed daily average Hgb levels for each day of hospitalization
where present for the first 7 days. Patients were grouped by
survival to discharge and by discharge service. The data were
analyzed by one-way analysis of variance[ANOVA]

Educational Grants-to be used for regional educational
activities:
 

Management of brain injury involves preventing secondary injury.
Secondary brain injury is associated with decreased brain oxygen
delivery and oxygen content. Oxygen content predominantly
determined by Hemoglobin [Hgb] concentration. Data are lacking
on optimal Hgb level in head injured patients. The American
College of Surgeons-Committee on Trauma [ACS-COT]
recommends management of head injured patients by an
organized Trauma service. Trauma services tend to transfer
patients with predominant head injury to be managed by
neurosurgery and medical services. The efficacy of this practice is
unknown.

NYC-RTAC NEWS �

 

 

Trauma Physician of Distinction

 

Trauma Program Manager/PI Coordinator of Distinction

 

Trauma Registrar of Distinction

 

Individual Injury Prevention Program-this is a new category
this year

Please take part in recognizing the outstanding work that is being
done at Trauma Centers throughout NY State!
Submitted by Jeanne Rubsam, RN
Vice-President, NY State Division, American Trauma Society
Pediatric Trauma Program Manager, New York-Presbyterian, Morgan
Stanley Children’s Hospital
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