Type-O Blood Is Not Associated With Elevated Mortality After Trauma: A North American Cohort Study

BACKGROUND

Recent studies have presented contradictory findings on the relationship between blood type and mortality in trauma patients. Using the largest population in a study of this type to date, we hypothesized that ABO genotype and Rhesus status would influence trauma-related mortality and morbidity given the relationship between blood type and hemostasis.

METHODS

Data from all trauma patients admitted to level I and level II trauma centers in one city over a five-year period was retrospectively analyzed. Patients were stratified by ABO type. Patient demographics and outcomes were then assessed. Chi-squared and Fisher's exact tests were used to analyze categorical variables. Continuous variables were analyzed using ANOVA or Kruskal-Wallis tests as appropriate. Logistic regression was used to determine independent associations for 28-day mortality and complications.

RESULTS

Of 5249 patients, severe injury (ISS >15) was present in 1469. Approximately one-quarter of patients with severe injury received blood products within the first 24 hours. There were no significant variations in demographics or complications between patients of different blood types. Univariate and multivariable regression analysis showed no association between blood type and mortality. However, penetrating injury, lower GCS, higher ISS, blood transfusion within 24 hours, and Asian descent were associated with higher overall mortality.

CONCLUSIONS

In contrast to previous studies, we found no evidence of an association between blood type and mortality. However, our findings suggest that patients of Asian descent may be at higher risk for mortality following trauma. Further research is warranted to explore this observation.

Contemporary Outcomes and Patterns of Injury Associated With Parachuting Accidents

BACKGROUND

Skydiving is an increasingly popular recreational activity in the United States and worldwide. While it is considered a high-risk sport, the United States Parachute Association reported a fatality of .28 per 100 000 jumps in 2022. Although mortality rates are low, the true rate of survivable injuries is unknown. Injuries requiring hospitalization are not uncommon and may be underreported in the literature. Anticipating these injuries and analyzing short-term outcomes following parachuting accidents would be useful for the development of mitigation strategies and to increase the safety of jumpers.

METHODS

A retrospective cohort review of 126 consecutive patients presenting to a Level II Trauma Center after skydiving accidents between 2016 and 2023. Patient baseline characteristics, patterns of injury, surgical procedures, and in-hospital outcomes were reviewed.

RESULTS

A total of 126 patients were included. One hundred and seventeen patients (93%) presented immediately following the accident, 65 (51.6%) were trauma activations, and 14 (11.1%) patients experienced loss of consciousness. Fractures of the lower extremity occurred in 57 (45%), fractures of the spine 48 (38%), upper extremity 13 (10%), pelvis 11 (9%). Of the spinal injuries, 10 injuries occurred in the cervical spine, 16 thoracic, 22 lumbar, 5 sacral, and 3 coccygeal spine. Eleven patients (9%) suffered multilevel spine injuries. Mean injury severity score was 7 (range 0-75). A third of patients required at least 1 surgical procedure (n = 43, 34%). Median length stay was 2 days (IQR 1, 5). Of patients who survived to our trauma center, there were two mortalities, both due to catastrophic intracranial hemorrhage.

DISCUSSION

Although the 30-day mortality rate for patient who presented to our trauma center is low, it can bear significant risks including major injury. The most common injuries were lower extremity and spinal in origin with a third of patients overall requiring at least one operation.

Comparison and Utility of Intravenous Iodinated Contrast in Chest, Abdomen, Pelvis Computerized Tomography for Trauma Patients With Blunt Mechanism of Injury Before and After the May 9, 2022 Global Contrast Shortage at a Level II Trauma Center

Background: Intravenous (IV) contrast improves the sensitivity and specificity of injury detection in computerized tomography (CT). Its use is recommended in the workup of trauma patients by the American College of Surgeons and American College of Radiology. On May 9, 2022, the Food and Drug Administration declared a shortage of iodinated contrast due to the COVID-19 pandemic. Although the shortage has ended, the temporary lack of IV contrast forced physicians to be prudent in ordering CT scans with IV contrast. We sought to determine if there was a change in the percentage of CT contrast studies performed during the contrast shortage and if this change affected patient outcomes.Methods: Retrospective chart review was performed on all adult tier 2 trauma patients at a 619-bed community-based level II trauma center who received CT chest, abdomen, and pelvis imaging as initial workup for blunt trauma from 5/9/2021-6/30/2021 (pre-shortage) and 5/9/2022-6/30/2022 (during shortage).Results: Patients were predominantly male with median age of 31-52 and of White or Hispanic ethnicity. Before the contrast shortage, all 110 trauma patients were scanned with contrast. During the shortage, 29 of 114 patients were scanned with contrast (P < 0.001). Injuries were identified in 59% of patients scanned with contrast (P < 0.001). There were no significant differences in blood transfusion needs, repeat CT, disposition, or mortality when comparing pre-shortage to during shortage or when comparing between non-contrast and contrast studies during the shortage.Discussion: There was a decrease in the percentage of CT contrast studies performed during the shortage. A higher percentage of injuries were identified in the patients scanned with contrast. However, there were no significant differences in patient outcomes. Certain trauma patients may be safely scanned without contrast.

Pediatric and Young Adult Trauma Recidivism

INTRODUCTION

Unintentional injury is the leading cause of death among children. Much can be gleaned from the adult literature in understanding the characteristics that lead to recidivism in efforts to establish interventions for prevention. Our study aims to evaluate the rates, demographics, and features of pediatric trauma recidivism.

METHODS

This was a retrospective single-institution review at a level-1 pediatric trauma center of children and young adults (ages 0-28) with traumatic injuries from January 2008 to April 2023. Patients with 1 or more prior visits to our institution's trauma center (recidivists) were identified and compared with those with single admissions. Chi-square tests were used to statistically analyze the two groups.

RESULTS

Pediatric/young adult trauma recidivists were 4.4% of the total trauma population captured (n = 14,613). Of the total trauma group, 55% were under 18 years old. Recidivists had higher percentages of patients who were male (82% vs 69%, P < .01), African American (36% vs 24%, P < .01), involved in penetrating trauma (33% vs 17%, P < .01), self-pay/uninsured (17% vs 12%, P < .01), and have abuse reported (5% vs 4%, P = .04). The primary county for recidivism patients was Forsyth with most patients from a specific zip code in an urban area of the county. The average time between visits for recidivists was 1,066 days.

CONCLUSIONS

Pediatric/young adult trauma recidivism is associated with specific characteristics including male, African American race, penetrating trauma, and uninsured status. Recidivists are primarily presenting from a zip code with low socioeconomic status. It is critical to develop targeted interventions to help this population in trauma prevention.

Risk Factors for Empyema Following Penetrating Diaphragmatic Injuries

Empyema resulting as a complication of penetrating diaphragmatic injuries is a subject that requires further investigation, and the aim of this study was to determine the risk factors associated with empyema in patients with penetrating trauma. Consecutive adult trauma patients from a level 1 trauma center were searched for penetrating diaphragm injuries. Data were collected on patient demographics, pre-existing conditions, injury type and severity, hospital interventions, in-hospital complications, and outcomes. Patients were stratified by empyema formation and univariant analyses were performed. 164 patients were identified, and 17 patients (10.4%) developed empyema. Empyema was associated with visible abdominal contamination (35.3% vs 15%, P = .04), thoracotomy (35.5% vs 13.6%, P = .03), pneumonia (41.2% vs 14.3%, P = .01), sepsis (35.3% vs 8.8%, P = .006), increased hospital length of stay (25.5 vs 10.1 days, p =<.001), increased intensive care unit length of stay (9.6 vs 4.3 days, P = .01), and decreased in-hospital mortality (0% vs 20.4%, P = .04).

