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.

To the point: Utility of laparoscopy for operative management of stabbing abdominal trauma

BACKGROUND

Algorithms for managing penetrating abdominal trauma are conflicting or vague regarding the role of laparoscopy. We hypothesized that laparoscopy is underutilized among hemodynamically stable patients with abdominal stab wounds.

METHODS

Trauma Quality Improvement Program data (2016-2019) were used to identify stable (SBP ≥110 and GCS ≥13) patients ≥16yrs with stab wounds and an abdominal procedure within 24hr of admission. Patients with a non-abdominal AIS ≥3 or missing outcome information were excluded. Patients were analyzed based on index procedure approach: open, therapeutic laparoscopy (LAP), or LAP-conversion to open (LCO). Center, clinical characteristics and outcomes were compared according to surgical approach and abdominal AIS using non-parametric analysis.

RESULTS

5984 patients met inclusion criteria with 7 ​% and 8 ​% receiving therapeutic LAP and LCO, respectively. The conversion rate for patients initially treated with LAP was 54 ​%. Compared to conversion or open, therapeutic LAP patients had better outcomes including shorter ICU and hospital stays and less infection complications, but were younger and less injured. Assessing by abdominal AIS eliminated ISS differences, meanwhile LAP patients still had shorter hospital stays. At time of admission, 45 ​% of open patients met criteria for initial LAP opportunity as indicated by comparable clinical presentation as therapeutic laparoscopy patients.

CONCLUSIONS

In hemodynamically stable patients, laparoscopy remains infrequently utilized despite its increasing inclusion in current guidelines. Additional opportunity exists for therapeutic laparoscopy in trauma, which appears to be a viable alternative to open surgery for select injuries from abdominal stab wounds.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Lessons for the next pandemic: analysis of the timing and outcomes including post-discharge decannulation rates for tracheostomy in severe COVID-19 respiratory failure

PURPOSE

COVID-19 patients with respiratory failure frequently require prolonged ventilatory support that would typically warrant early tracheostomy. There has been significant debate on timing, outcomes, and safety of these procedures. The purpose of this study was to determine the epidemiological, hospital, and post-discharge outcomes of this cohort, based on early (ET) versus late (LT) tracheostomy.

METHODS

Retrospective review (March 2020-January 2021) in a 5-hospital system of ventilated patients who underwent tracheostomy. Demographics, hospital/ICU length of stay (LOS), procedural characteristics, APACHE II scores at ICU admission, stabilization markers, and discharge outcomes were analyzed. Long-term decannulation rates were obtained from long-term acute care facility (LTAC) data.

RESULTS

A total of 97 patients underwent tracheostomy (mean 61 years, 62% male, 64% Hispanic). Despite ET being frequently performed during active COVID infection (85% vs. 64%), there were no differences in complication types or rates versus LT. APACHE II scores at ICU admission were comparable for both groups; however, > 50% of LT patients met PEEP stability at tracheostomy. ET was associated with significantly shorter ICU and hospital LOS, ventilator days, and higher decannulation rates. Of the cohort discharged to an LTAC, 59% were ultimately decannulated, 36% were discharged home, and 41% were discharged to a skilled nursing facility.

CONCLUSIONS

We report the first comprehensive analysis of ET and LT that includes LTAC outcomes and stabilization markers in relation to the tracheostomy. ET was associated with improved clinical outcomes and a short LOS, specifically on days of pre-tracheostomy ventilation and in-hospital decannulation rates.

Two-center analysis of cannabis on venous thromboembolism risk after traumatic injury: A matched analysis

BACKGROUND

Conflicting evidence exists evaluating associations between cannabis (THC) and post-traumatic DVT.

METHODS

Retrospective analysis (2014-2023) of patients ≥15yrs from two Level I trauma centers with robust VTE surveillance and prophylaxis protocols. Multivariable hierarchical regression assessed the association between THC and DVT risk. THC ​+ ​patients were direct matched to other drug use categories on VTE risk markers and hospital length of stay.

RESULTS

Of 7365 patients, 3719 were drug-, 575 were THC ​+ ​only, 2583 were other drug+, and 488 were TCH+/other drug+. DVT rates by exposure group did not differ. TCH ​+ ​only patients had higher GCS scores, shorter hospital length of stay, and the lowest pelvic fracture and mortality rates. A total of 458 drug-, 453 other drug+, and 232 THC+/other drug ​+ ​patients were matched to 458, 453, and 232 THC ​+ ​only patients. There were no differences in DVT event rates in any paired sub-cohort set. Additionally, iteratively adjusted paired models did not show an association between THC and DVT.

CONCLUSIONS

THC does not appear to be associated with increased DVT risk in patients with strict trauma chemoprophylaxis. Toxicology testing is useful for identifying substance abuse intervention opportunities, but not for DVT risk stratification in THC ​+ ​patients.

A Comparative Study of Laparoscopic versus Open Management of Index Small Bowel Obstruction in Children

INTRODUCTION

There is limited literature on the optimal approach to treat adhesive small bowel obstruction (ASBO) in children. We sought to compare rates and outcomes of laparoscopic (LAP) and open (OPEN) surgery for pediatric ASBO.

METHODS

A California statewide database was used to identify children (<18 years old) with an index ASBO from 2007 to 2020. The primary outcome was the type of operative management: LAP or OPEN. Secondary outcomes were hospital characteristics, patient demographics, and postoperative complications. We excluded patients treated non-operatively.

RESULTS

Our study group had 545 patients. 381 (70%) underwent OPEN and 164 (30%) LAP during the index admission. Over the study period, there was increasing use of laparoscopic surgery, with higher use in older children (p < 0.001). LAP was associated with fewer overall complications (65.2% vs. 81.6%, p < 0.001), with a decreasing trend in complications over time (p < 0.001). The LAP group had significantly lower rates of bowel resection (4.9% vs. 17.1%, p < 0.001), length of stay (LOS) (17 vs. 23 days, p < 0.001), and TPN use (12.2% vs. 29.1%, p < 0.001). Mortality rates were equivalent. Although the LAP group had lower readmission rates (22.6% vs. 37.3%, p < 0.001), the length of time between discharge and readmission was similar (171 vs. 165 days, p = 0.190).

DISCUSSION

The use of laparoscopic surgery for index ASBO increased over the study period. However, it was less commonly utilized in younger children. LAP had fewer overall complications as well as shorter LOS, decreased TPN use, and fewer readmissions. The benefits and risks of each approach must be weighed.

LEVEL OF EVIDENCE

III.

Modified Brain Injury Guidelines for preinjury anticoagulation in traumatic brain injury: An opportunity to reduce health care resource utilization

INTRODUCTION

The Brain Injury Guidelines (BIG) stratify patients by traumatic brain injury (TBI) severity to provide management recommendations to reduce health care resource burden but mandates that patients on anticoagulation (AC) are allocated to the most severe tertile (BIG 3). We sought to analyze TBI patients on AC therapy using a modified BIG model to determine if this population can offer further opportunity for safe reductions in health care resource utilization.

METHODS

Patients 55 years or older on AC with traumatic intracranial hemorrhage (ICH) from two centers were retrospectively stratified into BIG 1 to 3 risk groups using modified BIG criteria excluding AC as a criterion. Intracranial hemorrhage progression, neurosurgical intervention (NSI), death, and worsened discharge status were compared.

RESULTS

A total of 221 patients were included, with 23%, 29%, and 48% classified as BIG 1, BIG 2, and BIG 3, respectively. The BIG 3 cohort had a higher rate of AC reversal agents administered (66%) compared with the BIG 1 (40%) and BIG 2 (54%) cohorts ( p < 0.01), as well as ICH progression discovered on repeat head computed tomography (56% vs. 38% vs. 26%, respectively; p < 0.001). No patients in the BIG 1 and 2 cohorts required NSI. No patients in BIG 1 and 3% of patients in BIG 2 died secondary to the ICH. In the BIG 3 cohort, 16% of patients required NSI and 26% died. Brain Injury Guidelines 3 patients had 15 times the odds of mortality compared with BIG 1 patients ( p < 0.01).

CONCLUSION

The AC population had higher rates of ICH progression than the BIG literature, but this did not lead to more NSI or mortality in the lower tertiles of our modified BIG protocol. If the modified BIG used the original tertile management on our population, then NS consultation may have been reduced by up to 52%. These modified criteria may be a safe opportunity for further health care resource and cost savings in the TBI population.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Trends in Management of Index Adhesive Small Bowel Obstruction in Children

INTRODUCTION

To examine practice patterns and surgical outcomes of nonoperative versus operative management (OPM) of children presenting with an index adhesive small bowel obstruction (ASBO).

METHODS

A California statewide health discharge database was used to identify children (<18 y old) with an index ASBO from 2007 to 2020. The primary study outcome was evaluating initial management patterns (nonoperative versus OPM and early [≤3 d] versus late surgery [>3 d]) of ASBO. Secondary outcomes were hospital characteristics, patient demographics, and postoperative complications.

