Less is More: Dissecting Trauma Centers by Procedural Volume.

OBJECTIVE: This study aims to examine the relationship between procedural volume and annual trauma volume (ATV) of ACS Level I trauma centers (TC). SUMMARY BACKGROUND DATA: Although ATV is a hard criterion for TC verification, importance of procedural interventions as a potential quality indicator is understudied. METHODS: Patients managed at ACS level I TCs were identified from ACS-TQIP 2017-2021. TCs were identified using facility keys and stratified into quartiles based on ATV into low, low-medium, medium-high, and high volume. TCs were also stratified into tertiles (low [LV], medium [MV], high [HV]) based on procedural volume by assessing annual number of laparotomies, thoracotomies, craniotomies/craniectomies, angioembolizations, vascular repairs, and long bone fixations performed at each center. Cohen's κ statistic was used to assess concordance between ATV and procedural volume. RESULTS: 182 Level I TCs were identified: 76 low, 47 low-medium, 35 high-medium, and 24 high volume. Long bone fixation, laparotomy, and craniotomy/craniectomy were the most performed procedures with a median of 65, 59, and 46 cases/center/year respectively. 31% of HV laparotomy centers, 31% of HV thoracotomy centers, 22% of HV craniotomy/craniectomy centers, 22% of HV vascular repair centers, 32% of HV long bone fixation centers, and 33% of HV angioembolization centers contributed to the overall number of low-medium and low volume TCs. Cohen's κ statistic demonstrated poor concordance between ATV and procedural volumes for all procedures (Overall procedural volume-κ=0.378, laparotomy-κ=0.270, thoracotomy-κ=0.202, craniotomy/craniectomy- κ=0.394, vascular repair-κ=0.298, long bone fixation-κ=0.277, angioembolization-κ=0.286). CONCLUSION: ATV does not reflect the procedural interventions performed. Combination of procedural and ATV may provide a more accurate picture of the clinical experience at any given TC. LEVEL OF EVIDENCE: Level III.

Gender Disparity in Academic Trauma Surgery: The Current State of Affairs.

INTRODUCTION: Despite the increasing number of female surgeons in general surgery programs, women are still inadequately represented in leadership positions. This study aims to investigate the magnitude of gender bias in university-based trauma surgery fellowship programs and leadership positions in the United States of America. MATERIAL AND METHODS: FRIEDA was used to identify trauma surgery programs. A thorough website review of each program obtained further information on faculty members, including their name, age, gender, and faculty rank. Trauma surgeons with an MD or DO qualification and a faculty rank of Professor, Associate Professor, or Assistant Professor were selected for inclusion in this study. SCOPUS was used to assess the H-index and the number of publications and citations of surgeons. RESULTS: The total number of programs included was 136, consisting of 715 faculty members. Less than a quarter (n = 166; 23.2%) comprised females and less than one-fifth (n = 30; 19%) of female surgeons were Professors. The difference in the research productivity of male and female trauma surgeons was statistically significant (P < .05), with the average H-index being 10 vs 7.5, respectively, amongst the top 50 surgeons of both genders. Based on a multiple regression analysis, academic rank was significantly associated (P < .05), and gender was not significantly associated (P > .05) with H-index. CONCLUSION: Gender disparity exists in the field of trauma surgery, as noted in senior faculty ranks and leadership positions. Female-inclusive state policies, appropriate mentorship, and supportive institutions can help to bridge this gap.

The Role of Whole Blood Hemostatic Resuscitation in Bleeding Geriatric Trauma Patients.