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

More Harm Than Good: It is Time to Reconsider Prophylactic Fasciotomy in Lower-Extremity Vascular Injury

INTRODUCTION

Four-compartment calf fasciotomy (CF) can be limb-saving. Prophylactic fasciotomy (PP) is advised in high-risk situations to prevent limb loss. Calf fasciotomy can cause significant morbidity, particularly if performed unnecessarily. We hypothesized that selective use of fasciotomies (SF) after lower-extremity vascular injury would lead to a lower rate of overall fasciotomies without an increase in limb complications than prophylactic fasciotomies (PFs).

METHODS

Trauma patients who sustained lower-extremity vascular injury that required operative repair at a high-volume trauma center were retrospectively reviewed and grouped by SF or PF (2016-2022). SF were individuals who were observed and underwent CF only if signs of compartment syndrome developed, whereas PF were individuals who underwent CF without signs of compartment syndrome. The primary outcome was amputation rate. Secondary outcomes were fasciotomy rate, need for reoperative vascular surgery, and clinical characteristics predisposing use of PF.

RESULTS

Of 101 overall patients, 30 patients (29.4%) had PF. Of the remaining 71 (SF group), 43.7% (n = 31) were spared CF. The median time from injury to vascular repair in both groups was the same (7 hours, P = .15). There was no difference in rate of vascular reoperation per group (PF = 26.7% vs SF = 23.9%, P = .77). The only clinical characteristic associated with PF was need for arterial shunt (OR 4.2, P = .028).

CONCLUSIONS

In trauma patients with lower-extremity vascular injury undergoing vascular repair, selective use of fasciotomy can spare almost half of patients the need for fasciotomy without an increase in limb complications.

Implementation of a Trauma Bay Checklist Improves Antibiotic Prophylaxis Compliance in Open Extremity Fractures

BACKGROUND

Best practice guidelines from the ACS recommend that patients with open fractures receive antibiotics within 1-hour of presentation. Checklists are effective mechanisms for improving safety and compliance in surgical settings. The current study investigates implementation of a trauma bay checklist, referred to as MARTY, to improve administration of antibiotics in open extremity fractures at a level I trauma center.

METHODS

Retrospective pre-post design. Population consisted of trauma alerts from January to December 2021 (pre-MARTY) and 2022 (post-MARTY) with open fractures. Outcome measures included antibiotics administered within 1-hour of presentation and in the trauma bay. Bivariate and multivariate analyses were performed to estimate differences in both measures.

RESULTS

Our sample included 339 encounters, 174 pre-MARTY and 165 post-MARTY implementation. In the pre-MARTY period, 57.5% of encounters received antibiotics within 1-hour of presentation with 46.0% occurring in the trauma bay, in comparison to 65.5% and 54.5% in the post-MARTY period. In adjusted models, there were greater odds of antibiotic administration within 1-hour (OR = 1.654, P = .038) and prior to leaving the trauma bay (OR = 1.660, P = .041) than pre-MARTY. Encounters with higher-grade fractures were more likely to receive timely antibiotics (P<=.001).

DISCUSSION

Our study estimates improved compliance of antibiotic administration after implementation of MARTY after adjusting for encounter characteristics. Findings from this study demonstrate improved compliance, but this compliance is often still lacking in those with higher injury severity scores. Findings from this study may be used to inform approaches to further improve trauma care.

Prehospital Needle Decompression of Suspected Tension Pneumothorax: Outcomes and Consequences

Tension pneumothorax (TPT) identified in the prehospital setting requires prehospital needle decompression (PHND). This study aimed to evaluate complications from PHND when it was performed without meeting clinical criteria. A retrospective review was performed of patients undergoing (PHND) from 2016 through 2022 at a level 1 trauma center. Patient data who received PHND were reviewed. Of 115 patients, 85 did not meet at least one clinical criterion for PHND. The majority of patients in this cohort 76 (89%) required a chest tube and 22 (25%) had an iatrogenic pneumothorax from PHND. 5 patients (6%) were admitted due to iatrogenic PHND. Two vascular injuries in this population were directly due to PHND and required emergency operative repair. This study shows the negative consequences of PHND when performed without clear indications. Several patients underwent unnecessary procedures with significant clinical consequences.

Washington State Assault Weapon Firearm Violence Before and After Firearm Legislation Reform

BACKGROUND

In January of 2019, Washington State (WA) passed Initiative 1639 making it illegal for persons <21 years-old to buy assault weapons (AWs). This study aimed to evaluate the effects of WA-1639 on firearm-related incidents involving AWs by those <21 years-old in WA, hypothesizing a decrease in incidents after WA-1639.

METHODS

Retrospective (2016-2021) data on firearm violence (FV) events were gathered from the Gun Violence Archive. The rate of FV was weighted per 100,000 people. Total monthly incidents, injuries, and deaths were compared pre-law (January 2016-December 2018) vs post-law (January 2019-December 2021) implementation. Mann-Whitney U tests and Poisson's regression were used for analysis.

RESULTS

From 4091 FV incidents (2210 (54.02%) pre-law vs 1881 (45.98%) post-law), 50 involved AWs pre- (2.3%) and 15 (.8%) post-law. Of these, 11 were committed by subjects <21 years-old pre-law and only one occurred post-law. Total incidents of FV (z = -3.80, P < .001), AW incidents (z = -4.28, P < .001), and AW incidents involving someone <21 years-old (z = -3.01, P < .01) decreased post-law. Additionally, regression analysis demonstrated the incident rate ratio (IRR) of all FV (1.23, 95% CI [1.10-1.38], P < .001), all AW FV incidents (3.42, 95% CI [1.70-6.89], P = .001), and AW incidents by subjects <21 years-old (11.53, 95% CI [1.52-87.26], P = .02) were greater pre-law vs post-law.

DISCUSSION

Following implementation of WA-1639, there was a significant decrease in FV incidents and those involving AWs by individuals <21 years-old. This suggests targeted firearm legislation may help curtail FV. Further studies evaluating FV after legislation implementation in other states is needed to confirm these findings.

Rarely Seen Compartment Syndrome of the Shoulder and Back: Diagnosis and Management

Compartment syndrome (CS) is a well-known surgical emergency with high morbidity including potential long-term disability and limb loss. The most important factor determining the degree of morbidity with CS is time to treatment; therefore, early diagnosis and surgery are vital. We present a patient who fell off his bicycle and sustained cervical spine fractures causing near complete quadriplegia. He was found by the road over 12 hours later, so his creatine phosphokinase (CPK) was trended and serial examinations were performed. We identified tight deltoid, trapezius, and latissimus compartments and brought him to the operating room for fasciotomies. Although lab values and compartment pressures can be helpful, they should not guide treatment. It is important to consider atypical sites for CS and complete a head to toe physical examination. Patients should proceed to the operating room if clinical suspicion exists for CS because of the morbidity associated with a missed diagnosis.

The Effect of COVID-19 on Rib Fracture Patients in Michigan

This study aims to compare outcomes of rib fracture patients with and without COVID-19 in Michigan. Data from the Michigan Trauma Quality Improvement Program (MTQIP) identified adults hospitalized from January 1, 2020, to October 31, 2022, with at least one rib fracture and a completed COVID-19 test on admission. Patients were propensity score matched 1:1 using 20 variables. The primary outcome was hospital length of stay (LOS). Secondary outcomes were mortality, ventilator days, intensive care unit (ICU) LOS, pneumonia, and ventilator-assisted pneumonia (VAP). 13,305 total patients were identified. 232 patients matched into both the COVID+ and COVID- groups. COVID was associated with increased LOS (7 days vs. 5 days, P < 0.001). There were no significant differences between the two groups when evaluating secondary outcomes. Our study indicates that although COVID-19 infection is associated with increased LOS, COVID may not contribute to additional morbidity or mortality in traumatic rib fracture patients.

