Bio

Clinical Focus


  • General Surgery
  • Surgical Critical Care
  • Trauma

Academic Appointments


Professional Education


  • Board Certification: Surgical Critical Care, American Board of Surgery (2007)
  • Residency:University of Texas Sourthwestern Medical Center (2006) TX
  • Medical Education:University of Texas Sourthwestern Medical Center (1999) TX
  • Master's Degree, Stanford University, Health Services Research (2010)
  • Fellowship:UCSF/San Francisco Gen Hosp (2008) CA
  • Board Certification: General Surgery, American Board of Surgery (2006)

Teaching

2013-14 Courses


Publications

Journal Articles


  • Gunshot Injuries in Children Served by Emergency Services PEDIATRICS Newgard, C. D., Kuppermann, N., Holmes, J. F., Haukoos, J. S., Wetzel, B., Hsia, R. Y., Wang, N. E., Bulger, E. M., Staudenmayer, K., Mann, N. C., Barton, E. D., Wintemute, G. 2013; 132 (5): 862-870

    Abstract

    To describe the incidence, injury severity, resource use, mortality, and costs for children with gunshot injuries, compared with other injury mechanisms.This was a population-based, retrospective cohort study (January 1, 2006-December 31, 2008) including all injured children age ≤ 19 years with a 9-1-1 response from 47 emergency medical services agencies transporting to 93 hospitals in 5 regions of the western United States. Outcomes included population-adjusted incidence, injury severity score ≥ 16, major surgery, blood transfusion, mortality, and average per-patient acute care costs.A total of 49,983 injured children had a 9-1-1 emergency medical services response, including 505 (1.0%) with gunshot injuries (83.2% age 15-19 years, 84.5% male). The population-adjusted annual incidence of gunshot injuries was 7.5 cases/100,000 children, which varied 16-fold between regions. Compared with children who had other mechanisms of injury, those injured by gunshot had the highest proportion of serious injuries (23%, 95% confidence interval [CI] 17.6-28.4), major surgery (32%, 95% CI 26.1-38.5), in-hospital mortality (8.0%, 95% CI 4.7-11.4), and costs ($28,510 per patient, 95% CI 22,193-34,827).Despite being less common than other injury mechanisms, gunshot injuries cause a disproportionate burden of adverse outcomes in children, particularly among older adolescent males. Public health, injury prevention, and health policy solutions are needed to reduce gunshot injuries in children.

    View details for DOI 10.1542/peds.2013-1350

    View details for Web of Science ID 000326475000055

    View details for PubMedID 24127481

  • Triage of elderly trauma patients: a population-based perspective. Journal of the American College of Surgeons Staudenmayer, K. L., Hsia, R. Y., Mann, N. C., Spain, D. A., Newgard, C. D. 2013; 217 (4): 569-576

    Abstract

    Elderly patients are frequently undertriaged. However, the associations between triage patterns and outcomes from a population perspective are unknown. We hypothesized that triage patterns would be associated with differences in outcomes.This is a population-based, retrospective, cohort study of all injured adults aged 55 years or older, from 3 counties in California and 4 in Utah (2006 to 2007). Prehospital data were linked to trauma registry data, state-level discharge data, emergency department records, and death files. The primary outcome was 60-day mortality. Patients treated at trauma centers were compared with those treated at nontrauma centers. Undertriage was defined as an Injury Severity Score (ISS) >15, with transport to a nontrauma center.There were 6,015 patients in the analysis. Patients who were taken to nontrauma centers were, on average, older (79.4 vs 70.7 years, p < 0.001), more often female (68.6% vs 50.2%, p < 0.01), and less often had an ISS >15 (2.2% vs 6.7%, p < 0.01). There were 244 patients with an ISS >15 and the undertriage rate was 32.8% (n = 80). Overall 60-day mortality for patients with an ISS >15 was 17%, with no difference between trauma and nontrauma centers in unadjusted or adjusted analyses. However, the median per-patient costs were $21,000 higher for severely injured patients taken to trauma centers.This is the first population-based analysis of triage patterns and outcomes in the elderly. We have shown high rates of undertriage that are not associated with higher mortality, but are associated with higher costs. Future work should focus on determining how to improve outcomes for this population.

    View details for DOI 10.1016/j.jamcollsurg.2013.06.017

    View details for PubMedID 24054408

  • Cost-effectiveness of helicopter versus ground emergency medical services for trauma scene transport in the United States. Annals of emergency medicine Delgado, M. K., Staudenmayer, K. L., Wang, N. E., Spain, D. A., Weir, S., Owens, D. K., Goldhaber-Fiebert, J. D. 2013; 62 (4): 351-364 e19