RESULTS

Of the 2297 patients identified, 1948 (85%) underwent OPM for ASBO during the index admission. Of these, 14.7% underwent early surgery within 3 d. Teaching hospitals had higher operative intervention than nonteaching centers (87.1% versus 83.7%, P = 0.034). OPM was the highest in 0-5-year-olds compared to other ages (89% versus 82%, P < 0.001). In comparison to early surgery, late surgery was associated with longer length of stay (early 7[interquartile range 5-10], late 9[interquartile range 6-17], P < 0.001), increased infectious complications (16.4% versus 9.8%, P = 0.004), and greater use of total parenteral nutrition (28.0% versus 14.3%, P = 0.001); there was no difference in bowel resection (21% versus 18%, P = 0.102) or mortality (P = 0.423).

CONCLUSIONS

Our pediatric study demonstrated a high rate of OPM for index ASBO, especially in newborns and toddlers. Although operative intervention, especially late surgery, was associated with increased length of stay, increased infectious complications, and increased total parenteral nutrition use, the rates of bowel resection and mortality did not differ by management strategy. These trends need to be further evaluated to optimize outcomes.

Firearm Assaults in Communities: The Impact of COVID-19 Lockdown

BACKGROUND

Firearm violence has increased nationwide, with recent surges linked to the COVID-19 pandemic. We measured traumatic assault trends at our urban Level I trauma center and assessed rates of firearm violence over time and pre/post local COVID-19 lockdown based on levels of socioeconomic disadvantage.

METHODS

We conducted a retrospective review (2016-2022) of assault patients 16 years and older. Demographics and hospital outcomes were assessed by assault mechanism (firearm, knife, blunt). Patient address was correlated to Area Deprivation Index (ADI), a measure of socioeconomic disadvantage. COVID-19 lockdown onset was defined as initial date of lockdown (3/19/2020). Trend and time-series analyses compared all assault mechanisms and firearm-specific assaults pre/post-lockdown. Poisson regression assessed firearm assault risk.

RESULTS

Of the 1583 total assaults, firearm patients (n = 335) were younger (median 29 years), had longer hospital stays (median 2 days), and greater mortality (12%) than other mechanisms. The 2 years post-lockdown had significantly more firearm assaults (27% vs 15% pre-lockdown, P < .001) and time-series analysis found this abrupt and significant increase in firearm assaults occurred at lockdown onset (P = .01). Also post-lockdown, the rate of firearm assaults increased by 10% for every unit increase in socioeconomic deprivation (P < .01). There was no change in assault type by race/ethnicity.

DISCUSSION

Firearm assaults increased dramatically immediately post-COVID lockdown at our center and have maintained higher rates through 2022. Greater ADI was associated with increasing firearm assaults and has magnified post-lockdown, demonstrating lower socioeconomic groups are disproportionately and increasingly affected by firearm violence.

Ballistic Facial Trauma Reconstruction: Incidence and Practice Patterns in the Civilian Population

BACKGROUND

Management of nonfatal ballistic facial trauma is well described in the literature for wounds secondary to military combat. However, there is little literature describing such management in civilian practice. We aimed to describe nonmilitary patients with recent nonfatal facial injuries from ballistic trauma using the California Office of Statewide Health Planning and Development patient database.

METHODS

A retrospective study was performed using the California Office of Statewide Health Planning and Development Ambulatory Surgery and Inpatient datasets. All adults with the International Classification of Diseases, 10th Revision codes of severe nonfatal facial trauma from firearms requiring emergent surgery during 2016-2018 were included. Outcomes assessed include number and type of facial procedures performed, hospital length of stay, number of admissions, timing of definitive management, and lifetime hospitalization costs.

RESULTS

A total of 331 traceable patients were identified over this 3-year period. The average age was 35.4 years (SD, 15.2), and 87% were male. The median index admission length of stay was 8 days (interquartile range, 3-15 days). Subsequent readmission was required for 123 (37.2%) patients with 10% mortality in the index admission. Total median charges per patient for all admissions were $257,804 (interquartile range, $105,601-$531,916). A total of 215 patients (65%) had at least 1 facial repair performed. Of all 331 patients, 64.3% underwent musculoskeletal repair (n = 213), 31.4% underwent digestive system repair (n = 104), and 29.6% underwent respiratory system repair (n = 98). The average number of repairs per patient was 2.52 (SD, 3.38), with 35% not having any of the specified International Classification of Diseases, 10th Revision repair codes. A total of 27% of patients had 1 procedure performed, whereas 38% received 2 or more, for an average of 3.87 (SD, 3.5) repairs over the study duration.

DISCUSSION

To our knowledge, this is the first assessment of civilian characteristics of nonfatal ballistic facial trauma in California. Nonfatal facial ballistic trauma results in complex injuries to multiple body systems, requiring long admissions, costly hospital stays, and coordination of care across several surgical specialties. Many patients require a variety of procedures over multiple admissions, highlighting the overall morbidity of these injuries. Future studies will look at how care for these patients differs between various hospitals and geographic regions and whether current civilian management aligns with well-defined military reconstructive protocols for facial ballistic injuries.

Pediatric penetrating thoracic trauma: Examining the impact of trauma center designation and penetrating trauma volume on outcomes

INTRODUCTION

We analyzed the impact of treating center designation and case volume of penetrating trauma on outcomes after pediatric penetrating thoracic injuries (PTI).

METHODS

PTI patients <18 years were identified from the National Trauma Data Bank (2013-2016). Centers were categorized by type (Pediatric or Adult) and designation status (Level I, Level II, and other). Performance was calculated as the difference between observed and expected mortality and standardized using the total penetrating trauma volume per center. Expected mortality was calculated using the Trauma Mortality Prediction Model. Pearson correlation and linear mixed-effects models evaluated the association between variables and performance.

RESULTS

We identified 4,134 PTI patients treated at 596 trauma centers: 879 (21%) at Adult Level I, 608 (15%) at Adult Level II, 531 (13%) at Pediatric Level I, 320 (8%) at Pediatric Level II, and 1,796 (43%) at other centers. Primary injury mechanisms were firearm-related (58%) and cut/piercing (42%). Overall mortality was 16% and median predicted mortality was 3.6% (IQR: 1.5% - 11.2%). Among patients with thoracic firearm-related injuries, centers with lower penetrating case volume and total trauma care demonstrated significantly worse outcomes. Multivariable analysis revealed Adult Level I centers had superior outcomes compared with all other non-Level I centers. There was no difference in mortality between Pediatric and Adult Level I centers.

DISCUSSION

Adult Level I trauma center designation and annual case volume of penetrating thoracic trauma are associated with improved mortality after pediatric firearm-related thoracic injuries. Further study is needed to identify factors in higher volume centers that improve outcomes.

LEVEL OF EVIDENCE

Level III.

Why Trauma Care is Not Expensive: Detailed Analysis of Actual Costs and Cost Differences of Patient Cohorts

BACKGROUND

Trauma patients are resource intensive, requiring a variety of medical and procedural interventions during hospitalization. These expenses often label trauma care as "high cost" based on gross hospital charges. We hypothesized that a financial metric built on actual costs and clinically relevant trauma patient cohorts would demonstrate a lower true cost of trauma care than the standardly reported gross hospital charges.

METHODS

We examined all trauma patients (≥16 yr) treated in 2017 from a single institution and matched them to the institution's detailed financial accounting data. The organization's Financial Operations Division is uniquely able to allocate total operating costs across patient encounters to include medications, procedures, and salaries/fees from medical professionals and administrators. Patient subgroups were identified by Trauma Quality Improvement Program (TQIP) criteria for cost comparisons.

RESULTS

Overall median cost per patient was $6,544 [IQR $4,975-14,532] for 2,548 patients. The median cost per patient increased with Injury Severity Score (ISS) ranging from $5,457(ISS ≤ 7) to $34,898(ISS ≥ 21), each accompanied by an average 548% increase in gross charges. Costs also varied widely from $13,498 [IQR $8,247-26,254] to $45,759 [IQR $22,186-113,993] across TQIP patient cohorts. Of the total cost, 91% was attributed to personnel alone.

DISCUSSION

Measuring the true cost of trauma care is feasible. As hypothesized, the true cost of trauma care is lower than charges. True cost increased with injury severity with variable cost across subgroups. Non-physician staff and administration are the largest component of the cost of trauma care.

Pediatric trauma in the California-Mexico border region: Injury disparities by Area Deprivation Index

BACKGROUND

The California-Mexico border region is a high-volume trauma area with populations of widely disparate socioeconomic status. This work analyzed differences in demographics and mechanism of injury in children using the Area Deprivation Index (ADI), a composite measure of 17 markers of neighborhood socioeconomic disadvantage.

METHODS

A retrospective review was performed of pediatric patients evaluated at the regional Level I Pediatric Trauma Center between 2008 and 2018. Collected data included patient demographics and injury characteristics. Patient addresses were correlated to neighborhood disadvantage level using ADI quintiles, with a higher quintile representing greater socioeconomic disadvantage.