Causes and Timing of Unplanned ICU Admissions Among Trauma Patients at a Level 1 Trauma Center

BACKGROUND

Unexpected ICU admissions are a key quality metric in trauma care. The purpose of this study is to identify the most common causes of unplanned ICU admissions among trauma patients at an ACS-verified level 1 trauma center.

METHODS

A retrospective review was conducted of all trauma patients with unplanned admission to the ICU at a level 1 trauma center between 2019 and 2021. Unplanned ICU admissions were categorized into (1) "bounce-backs," patients previously admitted to the ICU and (2) "upgrades," patients who had not previously been cared for in the ICU.

RESULTS

Of 300 unexpected ICU transfers, bounce-backs accounted for 69% and upgrades 31%. The most common injuries were traumatic brain injuries (40%) and rib fractures (41.3%). In-hospital mortality rate was 10% and did not significantly differ between bounce-backs and upgrades (12 vs 5%, P = .92). Respiratory distress was the most common cause of transfer (41.1%), followed by neurologic (29.6%) and cardiovascular decline (21.2%). Patients were on average 928 mL fluid positive 72 hours prior to transfer (t > 0, P < .0001), and 295 mL fluid positive in the 24 hours prior to transfer (t > 0, P .0003). Patients transferred for respiratory distress were no more fluid over-balanced than those transferred for other reasons.

CONCLUSION

We found a large percent of unplanned transfers occurring within 48 hours of admission or transfer out of the ICU suggesting under-triage as a leading cause of bounce-backs and upgrades. Respiratory distress was the leading cause of transfer. These findings highlight opportunities for targeted interventions.

Is Traumatic Anterior Stove-In Chest Truly so Rare? A Single Institution Experience

INTRODUCTION

The anterior stove-in chest (ASIC) is a rare form of flail chest involving bilateral rib or sternal fractures resulting in an unstable chest wall that caves into the thoracic cavity. Given ASIC has only been described in a handful of case reports, this study sought to review our institution's experience in the surgical management of ASIC injuries.

METHODS

A retrospective review of patients with ASIC was conducted at our level I trauma center from 1//2021 to 3//2023. Information pertaining to patient demographics, fracture pattern, operative management, and outcomes was obtained and compared across patients in the case series.

RESULTS

6 patients met inclusion criteria, all males aged 37-78 years. 5 suffered motor vehicle collisions, and 1 was a pedestrian struck by an automobile. The median injury severity score was 28. All received ORIF within 5 days of admission, most commonly for ongoing respiratory distress. Patients 2 and 4 underwent bilateral ORIF of the ribs and sternum while patients 1, 5, and 6 underwent left-sided repair. Patient 3 required ORIF of left ribs and the sternum to stabilize their injuries. 5 of 6 patients were liberated from the ventilator and survived to discharge.

CONCLUSIONS

This study demonstrates successful operative management of 6 patients with ASIC and suggests that early operative intervention with ORIF for affected segments may improve respiratory mechanics, ability to wean from the ventilator, and overall survival. Further research is needed to generate standardized guidelines for the management of this uncommon and complex thoracic injury.

Thoracic and Lumbar Spine Injury: Evidence-Based Diagnosis, Management, and Outcomes

BACKGROUND

Traumatic thoracolumbar spine injuries are associated with significant morbidity and mortality. Targeted for non-spine specialist trauma surgeons, this systematic scoping review aimed to examine literature for up-to-date evidence on presentation, management, and outcomes of thoracolumbar spine injuries in adult trauma patients.

METHODS

This review was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. We searched four bibliographic databases: PubMed, EMBASE, Web of Science, and the Cochrane Library. Eligible studies included experimental, observational, and evidence-synthesis articles evaluating patients with thoracic, lumbar, or thoracolumbar spine injury, published in English between January 1, 2010 and January 31, 2021. Studies which focused on animals, cadavers, cohorts with N <30, and pediatric cohorts (age <18 years old), as well as case studies, abstracts, and commentaries were excluded.

RESULTS

A total of 2501 studies were screened, of which 326 unique studies were fully text reviewed and twelve aspects of injury management were identified and discussed: injury patterns, determination of injury status and imaging options, considerations in management, and patient quality of life. We found: (1) imaging is a necessary diagnostic tool, (2) no consensus exists for preferred injury characterization scoring systems, (3) operative management should be considered for unstable fractures, decompression, and deformity, and (4) certain patients experience significant burden following injury.

DISCUSSION

In this systematic scoping review, we present the most up-to-date information regarding the management of traumatic thoracolumbar spine injuries. This allows non-specialist trauma surgeons to become more familiar with thoracolumbar spine injuries in trauma patients and provides a framework for their management.

From Blunt Cardiac Injury to Heart Transplant Following Motorcycle Collision

Traumatic coronary artery occlusion and dissection is an exceedingly rare complication of blunt cardiac injury (BCI), though it has been previously noted in a number of case reports. However, it can also lead to heart transplant, which to our knowledge has not been previously described in the literature. We present a case of a healthy 24-year-old man without significant past medical history who was in a motorcycle accident, resulting in sternal fracture and BCI. He was ultimately found to have thrombotic occlusion and dissection of his left anterior descending artery (LAD), requiring mechanical thrombectomy and drug-eluting stent, as well as subsequent hospitalizations and operations due to various complications. It was suspected that he went into ventricular fibrillation and had a second motorcycle collision, resulting in cardiogenic shock. Ultimately, his progression of ischemic cardiomyopathy and mitral regurgitation led to the need for heart transplant. Blunt cardiac injury with myocardial contusion has such a broad range of pathologies. It is essential that patients with these injury patterns raise a high level of suspicion for BCI and are followed closely with appropriate diagnostic testing and rapid intervention for best possible outcomes.

The Cost of Poverty: The Relationship Between Insurance Status, Length of Stay, and Discharge Disposition in Trauma Patients

INTRODUCTION

Insurance status (IS) is known to be associated with length of stay (LOS). The impact of IS on excess LOS (ELOS), days between medical readiness and discharge date, has not been explored.

METHODS

We conducted a retrospective study of patients with pelvic fractures at a level I trauma center. Outcomes included ELOS (primary), discharge disposition (secondary), and ELOS-associated complications (secondary).

RESULTS

185 patients were included. Uninsured patients were the youngest and had the least baseline comorbidities (31.3 years (median), Charlson Comorbidity Index (CCI) .1) while publicly insured patients were the oldest and had the most baseline comorbidities (58.4 years (median), CCI 2.32). Excess LOS and associated complications did not differ among groups. After regression analysis, UIPs had longer LOS than PRPs (2.07 days, 95% CI .28-3.85). UIPs were recommended to go to inpatient rehabilitation 51.6% of the time but were discharged home 93.6% of the time; 81.0% of these changes were attributed to insufficient financial resources.

CONCLUSIONS

Excess LOS and complications associated with ELOS were not associated with IS. Although UIPs were younger and had fewer baseline comorbidities, they had longer LOS after regression analysis. While discharge recommendations differed based on insurance status, UIPs had limited access to rehabilitation due to financial disparities. Despite initial treatment team recommendations, UIPs had to be sent home as their lack of insurance precluded inpatient rehabilitation placement.