INTRODUCTION: Whole blood (WB) has recently gained increased popularity as an adjunct to the resuscitation of hemorrhaging civilian trauma patients. We aimed to assess the nationwide outcomes of using WB as an adjunct to component therapy (CT) versus CT alone in resuscitating geriatric trauma patients. METHODS: We performed a 5-y (2017-2021) retrospective analysis of the Trauma Quality Improvement Program. We included geriatric (age, ≥65 y) trauma patients presenting with hemorrhagic shock (shock index >1) and requiring at least 4 units of packed red blood cells in 4 h. Patients with severe head injuries (head Abbreviated Injury Scale ≥3) and transferred patients were excluded. Patients were stratified into WB-CT versus CT only. Primary outcomes were 6-h, 24-h, and in-hospital mortality. Secondary outcomes were major complications. Multivariable regression analysis was performed, adjusting for potential confounding factors. RESULTS: A total of 1194 patients were identified, of which 141 (12%) received WB. The mean ± standard deviation age was 74 ± 7 y, 67.5% were male, and 83.4% had penetrating injuries. The median [interquartile range] Injury Severity Score was 19 [13-29], with no difference among study groups (P = 0.059). Overall, 6-h, 24-h, and in-hospital mortality were 16%, 23.1%, and 43.6%, respectively. On multivariable regression analysis, WB was independently associated with reduced 24-h (odds ratio, 0.62 [0.41-0.94]; P = 0.024), and in-hospital mortality (odds ratio, 0.60 [0.40-0.90]; P = 0.013), but not with major complications (odds ratio, 0.78 [0.53-1.15]; P = 0.207). CONCLUSIONS: Transfusion of WB as an adjunct to CT is associated with improved early and overall mortality in geriatric trauma patients presenting with severe hemorrhage. The findings from this study are clinically important, as this is an essential first step in prioritizing the selection of WB resuscitation for geriatric trauma patients presenting with hemorrhagic shock.

A comparison of outcomes including bile duct injury of subtotal cholecystectomy versus open total cholecystectomy as bailout procedures for severe cholecystitis: A multicenter real-world study.

BACKGROUND: Dense inflammation obscuring the hepatocystic anatomy can hinder the ability to perform a safe standard laparoscopic cholecystectomy in severe cholecystitis, requiring use of a bailout procedure. We compared clinical outcomes of laparoscopic and open subtotal cholecystectomy against the traditional standard of open total cholecystectomy to identify the optimal bailout strategy for the difficult gallbladder. METHODS: A multicenter, multinational retrospective cohort study of patients who underwent bailout procedures for severe cholecystitis. Procedures were compared using one-way analysis of variance/Kruskal-Wallis tests and χ2 tests with multiple pairwise comparisons, maintaining a family-wise error rate at 0.05. Multiple multivariate linear/logistical regression models were created. RESULTS: In 11 centers, 727 bailout procedures were conducted: 317 laparoscopic subtotal cholecystectomies, 172 open subtotal cholecystectomies, and 238 open cholecystectomies. Baseline characteristics were similar among subgroups. Bile leak was common in laparoscopic and open fenestrating subtotal cholecystectomies, with increased intraoperative drain placements and postoperative endoscopic retrograde cholangiopancreatography(P < .05). In contrast, intraoperative bleeding (odds ratio = 3.71 [1.9, 7.22]), surgical site infection (odds ratio = 2.41 [1.09, 5.3]), intensive care unit admission (odds ratio = 2.65 [1.51, 4.63]), and length of stay (Δ = 2 days, P < .001) were higher in open procedures. Reoperation rates were higher for open reconstituting subtotal cholecystectomies (odds ratio = 3.43 [1.03, 11.44]) than other subtypes. The overall rate of bile duct injury was 1.1% and was not statistically different between groups. Laparoscopic subtotal cholecystectomy had a bile duct injury rate of 0.63%. CONCLUSION: Laparoscopic subtotal cholecystectomy is a feasible surgical bailout procedure in cases of severe cholecystitis where standard laparoscopic cholecystectomy may carry undue risk of bile duct injury. Open cholecystectomy remains a reasonable option.

Should We Keep or Transfer Our Severely Injured Geriatric Patients to Higher Levels of Care?

