Urine drug screen positive for cocaine and amphetamine is not an adverse risk factor for cardiovascular morbidity or mortality in trauma

Emergency Anesthesiology Encounters, Care Practices, and Outcomes for Patients with Firearm Injuries: A 9-Year Single-Center US Level 1 Trauma Experience

BACKGROUND

Firearm injuries cause significant morbidity and mortality. Patients with firearm injuries require urgent/emergency operative procedures but the literature incompletely describes how anesthesia care and outcomes differ between high acuity trauma patients with and without firearm injuries. Our objective was to examine anesthesia care, resource utilization, and outcomes of patients with acute firearm injuries compared to nonfirearm injuries.

METHODS

We conducted a retrospective cross-sectional study of patients ≥18 years admitted to a regional Level 1 trauma center between 2014 and 2022 who required operative management within the first 2 hours of hospital arrival. We examined clinical characteristics, anesthesiology care practices, and intra- and postoperative outcomes of patients with firearm injuries compared to patients with nonfirearm injuries.

RESULTS

Over the 9-year study period, firearm injuries accounted for the largest yearly average increase in trauma admissions (firearm 10.1%, blunt 3.2%, other 1.3%, motor-vehicle crash 0.9%). Emergency anesthesiology care within 2 hours of arrival was delivered to 4.7% of injured patients (2124; 541 firearm [25.4%] and 1583 [74.5%] nonfirearm). Patients with firearm injuries were younger (30 [23-40] years vs 41 [29-56] years; P < .0001), male (90% vs 75%; P < .0001), direct admissions from scene (78% vs 62%; P < .0001), had less polytrauma (10% vs 22%; P < .0001), arrived after hours (73% vs 63%; P < .0001), and received earlier anesthesiology care (0.4 [0.3-0.7] vs 0.9 [0.5-1.5] hours after arrival; P < .0001). Patients with firearm injuries more often received invasive arterial (83% vs 77%; P < .0001) and central venous (14% vs 10%; P = .02) cannulation, blood products (3 [0-11] vs 0 [0-7] units; P < .0001), tranexamic acid (30% vs 22%; P < .001), as well as had higher estimated blood loss (500 [200-1588] mL vs 300 [100-1000] mL; P < .0001), and were transferred to the intensive care unit (ICU) more frequently (83% vs 77%; P < .001) than patients with nonfirearm injuries. Intraoperative mortality was comparable (6% firearm vs 4% nonfirearm) but postoperative mortality was lower for patients with firearm injuries who survived the intraoperative course (6% vs 14%; P < .0001). Comparatively, more patients with firearm injuries were discharged to home, or to jail (P < .001).

CONCLUSIONS

Over the study period, anesthesiologists increasingly cared for patients with firearm injuries, who often present outside of daytime hours and require urgent operative intervention. Operating room readiness and high-intensity resuscitation capacity, such as access to hemostatic control measures, are critical to achieving intraoperative survival and favorable postoperative outcomes, particularly for patients with firearm injuries.

Opioid-related polysubstance use and its effect on mortality and health resource utilization among trauma patients

BACKGROUND

Pre-injury opioid use is common, but the effects of opioid-related polysubstance use on mortality and health resources utilization (HRU) have not been investigated yet. The objective of this study was to investigate the effects of opioid-related polysubstance use on mortality and HRU among patients in trauma centres in the US.

METHODS

We conducted a retrospective cross-sectional study using the US National Trauma Databank from the year 2017 to 2019. Patients (≥ 18 years of age) who tested positive for opioids were included. Patients were analysed based on the number of substances used (i.e., opioids only, two substances (opioids + 1 substance), and three or more than three substances (opioids +  ≥ 2 substances)), and polysubstance by type (i.e., opioids only, opioids and alcohol, opioids and stimulants, opioids and benzodiazepine, and other combinations). Multivariate logistic regression was used to determine the association between polysubstance use, mortality and HRU (i.e., need for hospital admission, ICU, and mechanical ventilation).

RESULTS

Both polysubstance by number and type analyses showed that opioid-related polysubstance use was not significantly associated with mortality compared to opioids only. The odds of hospital admission were higher among the opioids and benzodiazepines group (OR 1.15, 95% CI 1.06-1.24, p < 0.01). The need for ICU was magnified using benzodiazepines and stimulants with opioids (OR 1.44, 95% CI 1.27-1.63, p < 0.01) when compared to the opioids only group.