    Abstract

    STUDY OBJECTIVE: We determine the minimum mortality reduction that helicopter emergency medical services (EMS) should provide relative to ground EMS for the scene transport of trauma victims to offset higher costs, inherent transport risks, and inevitable overtriage of patients with minor injury. METHODS: We developed a decision-analytic model to compare the costs and outcomes of helicopter versus ground EMS transport to a trauma center from a societal perspective during a patient's lifetime. We determined the mortality reduction needed to make helicopter transport cost less than $100,000 and $50,000 per quality-adjusted life-year gained compared with ground EMS. Model inputs were derived from the National Study on the Costs and Outcomes of Trauma, National Trauma Data Bank, Medicare reimbursements, and literature. We assessed robustness with probabilistic sensitivity analyses. RESULTS: Helicopter EMS must provide a minimum of a 17% relative risk reduction in mortality (1.6 lives saved/100 patients with the mean characteristics of the National Study on the Costs and Outcomes of Trauma cohort) to cost less than $100,000 per quality-adjusted life-year gained and a reduction of at least 33% (3.7 lives saved/100 patients) to cost less than $50,000 per quality-adjusted life-year. Helicopter EMS becomes more cost-effective with significant reductions in patients with minor injury who are triaged to air transport or if long-term disability outcomes are improved. CONCLUSION: Helicopter EMS needs to provide at least a 17% mortality reduction or a measurable improvement in long-term disability to compare favorably with other interventions considered cost-effective. Given current evidence, it is not clear that helicopter EMS achieves this mortality or disability reduction. Reducing overtriage of patients with minor injury to helicopter EMS would improve its cost-effectiveness.

    View details for DOI 10.1016/j.annemergmed.2013.02.025

    View details for PubMedID 23582619

  • The Cost Of Overtriage: More Than One-Third Of Low-Risk Injured Patients Were Taken To Major Trauma Centers HEALTH AFFAIRS Newgard, C. D., Staudenmayer, K., Hsia, R. Y., Mann, N. C., Bulger, E. M., Holmes, J. F., Fleischman, R., Gorman, K., Haukoos, J., McConnell, K. J. 2013; 32 (9): 1591-1599

    Abstract

    Regionalized trauma care has been widely implemented in the United States, with field triage by emergency medical services (EMS) playing an important role in identifying seriously injured patients for transport to major trauma centers. In this study we estimated hospital-level differences in the adjusted cost of acute care for injured patients transported by 94 EMS agencies to 122 hospitals in 7 regions, overall and by injury severity. Among 301,214 patients, the average adjusted per episode cost of care was $5,590 higher in a level 1 trauma center than in a nontrauma hospital. We found hospital-level differences in cost among patients with minor, moderate, and serious injuries. Of the 248,342 low-risk patients-those who did not meet field triage guidelines for transport to trauma centers-85,155 (34.3 percent) were still transported to major trauma centers, accounting for up to 40 percent of acute injury costs. Adhering to field triage guidelines that minimize the overtriage of low-risk injured patients to major trauma centers could save up to $136.7 million annually in the seven regions we studied.

    View details for DOI 10.1377/hlthaff.2012.1142

    View details for Web of Science ID 000324681500012

    View details for PubMedID 24019364

  • Patient Choice in the Selection of Hospitals by 9-1-1 Emergency Medical Services Providers in Trauma Systems ACADEMIC EMERGENCY MEDICINE Newgard, C. D., Mann, N. C., Hsia, R. Y., Bulger, E. M., Ma, O. J., Staudenmayer, K., Haukoos, J. S., Sahni, R., Kuppermann, N. 2013; 20 (9): 911-919

    Abstract

    Reasons for undertriage (transporting seriously injured patients to nontrauma centers) and the apparent lack of benefit of trauma centers among older adults remain unclear; understanding emergency medical services (EMS) provider reasons for selecting certain hospitals in trauma systems may provide insight to these issues. In this study, the authors evaluated reasons cited by EMS providers for selecting specific hospital destinations for injured patients, stratified by age, injury severity, field triage status, and prognosis.This was a retrospective cohort study of injured children and adults transported by 61 EMS agencies to 93 hospitals (trauma and nontrauma centers) in five regions of the western United States from 2006 through 2008. Hospital records were probabilistically linked to EMS records using trauma registries, state discharge data, and emergency department data. The seven standardized reasons cited by EMS providers for selecting hospital destinations included closest facility, ambulance diversion, physician choice, law enforcement choice, patient or family choice, specialty resource center, and other. "Serious injury" was defined as an Injury Severity Score (ISS) ≥ 16, and unadjusted in-hospital mortality was considered as a marker of prognosis. All analyses were stratified by age in 10-year increments, and descriptive statistics were used to characterize the findings.A total of 176,981 injured patients were evaluated and transported by EMS over the 3-year period, of whom 5,752 (3.3%) had ISS ≥ 16 and 2,773 (1.6%) died. Patient or family choice (50.6%), closest facility (20.7%), and specialty resource center (15.2%) were the most common reasons indicated by EMS providers for selecting destination hospitals; these frequencies varied substantially by patient age. The frequency of patient or family choice increased with increasing age, from 36.4% among 21- to 30-year-olds to 75.8% among those older than 90 years. This trend paralleled undertriage rates and persisted when restricted to patients with serious injuries. Older patients with the worst prognoses were preferentially transported to major trauma centers, a finding that was not explained by field triage protocols.Emergency medical services transport patterns among injured patients are not random, even after accounting for field triage protocols. The selection of hospitals appears to be heavily influenced by patient or family choice, which increases with patient age and involves inherent differences in patient prognosis.

