Thoracic irrigation for prevention of secondary intervention after thoracostomy tube drainage for hemothorax: A Western Trauma Association multi-center study

BACKGROUND

Retained hemothorax (rHTX) requiring intervention occurs in up to 20% of patients who undergo chest tube (TT) placement for a hemothorax (HTX). Thoracic irrigation at the time of TT placement decreases the need for secondary intervention in this patient group but those findings are limited because of the single center design. A multi-center study was conducted to evaluate the effectiveness of thoracic irrigation.

METHODS

A multi-center, prospective, observational study was conducted between June 2018 and July 2023. Eleven sites contributed patients. Patients were included if they had a TT placed for a HTX and were excluded if: age < 18 years, TT for pneumothorax, thoracotomy or VATS performed within 6 hours of TT, TT >24 hours after injury, TT removed <24 hours, or death within 48 hours. Thoracic irrigation was performed at the discretion of the attending. Each hemithorax was considered separately if bilateral HTX. The primary outcome was secondary intervention for HTX-related complications (rHTX, effusion, or empyema). Secondary intervention was defined as: TT placement, instillation of thrombolytics, VATS, or thoracotomy. Irrigated and non-irrigated hemithoraces were compared using a propensity weighted analysis with age, sex, mechanism of injury, Abbreviated Injury Scale (AIS) chest and TT size as predictors.

RESULTS

493 patients with 462 treated hemothoraces were included, 123 (25%) had thoracic irrigation at TT placement. There were no significant demographic differences between the cohorts. Fifty-seven secondary interventions were performed, 10 (8%) and 47 (13%) in the irrigated and non-irrigated groups, respectively (p = 0.015). Propensity weighted analysis demonstrated a reduction in secondary interventions in the irrigated cohort (Odds Ratio 0.56 (0.34-0.85); p = 0.005).

CONCLUSION

This Western Trauma Association multi-center study demonstrates a benefit of thoracic irrigation at the time of TT placement for a HTX. Thoracic irrigation reduces the odds of a secondary intervention for rHTX-related complications by 44%.

LEVEL OF EVIDENCE

Therapeutic Study, Level II.

Placement of Intracranial Pressure Monitors by Non-neurosurgeons: A Follow-Up Study

BACKGROUND

Some research suggests that physicians who are not neurosurgeons can safely place intracranial pressure (ICP) monitors. The purpose of this study was to compare intracranial pressure monitor placement complications between neurosurgeons, trauma physicians, and general surgery residents. We hypothesized that with appropriate training, general residents can safely place ICP monitors.

METHODS

A 10-year retrospective chart review of all trauma patients that required ICP monitor placement between January 1, 2012, and December 31, 2021, was conducted. Comparisons were made between treatment groups.

RESULTS

During the study period, 194 patients required ICP monitor placement. General surgery residents placed 94.3% of ICP monitors, 3.6% were placed by attending trauma physicians, and 2.1% by neurosurgeons. No ICP monitors were placed by attending trauma physicians or neurosurgeons between 2015 and 2018. Overall, minor complications during ICP monitor placement included device malfunction (2.7%) and inaccurate readings (.5%). There were no major complications during ICP monitor placement. Post-ICP monitor placement complications included one patient who experienced a central nervous system infection (.5%) and three patients who had mechanical problems (1.5%). No complications occurred among the neurosurgeon or attending trauma physician treatment groups.

CONCLUSION

Most intracranial pressure monitors in our study sample were safely placed by surgical residents. Based on our study findings and considering the shortage and downtrend of neurosurgery specialists, ICP bolt placement needs to become a core clinical skill in surgical resident programs across the United States.

A western trauma association multicenter comparison of mesh versus non-mesh repair of blunt traumatic abdominal wall hernias

BACKGROUND

Blunt traumatic abdominal wall hernias (TAWH) occur in <1 % of trauma patients. Optimal repair techniques, such as mesh reinforcement, have not been studied in detail. We hypothesize that mesh use will be associated with increased surgical site infections (SSI) and not improve hernia recurrence.

MATERIALS AND METHODS

A secondary analysis of the Western Trauma Association blunt TAWH multicenter study was performed. Patients who underwent TAWH repair during initial hospitalization (1/2012-12/2018) were included. Mesh repair patients were compared to primary repair patients (non-mesh). A logistic regression was conducted to assess risk factors for SSI.

RESULTS

157 patients underwent TAWH repair during index hospitalization with 51 (32.5 %) having mesh repair: 24 (45.3 %) synthetic and 29 (54.7 %) biologic. Mesh patients were more commonly smokers (43.1 % vs. 22.9 %, p = 0.016) and had a larger defect size (10 vs. 6 cm, p = 0.003). Mesh patients had a higher rate of SSI (25.5 % vs. 9.5 %, p = 0.016) compared to non-mesh patients, but a similar rate of recurrence (13.7 % vs. 10.5%, p = 0.742), hospital length of stay (LOS), and mortality. Mesh use (OR 3.66) and higher ISS (OR 1.06) were significant risk factors for SSI in a multivariable model.

CONCLUSION

Mesh was used more frequently in flank TAWH and those with a larger defect size. Mesh use was associated with a higher incidence and risk of SSI but did not reduce the risk of hernia recurrence. When repairing TAWH mesh should be employed judiciously, and prospective randomized studies are needed to identify clear indications for mesh use in TAWH.

Evaluation of Resuscitative Endovascular Balloon Occlusion of the Aorta Complications in a Community-Based Trauma Center

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a method of management of noncompressible torso hemorrhage in trauma patients. Increased utilization has shown increased vascular complications and mortality. This study aimed to evaluate complications of REBOA placement in a community trauma setting.

METHODS

A 3-year retrospective review was performed of all trauma patients that underwent REBOA placement. Data collection included demographics, injury characteristics, complications, and mortality.

RESULTS

Twenty-three patients were included, and the overall mortality was 65.2%. Most patients suffered blunt trauma (73.9%), and median ISS and TRISS (survival probability) were 24 and 42.2%, respectively. The median time to REBOA placement was 22 minutes, and hemorrhagic control was achieved in all patients. The most common complication was acute kidney injury at 34.8%. There was one complication associated with placement that required vascular intervention but did not lead to limb amputation.

CONCLUSION

Resuscitative endovascular balloon occlusion of the aorta was shown to have higher rates of acute kidney injury, similar rates of vascular injury, and lower rate of limb complications compared to published literature. Resuscitative endovascular balloon occlusion of the aorta remains a useful tool for trauma resuscitation without the fear of increased complications.

Characteristics of Attempted and Completed Suicides During the COVID-19 Pandemic

BACKGROUND

This study aimed to describe patients admitted for attempted or completed suicide during the COVID-19 pandemic.

METHODS

A 1-year retrospective review was performed of adult patients admitted for attempted or completed suicide.

RESULTS

Of the 30 patients included, most injuries involved firearms (37%) and cutting/piercing (30%). Sixty-three percent of patients presented with an Injury Severity Score ≥16, and 37% of injuries involved the head. Upon admission, an alcohol test was completed for 83% of patients, 56% of whom tested positive. Thirty percent of patients died from their injuries, with all but one involving a firearm. Most of those who survived to discharge (62%) were discharged to an inpatient behavioral health facility.

DISCUSSION

The current study indicated a large proportion of suicides during the COVID-19 pandemic involved firearms and alcohol use. These findings point to the need for interventions aimed at preventing suicide and substance abuse during pandemic situations.

Falls Among Older Adults During the COVID-19 Pandemic Compared to a Pre-pandemic Period: A Case-Control Study

BACKGROUND

Little is known about how the COVID-19 pandemic impacted older adults admitted to the hospital with fall-related injuries. This research sought to determine if there was a difference in patient characteristics and hospital outcomes among older adults with fall-related injuries during the COVID-19 pandemic compared to a non-pandemic period.

METHODS

A retrospective chart review of patients 65 years or older admitted for traumatic falls before and during COVID-19 was undertaken. Data abstracted included demographics, fall details, injury data, and hospital course.

