Blunt Abdominal Trauma in Pregnancy: Higher Rates of Severe Abdominal Injuries

BACKGROUND

Previous studies suggest increased abdominal girth in obese individuals provides a "cushion effect," against severe abdominal trauma. In comparison, the unique anatomic/physiological condition of pregnancy, such as the upward displacement of organs by an expanding uterus, may decrease risk of abdominal injury. However, increased overall blood volume and vascularity of organs during pregnancy raise concerns for increased bleeding and potentially more severe injuries. Therefore, this study aimed to elucidate whether the "cushion effect" observed in obese patients extends to pregnant trauma patients (PTPs). We hypothesized a lower risk of blunt solid organ injury (BSOI) (liver, spleen, and kidney) in pregnant vs non-pregnant blunt trauma patients.

METHODS

The 2020-2021 Trauma Quality Improvement Program was queried for all female blunt trauma patients (age<50 years) involved in motor vehicle collisions (MVCs). We compared pregnant vs non-pregnant patients. The primary outcomes were incidence of BSOI, and severity of abdominal trauma defined by abbreviated injury scale (AIS).

RESULTS

From 94,831 female patients, 2598 (2.7%) were pregnant. When compared to non-pregnant patients, PTPs had lower rates of liver (5.5% vs 7.6%, P < .001) and kidney (1.8% vs 2.6%, P = .013) injury. However, PTPs had higher rates of serious (13.4% vs 9.0%, P < .001) and severe abdominal injury (7.5% vs 4.3%, P < .001).

DISCUSSION

BSOI occurred at a lower rate in PTPs compared to non-PTPs; however, contrary to the "cushion effect" observed in obese populations, pregnant women had a higher rate of severe abdominal injuries. These data support comprehensive evaluations for PTPs presenting after a MVC.

LEVEL OF EVIDENCE

IV (therapeutic).

Immediate Operative Trauma Assessment Score: A Simple and Reliable Predictor of Mortality in Trauma Patients Undergoing Urgent/Emergent Surgery

Objective: Many current trauma mortality prediction tools are either too intricate or rely on data not readily available during a trauma patient's initial evaluation. Moreover, none are tailored to those necessitating urgent or emergent surgery. Our objective was to design a practical, user-friendly scoring tool using immediately available variables, and then compare its efficacy to the widely-known Revised Trauma Score (RTS). Methods: The adult 2017-2021 Trauma Quality Improvement Program (TQIP) database was queried to identify patients ≥18 years old undergoing any urgent/emergent operation (direct from Emergency Department to operating room). Patients were divided into derivation and validation groups. A three-step methodology was used. First, multiple logistic regression models were created to determine risk of death using only variables available upon arrival. Second, the weighted average and relative impact of each independent predictor was used to derive an easily calculated Immediate Operative Trauma Assessment Score (IOTAS). We then validated IOTAS using AUROC and compared it to RTS. Results: From 249 208 patients in the derivation-set, 14 635 (5.9%) died. Age ≥65, Glasgow Coma Scale score <9, hypotension (SBP <90 mmHg), and tachycardia (>120/min) on arrival were identified as independent predictors for mortality. Using these, the IOTAS was structured, offering scores between 0-8. The AUROC for this was .88. A clear escalation in mortality was observed across scores: from 4.4% at score 1 to 60.5% at score 8. For the validation set (250 182 patients; mortality rate 5.8%), the AUROC remained consistent at .87, surpassing RTS's AUROC of .83. Conclusion: IOTAS is a novel, accurate, and now validated tool that is intuitive and efficient in predicting mortality for trauma patients requiring urgent or emergent surgeries. It outperforms RTS, and thereby may help guide clinicians when determining the best course of action in patient management as well as counseling patients and their families.

iPad-Based Neurocognitive Testing (ImPACT-QT) in Acute Adult Mild Traumatic Brain Injury/Concussion: Study on Practicality and Bedside Cognitive Scores in a Level-1 Trauma Center

BACKGROUND

There lacks rapid standardized bedside testing to screen cognitive deficits following mild traumatic brain injury (mTBI). Immediate Post-Concussion Assessment & Cognitive Testing-Quick Test (ImPACT-QT) is an abbreviated-iPad form of computerized cognitive testing. The aim of this study is to test ImPACT-QT utility in inpatient settings. We hypothesize ImPACT-QT is feasible in the acute trauma setting.

METHOD

Trauma patients ages 12-70 were administered ImPACT-QT (09/2022-09/2023). Encephalopathic/medically unstable patients were excluded. Mild traumatic brain injury was defined as documented-head trauma with loss-of-consciousness <30 minutes and arrival Glasgow Coma Scale 13-15. Patients answered Likert-scale surveys. Bivariate analyses compared demographics, attention, motor speed, and memory scores between mTBI and non-TBI controls. Multivariable logistic regression assessed memory score as a predictor of mTBI diagnosis.

RESULTS

Of 233 patients evaluated (36 years [IQR 23-50], 71% [166/233] female), 179 (76%) were mTBI patients. For all patients, mean test-time was 9.3 ± 2 minutes with 93% (73/76) finding the test "easy to understand." Mild traumatic brain injury patients than non-TBI control had lower memory scores (25 [IQR 7-100] vs 43 [26-100], P = .001) while attention (5 [1-23] vs 11 [1-32]) and motor score (14 [3-28] vs 13 [4-32]) showed no significant differences. Multivariable-regression (adjustment: age, sex, race, education level, ISS, and time to test) demonstrated memory score predicted mTBI positive status (OR .96, CI .94-.98, P = .004).

DISCUSSION

Immediate Post-Concussion Assessment & Cognitive Testing-Quick Test is feasible in trauma patients. Preliminary findings suggest acute mTBIs have lower memory but not attention/motor scores vs non-TBI trauma controls.

Similar rate of venous thromboembolism (VTE) and failure of non-operative management for early versus delayed VTE chemoprophylaxis in adolescent blunt solid organ injuries: a propensity-matched analysis

BACKGROUND

Early initiation of venous thromboembolism (VTE) chemoprophylaxis in adults with blunt solid organ injury (BSOI) has been demonstrated to be safe but this is controversial in adolescents. We hypothesized that adolescent patients with BSOI undergoing non-operative management (NOM) and receiving early VTE chemoprophylaxis (eVTEP) (≤ 48 h) have a decreased rate of VTE and similar rate of failure of NOM, compared to similarly matched adolescents receiving delayed VTE chemoprophylaxis (dVTEP) (> 48 h).

METHODS

The 2017-2019 Trauma Quality Improvement Program database was queried for adolescents (12-17 years of age) with BSOI (liver, kidney, and/or spleen) undergoing NOM. We compared eVTEP versus dVTEP using a 1:1 propensity score model, matching for age, comorbidities, BSOI grade, injury severity score, hypotension on arrival, and need for transfusions. We performed subset analyses in patients with isolated spleen, kidney, and liver injury.

RESULTS

From 1022 cases, 417 (40.8%) adolescents received eVTEP. After matching, there was no difference in matched variables (all p > 0.05). Both groups had a similar rate of VTE (dVTEP 0.6% vs. eVTEP 1.7%, p = 0.16), mortality (dVTEP 0.3% vs. eVTEP 0%, p = 0.32), and failure of NOM (eVTEP 6.7% vs. dVTEP 7.3%, p = 0.77). These findings remained true in all subset analyses of isolated solid organ injury (all p > 0.05).

CONCLUSIONS

The rate of VTE with adolescent BSOI is exceedingly rare. Early VTE chemoprophylaxis in adolescent BSOI does not increase the rate of failing NOM. However, unlike adult trauma patients, adolescent patients with BSOI receiving eVTEP had a similar rate of VTE and death, compared to adolescents receiving dVTEP.

Combined Arterial and Venous Lower Extremity Injury

This case-control study assesses the need for prophylactic fasciotomy and delayed fasciotomy in combined arterial and venous injury compared with those with isolated artery or vein injury.

Development of a novel scoring tool to predict the need for early cricothyroidotomy in trauma patients

Background

The lack of a widely-used tool for predicting early cricothyroidotomy in trauma patients prompted us to develop the Cricothyroidotomy After Trauma (CAT) score. We aimed to predict the need for cricothyroidotomy within one hour of trauma patient arrival.

Methods

Derivation and validation datasets were obtained from the Trauma Quality Improvement Program (TQIP) database. Logistic modeling identified predictors, and weighted averages were used to create the CAT score. The score's performance was assessed using AUROC.

Results

Among 1,373,823 derivation patients, <1 % (n = 339) underwent cricothyroidotomy within one hour. The CAT score, comprising nine predictors, achieved an AUROC of 0.88. Severe neck injury and gunshot wound were the strongest predictors. Cricothyroidotomy rates increased from 0.4 % to 9.3 % at scores of 5 and 8, respectively. In the validation set, the CAT tool yielded an AUROC of 0.9.

Conclusion

The CAT score is a validated tool for predicting the need for early cricothyroidotomy in trauma patients. Further research is necessary to enhance its utility and assess its value in trauma care.

Obesity Does Not Increase Risk for Mortality in Severe Sepsis Trauma Patients

INTRODUCTION

The prevalence of obesity in the United States is up to 40% in adults. Obese patients with severe sepsis have a lower mortality rate compared with normal body mass index (BMI) patients. We hypothesized that trauma patients with severe sepsis and obese BMI will have a decreased mortality risk in comparison with normal BMI patients.

METHODS

The Trauma Quality Improvement Program (2017) was queried for adult trauma patients with documented BMI and severe sepsis. Patients were grouped based on BMI: non-obese trauma patients (nOTP) BMI <30 kg/m2 and obese trauma patients (OTP) ≥30 kg/m2. A multivariable logistic regression model was used for analysis of mortality.