    View details for DOI 10.1111/acem.12213

    View details for Web of Science ID 000324579700007

    View details for PubMedID 24050797

  • Variability of ICU use in adult patients with minor traumatic intracranial hemorrhage. Annals of emergency medicine Nishijima, D. K., Haukoos, J. S., Newgard, C. D., Staudenmayer, K., White, N., Slattery, D., Maxim, P. C., Gee, C. A., Hsia, R. Y., Melnikow, J. A., Holmes, J. F. 2013; 61 (5): 509-517 e4

    Abstract

    Patients with minor traumatic intracranial hemorrhage are frequently admitted to the ICU, although many never require critical care interventions. To describe ICU resource use in minor traumatic intracranial hemorrhage, we assess (1) the variability of ICU use in a cohort of patients with minor traumatic intracranial hemorrhage across multiple trauma centers, and (2) the proportion of adult patients with traumatic intracranial hemorrhage who are admitted to the ICU and never receive a critical care intervention during hospitalization. In addition, we evaluate the association between ICU admission and key independent variables.A structured, historical cohort study of adult patients (aged 18 years and older) with minor traumatic intracranial hemorrhage was conducted within a consortium of 8 Level I trauma centers in the western United States from January 2005 to June 2010. The study population included patients with minor traumatic intracranial hemorrhage, defined as an emergency department (ED) Glasgow Coma Scale (GCS) score of 15 (normal mental status) and an Injury Severity Score less than 16 (no other major organ injury). The primary outcome measure was initial ICU admission. The secondary outcome measure was a critical care intervention during hospitalization. Critical care interventions included mechanical ventilation, neurosurgical intervention, transfusion of blood products, vasopressor or inotrope administration, and invasive hemodynamic monitoring. ED disposition and the proportion of ICU patients not receiving a critical care intervention were compared across sites with descriptive statistics. The association between ICU admission and predetermined independent variables was analyzed with multivariable regression.Among 11,240 adult patients with traumatic intracranial hemorrhage, 1,412 (13%) had minor traumatic intracranial hemorrhage and complete ED disposition data (mean age 48 years; SD 20 years). ICU use within this cohort across sites ranged from 50% to 97%. Overall, 847 of 888 patients (95%) with minor traumatic intracranial hemorrhage who were admitted to the ICU did not receive a critical care intervention during hospitalization (range between sites 80% to 100%). Three of 524 (0.6%) patients discharged home or admitted to the observation unit or ward received a critical care intervention. After controlling for severity of injury (age, blood pressure, and Injury Severity Score), study site was independently associated with ICU admission (odds ratios ranged from 1.5 to 30; overall effect P<.001).Across a consortium of trauma centers in the western United States, there was wide variability in ICU use within a cohort of patients with minor traumatic intracranial hemorrhage. Moreover, a large proportion of patients admitted to the ICU never required a critical care intervention, indicating the potential to improve use of critical care resources in patients with minor traumatic intracranial hemorrhage.

    View details for DOI 10.1016/j.annemergmed.2012.08.024

    View details for PubMedID 23021347

  • The trade-offs in field trauma triage: A multiregion assessment of accuracy metrics and volume shifts associated with different triage strategies JOURNAL OF TRAUMA AND ACUTE CARE SURGERY Newgard, C. D., Hsia, R. Y., Mann, N. C., Schmidt, T., Sahni, R., Bulger, E. M., Wang, N. E., Holmes, J. F., Fleischman, R., Zive, D., Staudenmayer, K., Haukoos, J. S., Kuppermann, N. 2013; 74 (5): 1298-1306

    Abstract

    BACKGROUND: National benchmarks for trauma triage sensitivity (?95%) and specificity (?50%) have not been rigorously evaluated across broad populations of injured patients. We evaluated the impact of different field triage schemes for identifying seriously injured patients across a range of sensitivity values. Impact metrics included specificity and number of undertriaged and overtriaged patients compared with current triage practices. METHODS: This was a retrospective cohort study of injured children and adults transported by 48 emergency medical service (EMS) agencies to 105 hospitals in 6 regions of the Western United States from 2006 through 2008. Hospital outcomes were probabilistically linked to EMS records through trauma registries, state discharge databases, and state emergency department databases. The primary outcome was an Injury Severity Score (ISS) of 16 or greater. We evaluated 40 field predictor variables, including 31 current field triage criteria, using classification and regression tree analysis and cross-validation to generate estimates for sensitivity and specificity. RESULTS: A total of 89,261 injured patients were evaluated and transported by EMS providers during the 3-year period, of whom 5,711 (6.4%) had ISS of 16 or greater. As the 95% sensitivity target for triage was approached (from the current value of 87.5%), decision tree complexity increased, specificity decreased (from 62.8% to 18.7%), and the number of triage-positive patients without serious injury doubled (67,927 vs. 31,104). Analyses restricted to children and older adults were similar. The most consistent modification to the current triage algorithm to increase sensitivity without a major decrease in specificity was altering the Glasgow Coma Scale (GCS) score cutoff point from 13 or less to 14 or less (sensitivity increase to 90.4%). CONCLUSION: Reaching the field triage sensitivity benchmark of 95% would require a large decrease in specificity (increase in overtriage). A 90% sensitivity target seems more realistic and may be obtainable by modest changes to the current triage algorithm. LEVEL OF EVIDENCE: Diagnostic test, level II.