RESULTS

A total of 9,715 children were identified, of which 4,307 (44%) were Hispanic. Hispanic children were more likely to live in more disadvantaged neighborhoods than non-Hispanic children (p < 0.001). There were markedly different injury mechanisms in neighborhoods with greater socioeconomic disadvantage (higher ADI) compared with those with less socioeconomic disadvantage. Sports-related and nonmotorized vehicular trauma predominated in less disadvantaged neighborhoods, while higher ADI quintiles were strongly associated with pedestrian versus automobile, motorized vehicle accidents/collisions, and nonaccidental injuries (p < 0.001).

CONCLUSION

This analysis represents the first study to characterize pediatric traumatic injury patterns based upon the neighborhood ADI metric. Area Deprivation Index can be a useful resource in identifying disparities in pediatric trauma and children at increased risk for vehicular and abusive injury who may benefit from increased resource allocation, social support, and prevention programs.

LEVEL OF EVIDENCE

Prognostic and epidemiological, Level III.

Fragmentation of care in the blunt abdominal trauma patient: Capturing our true outcomes and impact on care

BACKGROUND

Trauma care is associated with unplanned readmissions, which may occur at facilities other than the index treatment facility. This "fragmentation of care" may be associated with adverse outcomes. We evaluated a statewide database that includes readmissions to analyze the incidence and impact of FC.

METHODS

The California Office of Statewide Health Planning and Development patient discharge data set was evaluated for calendar years 2016 to 2018. Patients 15 years or older diagnosed with blunt abdominal solid organ injury during the index admission were identified. Readmissions were evaluated postdischarge at 1, 3, and 6 months. Patients readmitted within 6 months to a facility other than the index admission facility (fragmented care [FC]) were compared with those readmitted to their index admission facility (non-FC). Logistic regression modeling was used to evaluate risk of FC.

RESULTS

Of the total 1,580 patients, there were 752 FC (47.6%) and 828 (52.4%) non-FC. Readmissions representing FC at months 1, 3, and 6 were 40.3%, 49.3%, and 53.4%, respectively. At index admission, the groups were demographically and clinically similar, with similar rates of abdominal operations and complications. Non-FC patients had a higher rate of abdominal reoperation at readmission (5.8% non-FC vs. 2.9% FC, p = 0.006). In an adjusted model, multiple readmissions (odds ratio [OR] 1.11, p = 0.014), readmission >30 days after index facility discharge (OR, 1.98; p < 0.001), and discharge to a nonmedical facility (OR, 2.46; p < 0.0001) were associated with increased odds of FC. Operative intervention at index admission was associated with lower odds of FC (OR, 0.77; p = 0.039). However, FC was not independently associated with demographic or insurance characteristics.

CONCLUSION

The rate of FC among patients with blunt abdominal injury is high. The risk of FC is mitigated when patients are managed operatively during the index admission. Trauma systems should implement measures to ensure that these patients are followed postdischarge.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III; Care management, level IV.

A tale of two centers: Is low-molecular-weight heparin really superior for prevention of posttraumatic venous thromboembolism?

BACKGROUND

Low-molecular-weight heparin (LMWH) is widely used for venous thromboembolism chemoprophylaxis following injury. However, unfractionated heparin (UFH) is a less expensive option. We compared LMWH and UFH for prevention of posttraumatic deep venous thrombosis (DVT) and pulmonary embolism (PE).

METHODS

Trauma patients 15 years or older with at least one administration of venous thromboembolism chemoprophylaxis at two level I trauma centers with similar DVT-screening protocols were identified. Center 1 administered UFH every 8 hours for chemoprophylaxis, and center 2 used twice-daily antifactor Xa-adjusted LMWH. Clinical characteristics and primary chemoprophylaxis agent were evaluated in a two-level logistic regression model. Primary outcome was incidence of DVT and PE.

RESULTS

There were 3,654 patients: 1,155 at center 1 and 2,499 at center 2. The unadjusted DVT rate at center 1 was lower than at center 2 (3.5% vs. 5.0%; p = 0.04); PE rates did not significantly differ (0.4% vs. 0.6%; p = 0.64). Patients at center 2 were older (mean, 50.3 vs. 47.3 years; p < 0.001) and had higher Injury Severity Scores (median, 10 vs. 9; p < 0.001), longer stays in the hospital (mean, 9.4 vs. 7.0 days; p < 0.001) and intensive care unit (mean, 3.0 vs. 1.3 days; p < 0.001), and a higher mortality rate (1.6% vs. 0.6%, p = 0.02) than patients at center 1. Center 1's patients received their first dose of chemoprophylaxis earlier than patients at center 2 (median, 1.0 vs. 1.7 days; p < 0.001). After risk adjustment and accounting for center effects, primary chemoprophylaxis agent was not associated with risk of DVT (odds ratio, 1.01; 95% confidence interval, 0.69-1.48; p = 0.949). Cost calculations showed that UFH was less expensive than LMWH.

CONCLUSION

Primary utilization of UFH is not inferior to LMWH for posttraumatic DVT chemoprophylaxis and rates of PE are similar. Given that UFH is lower in cost, the choice of this chemoprophylaxis agent may have major economic implications.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level II; Therapeutic, level III.

Isolated Intracranial Hemorrhage in Elderly Patients With Pre-Injury Anticoagulation: Is Full Trauma Team Activation Necessary?

BACKGROUND

Traumatic intracranial hemorrhage (ICH) is a highly morbid injury, particularly among elderly patients on preinjury anticoagulants (AC). Many trauma centers initiate full trauma team activation (FTTA) for these high-risk patients. We sought to determine if FTTA was superior compared with those who were evaluated as a trauma consultation (CON).

METHODS

Patients aged ≥55 on preinjury AC who presented from January 2015 to December 2019 with blunt isolated head injury (non-head AIS ≤2) and confirmed ICH were identified. CON patients and FTTA patients were matched by age and head AIS. Cox proportional hazard model was used to assess patient and injury characteristics with mortality and survivor discharge disposition.

REASULTS

There were 45 CON patients and 45 FTTA patients. Mean age was 80 years in both groups. Fall was the most common mechanism (98% CON vs. 92% FTTA). Glasgow Coma Score (GCS) was lower in FTTA (14 vs. 15, p<0.01). CON had a significantly longer time from arrival to CT scan (1.3 vs. 0.4 hrs, p<0.01). Hospital days were similar (CON: 3.9 vs. FTTA: 3.7 days). However, CON had increased ventilator use (p=0.03). Lower admission GCS was the only factor associated with increased risk of death. Among survivors, only head AIS increased the risk of discharge to a level of care higher than that of preinjury (p=0.01).

CONCLUSION

There was no difference in mortality or adverse discharge disposition between FTTA and CON, although FTTA was associated with a more rapid evaluation and diagnosis. Any alteration in GCS was strongly associated with mortality and should prompt evaluation by FTTA.

Between the devil and the deep blue sea: A review of 25 modern naval mass casualty incidents with implications for future Distributed Maritime Operations

ABSTRACT

In the future, United States Navy Role 1 and Role 2 shipboard medical departments will be caring for patients during Distributed Maritime Operations in both contested and noncontested austere environments; likely for prolonged periods of time. This literature review examines 25 modern naval mass casualty incidents over a 40-year period representative of naval warfare, routine naval operations, and ship-based health service support of air and land operations. Challenges, lessons learned, and injury patterns are identified to prepare afloat medical departments for the future fight.

LEVEL OF EVIDENCE

Literature Review, level V.

Revealing the scope of surgical device malfunctions: Analysis of the "hidden" Food and Drug Administration device database

BACKGROUND

We compared surgical device malfunction reports in the Food and Drug Administration (FDA) public Manufacturer and User Facility Device Experience (MAUDE) with those in the FDA nonpublic Alternative Summary Reporting (ASR).

METHODS

General surgery device product code categories in MAUDE and ASR from 1999 to 2018 were identified. Changes in the rates of categories and adverse events were evaluated by Poisson regression.

RESULTS

There were 283,308 (72%) general surgical device malfunctions in MAUDE and 109,954 (28%) in ASR. Reports increased annually in ASR versus MAUDE, particularly for surgical staplers and clip devices (p < 0.05). ASR contained approximately 80% of these reports; MAUDE 20%. In MAUDE, 42.9% of surgical device malfunctions and 20.2% of stapler/clip malfunctions resulted in patient injury or death. ASR listed no injury or death information.

CONCLUSIONS

ASR contained a significant portion of surgical device malfunctions hidden from public scrutiny. Access to such data is essential to safe surgical care.

The rising tide of methamphetamine use in elderly trauma patients

BACKGROUND

Methamphetamine (METH) is associated with an elevated risk of injury and the outcomes in the elderly remain unclear. We analyzed METH's impact in elderly trauma patients.