INTRODUCTION: Interfacility transfer to higher levels of care is becoming increasingly common. This study aims to evaluate the association between transfer to higher levels of care and prolonged transfer times with outcomes of severely injured geriatric trauma patients compared to those who are managed definitively at lower-level trauma centers. METHODS: Severely injured (Injury Severity Score >15) geriatric (≥60 y) trauma patients in the 2017-2018 American College of Surgeons Trauma Quality Improvement Program database managing at an American College of Surgeons/State Level III trauma center or transferring to a level I or II trauma center were included. Outcome measures were 24-h and in-hospital mortality and major complications. RESULTS: Forty thousand seven hundred nineteen patients were identified. Mean age was 75 ± 8 y, 54% were male, 98% had a blunt mechanism of injury, and the median Injury Severity Score was 17 [16-21]. Median transfer time was 112 [79-154] min, and the most common transport mode was ground ambulance (82.3%). Transfer to higher levels of care within 90 min was associated with lower 24-h mortality (adjusted odds ratio [aOR]: 0.493, P < 0.001) and similar odds of in-hospital mortality as those managed at level III centers. However, every 30-min delay in transfer time beyond 90 min was progressively associated with increased odds of 24-h (aOR: 1.058, P < 0.001) and in-hospital (aOR: 1.114, P < 0.001) mortality and major complications (aOR: 1.127, P < 0.001). CONCLUSIONS: Every 30-min delay in interfacility transfer time beyond 90 min is associated with 6% and 11% higher risk-adjusted odds of 24-h and in-hospital mortality, respectively. Estimated interfacility transfer time should be considered while deciding about transferring severely injured geriatric trauma patients to a higher level of care.

Predicting the time of mortality among older adult trauma patients: Is frailty the answer?

INTRODUCTION: This study aims to evaluate the temporal trends of mortality among frail versus non-frail older adult trauma patients during index hospitalization. METHODS: We performed a 3-year (2017-2019) analysis of ACS-TQIP. We included all older adult (age ≥65 years) trauma patients. Patients were stratified into two groups (Frail vs. Non-Frail). Outcomes were acute (<24 â€‹h), early (24-72 â€‹h), intermediate (72 hours-1 week), and late (>1 week) mortality. RESULTS: A total of 1,022,925 older adult trauma patients were identified, of which 19.7 â€‹% were frail. The mean(SD) age was 77(8) years and 57.4 â€‹% were female. Median[IQR] ISS was 9[4-10] and both groups had comparable injury severity (p â€‹= â€‹0.362). On multivariable analysis, frailty was not associated with acute (aOR 1.034; p â€‹= â€‹0.518) and early (aOR 1.190; p â€‹= â€‹0.392) mortality, while frail patients had independently higher odds of intermediate (aOR 1.269; p â€‹= â€‹0.042) and late (aOR 1.835; p â€‹< â€‹0.001) mortality. On sub-analysis, our results remained consistent in mild, moderate, and severely injured patients. CONCLUSION: Frailty is an independent predictor of mortality in older adult trauma patients who survive the initial 3 days of admission, regardless of injury severity.

Pediatric Acute Compartment Syndrome in Long Bone Fractures: Who is at Risk?