    View details for DOI 10.1097/TA.0b013e31828b7848

    View details for Web of Science ID 000319316600024

    View details for PubMedID 23609282

  • Predictors of emergency department death for patients presenting with ruptured abdominal aortic aneurysms JOURNAL OF VASCULAR SURGERY Mell, M. W., Callcut, R. A., Bech, F., Delgado, M. K., Staudenmayer, K., Spain, D. A., Hernandez-Boussard, T. 2012; 56 (3): 651-655

    Abstract

    Ruptured abdominal aortic aneurysm (rAAA) is a critically time-sensitive condition with outcomes dependent on rapid diagnosis and definitive treatment. Emergency department (ED) death reflects the hemodynamic stability of the patient upon arrival and the ability to mobilize resources before hemodynamic stability is lost. The goals of this study were to determine the incidence and predictors of ED death for patients presenting to EDs with rAAAs.Data for patients presenting with International Classification of Disease, 9th Revision, Clinical Modification codes for rAAA from 2006 to 2008 were extracted from discharge data using the Nationwide Emergency Department Sample (NEDS), Healthcare Cost and Utilization Project, and Agency for Healthcare Research and Quality. The NEDS is the largest stratified weighted sample of US hospital-based ED visits with links to inpatient files. We compared those transferred to those admitted and treated. Sample weights were applied to produce nationally representative estimates. Patient and hospital factors associated with transfer were identified using multivariate logistic regression. These factors were then analyzed for a relationship with ED deaths.A total of 18,363 patients were evaluated for rAAAs. Of these, 7% (1201) died in the ED, 6% (1160) were admitted and died without a procedure, 42% (7731) were admitted and died after repair, and 41% (7479) were admitted, treated, and survived. Transfers accounted for 4% (793) of all ED visits for rAAAs. ED death was more likely for patients seen in nonmetropolitan hospitals (12.7%) vs metropolitan nonteaching (7.0%) or metropolitan teaching hospitals (4.5%; P < .0001). Compared with other regions, the West had a higher ED mortality rate (9.6% vs 5.1%-6.9%; P = .0038). On multivariate analysis, ED death was associated with hospital groups exhibiting both high and low transfer rates.ED death remains a significant cause for mortality for rAAAs and varies by hospital type, rural/urban location, and geographic region. Both delays in ED arrival and delays in providing definitive care may contribute to increased ED death rates, suggesting that improved regional systems of care may improve survival after rAAA.

    View details for DOI 10.1016/j.jvs.2012.02.025

    View details for Web of Science ID 000308085500010

    View details for PubMedID 22560234

  • Evaluating Age in the Field Triage of Injured Persons ANNALS OF EMERGENCY MEDICINE Nakamura, Y., Daya, M., Bulger, E. M., Schreiber, M., Mackersie, R., Hsia, R. Y., Mann, N. C., Holmes, J. F., Staudenmayer, K., Sturges, Z., Liao, M., Haukoos, J., Kuppermann, N., Barton, E. D., Newgard, C. D. 2012; 60 (3): 335-345

    Abstract

    We evaluate trauma undertriage by age group, the association between age and serious injury after accounting for other field triage criteria and confounders, and the potential effect of a mandatory age triage criterion for field triage.This was a retrospective cohort study of injured children and adults transported by 48 emergency medical services (EMS) agencies to 105 hospitals in 6 regions of the western United States from 2006 through 2008. We used probabilistic linkage to match EMS records to hospital records, including trauma registries, state discharge databases, and emergency department databases. The primary outcome measure was serious injury, as measured by an Injury Severity Score greater than or equal to 16. We assessed undertriage (Injury Severity Score ?16 and triage-negative or transport to a nontrauma center) by age decile and used multivariable logistic regression models to estimate the association (linear and nonlinear) between age and Injury Severity Score greater than or equal to 16, adjusted for important confounders. We also evaluated the potential influence of age on triage efficiency and trauma center volume.Injured patients (260,027) were evaluated and transported by EMS during the 3-year study period. Undertriage increased for patients older than 60 years, reaching approximately 60% for those older than 90 years. There was a strong nonlinear association between age and Injury Severity Score greater than or equal to 16. For patients not meeting other triage criteria, the probability of serious injury was most notable after 60 years. A mandatory age triage criterion would have decreased undertriage at the expense of overtriage, with 1 patient with Injury Severity Score greater than or equal to 16 identified for every 60 to 65 additional patients transported to major trauma centers.Trauma undertriage increases in patients older than 60 years. Although the probability of serious injury increases among triage-negative patients with increasing age, the use of a mandatory age triage criterion appears inefficient for improving field triage.