METHODS

Retrospective analysis (2009-2018) of trauma patients at a Level I trauma center. Elderly patients were defined as age ≥55. Substance use was identified by blood alcohol test and urine drug screen. Cox proportional hazard model was used to assess patient and injury characteristics with mortality.

RESULTS

Of 15,770 patient encounters with substance use testing, 5278 (34%) were elderly. Elderly METH use quadrupled over time (2%-8%; p < 0.01). Elderly METH + patients were more likely to require surgical intervention (35% vs. 17%), mechanical ventilation (15% vs. 7%), and a longer hospitalization (6.5 vs. 3.6 days) compared with elderly substance negative. Multivariate analysis showed increasing age, ventilator use, and injury severity were associated with mortality (ps < 0.01); METH was not related to mortality.

CONCLUSION

Substance use in elderly trauma patients increased significantly. METH use in elderly trauma patients is a risk factor for significantly greater resource utilization.

Outcomes after single-look trauma laparotomy: A large population-based study

BACKGROUND

Outcomes following damage control laparotomy for trauma have been studied in detail. However, outcomes following a single operation, or "single-look trauma laparotomy" (SLTL), have not. We evaluated the association between SLTL and both short-term and long-term outcomes in a large population-based data set.

METHODS

The California Office of Statewide Health Planning and Development patient discharge database was evaluated for calendar years 2007 through 2014. Injured patients with SLTL during their index admission were identified using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. Diagnosis and procedure codes were used to identify specific abdominal organ injuries, surgical interventions, and perioperative complications. Subsequent acute care admissions were examined for postoperative complications and related surgical interventions. Clinical characteristics, injuries, surgical interventions, and outcomes were analyzed by mechanism of injury.

RESULTS

There were 2113 patients with SLTL during their index admission; 712 (33.7%) had at least one readmission to an acute care facility. Median time to first readmission was 110 days. Penetrating mechanism was more common than blunt (60.6% vs. 39.4%). Compared to patients with penetrating injury, blunt-injured patients had a significantly higher median Injury Severity Score (9 vs. 18, p < 0.0001) and a significantly higher mortality rate during the index admission (4.1% vs. 27.0%, p < 0.0001). More than 30% of SLTL patients requiring readmission had a surgery-related complication. The most common primary reasons for readmission were bowel obstruction (17.7%), incisional hernia (11.8%), and infection (9.1%). There was no significant association between mechanism of injury and development of surgery-related complications requiring readmission.

CONCLUSIONS

Patients with SLTL had postinjury morbidity and mortality, and more than 30% required readmission. Complication rates for SLTL were comparable to those reported for emergency general surgery procedures. Patients should be educated on signs and symptoms of the most common complications before discharge following SLTL. Further investigation should focus on the factors associated with the development of these complications.

LEVEL OF EVIDENCE

Prognostic and epidemiologic study, level III.

Association of Operative Repair Type and Trauma Center Designation With Outcomes in Ruptured Abdominal Aortic Aneurysm Repair

OBJECTIVE

Open repair of ruptured abdominal aortic aneurysm (rAAA) has shown improved outcomes at trauma centers. Whether the benefit of trauma center designation extends to endovascular repair of rAAA is unknown.

METHODS

Retrospective cohort study using the California Office of Statewide Health Planning and Development 2007 to 2014 discharge database to identify patients with rAAA. Data included demographic and admission factors, discharge disposition, International Classification of Diseases, Ninth Revision, Clinical Modification codes, and hospital characteristics. Hospitals were categorized by trauma center designation and teaching hospital status. The effect of repair type and trauma center designation (level I, level II, or other-other trauma centers and nondesignated hospitals) was evaluated to determine rates and risks of 9 postoperative complications, in-hospital mortality, and 30-day postdischarge mortality.

RESULTS

Of 1941 rAAA repair patients, 61.2% had open and 37.8% had endovascular; 1.0% had both. Endovascular repair increased over the study interval. Hospitals were 12.0% level I, 25.0% level II, and 63.0% other. A total of 48.7% of hospitals were teaching hospitals (level I, 100%; level II, 42.2%; and other, 41.8%). Endovascular repair was significantly more common at teaching hospitals (41.5% vs 34.3%, P < .001) and was the primary repair method at level I trauma centers (P < .001). Compared with open repair, endovascular repair was protective for most complications and in-hospital mortality. The risk for in-hospital mortality was highest among endovascular patients at level II trauma centers (hazard ratio 1.67, 95% confidence interval [CI]: 0.95-2.92) and other hospitals (hazard ratio 1.66, 95% CI: 1.01-2.72).

CONCLUSIONS

Endovascular repair overall was associated with a lower risk of adverse outcomes. Endovascular repair at level I trauma centers had a lower risk of in-hospital mortality which may be a result of their teaching hospital status, organizational structure, and other factors. The weight of the contributions of such factors warrants further study.

Evaluating surgical outcomes in pediatric extremity vascular trauma

BACKGROUND

The purpose of this study was to evaluate the epidemiology and management of pediatric vascular extremity trauma to assess injury patterns and other factors that may contribute to poor outcomes.

METHODS

Using the California Office of Statewide Health Planning and Development discharge database, we identified pediatric patients with extremity arterial trauma admitted to acute-care hospitals from 2007 to 2014. Demographics, management patterns, and outcomes were collected and analyzed.

RESULTS

A total of 775 patients were treated for an extremity arterial injury. Overall, 40% were admitted to pediatric trauma centers and 39% to adult trauma centers. Management was predominantly by open surgical repair. Injury to the common femoral artery was associated with mortality (Hazard Ratio 3.9; 95% CI 1.1-14.5; p < 0.05). Popliteal artery injuries (Odds Ratio [OR] 4.8; 95% CI 1.2-19.9; p < 0.05) and anterior tibial artery injuries (OR 7.1; 95% CI 1.4-37.3; p < 0.05) had an increased risk of amputation. There was no difference in amputation or mortality rates by hospital category.

CONCLUSIONS

Pediatric extremity arterial injuries are rare. In California, outcomes are similar by hospital type. Common femoral artery injuries are associated with an increased risk of mortality, while popliteal and anterior tibial artery injuries are associated with an increased risk of amputation.

TYPE OF STUDY

Prognosis Study.

LEVEL OF EVIDENCE

Level III.

Association of complicated gallstone disease in pregnancy and adverse birth outcomes

BACKGROUND

Complicated gallstone disease (CGD) is a common condition requiring intervention during pregnancy to avert adverse birth outcomes (ABO).

METHODS

Cohort study using the California OSHPD 2007-2014 database. Records of pregnant patients were analyzed for gallbladder calculus within four months of delivery. Biliary system interventions were evaluated as the primary exposure.

RESULTS

Of 7,597 patients, those with CGD had a greater likelihood of biliary system procedures than those with uncomplicated gallstone disease (36.6% vs. 2.5%, p < 0.001). Patients with CGD also had increased odds of ABO (OR 2.02, 95% CI, 1.48-2.76). Compared to patients without biliary system procedures, those with interventions for gallstones had an OR of 3.46 (95% CI, 2.48-4.82) for ABO. After adjustment, biliary system intervention for CGD had an even greater risk of ABO (OR 4.26, 95% CI, 2.86-6.35).

CONCLUSIONS

The risk of ABO is significantly increased in women with CGD and intervention for gallstones.

Outcomes in adhesive small bowel obstruction from a large statewide database: What to expect after nonoperative management

BACKGROUND

Although adhesive small-bowel obstruction (ASBO) is frequently managed nonoperatively, little is known regarding outcomes on readmission following this approach. Using a large population-based dataset, we evaluated risk factors for operative intervention and mortality at readmission in patients with ASBO who were initially managed nonoperatively.

METHODS

The ASBO patients were identified in the California Office of Statewide Health Planning and Development 2007 to 2014 patient discharge database. Patients who were managed operatively at index admission or had an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code for nonadhesive obstructive small bowel disease were excluded. Associations between risk factors and both operative intervention and death following readmission were evaluated using survival analysis.

RESULTS

Among 15,963 ASBO patients, 3,103 (19.4%) had at least one readmission. The 1,069 (34.5%) who received an operation during their first readmission presented sooner (175 days vs. 316 days, p < 0.001) and were more likely to die during that readmission (5.2% vs. 0.7%, p < 0.001). Operative management at first readmission was associated with younger age, fewer comorbidities, and shorter times to readmission. Patients operatively managed at first readmission had longer times to second readmission compared with nonoperative patients. Stratified analyses using nonoperative patients as the reference over the study period revealed that patients who underwent lysis of adhesions and bowel resection were 5.04 times (95% confidence interval [CI], 2.82-9.00) as likely to die while those who underwent lysis only were 2.09 times (95% CI, 1.14-3.85) as likely to die. Patients with bowel resection only were at an increased risk for subsequent interventions beyond the first readmission (hazard ratio, 1.79; 95% CI, 1.11-2.87).