RESULTS

Of 1598 patients, 50.5% presented during COVID-19 (cases), and 49.5% presented pre-pandemic (controls). Fewer cases fell in rural areas (28.6% vs 34.1%, P = .018) and were transferred from outside hospitals (32.1% vs 38.2%, P = .011). More cases experienced alcohol (4.6% vs 2.4%, P = .017) and substance use disorders (1.4% vs .4%, P = .029). Fewer cases had subdural hemorrhages (11.8% vs 16.4%, P = .007), and more had pneumothoraxes (3.5% vs 1.8%, P = .032). More patients admitted during COVID-19 experienced acute respiratory failure (2.0% vs .0%, P < .001), hypoxia (1.5% vs .3%, P = .005), and delirium (6.3% vs 1.0%, P < .001). Fewer cases were discharged to skilled nursing facilities (50.8% vs 57.3%, P = .009) and more to home with services (13.1% vs 8.3%, P = .002).

DISCUSSION

This study suggested there was a similar frequency of presentation for falls among older adults during the two study periods. Older adults with fall-related injuries experienced differences in presenting comorbidities, injury patterns, complications, and discharge locations during the study periods.

Should Infants with Blunt Traumatic Brain Injuries and Intracranial Hemorrhage Have Routine Repeat Imaging?

Introduction

The practice of repeat head CT imaging in infants as a distinct population is poorly studied. The purpose of this study was to evaluate the incidence and utility of repeat head CT in the infant population.

Methods

A 10-year retrospective review was conducted of infants with blunt traumatic head injuries (N = 50) that presented to a trauma center. Information from the hospital trauma registry and patient medical records were extracted regarding the size and type of injury, number and results of computed tomography (CT) imaging, changes in neurological exams, and any interventions that were required.

Results

Most patients (68%) had at least one repeat CT, with 26% showing progression of hemorrhage. Decreased Glasgow Coma Scale was associated with having repeat CT scans. Nearly one in four infants had a change in management associated with repeat imaging. Repeat CT scans resulted in operative interventions in 11.8% of cases and longer intensive care unit (ICU) stays in 8.8% of cases. Repeat CT scans were associated with increased hospital length of stay, but not with increased ventilator days, ICU length of stay, or mortality. Worsening bleeds were associated with mortality, but not with other hospital outcomes.

Conclusions

Changes in management following repeat CT appeared to be more common in this population than in older children or adults. Findings from this study supported repeat CT imaging in infants, however, further research is needed to validate results of this study.

Evaluation of Outcomes and Treatment Options Among Trauma Patients with Abdominal Vascular Injuries

Introduction

Abdominal vascular injuries are associated with significant morbidity and mortality. Treatment options include non-operative management, open repair, and endovascular procedures. This study aimed to characterize patients and detail treatment modalities among those who sustained a traumatic abdominal vascular injury.

Methods

A six-year descriptive retrospective study was conducted at a level 1 trauma center and included all adult patients who sustained an abdominal vascular injury. Data abstracted included demographics, admitting characteristics, mechanism of injury, admitting vitals, injury details, diagnostic and treatment information, hospital course, and follow-up data.

Results

Fifty-seven patients were admitted with abdominal vascular injuries, however, 14 patients sustained injuries to smaller vascular branches and were excluded. Most vascular injuries involved the iliac artery (27.9%, n = 12), abdominal aorta (25.6%, n = 11), and inferior vena cava (25.6%, n = 11). Twenty-seven percent (n = 12) of patients sustained an injury to more than one vascular structure. Thirty-four percent of patients (n = 15) died before treatment of the abdominal vascular injury. Among the 28 patients (65.1%) treated for their vascular injuries, 46.4% (n = 13) were treated with open surgery, 32.1% (n = 9) were treated non-operatively, and 21.4% (n = 6) with coil embolization. Sixty-four percent of the patients (n = 18) who survived to discharge presented for follow-up care with a mean follow-up period of 3 ± 4.1 months. There were no vascular reinterventions after discharge for patients who followed up with our hospital.

Conclusions

Study findings suggested that appropriately selected cases of traumatic vascular injuries may be managed non-operatively and safely, as there were no mortalities, complications, or reinterventions among these patients.

Risk factors for recurrence in blunt traumatic abdominal wall hernias: A secondary analysis of a Western Trauma association multicenter study

BACKGROUND

Few studies have investigated risk factors for recurrence of blunt traumatic abdominal wall hernias (TAWH).

METHODS

Twenty trauma centers identified repaired TAWH from January 2012 to December 2018. Logistic regression was used to investigate risk factors for recurrence.

RESULTS

TAWH were repaired in 175 patients with 21 (12.0%) known recurrences. No difference was found in location, defect size, or median time to repair between the recurrence and non-recurrence groups. Mesh use was not protective of recurrence. Female sex, injury severity score (ISS), emergency laparotomy (EL), and bowel resection were associated with hernia recurrence. Bowel resection remained significant in a multivariable model.

CONCLUSION

Female sex, ISS, EL, and bowel resection were identified as risk factors for hernia recurrence. Mesh use and time to repair were not associated with recurrence. Surgeons should be mindful of these risk factors but could attempt acute repair in the setting of appropriate physiologic parameters.

Rodeo Trauma: Outcome Data from 10 Years of Injuries

Introduction

There are few data addressing rodeo injury outcomes, though injury incidence has been well described. The purpose of this study was to describe rodeo-related injury patterns and outcomes.

Methods

A 10-year retrospective case series was performed of patients injured in rodeo events and who were treated at an ACS-verified level I trauma center. Data regarding demographics, injury characteristics, and outcomes were summarized.

Results

Seventy patients were identified. Half were injured by direct contact with rodeo stock and 34 by falls. Head injuries were most common, occurring in 38 (54.3%). Twenty injuries (28.6%) required surgery. Sixty-nine patients (98.6%) were discharged to home. There was one death.

Conclusions

Head injuries were the most common injury among this cohort. Apart from one fatality, immediate outcomes after injury were good, with most patients dismissed home. Improved data collection at the time of admission may help to evaluate the success of current safety equipment use.

Pre-Hospital Spinal Immobilization: Neurological Outcomes for Spinal Motion Restriction vs. Spinal Immobilization

Introduction

New recommendations for emergency medical services spinal precautions limit long spinal board use to extrication purposes only and are to be removed immediately. Outcomes for spinal motion restriction against spinal immobilization were studied.

Methods

A retrospective chart review of trauma patients was conducted over a six-month period at a level I trauma center. Injury severity details and neurologic assessments were collected on 277 patients.

Results

Upon arrival, 25 (9.0%) patients had a spine board in place. Patients placed on spine boards were more likely to be moderately or severely injured [injury severity score (ISS) > 15: 36.0% vs. 9.9%, p = 0.001] and more likely to have neurological deficits documented by emergency medical services (EMS; 30.4% vs. 8.8%, p = 0.01) and the trauma team (29.2% vs. 10.9%, p = 0.02).

Conclusions

This study suggested that the long spine board was being used properly for more critically injured patients. Further research is needed to compare neurological outcomes using a larger sample size and more consistent documentation.

Geriatric Trauma Patients: Outcomes Before and After Addition of a Hospitalist Consultation

BACKGROUND

Research has shown improvements in patient care and outcomes with addition of a rounding geriatrician. The purpose of this study was to determine if addition of a hospitalist consultation improved patient outcomes.

METHODS

A retrospective review was conducted of all trauma patients, ≥65 years, before (n=481) and after (n=430) addition of a hospitalist consultant. Data included were demographics, comorbidities, injury severity, blood pressure, laboratory levels, pain control methods, ICU and ventilator requirements, complications, hospital length of stay, mortality, preexisting wishes, and 30-day readmission.

RESULTS

Adding a hospitalist consultation did not improve blood glucose or blood pressure control. It decreased narcotics-only use (36.0% vs 73.8%) while increasing multimodal pain control use (51.8% vs 14.8%, P<.001) and testing of HbA1c (7% vs .6%, P<.001). There was also increased knowledge of patient resuscitation status preferences (29.1% vs 12.9%, P<.001).

CONCLUSIONS

This article does not support use of routine hospitalist consultation in the geriatric trauma population. However, with study limitations, we continue to evaluate hospitalist utility and will adjust our daily rounds to more closely match prior studies.

Octogenarian Motor Vehicle Collisions: Injury Patterns Matter

Introduction

Motor vehicle collision (MVC) is the second most common mechanism of injury among octogenarians and is on the rise. These “oldest old” trauma patients have higher mortality rates than expected. This study examined potential factors influencing this increased mortality including comorbidities, medications, injury patterns, and hospital interventions.