    View details for DOI 10.1016/j.annemergmed.2012.04.006

    View details for Web of Science ID 000308620500015

    View details for PubMedID 22633339

  • Payer status is associated with the use of prophylactic inferior vena cava filter in high-risk trauma patients SURGERY Pickham, D. M., Callcut, R. A., Maggio, P. M., Mell, M. W., Spain, D. A., Bech, F., Staudenmayer, K. 2012; 152 (2): 232-237

    Abstract

    It is controversial whether patients at high risk for pulmonary embolism (PE) should receive prophylactic inferior vena cava filters (IVC) filters. This lack of clarity creates the potential for variability and disparities in care. We hypothesized there would be differential use of prophylactic IVC filters for patients at high risk for PE on the basis of insurance status.We performed a retrospective analysis using the National Trauma Databank (2002-2007). We included adult patients at high risk for PE (traumatic brain injury or spinal cord injury) and excluded patients with a diagnosis of deep venous thrombosis (DVT) or PE. Logistic regression was performed to control for confounders and a hierarchical mixed effects model was used to control for center.A prophylactic filter was placed in 3,331 (4.3%) patients in the study cohort. Patients without insurance had an IVC filter placed less often compared with those with any form of insurance (2.7% vs 4.9%, respectively). After adjusting for confounders, we found that patients without insurance were less likely to receive a prophylactic IVC filter, even when we controlled for center (OR 5.3, P < .001).When guidelines lack clarity, unconscious bias has the potential to create a system with different levels of care based on socioeconomic disparities.

    View details for DOI 10.1016/j.surg.2012.05.041

    View details for Web of Science ID 000307157500013

    View details for PubMedID 22828145

  • Evaluating the Use of Existing Data Sources, Probabilistic Linkage, and Multiple Imputation to Build Population-based Injury Databases Across Phases of Trauma Care ACADEMIC EMERGENCY MEDICINE Newgard, C., Malveau, S., Staudenmayer, K., Wang, N. E., Hsia, R. Y., Mann, N. C., Holmes, J. F., Kuppermann, N., Haukoos, J. S., Bulger, E. M., Dai, M., Cook, L. J. 2012; 19 (4): 469-480

    Abstract

    The objective was to evaluate the process of using existing data sources, probabilistic linkage, and multiple imputation to create large population-based injury databases matched to outcomes.This was a retrospective cohort study of injured children and adults transported by 94 emergency medical systems (EMS) agencies to 122 hospitals in seven regions of the western United States over a 36-month period (2006 to 2008). All injured patients evaluated by EMS personnel within specific geographic catchment areas were included, regardless of field disposition or outcome. The authors performed probabilistic linkage of EMS records to four hospital and postdischarge data sources (emergency department [ED] data, patient discharge data, trauma registries, and vital statistics files) and then handled missing values using multiple imputation. The authors compare and evaluate matched records, match rates (proportion of matches among eligible patients), and injury outcomes within and across sites.There were 381,719 injured patients evaluated by EMS personnel in the seven regions. Among transported patients, match rates ranged from 14.9% to 87.5% and were directly affected by the availability of hospital data sources and proportion of missing values for key linkage variables. For vital statistics records (1-year mortality), estimated match rates ranged from 88.0% to 98.7%. Use of multiple imputation (compared to complete case analysis) reduced bias for injury outcomes, although sample size, percentage missing, type of variable, and combined-site versus single-site imputation models all affected the resulting estimates and variance.This project demonstrates the feasibility and describes the process of constructing population-based injury databases across multiple phases of care using existing data sources and commonly available analytic methods. Attention to key linkage variables and decisions for handling missing values can be used to increase match rates between data sources, minimize bias, and preserve sampling design.

    View details for DOI 10.1111/j.1553-2712.2012.01324.x

    View details for Web of Science ID 000302858200014

    View details for PubMedID 22506952

  • The forgotten trauma patient: Outcomes for injured patients evaluated by emergency medical services but not transported to the hospital JOURNAL OF TRAUMA AND ACUTE CARE SURGERY Staudenmayer, K., Hsia, R., Wang, E., Sporer, K., Ghilarducci, D., Spain, D., Mackersie, R., Sherck, J., Kline, R., Newgard, C. 2012; 72 (3): 594-599

    Abstract

    Injured patients who are not transported by an ambulance to the hospital are often not included in trauma registries. The outcomes of these patients have until now been unknown. Understanding what happens to nontransports is necessary to better understand triage validity, patient outcomes, and costs associated with injury. We hypothesized that a subset of patients who were not transported from the scene would later present for evaluation and that these patients would have a nonzero mortality rate.This is a population-based, retrospective cohort study of injured adults and children for three counties in California from 2006 to 2008. Prehospital data for injured patients for whom an ambulance was dispatched were probabilistically linked to trauma registry data from four trauma centers, state-level discharge data, emergency department records, and death files (1-year mortality).A total of 69,413 injured persons who were evaluated at the scene by emergency medical services were included in the analysis. Of them, 5,865 (8.5%) were not transported. Of those not transported, 1,616 (28%) were later seen in an emergency department and discharged and 92 (2%) were admitted. Seven (0.2%) patients later died.Patients evaluated by emergency medical services, but not initially transported from the field after injury, often present later to the hospital. The mortality rate in this population was not zero, and these patients may represent preventable deaths.III, therapeutic study.