CONCLUSION

In a large cohort readmitted for ASBO and initially managed nonoperatively, subsequent operative intervention conferred a greater risk of death and a longer time to readmission among survivors. Prospective research is needed to further delineate outcomes associated with initial nonoperative management of ASBO.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.

Quantifying the burden of pre-existing conditions in older trauma patients: A novel metric based on mortality risk

INTRODUCTION

Pre-existing medical conditions (PEC) represent a unique domain of risk among older trauma patients. The study objective was to develop a metric to quantify PEC burden for trauma patients.

METHODS

A cohort of 4526 non-severe blunt-injured trauma patients aged 55 years and older admitted to a Level I trauma center between January 2006 and December 2012 were divided into development (80%) and test (20%) sets. Cox regression was used to develop the model based on in-hospital and 90-day mortality. Regression coefficients were converted into a point-based PEC Risk Score. Performance of the PEC Risk Score was compared in the test set with two other PEC-based metrics and three injury-based metrics. An external cohort of 2284 trauma patients admitted in 2013 was used to evaluate combined metric performance.

RESULTS

Total mortality was 9.4% and 9.1% in the development and test set, respectively. The final model included 12 PEC. In the test set, the PEC Risk Score (c-statistic: 79.7) was superior for predicting in-hospital and 90-day mortality compared with all other metrics. For in-hospital mortality alone, the PEC Risk Score similarly outperformed all other metrics. Combination of the PEC Risk Score and any injury-based metric significantly improved prediction compared with any injury-based metric alone.

CONCLUSION

Our 12-item PEC Risk Score performed well compared with other metrics, suggesting that the classification of trauma-related mortality risk may be improved through its use. Among non-severely injured older trauma patients, the utility of prognostic metrics may be enhanced through the incorporation of comorbidities.

Characteristics of Cannabis-Only and Other Drug Users Who Visit the Emergency Department

Emergency department (ED) settings have gained interest as venues for illegal drug misuse prevention and intervention, with researchers and practitioners attempting to capitalize on the intersection of need and opportunity within these settings. This study of 686 adult patients visiting two EDs for various reasons who admitted drug use compared daily cannabis-only users, nondaily cannabis-only users, and other drug users on sociodemographic and drug-related severity outcomes. The three drug use groups did not differ on most sociodemographic factors or medical problem severity scores. Forty-five percent of the sample was identified as having a drug use problem. ED patients who used drugs other than cannabis were at particular risk for high drug use severity indicators and concomitant problems such as psychiatric problems and alcohol use severity. However, 19-29% of cannabis-only users were identified as having problematic drug use. Furthermore, daily cannabis-only users fared less well than nondaily cannabis users with regard to drug use severity indicators and self-efficacy for avoiding drug use. Results may assist emergency medicine providers and medical social workers in matching patients to appropriate intervention. For example, users of drugs other than cannabis (and perhaps heavy, daily cannabis-only users) may need referral to specialty services for further assessment. Enhancement of motivation and self-efficacy beliefs could be an important target of prevention and treatment for cannabis-only users screened in the ED.

Heparin versus enoxaparin for prevention of venous thromboembolism after trauma: A randomized noninferiority trial

BACKGROUND

Research comparing enoxaparin with unfractionated heparin (UFH) given every 12 hours for venous thromboembolism (VTE) prophylaxis after trauma overlooks original recommendations that UFH be given every 8 hours. We conducted a prospective, randomized, noninferiority trial comparing UFH every 8 hours and standard enoxaparin every 12 hours. We hypothesized that the incidence of VTE in trauma patients receiving UFH every 8 hours would be no more than 10% higher than that in patients receiving enoxaparin every 12 hours.

METHODS

Trauma patients who met criteria for VTE prophylaxis at a Level I trauma center were randomly assigned to 5,000-U UFH every 8 hours or 30-mg enoxaparin every 12 hours between November 2012 and September 2014. Surveillance duplex ultrasound was performed twice weekly on intensive care unit patients and weekly on ward patients. Primary end points were deep vein thrombosis diagnosed by duplex ultrasound and pulmonary embolism diagnosed by computed tomography angiography.

RESULTS

Of 495 randomized patients, 220 received UFH and 216 received enoxaparin for analysis. Overall, 105 in the UFH group and 103 in the enoxaparin group underwent VTE surveillance or diagnostic testing. In the analysis of randomized patients who received treatment, UFH was noninferior compared with enoxaparin (absolute VTE risk difference, 3.1%; 95% confidence interval, -1.6% to 7.7%; p = 0.196); however, in the screening ultrasound group, the noninferiority of UFH was inconclusive (absolute VTE risk difference, 6.5%; 95% confidence interval, -2.9% to 15.8%; p = 0.179). The two treatments did not differ with regard to adverse events. The pharmaceutical cost for the regimen of UFH ($2,809) was nearly 20-fold lower than that for enoxaparin ($54,138).

CONCLUSION

A regimen of UFH every 8 hours may be noninferior to enoxaparin every 12 hours for the prevention of VTE following trauma. Given UFH's cost advantage, the use of UFH for VTE prophylaxis may offer greater value.

LEVEL OF EVIDENCE

Therapeutic/care management study, level II.

A Geospatial Analysis of Severe Firearm Injuries Compared to Other Injury Mechanisms: Event Characteristics, Location, Timing, and Outcomes

OBJECTIVES

Relatively little is known about the context and location of firearm injury events. Using a prospective cohort of trauma patients, we describe and compare severe firearm injury events to other violent and nonviolent injury mechanisms regarding incident location, proximity to home, time of day, spatial clustering, and outcomes.

METHODS

This was a secondary analysis of a prospective cohort of injured children and adults with hypotension or Glasgow Coma Scale score ≤ 8, injured by one of four primary injury mechanisms (firearm, stabbing, assault, and motor vehicle collision [MVC]) who were transported by emergency medical services to a Level I or II trauma center in 10 regions of the United States and Canada from January 1, 2010, through June 30, 2011. We used descriptive statistics and geospatial analyses to compare the injury groups, distance from home, outcomes, and spatial clustering.

RESULTS

There were 2,079 persons available for analysis, including 506 (24.3%) firearm injuries, 297 (14.3%) stabbings, 339 (16.3%) assaults, and 950 (45.7%) MVCs. Firearm injuries resulted in the highest proportion of serious injuries (66.3%), early critical resources (75.3%), and in-hospital mortality (53.5%). Injury events occurring within 1 mile of a patient's home included 53.9% of stabbings, 49.2% of firearm events, 41.3% of assaults, and 20.0% of MVCs; the non-MVC events frequently occurred at home. While there was geospatial clustering, 94.4% of firearm events occurred outside of geographic clusters.

CONCLUSIONS

Severe firearm events tend to occur within a patient's own neighborhood, often at home, and generally outside of geospatial clusters. Public health efforts should focus on the home in all types of neighborhoods to reduce firearm violence.

Randomized clinical trial of the effects of screening and brief intervention for illicit drug use: the Life Shift/Shift Gears study

Background

Although screening, brief intervention, and referral to treatment (SBIRT) has shown promise for alcohol use, relatively little is known about its effectiveness for adult illicit drug use. This randomized controlled trial assessed the effectiveness of the SBIRT approach for outcomes related to drug use among patients visiting trauma and emergency departments (EDs) at two large, urban hospitals.

Methods

A total of 700 ED patients who admitted using illegal drugs in the past 30 days were recruited, consented, provided baseline measures of substance use and related problems measured with the Addiction Severity Index-Lite (ASI-Lite), and then randomized to the Life Shift SBIRT intervention or to an attention-placebo control group focusing on driving and traffic safety (Shift Gears). Both groups received a level of motivational intervention matched to their condition and risk level by trained paraprofessional health educators. Separate measurement technicians conducted face-to-face follow-ups at 6 months post-intervention and collected hair samples to confirm reports of abstinence from drug use. The primary outcome measure of the study was past 30-day drug abstinence at 6 months post-intervention, as self-reported on the ASI-Lite.

Results

Of 700 participants, 292 (42%) completed follow-up. There were no significant differences in self-reported abstinence (12.5% vs. 12.0% , p = 0.88) for Life Shift and Shift Gears groups, respectively. When results of hair analyses were applied, the abstinence rate was 7 percent for Life Shift and 2 percent for Shift Gears (p = .074). In an analysis in which results were imputed (n = 694), there was no significant difference in the ASI-Lite drug use composite scores (Life Shift +0.005 vs. Shift Gears +0.017, p = 0.12).

Conclusions

In this randomized controlled trial, there was no evidence of effectiveness of SBIRT on the primary drug use outcome.

Trial registration

ClinicalTrials.gov NCT01683227.

Resource commitment to improve outcomes and increase value at a level I trauma center

BACKGROUND

Optimal care of trauma patients requires cost-effective organization and commitment of trauma center resources. We examined the impact of creating a dedicated trauma care unit (TCU) and adding advanced practice nurses on the quality and cost of care at an adult Level I trauma center.