Methods

A 10-year retrospective review was conducted of patients aged 80 and over who were injured in an MVC. Data collected included patient demographics, comorbidities, medication use prior to injury, collision details, injury severity and patterns, hospitalization details, outcomes, and discharge disposition.

Results

A total of 239 octogenarian patients were identified who were involved in an MVC. Overall mortality was 18.8%. An increased mortality was noted for specific injury patterns, patients injured in a rural setting, and those who were transfused, intubated, or admitted to the ICU. No correlation was found between mortality and medications or comorbidities.

Conclusions

The high mortality rate for octogenarian patients involved in an MVC was related to injury severity, type of injury, and in-hospital complications, and not due to comorbidities and prior medications.

Eastern Association for the Surgery of Trauma Multicenter Trial: Comparison of pre-injury antithrombotic use and reversal strategies among severe traumatic brain injury patients

BACKGROUND

Trauma teams are often faced with patients on antithrombotic (AT) drugs, which is challenging when bleeding occurs. We sought to compare the effects of different AT medications on head injury severity and hypothesized that AT reversal would not improve mortality in severe traumatic brain injury (TBI) patients.

METHODS

An Eastern Association for the Surgery of Trauma-sponsored prospective, multicentered, observational study of 15 trauma centers was performed. Patient demographics, injury burden, comorbidities, AT agents, and reversal attempts were collected. Outcomes of interest were head injury severity and in-hospital mortality.

RESULTS

Analysis was performed on 2,793 patients. The majority of patients were on aspirin (acetylsalicylic acid [ASA], 46.1%). Patients on a platelet chemoreceptor blocker (P2Y12) had the highest mean Injury Severity Score (9.1 ± 8.1). Patients taking P2Y12 inhibitors ± ASA, and ASA-warfarin had the highest head Abbreviated Injury Scale (AIS) mean (1.2 ± 1.6). On risk-adjusted analysis, warfarin-ASA was associated with a higher head AIS (odds ratio [OR], 2.43; 95% confidence interval [CI], 1.34-4.42) after controlling for Injury Severity Score, Charlson Comorbidity Index, initial Glasgow Coma Scale score, and initial systolic blood pressure. Among patients with severe TBI (head AIS score, ≥3) on antiplatelet therapy, reversal with desmopressin (DDAVP) and/or platelet transfusion did not improve survival (82.9% reversal vs. 90.4% none, p = 0.30). In severe TBI patients taking Xa inhibitors who received prothrombin complex concentrate, survival was not improved (84.6% reversal vs. 84.6% none, p = 0.68). With risk adjustment as described previously, mortality was not improved with reversal attempts (antiplatelet agents: OR 0.83; 85% CI, 0.12-5.9 [p = 0.85]; Xa inhibitors: OR, 0.76; 95% CI, 0.12-4.64; p = 0.77).

CONCLUSION

Reversal attempts appear to confer no mortality benefit in severe TBI patients on antiplatelet agents or Xa inhibitors. Combination therapy was associated with severity of head injury among patients taking preinjury AT therapy, with ASA-warfarin possessing the greatest risk.

LEVEL OF EVIDENCE

Prognostic, level II.

Management of blunt traumatic abdominal wall hernias: A Western Trauma Association multicenter study

BACKGROUND

Blunt traumatic abdominal wall hernias (TAWH) occur in approximately 15,000 patients per year. Limited data are available to guide the timing of surgical intervention or the feasibility of nonoperative management.

METHODS

A retrospective study of patients presenting with blunt TAWH from January 2012 through December 2018 was conducted. Patient demographic, surgical, and outcomes data were collected from 20 institutions through the Western Trauma Association Multicenter Trials Committee.

RESULTS

Two hundred and eighty-one patients with TAWH were identified. One hundred and seventy-six (62.6%) patients underwent operative hernia repair, and 105 (37.4%) patients underwent nonoperative management. Of those undergoing surgical intervention, 157 (89.3%) were repaired during the index hospitalization, and 19 (10.7%) underwent delayed repair. Bowel injury was identified in 95 (33.8%) patients with the majority occurring with rectus and flank hernias (82.1%) as compared with lumbar hernias (15.8%). Overall hernia recurrence rate was 12.0% (n = 21). Nonoperative patients had a higher Injury Severity Score (24.4 vs. 19.4, p = 0.010), head Abbreviated Injury Scale score (1.1 vs. 0.6, p = 0.006), and mortality rate (11.4% vs. 4.0%, p = 0.031). Patients who underwent late repair had lower rates of primary fascial repair (46.4% vs. 77.1%, p = 0.012) and higher rates of mesh use (78.9% vs. 32.5%, p < 0.001). Recurrence rate was not statistically different between the late and early repair groups (15.8% vs. 11.5%, p = 0.869).

CONCLUSION

This report is the largest series and first multicenter study to investigate TAWHs. Bowel injury was identified in over 30% of TAWH cases indicating a significant need for immediate laparotomy. In other cases, operative management may be deferred in specific patients with other life-threatening injuries, or in stable patients with concern for bowel injury. Hernia recurrence was not different between the late and early repair groups.

LEVEL OF EVIDENCE

Therapeutic/care management, Level IV.

An Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients

BACKGROUND

Prehospital procedures (PHP) by emergency medical services (EMS) are performed regularly in penetrating trauma patients despite previous studies demonstrating no benefit. We sought to examine the influence of PHPs on outcomes in penetrating trauma patients in urban locations where transport to trauma center is not prolonged. We hypothesized that patients without PHPs would have better outcomes than those undergoing PHP.

METHODS

This was an Eastern Association for the Surgery of Trauma-sponsored, multicenter, prospective, observational trial of adults (18+ years) with penetrating trauma to the torso and/or proximal extremity presenting at 25 urban trauma centers. The impact of PHPs and transport mechanism on in-hospital mortality were examined.

RESULTS

Of 2,284 patients included, 1,386 (60.7%) underwent PHP. The patients were primarily Black (n = 1,527, 66.9%) males (n = 1,986, 87.5%) injured by gunshot wound (n = 1,510, 66.0%) with 34.1% (n = 726) having New Injury Severity Score of ≥16. A total of 1,427 patients (62.5%) were transported by Advanced Life Support EMS, 17.2% (n = 392) by private vehicle, 13.7% (n = 312) by police, and 6.7% (n = 153) by Basic Life Support EMS. Of the PHP patients, 69.1% received PHP on scene, 59.9% received PHP in route, and 29.0% received PHP both on scene and in route. Initial scene vitals differed between groups, but initial emergency department vitals did not. Receipt of ≥1 PHP increased mortality odds (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.01-1.83; p = 0.04). Logistic regression showed increased mortality with each PHP, whether on scene or during transport. Subset analysis of specific PHP revealed that intubation (OR, 10.76; 95% CI, 4.02-28.78; p < 0.001), C-spine immobilization (OR, 5.80; 95% CI, 1.85-18.26; p < 0.01), and pleural decompression (OR, 3.70; 95% CI, 1.33-10.28; p = 0.01) had the highest odds of mortality after adjusting for multiple variables.

CONCLUSION

Prehospital procedures in penetrating trauma patients impart no survival advantage and may be harmful in urban settings, even when performed during transport. Therefore, PHP should be forgone in lieu of immediate transport to improve patient outcomes.

LEVEL OF EVIDENCE

Prognostic, level III.

Demographics and Incident Location of Gunshot Wounds at a Single Level I Trauma Center

Introduction

Kansas has seen a steady increase in the rate of firearm deaths and injuries. Little is known surrounding the demographic and geospatial factors of these firearm-related traumas. The purpose of this study was to describe the overall incidence of firearm-related traumas, identify high injury locations, and examine any racial/ethnic disparities that may exist.

Methods

A retrospective review was conducted of all patients 14 years or older who were admitted with a gunshot wound (GSW) to a Level I trauma center between 2016 and 2017.

