Clinical Implications of Over- and Under-Triage Using Need for Trauma Intervention and Cribari Indices

BACKGROUND

Need for Trauma Intervention (NFTI) score was proposed to help identify injured trauma patients while minimizing under (UT) and over triage (OT). Using a national database, we aimed to describe UT and OT of NFTI vs standard Cribari method (CM) and hypothesized triage sensitivity remains poor.

METHODS

The 2021 Trauma Quality Improvement Program (TQIP) database was queried. Demographics, mechanism, verification level, interfacility transfer (IF), and level of activation were collected. Patients were stratified by both NFTI [+ vs -] and CM [Injury severity score (ISS) < 15 vs > 15]. UT was defined as NFTI + or ISS >15 without full trauma activation.

RESULTS

1,030,526 patients were identified in TQIP. 84,969 were UT and 97,262 were OT using NFTI while 94,020 were UT and 108,823 were OT using CM. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of NFTI is 49%, 89%, 45%, and 90%, respectively vs 43%, 87%, 39%, and 89% of CM, respectively. Age was higher in the UT group using both scores (52 vs 42, P < .0001 and 54 vs 42, P < .0001, respectively). Using MLR, level 2 and 3 verification, blunt mechanism, female, IF, and older age were associated with UT in both NFTI and CM. Level 1 verification, penetrating mechanism, male, no IF, and younger age were associated with OT.

CONCLUSIONS

Current prehospital triage criteria have poor sensitivity for identifying severely injured trauma patients by both NFTI and CM. UT increases as age of the patient increases. Further studies are needed to improve triage.

Outcomes and Predictors of Delayed Intervention After Renal Trauma

INTRODUCTION

Historically, a zone II hematoma mandated exploration after penetrating trauma, but this has been challenged given potentially higher nephrectomy rates and the advent of therapeutic endovascular and endoscopic interventions. We hypothesized penetrating mechanism was not a predictor for delayed intervention in the modern era.

METHODS

This single-center, retrospective study included renal trauma patients from 3/2019 to 6/2022. Our institutional practice is selective exploration of zone II hematomas for active bleeding and expanding hematoma only, regardless of mechanism. Descriptive statistics and multivariable logistic regression (MLR) were performed.

RESULTS

One-hundred and forty-four patients were identified, with median age 32 years (IQR:23,49), 66% blunt mechanism, and injury severity score 17(IQR:11,26). Forty-three (30%) required operative intervention, and of the 20 that had a zone II exploration, 3 (15%) underwent renorrhaphy and 17 (85%) underwent nephrectomy. Penetrating patients more frequently underwent immediate operative intervention (67%vs10%,P < .0001), required nephrectomy (27%vs5%,P = .0003), and were less likely to undergo pre-intervention CT (51%vs96%,P < .0001) compared to blunt patients. Delayed renal interventions were higher in penetrating (33%vs13%,P = .004) with no difference in mortality or length of stay compared to blunt mechanism. Ureteral stent placement and renal embolization were the most common delayed interventions. On MLR, the only independent predictor for delayed intervention was need for initial operative intervention (OR 3.803;95%CI:1.612-8.975,P = .0023). Four (3%) required delayed nephrectomy, of which only one underwent initial operative intervention without zone 2 exploration.

CONCLUSIONS

The most common delayed interventions after renal trauma were renal embolization and ureteral stent. Penetrating mechanism was not a predictor of delayed renal intervention in a trauma center that manages zone II retroperitoneal hematomas similarly regardless of mechanism.

Drilling on Midway Atoll, Hawaii

Two holes drilled through reef sediments into basalt have established a geologic section through the Miocene. Midway was built above the sea by flows that were weathered and partially truncated in pre-Miocene time. After submergence, volcanic clays were reworked and covered by limestones. Overall ubmergence was interrupted at least twice by emergence. The limestones have been leached, recrystallized, and partially dolomitized.

Sediment Movement on the Continental Shelf near Washington and Oregon

The nuclides zinc-65 and cobalt-60 associated with river-borne particulate matter are incorporated in sediment on the Continental Shelf near the Colum- ia River. Changes in the relative concentrations of zinc-65 and cobalt-60 and in the ratio of the activity of zinc-65 and cobalt-60 suggest that radioactive sediment moves northward 12 to 30 kilometers per year along the shelf and 2.5 to 10 kilometers per year westward away from the coast.

Oxygen and Carbon Isotopic Composition of Limestones and Dolomites, Bikini and Eniwetok Atolls

Aragonitic, unconsolidated sediments from the borings on the Eniwetok and Bikini atolls are isotopically identical with unaltered skeletal fragments, whereas the recrystallized limestones exhibit isotopic variations resulting from alteration in meteoric waters during periods of emergence. Dolomites and associated calcites are enriched in O(18), perhaps because of interaction with hypersaline brines.

Radioactivity of the Columbia River Effluent

Chromium-51 and zinc-65 were detected as far as 115 and 15 kilometers, respectively, from the mouth of the Columbia River; zinc-65 also was found at a few isolated stations. Zirconium-95 and niobium-95 from atmospheric fallout occurred in the river effluent but they were most abundant in surface waters further ofJshore. Distribution of the radionuclides is controlled largely by surface currents and by upwelling of sea water near the coast.

Varved Marine Sediments in a Stagnant Fjord

Varved sediments, containing planktonic marine diatoms, occur in Saanich Inlet, British Columbia. An olive-gray lamina, rich in opal, apparently forms during the bloom of Skeletonema costatum in the spring or summer, after which an olive-black lamina is deposited.