METHODS

Patient demographic and injury data, length of stay, complications, outcomes, and total direct cost of care were evaluated for four 1-year intervals in the recent history of our trauma center: Year A, a trauma team of in-house trauma surgeons and resident physicians; Year B, the addition of nurse practitioners to the trauma team 5 days/week; Year C, the creation of a dedicated TCU for all non intensive care unit trauma patients; and Year D, the addition of a permanent clinical nurse specialist and an increase in nurse practitioner coverage to 7 days/week. For each year, value was determined by calculating the median cost of a survivor and the median cost of a survivor with no complications. Significance was attributed to p<0.05.

RESULTS

Patient volume increased from 1,927 in year A to 2,546 by year D. Over the period of study, there was an increase in blunt trauma (87.1-89.9%; p<0.05), median Injury Severity Score (5-6; p<0.05), and patients aged ≥65 years (11.4-19.8%; p<0.05). However, risk-adjusted mortality was unchanged. There was a decrease in patients with a complication (20.8-14.9%; p < 0.05), median intensive care unit length of stay (39.5-23.4 hours; p < 0.05), and median cost of care ($4,306-$3,698; p<0.05). Value increased: both the median costs of a survivor and of a survivor with no complications decreased from $4,259 to $3,658 (p<0.05) and from $3,898 to $3,317 (p<0.05), respectively. The median cost of a survivor with severe injury (Injury Severity Score ≥15) decreased from $17,651 to $12,285 (p<0.05).

CONCLUSION

The addition of a dedicated TCU and advanced practice nurses improved the quality and reduced the cost of care, resulting in increased value at an adult Level I trauma center.

Damage Control in the Management of Ruptured Abdominal Aortic Aneurysm: Preliminary Results

Background: This study compared damage control measures (DCM), including operative techniques (DCO) and resuscitative measures (DCR), with standard treatment (ST) for ruptured abdominal aortic aneurysm (rAAA). Methods: Historical cohort study methodology was used to evaluate outcomes for rAAA repairs related to DCM or ST over a 74-month period at a level I trauma center. Results: Of 28 repairs, 13 (46.4%) were DCM. Compared to ST patients, DCM patients had a lower mean preoperative BP (64.6 vs. 83.2 mm Hg, P = .03) and greater intraoperative blood loss (4.6 vs. 2.1 liters, P = .033). Patients who had both DCR and DCO (DCO & DCR) received more plasma (6.8 vs 2.6 units, P = .039) and less crystalloid (2.8 vs 10.5 liters, P = .005) than those receiving DCO only. A modest decrease in mortality was seen in the DCO & DCR group compared to DCO only. No DCO-related graft infections were observed. Conclusion: DCR use may prove beneficial in the management of rAAA.

The Safety andEfficacy of Prehospital Needle andTube Thoracostomy by Aeromedical Personnel

BACKGROUND

Aeromedical crews routinely use needle thoracostomy (NT) and tube thoracostomy (TT) to treat major trauma victims (MTVs) with potential tension pneumothorax; however, the efficacy of prehospital NT and TT is unclear.

OBJECTIVES

To explore the efficacy of aeromedical NT and TT in MTVs.

METHODS

A retrospective chart review was performed using prehospital medical records and the county trauma registry over a seven-year period. All MTVs undergoing placement of NT or TT by aeromedical personnel were included; patients with incomplete data were excluded. Descriptive statistics were used to report the incidence of air release, clinical improvement (improved breath sounds or compliance if intubated, decreased dyspnea if nonintubated), and vital signs improvements (systolic blood pressure [SBP] increase to =90 mm Hg or increase by 5 mm Hg if < 90 mm Hg; heart rate improvement to 60-100 beats/min, increase by 10 beats/min if < 60 BPM, or decrease by 10 beats/min if > 100 beats/min; oxygen saturation increase if < 95%) for both NT and TT as documented in prehospital medical records. Survival and improvement in SBP based on trauma registry data were recorded for patients stratified by initial SBP.

RESULTS

A total of 136 procedures (89 NTs and 47 TTs) in 81 patients were identified using prehospital medical records over a four-year period. Response rates to NT (60% overall, 32% vital signs) and TT (75% overall, 60% vital signs) were high. Vital signs improvements were observed more often in patients with a pulse and in nonintubated patients. A total of 168 patients were identified in the trauma registry over the seven-year study period. Normalization of SBP was observed in two-thirds of patients with a field SBP = 90 mm Hg and one-third of patients in whom field SBP could not be obtained. A small but significant proportion of patients undergoing prehospital NT and TT, including some with prehospital hypotension and high injury severity, survived to hospital discharge. The incidence of complications was low.

CONCLUSIONS

Aeromedical crews appear to appropriately select MTVs to undergo field NT or TT. A low incidence of complications and a small but significant group of unexpected survivors support continued use of this procedure by aeromedical personnel.

The Impact of Safety Belt Use on Liver Injuries in Motor Vehicle Crashes: The Importance of Motor Vehicle Safety Systems

BACKGROUND

Liver injuries (LIs) are one of the most serious and common consequences of motor vehicle crashes (MVCs). In the unstable patient, early detection of LI based on clinical suspicion will improve acute trauma care and outcomes. The specific objectives of this analysis are to identify crash scene and occupant risk factors for LI from MVC.

METHODS

Crash Injury Research and Engineering Network data were used to identify risk factors for LI; age, sex, safety belt use, air bag deployment, DeltaV (change in velocity), principal direction of force, vehicle crush, and intrusion. Occupants with LI were compared with four control groups without LI; (1) no abdominal (ABD) injury (NO_ABD), (2) any ABD (ANY_ABD), (3) ABD Abbreviated Injury Scale score of 1 to 2 (ABD_1-2), and (4) ABD Abbreviated Injury Scale score of 3 or more (ABD_3+). LI occupants were compared with each control group and odds ratios (OR) for risk of LI were computed.

RESULTS

There were 311 Crash Injury Research and Engineering Network subjects aged 5 or more years with LI. The total mean Injury Severity Score was 37.6. LI was strongly and significantly associated with safety belt restraint use without air bag deployment, compared with each control group: Liver injury - restrained + air bag not deployed versus (1) NO_ABD, N = 1,519; OR = 4.4, (2) ANY_ABD, N = 317; OR = 2.6, (3) ABD_1 to 2, N = 155; OR = 3.1, (4) ABD_3+, N = 217; OR = 2.4 (p < 0.001). This association was independent of driver or passenger status and principal direction of force. LIs were also strongly and significantly associated with greater vehicle interior intrusion.

CONCLUSIONS

LIs were strongly associated with a safety belt restraint in use in the absence of air bag deployment during MVC. This data may have profound importance to the trauma surgeon as an early indicator for LI during resuscitation. These findings also have important implications for future research efforts to improve safety systems in motor vehicles and reduce morbidity and mortality from MVCs in the United States.

Trauma in Adolescents Causes Long-Term Marked Deficits in Quality of Life: Adolescent Children do not Recover Preinjury Quality of Life or Function up to Two Years Postinjury Compared to National Norms

BACKGROUND

Injury is a leading cause of death and preventable morbidity in adolescents. Little is known about long-term quality of life (QoL) outcomes in injured adolescents. The objectives of the present report are to describe long-term QoL outcomes and compare posttrauma QoL to national norms for QoL in uninjured adolescents from the National Health Interview Survey (NHIS).

METHODS

In all, 401 trauma patients aged 12 to 19 years were enrolled in the study. Enrollment criteria excluded spinal cord injury. QoL after trauma was measured using the Quality of Well-being (QWB) scale, a sensitive and well-validated functional index (range: 0 = death to 1.000 = optimum functioning). Patient outcomes were assessed at discharge, and 3, 6, 12, 18, and 24 months after discharge. NHIS data were based on 3 survey years and represent a population-based U.S. national random sample of uninjured adolescents.

RESULTS

Major trauma in adolescents was associated with significant and marked deficits in QoL throughout the 24-month follow-up period, compared with NHIS norms for this age group. Compared with NHIS norms for QoL in uninjured adolescents aged 12 to 19 years (N = 81,216,835; QWB mean = 0.876), injured adolescents after major trauma had striking and significant QoL deficits beginning at 3-month follow-up (QWB mean = 0.694, p < 0.0001), that continued throughout the long-term follow-up 24 months after discharge (6-month follow-up QWB mean = 0.726, p < 0.0001; 12-month follow-up QWB mean = 0.747, p < 0.0001; 18-month follow-up QWB mean = 0.758, p < 0.0001; 24-month follow-up QWB mean = 0.766, p < 0.0001). QoL deficits were also strongly associated with age (>or=15 years) and female sex. Other significant risk factors for poor QoL outcomes were perceived threat to life, pedestrian struck mechanism, and Injury Severity Scores >16.

CONCLUSIONS

Major trauma in adolescents is associated with significant and marked deficits in long-term QoL outcomes, compared with U.S. norms for healthy adolescents. Early identification and treatment of risk factors for poor long-term QoL outcomes must become an integral component of trauma care in mature trauma care systems.