Results

Forty-nine percent of patients were Caucasian, 26.5% African American, and 19.6% Hispanic/Latino. Hispanic/Latino patients were the youngest (25.8 ± 8.8 years) and Caucasians were the oldest (34.3 ± 14.1 years, p = 0.002). Compared to Caucasian patients, African American (42.0%) and Hispanic/Latino (54.1%) patients were more likely to be admitted to the intensive care unit (ICU; p = 0.034) and experienced longer ICU lengths of stay (2.5 ± 6.3 and 2.4 ± 4.7 days, p = 0.031, respectively). African American patients (96.0%) experienced more assaults, while Caucasians were more likely to receive gunshot wounds accidentally (26.9%, p = 0.001). More African American (86.0%) and Hispanic/Latino (89.2%) patients were injured with a handgun and Caucasians sustained the highest percentage of shotgun/rifle related injuries (16.1%, p = 0.012). Most GSWs occurred in zip codes 67202, 67203, 67213, 67211, and 67214. Geographical maps indicated that GSWs occur in neighborhoods with low-income and high minority residents and in the downtown and nightclub areas of the city.

Conclusions

Most GSW victims were older Caucasian males. Racial differences were noted and injury locations concentrated in certain locations.

Demographics and Incident Location of Traumatic Injuries at a Single Level I Trauma Center

Introduction

Traumatic injuries are preventable and understanding determinants of injury, such as socio-economic and environmental factors, is vital. This study evaluated traumatic injuries and identified areas of high trauma incidence.

Methods

A retrospective review was conducted of all patients 14 years or older who were admitted with a traumatic injury to a Level I trauma center between 2016 and 2017. Descriptive analyses were presented and maps of high injury areas were generated.

Results

The most frequent mechanisms of injury were falls (58.3%), motor vehicle crashes (22.3%), and motorcycle crashes (5.7%). Fall patients were more likely to be female (59.6%) and were the oldest age group (72.1 ± 17.2) compared to motor vehicle and motorcycle crash patients. Severe head (22.1%, p = 0.007) and extremity (35.7%, p = 0.001) injuries were most frequent among fall patients, however, more motorcycle crash patients required mechanical ventilation (16.1%, p < 0.001) and experienced the longest intensive care unit length of stay (5.3 ± 6.8 days, p < 0.001) and mechanical ventilation days (6.6 ± 8.5, p < 0.036). Motorcycle crash patients also had the greatest number of deaths (7.5%, p < 0.001). The generated maps of all traumas suggested that most injuries occur near our hospital and are located in several of the most population-dense zip codes.

Conclusion

Patient demographics, injury severity, and hospital outcomes varied by mechanisms of injury. Traumatic injuries occurred near our hospital and were located in several of the most populationdense zip codes. Injury prevention efforts should target high incident areas.

Fatal Agricultural Accidents in Kansas: A Thirty-Nine-Year Follow-Up Study with an Emphasis on Vehicular Fatalities

The purpose of this study was to evaluate trends in agricultural mortality before and after implementation of safety initiatives. Retrospective review of Kansas mortality data from agriculture-related injuries from 1979 to 2018. The 39-year period was stratified into four periods to compare mechanisms of injury and fatality rates between study periods. There were 780 agricultural-related deaths. Mean age significantly increased between study Period I to Period IV from 46.4 to 55.3 years (P = 0.013). Tractors remain the primary cause of farm-vehicle mortality overall; however, tractor-related deaths significantly decreased during the study periods from 75.6% to 44.3% (P < 0.001). Tractor rollover mortality also decreased from 50.8% to 25.6% (P = 0.036). ATV-related deaths significantly increased from study Period II to III (5.1% to 23.9%, P < 0.001), but decreased from Period III to IV (23.9% to 17.0%). Tractor-related fatalities are decreasing, but tractors still remain the most dangerous piece of farm equipment. ATV-related fatalities are a continued concern. Continued rural education and emphasis on the use of rollover protection structures is a critical focus in the effort to prevent fatal farming injuries.

Patterns of Injuries in Drowning Patients - Do These Patients Need a Trauma Team?

INTRODUCTION

Drowning is a major public health hazard worldwide, but associated traumatic injuries are rare. This study examined injuries and interventions performed on this population to assess the need for the trauma team activation.

METHODS

A 12-year retrospective review was conducted on all fatal and non-fatal drowning patients who underwent a trauma work-up. Data collection included demographics, injury characteristics, interventions, and outcomes.

RESULTS

Forty-three patients met inclusion criteria. Median patient age was six years (interquartile range 2 - 20) with 27.9% of patients under the age of 2 years. Most patients were white (62.8%) and male (69.8%), with median GCS score of 3 (60.5% had initial GCS = 3 with 25.6% with GCS = 15). Only two patients suffered traumatic injuries. Only two patients required operations, neither of which suffered traumatic injury. Eleven patients suffered anoxic brain injury (25.6%). Overall mortality was 48.8% (n = 21).

CONCLUSION

Patients who present with drowning and no traumatic mechanism have a very low rate of traumatic injuries. Work-up and treatment would be appropriate for emergency physicians without the need for a trauma activation.

Incidence and circumstances of pediatric fall-related injuries: Which fall variables matter?

BACKGROUND

This study's purpose was to determine if age, fall height, fall mechanism, landing surface, and landing position are associated with injury severity and hospital outcomes among pediatric fall patients.

METHODS

A retrospective review was conducted of patients aged ≤18 years who sustained fall-related injuries admitted to an American College of Surgeons verified Level 1 trauma center from January 1, 2006 through December 31, 2015.

RESULTS

Patient age, fall mechanism, landing position, and landing surface were associated with the need for surgery. Patient age, fall mechanism, and landing position were also associated with intensive care unit admissions. Fall mechanism was the only variable associated with injury severity. No variables were associated with the need for mechanical ventilation or mortality.

CONCLUSIONS

Patient age, fall mechanism, landing surface, and landing position need to be considered with regard to injury severity and patient outcomes among pediatric fall patients.

Incidence of Gunshot Wounds: Before and After Implementation of a Shall Issue Conceal Carry Law

INTRODUCTION

This study examined the incidence of gunshot wounds before and after enacting a conceal carry (CC) law in a predominately rural state.

METHODS

A retrospective review was conducted of all patients who were admitted with a gunshot injury to a Level I trauma center. Patient data collected included demographics, injury details, hospital course, and discharge destination.

RESULTS

Among the 238 patients included, 44.6% (n = 107) were admitted during the pre-CC period and 55.4% (n = 131) in the post-CC period. No demographic differences were noted between the two periods except for an increase in uninsured patients from 43.0% vs 61.1% (p = 0.020). Compared to pre-CC patients, post-CC patients experienced a trend toward increased abdominal injury (11.2% vs 20.6%, p = 0.051) and increased vascular injuries (11.2% vs 22.1%, p = 0.026) while lower extremity injuries decreased significantly (38.3% vs 26.0%, p = 0.041). Positive focused assessment with sonography in trauma (FAST) exams (2.2% vs 16.8, p < 0.001), intensive care unit admission (26.2% vs 42.0%, p = 0.011) and need for ventilator support (11.2% vs 22.1%, p = 0.026) all increased during the post-CC period. In-hospital mortality more than doubled (8.4% vs 18.3%, p = 0.028) across the pre- and post-CC time periods.

CONCLUSION

Implementation of a CC law was not associated with a decrease in the overall number of penetrating injuries or a decrease in mortality.

Outcomes Following Blunt Traumatic Splenic Injury Treated with Conservative or Operative Management

INTRODUCTION

Laparotomy, embolization, and observation are described for blunt splenic injury management. This study evaluated outcomes of blunt splenic injury management based on baseline factors, splenic injury severity, and associated injuries.

METHODS

A nine-year retrospective review was conducted of adult patients with blunt splenic injury. Collected data included demographics, injury characteristics, treatment modality, complications, and outcomes (mechanical ventilation, days on mechanical ventilation, intensive care unit [ICU] admission and length of stay, hospital length of stay, and in-hospital mortality). Categorical and continuous variables were analyzed using χ² analysis and one-way analysis of variance for normally distributed variables and a non-parametric test of medians for variables that did not meet the assumption of normality, respectively.

RESULTS

Splenic injury grade was similar between operative and embolization groups, but severe hemoperitoneum was more common in the operative group. Complications and mortality were highest in the operative group (50.7% and 26.3%, respectively) and lowest in the embolization group (5.3% and 2.6%, respectively). Operative patients required more advanced interventions (ICU admission, mechanical ventilation). There were no differences between those treated with proximal versus distal embolization. Observation carried a failure rate of 11.2%, with no failures of embolization.

CONCLUSIONS

Embolization patients had the lowest rates of complications and mortality, with comparable splenic injury grades to those treated operatively. Further prospective research is warranted to identify patients that may benefit from early embolization and avoidance of major abdominal surgery.