Antithrombotics in the Fall Patient: Appropriateness and Risk-Benefit Analysis

Falls are the leading cause of hospitalizations following trauma nationwide, resulting in over 3 million admissions in 2020. This population is typically aged, and many are prescribed antithrombotic (AT) therapy. In this prospective study, we aimed to analyze fall history while assessing appropriateness of AT regimen relative to fall risk. Patients presenting following ground level fall (GLF) and meeting inclusion criteria during the study period were enrolled. Primary outcome was the relationship between AT therapy necessity (CHA2DS2-VASc) and fall risk (Morse Fall Risk). The cohort of 30 patients had an average age of 77. CHA2DS2-VASc and Morse Fall Risk showed a moderate-positive correlation (r = 0.47; P = 0.012); however, 17% of patients categorized as high fall risk had a <5% 1-year risk of VTE. This study demonstrates that risks of hemorrhage may outweigh thromboembolism prophylaxis in a significant number of patients and sheds light on the astonishing fall volume in this population.

The Effect of a Hip Fragility Pathway on Outcomes of Ground Level Falls in the Elderly

Fragility hip fractures result from low energy mechanisms and are associated with morbidity and mortality, especially in the elderly. We examined outcomes 2 years before and after implementation of a fragility fracture program. The pathway involves emergency department clearance and admission by a medical service with orthopedic consultation. Demographics include age, gender, fracture location, injury severity score (ISS), and ASA. Outcomes include DVT/PE, mortality, disposition, non-operative rate, ICU admission, time to surgery (TTS), length of stay (LOS), and admission service. 777 patients were included (383 PRE/394 POS). POS patients were slightly younger. Trauma admission decreased and LOS and TTS increased. There were no other demographic or outcome differences. Although TTS increased, it remained under 48 hours. Length of stay increase was possibly a reflection of COVID-19. Decreased trauma admission demonstrates pathway adherence. Further studies need to be conducted to verify that quality care can be maintained after initiation of a hip fragility pathway.

Use of Thromboelastography in Assessment of Snake Bite Coagulopathy

Background: Monitoring for envenomation coagulopathy following snake bites has traditionally involved using serial coagulation studies.Purpose: Thromboelastography (TEG), with its real-time assessment, could offer an alternative to standard of care. This study aims to evaluate the use of TEG with traditional coagulation labs in the assessment of snake bite coagulopathy.Research Design: A retrospective review of patients who presented to a level 1 trauma center between 2014 and 2020 with snake bite envenomation was conducted, comparing traditional coagulation studies to TEG plus coagulation studies.Results: The 12 patients who had studies within the stipulations of our review were tracked and subsequently progressed well clinically with no adverse effects and ultimately discharged home with an average hospital stay of 2.2 days.Conclusions: Our data suggests that patients can be observed clinically without needing repeat coagulation studies if initial TEG and TCS are within normal limits.

Diabetes in Trauma Patients: A Potential Gateway to a Medical Home

BACKGROUND

Diabetes is a major determinant of health outcomes. Trauma patients are disproportionately from lower socioeconomic status, where lack of access to health care prevents timely treatment. Trauma centers could play a role in identifying patients in need of improved glucose management, but the current burden of disease is not known. We assessed the incidence of patients in need of intervention that presented to a level 1 trauma center over a 6-month period.

METHODS

A retrospective chart review over 6 months of all trauma patients admitted to a level 1 trauma center was performed. Patients' past medical history (PMH), medication reconciliation, and hemoglobin A1c (HbA1c) were recorded on initial assessment; patients <18 years old, lacking an HbA1c, or missing PMH were excluded. Patients with PMH of diabetes or antihyperglycemic use were classified by HbA1c: well-controlled ≤8.0% or poorly controlled >8.0%. Patients with no history of diabetes or antihyperglycemic use were classified based on their HbA1c: non-diabetic <5.7%, pre-diabetic 5.7-6.4%, and undiagnosed diabetic ≥6.5%.

RESULTS

Overall, 1377 patients were identified. After exclusion criteria, 903 patients were classified as follows: 593 (66%) non-diabetics, 160 (18%) pre-diabetics, and 150 (17%) diabetics. Fifteen diabetics were undiagnosed; 39 of the diagnosed diabetics were poorly controlled. Including pre-diabetics, a total of 214 (24%) trauma patients were in need of improved glycemic control.

DISCUSSION

One in four trauma patients would benefit from improved outpatient glycemic management, representing a missed opportunity for preventative health care. Trauma centers should develop strategies to meet this need as part of their post-discharge care.

Application of the Geriatric Trauma Outcome Score in a Rural Setting

OBJECTIVE

To retrospectively apply the Geriatric Trauma Outcome (GTO) score to the patient population of a rural South Central Appalachian level 1 trauma center and identify the potential utility of the GTO score in guiding goals of care discussions.

METHODS

Trauma registry data was extracted for 5,627 patients aged 65+ from 2017 to 2021. GTO score was calculated for each patient. Descriptive statistics were calculated for age, Injury Severity Score (ISS), GTO score, receipt of red blood cells, discharge status, and code status. A simple logistic regression model was used to determine the relationship between GTO score and discharge status. The probability of mortality was then calculated using GTO score, and the distribution of code status among patients with ≤50, 51-75%, and >75% probability of mortality was examined.

RESULTS

For every 10-point increase in GTO score, odds of mortality increased by 79% (OR = 1.79; P < .001). Patients had an estimated 50% probability of mortality with a GTO score of 156, 75% with 174, and 99% with a score of 234, respectively. Seventeen patients had a GTO score associated with >75% probability of mortality. Of those 17 patients, four retained a full code status.

CONCLUSIONS

Our analysis demonstrates that the GTO score is a validated measure in a rural setting and can be an easily calculated metric to help determine a geriatric patient's probability of mortality following a trauma. The results of our study also found that GTO score can be used to inform goals of care discussions with patients.

Assessing Futile Trauma Transfers in Rural Appalachia Following a Regional Health Care System Consolidation

This study sought to define and analyze rates of futile trauma transfers (FTTs) after the consolidation of two rural level 1 trauma centers into one. Data was extracted from the regional trauma registry for a period of 5 years (2017-2022) for all trauma patients transferred into our level 1 trauma center (n = 3369). An FTT was defined as a transfer that (1) received no major interventions and (2) died or was discharged to a hospice facility within 72 hours. Out of the 3369 transfer patients analyzed during the 33-month pre-consolidation and 33-month post-consolidation periods, 34 patients met the criteria of an FTT within the transfer-to-discharge window. The pre-consolidation category contained 12, and the post-consolidation category contained 22. Chi-square analysis indicated no significant difference in FTT rate between categories. Furthermore, the post-consolidation FTT rate of 1.1% remained consistent with the estimated national average of 1.5%.

Outcomes of Injured Patients Before and After the Institution of a Third-Tier Activation at a Level 1 Trauma Center

BACKGROUND

We hypothesized that the addition of a third-level trauma activation would improve outcomes by formalizing an evaluation process for patients in need of urgent evaluation who did not meet the criteria for full or partial trauma alert activation.

METHODS

Admission records for all trauma patients admitted between 2000 and 2021 were obtained. The gamma alert trauma activation was implemented in 2011. A washout period of 6 months was used to account for adjustment to the new protocol. Propensity score matching was performed based on ISS scores, age, injury mechanism, and best-validated comorbidities to create a balanced patient distribution. Patients with missing data were excluded from this study. The association between era and outcomes was determined using logistic and linear regression analyses.

RESULTS

The matched cohort was well balanced (SMD <.1, all balanced covariates) and included 18,572 patients. Patients in the gamma alert era had decreased ED dwell time, hospital length of stay, and intensive care unit (ICU) length of stay. Readmission rates and rates of upgrade to ICU status were reduced in the gamma alert era. This era was also associated with lower rates of renal failure, UTI, and pneumonia. There was no significant difference in mortality following implementation of the gamma alert.

DISCUSSION

Implementation of the gamma alert was associated with an improvement in ED dwell times, fewer unplanned admissions to the ICU, decreased readmissions, and a reduction in other in-hospital events. We believe that this reflects improved triage of patients to the ICU and more effective care of trauma patients.