    View details for DOI 10.1097/TA.0b013e31824764ef

    View details for Web of Science ID 000301371100016

    View details for PubMedID 22491541

  • A Multisite Assessment of the American College of Surgeons Committee on Trauma Field Triage Decision Scheme for Identifying Seriously Injured Children and Adults JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Newgard, C. D., Zive, D., Holmes, J. F., Bulger, E. M., Staudenmayer, K., Liao, M., Rea, T., Hsia, R. Y., Wang, N. E., Fleischman, R., Jui, J., Mann, N. C., Haukoos, J. S., Sporer, K. A., Gubler, K. D., Hedges, J. R. 2011; 213 (6): 709-721

    Abstract

    The American College of Surgeons Committee on Trauma (ACSCOT) has developed and updated field trauma triage protocols for decades, yet the ability to identify major trauma patients remains unclear. We estimate the diagnostic value of the Field Triage Decision Scheme for identifying major trauma patients (Injury Severity Score [ISS] ? 16) in a large and diverse multisite cohort.This was a retrospective cohort study of injured children and adults transported by 94 emergency medical services (EMS) agencies to 122 hospitals in 7 regions of the Western US from 2006 through 2008. Patients who met any of the field trauma triage criteria (per EMS personnel) were considered triage positive. Hospital outcomes measures were probabilistically linked to EMS records through trauma registries, state discharge data, and emergency department data. The primary outcome defining a "major trauma patient" was ISS ? 16.There were 122,345 injured patients evaluated and transported by EMS over the 3-year period, 34.5% of whom met at least 1 triage criterion and 5.8% had ISS ? 16. The overall sensitivity and specificity of the criteria for identifying major trauma patients were 85.8% (95% CI 85.0% to 86.6%) and 68.7% (95% CI 68.4% to 68.9%), respectively. Triage sensitivity and specificity, respectively, differed by age: 84.1% and 66.4% (0 to 17 years); 89.5% and 64.3% (18 to 54 years); and 79.9% and 75.4% (?55 years). Evaluating the diagnostic value of triage by hospital destination (transport to Level I/II trauma centers) did not substantially improve these findings.The sensitivity of the Field Triage Decision Scheme for identifying major trauma patients is lower and specificity higher than previously described, particularly among elders.

    View details for DOI 10.1016/j.jamcollsurg.2011.09.012

    View details for Web of Science ID 000298003700005

    View details for PubMedID 22107917

  • Ruptured Biliary Cystadenoma Managed by Angiographic Embolization and Interval Partial Hepatectomy DIGESTIVE DISEASES AND SCIENCES Ghole, S. A., Bakhtary, S., Staudenmayer, K., Sze, D. Y., Pai, R. K., Visser, B. C., Norton, J. A., Poultsides, G. A. 2011; 56 (7): 1949-1953

    View details for DOI 10.1007/s10620-011-1677-z

    View details for Web of Science ID 000291481800006

    View details for PubMedID 21445579

  • Systematic Review: Benefits and Harms of In-Hospital Use of Recombinant Factor VIIa for Off-Label Indications ANNALS OF INTERNAL MEDICINE Yank, V., Tuohy, C. V., Logan, A. C., Bravata, D. M., Staudenmayer, K., Eisenhut, R., Sundaram, V., McMahon, D., Olkin, I., McDonald, K. M., Owens, D. K., Stafford, R. S. 2011; 154 (8): 529-W190

    Abstract

    Recombinant factor VIIa (rFVIIa), a hemostatic agent approved for hemophilia, is increasingly used for off-label indications.To evaluate the benefits and harms of rFVIIa use for 5 off-label, in-hospital indications: intracranial hemorrhage, cardiac surgery, trauma, liver transplantation, and prostatectomy.Ten databases (including PubMed, EMBASE, and the Cochrane Library) queried from inception through December 2010. Articles published in English were analyzed.Two reviewers independently screened titles and abstracts to identify clinical use of rFVIIa for the selected indications and identified all randomized, controlled trials (RCTs) and observational studies for full-text review.Two reviewers independently assessed study characteristics and rated study quality and indication-wide strength of evidence.16 RCTs, 26 comparative observational studies, and 22 noncomparative observational studies met inclusion criteria. Identified comparators were limited to placebo (RCTs) or usual care (observational studies). For intracranial hemorrhage, mortality was not improved with rFVIIa use across a range of doses. Arterial thromboembolism was increased with medium-dose rFVIIa use (risk difference [RD], 0.03 [95% CI, 0.01 to 0.06]) and high-dose rFVIIa use (RD, 0.06 [CI, 0.01 to 0.11]). For adult cardiac surgery, there was no mortality difference, but there was an increased risk for thromboembolism (RD, 0.05 [CI, 0.01 to 0.10]) with rFVIIa. For body trauma, there were no differences in mortality or thromboembolism, but there was a reduced risk for the acute respiratory distress syndrome (RD, -0.05 [CI, -0.02 to -0.08]). Mortality was higher in observational studies than in RCTs.The amount and strength of evidence were low for most outcomes and indications. Publication bias could not be excluded.Limited available evidence for 5 off-label indications suggests no mortality reduction with rFVIIa use. For some indications, it increases thromboembolism.