Outcomes Following Blunt Traumatic Splenic Injury Treated with Conservative or Operative Management

Introduction Laparotomy, embolization, and observation are described for blunt splenic injury management. This study evaluated outcomes of blunt splenic injury management based on baseline factors, splenic injury severity, and associated injuries. Methods A nine-year retrospective review was conducted of adult patients with blunt splenic injury. Collected data included demographics, injury characteristics, treatment modality, complications, and outcomes (mechanical ventilation, days on mechanical ventilation, intensive care unit [ICU] admission and length of stay, hospital length of stay, and in-hospital mortality). Categorical and continuous variables were analyzed using χ2 analysis and one-way analysis of variance for normally distributed variables and a non-parametric test of medians for variables that did not meet the assumption of normality, respectively. Results Splenic injury grade was similar between operative and embolization groups, but severe hemoperitoneum was more common in the operative group. Complications and mortality were highest in the operative group (50.7% and 26.3%, respectively) and lowest in the embolization group (5.3% and 2.6%, respectively). Operative patients required more advanced interventions (ICU admission, mechanical ventilation). There were no differences between those treated with proximal versus distal embolization. Observation carried a failure rate of 11.2%, with no failures of embolization. Conclusions Embolization patients had the lowest rates of complications and mortality, with comparable splenic injury grades to those treated operatively. Further prospective research is warranted to identify patients that may benefit from early embolization and avoidance of major abdominal surgery.

Injury Patterns in Near-Hanging Patients: How Much Workup Is Really Needed?

Survivors of near-hangings suffer anoxic brain injuries, but it remains uncertain whether the incidence of associated injuries warrants extensive workup or trauma activation. An 11-year retrospective review was conducted on adult patients with a hanging mechanism who underwent trauma workup and management. The majority of patients (n = 98) were white (88.8%) males (75.5%) with an average age of 30 ± 12.3 years. Two-hundred fifty-four CT and magnetic resonance scans were performed and eight injuries were uncovered: three thyroid cartilage/hyoid fractures; three vertebral injuries; and two cervical vascular injuries. Anoxic brain injury was diagnosed clinically in 35 patients (35.7%) and was present in all 19 patients (19.4%) who died. Only one patient had intra-abdominal injury requiring surgical intervention. Injuries were more likely in patients with abnormal Glasgow Coma Scale (GCS) versus normal GCS (55% vs 10.5%, respectively). Patients who present after near-hanging have a low incidence of associated injuries. Workup can be restricted to patients with abnormal GCS scores and for specific signs and symptoms or high-risk energy mechanisms. The trauma team can be activated for signs of trauma.

Injury Patterns in Near-Hanging Patients: How Much Workup is Really Needed?

Survivors of near-hangings suffer anoxic brain injuries, but it remains uncertain whether the incidence of associated injuries warrants extensive workup or trauma activation. An 11-year retrospective review was conducted on adult patients with a hanging mechanism who underwent trauma workup and management. The majority of patients (n = 98) were white (88.8%) males (75.5%) with an average age of 30 ± 12.3 years. Two-hundred fifty-four CTand magnetic resonance scans were performed and eight injuries were uncovered: three thyroid cartilage/hyoid fractures; three vertebral injuries; and two cervical vascular injuries. Anoxic brain injury was diagnosed clinically in 35 patients (35.7%) and was present in all 19 patients (19.4%) who died. Only one patient had intra-abdominal injury requiring surgical intervention. Injuries were more likely in patients with abnormal Glasgow Coma Scale (GCS) versus normal GCS (55% vs 10.5%, respectively). Patients who present after near-hanging have a low incidence of associated injuries. Workup can be restricted to patients with abnormal GCS scores and for specific signs and symptoms or high-risk energy mechanisms. The trauma team can be activated for signs of trauma.

Computed Tomography in Trauma Patients Accepted in Transfer: Missed Injuries and Rationale for Repeat Imaging. Can we do Better?

INTRODUCTION

Computed tomography scans often are repeated on trauma patient transfers, leading to increased radiation exposure, resource utilization, and costs. This study examined the incidence of repeated computed tomography scans (RCT) in trauma patient transfers before and after software upgrades, physician education, and encouragement to reduce RCT.

METHODS

The number of RCTs at an American College of Surgeons Committee on Trauma verified level 1 trauma center was measured. The trauma team was educated and encouraged to use the computed tomography scans received with transfer trauma patients as per study protocol. All available images were reviewed and reasons for a RCT when ordered were recorded and categorized. Impact of system improvements and education on subsequent RCT were evaluated.

RESULTS

A RCT was done on 47.2% (n = 76) of patients throughout the study period. Unacceptable image quality and possible missed diagnoses were the most commonly reported reasons for a RCT. Preventable reasons for a RCT (attending refusal to read outside films, incompatible software, and physician preference) decreased from 25.8 to 14.3% over the study periods.

CONCLUSIONS

The volume of unnecessary RCT can be reduced primarily through software updates and physician education, thereby decreasing radiation exposure, patient cost, and inefficiencies in hospital resource usage.

Computed Tomography in Trauma Patients Accepted in Transfer:

Introduction. Computed tomography scans often are repeated ontrauma patient transfers, leading to increased radiation exposure,resource utilization, and costs. This study examined the incidenceof repeated computed tomography scans (RCT) in trauma patienttransfers before and after software upgrades, physician education,and encouragement to reduce RCT.Methods.xThe number of RCTs at an American College of SurgeonsCommittee on Trauma verified level 1 trauma center was measured.The trauma team was educated and encouraged to use the computedtomography scans received with transfer trauma patients as perstudy protocol. All available images were reviewed and reasons for aRCT when ordered were recorded and categorized. Impact of systemimprovements and education on subsequent RCT were evaluated.Results. A RCT was done on 47.2% (n = 76) of patients throughoutthe study period. Unacceptable image quality and possible misseddiagnoses were the most commonly reported reasons for a RCT. Preventablereasons for a RCT (attending refusal to read outside films,incompatible software, and physician preference) decreased from25.8 to 14.3% over the study periods.Conclusions. The volume of unnecessary RCT can be reduced primarilythrough software updates and physician education, therebydecreasing radiation exposure, patient cost, and inefficiencies in hospitalresource usage. Kans J Med 2019;12(1):7-10.

Evaluation of Protective Equipment Used Among Motorbike Riders

Introduction. This study compared outcomes between patientsinjured at a motorbike track, which requires riders to follow safetyequipment guidelines, and those involved in recreational riding wheresafety equipment usage is voluntary. Methods. A retrospective review was conducted of all patients presentingwith motorbike-related injuries at an American College ofSurgeons verified level-I trauma center between January 1, 2009 andDecember 31, 2013. Data collected included demographics, injurydetails, safety equipment use, hospitalization details, and dischargedisposition. Comparisons were made regarding protective equipmentusage. Results. Among the 115 patients admitted, more than half (54.8%, n =63) were injured on a motorbike track, and 45.2% (n = 52) were injuredin a recreational setting. The majority of patients were male (93.9%),Caucasian (97.4%), and between the ages of 18 to 54 (64.4%). Helmetusage was higher among track riders (95.2%, n = 60) than recreationalriders (46.2%, n = 24, p < 0.0001). Comparisons of injury severity andoutcomes between those who wore protective equipment and thosewho did not were not significant. Conclusions. Even though track riders wore protective equipmentmore than recreational riders, there was no difference between thegroups regarding injury severity or hospital outcomes. These resultssuggested that motocross riders should not rely on protective equipmentas the only measure of injury prevention.Kans J Med 2018;11(2):44-47.