RESULTS

From 1246 trauma patients with severe sepsis, 566 (42.4%) were nOTP and 680 (57.6%) were OTP. OTP had increased length of stay (LOS) (19 vs 21 days, P < .001), intensive care unit (ICU) LOS (13 vs 18 days, P < .001) and ventilator days (10 vs 11 days, P < .001). After adjusting for covariates, when compared to normal BMI patients, patients who were overweight (OR 1.11 CI .875-1.41 P = .390), obese (OR .797 CI .59-1.06 P = .126), severely obese (OR .926 CI .63-1.36 P = .696) and morbidly obese (OR 1.448 CI 1.01-2.07 P = .04) all had a similar associated risk for mortality compared to patients with normal BMI.

CONCLUSION

In adult trauma patients with severe sepsis, this national analysis demonstrated OTP had increased LOS, ICU LOS, and ventilator days compared to nOTP. However, patients with increasing degrees of obesity had similar associated risk of mortality compared to trauma patients with severe sepsis and a normal BMI.

Scoring Tool to Predict Need for Early Video-Assisted Thoracoscopic Surgery (VATS) After Pediatric Trauma

BACKGROUND

No widely used stratification tool exists to predict which pediatric trauma patients may require a video-assisted thoracoscopic surgery (VATS). We sought to develop a novel VATS-In-Pediatrics (VIP) score to predict the need for early VATS (within 72 h of admission) for pediatric trauma patients.

METHODS

The pediatric 2017-2020 Trauma Quality Improvement Program database was used and divided into two sets (derivation set using 2017-2019 data and validation set using 2020 data). First, multiple logistic regression models were created to determine the risk of early VATS for patients ≤ 17 years old. Second, the weighted average and relative impact of each independent predictor were used to derive a VIP score. We then validated the score using the area under the receiver operating characteristic (AROC) curve.

RESULTS

From 218,628 patients in the derivation set, 2183 (1.0%) underwent early VATS. A total of 8 independent predictors of VATS were identified, and the VIP score was derived with scores ranging from 0 to 9. The AROC for this was 0.91. The VATS rate increased steadily from 12.5 to 32% then 60.5% at scores of 3, 4, and 6, respectively. In the validation set, from 70,316 patients, 887 (1.3%) underwent VATS, and the AROC was 0.91.

CONCLUSIONS

VIP is a novel and validated scoring tool to predict the need for early VATS in pediatric trauma. This tool can potentially help hospital systems prepare for pediatric patients at high risk for requiring VATS during their first 72 h of admission. Future prospective research is needed to evaluate VIP as a tool that can improve clinical outcomes.

Diagnostic Peritoneal Aspiration or Lavage in Stratified Groups of Hypotensive Blunt Trauma Patients

BACKGROUND

Some reports suggest Diagnostic peritoneal aspiration (DPA) or lavage (DPL) may better select which hypotensive blunt trauma patients (BTPs) require operation, compared to ultrasonography. However, whether both moderately hypotensive (systolic blood pressure [SBP] < 90 mmHg) and severely hypotensive (SBP < 70 mmHg) patients benefit from DPA/DPL is unclear. We hypothesized DPA/DPL used within the first hour increases risk of death for severely vs moderately hypotensive BTPs.

METHODS

The 2017-2019 Trauma Quality Improvement Program database was queried for BTPs ≥ 18 years old with hypotension upon arrival. We compared moderately and severely hypotensive groups. A multivariable logistic regression analysis was performed controlling for age, comorbidities, emergent operation, blood transfusions, and injury profile.

RESULTS

From 134 hypotensive patients undergoing DPA/DPL, 66 (49.3%) had severe hypotension. Patients in both groups underwent an emergent operation (43.9% vs 58.8%, P = .09) in a similar amount of time (median, 42-min vs 54-min, P = .11). Compared to the moderately hypotensive group, severely hypotensive patients had a higher rate and associated risk of death (84.8% vs 50.0%, P < .001) (OR 5.40, CI 2.07-14.11, P < .001). The strongest independent risk factor for death was age ≥ 65 (OR 24.81, CI 4.06-151.62, P < .001).

DISCUSSION

Among all BTPs undergoing DPA/DPL within the first hour of arrival, an over 5-fold increased risk of death for patients with severe hypotension was demonstrated. As such, DPA/DPL within this group should be used with caution, particularly for older patients, as they may be better served by immediate surgeries. Future prospective research is needed to confirm these findings and elucidate the ideal DPA/DPL population in the modern era of ultrasonography.

Antibiotic administration within 1 hour for open lower extremity fractures is not associated with decreased risk of infection

BACKGROUND

Open fractures have a high risk of infection with limited data correlating timing of prophylactic antibiotic administration and rate of subsequent infection. The Trauma Quality Improvement Program has established a standard of antibiotic administration within 1 hour of arrival, but there is a lack of adequately powered studies validating this quality metric. We hypothesize that open femur and/or tibia fracture patients undergoing orthopedic surgery have a decreased risk of infectious complications (osteomyelitis, deep and superficial surgical site infection) if antibiotics are administered within 1 hour of presentation compared with administration after 1 hour.

METHODS

The 2019 Trauma Quality Improvement Program was queried for adults with isolated (Abbreviated Injury Scale <1 for the head/face/spine/chest/abdomen/upper extremity) open femur and/or tibia fractures undergoing orthopedic surgery. Transfer patients were excluded. Patients receiving early antibiotics (EA) within 1 hour were compared with patients receiving delayed antibiotics (DA) greater than 1 hour from arrival.

RESULTS

Of 3,367 patients identified, 2,400 (70.4%) received EA. Patients receiving EA had a higher rate of infections compared with DA (1.1% vs. 0.2%, p = 0.011). After adjusting for age, comorbidities, injury severity, nerve/vascular trauma to the lower extremity, washout of the femur/tibia performed in <6 hours, blood transfusion, and admission vitals, patients in the EA group had a similar associated risk of surgical site infection/osteomyelitis compared with the DA cohort ( p = 0.087). These results remained in subset analyses of patients with only femur, only tibia, and combined femur/tibia open fractures (all p > 0.05).

CONCLUSION

In this large national analysis, approximately 70% of isolated open femur or tibia fracture patients undergoing surgery received antibiotics within 1 hour. After adjusting for known risk factors of infection, there was no association between timing of antibiotic administration and infection. Reconsideration of the quality metric of antibiotic administration within 1 hour for open fractures appears warranted.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Discrepancies in Thyroidectomy Outcomes Between General Surgeons and Otolaryngologists

Thyroidectomy is a common operation, performed by general surgeons and otolaryngologists. Few studies compare complication rates between these two specialties. We hypothesized that there would be no difference in the incidence of postoperative complications including recurrent laryngeal nerve (RLN) injury, hypocalcemia, or hematoma based on the surgical specialty performing the thyroidectomy. The 2016-2017 National Surgical Quality Improvement Program Targeted Thyroidectomy database was queried for patients who underwent thyroidectomy for both benign and malignant thyroid diseases. Thyroidectomies performed by general surgeons were compared to those performed by otolaryngologists. Multivariate logistic regression was used to identify risk factors associated with RLN injury, hematoma, and hypocalcemia. From 11,595 patients, 6313 (54.4%) were performed by general surgeons and 5282 (45.6%) by otolaryngologists. Goiter (43.7%) and nodule/neoplasm (40.8%) were the most common indications for the general surgery and otolaryngology cohorts respectively. General surgeons used an energy vessel sealant device more frequently (77.7% vs. 51.5%, p < 0.001), whereas RLN monitoring (67.4% vs. 58.3%, p < 0.001) and drain placement (44.3% vs. 14.8%, p < 0.001) were utilized more often by otolaryngology. After controlling for covariates, thyroidectomy by general surgeons had an increased associated risk of RLN injury (OR = 1.26, CI = 1.07-1.48, p = 0.006) and post-operative hypocalcemia (OR = 1.17, CI = 1.00-1.37, p = 0.046). Thyroidectomy volume is relatively equally distributed among general surgeons and otolaryngologists. Operation by a general surgeon is associated with an increased risk for RLN injury and postoperative hypocalcemia. This discrepancy may be explained by case volume, training, and/or completion of an endocrine surgery fellowship; however, this discrepancy still merits ongoing attention.

Comparison of Same and Different Level Height Falls on Subsequent Midline Shift in Pediatric Traumatic Brain Injury

OBJECTIVES

Up to 44% of pediatric traumatic brain injury occurs as a result of a fall. We hypothesized that a fall from height is associated with higher risk for subsequent midline shift in pediatric traumatic brain injury compared with a fall from same level.

METHODS

The Pediatric Trauma Quality Improvement Program 2016 was queried for kids younger than 16 years with an injury in the abbreviated injury scale for the head after a fall. Patients with midline shift were identified. A logistic regression model was used for analysis.

RESULTS

The risk of a midline shift was lower in those with a fall from a height (odds ratio, 0.64; 95% confidence interval, 0.46-0.91, P = 0.01). In kids older than 4 years, there was no association between the level of height of the fall and subsequent midline shift (P = 0.62). The risk for midline shift in kids younger than 4 years after a fall from same level was lower (odds ratio, 0.40; 95% confidence interval, 0.24-0.67; P = 0.001).

CONCLUSIONS

In kids with traumatic brain injury, trauma activations due to falls from the same level are associated with a 2.5-fold higher risk of subsequent midline shift, compared with falling from height.

Race, Age, and Lack of Insurance Increase Risk of Suicide Attempt in Trauma Patients

OBJECTIVE

The overall rate of suicide between 1999 and 2017 increased by 33% in the United States. We sought to examine suicide attempts in the trauma patient population, hypothesizing that in adult trauma patients race and lack of insurance status would be predictors of suicide attempt.