    View details for Web of Science ID 000289622000016

    View details for PubMedID 21502651

  • Outcomes and complications of open abdomen technique for managing non-trauma patients. Journal of emergencies, trauma, and shock Kritayakirana, K., M Maggio, P., Brundage, S., Purtill, M., Staudenmayer, K., A Spain, D. 2010; 3 (2): 118-122

    Abstract

    Damage control surgery and the open abdomen technique have been widely used in trauma. These techniques are now being utilized more often in non-trauma patients but the outcomes are not clear. We hypothesized that the use of the open abdomen technique in non-trauma patients 1) is more often due to peritonitis, 2) has a lower incidence of definitive fascial closure during the index hospitalization, and 3) has a higher fistula rate.Retrospective case series of patients treated with the open abdomen technique over a 5-year period at a level-I trauma center. Data was collected from the trauma registry, operating room (OR) case log, and by chart review. The main outcome measures were number of operations, definitive fascial closure, fistula rate, complications, and length of stay.One hundred and three patients were managed with an open abdomen over the 5-year period and we categorized them into three groups: elective (n = 31), urgent (n = 35), and trauma (n = 37). The majority of the patients were male (69%). Trauma patients were younger (39 vs 53 years; P < 0.05). The most common indications for the open abdomen technique were intraabdominal hypertension in the elective group (n = 18), severe intraabdominal infection in the urgent group (n = 19), and damage control surgery in the trauma group (n = 28). The number of abdominal operations was similar (3.1-3.7) in the three groups, as was the duration of intensive care unit (ICU) stay (average: 25-31 days). The definitive fascial closure rates during initial hospitalization were as follows: 63% in the elective group, 60% in the urgent group, and 54% in the trauma group. Intestinal fistula formation occurred in 16%, 17%, and 11%, respectively, in the three groups, with overall mortality rates of 35%, 31%, and 11%.Intra-abdominal infection was a common reason for use of the open abdomen technique in non-trauma patients. However, the definitive fascial closure and fistula rates were similar in the three groups. Despite differences in indications, damage control surgery and the open abdomen technique have been successfully transitioned to elective and urgent non-trauma patients.

    View details for DOI 10.4103/0974-2700.62106

    View details for PubMedID 20606786

  • Trauma training in simulation: Translating skills from SIM time to real time JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE Knudson, M. M., Khaw, L., Bullard, M. K., Dicker, R., Cohen, M. J., Staudenmayer, K., Sadjadi, J., Howard, S., Gaba, D., Krummel, T. 2008; 64 (2): 255-263

    Abstract

    : Training surgical residents to manage critically injured patients in a timely fashion presents a significant challenge. Simulation may have a role in this educational process, but only if it can be demonstrated that skills learned in a simulated environment translate into enhanced performance in real-life trauma situations.: A five-part, scenario-based trauma curriculum was developed specifically for this study. Midlevel surgical residents were randomized to receiving this curriculum in didactic lecture (LEC) fashion or with the use of a human performance simulator (HPS). A written learning objectives test was administered at the completion of the training. The first four major trauma resuscitations performed by each participating resident were captured on videotape in the emergency department and graded by two experienced judges blinded to the method of training. The assessment tool used by the judges included an evaluation of both initial trauma evaluation or treatment skills (part I) and crisis management skills (part II) as well as an overall score (poor/fail, adequate, or excellent).: The two groups of residents received almost identical scores on the posttraining written test. Average SIM and LEC scores for part I were also similar between the two groups. However, SIM-trained residents received higher overall scores and higher scores for part II crisis management skills compared with the LEC group, which was most evident in the scores received for the teamwork category (p = 0.04).: A trauma curriculum incorporating simulation shows promise in developing crisis management skills that are essential for evaluation of critically injured patients.

    View details for DOI 10.1097/TA.0b013e31816275b0

    View details for Web of Science ID 000253287100001

    View details for PubMedID 18301184

  • Angiopoietin-2, marker and mediator of endothelial activation with prognostic significance early after trauma? ANNALS OF SURGERY Ganter, M. T., Cohen, M. J., Brohi, K., Chesebro, B. B., Staudenmayer, K. L., Rahn, P., Christiaans, S. C., Bir, N. D., Pittet, J. 2008; 247 (2): 320-326