Head CT Guidelines Following Concussion Among the Youngest Trauma Patients

Introduction. Recent studies have provided guidelines on the use ofhead computed tomography (CT) scans in pediatric trauma patients.The purpose of this study was to identify the prevalence of theseguidelines among concussed pediatric patients. Methods. A retrospective review was conducted of patients fouryears or younger with a concussion from blunt trauma. Demographics,head injury characteristics, clinical indicators for head CT scan(severe mechanism, physical exam findings of basilar skull fracture,non-frontal scalp hematoma, Glasgow Coma Scale score, loss ofconsciousness, neurologic deficit, altered mental status, vomiting,headache, amnesia, irritability, behavioral changes, seizures, lethargy),CT results, and hospital course were collected. Results. One-hundred thirty-three patients (78.2%) received a headCT scan, 7 (5.3%) of which demonstrated fractures and/or bleeds. Allpatients with skull fractures and/or bleeds had at least one clinicalindicator present on arrival. Clinical indicators that were observedmore commonly in patients with positive CT findings than in thosewith negative CT findings included severe mechanism (100% vs.54.8%, respectively, p = 0.020) and signs of a basilar skull fracture(28.6% vs. 0.8%, respectively, p = 0.007). Severe mechanism alonewas found to be sensitive, but not specific, whereas signs of a basilarskull fracture, headache, behavioral changes, and vomiting were specific,but not sensitive. No neurosurgical procedures were necessary,and there were no deaths. Conclusions. Clinical indicators were present in patients with positiveand negative CT findings. However, severe mechanism of injuryand signs of basilar skull fracture were more common for patients withpositive CT findings. Kans J Med 2018;11(2):38-43.

Increasing Onshore Oil Production

Introduction. Few data currently exist which are focused on typeand severity of onshore oil extraction-related injuries. The purposeof this study was to evaluate injury patterns among onshore oil fieldoperations. Methods. A retrospective review was conducted of all traumapatients aged 18 and older with an onshore oil field-related injuryadmitted to an American College of Surgeons-verified level 1 traumacenter between January 1, 2003 and June 30, 2012. Data collectedincluded demographics, injury severity and details, hospital outcomes,and disposition. Results. A total of 66 patients met inclusion criteria. All patientswere male, of which the majority were Caucasian (81.8%, n = 54)with an average age of 36.5 ± 11.8 years, injury severity score of 9.4 ±8.9, and Glasgow Coma Scale score of 13.8 ± 3.4. Extremity injurieswere the most common (43.9%, n = 29), and most were the resultof being struck by an object (40.9%, n = 27). Approximately onethirdof patients (34.8%, n = 23) were admitted to the intensive careunit. Nine patients (13.6%) required mechanical ventilation while27 (40.9%) underwent operative treatment. The average hospitallength of stay was 5.8 ± 16.6 days, and most patients (78.8%, n = 52)were discharged home. Four patients suffered permanent disabilities,and there were two deaths. Conclusions. Increased domestic onshore oil production inevitablywill result in higher numbers of oil field-related traumas. By focusingon employees who are at the greatest risk for injuries and by targetingthe main causes of injuries, training programs can lead to a decreasein injury incidence. Kans J Med 2018;11(2):34-37.

Pediatric Farm Injuries

Introduction. Agriculture is an industry where family members oftenlive and work on the same premises. This study evaluated injury patternsand outcomes in children from farm-related accidents. Methods. A 10-year retrospective review of farm-accident relatedinjuries was conducted of patients 17 years and younger. Data collectedincluded demographics, injury mechanism, accident details, injuryseverity and patterns, treatments required, hospitalization details, anddischarge disposition. Results. Sixty-five patients were included; 58.5% were male and themean age was 9.7 years. Median Injury Severity Score and GlasgowComa Scale were 5 and 15, respectively. Accident mechanisms includedanimal-related (43.1%), fall (21.5%), and motor vehicle (21.5%).Soft tissue injuries, concussions and upper extremity fractures werethe most common injuries observed (58.5%, 29.2%, and 26.2%,respectively). Twenty-six patients (40%) required surgical intervention.Mean hospital length of stay was 3.4 ± 4.7 days. The majority ofpatients were discharged to home (n = 62, 95.4%) and two patientssuffered permanent disability. Conclusion. Overall, outcomes for this population were favorable,but additional measures to increase safety, such as fall prevention,animal handling, and driver safety training should be advocated.KS J Med 2017;10(4):92-95.

Comparisons of Medical Student Knowledge Regarding Life-Threatening CT Images Before and After Clinical Experience

Introduction. Currently, no national standard exists for educatingmedical students regarding radiography or formal research indicatingthe level of improvement regarding computed tomography(CT) interpretation of medical students during clinical rotations. Methods. Students were evaluated based on their response totwenty-two open-ended questions regarding diagnosis and treatmentof eleven de-identified CT images of life-threatening injuries.The number of incorrect answers was compared withcorrect or partially correct answers between students startingthird-year clinical rotations and those starting their fourth year. Results. Survey results were collected from 65 of 65 (100%) beginningthird-year students and 9 of 60 (15%) beginning fourthyearstudents. Students in their fourth-year had less incorrectanswers compared to third-year students, with five questionsreflecting a statistically significant reduction in incorrect responses.The image with the least incorrect for both groups wasepidural hemorrhage, 33.9% and 18.5% incorrect for third-yearstudents for diagnosis and treatment, respectively, and 11.1%and 0% incorrect for fourth-year students. Outside of this image,the range of incorrect answers for third-year students was75.4% to 100% and 44.4% to 100% for fourth-year students. Conclusion. Baseline CT knowledge of medical students,regardless of clinical experience, indicated a strong deficit,as more students were incorrect than correct for themajority of CT images. KS J Med 2017;10(3):55-58.

Evaluation of Protective Equipment Used Among Motorbike Riders

INTRODUCTION

This study compared outcomes between patients injured at a motorbike track, which requires riders to follow safety equipment guidelines, and those involved in recreational riding where safety equipment usage is voluntary.

METHODS

A retrospective review was conducted of all patients presenting with motorbike-related injuries at an American College of Surgeons verified level-I trauma center between January 1, 2009 and December 31, 2013. Data collected included demographics, injury details, safety equipment use, hospitalization details, and discharge disposition. Comparisons were made regarding protective equipment usage.

RESULTS

Among the 115 patients admitted, more than half (54.8%, n = 63) were injured on a motorbike track, and 45.2% (n = 52) were injured in a recreational setting. The majority of patients were male (93.9%), Caucasian (97.4%), and between the ages of 18 to 54 (64.4%). Helmet usage was higher among track riders (95.2%, n = 60) than recreational riders (46.2%, n = 24, p < 0.0001). Comparisons of injury severity and outcomes between those who wore protective equipment and those who did not were not significant.

CONCLUSION

Even though track riders wore protective equipment more than recreational riders, there was no difference between the groups regarding injury severity or hospital outcomes. These results suggested that motocross riders should not rely on protective equipment as the only measure of injury prevention.

Increasing Onshore Oil Production: An Unexpected Explosion in Trauma Patients

INTRODUCTION

Few data currently exist which are focused on type and severity of onshore oil extraction-related injuries. The purpose of this study was to evaluate injury patterns among onshore oil field operations.

METHODS

A retrospective review was conducted of all trauma patients aged 18 and older with an onshore oil field-related injury admitted to an American College of Surgeons-verified level 1 trauma center between January 1, 2003 and June 30, 2012. Data collected included demographics, injury severity and details, hospital outcomes, and disposition.

RESULTS

A total of 66 patients met inclusion criteria. All patients were male, of which the majority were Caucasian (81.8%, n = 54) with an average age of 36.5 ± 11.8 years, injury severity score of 9.4 ± 8.9, and Glasgow Coma Scale score of 13.8 ± 3.4. Extremity injuries were the most common (43.9%, n = 29), and most were the result of being struck by an object (40.9%, n = 27). Approximately one-third of patients (34.8%, n = 23) were admitted to the intensive care unit. Nine patients (13.6%) required mechanical ventilation while 27 (40.9%) underwent operative treatment. The average hospital length of stay was 5.8 ± 16.6 days, and most patients (78.8%, n = 52) were discharged home. Four patients suffered permanent disabilities, and there were two deaths.

CONCLUSION

Increased domestic onshore oil production inevitably will result in higher numbers of oil field-related traumas. By focusing on employees who are at the greatest risk for injuries and by targeting the main causes of injuries, training programs can lead to a decrease in injury incidence.

Head CT Guidelines Following Concussion among the Youngest Trauma Patients: Can We Limit Radiation Exposure Following Traumatic Brain Injury?

INTRODUCTION

Recent studies have provided guidelines on the use of head computed tomography (CT) scans in pediatric trauma patients. The purpose of this study was to identify the prevalence of these guidelines among concussed pediatric patients.