METHOD

The Trauma Quality Improvement Program (2010-2016) was queried for trauma patients ≥18 years old. The primary outcome was suicide attempt. A multivariable logistic regression model was performed including covariates that influence risk of suicide attempt.

RESULTS

From 1,403,466 adult trauma admissions, 16,263 (1.2%) patients attempted suicide. Death after suicide attempt occurred in 30.2% of patients. Independent predictors of suicide attempt were age < 40 years old (odds ratio [OR] = 1.46, 95% confidence interval [CI] [1.41, 1.51], p < .001) and no insurance (OR = 1.92, 95% CI [1.85, 2.00], p < .001). Black (vs. White) race was associated with decreased risk of suicide attempt (OR = 0.63, 95% CI [0.60, 0.67], p < .001). Hispanic (versus non-Hispanic) patients demonstrated lower associated risk of suicide attempt by gun (OR = 0.50, 95% CI [0.45, 0.54], p < .001), while Asian (vs. White) patients exhibited higher risk of suicide attempt overall (OR = 1.25, 95% CI [1.12, 1.39], p < .001) and more specifically by knife (OR = 2.55, 95% CI [2.16, 3.00], p < .001).

CONCLUSIONS

Age younger than 40 years and lack of insurance were associated with higher risk of suicide attempt in adult trauma patients. Asian race was associated with the highest risk of suicide, with >2.5 times increased risk of attempt by knife. Awareness of these demographic-specific risk factors for suicide attempt, and in particular violent mechanisms of suicide attempt, is critical to implementation of effective suicide prevention efforts.HighlightsAge younger than 40 and no insurance were associated with risk of suicide attempt.Black (vs. White) race was associated with decreased risk of suicide attempt.Asian race was associated with an increased risk of suicide attempt with a knife.

Blunt Trauma Mortality: Does Trauma Center Level Matter?

INTRODUCTION

Trauma centers have improved outcomes compared to nontrauma centers when caring for injured patients. A multicenter report found blunt trauma patients treated at American College of Surgeons' Level I trauma centers have improved survival compared to Level II centers. In a subsequent multicenter study, Level II centers had improved survival in all trauma patients. We sought to provide a more granular analysis by stratifying blunt mechanisms-to determine if there was a difference in mortality between Level I and Level II centers.

METHODS

The Trauma Quality Improvement Program (2010-2016) was queried for patients presenting to an American College of Surgeons' Level I or II trauma center after blunt trauma. A multivariable logistic regression analysis was performed controlling for comorbidities and Trauma and Injury Severity Score.

RESULTS

From 734,473 patients with blunt trauma, 507,715 (69.1%) were treated at a Level I center and 226,758 (30.9%) at a Level II center. The Level I cohort was younger (median age, 53 versus 58, P = 0.01), with a higher median injury severity score (13 versus 10, P < 0.001) and with more patients presenting after a motor vehicle accident (MVA) (27.9% versus 22.4%, P < 0.001) and lower rates of falls (46.6% versus 54.5%, P < 0.001). After adjusting for covariates, there was no difference in mortality between Level I and Level II centers (P > 0.05). When stratifying by mechanisms, Level I centers had a decreased associated mortality for MVA (odds ratio = 0.94, CI: 0.88-0.99, P = 0.04) and bicycle accidents (odds ratio = 0.77, CI: 0.74-0.03, P = 0.01) but no difference in falls or pedestrians struck (P > 0.05).

CONCLUSIONS

Overall, blunt trauma patients presenting to a Level I center have no difference in mortality compared to a Level II center. However, when stratified by mechanism, those involved in MVA or bicycle accidents have a decreased associated risk of mortality. Future prospective studies examining variations in practice to account for these differences are warranted.

Comparative Outcomes for Trauma Patients in Prison and the General Population

BACKGROUND

Prisoners are a vulnerable population, and there are few contemporary studies that consider trauma patient outcomes within the prisoner population. Therefore, we sought to provide a descriptive analysis of prisoners involved in trauma and evaluate whether a healthcare disparity exists. We hypothesized that prisoners and non-prisoners have a similar risk of mortality and in-hospital complications after trauma.

METHODS

The Trauma Quality Improvement Program (2015-2016) was queried for trauma patients based upon location inside or outside of prison at the time of injury. A multivariable logistic regression analysis was performed to compare these groups for risk of mortality-the primary outcome.

RESULTS

From 593,818 trauma patients, 1115 were located in prison. Compared to non-prisoners, prisoner trauma patients had no significant difference in mortality (5.1 vs 6.0%, P = .204). However, after adjusting for covariates, prisoners had a shorter length of stay (LOS) (mean days, 6.3 vs 7.8, P < .001), shorter intensive care unit (ICU) LOS (mean days, 5.44 vs 5.89, P = .004), and fewer complications, including lower rates of drug/alcohol withdrawal (.4% vs 1.1%, P = .030), pneumonia (.5 vs 1.6%, P = .004), and urinary tract infections (.0 vs 1.1%, P < .001). Upon performing a multivariable logistic regression model, prisoner trauma patients had a similar associated risk of mortality compared to non-prisoners (OR 1.61, CI .52-4.94, P = .409).

DISCUSSION

Our results suggest that prisoner trauma patients at least receive equivalent treatment in terms of mortality and may have better outcomes when considering some complications. Future prospective studies are needed to confirm these results and explore other factors, which impact prisoner patient outcomes.

Laparoscopy in the Evaluation of Blunt Abdominal Injury in Level-I and II Pediatric Trauma Centers

Introduction

An American College of Surgeons (ACS) Level-I (L-I) pediatric trauma center demonstrated successful laparoscopy without conversion to laparotomy in ∼65% of trauma cases. Prior reports have demonstrated differences in outcomes based on ACS level of trauma center. We sought to compare laparoscopy use for blunt abdominal trauma at L-I compared to Level-II (L-II) centers.

Methods

The Pediatric Trauma Quality Improvement Program was queried (2014-2016) for patients ≤16 years old who underwent any abdominal surgery. Bivariate analyses comparing patients undergoing abdominal surgery at ACS L-I and L-II centers were performed.

Results

970 patients underwent abdominal surgery with 14% using laparoscopy. Level-I centers had an increased rate of laparoscopy (15.6% vs 9.7%, P = .019 ); however they had a lower mean Injury Severity Score (16.2 vs 18.5, P = .002) compared to L-II centers. Level-I and L-II centers had similar length of stay ventilator days, and SSIs (all P > .05).

Conclusion

While use of laparoscopy for pediatric trauma remains low, there was increased use at L-I compared to L-II centers with no difference in LOS or SSIs. Future studies are needed to elucidate which pediatric trauma patients benefit from laparoscopic surgery.

Helmets Protect Pediatric Bicyclists From Head Injury and Do Not Increase Risk of Cervical Spine Injury

OBJECTIVES

Only 21 states have mandatory helmet laws for pediatric bicyclists. This study sought to determine the incidence of helmeted riders among pediatric bicyclists involved in a collision and hypothesized the risk of a serious head and cervical spine injuries to be higher in nonhelmeted bicyclists (NHBs) compared with helmeted bicyclists (HBs).

METHODS

The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for pediatric (age <16 years) bicyclists involved in a collision. Helmeted bicyclists were compared with NHBs. A serious injury was defined by an abbreviated injury scale grade of greater than 2.

RESULTS

From 3693 bicyclists, 3039 (82.3%) were NHBs. Compared with HBs, NHBs were more often Black (21.6% vs 3.8%, P < 0.001), Hispanic (17.5% vs 9.3%, P < 0.001), without insurance (4.6% vs 2.4%, P = 0.012), and had a higher rate of a serious head injury (24.6% vs 9.3%, P < 0.001). Both groups had similar rates of complications and mortality (P > 0.05). The associated risk of a serious head (odds ratio = 3.17, P < 0.001) and spine injury (odds ratio = 0.41, P = 0.012) were higher and lower respectively in NHBs. Associated risks for cervical spine fracture or cord injury were similar (P > 0.05).

CONCLUSIONS

Pediatric bicyclists involved in a collision infrequently wear helmets, and NHBs was associated with higher risks of serious head injury. However, the associated risk of serious spine injury among NHBs was lower. The associated risks for cervical spine fracture or cervical cord injuries were similar. Nonhelmeted bicyclists were more likely to lack insurance and to be Black or Hispanic. Targeted outreach programs may help decrease the risk of injury, especially in at-risk demographics.

Firearm violence against children in the United States: Trends in the wake of the COVID-19 pandemic

BACKGROUND

This study aimed to evaluate the patterns of firearm violence against children before and after the COVID-19 pandemic, as well as the patterns of specific types of firearm violence against children over time (2016-2020).

METHODS

Retrospective firearm violence data were obtained from the Gun Violence Archive. The rate of firearm violence was weighted per 100,000 children. A scatterplot was created to depict the rate of total annual child-involved shooting incidents over time; with a linear trendline fit to 2016 to 2019 data to show projected versus actual 2020 firearm violence. All 50 states were categorized into either "strong gun law" (n = 25) or "weak gun law" (n = 25) cohorts. Multivariate linear regressions were performed for number of child-involved shootings over time.

RESULTS

There were a total of 1,076 child-involved shootings in 2020, 811 in 2019, and 803 in 2018. The median total child-involved shooting incidents per month per 100,000 children increased from 2018 to 2020 (0.095 vs. 0.124, p = 0.003) and from 2019 to 2020 (0.097 vs. 0.124, p = 0.010). Child killed by adult incidents also increased in 2020 compared with 2018 (p = 0.024) and 2019 (p = 0.049). The scatterplot demonstrates that total child-involved shootings in addition to both fatal and nonfatal firearm violence incidents exceeded the projected number of incidents extrapolated from 2016 to 2019 data. Multivariate linear regression demonstrated that, compared with weak gun law states, strong gun law states were associated with decreased monthly total child-involved shooting incidents between 2018 and 2020 (p < 0.001), as well as between 2019 and 2020 (p < 0.001).