Firearm Violence Involving Adults 65 and Older During the Novel Coronavirus Disease Pandemic

BACKGROUND

Rates of firearm violence (FV) surged during the COVID-19 pandemic. However, there is a paucity of data regarding older adults (OAs) (≥65 years old). This study aimed to evaluate patterns of FV against OAs before and after the COVID-19 pandemic, hypothesizing decreased firearm incidents, injuries, and deaths for OAs due to restricted social movement.

METHODS

Retrospective (2016-2021) data for OAs were obtained from the Gun Violence Archive. The rate of FV was weighted per 10,000 OAs using annual population data from the United States Census Bureau. Mann-Whitney U tests were performed to compare annual firearm incidence rates, number of OAs killed, and number of OAs injured from 2016-2020 to 2021.

RESULTS

From 944 OA-involved shootings, 842 died in 2021. The median total firearm incidents per month per 10,000 OAs decreased in 2021 vs 2016 (.65 vs .38, P < .001), 2017 (.63 vs .38, P < .001), 2018 (.61 vs .38, P < .001), 2019 (.39 vs .38, P = .003), and 2020 (.43 vs .38, P = .012). However, there was an increased median number of OAs killed in 2021 vs 2020 (.38 vs .38, P = .009), but no difference from 2016-2019 vs 2021 (all P > .05). The median number of firearm injuries decreased from 2017 to 2021 (.21 vs .19, P = .001) and 2020 to 2021 (.19 vs .19 P < .001).

DISCUSSION

Firearm incidents involving OAs decreased in 2021 compared to pre-pandemic years; however, there was a slight increase in deaths compared to 2020. This may reflect increased social isolation; however, future research is needed to understand why this occurred.

Maternal and Neonatal Outcomes of Gunshot Wounds in Pregnancy: A Systematic Review of Case Reports

A systematic review was performed to compare adverse maternal and neonatal outcomes among pregnant patients with gunshot wounds (GSW) to the abdominopelvic vs other region(s) at > 20 weeks gestation. A search of Medline Ovid, Elsevier Embase, EBSCO CINAHL, and Cochrane Library in July 2022 and reference searches resulted in 1742 studies, which were screened. The 41 included studies reported outcomes for 59 pregnant patients with GSW, of which 31 (52.5%) had an isolated abdominopelvic GSW and 28 (47.5%) had an extremity, thorax, head/neck, back/spine, poly-site, or other/unknown GSW. Stillbirth occurred in 26.7% of abdominopelvic GSW and 26% of non-abdominopelvic GSW. Maternal death occurred in 3.7% of abdominopelvic GSW and 10.7% of non-abdominopelvic GSW. Neonatal death occurred in 9.1% of abdominopelvic GSW and 5.3% of non-abdominopelvic GSW. Further research is needed to standardize the approach for the evaluation and management of patients with GSW in pregnancy.

Understanding Chest CT Scan Usage Among Adolescent Blunt Trauma Patients at Adult Trauma Centers

PURPOSE

The utility of chest computed tomography (CCT) is not well established in the diagnostic algorithm of adolescent blunt trauma patients. Our study's aim was to review CCT usage in the initial evaluation of adolescent blunt trauma.

METHODS

We retrospectively reviewed adolescent blunt trauma patients treated at our urban level 1 adult trauma center from 2015 to 2019. Our primary outcome was the rate of positive CCT findings. Univariate and multivariate logistic regression analyses were performed.

RESULTS

There were 288 patients that met our inclusion criteria and 153 positive CCT and 135 negative CCT. There was no statistically significant difference between both groups in terms of age, gender, and race. Those with a positive CCT were found to have a statistically significant higher ISS than the negative CCT group (20.6 ± 12.3 vs 12.3 ± 7.6; P < .01). Those with a positive CCT were more likely to have a GCS <15 (40% vs 25%), have a positive CXR (38% vs 2%), have chest pain (16% vs 7%), and have an abnormal chest exam (27% vs 7%) than those with a negative CCT (P < .01). On multivariate analysis, positive CXR (P < .05, OR = 13.96) and ISS (P < .05, OR = 3.10) were independently associated with a positive CCT.

CONCLUSION

While CCT may provide valuable information, clinical exam coupled with low-ionizing radiographic imaging (i.e., CXR) may sufficiently identify chest trauma after blunt mechanisms. This shift in management can potentially reduce the risk of radiation without compromising the care of adolescent trauma patients at adult trauma centers.

Extracorporeal Membrane Oxygenation During Surgical Stabilization of Rib Fractures in Successful Management of Severe Blunt Chest Trauma

Early surgical stabilization of rib fracture (SSRF) improves outcomes in patients with flail physiology and severely displaced fractures. We present two cases of patients with severe chest injury and large flail segment who underwent SSRF while on veno-venous extracorporeal membrane oxygenation (VV-ECMO). The patients developed respiratory failure within 24 hours of admission requiring VV-ECMO. The extent of their chest wall injury limited pulmonary mechanics prohibiting transition off VV-ECMO. Therefore, SSRF was performed on hospital days 2 and 3 and while on VV-ECMO support. Stabilizing the chest wall allowed for improved ventilation and successful decannulation from VV-ECMO on postoperative days 3 and 4. Ultimately, both achieved a functional recovery and were discharged home. These cases demonstrate a unique thoracic damage control strategy wherein SSRF is performed while on VV-ECMO. Improving chest stability and pulmonary mechanics with SSRF allowed for safe transition off VV-ECMO and achieved a favorable long-term outcome.

Early Pharmacologic Therapy in Patients With Blunt Cerebrovascular Injury and TBI: Is it Safe and Effective? An EAST Multicenter Study

BACKGROUND

Blunt cerebrovascular injury (BCVI) with concurrent traumatic brain injury (TBI) presents increased risk of both ischemic stroke and bleeding. This study investigated the safety and survival benefit of BCVI treatment (antithrombotic and/or anticoagulant therapy) in this population. We hypothesized that treatment would be associated with fewer and later strokes in patients with BCVI and TBI without increasing bleeding complications.

METHODS

Patients with head AIS >0 were selected from a database of BCVI patients previously obtained for an observational trial. A Kaplan-Meier analysis compared stroke survival in patients who received BCVI treatment to those who did not. Logistic regression was used to evaluate for confounding variables.

RESULTS

Of 488 patients, 347 (71.1%) received BCVI treatment and 141 (28.9%) did not. BCVI treatment was given at a median of 31 h post-admission. BCVI treatment was associated with lower stroke rate (4.9% vs 24.1%, P < .001 and longer stroke-free survival (P < .001), but also less severe systemic injury. Logistic regression identified motor GCS and BCVI treatment as the only predictors of stroke. No patients experienced worsening TBI because of treatment.

DISCUSSION

Patients with BCVI and TBI who did not receive BCVI treatment had an increased rate of stroke early in their hospital stay, though this effect may be confounded by worse motor deficits and systemic injuries. BCVI treatment within 2-3 days of admission may be safe for patients with mean head AIS of 2.6. Future prospective trials are needed to confirm these findings and determine optimal timing of BCVI treatment in TBI patients with BCVI.

Chest X-Ray Remains a Vital Component Prior to Tube Thoracostomy

INTRODUCTION

The identification and treatment of traumatic pneumothorax (PTX) has long been a focus of bedside imaging in the trauma patient. While the emergence of bedside ultrasound (BUS) provides an opportunity for earlier detection, the need for tube thoracostomy (TT) based on bedside imaging, including BUS and supine AP chest X-ray (CXR) is less established in the medical literature.