INTRODUCTION: There is a paucity of large-scale data on the factors that suggest an impending or underlying extremity pediatric acute compartment syndrome (ACS). In addition, literature regarding the timing of operative fixation and the risk of ACS is mixed. We aimed to describe the factors associated with pediatric ACS. METHODS: Analysis of 2017-2019 Trauma Quality Improvement Program. We included patients aged <18 y diagnosed with upper extremity (UE) and lower extremity (LE) fractures. Burns and insect bites/stings were excluded. Multivariable regression analyses were performed to identify the predictors of ACS. RESULTS: 61,537 had LE fractures, of which 0.5% developed ACS. 76,216 had UE fractures, of which 0.16% developed ACS. Multivariable regression analyses identified increasing age, male gender, motorcycle collision, and pedestrian struck mechanisms of injury, comminuted and open fractures, tibial and concurrent tibial and fibular fractures, forearm fractures, and operative fixation as predictors of ACS (P value <0.05). Among LE fractures, 34% underwent open reduction internal fixation (time to operation = 14 [8-20] hours), and 2.1% underwent ExFix (time to operation = 9 [4-17] hours). Among UE fractures, 54% underwent open reduction internal fixation (time to operation = 11 [6-16] hours), and 1.9% underwent ExFix (time to operation = 9 [4-14] hours). Every hour delay in operative fixation of UE and LE fractures was associated with a 0.4% increase in the adjusted odds of ACS (P value <0.05). CONCLUSIONS: Our results may aid clinicians in recognizing children who are "at risk" for ACS. Future studies are warranted to explore the optimal timing for the operative fixation of long bone fractures to minimize the risk of pediatric ACS.

The Importance of Circulation in Airway Management: Preventing Post-Intubation Hypotension in The Trauma Bay.

OBJECTIVE: To identify the modifiable and non-modifiable risk factors associated with post-intubation hypotension (PIH) among trauma patients who required endotracheal intubation (ETI) in the trauma bay. SUMMARY BACKGROUND DATA: ETI has been associated with hemodynamic instability, termed PIH, yet its risk factors in trauma patients remain under-investigated. METHODS: This is a prospective observational study at a level I trauma center over 4 years (2019-2022). All adult (≥18) trauma patients requiring ETI in the trauma bay were included. Blood pressure was monitored both pre- and post-intubation. Multivariable logistic regression analysis was performed to identify the modifiable and non-modifiable factors associated with PIH. RESULTS: 708 patients required ETI in the trauma bay, of which, 435 (61.4%) developed PIH. The mean (SD) age was 43 (21) and 71% were male. Median [IQR] arrival GCS was 7 [3-13]. Patients who developed PIH had a lower mean (SD) pre-intubation SBP (118 (46) vs. 138 (28), P<0.001) and higher median [IQR] ISS (27 [21-38] vs. 21 [9-26], P<0.001). Multivariable regression analysis identified BMI>25, increasing ISS, penetrating injury, spinal cord injury, Pre-intubation PRBC requirements, and diabetes mellitus as non-modifiable risk factors associated with increased odds of PIH. In contrast, pre-intubation administration of 3% hypertonic saline and vasopressors were identified as the modifiable factors significantly associated with reduced PIH. CONCLUSION: More than half of the patients requiring ETI in the trauma bay developed PIH. This study identified modifiable and non-modifiable risk factors that influence the development of PIH, which will help physicians when considering ETI upon patient arrival. LEVEL OF EVIDENCE: Level III, Prognostic Study.

The role of number of affected vessels on radiologic and clinical outcomes of patients with blunt cerebrovascular injury.

OBJECTIVE: There is a lack of data on the role of characteristics of injured vessels on the outcomes of patients with blunt cerebrovascular injuries (BCVIs). The aim of this study was to assess the effect of the number (single vs multiple) of injured vessels on outcomes. METHODS: This is a retrospective study at two American College of Surgeons Level I trauma centers (2017-2021). Adult (>16 years) trauma patients with BCVIs are included. Injuries were graded by the Denver Scale based on the initial computed tomography angiography (CTA). Early repeat CTA was performed 7 to 10 days after diagnosis. Patients were stratified by the number (single vs multiple) of the involved vessels. Outcomes included progression of BCVIs on repeat CTA, stroke, and in-hospital mortality attributable to BCVIs. Multivariable regression analyses were performed to identify the association between the number of injured vessels and outcomes. RESULTS: A total of 491 patients with 591 injured vessels (285 carotid and 306 vertebral arteries) were identified. Sixty percent were male, the mean age was 44 years, and the median Injury Severity Score was 18 (interquartile range, 11-25). Overall, 18% had multiple-vessel injuries, 16% had bilateral vessel injuries, and 3% had multiple injuries on the same side. The overall rates of progression to higher-grade injuries, stroke, and mortality were 23%, 7.7%, and 8.8%, respectively. On uni- and multivariable analyses, multiple BCVIs were associated with progression to higher-grade injuries on repeat imaging, stroke, and mortality compared with single-vessel injuries. CONCLUSIONS: BCVIs with multiple injured vessels are more likely to progress to higher grades on repeat CTA, with multiple injuries independently associated with worse clinical outcomes, compared with those with single injuries. These findings highlight the importance of incorporating the number of injured vessels in clinical decision-making and in defining protocols for repeat imaging.