What is the role of chest X-ray in the initial assessment of stable trauma patients?

BACKGROUND

The Advanced Trauma Life Support course advocates the liberal use of chest X-ray (CXR) during the initial evaluation of trauma patients. We reviewed CXR performed in the trauma resuscitation room (TR) to determine its usefulness.

METHODS

A retrospective, registry-based review was conducted and included 1,000 consecutive trauma patients who underwent CXR in the TR at a Level I trauma center during a 7-month period.

RESULTS

Patients receiving CXR comprised 91.5% of all patients evaluated in the TR during the study period. CXR followed by chest computed tomography (CCT) was performed in 820 (82.0%) patients. Subsequent CCT identified missed findings in 235 (35.6%) of the 660 patients with an initial negative CXR who went on to receive CCT. CXR alone was performed in 127 (26.1%) of the 487 patients who were stable, not intubated, and had a normal chest physical examination (CPE). Seven patients (5.5%) in this group had potentially significant findings but none required intervention beyond physiotherapy or antibiotics. Three hundred and sixty (73.9%) of the 487 patients who were hemodynamically stable with a normal CPE underwent both CXR and CCT. Fifty-four patients (15%) in this group had findings of significance, and two (0.6%) required intervention. One patient received bilateral chest tubes for large pre-existing pleural effusions found on CXR and CCT; another patient undergoing general anesthesia required a chest tube for a pneumothorax found only on CCT.

CONCLUSION

In stable trauma patients with a normal CPE, CXR appears to be unnecessary in their initial evaluation. CXR should be relegated to a role similar to cervical spine and pelvis radiographs in the initial evaluation of hemodynamically stable trauma patients with a normal physical examination, and should be limited to use only for clear clinical indications.

Head-Injured Patients Who “Talk and Die”: The San Diego Perspective

BACKGROUND

Head-injured patients who "talk and die" are potentially salvageable, making their early identification important. This study uses a large, comprehensive database to explore risk factors for head-injured patients who deteriorate after their initial presentation.

METHODS

Patients with a head Abbreviated Injury Score (AIS) score of 3+ and a preadmission verbal Glasgow Coma Scale (GCS) score of 3+ were identified from our county trauma registry during a 16-year period. Survivors and nonsurvivors were compared with regard to demographics, initial clinical presentation, and various risk factors. Logistic regression was used to explore the impact of multiple factors on outcome, including the significance of a change in GCS score from field to arrival. In addition, patients were stratified by injury severity and hospital day of death to further define the relationship between outcome and multiple clinical variables.

RESULTS

A total of 7,443 patients were identified with head AIS 3+ and verbal GCS score 3+. Overall mortality was 6.1%. About one-third of deaths occurred on the first hospital day, with more than one-third occurring after hospital day 5. Logistic regression revealed an association between mortality and older age, more violent mechanisms of injury (fall, gunshot wound, pedestrian versus automobile), greater injury severity (higher head AIS and Injury Severity Score), lower GCS score, and hypotension. In addition, mortality was associated with a decrease in GCS score from field to arrival, the use of anticoagulants, and a diagnosis of pulmonary embolus. Two important groups of "talk-and-die" patients were identified. Early deaths occurred in younger patients with more critical extracranial injuries. Anticoagulant use was also an independent risk factor in these early deaths. Later deaths occurred in older patients with less significant extracranial injuries. Pulmonary embolus also appeared to be an important contributor to late mortality.

CONCLUSIONS

More severe injuries and use of anticoagulants are independent risk factors for early death in potentially salvageable traumatic brain injury patients, whereas older age and pulmonary embolus are associated with later deaths.

Incidental CT Findings in Trauma Patients: Incidence and Implications for Care of the Injured

BACKGROUND

The evaluation of patients with head, neck, and torso trauma frequently includes high-definition spiral computed tomography (SCT) scanning, which can reveal non-injury-related lesions. These incidental findings vary in their importance, from trivial lesions to findings that may have a greater impact on the health of the trauma patient than the injuries that led to the SCT. We evaluated the incidence and clinical importance of incidental findings found on SCT, and the effectiveness of a trauma practice guideline calling for appropriate management and follow-up.

METHODS

The trauma registry was accessed to identify patients evaluated at an urban Level I trauma center from January to November, 2002. Trauma registry data, inpatient chart records, and the digital record of the filmless radiology archives were reviewed. Demographic data, including age, sex, type and mechanism of injury, and outcome, were recorded. All CT studies were reviewed for incidental findings. Mucus retention cysts, sinusitis (except mastoiditis), degenerative joint disease, evidence of previous operation, and age-related cerebral atrophy were excluded. Incidental findings were divided into three categories based on clinical importance. Category 1 required attention before discharge. Category 2 required follow-up with primary doctor within 1 or 2 weeks, and Category 3 required no specific follow-up. Categories 1 and 2 were considered clinically significant findings.

RESULTS

Complete data were available for 991 patients (677 men, 314 women). Eight hundred and forty-eight (85.6%) patients received at least one CT scan. A total of 289 incidental findings were discovered. Thirty-one patients (3.1%) had 36 Category 1 findings. There were 108 Category 2 and 145 Category 3 findings. When comparing those patients with at least one incidental finding, the incidence of incidental findings was higher in women than in men (34.1% versus 27.6%; p < 0.05). Older patients also had a higher incidence of all categories of findings (over 40 versus 40 and younger: 46.1% versus 19.9%; p < 0.001). SCT yielded 90 (62.5%) of the clinically significant incidental findings in the abdomen/pelvis, 29 (20.1%) in the chest, and 25 (17.4%) in the head and neck. The charts of only 15 (48.4%) of the patients with Category 1 findings adequately documented the management of the incidental finding.

CONCLUSIONS

SCT for the evaluation of trauma patients reveals a significant number of incidental findings. These lesions are common in the abdomen and pelvis and show an increased incidence in women and among older patients. Although many require early follow-up and specialty physician referral, there was insufficient documentation of the management of these injuries. Incidental findings in the injured remain a significant challenge for trauma centers. An organized approach is required for successful follow-up and management.

Spiral Computed Tomography for the Initial Evaluation of Spine Trauma: A New Standard of Care?

BACKGROUND

Although spiral computed tomographic scanning (SCT) is frequently used for spinal imaging in injured patients, many trauma centers continue to rely on plain film radiography (PFR). The purpose of this study was to determine the effects of a trauma center's transition from PFR to SCT for initial spine evaluation in trauma patients by comparing diagnostic sensitivity, time required for radiographic imaging, costs, charges, and radiation exposure.

METHODS

Registry-based review of all trauma patients evaluated for spinal trauma during two three-month intervals, one before (1999, "X-ray Group"), and one after (2002, "CT Group") adopting SCT as the initial spinal imaging method. Demographic data, mechanism of injury, Injury Severity Score (ISS), the presence and location of spine fractures, and the results of all spine imaging were recorded. The dates and diagnostic sensitivity for spine fractures, time for initial imaging, costs, and charges were compared between groups. Radiation exposure associated with both SCT and PFR of the spine was measured.

RESULTS

There were 254 patients in the X-ray Group and 319 in the CT Group, with similar demographic data, ISS, mechanism of injury, and incidence of spine fractures. Sensitivity in the detection of spine fractures was 70% (14 out of 20) in the X-ray Group compared with 100% (34 out of 34) for the CT Group (p < 0.001). Mean time in the radiology department during initial evaluation decreased significantly in the CT Group compared with the X-ray Group (1.0 hours vs. 1.9 hours; p < 0.001). SCT of the spine was associated with higher mean overall spinal imaging charges than PFR (4,386 dollars vs. 513 dollars, p < 0.001), but a similar mean overall spinal imaging cost per patient (172 dollars vs. 164 dollars). Radiation exposure was higher with SCT versus PFR for cervical spine imaging (26 mSv vs. 4 mSv) but SCT involved lower levels of exposure than PFR for thoracolumbar imaging (13 mSv vs. 26 mSv).

CONCLUSIONS

SCT is a more rapid and sensitive modality for evaluating the spine compared with PFR and is obtained at a similar cost. The advantages of SCT suggest that this readily available diagnostic modality may replace PFR as the standard of care for the initial evaluation of the spine in trauma patients.