METHODS

Retrospective data from 2017 to 2020 were collected of all adult trauma activations at a level 1 rural trauma facility. Every adult patient included in this study received a CXR and BUS (eFast) upon arrival. The need for TT was determined by the emergency medicine attending or the trauma surgery attending evaluating the patient. McNemar's chi-squared test and conditional logistic regression analysis were performed comparing BUS, CXR, and the combination of BUS and CXR findings for the need for TT. Subgroup analyses were performed comparing BUS, CXR, and the combination of BUS and CXR for the detection of PTX compared to CT scan.

RESULTS

Of the 12,244 patients who underwent trauma activation during this timeframe, 602 were included in the study. 74.9% were males with an age range of 36-63 years. Of the 602 patients, 210 received TT. Positive PTX was recorded with BUS in 128 (21%) patients with 16 false negatives (FNs) and 98 false positives (FPs), 100 (17%) PTX were identified with CXR with 114 FNs and 4 FPs, and 72 (11.9%) were noted on both CXR and BUS with 140 FNs and 2 FPs. The odds ratio of TT placement was 22 times with positive BUS alone (P < .0001, 95% CI: 10.9-43.47), 47 times with positive CXR alone (P < .0001, 95% CI: 16.99-127.5), and 70 times with both positive CXR and BUS (P < .0001, 95% CI: 17.08-288.4).

CONCLUSION

A positive finding of PTX on BUS combined with CXR is more indicative of the need for TT in the trauma patient when compared with BUS or CXR alone.

Splenic Salvage: Is There a Role for Splenorrhaphy in the Management of Adult Splenic Trauma?

INTRODUCTION

Nonoperative management of splenic injuries is recommended. Total splenectomy is the primary operative management, and the current role of splenorrhaphy in splenic salvage is not well delineated.

METHODS

We reviewed the National Trauma Data Bank (2007-2019) for adult splenic injuries. Operative splenic injury management were compared. We performed bivariate analysis and multivariable logistic regression to estimate the effect of surgical management on mortality.

RESULTS

189,723 patients met the inclusion criteria. Splenic injury management was stable, with 18.2% undergoing a total splenectomy and 1.9% splenorrhaphy. Splenorrhaphy patients had lower crude mortality (2.7% vs 8.3%, P < .001) than total splenectomy patients. Failed splenorrhaphy patients had higher crude mortality (10.1% vs 8.3%, P < .001) than patients who underwent initial total splenectomy. Patients who underwent total splenectomy had an adjusted odd of 2.30 (95% CI 1.82-2.92, P < .001) for mortality compared to successful splenorrhaphy. Patients who failed splenorrhaphy had an adjusted odd of 2.36 (95% CI 1.19-4.67, P < .014) for mortality compared to successful splenorrhaphy.

CONCLUSION

Adults with splenic injuries requiring operative intervention have twice the odds of mortality when a total splenectomy is performed or when splenorrhaphy fails compared to successful splenorrhaphy.

Traumatic Amputations Treated in US Emergency Departments: A Review of the NEISS Database

BACKGROUND

Trauma is the second most common cause of limb loss in the United States (US), second only to vascular disease. The aim of this study was to evaluate the demographics and commercial products associated with traumatic amputations in the United States.

METHODS

The National Electronic Injury Surveillance System (NEISS) database was analyzed from 2012 to 2021 to identify patients presenting to the Emergency Department (ED) with the diagnosis of amputation. Additional variables included patient demographics, body part amputated, commercial products associated with amputation, and ED treatment disposition.

RESULTS

A total of 7323 patients diagnosed with amputation were identified in the NEISS database. Amputations were most frequent in the 0-5 years age group, followed by 51-55 years. More males than females suffered an amputation during the study period (77% vs 22%). Most patients were Caucasian. Fingers were most frequently amputated (91%), followed by toes (5%). Most injuries occurred in the home (56%). The top commercial product behind these traumatic amputations was doors (18%), followed by bench or table saws (14%) and power lawn mowers (6%). Over 70% of patients were able to be treated and released from the ED, while 22% required hospitalization and 5% were transferred to another facility.

DISCUSSION

Traumatic amputations can cause significant injuries. A better understanding of the incidence and mechanisms behind traumatic amputations may help with injury prevention. Pediatric patients had a high incidence of traumatic amputations, which warrants further research and dedication to injury prevention in this vulnerable group.

Victims of Violence, How a Trauma Center and Family Justice Center Can Provide Continued Care After Initial Hospitalization

BACKGROUND

Intentional injuries are the second leading cause of death in the U.S. between the ages of 1 and 44. Each traumatic event is approached best with a multiagency and multidisciplinary approach. Family Justice Centers (FJCs) are structured as one-stop centers for victims of all forms of violence to provide services.

OBJECTIVE

The purpose of this study is to describe trauma patients evaluated in an FJC and determine the effect of the referrals on injury-related hospital recidivism.

METHOD

This is a cross-sectional descriptive study of traumatically injured patients that were evaluated in an adult level II trauma center for 3 years and were referred to Ventura County's FJC.

RESULTS

There were 415 trauma admissions for intentional injuries, which accounted for 10.4% of the total trauma-related hospital admissions. Of these patients, 203 (49%) were evaluated in Ventura County's FJC. The remaining 212 (51%) had an open judicial case, thus, were not processed through the FJC due to conflict of interest. The mechanisms of injuries of patients that were evaluated at the FJC (N = 203) were mostly assaults (83%). Majority of the patients were of the Hispanic race (70%), males (69%), English speaking (77%), and aged 18-59 (84%). 573 individual services were provided to these patients. The patients evaluated through the FJC (N = 203) had zero recidivism, while those with open cases had a 1% recidivism rate (P = NS).

CONCLUSION

By collaborating with FJCs, trauma center outcomes contribute to a pathway for healing and may prevent future acts of intentional injuries.

Prospective Assessment of Social Determinants of Health and Length of Stay Among Emergency General Surgery and Trauma Patients

BACKGROUND

Social determinants of health (SDOH) including insurance and substance use affect 50-90% of health outcomes, yet there remains no standard means to quantify or predict their impact. We prospectively evaluated the effects of SDOH on length of stay (LOS) and readmissions among emergency general surgery (EGS) and trauma patients. We compared these outcomes with Medicare Diagnosis Related Group (DRG) data to better quantify the impact of SDOH.

METHODS

Adult (≥18 years old) EGS/trauma patients admitted July 7-28, 2020 at a Level 1 trauma center were prospectively enrolled. Primary outcomes were overall LOS, one-year readmissions, and excess LOS (eLOS), defined as days beyond DRG mean LOS.

RESULTS

Assessment of SDOH among the 52 patients enrolled revealed that 5.8% of patients were homeless; 26.9% experienced substance abuse; 13.5% were uninsured on admission; and 7.7% on discharge. Mean LOS was 5 ± 4 days; 1-year readmission rate 25.0%; eLOS mean 1.75 ± 2.4 days. LOS was associated with substance use (OR 70.6 95% CI 11.7-160.4). eLOS was associated with substance use (OR 6.1, 95% CI 1.5-25.1) and public or no insurance (OR 26.0, 95% CI 4.9-138.1). No correlations were found between SDOH and readmission rates.

DISCUSSION

EGS and trauma patients experience high rates of negative SDOH which affect clinical outcomes including LOS and readmissions. Medicare DRG determined eLOS is a fiscally relevant measure of the impact of SDOH and differs from LOS and readmissions. Further investigation is required to determine if eLOS can delineate the effects of other SDOH on admission outcomes for this patient population.

Field Measures Are All You Need: Predicting Need for Surgery in Elderly Ground-Level Fall Patients via Machine Learning

BACKGROUND

As ground-level falls (GLFs) are a significant cause of mortality in elderly patients, field triage plays an essential role in patient outcomes. This research investigates how machine learning algorithms can supplement traditional t-tests to recognize statistically significant patterns in medical data and to aid clinical guidelines.