Impact of resuscitation adjuncts on postintubation hypotension in patients with isolated traumatic brain injury.

INTRODUCTION: Postintubation hypotension (PIH) is a risk factor of endotracheal intubation (ETI) after injury. For those with traumatic brain injury (TBI), one episode of hypotension can potentiate that injury. This study aimed to identify the resuscitation adjuncts that may decrease the incidence of PIH in this patient population. METHODS: This is a 4-year (2019-2022) prospective observational study at a level I trauma center. Adult (18 years or older) patients with isolated TBI requiring ETI in the trauma bay were included. Blood pressures were measured 15 minutes preintubation and postintubation. Primary outcome was PIH, defined as a decrease in systolic blood pressure of ≥20% from baseline or to ≤80 mm Hg, or any decrease in mean arterial pressure to ≤60 mm Hg. Multivariable logistic regression was performed to identify the associations of preintubation vasopressor, hypertonic saline (HTS), packed red blood cell, and crystalloids on PIH incidence. RESULTS: Of the 490 enrolled patients, 16% had mild (head AIS, ≤2), 35% had moderate (head AIS, 3-4), and 49% had severe TBI (head AIS, ≥5). The mean ± SD age was 42 ± 22 years, and 71% were male. The median ISS, head AIS, and Glasgow Coma Scale were 26 (19-38), 4 (3-5), and 6 (3-11), respectively. The mean ± SD systolic blood pressure 15 minutes preintubation and postintubation were 118 ± 46 and 106 ± 45, respectively. Before intubation, 31% received HTS; 10%, vasopressors; 20%, crystalloids; and 14%, at least 1 U of packed red blood cell (median, 2 [1-2] U). Overall, 304 patients (62%) developed PIH. On multivariable regression analysis, preintubation use of vasopressors and HTS was associated with significantly decreased odds of PIH independent of TBI severity, 0.310 (0.102-0.944, p = 0.039) and 0.393 (0.219-0.70, p = 0.002), respectively. CONCLUSION: Nearly two thirds of isolated TBI patients developed PIH. Preintubation vasopressors and HTS are associated with a decreased incidence of PIH. Such adjuncts should be considered prior to ETI in patients with suspected TBI. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Predictors of Receiving Mental Health Services in Trauma Patients With Positive Drug Screen.

INTRODUCTION: Initial interaction with health care system presents an important opportunity to provide substance use disorder (SUD) rehabilitation in the form of mental health services (MHSs). This study aims to identify predictors of receipt of MHSs among adult trauma patients with SUD and positive drug screen. METHODS: In this analysis of 2017-2021 American College of Surgeons-Trauma Quality Improvement Program (ACS TQIP), adult(≥18 y) patients with SUD and positive drug screen who survived the hospital admission were included. Outcomes measure was the receipt of MHS. Poisson regression analysis with clustering by facility was performed to identify independent predictors of receipt of MHS. RESULTS: 128,831 patients were identified of which 3.4% received MHS. Mean age was 41 y, 76% were male, 63% were White, 25% were Black, 12% were Hispanic, and 82% were insured. Median injury severity score was 9, and 54% were managed at an ACS level I trauma center. On regression analysis, female gender (aOR = 1.17, 95% CI = 1.09-1.25), age ≥65 y (aOR = 0.98, 95% CI = 0.97-0.99), White race (aOR = 1.37, 95% CI = 1.28-1.47), Hispanic ethnicity (aOR = 0.84, 95% CI = 0.76-0.93), insured status (aOR = 1.22, 95% CI = 1.13-1.33), and management at ACS level I trauma centers (aOR = 1.47, 95% CI = 1.38-1.57) were independent predictors of receipt of MHS. CONCLUSIONS: Race, ethnicity, and socioeconomic factors predict the receipt of MHS in trauma patients with SUD and positive drug screens. It is unknown if these disparities affect the long-term outcomes of these vulnerable patients. Further research is warranted to expand on the contributing factors leading to these disparities and possible strategies to address them.