METHODS

A retrospective review was conducted of patients four years or younger with a concussion from blunt trauma. Demographics, head injury characteristics, clinical indicators for head CT scan (severe mechanism, physical exam findings of basilar skull fracture, non-frontal scalp hematoma, Glasgow Coma Scale score, loss of consciousness, neurologic deficit, altered mental status, vomiting, headache, amnesia, irritability, behavioral changes, seizures, lethargy), CT results, and hospital course were collected.

RESULTS

One-hundred thirty-three patients (78.2%) received a head CT scan, 7 (5.3%) of which demonstrated fractures and/or bleeds. All patients with skull fractures and/or bleeds had at least one clinical indicator present on arrival. Clinical indicators that were observed more commonly in patients with positive CT findings than in those with negative CT findings included severe mechanism (100% vs. 54.8%, respectively, p = 0.020) and signs of a basilar skull fracture (28.6% vs. 0.8%, respectively, p = 0.007). Severe mechanism alone was found to be sensitive, but not specific, whereas signs of a basilar skull fracture, headache, behavioral changes, and vomiting were specific, but not sensitive. No neurosurgical procedures were necessary, and there were no deaths.

CONCLUSION

Clinical indicators were present in patients with positive and negative CT findings. However, severe mechanism of injury and signs of basilar skull fracture were more common for patients with positive CT findings.

Fatal Agricultural Accidents in Kansas: A Thirty-One-Year Study

Agricultural work results in numerous injuries and deaths. Efficacy of farm equipment safety interventions remains unclear. This study evaluated agricultural mortality pre- and postimplementation of safety initiatives. A 31-year retrospective review of mortality data from agriculture-related injuries was conducted. Demographics and injury patterns were evaluated by mechanism of injury. There were 660 deaths (mean age 48.6 years). Female deaths increased from 5.2 to 11.7 per cent (P = 0.032). Mortality associated with tractors decreased (75.6% vs 53.9%; P < 0.001) and with all-terrain vehicles increased (3.5% vs 22.0%; P < 0.001) from Period I to III. However, tractors remain the primary cause of mortality. For mechanical equipment-associated mortality, there was a decrease (83.3% vs 50.0%) in "caught in equipment," and an increase (6.7% vs 38.9%) in those killed by "crush injury" from Period I to III. Application of safety devices to enclose and stabilize machinery has led to an overall decrease in mortality associated with tractors and "caught in equipment." Expanded rural education, as well as further development and use of safety devices, is warranted to curtail farm-related injuries and deaths.

Fatal Agricultural Accidents in Kansas: A Thirty-One-Year Study

Agricultural work results in numerous injuries and deaths. Efficacy of farm equipment safety interventions remains unclear. This study evaluated agricultural mortality pre- and post-implementation of safety initiatives. A 31-year retrospective review of mortality data from agriculture-related injuries was conducted. Demographics and injury patterns were evaluated by mechanism of injury. There were 660 deaths (mean age 48.6 years). Female deaths increased from 5.2 to 11.7 per cent ( P = 0.032). Mortality associated with tractors decreased (75.6% vs 53.9%; P < 0.001) and with all-terrain vehicles increased (3.5% vs 22.0%; P < 0.001) from Period I to III. However, tractors remain the primary cause of mortality. For mechanical equipment–associated mortality, there was a decrease (83.3% vs 50.0%) in “caught in equipment,” and an increase (6.7% vs 38.9%) in those killed by “crush injury” from Period I to III. Application of safety devices to enclose and stabilize machinery has led to an overall decrease in mortality associated with tractors and “caught in equipment.” Expanded rural education, as well as further development and use of safety devices, is warranted to curtail farm-related injuries and deaths.

The Impact of Methamphetamine Use on Trauma Patients at a Level I Trauma Center: A 10-Year Retrospective Review

The effects of methamphetamines (MAs) on trauma patient outcomes have been evaluated, but with discordant results. The purpose of this study was to identify hospital outcomes associated with MA use after traumatic injury. Retrospective review of adult trauma patients admitted to an American College of Surgeons verified–Level I trauma center who received a urine drug screen (UDS) between January 1, 2004 and December 31, 2013. Logistic regression analysis was used to identify factors associated with mortality. Patients with a negative UDS were used as controls. Among the 2321 patients included, 75.1 per cent were male, 81.9 per cent were white, and the average age was 39. Patients were grouped by UDS results (negative, MA only, other drug plus MA, or other drug without MA). A positive drug screen result of other drug without MA demonstrated a significantly lower risk for mortality, but longer intensive care unit and hospital length of stay, as well as increased ventilator days than negative results. Results of MA only did not alter the risk of mortality. These findings suggest that patients who test positive for MAs are not at an increased risk of in-hospital mortality when compared with patients having a negative drug screen.

The Impact of Methamphetamine Use on Trauma Patients at a Level I Trauma Center: A 10-Year Retrospective Review

The effects of methamphetamines (MAs) on trauma patient outcomes have been evaluated, but with discordant results. The purpose of this study was to identify hospital outcomes associated with MA use after traumatic injury. Retrospective review of adult trauma patients admitted to an American College of Surgeons verified-Level I trauma center who received a urine drug screen (UDS) between January 1, 2004 and December 31, 2013. Logistic regression analysis was used to identify factors associated with mortality. Patients with a negative UDS were used as controls. Among the 2321 patients included, 75.1 per cent were male, 81.9 per cent were white, and the average age was 39. Patients were grouped by UDS results (negative, MA only, other drug plus MA, or other drug without MA). A positive drug screen result of other drug without MA demonstrated a significantly lower risk for mortality, but longer intensive care unit and hospital length of stay, as well as increased ventilator days than negative results. Results of MA only did not alter the risk of mortality. These findings suggest that patients who test positive for MAs are not at an increased risk of in-hospital mortality when compared with patients having a negative drug screen.

Prehospital Extrication Techniques: Neurological Outcomes Associated with the Rapid Extrication Method and the Kendrick Extrication Device

Most emergency medical service personnel rely on one of two techniques to extricate motor vehicle crash victims; the Rapid Extrication Maneuver (REM) or the Kendrick Extrication Device (KED). The purpose of this study was to compare pre- and postextrication neurological outcomes between these two techniques. A retrospective review was conducted of all adult patients with a vertebral column injury resulting from motor vehicle collision and admitted to a Level I trauma center between January 1, 2003 and December 31, 2010. Standardized pre- and postextrication neurological examinations were reviewed for all patients. More than half of patients (N = 81) were extricated using the KED (53.1%, n = 43) and 46.9 per cent (n = 38) were extricated with the REM. Except for the thoracic Abbreviated Injury Score, no differences between groups emerged related to the Glasgow Coma Scale score, Injury Severity Score or Abbreviated Injury Score. There were no pre- and postextrication changes for motor to all extremities and sensation to all extremities using either method. The results of this study suggest that the REM and the KED are equivalent in protecting the patient from neurologic injury after motor vehicle collision.

Prehospital Extrication Techniques: Neurological Outcomes Associated with the Rapid Extrication Method and the Kendrick Extrication Device

Most emergency medical service personnel rely on one of two techniques to extricate motor vehicle crash victims; the Rapid Extrication Maneuver (REM) or the Kendrick Extrication Device (KED). The purpose of this study was to compare pre- and postextrication neurological outcomes between these two techniques. A retrospective review was conducted of all adult patients with a vertebral column injury resulting from motor vehicle collision and admitted to a Level I trauma center between January 1, 2003 and December 31, 2010. Standardized pre- and postextrication neurological examinations were reviewed for all patients. More than half of patients (N = 81) were extricated using the KED (53.1%, n = 43) and 46.9 per cent (n = 38) were extricated with the REM. Except for the thoracic Abbreviated Injury Score, no differences between groups emerged related to the Glasgow Coma Scale score, Injury Severity Score or Abbreviated Injury Score. There were no pre- and postextrication changes for motor to all extremities and sensation to all extremities using either method. The results of this study suggest that the REM and the KED are equivalent in protecting the patient from neurologic injury after motor vehicle collision.

Pediatric Farm Injuries: Morbidity and Mortality

BACKGROUND

Agriculture is an industry where family members often live and work on the same premises. This study evaluated injury patterns and outcomes in children from farm-related accidents.

METHODS

A 10-year retrospective review of farm-accident related injuries was conducted of patients 17 years and younger. Data collected included demographics, injury mechanism, accident details, injury severity and patterns, treatments required, hospitalization details, and discharge disposition.