METHODS

This is a retrospective study using data from 715 GLF patients over 75 years old. We first calculated P-values for each recorded factor to determine the factor's significance in contributing to a need for surgery (P < .05 is significant). We then utilized the XGBoost machine learning method to rank contributing factors. We applied SHapley Additive exPlanations (SHAP) values to interpret the feature importance and provide clinical guidance via decision trees.

RESULTS

The three most significant P-values when comparing patients with and without surgery are as follows: Glasgow Coma Scale (GCS) (P < .001), no comorbidities (P < .001), and transfer-in (P = .019). The XGBoost algorithm determined that GCS and systolic blood pressure contribute most strongly. The prediction accuracy of these XGBoost results based on the test/train split was 90.3%.

DISCUSSION

When compared to P-values, XGBoost provides more robust, detailed results regarding the factors that suggest a need for surgery. This demonstrates the clinical applicability of machine learning algorithms. Paramedics can use resulting decision trees to inform medical decision-making in real time. XGBoost's generalizability power increases with more data and can be tuned to prospectively assist individual hospitals.

Blunt Traumatic Abdominal Wall Hernias: An Indicator for Emergent Laparotomy?

BACKGROUND

Traumatic abdominal wall hernias (TAWH) are relatively uncommon; however, the shearing force that results in fascial disruption could indicate an increased risk of visceral injury. The aim of our study was to evaluate whether the presence of a TAWH was associated with intra-abdominal injury requiring emergent laparotomy.

METHODS

The trauma registry was queried over an 8-year period (7/2012-7/2020) for adult patients with blunt thoracoabdominal trauma diagnosed with a TAWH. Those patients who were identified with a TAWH and greater than 15 years of age were included in the study. Demographics, mechanism of injury, ISS, BMI, length of stay, TAWH size, type of TAWH repair, and outcomes were analyzed.

RESULTS

Overall, 38,749 trauma patients were admitted over the study period, of which 64 (.17%) had a TAWH. Patients were commonly male (n = 42, 65.6%); the median age was 39 years (range 16-79 years) and a mean ISS of 21. Twenty-eight percent had a clinical seatbelt sign. Twenty-seven (42.2%) went emergently to the operating room, the majority for perforated viscus requiring bowel resection (n = 16, 25.0%), and 6 patients (9.4%) who were initially managed nonoperatively underwent delayed laparotomy. Average ventilator days was 14 days, with a mean ICU LOS of 14 days and mean hospital LOS of 18 days. About half of the hernias were repaired at the index operation, 6 of which were repaired primarily and 10 with mesh.

CONCLUSION

The presence of a TAWH alone was an indication for immediate laparotomy to evaluate for intra-abdominal injury. In the absence of other indications for exploration, nonoperative management may be safe.

Abruption of Abdominal Pregnancy Following Blunt Trauma

Abdominal pregnancy represents a rare subset of ectopic pregnancy with a reported incidence around one per 10,000 live births. It is associated with high fetal and maternal morbidity and mortality. In this case, we describe a 25-year-old primigravida female who presented as a trauma activation with acute hypotension following blunt trauma to the abdomen and who was found to have a viable abdominal pregnancy with placental abruption. Given hypotension and non-reassuring fetal heart tones, the decision was made to take the patient to the operating room for emergent exploratory laparotomy and cesarean section. The placenta was severely adhered to a portion of small bowel, the appendix, and the right adnexa with an approximate 20% abruption. The placenta and adhered structures were removed. In pregnant patients presenting after blunt trauma with free intraabdominal fluid and hypotension, abdominal pregnancy with abruption should be considered as an unlikely differential.

Psychological Impacts of Retained Bullets From the Perspective of Survivors

INTRODUCTION

Despite a high prevalence of retained bullet fragments (RBFs) after firearm related injury (FRI) there is limited data on the full spectrum of their consequences, particularly the psychological impacts on those injured. Further, the experiences of FRI survivors with RBFs are missing from existing literature. The objective of this study was to explore the psychological impacts of RBFs on individuals who have experienced recent FRI.

METHODS

Adult (18-65 years) survivors of FRI with radiographically confirmed RBFs were purposively selected from an urban Level 1 trauma center in Atlanta, Georgia, to participate in an in-depth interview. Interviews were conducted between March 2019 and February 2020. Thematic analysis was used to identify a range of psychological effects from RBFs.

RESULTS

Interviews from 24 FRI survivors were analyzed: the majority of participants were Black males (N = 22, 92%) with a mean age of 32 years whose FRI occurred ∼8.6 months prior to data collection. The psychological effects of RBFs were grouped into four categories: physical health (eg, pain, limited mobility), emotional well-being (eg, anger, fear), social isolation, and occupational welfare (eg, disability leading to inability to work). A range of coping mechanisms were also identified.

CONCLUSION

Survivors of FRI with RBFs experience a range of psychological impacts that are far-reaching and affect daily activities, mobility, pain and emotional wellbeing. Study results indicate a need for enhanced resources to support those with RBFs. Further, changes to clinical protocols are warranted on removal of RBFs and communication about the effects of leaving RBFs in situ.

Intravenous Versus Rectal Contrast in CT Imaging for Abdominal Gunshot Wounds

CT imaging with rectal contrast historically has been a useful tool to help identify potential colon/rectal injuries; however, recent trends have shown less utilization of rectal contrast, in favor of IV contrast CT imaging alone. A retrospective review of patients with abdominal gunshot wounds was carried out to compare the two CT imaging techniques. An analysis of patients with colorectal injuries was conducted. Patients with IV contrast had a sensitivity of 84% and specificity of 96.8%. The PPV was 87.5% and NPV was 95.8%. In the IV and rectal contrast group, the sensitivity was 88.9% and specificity was 90.5%. The PPV was 80% and NPV was 95%. The proportion of missed injuries between the two was not statistically significant, p=0.18. The study suggests that while CT imaging with rectal contrast confidently identifies colon/rectal injuries, there are often secondary findings that will correctly prompt surgical exploration.

Effects of the COVID-19 Pandemic on the Trauma Population in a Level 1 Trauma Center

In this study, we evaluated the effects of the pandemic on our trauma population. We performed a retrospective review of the trauma registry in the 2 years prior, and then 2 years during the pandemic. We evaluated age, race, gender, injury severity score (ISS), mechanism of trauma, rate of self-inflicted injury, rate of gunshot wounds (GSW), presence of EtOH, drug screen results, mortality, rate of burn traumas, and zip code of residence. Our query captured 5 054 patients before, and 5 731 during the pandemic. We found no statistical difference in age, gender, mechanism of trauma, rate of self-inflicted injuries, and mortality during the pandemic when compared to before. There were statistically significant differences in race, ISS, rate of GSWs, EtOH use, drug screen results, and burn traumas. Geospatial mapping found a rise in GSWs for zip code 36606. Gun violence and substance use rose in our trauma population during COVID-19.

Trends in Adolescent Firearm-Related Injury: A Time Series Analysis

BACKGROUND

Firearm-related injury (FRI) became the leading cause of death among children/adolescents in 2019.

PURPOSE

This study sought to determine changes over time in the population of adolescents affected by FRI in Atlanta, Georgia, such that high risk cohorts could be identified.

RESEARCH DESIGN

City-wide retrospective cohort review.

STUDY SAMPLE

Adolescent victims (age 11-21 years of age) of FRI, defined by ICD9/10 codes, in Atlanta, Georgia.

DATA ANALYSIS

Descriptive, multivariate and time series analysis.

RESULTS

There were 1,453 adolescent FRI victims in this time period, predominantly Black (86%) and male (86.6%). Unintentional injury was higher among ages 11-14 years (43.1%) compared to 15-17 years (10.2%) and 18-21 years (9.3%) (P < .01). FRI affecting females increased at a rate of 8.1 injuries/year (P < .01), and unintentional injuries increased at by 7.6/year (P < .01). Mortality declined from 16% in 2016 to 7.7% in 2021.