CONCLUSION

Child-involved shooting incidents increased significantly in 2020 surrounding the COVID-19 pandemic. Given that gun law strength was associated with a decreased rate of monthly child-involved firearm violence, public health and legislative efforts should be made to protect this vulnerable population from exposure to firearms.

LEVEL OF EVIDENCE

Epidemiological, level III.

Association of Risk of Mortality in Pediatric Patients Transferred From Scene by Helicopter With Major But Not Minor Injuries

OBJECTIVES

Helicopter emergency medical services (HEMS) are used for 16% of pediatric trauma. National HEMS guidelines advised that triage criteria be standardized for pediatric patients. A national report found pediatric HEMS associated with decreased mortality compared with ground emergency medical services (GEMS) but did not control for transport time. We hypothesized that the rate of HEMS has decreased nationally and the mortality risk for HEMS to be similar when adjusting for transport time compared with GEMS.

METHODS

The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients younger than 16 years transported by HEMS or GEMS. A multivariable logistic regression was used.

RESULTS

From 25,647 patients, 4527 (17.7%) underwent HEMS. The rate of HEMS from scene decreased from 21.2% in 2014 to 18.2% in 2016. The rate of HEMS for minor trauma (Injury Severity Score <15) decreased from 14.9% in 2014 to 13.5% in 2016 and major trauma (Injury Severity Score > 15) from 38.4% in 2014 to 35.9% in 2016. After controlling for predictors of mortality and transport time, HEMS was associated with decreased risk of mortality for only those with major injuries transferred from scene (odds ratio, 0.48; 95% confidence interval, 0.26-0.88; P = 0.01) compared with GEMS.

CONCLUSIONS

The rate of HEMS in pediatric trauma has decreased. However, there is room for improvement as 14% of those with minor trauma are transported by HEMS. Given the similar risk of mortality compared with GEMS, further development of guidelines that avoid the unnecessary use of HEMS appears warranted. However, utilization of HEMS for transport of pediatric major trauma should continue.

Early cognitive impairment is common in pediatric patients following mild traumatic brain injury

INTRODUCTION

The incidence and factors related to early cognitive impairment (ECI) after mild traumatic brain injury (mTBI) in pediatric trauma patients (PTPs) are unknown. Prior data in the adult population demonstrated an ECI incidence of 51% after mTBI and strong correlation with initial Glasgow Coma Scale (GCS) and Brain Injury Guidelines (BIG) category. Therefore, we hypothesized that ECI is common after mTBI in PTPs and associated with initial GCS and BIG category.

METHODS

A single-center, retrospective review of PTPs (age, 8-17 years) from 2015 to 2019 with intracranial hemorrhage and mTBI (GCS score, 13-15) was performed. Primary outcome was ECI, defined as Ranchos Los Amigos score less than 8. Comparisons between ECI and non-ECI groups regarding Injury Severity Score (ISS), demographics, and cognitive and clinical outcomes were evaluated using χ2 statistics and Wilcoxon rank sum tests. Odds of ECI were evaluated using multivariable logistic regression.

RESULTS

From 47 PTPs with mTBI, 18 (38.3%) had ECI. Early cognitive impairment patients had a higher ISS than non-ECI patients (19.7 vs. 12.6, p = 0.003). Injuries involving motor vehicles were more often related to ECI than non-auto-involved mechanisms (55% vs. 15%, p = 0.005). Lower GCS score (odds ratio [OR], 6.60; 95% confidence interval [CI], 1.34-32.51, p = 0.02), higher ISS (OR, 1.12; 95% CI, 1.01-1.24; p = 0.030), and auto-involved injuries (OR, 6.06; 95% CI, 1.15-31.94; p = 0.030) were all associated with increased risk of ECI. There was no association between BIG category and risk of ECI (p > 0.05).

CONCLUSION

Nearly 40% of PTPs with mTBI suffer from ECI. Lower initial GCS score, higher ISS, and autoinvolved mechanism of injury were associated with increased risk of ECI. Brain Injury Guidelines category was not associated with ECI in pediatric patients.

LEVEL OF EVIDENCE

Prognostic study, Level III.

Blunt Trauma Massive Transfusion (B-MaT) Score: A Novel Scoring Tool

BACKGROUND

Multiple tools predicting massive transfusion (MT) in trauma have been developed but utilize variables that are not immediately available. Additionally, they only differentiate blunt from penetrating trauma and do not account for the large range of blunt mechanisms and their difference in force. We aimed to develop a Blunt trauma Massive Transfusion (B-MaT) score that accounts for high-risk blunt mechanisms and predicts MT needs in blunt trauma patients (BTPs) prior to arrival.

MATERIALS AND METHODS

The adult 2017 Trauma Quality Improvement Program database was used to identify BTPs who were divided into 2 sets at random (derivation/validation). First, multiple logistic regression models were created to determine risk factors of MT (≥6 units of PRBCs within 4-hours or ≥10 units within 24-hours). Next, the weighted average and relative impact of each independent predictor was used to derive a B-MaT score. Finally, the area under the receiver-operating curve (AROC) was calculated.

RESULTS

Of 172,423 patients in the derivation-set, 1,160 (0.7%) required MT. Heart rate ≥ 120bpm, systolic blood pressure ≤ 90mmHg, and high-risk blunt mechanisms were identified as independent predictors for MT. B-MaT scores were derived ranging from 0 -9, with scores of 6, 7, and 9 yielding a MT rate of 11.7%, 19.4%, and 32.4%, respectively. The AROC was 0.86. The validation-set had an AROC of 0.85.

CONCLUSIONS

B-MaT is a novel scoring tool that predicts need for MT in BTPs and can be calculated prior to arrival. B-MaT warrants prospective validation to confirm its accuracy and assess its ability to improve patient outcomes and blood product allocation.

Nerve monitoring decreases recurrent laryngeal nerve injury risk for neoplasm-related thyroidectomy

OBJECTIVE

Conflicting reports exist regarding the benefit of intraoperative neuromonitoring (INM) for patients undergoing thyroidectomy. We hypothesized that in a national sample, the risk of mild and severe RLNi is decreased for patients undergoing neoplasm-related disease (NRD) thyroidectomy with INM compared to patients without INM.

METHODS

The database was queried for patients that underwent total thyroidectomy for NRD with and without INM. A multivariable logistic regression model was used to determine the associated odds of RLNi.

RESULTS

From 6942 patients, 4269 (61.5%) had INM during thyroidectomy. Patients with INM had a similar rate of overall RLNi compared to patients without INM (5.7% vs. 6.6%, p = 0.118). After adjusting for covariates, INM was associated with decreased odds of severe-RLNi (OR 0.23, p = 0.036) but not mild-RLNi (p = 0.16).

CONCLUSION

INM is associated with a nearly 80% decreased associated odds of severe RLNi during thyroidectomy for NRD. Future prospective confirmation is needed, and if confirmed, patients undergoing thyroidectomy for NRD should have INM to reduce the risk of RLNi and its associated morbidity.

Prehospital Variables Alone Can Predict Mortality After Blunt Trauma: A Novel Scoring Tool

BACKGROUND

We sought to develop a novel Prehospital Injury Mortality Score (PIMS) to predict blunt trauma mortality using only prehospital variables.

STUDY DESIGN

The 2017 Trauma Quality Improvement Program database was queried and divided into two equal sized sets at random (derivation and validation sets). Multiple logistic regression models were created to determine the risk of mortality using age, sex, mechanism, and trauma activation criterion. The PIMS was derived using the weighted average of each independent predictor. The discriminative power of the scoring tool was assessed by calculating the area under the receiver operating characteristics (AUROC) curve. The PIMS ability to predict mortality was then assessed by using the validation cohort. The score was compared to the Revised Trauma Score (RTS) using the AUROC curve, including a subgroup of patients with normal vital signs.

RESULTS

The derivation and validation groups each consisted of 163 694 patients. Seven independent predictors of mortality were identified, and the PIMS was derived with scores ranging from 0 to 20. The mortality rate increased from 1.4% to 43.9% and then 100% at scores of 1, 10, and 19, respectively. The model had very good discrimination with an AUROC of .79 in both the derivation and validation groups. When compared to the RTS, the AUROC were similar (.79 vs. .78). On subgroup analysis of patients with normal prehospital vital signs, the PIMS was superior to the RTS (.73 vs. .56).

CONCLUSION

The PIMS is a novel scoring tool to predict mortality in blunt trauma patients using prehospital variables. It had improved discriminatory power in blunt trauma patients with normal vital signs compared to the RTS.

No Difference in Morbidity or Mortality Between Octogenarians and Other Geriatric Burn Trauma Patients

BACKGROUND

Geriatric burn trauma patients (age ≥65 years) have a 5-fold higher mortality rate than younger adults. With the population of the US aging, the number of elderly burn and trauma patients is expected to increase. A past study using the National Burn Repository revealed a linear increase in mortality for those >65 years old. We hypothesized that octogenarians with burn and trauma injuries would have a higher rate of in-hospital complications and mortality, than patients aged 65-79 years old.

METHODS

The Trauma Quality Improvement Program (2010-2016) was queried for burn trauma patients. To detect mortality risk a multivariable logistic regression model was used.