Traumatic brain injury outcomes in pre- and post- menopausal females versus age-matched males

Gender differences in outcomes from major trauma have been described previously, and exogenous female hormone administration appears to be neuroprotective following traumatic brain injury (TBI). This analysis explored outcomes in pre- and post-menopausal females versus age-matched males. A total of 13,437 patients (n = 3,178 females, n = 10,259 males) with moderate-to-severe TBI (head AIS > or = 3) were identified from our county trauma registry. Overall mortality was similar between males and females (22% for both). Logistic regression was used to compare gender outcome differences, with a separate analysis performed for premenopausal (< 50 years) versus postmenopausal (> or = 50 years) patients, and after stratification by decade of life. No statistically significant difference in outcomes was observed for pre-menopausal females versus males (odds ratio [OR] 1.06; 95% confidence interval [CI] 0.83, 1.35; p = 0.633), but outcomes were significantly better in postmenopausal females versus males (OR 0.63, 95% CI 0.48-0.81, p < 0.001) after adjusting for age, mechanism of injury, Glasgow Coma Scale (GCS), hypotension (SBP < or = 90 mm Hg), head Abbreviated Injury Score (AIS), and Injury Severity Score (ISS). Stratification by decade of life revealed the gender survival differential inflection point to occur between ages 40-49 (OR 1.06, 95% CI 0.66-1.71, p = 0.798) and ages 50-59 (OR 0.38, 95% CI 0.20-0.74, p = 0.005). In addition, Revised Trauma Score and Injury Severity Score (TRISS) was used to calculate probability of survival (PS); all patients were then stratified by decade of life, and males and females were compared with regard to mean survival differential (outcome - PS). The identical pattern of improved outcomes in post-menopausal but not pre-menopausal females versus age-matched males was observed. These data suggest that endogenous female sex hormone production is not neuroprotective.

The predictive value of field versus arrival Glasgow Coma Scale score and TRISS calculations in moderate-to-severe traumatic brain injury

BACKGROUND

Glasgow Coma Scale (GCS) scores are widely used to quantify level of consciousness in the prehospital environment. The predictive value of field versus arrival GCS is not well defined but has tremendous implications with regard to triage and therapeutic decisions as well as the use of various predictive scoring systems, such as Trauma Score and Injury Severity Score (TRISS). This study explores the predictive value of field GCS (fGCS) and arrival GCS (aGCS) as well as TRISS calculations using field (fTRISS) and arrival (aTRISS) data in patients with moderate-to-severe traumatic brain injury (TBI).

METHODS

Major trauma victims with head Abbreviated Injury Scores of 3 or greater were identified from our county trauma registry over a 16-year period. The predictive ability of fGCS with regard to aGCS was explored using univariate statistics and linear regression modeling. The difference between aGCS and fGCS was also modeled against mortality and the composite endpoint using logistic regression, adjusting for fGCS. The predictive value of preadmission GCS (pGCS), defined as either fGCS or aGCS in nonintubated patients without a documented fGCS, with regard to mortality and a composite endpoint representing the need for neurosurgical care (death, craniotomy, invasive intracranial pressure monitoring, or intensive care unit care >48 hours) was determined using receiver-operator curve (ROC) analysis. Finally, fTRISS and aTRISS predicted survival values were compared with each other and to observed survival.

RESULTS

A total of 12,882 patients were included. Mean values for fGCS and aGCS were similar (11.4 and 11.5, respectively, p = 0.336), and a strong correlation (r = 0.67, 95% CI 0.66-0.69, p < 0.0001) was observed between them. The difference between fGCS and aGCS was also predictive of outcome after adjusting for fGCS. Good predictive ability was observed for pGCS with regard to both mortality and neurosurgical intervention. Both fTRISS and aTRISS predicted survival values were nearly identical to observed survival. Observed and fTRISS predicted survival were nearly identical in patients undergoing prehospital intubation

CONCLUSIONS

Values for fGCS are highly predictive of aGCS, and both are associated with outcome from TBI. A change in GCS from the field to arrival is highly predictive of outcome. The use of field data for TRISS calculations appears to be a valid methodological approach, even in severely injured TBI patients undergoing prehospital intubation.

Early ventilation and outcome in patients with moderate to severe traumatic brain injury

OBJECTIVES

An increase in mortality has been reported with early intubation in severe traumatic brain injury, possibly due to suboptimal ventilation. This analysis explores the impact of early ventilation on outcome in moderate to severe traumatic brain injury.

DESIGN

Retrospective, registry-based analysis.

SETTING

This study was conducted in a large county trauma system that includes urban, suburban, and rural jurisdictions.

PATIENTS

Nonarrest trauma victims with a Head Abbreviated Injury Score of > or =3 were identified from our county trauma registry.

INTERVENTIONS

Intubated patients were stratified into 5 mm Hg arrival PCO(2) increments. Logistic regression was used to calculate odds ratios for each increment, adjusting for age, gender, mechanism of injury, year of injury, preadmission Glasgow Coma Scale score, hypotension, Head Abbreviated Injury Score, Injury Severity Score, PO(2), and base deficit. Increments with the highest relative survival were used to define the optimal PCO(2) range. Outcomes for patients with arrival PCO(2) values inside and outside this optimal range were then explored for both intubated and nonintubated patients, adjusting for the same factors as defined previously. In addition, the independent outcome effect of hyperventilation and hypoventilation was assessed.

MEASUREMENTS AND MAIN RESULTS

A total of 890 intubated and 2,914 nonintubated patients were included. Improved survival was observed for the arrival PCO(2) range 30-49 mm Hg. Patients with arrival PCO(2) values inside this optimal range had improved survival and a higher incidence of good outcomes. Conversely, there was no improvement in outcomes for patients within this optimal PCO(2) range for nonintubated patients after adjusting for all of the factors defined previously. Both hyperventilation and hypoventilation were associated with worse outcomes in intubated but not nonintubated patients. The proportion of arrival PCO(2) values within the optimal range was lower for intubated vs. nonintubated patients.

CONCLUSIONS

Arrival hypercapnia and hypocapnia are common and associated with worse outcomes in intubated but not spontaneously breathing patients with traumatic brain injury.

Surgeons’ Attitudes About Communicating With Patients and Their Families

CONTEXT

Surgeons face difficult communication challenges with patients and their families. There is a need for improved education in communication skills, especially in giving bad news. Understanding surgeons' attitudes is the first step in designing effective education programs.

OBJECTIVE

To determine surgeons' self-assessment of competence, rating of importance, and perceived need for training in communication skills relevant to patient care.

DESIGN

Anonymous self-report mail survey of demographic information and attitudes toward 12 patient care-related communication skills.

SETTING

San Diego County, California, a geographically distinct area of close to 3 million inhabitants receiving health care from over 6000 physicians.

PARTICIPANTS

A total of 351 (43.4%) respondents from the 833 surgical specialists in the San Diego County Medical Society list of member and nonmember physicians.

MAIN OUTCOME MEASURES

Measurement of surgeons' attitudes toward self-perceived competence, importance, need for training in the communication skills, and the influence of age, duration of practice, and surgical-specialty on attitudes.

RESULTS

Most respondents rated their competence high except in 3 skills relating to a patient's death. They found all skills important and indicated a need for training in them. Younger surgeons rated their competence and the importance significantly lower in the 3 skills relating to a patient's death (p < 0.05). Critical care surgical specialists rated their competence and the importance higher in skills relating to breaking bad news and a patient's death than did the non-critical care group (p < 0.05). Older surgeons and critical care specialists also indicated a higher level of support for training in these skills.

CONCLUSION

These results suggest that surgical specialists rate themselves as competent in effective communication, believe in its importance, and agree with the need for training. An organized approach to training in interaction skills, especially in giving bad news, is warranted.

Measuring Trauma Center Injury Prevention Activity: An Assessment and Reporting Tool

OBJECTIVE

To develop an assessment and reporting tool for a trauma center's community partnership strategy to deliver injury prevention programs in a large metropolitan area.

METHOD

The tool was designed to track prevention activity and serve as a reporting format for the parent health system, county designating agency, and the American College of Surgeons' Trauma Center Verification Process. The tool collected data including trauma center paid and volunteer personnel time, equipment, resource, and financial costs, community group and public agency contributions, number of community members receiving prevention material or presentations, impact on public policy, and print and broadcast media coverage. These measurements were incorporated in a reporting grid format. Six youth injury prevention programs were evaluated over a recent 2-year interval to demonstrate the tool's usefulness.

RESULTS

Of six programs, three focused on motor vehicle injuries, one on teen suicide, one on firearm injuries, and one on drug and alcohol abuse. Trauma Center personnel asset allocation included 3% full-time equivalent by the Trauma Medical Director, 30% by the Injury Prevention and Community Outreach Coordinator, and 473 person hours (both work and volunteer) by physicians, nurses, and other personnel. Trauma Center equipment and fixed asset expenses totaled $3,950 and monetary contribution totaled $4,430. Community groups and public agencies contributed 20,400 person hours with estimated in-kind costs exceeding $750,000. Five of the six programs continued during the 2-year period. A gun-lock giveaway program was suspended because of a product recall. A total of over 29,000 youth received prevention material and presentations. Four public policy initiatives and 18 Trauma Center media stories with over 50 mentions and 37 new community partnerships resulted. The reports generated were easily incorporated in the trauma center's reports to local and national organizations and agencies.

CONCLUSION

This assessment tool provided a detailed but concise accounting of trauma center injury prevention activity. The reports generated were effective in displaying the center's work.