CONCLUSION

Our data provides evidence for firearm policy reform. Interventions should target prevention of intentional injury among AQ4 females and seek to reverse the trend in unintentional injuries.

The Effect of Area Social Deprivation on Health Behavior and Health Care Utilization in an Adult Trauma Population

Social determinants of health may mediate health disparities, but these variables are not routinely measured in clinical practice. This is a retrospective, single-institution study that evaluates the effect of area deprivation on outcomes after trauma admission. Adult trauma patients 18 years and older were eligible. Patients were stratified into high-area (HSD) or low-area (LSD) social deprivation cohorts using zip code of residence. Regression modeling was used to explain the association between HSD, sociodemographic characteristics, and clinical outcomes. Patients who resided in HSD areas made up 29.5% of the study population, were more likely to be younger, male, and identify as a non-White race. Patients in the HSD cohort were also less likely to be admitted to the ICU (OR 0.84, CI 0.71-0.98) and discharged with additional services (OR 0.73, CI 0.57-0.94). We found that independently, area social deprivation affects trauma outcomes and the resources a patient is provided after discharge.

Small Rotational Changes of the Chest on Portable Chest Films Produce Large Displacements of Test Projectiles in the Cardiac Box

The cardiac box has been used to guide the management of trauma patients for decades. However, improper imaging can lead to erroneous assumptions about operative management in this patient population. In this study, we used a thoracic model to demonstrate imaging's effect on chest radiography. The data demonstrate that even small changes in rotation can lead to large discrepancies in results.

Increased Penetrating Trauma and Trauma Severity During the COVID-19 Lockdown

The COVID-19 mandated lockdown created unintended outcomes in traumatic injury patterns and psychosocial behaviors compared to previous years during the same timeframe. The aim of this research is to describe a population of trauma patients during the past 5 years to determine particular trends in trauma patterns and trauma severity. A retrospective cohort study on all adult (≥18 years) trauma patients admitted to this ACS verified Level I trauma center in South Carolina, inclusive years 2017 to 2021. A total of 3281 adult trauma patients were included during the lockdown period across 5 years. There was an increase in penetrating injuries in 2020 compared to 2019 (9% vs 4%, P < .01). The psychosocial impacts of government-mandated lockdowns may lead to increased alcohol consumption leading to a higher degree of injury severity and morbidity markers in the trauma population.

Successful Utilization of Resuscitative Endovascular Balloon Occlusion of the Aorta in a Pediatric Patient

In the United States, pediatric trauma resulting in traumatic brain injury (TBI) and massive hemorrhage is the leading cause of death. Although use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) continues to gain favor, limited data exists on use and efficacy in pediatric patients. We describe a case using REBOA in a pediatric patient with blunt abdominal injury causing hemorrhagic shock. A 14-year-old female presented via air to a level 1 trauma center post motor vehicle collision with prolonged extraction. At landing, she was hemodynamically unstable with GCS and vitals indicating severe injuries. Further assessment indicated REBOA catheter placement with advancement to zone 1. Upon surgical stabilization, REBOA was deflated and distal pulses were maintained without complication. In cases where massive hemorrhage is the major threat to survival, REBOA may improve outcomes. Unfortunately, this patient had sustained a nonsurvivable TBI, and the family decided upon organ donation.

Safety of the Trauma Quality Improvement Program Guideline for Venous Thromboembolism Prophylaxis in Traumatic Brain Injury

BACKGROUND

The American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) provides a guideline for when to initiate pharmacologic venous thromboembolism (VTE) prophylaxis in traumatic brain injury (TBI) patients. We hypothesized that implementation of the guideline would not result in progression in intracranial hemorrhage.

METHODS

The TBI TQIP guideline was implemented at a Level I Trauma Center. Patients with a stable Computerized tomography (CT) of the brain were started on chemical prophylaxis per the Modified Berne-Norwood Criteria. CT scans before and after initiation of treatment were retrospectively reviewed by one board-certified radiologist to determine if there was progression of hemorrhage. Patients without a follow-up CT scan were evaluated for progression of bleed/neurologic deterioration by review of physician notes, nursing documentation, and Glasgow coma scale (GCS).

RESULTS

From July 2017 to December 2020, 12,922 patients were admitted to the trauma service. A total of 552 of these patients had TBI and 269 met inclusion criteria. 55 patients had at least one CT of the brain after initiation of prophylaxis. None of these 55 patients had progression of hemorrhage. 214 patients did not have a CT of the brain after prophylaxis. Chart review showed that none of these patients had a clinical decline. Overall, there was no progression of hemorrhage in the 269 patients that met inclusion criteria.

DISCUSSION

Initiation of the TQIP TBI VTE prophylaxis guideline was found to be safe with no progression of intracranial hemorrhage.

Impact of Non-Automobile Rollover Accidents on Patient Outcomes at an Appalachian Level I Trauma Center

The objective of this study was to evaluate outcomes of patients involved in rollover accidents in non-automobile vehicles in a rural level I trauma center. This was a retrospective study including a total of 127 patients over 5 years who were admitted to our level I trauma center following rollover accidents in either of the following: ATV, lawnmower, or tractor. Patients were significantly older in the tractor and lawnmower rollover groups, and patients less than 65 years old were significantly more likely to sustain an injury in a rollover accident when compared to those greater than 65. Patients with extremity fractures secondary to tractor rollovers were more likely to be older, and patients who sustained spinal injuries secondary to tractor rollovers were more likely to be younger. Non-automobile rollovers have the potential to cause traumatic injuries; however, there does not appear to be 1 vehicle type that is more prone to injury.

Does Vehicle Intrusion Alone Still Predict Injury: A Retrospective Analysis of Mechanism as Trauma Activation Criteria

Automobile collisions with driver side intrusion >12 inches or >18 elsewhere meet criteria for trauma activation. However, vehicle safety features have improved since this inception. We hypothesized vehicle intrusion (VI) alone as mechanism-of-injury (MOI) criteria inadequately predicts trauma center activation. A retrospective, single-center chart review of adult patients involved in motor vehicle collisions presenting to a level 1 trauma center from July 2016 to March 2022 was performed. Patients were divided by MOI criteria: VI vs. multiple MOI criteria. 2940 patients met inclusion criteria. The VI group reported lower injury severity scores (P = 0.004), higher incidence of ED discharge (P = 0.001), lower ICU admissions (P = 0.004), and fewer in-hospital procedures (P = 0.03). Vehicle intrusion was found to have a positive likelihood ratio of 0.889 for predicting trauma center need. According to current guidelines, these results suggest that VI criteria alone may not be an accurate predictor for trauma center transport and require further investigation.

Aortic Injury From High-Speed Deceleration Against a Lap Belt in a 10-year-Old

Traumatic aortic injuries in children and adolescents are rare, and even more rare are blunt traumatic injury to the abdominal aorta in this population. Therefore, there are few reports discussing the presentation and repair of such injuries, especially within the pediatric population. We report the successful repair of traumatic abdominal aortic transection in a 10-year-old female after a high speed MVC. She arrived in extremis with a seatbelt sign and was taken emergently for damage control laparotomy with subsequent postoperative CT findings of aortic transection/dissection at L3 with active extravasation. She immediately underwent open thrombectomy of the bilateral iliac arteries, and repair of her aortic injury with a 12 × 7 mm Hemashield interposition graft extending just distal to the IMA and 1 cm proximal to the aortic bifurcation. There are little data regarding long-term outcomes of pediatric patients undergoing different aortic repair techniques, and further research is needed.