RESULTS

From 282 patients, there were 73 (25.9%) octogenarians and 209 (74.1%) aged 65-79 years old. The two cohorts had similar median injury severity scores (16 vs. 15 in octogenarians, P = .81), total body surface area burned (P = .30), and comorbidities apart from an increased smoking (12.9% vs. 4.1%, P = .04) and decreased hypertension (52.2% vs. 65.8%, P = .04) in the younger cohort. Octogenarians had similar complications, including acute respiratory distress syndrome, pulmonary embolism, deep vein thrombosis (P > .05), and mortality (15.1% vs. 10.5%, P = .30), compared to the younger cohort. Octogenarians were not associated with an increased mortality risk (odds ratio 1.51, confidence interval 0.24-9.56, P = .67).

DISCUSSION

Among burn trauma patients ≥65 years, age should not be a sole predictor for mortality risk. Continued research is necessary in order to determine more accurate approaches to prognosticate mortality in geriatric burn trauma patients, such as the validation and refinement of a burn-trauma-related frailty index.

Injury and Mortality Profiles in Level II and III Trauma Centers

BACKGROUND

While the benefit of admission to trauma centers compared to non-trauma centers is well-documented and differences in outcomes between Level-I and Level-II trauma centers are well-studied, data on the differences in outcomes between Level-II trauma centers (L2TCs) and Level-III trauma centers (L3TCs) are scarce.

OBJECTIVES

We sought to compare mortality risk between patients admitted to L2TCs and L3TCs, hypothesizing no difference in mortality risk for patients treated at L3TCs compared to L2TCs.

METHODS

A retrospective analysis of the 2016 Trauma Quality Improvement Program (TQIP) database was performed. Patients aged 18+ years were divided into 2 groups, those treated at American College of Surgeons (ACS) verified L2TCs and L3TCs.

RESULTS

From 74,486 patients included in this study, 74,187 (99.6%) were treated at L2TCs and 299 (.4%) at L3TCs. Both groups had similar median injury severity scores (ISSs) (10 vs 10, P < .001); however, L2TCs had a higher mean ISS (14.6 vs 11.9). There was a higher mortality rate for L2TC patients (6.0% vs 1.7%, P = .002) but no difference in associated risk of mortality between the 2 groups (OR .46, CI .14-1.50, P = .199) after adjusting predictors of mortality. L2TC patients had a longer median length of stay (5.0 vs 3.5 days, P < .001). There was no difference in other outcomes including myocardial infarction (MI) and cerebrovascular accident (CVA) (P > .05).

DISCUSSION

Patients treated at L2TCs had a longer LOS compared to L3TCs. However, after controlling for covariates, there was no difference in associated mortality risk between L2TC and L3TC patients.

Isolated Thoracic Injury Patients With Rib Fractures Undergoing Rib Fixation Have Improved Mortality

BACKGROUND

Despite a lack of consensus recommendations for surgical stabilization of rib fractures (SSRF), SSRF has increased over the past decade. Outcomes of patients with isolated thoracic injuries undergoing SSRF are unknown. We hypothesized adult trauma patients with isolated thoracic injuries and rib fractures undergoing SSRF would have a decreased risk of mortality and in-hospital respiratory complications compared with those not undergoing SSRF.

MATERIALS AND METHODS

The Trauma Quality Improvement Program (2010-2016) was queried for patients presenting with a rib fracture. Patients who died in the emergency department or within 24-h, as well as those with a grade>1 for abbreviated injury scale of the head, face, neck, spine, abdomen, and extremities, were excluded. A multivariable logistic regression analysis was performed.

RESULTS

From 60,000 patients with isolated thoracic injuries and rib fractures, 688 (1.1%) underwent SSRF. Compared with patients without SSRF, those undergoing SSRF had a similar median age (P = 0.83) and higher injury severity score (P < 0.001). Patients undergoing SSRF had a longer length of stay (P < 0.001), higher rate of acute respiratory distress syndrome (P < 0.001), unplanned intubation (P < 0.001), and pneumonia (P < 0.001) but lower rate of mortality (0.9% versus 1.7%, P = 0.084). After adjusting for confounding variables, patients undergoing SSRF had a decreased associated risk of mortality (OR 0.40, P = 0.036) compared with those not undergoing SSRF.

CONCLUSIONS

The risk of mortality in trauma patients with isolated thoracic injuries and rib fractures is lower when undergoing SSRF despite being associated with a higher rate of respiratory complications during their increased length of stay.

A Dual Pandemic: The Influence of Coronavirus Disease 2019 on Trends and Types of Firearm Violence in California, Ohio, and the United States

BACKGROUND

This study sought to determine the impact of coronavirus disease 2019 stay-at-home (SAH) and reopening orders on trends and types of firearm violence in California, Ohio, and the United States, hypothesizing increased firearm violence after SAH.

MATERIALS AND METHODS

Retrospective data (January 1, 2018, to July 31, 2020) on firearm incidents/injuries/deaths and types of firearm violence were obtained from the Gun Violence Archive. The periods for SAH and reopening for the US were based on dates for California. Ohio dates were based on Ohio's timeline. Mann-Whitney U analyses compared trends and types of daily firearm violence per 100,000 legal firearm owners across 2018-2020 periods.

RESULTS

In California, SAH and reopening orders had no effect on firearm violence in 2020 compared with 2018 and 2019 periods, respectively. In Ohio, daily median firearm deaths increased during 2020 SAH compared with 2018 and 2019 and firearm incidents and injuries increased during 2020 reopening compared with 2018, 2019 and 2020 SAH. In the United States, during 2020, SAH firearm deaths increased compared with historical controls and firearm incidents, deaths and injuries increased during 2020 reopening compared with 2018, 2019 and 2020 SAH (all P < 0.05). Nationally, when compared with 2018 and 2019, 2020 SAH had increased accidental shootings deaths with a decrease in defensive use, home invasion, and drug-involved incidents.

CONCLUSIONS

During 2020 SAH, the rates of firearm violence increased in Ohio and the United States but remained unchanged in California. Nationally, firearm incidents, deaths and injuries also increased during 2020 reopening versus historical and 2020 SAH data. This suggests a secondary "pandemic" as well as a "reopening phenomenon," with increased firearm violence not resulting from self-defense.

Regional, Racial, and Mortality Disparities Associated With Neurosurgeon Staffing at Level I Trauma Centers

BACKGROUND

Traumatic brain injury (TBI) occurs in approximately 30% of trauma patients. Because neurosurgeons hold expertise in treating TBI, increased neurosurgical staffing may improve patient outcomes. We hypothesized that TBI patients treated at level I trauma centers (L1TCs) with ≥3 neurosurgeons have a decreased risk of mortality vs. those treated at L1TCs with <3 neurosurgeons.

METHODS

The Trauma Quality Improvement Program database (2010-2016) was queried for patients ≥18 years with TBI. Patient characteristics and mortality were compared between ≥3 and <3 neurosurgeon-staffed L1TCs. A multivariable logistic regression analysis was used to identify risk factors associated with mortality.

RESULTS

Traumatic brain injury occurred in 243 438 patients with 5188 (2%) presenting to L1TCs with <3 neurosurgeons and 238 250 (98%) to L1TCs with ≥3 neurosurgeons. Median injury severity score (ISS) was similar between both groups (17, P = .09). There were more Black (37% vs. 12%, P < .001) and Hispanic (18% vs. 12%, P < .001) patients in the <3 neurosurgeon group. Nearly 60% of L1TCs with <3 neurosurgeons are found in the South. Mortality was higher in the <3 vs. the ≥3 group (12% vs. 10%, P < .001). Patients treated in the <3 neurosurgeon group had a higher risk for mortality than those treated in the ≥3 neurosurgeon group (odds ratio (OR) 1.13, 95% confidence intervals (CI) 1.01-1.26, P = .028).

DISCUSSION

There exists a significant racial disparity in access to neurosurgeon staffing with additional disparities in outcomes based on staffing. Future efforts are needed to improve this chasm of care that exists for trauma patients of color.

Racial and Sex Disparities in Trauma Outcomes Based on Geographical Region

OBJECTIVES

Disparities in outcomes among trauma patients have been shown to be associated with race and sex. The purpose of this study was to analyze racial and sex mortality disparities in different regions of the United States, hypothesizing that the risk of mortality among black and Asian trauma patients, compared to white trauma patients, will be similar within all regions in the United States.

METHODS

The Trauma Quality Improvement Program (2010-2016) was queried for adult trauma patients, separating by U.S. Census regions. Multivariable logistic regression analyses were performed for each region, controlling for known predictors of morbidity and mortality in trauma.

RESULTS

Most trauma patients were treated in the South (n = 522 388, 40.7%). After risk adjustment, black trauma patients had a higher associated risk of death in all regions, except the Northeast, compared to white trauma patients. The highest associated risk of death for blacks (vs. whites) was in the Midwest (odds ratio [OR] 1.30, P < .001). Asian trauma patients only had a higher associated risk of death in the West (OR 1.39, P < .001). Male trauma patients, compared to women, had an increased associated risk of mortality in all four regions.

DISCUSSION

This study found major differences in outcomes among different races within different regions of the United States. There was also both an increased rate and associated risk of mortality for male patients in all regions. Future prospective studies are needed to identify what regional differences in trauma systems including population density, transport times, hospital access, and other trauma resources explain these findings.

Endovascular management of traumatic pseudoaneurysms

Background

Pseudoaneurysms (PAs) caused by traumatic injury to the arterial vasculature have a high risk of rupture, leading to life-threatening hemorrhage and mortality, requiring urgent treatment. The purpose of this study was to determine the technical and clinical outcomes of endovascular treatment of visceral and extremity traumatic pseudoaneurysms.