Defining the Problem: 53 Years of Firearm Violence Afflicting America's Schools.

BACKGROUND: Firearm violence and school shootings remain a significant public health problem. This study aimed to examine how publicly available data from all 50 states might improve our understanding of the situation, firearm type, and demographics surrounding school shootings. STUDY DESIGN: School shootings occurring in the US for 53 years ending in May 2022 were analyzed, using primary data files that were obtained from the Center for Homeland Defense and Security. Data analyzed included situation, injury, firearm type, and demographics of victims and shooters. We compared the ratio of fatalities per wounded after stratifying by type of weapon. Rates (among children) of school shooting victims, wounded, and fatalities per 1 million population were stratified by year and compared over time. RESULTS: A total of 2,056 school shooting incidents involving 3,083 victims were analyzed: 2,033 children, 5 to 17 years, and 1,050 adults, 18 to 74 years. Most victims (77%) and shooters (96%) were male individuals with a mean age of 18 and 19 years, respectively. Of the weapons identified, handguns, rifles, and shotguns accounted for 84%, 7%, and 4%, respectively. Rifles had a higher fatality-to-wounded ratio (0.45) compared with shooters using multiple weapons (0.41), handguns (0.35), and shotguns (0.30). Linear regression analysis identified a significant increase in the rate of school shooting victims (ß = 0.02, p = 0.0003), wounded (ß = 0.01, p = 0.026), and fatalities (ß = 0.01, p = 0.0003) among children over time. CONCLUSIONS: Despite heightened public awareness, the incidence of school shooting victims, wounded, and fatalities among children has steadily and significantly increased over the past 53 years. Understanding the epidemic represents the first step in preventing continued firearm violence in our schools.

Surgical stabilization of rib fractures: The impact of volume and the need for standardized indications.

INTRODUCTION: We aimed to examine impact of trauma center (TC) surgical stabilization of rib fracture (SSRF) volume on outcomes of patients undergoing SSRF. METHODS: Blunt rib fracture patients who underwent SSRF were included from ACS-TQIP2017-2021. TCs were stratified according to tertiles of SSRF volume:low (LV), middle, and high (HV). Outcomes were time to SSRF, respiratory complications, prolonged ventilator use, mortality. RESULTS: 16,872 patients were identified (LV:5470,HV:5836). Mean age was 56 years, 74% were male, median thorax-AIS was 3. HV centers had a lower proportion of patients with flail chest (HV41% vs LV50%), pulmonary contusion (HV44% vs LV52%) and had shorter time to SSRF(HV58 vs LV76 â€‹h), less respiratory complications (HV3.2% vs LV4.5%), prolonged ventilator use (HV15% vs LV26%), mortality (HV2% vs LV2.6%) (all p â€‹< â€‹0.05). On multivariable regression analysis, HV centers were independently associated with reduced time to SSRF(ߠ​= â€‹-18.77,95%CI â€‹= â€‹-21.30to-16.25), respiratory complications (OR â€‹= â€‹0.67,95%CI â€‹= â€‹0.49-0.94), prolonged ventilator use (OR â€‹= â€‹0.49,95%CI â€‹= â€‹0.41-0.59), but not mortality. CONCLUSIONS: HV SSRF centers have improved outcomes, however, there are variations in threshold for SSRF and indications must be standardized. LEVEL OF EVIDENCE: Level III. STUDY TYPE: Therapeutic/Care Management.