    Abstract

    To measure plasma levels of angiopoietin-1 (Ang-1), angiopoietin-2 (Ang-2), and vascular endothelial growth factor (VEGF) early after trauma and to determine their clinical significance.Angiopoietins and VEGF play a central role in the physiology and pathophysiology of endothelial cells. Ang-2 has recently been shown to have pathogenetic significance in sepsis and acute lung injury. Little is known about the role of angiopoietins and VEGF early after trauma.Blood specimens from consecutive major trauma patients were obtained immediately upon arrival in the emergency department and plasma samples assayed for Ang-1, Ang-2, VEGF, markers of endothelial activation, protein C pathway, fibrinolytic system, and complement. Base deficit was used as a measure of tissue hypoperfusion. Data were collected prospectively.Blood samples were obtained from 208 adult trauma patients within 30 minutes after injury before any significant fluid resuscitation. Plasma levels of Ang-2, but not Ang-1 and VEGF were increased and correlated independently with severity of injury and tissue hypoperfusion. Furthermore, plasma levels of Ang-2 correlated with markers of endothelial activation, coagulation abnormalities, and activation of the complement cascade and were associated with worse clinical outcome.Ang-2 is released early after trauma with the degree proportional to both injury severity and systemic hypoperfusion. High levels of Ang-2 were associated with an activated endothelium, coagulation abnormalities, complement activation, and worse clinical outcome. These data indicate that Ang-2 is a marker and possibly a direct mediator of endothelial activation and dysfunction after severe trauma.

    View details for DOI 10.1097/SLA.0b013e318162d616

    View details for Web of Science ID 000252758500018

    View details for PubMedID 18216540

  • Ethnic disparities in long-term function outcomes after traumatic brain injury JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE Staudenmayer, K. L., Diaz-Arrastia, R., de Oliveira, A., Gentilello, L. M., Shafi, S. 2007; 63 (6): 1364-1369

    Abstract

    Ethnic disparities in access to acute rehabilitation and in long-term global neurologic outcomes after traumatic brain injury (TBI) have been previously documented. The current study was undertaken to determine whether there are specific types of functional deficits that disproportionately affect ethnic minorities after TBI.The TBI Clinical Trials Network is a National Institutes of Health-funded multicenter prospective study. Local data from trauma centers in a single ethnically diverse major metropolitan study site were analyzed. Functional outcomes were measured in 211 patients with blunt TBI (head Abbreviated Injury Scale score 3-5) who were alive >/=6 months after discharge using the Functional Status Examination (FSE), which measures outcome in 10 functional domains and compares current functional status to preinjury status. For each domain, patients were classified as functionally independent (FSE score 1, 2) or dependent upon others (FSE score 3, 4). Ethnic minorities (n = 66) were compared with non-Hispanic whites (n = 145), with p < 0.05 considered significant.The two groups had similar injury severity (head Abbreviated Injury Scale score, initial Glasgow Coma Scale score, Injury Severity Score) and were equally likely to be placed in rehabilitation after trauma center discharge (minorities 51%, whites 46%, p = 0.28). Minority patients experienced worse long-term functional outcomes in all domains, which reached statistical significance in post-TBI standard of living, engagement in leisure activities, and return to work or school.Ethnic minorities with TBI suffer worse long-term deficits in three specific functional domains. TBI rehabilitation programs should target these specific areas to reduce disparities in functional outcomes in ethnic minorities.

    View details for DOI 10.1097/TA.0b013e31815b897b

    View details for Web of Science ID 000251768100031

    View details for PubMedID 18212662

  • Civilian hospital response to mass casualty events: basic principles. Bulletin of the American College of Surgeons Staudenmayer, K., Schecter, W. P. 2007; 92 (8): 16-20

    View details for PubMedID 17715580

  • Hypertonic saline modulates innate immunity in a model of systemic inflammation SHOCK Staudenmayer, K. L., Maier, R. V., Jelacic, S., Bulger, E. M. 2005; 23 (5): 459-463

    Abstract

    We sought to determine if hypertonic saline (HTS) impacted alveolar macrophage (AM) activation and intracellular inflammatory gene signaling in a model of systemic inflammation. Rats received an intravenous administration of 4 mL/kg of 7.5% HTS or L-lactate lactated Ringer's (L-LR). They were simultaneously treated with an intraperitoneal injection of zymosan, which induces noninfectious systemic inflammation. AM were harvested by bronchoalveolar lavage 24 h after treatment. AM activation was analyzed by measurement of baseline and lipopolysaccharide (LPS)-induced TNF-alpha production. Intracellular signaling was analyzed for activation of the mitogen-activated protein kinases (MAPKs): ERK1/2, JNK, and p38. AM from HTS-treated rats produced less TNF-alpha than from L-LR-treated rats (927 +/- 335 pg/mL [SEM] vs. 3628 +/- 783 pg/mL [SEM], P = 0.001) and were also less responsive to LPS (4444 +/- 86 pg/mL [SEM] vs. 6666 +/- 91 pg/mL [SEM], P = 0.058). However, there was no difference in MAPK activation. In vivo HTS prevents excessive AM activation during systemic inflammation. This suppression is mediated through alternate pathways and does not induce the classic MAPK signaling cascade.

    View details for DOI 10.1097/01.shk.0000160523.37106.33

    View details for Web of Science ID 000228913500011

    View details for PubMedID 15834313

Conference Proceedings


  • Comparison of Thromboembolic Event Rates in Randomized Controlled Trials and Observational Studies of Recombinant Factor VIIa for Off-Label Indications. Yank, V., Logan, A. C., Tuohy, C. V., Bravata, D. M., Staudenmayer, K., Eisenhut, R., Sundaram, V., McMahon, D., McDonald, K. M., Owens, D., Stafford, R. S. AMER SOC HEMATOLOGY. 2009: 571-572

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