Methods

Clinical data were retrospectively collected from all patients presenting for endovascular treatment of PAs between September 2012 and September 2018 at a single academic level one trauma center. Technical success was defined as successful treatment of the PA with no residual filling on post-embolization angiogram. Clinical success was defined as technical successful treatment with no rebleeding throughout the follow-up period and no reintervention for the PA.

Results

Thirty-five patients (10F/25M), average age (± stdev) 41.7 ± 20.1 years, presented with PAs secondary to blunt (n = 31) or penetrating (n = 4) trauma. Time from trauma to intervention ranged from 2 h - 75 days (median: 4.4 h, IQR: 3.5–17.1 h) with 27 (77%) of PAs identified and treated within 24 h of trauma. Average hospitalization was 13.78 ± 13.4 days. Ten patients underwent surgery prior to intervention. PA number per patient ranged from 1 to 5 (multiple diffuse). PAs were located on the splenic (n = 12, 34.3%), pelvic (n = 11, 31.4%), hepatic (n = 9, 25.7%), upper extremity/axilla (n = 2, 5.7%), and renal arteries (n = 1, 2.9%). Technical success was 85.7%. Clinical success was 71.4%, for technical failure (n = 5), repeat embolization (n = 1) or post-IR surgical intervention (n = 4). There was no PA rebleeding or reintervention for any patient after discharge over the reported follow-up periods. Three patients died during the trauma hospitalization for reasons unrelated to the PAs.

Conclusions

Endovascular treatment of traumatic visceral and extremity PAs is efficacious with minimal complication rates and low reintervention requirements.

New York State and the Nation: Trends in Firearm Purchases and Firearm Violence During the COVID-19 Pandemic

BACKGROUND

The impacts of social stressors on violence during the coronavirus disease 2019 (COVID-19) pandemic are unknown. We hypothesized that firearm purchases and violence would increase surrounding the pandemic. This study determined the impact of COVID-19 and shelter-in-place (SIP) orders on firearm purchases and incidents in the United States (US) and New York State (NYS).

METHODS

Scatterplots reflected trends in firearm purchases, incidents, and deaths over a 16-month period (January 2019 to April 2020). Bivariate comparisons of SIP and non-SIP jurisdictions before and after SIP (February 2020 vs. April 2020) and April 2020 vs. April 2019 were performed with the Mann-Whitney U test.

RESULTS

The incidence of COVID-19 in the US increased between February and April 2020 from 24 to 1 067 660 and in NYS from 0 to 304 372. When comparing February to March to April in the US, firearm purchases increased 33.6% then decreased 22.0%, whereas firearm incidents increased 12.2% then again increased by 3.6% and firearm deaths increased 23.8% then decreased in April by 3.8%. In NYS, comparing February to March to April 2020, firearm purchases increased 87.6% then decreased 54.8%, firearm incidents increased 110.1% then decreased 30.8%, and firearm deaths increased 57.1% then again increased by 6.1%. In both SIP and non-SIP jurisdictions, April 2020 firearm purchases, incidents, deaths, and injuries were similar to April 2019 and February 2020 (all P = NS).

DISCUSSION

Coronavirus disease 2019-related stressors may have triggered an increase in firearm purchases nationally and within NYS in March 2020. Firearm incidents also increased in NYS. SIP orders had no effect on firearm purchases and firearm violence.

Brachial Plexus Injury Significantly Increases Risk of Axillosubclavian Vessel Injury in Blunt Trauma Patients With Clavicle Fractures

BACKGROUND

A national analysis of clavicle fractures is lacking and the risk of concomitant axillosubclavian vessel injury (ASVI) in patients with clavicle fractures is unknown. A minority of patients may have a combined brachial plexus injury (BPI). We sought to describe risk factors for concomitant ASVI in patients with a clavicle fracture; hypothesizing patients with combined clavicle fracture and BPI has a higher risk of ASVI.

METHODS

The Trauma Quality Improvement Program (2010-2016) was queried for blunt trauma patients with a clavicle fracture. A multivariable logistic regression model was used to determine risk factors for ASVI. A subset analysis on patients with isolated clavicle fractures was additionally performed.

RESULTS

From 59 198 patients with clavicle fractures, 341 (.6%) had concomitant ASVI. Compared to patients without ASVI, patients with ASVI had a higher median injury severity score (24 vs. 17, P < .001) and rates of pulmonary contusions (43.4% vs. 37.7%, P = .029) and BPI (18.2% vs. .4%, P < .001). After controlling for associated chest wall injuries and humerus fracture, the BPI odds ratio (OR 49.17, 35.59-67.92, P < .001) was independently associated with risk for ASVI. In a subset analysis of isolated clavicle fractures, BPI remained associated with risk of ASVI (OR 60.01, confidence intervals 25.29-142.39, P < .001).

CONCLUSION

The rate of concomitant ASVI in patients with a clavicle fracture is <1%. Patients presenting with a clavicle fracture had a high rate of injuries including pulmonary contusion. Patients with findings suggestive of underlying BPI had a nearly 50 times increased associated risk of ASVI. Thus, a detailed physical exam in this setting including brachial-brachial index appears warranted.

University Teaching Trauma Centers: Decreased Mortality but Increased Complications

BACKGROUND

Teaching hospitals are often regarded as excellent institutions with significant resources and prominent academic faculty. However, the involvement of trainees may contribute to higher rates of complications. Conflicting reports exist regarding outcomes between teaching and nonteaching hospitals, and the difference among trauma centers is unknown. We hypothesized that university teaching trauma centers (UTTCs) and nonteaching trauma centers (NTTCs) would have a similar risk of complications and mortality.

METHODS

We queried the Trauma Quality Improvement Program (2010-2016) for adults treated at UTTCs or NTTCs. A multivariable logistic regression analysis was performed to evaluate the risk of mortality and in-hospital complications, such as respiratory complications (RCs), venous thromboembolisms (VTEs), and infectious complications (ICs).

RESULTS

From 895,896 patients, 765,802 (85%) were treated at UTTCs and 130,094 (15%) at NTTCs. After adjusting for covariates, UTTCs were associated with an increased risk of RCs (odds ratio (OR) 1.33, confidence interval (CI) 1.28-1.37, P < 0.001), VTEs (OR 1.17, CI 1.12-1.23, P < 0.001), and ICs (OR 1.56, CI 1.49-1.64, P < 0.001). However, UTTCs were associated with decreased mortality (OR 0.96, CI 0.93-0.99, P = 0.008) compared with NTTCs.

CONCLUSIONS

Our study demonstrates increased associated risks of RCs, VTEs, and ICs, yet a decreased associated risk of in-hospital mortality for UTTCs when compared with NTTCs. Future studies are needed to identify the underlying causative factors behind these differences.

An increasing trend in geriatric trauma patients undergoing surgical stabilization of rib fractures

Purpose

The proportion of geriatric trauma patients (GTPs) (age ≥ 65 years old) with chest wall injury undergoing surgical stabilization of rib fractures (SSRF) nationally is unknown. We hypothesize a growing trend of GTPs undergoing SSRF, and sought to evaluate risk of respiratory complications and mortality for GTPs compared to younger adults (18–64 years old) undergoing SSRF.

Methods

The Trauma Quality Improvement Program (2010–2016) was queried for patients with rib fracture(s) who underwent SSRF. GTPs were compared to younger adults. A multivariable logistic regression analysis was performed.

Results

From 21,517 patients undergoing SSRF, 3,001 (16.2%) were GTPs. Of all patients undergoing SSRF in 2010, 10.6% occurred on GTPs increasing to 17.9% in 2016 (p < 0.001) with a geometric-mean-annual increase of 11.5%. GTPs had a lower median injury severity score (18 vs. 22, p < 0.001), but had a higher rate of mortality (4.7% vs. 1.2%, p < 0.001). After controlling for covariates, GTPs had an increased associated risk of mortality (OR 4.80, CI 3.62–6.36, p < 0.001). On a separate multivariate analysis for all trauma patients with isolated chest Abbreviated Injury Scale 3, GTPs were associated with a similar four-fold risk of mortality (OR 4.21, CI 1.98–6.32, p < 0.001).

Conclusion

Spanning 7 years of data, the proportion of GTPs undergoing SSRF increased by over 7%. Although GTPs undergoing SSRF had lesser injuries, their risk of mortality was four times higher than other adult trauma patients undergoing SSRF, which was similar to their increased background risk of mortality. Ultimately, SSRF in GTPs should be considered on an individualized basis with careful attention to risk–benefit ratio.

Electronic supplementary material

The online version of this article (10.1007/s00068-020-01526-7) contains supplementary material, which is available to authorized users.

No difference in mortality between level I and level II trauma centers performing surgical stabilization of rib fracture

BACKGROUND

A comparison of outcomes between Level I (LI) and Level II (LII) Trauma Centers (TCs) performing surgical stabilization of rib fracture (SSRF) has not been well described. We sought to compare risk of mortality for patients undergoing SSRF between LI and LII TCs.

METHODS

The Trauma Quality Improvement Program was queried for patients presenting with rib fracture to LI or LII TCs from 2010 to 2015. A multivariable logistic regression analysis was performed.

RESULTS

14,046 (7.1%) of 199,020 patients with rib fractures underwent SSRF. SSRF increased from 1304 in 2010 to 3489 in 2015: a geometric mean annual increase of 22%. LI TCs demonstrated a mortality incidence of 1.6% while LII TCs demonstrated a mortality incidence of 1.5% (p > 0.05). There was no statistically significant difference in risk of mortality after SSRF between LI and LII TCs (odds ratio 1.12, confidence interval 0.79-1.59, p-value 0.529).

CONCLUSIONS

Patients undergoing SSRF at LI and LII TCs have no significant difference in risk of mortality. Additionally, there is an annually growing trend across all centers in SSRF performed both for flail and non-flail segments.