RESULTS

Sixty-five patients were included; 58.5% were male and the mean age was 9.7 years. Median Injury Severity Score and Glasgow Coma Scale were 5 and 15, respectively. Accident mechanisms included animal-related (43.1%), fall (21.5%), and motor vehicle (21.5%). Soft tissue injuries, concussions and upper extremity fractures were the most common injuries observed (58.5%, 29.2%, and 26.2%, respectively). Twenty-six patients (40%) required surgical intervention. Mean hospital length of stay was 3.4 ± 4.7 days. The majority of patients were discharged to home (n = 62, 95.4%) and two patients suffered permanent disability.

CONCLUSIONS

Overall, outcomes for this population were favorable, but additional measures to increase safety, such as fall prevention, animal handling, and driver safety training should be advocated.

Comparisons of Medical Student Knowledge Regarding Life-Threatening CT Images Before and After Clinical Experience

BACKGROUND

Currently, no national standard exists for educating medical students regarding radiography or formal research indicating the level of improvement regarding computed tomography (CT) interpretation of medical students during clinical rotations.

METHODS

Students were evaluated based on their response to twenty-two open-ended questions regarding diagnosis and treatment of eleven de-identified CT images of life-threatening injuries. The number of incorrect answers was compared with correct or partially correct answers between students starting third-year clinical rotations and those starting their fourth year.

RESULTS

Survey results were collected from 65 of 65 (100%) beginning third-year students and 9 of 60 (15%) beginning fourth-year students. Students in their fourth-year had less incorrect answers compared to third-year students, with five questions reflecting a statistically significant reduction in incorrect responses. The image with the least incorrect for both groups was epidural hemorrhage, 33.9% and 18.5% incorrect for third-year students for diagnosis and treatment, respectively, and 11.1% and 0% incorrect for fourth-year students. Outside of this image, the range of incorrect answers for third-year students was 75.4% to 100% and 44.4% to 100% for fourth-year students.

CONCLUSION

Baseline CT knowledge of medical students, regardless of clinical experience, indicated a strong deficit, as more students were incorrect than correct for the majority of CT images.

Dementia as a predictor of mortality in adult trauma patients

BACKGROUND

The specific contribution of dementia towards mortality in trauma patients is not well defined. The purpose of the study was to evaluate dementia as a predictor of mortality in trauma patients when compared to case-matched controls.

METHODS

A 5-year retrospective review was conducted of adult trauma patients with a diagnosis of dementia at an American College of Surgeons-verified level I trauma center. Patients with dementia were matched with non-dementia patients and compared on mortality, ICU length of stay, and hospital length of stay.

RESULTS

A total of 195 patients with dementia were matched to non-dementia controls. Comorbidities and complications (11.8% vs 12.4%) were comparable between both groups. Dementia patients spent fewer days on the ventilator (1 vs 4.5, P = 0.031). The length of ICU stay (2 days), hospital length of stay (3 days), and mortality (5.1%) were the same for both groups (P > 0.05).

CONCLUSIONS

Dementia does not appear to increase the risk of mortality in trauma patients. Further studies should examine post-discharge outcomes in dementia patients.

Analysis of patients ≥65 with predominant cervical spine fractures: Issues of disposition and dysphagia

Background:

Cervical spine fractures occur in 2.6% to 4.7% of trauma patients aged 65 years or older. Mortality rates in this population ranges from 19% to 24%. A few studies have specifically looked at dysphagia in elderly patients with cervical spine injury.

Aims:

The aim of this study is to evaluate dysphagia, disposition, and mortality in elderly patients with cervical spine injury.

Settings and Design:

Retrospective review at an the American College of Surgeons-verified level 1 trauma center.

Methods:

Patients 65 years or older with cervical spine fracture, either isolated or in association with other minor injuries were included in the study. Data included demographics, injury details, neurologic deficits, dysphagia evaluation and treatment, hospitalization details, and outcomes.

Statistical Analysis:

Categorical and continuous data were analyzed using Chi-square analysis and one-way analysis of variance, respectively.

Results:

Of 136 patients in this study, 2 (1.5%) had a sensory deficit alone, 4 (2.9%) had a motor deficit alone, and 4 (2.9%) had a combined sensory and motor deficit. Nearly one-third of patients (n = 43, 31.6%) underwent formal swallow evaluation, and 4 (2.9%) had a nasogastric tube or Dobhoff tube placed for enteral nutrition, whereas eight others (5.9%) had a gastrostomy tube or percutaneous endoscopic gastrostomy tube placed. Most patients were discharged to a skilled nursing unit (n = 50, 36.8%), or to home or home with home health (n = 48, 35.3%). Seven patients (5.1%) died in the hospital, and eight more (5.9%) were transferred to hospice.

Conclusion:

Cervical spine injury in the elderly patient can lead to significant consequences, including dysphagia and need for skilled nursing care at discharge.

Utility of clinical decision rule for intensive care unit admission in patients with traumatic intracranial hemorrhage

BACKGROUND

Recent literature suggests the majority of traumatic intracranial hemorrhage does not require intervention. One recently described clinical decision rule was sensitive in identifying patients requiring critical care interventions in an urban setting. We sought to validate its effectiveness in our predominately rural setting.

METHODS

A retrospective study was conducted of adult patients with traumatic intracranial hemorrhage. The rule, based on age, initial Glasgow coma scale score, and presence of a non-isolated head injury, was applied to externally validate the previously reported findings.

RESULTS

In our population, the rule displayed a sensitivity of 0.923, specificity of 0.251, positive predictive value of 0.393, and negative predictive value of 0.862. The area under curve was 0.587. While our population has a similar adjusted head injury severity score as that from which the rule was developed, significant differences in age and intracranial hemorrhage pattern were noted.

CONCLUSIONS

The rule displayed decreased performance in our population, most likely secondary to differences in age and intracranial hemorrhage patterns. Prospective evaluation and cost-savings analysis are appropriate subsequent steps for the rule.

Outcomes in elderly fall victims: what happens after hospital discharge?

BACKGROUND

Falls are the leading cause of trauma-related death in the elderly, but postdischarge outcomes' data are lacking. The purpose of this study was to evaluate 12-month postdischarge mortality and causes of death.

METHODS

A retrospective review was conducted of patients 65 years and older admitted for a fall and discharged alive. Data collection included demographics, injury characteristics, hospitalization details, and outcomes. A state death database and hospital records were queried to identify patients who died within 12 months of hospital discharge.

RESULTS

Of 347 patients meeting inclusion criteria, 74 (21.3%) died within 12 months postdischarge. These patients were older than those who survived (83.4 vs 79.1 years, P < .001). Most injury patterns were not predictive of postdischarge death, whereas several comorbidities were more common in those who died. Death was fall-related in 13 of 74 (17.6%) who died.

CONCLUSIONS

Injury characteristics do not predict postdischarge mortality. However, pre-existing comorbidities, including advanced age were predictive of postdischarge mortality. Further study is needed to determine whether a focus on medical optimization can reduce 1-year postdischarge death.

Pediatric trauma system models: do systems using adult trauma surgeons exclusively compare favorably with those using pediatric surgeons after initial resuscitation with an adult trauma surgeon?

BACKGROUND

A shortage of pediatric surgeons exists. The purpose of this study was to evaluate pediatric outcomes using pediatric surgeons vs adult trauma surgeons.

METHODS

A review was conducted at 2 level II pediatric trauma centers. Center I provides 24-hour in-house trauma surgeons for resuscitations, with patient hand-off to a pediatric surgery service. Center II provides 24-hour in-house senior surgical resident coverage with an on-call trauma surgeon. Data on demographics, resource utilization, and outcomes were collected.

RESULTS

Center I patients were more severely injured (injury severity score = 8.3 vs 6.2; Glasgow coma scale score = 13.7 vs 14.3). Center I patients were more often admitted to the intensive care unit (52.2% vs 33.5%) and more often mechanically ventilated (12.9% vs 7.7%), with longer hospital length of stay (2.8 vs 2.3 days). However, mortality was not different between Center I and II (3.1% vs 2.4%). By logistic regression analyses, the only variables predictive of mortality were injury severity score and Glasgow coma scale score.

CONCLUSION

As it appears that trauma surgeons' outcomes compare favorably with those of pediatric surgeons, utilizing adult trauma surgeons may help alleviate shortages in pediatric surgeon coverage.