BACKGROUND Blunt cerebrovascular injuries (BCVIs) are associated with significant morbidity and mortality. This guideline evaluates several aspects of BCVI diagnosis and management including the role of screening protocols, criteria for screening cervical spine injuries, and the use of antithrombotic therapy (ATT) and endovascular stents. METHODS Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, a taskforce of the Practice Management Guidelines Committee of the Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of currently available evidence. Four population, intervention, comparison, and outcome questions were developed to address diagnostic and therapeutic issues relevant to BCVI. RESULTS A total of 98 articles were identified. Of these, 23 articles were selected to construct the guidelines. In these studies, the detection of BCVI increased with the use of a screening protocol versus no screening protocol (odds ratio [OR], 4.74; 95% confidence interval [CI], 1.76–12.78; p = 0.002), as well as among patients with high-risk versus low-risk cervical spine injuries (OR, 12.7; 95% CI, 6.24–25.62; p = 0.003). The use of ATT versus no ATT resulted in a decreased risk of stroke (OR, 0.20; 95% CI, 0.06–0.65; p < 0.0001) and mortality (OR, 0.17; 95% CI, 0.08–0.34; p < 0.0001). There was no significant difference in the risk of stroke among patients with Grade II or III injuries who underwent stenting as an adjunct to ATT versus ATT alone (OR, 1.63; 95% CI, 0.2–12.14; p = 0.63). CONCLUSION We recommend using a screening protocol to detect BCVI in blunt polytrauma patients. Among patients with high-risk cervical spine injuries, we recommend screening computed tomography angiography to detect BCVI. For patients with low-risk risk cervical injuries, we conditionally recommend performing a computed tomography angiography to detect BCVI. We recommend the use of ATT in patients diagnosed with BCVI. Finally, we recommend against the routine use of endovascular stents as an adjunct to ATT in patients with Grade II or III BCVIs. LEVEL OF EVIDENCE Guidelines, Level III.

Background Rural hospitals have variable degrees of involvement within the nationwide trauma system because of differences in resources and operational goals. “Secondary overtriage” refers to the patient who is discharged home shortly after being transferred from another hospital. An analysis of these occurrences is useful to determine the efficiency of the trauma system as a whole. Materials and methods Data was extracted from a statewide trauma registry from 2007–2012 to include those who were: 1) discharged home within 48h of arrival, and 2) did not undergo a surgical procedure. We then identified those who arrived as a transfer prior to being discharged (secondary overtriage) from those who arrived from the scene. Factors associated with transfers were analyzed using a logistic regression. Injuries were classified based on the need of a specific consultant. Time of arrival to ED was analyzed using 8-hour blocks, with the 7AM–3PM block as reference. Results 19,319 patients fit our inclusion criteria of which 1,897 (9.8%) arrived as transfers. Descriptive analysis showed a number of differences between transfers and non-transfers due to our large sample size. Thus, we examined variables that had more clinical significance using logistic regression controlling for age, ISS, the type of injury, blood products given, the time of arrival to initial ER, and whether a CT scan was obtained initially. Factors associated with being transferred were ISS>15, transfusion of PRBC’s, graveyard-shift arrivals, and neurosurgical, spine, and facial injuries. Patients having a CT scan were less likely to be transferred. Conclusions Secondary overtriage may result from the hospital’s limited resources. Some of these limitations are the availability of surgical specialists, blood products, and overall coverage during the “graveyard-shift.” More liberal use of the CT scan may prevent unnecessary transfers.

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Context: Medicaid has been linked to worse outcomes in a variety of diagnoses such as lung cancer, uterine cancer, and cardiac valve procedures. It has furthermore been linked to the reduced health-related quality of life outcomes after traumatic injuries when compared to other insurance groups. In spinal cord injury (SCI), the care provided in the subacute setting may vary based upon payor status, which may have implications on outcomes and cost of care. Design: A retrospective review utilizing the institutional trauma databank was performed for all adult patients with spinal cord injury since 2009. Pediatric patients were excluded. Insurance type, race, length of stay, discharge status (alive/dead), discharge disposition, injury severity score (ISS), and hospital charges billed were recorded. Results: Two hundred patients were identified. Overall 27.5% of patients with SCI during the period of our review were Medicaid beneficiaries. ISS was similar between Medicaid and non-Medicaid patients, but the Medicaid beneficiaries were younger (37 vs 50 years of age; P < .001). Medicaid beneficiaries had a significantly longer length of stay (20.9 days; P < .001) when compared to all other patients. They furthermore were more likely to be discharged home or to a skilled nursing facility rather than an acute rehabilitation center. Inpatient charges billed for Medicaid beneficiaries were significantly higher than those of non-Medicaid patients (203,264 USD vs 140,114 USD; P = .015), likely reflecting the increased length of stay while awaiting appropriate disposition. Conclusion: Medicaid patients with SCI in West Virginia had a longer hospital stay, higher charges billed, and were more likely to be discharged home or to a skilled nursing facility rather than an acute rehabilitation center, when compared to non-Medicaid patients. The lack of availability of rehabilitation facilities for Medicaid beneficiaries likely explains this difference.

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