Evolving Utility of Endovascular Treatment of Juxtarenal, Pararenal, and Suprarenal Abdominal Aortic Aneurysms Associated With Increased Risk of Mortality Over Time

BACKGROUND

Continued advances in endovascular technologies are resulting in fewer open abdominal aortic aneurysm (AAA) repairs. In addition, more complex juxtarenal, pararenal, and suprarenal (JPS) AAAs are being managed with various endovascular techniques. This study sought to evaluate the evolving trends in endovascular aneurysm repair (EVAR) of AAAs, hypothesizing increased rate of JPS AAA repair by EVAR. We also sought to evaluate the risk for morbidity and mortality for EVAR and open aneurysm repair (OAR) of JPS AAAs over time.

METHODS

The 2011-2017 American College of Surgeons National Surgical Quality Improvement Program Procedure-Targeted Vascular database was queried for patients undergoing OAR or EVAR for AAAs. A multivariable logistic regression analysis was performed for both infrarenal and JPS AAA repairs.

RESULTS

Of 18,661 patients who underwent AAA repair, 3,941 (21.1%) were OAR and 14,720 (78.9%) were EVAR. The rate of OAR decreased from 29.5% in 2011 to 21.3% in 2017 (P < 0.001) with a geometric-mean-annual decrease of 27.8%. The rate of EVAR increased from 70.5% to 78.7% during the same time period (P < 0.001) with a geometric-mean-annual increase of 11.6%. These trends remained true for both infrarenal and JPS AAAs. After adjusting for covariates, there was no difference in associated risk of 30-day mortality, renal complications, or ischemic colitis for either OAR or EVAR over each incremental year for infrarenal AAAs (P > 0.05). However, in patients undergoing EVAR for JPS AAAs, the associated risk of mortality increased with each incremental year (odds ratio [OR]: 1.30, confidence interval [CI]: 1.01-1.69, P = 0.039), whereas there was no difference in the risk of mortality for OAR of JPS AAAs with each incremental year (OR: 1.11, CI: 0.99-1.23, P = 0.067).

CONCLUSIONS

The rate of OAR for AAA has decreased over the past seven years with an increase in EVAR, particularly for more complex JPS AAAs. The associated risk for morbidity and mortality for treatment of infrarenal AAAs was not significantly affected by this increased utility of EVAR. The associated risk of mortality for JPS AAAs treated by EVAR increased over time, whereas this trend for associated risk of mortality was not seen for OAR of JPS AAAs. These findings, especially the increased associated risk of mortality over time with EVAR for JPS AAAs, warrant careful prospective analysis.

Fat embolism syndrome in blunt trauma patients with extremity fractures

OBJECTIVE

This study sought to provide a national, descriptive analysis to determine fat embolism syndrome (FES) risk factors, hypothesizing that femur fractures and multiple fractures are associated with an increased risk.

METHODS

The Trauma Quality Improvement Program was queried (2010-2016) for patients with extremity fractures. A multivariable logistic regression analysis model was used.

RESULTS

From 324,165 patients, 116 patients (0.04%) were diagnosed with FES. An age ≤30, closed femur fracture, and multiple long bone fractures were associated with an increased risk of FES.

CONCLUSION

Future research to validate these findings and develop a clinical risk stratification tool appears warranted.

Penetrating Abdominal Aortic Injury: Comparison of ACS-Verified Level-I and II Trauma Centers

OBJECTIVES

Penetrating abdominal aortic injury (PAAI) is a highly acute injury requiring prompt surgical management. When compared to surgeons at level-II trauma centers, surgeons at level-I trauma centers are more likely to take in-house call, and may more often be available within 15 minutes of patient arrival. Thus, we hypothesized that level-I trauma centers would have a lower mortality rate than level-II trauma centers in patients with PAAI.

METHODS

We queried the Trauma Quality Improvement Program database for patients with PAAI, and compared patients treated at American College of Surgeons (ACS)-verified level-I centers to those treated at ACS level-II centers.

RESULTS

PAAI was identified in 292 patients treated at level-I centers and 86 patients treated at level-II centers. Patients treated at the 2 center types had similar median age, injury severity scores and prevalence of diabetes, hypertension, and smoking (p > 0.05). There was no difference in the frequency of additional intra-abdominal vascular injuries (p > 0.05). Median time to hemorrhage control (level-I: 40.8 vs level-II: 49.2 minutes, p = 0.21) was similar between hospitals at the 2 trauma center levels. We found no difference in the total hospital length of stay or post-operative complications (p > 0.05). When controlling for covariates, we found no difference in the risk of mortality between ACS verified level-I and level-II trauma centers (OR:1.01, CI:0.28-2.64, p = 0.99).

CONCLUSION

Though the majority of PAAIs are treated at level-I trauma centers, we found no difference in the time to hemorrhage control, or the risk of mortality in those treated at level-I centers when compared to those treated at level-II trauma centers. This finding reinforces the ACS-verification process, which strives to achieve similar outcomes between level-I and level-II centers.

Analysis of Endovascular Aneurysm Repair for Small Abdominal Aortic Aneurysms in Males

BACKGROUND

Current guidelines recommend repair of abdominal aortic aneurysms (AAAs) when ≥5.5 cm. This study sought to evaluate the incidence of male patients undergoing endovascular aneurysm repair (EVAR) for AAAs of various diameters (small <4 cm; intermediate 4-5.4 cm; standard ≥5.5 cm). We analyzed predictors of mortality, hypothesizing that smaller AAAs (<5.5 cm) have no differences in associated risk of mortality compared to standard AAAs (≥5.5 cm).

METHODS

The 2011-2017 American College of Surgeons National Surgical Quality Improvement Program Procedure-Targeted Vascular database was queried for male patients undergoing elective EVAR. Patients were stratified by aneurysm diameter. A multivariable logistic regression analysis for clinical outcomes, adjusting for age, clinical characteristics, and comorbidities, was performed.

RESULTS

A total of 8037 male patients underwent EVAR with 3926 (48.9%) performed for AAAs <5.5 cm. There was no difference in mortality, readmission, major complications, myocardial infarction, stroke, or ischemic complications among the 3 groups (P > 0.05). In AAAs <5.5 cm, predictors of mortality included prior abdominal surgery (odds ratio [OR], 5.77; confidence interval [CI], 1.38-24.13; P = 0.016), weight loss (OR, 43.4; CI, 3.78-498.7; P = 0.002), disseminated cancer (OR, 17.9; CI, 1.30-245.97; P = 0.031), and diabetes (OR, 6.09; CI, 1.52-24.36; P = 0.011).

CONCLUSIONS

Nearly 50% of male patients undergoing elective EVAR were treated for AAAs <5.5 cm. There was no difference in associated risk of mortality for smaller AAAs compared to standard AAAs. The strongest predictors of mortality for patients with smaller AAAs were prior abdominal surgery, weight loss, disseminated cancer, and diabetes.

Chemoprophylaxis and Venous Thromboembolism in Traumatic Brain Injury at Different Trauma Centers

Patients with severe traumatic brain injury (TBI) are at an increased risk of venous thromboembolism (VTE). Because of concerns of worsening intracranial hemorrhage, clinicians are hesitant to start VTE chemoprophylaxis in this population. We hypothesized that ACS Level I trauma centers would be more aggressive with VTE chemoprophylaxis in adults with severe TBI than Level II centers. We also predicted that Level I centers would have a lower risk of VTE. We queried the Trauma Quality Improvement Program (2010–2016) database for patients with Abbreviated Injury Scale scores of 4 and 5 of the head and compared them based on treating the hospital trauma level. Of 204,895 patients with severe TBI, 143,818 (70.2%) were treated at Level I centers and 61,077 (29.8%) at Level II centers. The Level I cohort had a higher rate of VTE chemoprophylaxis use (43.2% vs 23.3%, P < 0.001) and a shorter median time to chemoprophylaxis (61.9 vs 85.9 hours, P < 0.001). Although Level I trauma centers started VTE chemoprophylaxis more often and earlier than Level II centers, there was no difference in the risk of VTE ( P = 0.414) after controlling for covariates. Future prospective studies are warranted to evaluate the timing, safety, and efficacy of early VTE chemoprophylaxis in severe TBI patients.

Esophageal Trauma: Analysis of Incidence, Morbidity, and Mortality

Traumatic esophageal injury is a highly lethal but rare injury with minimal data in the trauma population. We sought to provide a descriptive analysis of esophageal trauma (ET) to identify the incidence, associated injuries, interventions, and outcomes. We hypothesized that blunt trauma is associated with higher risk of death than penetrating trauma. The Trauma Quality Improvement Program (2010–2016) was queried for patients with ET. Patients with blunt and penetrating trauma were compared using chi-square and Mann-Whitney U tests. A multivariable logistic regression model was used to determine risk of mortality. Of 1,403,466 adult patients, 651 (<0.01%) presented with ET. The most common associated thoracic injuries were rib fractures (38.7%) and pneumothorax (26.7%). More patients with a penetrating mechanism underwent open repair of the esophagus than those with blunt mechanism (46.2% vs 11.7%, P < 0.001). After controlling for covariates, there was no difference in risk of mortality between blunt and penetrating trauma ( P = 0.65). The mortality rate for patients with esophageal injury surviving greater than 24 hours was 7.5 per cent. In this large national database analysis, ET was rare and most commonly associated with rib fractures and pneumothorax. Contrary to our hypothesis, the risk of mortality was equivalent between blunt and penetrating ET.