CONCLUSION

Opioid-related pre-injury polysubstance use was associated with higher HRU in trauma patients. The evidence can be used by policymakers and practitioners to improve patient outcomes in trauma centers.

Cocaine use in trauma: the vices-paradox revisited

BACKGROUND

The "vices-paradox" describes the paradoxical association between illicit substance use and decreased mortality risk in trauma patients. Cocaine's vasoconstrictive effects may decrease hemorrhage but also increase the risk of thromboembolic complications. To clarify the effects of cocaine use on trauma patients, we compared the risk of mortality and thromboembolic complications in patients screening positive for cocaine with those screening negative.

METHODS

We searched the Trauma Quality Improvement Program database to identify patients 18 years and over who had presented with a drug and alcohol screen on admission between 2017 and 2019. After excluding all patients who had tested positive for alcohol and substances other than cocaine, we then compared the clinical outcomes of patients who were positive and negative for cocaine use.

RESULTS

Of the 312,553 patients identified, 11,942 (3.82%) had tested positive for cocaine. Cocaine users were significantly more likely to present with stab (8.0% vs 3.1%) or gunshot wounds (8.0% vs 3.0%) but had lower rates of mortality (3.6% vs 4.7%), myocardial infarction (0.1% vs 0.2%,) and cerebrovascular accident (0.3% vs 0.4%,). After controlling for covariates, the risk of death, myocardial infarction, and cerebrovascular accident did not significantly differ between cocaine and non-cocaine users.

CONCLUSION

Trauma patients positive for cocaine have similar risks of death and thromboembolic complications and so have a similar prognosis to patients negative for all drugs or alcohol, indicating that the "vices-paradox" does not apply to cocaine use. However, these patients more commonly present after penetrating trauma, suggesting cocaine use in hazardous environments.

Perioperative Considerations for Patients Exposed to Psychostimulants

Concerns regarding the perioperative management of acute psychostimulant intoxication have been recognized for decades, but novel and diverse substances in this class continue to be developed. Despite the similarities in mechanisms of action among psychostimulants, each subclass within this broad category has unique receptor specificity and different mechanisms that play a role in patient clinical presentation. These issues present challenges to anesthesia providers when caring for patients with either acute or chronic exposure to psychostimulants during the perioperative period. Challenges result from both physiological and psychological effects that influence the action of the primary anesthetic agent, adjuvant anesthetics, and analgesics used for perioperative management of pain. The epidemiology, pharmacology, and perioperative implications of psychostimulant use are presented for amphetamines and similar acting nonamphetamines, cocaine, and, finally, the mixed-action drugs known as entactogens that share stimulant and psychedelic properties. This information is then used as the foundation for safe and effective perioperative management of patients exposed to psychostimulants.

Pre-injury stimulant use in isolated severe traumatic brain injury: effect on outcomes

PURPOSE

The aim of this study was to assess the impact of pre-injury stimulant use (amphetamine, cocaine, methamphetamine and/or ecstasy) on outcomes after isolated severe traumatic brain injury (TBI).

METHODS

Retrospective 2017 TQIP study, including adult trauma patients (≥16 years old) who underwent drug and alcohol screening on admission and sustained an isolated severe TBI (head AIS ≥3). Patients with significant extracranial trauma (AIS ≥3) were excluded. Epidemiological and clinical characteristics, procedures and outcome variables were collected. Patients with isolated stimulant use were matched 1:1 for age, gender, mechanism of injury, head AIS and overall comorbidities, with patients with negative toxicology and alcohol screen. Outcomes in the two groups were compared with univariable and multivariable regression analysis.

RESULTS

681 patients with isolated TBI and stimulant use were matched with 681 patients with negative toxicology and alcohol screen. The incidence of hypotension and CGS <9 was similar in the two groups. In multivariable regression analysis, stimulant use was not independently associated with mortality (OR 0.95, 95% CI 0.61-1.49). However, stimulant use was associated with longer hospital length of stay (HLOS) (RC 1.13, 95%CI 1.03-1.24).

CONCLUSION

Pre-injury stimulant use is common in patients admitted for severe TBI, but was not independently associated with mortality when compared to patients with negative toxicology. However, stimulant use was associated with a significant longer HLOS.