A seven-center examination of the relationship between monthly volume and mortality in trauma: a hypothesis-generating study.

INTRODUCTION: The relationship between trauma volumes and patient outcomes continues to be controversial, with limited data available regarding the effect of month-to-month trauma volume variability on clinical results. This study examines the relationship between monthly trauma volume variations and patient mortality at seven Level I Trauma Centers located in the Eastern United States. We hypothesized that higher monthly trauma volumes may be associated with lower corresponding mortality. METHODS: Monthly patient volume data were collected from seven Level I Trauma Centers. Additional information retrieved included monthly mortality, demographics, mean monthly injury severity (ISS), and trauma mechanism (blunt versus penetrating). Mortality was utilized as the primary study outcome. Statistical corrections for mean age, gender distribution, ISS, and mechanism of injury were made using analysis of co-variance (ANCOVA). Center-specific, annually-adjusted median monthly volumes (CSAA-MMV) were calculated to standardize patient volume differences across participating institutions. Statistical significance was set at α < 0.05. RESULTS: A total of 604 months of trauma admissions, encompassing 122,197 patients, were analyzed. Controlling for patient age, gender, ISS, and mechanism of injury, aggregate data suggested that monthly trauma volumes < 100 were associated with significantly greater mortality (3.9%) than months with volumes > 400 (mortality 2.9%, p < 0.01). To account for differences in monthly volumes between centers, as well as for temporal bias associated with potential differences over the entire study duration period, data were normalized using CSAA-MMV as a standardized reference point. Monthly volumes ≤ 33% of the CSAA-MMV were associated with adjusted mortality of 5.0% whereas monthly volumes ≥ 134% CSAA-MMV were associated with adjusted mortality of 2.7% (p < 0.01). CONCLUSIONS: This hypothesis-generating study suggests that greater monthly trauma volumes appear to be associated with lower mortality. In addition, our data also suggest that across all participating centers mortality may be a function of relative month-to-month volume variation. When normalized to institution-specific, annually-adjusted "median" monthly trauma contacts, we show that months with patient volumes ≤ 33% median may be associated with subtly but not negligibly (1.4-2.3%) higher mortality than months with patient volumes ≥ 134% median.

Delayed intracranial hemorrhage in the patient with blunt trauma on anticoagulant or antiplatelet agents: routine repeat head computed tomography is unnecessary.

OBJECTIVE: We postulate that in patients with blunt trauma on anticoagulant or antiplatelet agents, incidence and complication rate of delayed intracranial hemorrhage (DICH) after an initially negative head CT is low and routine repeat head CT is not warranted. DESIGN: A retrospective, observational study performed from 2008 to 2012. PATIENTS: A total of 338 patients with blunt trauma with pre-admission history of any anticoagulant use, who had an initially negative head CT, followed by a repeat CT within 48 hours. INTERVENTIONS: There were no interventions, this was an observational study only. MEASUREMENTS AND MAIN RESULTS: The sample had mean ISS of 8.6 and an average GCS of 15. 55% had obvious head trauma, 27.2% reported LOC. Incidence of DICH was 2.4% (8/338). All patients with DICH were taking aspirin (ASA) either alone or in combination with another anticoagulant. Of the eight patients with DICH, none required medical or surgical intervention and there were no mortalities. We identified no significant predictors of delayed ICH. CONCLUSIONS: Routine repeat head CT in patients with blunt trauma taking anticoagulant or antiplatelet agents is unnecessary. Incidence of DICH is low and, when found, DICH was clinically insignificant. We recommend close supervision in this population, especially those taking ASA alone or in combination with another anticoagulant.

Complications of pericardiocentesis: A clinical synopsis.

Pericardiocentesis (PC) is both a diagnostic and a potentially life-saving therapeutic procedure. Currently echocardiography-guided pericardiocentesis is considered the standard clinical practice in the treatment of large pericardial effusions and cardiac tamponade. Although considered relatively safe, this invasive procedure may be associated with certain risks and potentially serious complications. This review provides a summary of pericardiocentesis and a focused overview of the potential complications of this procedure.

You cannot go home: routine concussion evaluation is not enough.

Traditional care of mild traumatic brain injury (MTBI) is to discharge patients from the emergency department (ED) if they have a Glasgow Coma Score (GCS) of 15 and a normal head computed tomography (CT) scan. However, this does not address short-term neurocognitive deficits. Our hypothesis is that a notable percentage of patients will need outpatient neurocognitive therapy despite a reassuring initial presentation. This is a retrospective review of patients with MTBI at an urban Level I trauma center. Inclusion criteria were a diagnosis of MTBI in patients 14 years old or older, GCS 15, negative head CT scan, a completed neurocognitive evaluation, blunt mechanism, and no confounding psychiatric comorbidities. Six thousand thirty-two patients were admitted over 18 months. Three hundred ninety-five patients met inclusion criteria. Average age was 38 years (range, 14 to 93 years), 64 per cent were male, and mean Injury Severity Score (ISS) was 8.1. Forty-one per cent were cleared for discharge without follow-up. Twenty-seven per cent required ongoing neurocognitive therapy. Three per cent were deemed unsafe for discharge home. Of the patients cleared for discharge, 88 per cent had positive/questionable loss of consciousness (LOC), whereas 81 per cent who required additional therapy had positive/questionable LOC (P = 0.20). Age, gender, ISS, and alcohol use were compared between the groups and not found to be statistically different rendering them poor predictors for appropriate discharge from the ED. A surprisingly high percentage (27%) of patients who would have met traditional ED discharge criteria were found to have persistent deficits after neurocognitive testing and were referred for ongoing therapy. We provide evidence to suggest that we should take pause before discharging patients with MTBI without a cognitive evaluation.