Seatbelt Sign as an Indication for Four-vessel Computed Tomography Angiogram of the Neck to Diagnose Blunt Carotid Artery and Other Cervical Vascular Injuries

Computed tomography angiography (CTA) of the neck has become the most common modality for diagnosing blunt carotid artery injury (BCAI). The protocol at our institution includes CTA on trauma patients with a seatbelt sign. The purpose of this study is to evaluate whether a solitary seatbelt sign is an indication for CTA of the neck to diagnose BCAI. We conducted a retrospective review of patients from 2000 to 2010 who received CTAs as a result of a seatbelt sign performed at our Level I trauma center. Four hundred eighteen patients received CTAs based on the presence of a seatbelt sign. Two hundred twenty-six had skeletal injuries, obvious soft tissue injuries, and/or positive findings on imaging, including 11 positive vascular findings with two BCAIs found. Patients with noncarotid vascular injuries on CTA had a higher Injury Severity Score than patients with solitary seatbelt signs (11.4 ± 7.6 vs 3.4 ± 4.2, P < 0.01). The correlation between seatbelt sign and positive finding on CTA was weak ( r = 0.007). Patients with vascular findings on CTA also had obvious hard/soft tissue injuries and/or positive findings on standard trauma imaging. This suggests that a protocol for CTA of the neck for patients with a seatbelt sign can be reserved for those with associated injuries on physical examination and/or findings on standard trauma imaging.

Risk for Contrast-Induced Nephropathy in Elderly Trauma Patients

The objective of this study was to determine if elderly trauma patients are at risk for contrast-induced nephropathy (CIN). A retrospective study was conducted identifying 362 patients 65 years and older in our Level I trauma center who received computerized tomography (CT) scans with intravenous contrast. CIN was defined as a 25 per cent increase in serum creatinine levels or a 0.5 mg/dL increase above baseline after CT. History of diabetes mellitus, hospital length of stay, intensive care unit length of stay, Injury Severity Score (ISS), and age were recorded. Eighteen per cent (21 of 118) of the patients had a peak in creatinine, 12 per cent (14 of 118) peaked and returned to baseline, and 6 per cent (7 of 118) peaked and stayed high. Pre-CT elevated creatinine, diabetes mellitus, increased hospital length of stay, ISS, and age show little association to CIN. The data suggest that CIN in elderly trauma patients is rare, regardless of history of diabetes mellitus, age, creatinine, high ISS, or result in higher length of stay. Therefore, there is little justification for the delay in diagnosis to assess a patient's renal susceptibility.

Geriatric patients undergoing appendectomy have increased risk of intraoperative perforation and/or abscess

BACKGROUND

The number of geriatric patients is expected to grow 3-fold over the next 30 years, and as many as 50% of the surgeries done in the United States may occur in geriatric patients. Geriatric patients often have increased comorbidities and more often present in a delayed manner for acute appendicitis. The aim of this study was to evaluate outcomes between geriatric patients and younger patients undergoing appendectomy, hypothesizing that geriatric patients will have a higher risk of abscess and/or perforation, conversion to open surgery, postoperative intra-abdominal abscess, and 30-day readmission.

METHODS

The 2016 to 2017 American College of Surgeons National Surgical Quality Improvement Program Procedure Targeted Appendectomy database was queried for patients with preoperative image findings consistent with acute appendicitis. Geriatric patients (age ≥65 years old) were compared with younger patients (age <65 years old). A multivariable logistic regression model was used for analysis.

RESULTS

From 21,586 patients undergoing appendectomy, 2,060 (9.5%) were geriatric patients. Compared with the younger cohort, geriatric patients were less likely to have leukocytosis (59.0% vs 65.8%, P < .001) and more likely to have a tumor and/or malignancy involving the appendix on final pathology (2.0% vs 0.8%, P < .001), an unplanned laparoscopic conversion to open surgery (4.2% vs 1.5%, P < .001), and 30-day readmission (7.0% vs 3.3%, P < .001). Geriatric patients had a longer median length of stay (2 vs 1 days, P < .001) and higher mortality rate (0.5% vs <0.1%, P < .001). After adjusting for covariates, there was an increased associated risk of intraoperative abscess and/or perforation (odds ratio 2.23, 2.01-2.48, P < .001) and postoperative intra-abdominal abscess (odds ratio 1.43, 1.12-1.83, P = .005) but no difference in associated risk for mortality (odds ratio 2.56, 0.79-8.25, P = .116), compared with the younger cohort.

CONCLUSION

Nearly 10% of laparoscopic appendectomies are done on geriatric patients with geriatric patients having a higher rate of conversion to open surgery and tumor and/or malignancy on final pathology. Geriatric patients have an associated increased risk of intraoperative perforation and/or abscess and postoperative intra-abdominal abscess but have similar risk for mortality compared with nongeriatric patients undergoing laparoscopic appendectomy.

Helicopter Transport Has Decreased Over Time and Transport From Scene or Hospital Matters

OBJECTIVE

Several reports have found helicopter emergency medical services (HEMS) to be associated with a lower risk of mortality compared with ground emergency medical services (GEMS); however, most studies did not control for transport time or stratify interfacility versus scene. We hypothesize that the HEMS transport rate has decreased nationally and that the risk of mortality for HEMS is similar to GEMS when adjusting for transport time and stratifying by scene or interfacility.

METHODS

The Trauma Quality Improvement Program (2010-2016) was queried for adult patients transported by HEMS or GEMS. Multivariable logistic regression was used.

RESULTS

The HEMS transport rate decreased by 38.2% from 2010 to 2016 (P < .001). After controlling for known predictors of mortality and transport time, HEMS was associated with a decreased risk of mortality compared with GEMS for adult trauma patient transports (odds ratio = 0.74; 95% confidence interval [CI], 0.71-0.77; P < .001). Compared with GEMS, HEMS transports from the scene were associated with a decreased risk of mortality (OR = 0.63; 95% CI, 0.60-0.66; P < .001), whereas HEMS interfacility transfer was associated with an increased risk of mortality (OR = 1.22; 95% CI, 1.14-1.31; P < .001).

CONCLUSION

The rate of HEMS transports in trauma has decreased by nearly 40% over the past 7 years. Our results suggest that HEMS use for scene transports is beneficial for the survival of trauma patients.

Octogenarians with blunt splenic injury: not all geriatrics are the same

Geriatric trauma patients (GTP) (age ≥ 65 years) with blunt splenic injury (BSI) have up to a 6% failure rate of non-operative management (NOM). GTPs failing NOM have a similar mortality rate compared to GTPs managed successfully with NOM. However, it is unclear if this remains true in octogenarians (aged 80–89 years). We hypothesized that the failure rate for NOM in octogenarians would be similar to their younger geriatric cohort, patients aged 65–79 years; however risk of mortality in octogenarians who fail NOM would be higher than that of octogenarians managed successfully with NOM. The Trauma Quality Improvement Program (2010–2016) was queried for patients with BSI. Those undergoing splenectomy within 6 h were excluded to select for patients undergoing NOM. Patients aged 65–79 years (young GTPs) were compared to octogenarians. A multivariable logistic regression model was used to determine the risk for failed NOM and mortality. From 43,041 BSI patients undergoing NOM, 3660 (8.5%) were aged 65–79 years and 1236 (2.9%) were octogenarians. Both groups had a similar median Injury Severity Score (ISS) (p = 0.10) and failure rate of NOM (6.6% young GTPs vs. 6.8% octogenarians p = 0.82). From those failing NOM, octogenarians had similar units of blood products transfused (p > 0.05) and a higher mortality rate (40.5% vs. 18.2%, p < 0.001), compared to young GTPs. Independent risk factors for failing NOM in octogenarians included ≥ 1 unit of packed red blood cells (PRBC) (p = 0.039) within 24 h of admission. Octogenarians who failed NOM had a higher mortality rate compared to octogenarians managed successfully with NOM (40.5% vs 23.6% p = 0.001), which persisted in a multivariable logistic regression analysis (OR 2.25, CI 1.37–3.70, p < 0.001). Late failure of NOM ≥ 24 h (vs. early failure) was not associated with increased risk of mortality (p = 0.88), but ≥ 1 unit of PRBC transfused had higher risk (OR 1.88, CI 1.20–2.95, p = 0.006). Compared to young GTPs with BSI, octogenarians have a similar rate of failed NOM. Octogenarians with BSI who fail NOM have over a twofold higher risk of mortality compared to those managed successfully with NOM. PRBC transfusion increases risk for mortality. Therefore, clinicians should consider failure of NOM earlier in the octogenarian population to mitigate the risk of increased mortality.

Chemoprophylaxis and Venous Thromboembolism in Traumatic Brain Injury at Different Trauma Centers

Patients with severe traumatic brain injury (TBI) are at an increased risk of venous thromboembolism (VTE). Because of concerns of worsening intracranial hemorrhage, clinicians are hesitant to start VTE chemoprophylaxis in this population. We hypothesized that ACS Level I trauma centers would be more aggressive with VTE chemoprophylaxis in adults with severe TBI than Level II centers. We also predicted that Level I centers would have a lower risk of VTE. We queried the Trauma Quality Improvement Program (2010-2016) database for patients with Abbreviated Injury Scale scores of 4 and 5 of the head and compared them based on treating the hospital trauma level. Of 204,895 patients with severe TBI, 143,818 (70.2%) were treated at Level I centers and 61,077 (29.8%) at Level II centers. The Level I cohort had a higher rate of VTE chemoprophylaxis use (43.2% vs 23.3%, P < 0.001) and a shorter median time to chemoprophylaxis (61.9 vs 85.9 hours, P < 0.001). Although Level I trauma centers started VTE chemoprophylaxis more often and earlier than Level II centers, there was no difference in the risk of VTE (P = 0.414) after controlling for covariates. Future prospective studies are warranted to evaluate the timing, safety, and efficacy of early VTE chemoprophylaxis in severe TBI patients.