Effect of PCC on outcomes of severe traumatic brain injury patients on preinjury anticoagulation.

INTRODUCTION: This study aims to evaluate effect of 4-factor PCC on outcomes of severe TBI patients on preinjury anticoagulants undergoing craniotomy/craniectomy. METHODS: In this analysis of 2018-2020 ACS-TQIP, patients with isolated blunt severe TBI (Head-AIS≥3, nonhead-AIS<2) using preinjury anticoagulants who underwent craniotomy/craniectomy were identified and stratified into PCC and No-PCC groups. Outcomes were time to surgery and mortality. Multivariable binary logistic and linear regression analyses were performed. RESULTS: 1598 patients were identified (PCC-107[7 %], No-PCC-1491[93 %]). Mean age was 74(11) years, 65 % were male, median head AIS was 4. Median time to PCC administration was 109 â€‹min. On univariable analysis, PCC group had shorter time to surgery (PCC-341, No-PCC-620 â€‹min, p â€‹= â€‹0.002), but higher mortality (PCC35 %, No-PCC21 %,p â€‹= â€‹0.001). On regression analysis, PCC was independently associated with shorter time to surgery (ߠ​= â€‹-1934,95 %CI â€‹= â€‹-3339to-26), but not mortality (aOR â€‹= â€‹0.70,95 %CI â€‹= â€‹0.14-3.62). CONCLUSION: PCC may be a safe adjunct for urgent reversal of coagulopathy in TBI patients using preinjury anticoagulants.

Geriatric trauma, frailty, and ACS trauma center verification level: Are there any correlations with outcomes?

INTRODUCTION: It remains unclear whether geriatrics benefit from care at higher-level trauma centers (TCs). We aimed to assess the impact of the TC verification level on frail geriatric trauma patients' outcomes. We hypothesized that frail patients cared for at higher-level TCs would have improved outcomes. STUDY DESIGN: Patients ≥65 years were identified from the Trauma Quality Improvement Program (TQIP) database (2017-2019). Patients transferred, discharged from emergency department (ED), and those with head abbreviated injury scale >3 were excluded. 11-factor modified frailty index was utilized. Propensity score matching (1:1) was performed. Outcomes included discharge to skilled nursing facility or rehab (SNF/rehab), withdrawal of life-supporting treatment (WLST), mortality, complications, failure-to-rescue, intensive care unit (ICU) admission, hospital length of stay (LOS), and ventilator days. RESULTS: 110,680 patients were matched (Frail:55,340, Non-Frail:55,340). Mean age was 79 (7), 90% presented following falls, and median ISS was 5 [2-9]. Level-I/II TCs had lower rates of discharge to SNF/rehab (52.6% vs. 55.8% vs. 60.9%; p < 0.001), failure-to-rescue (0.5% vs. 0.4% vs. 0.6%;p = 0.005), and higher rates of WLST (2.4% vs. 2.1% vs. 0.3%; p < 0.001) compared to level-III regardless of injury severity and frailty. Compared to Level-III centers, Level-I/II centers had higher complications among moderate-to-severely injured patients (4.1% vs. 3.3% vs. 2.7%; p < 0.001), and lower mortality only among frail patients regardless of injury severity (1.8% vs. 1.5% vs. 2.6%; p < 0.001). Patients at Level-I TCs were more likely to be admitted to ICU, and had longer hospital LOS and ventilator days compared to Level-II and III TCs (p < 0.05). CONCLUSION: Frailty may play an important role when triaging geriatric trauma patients. In fact, the benefit of care at higher-level TCs is particularly evident for patients who are frail. Level III centers may be underperforming in providing access to palliative and end-of-life care.

Beyond the short-term relief: Outcomes of geriatric rib fracture patients receiving paravertebral nerve blocks and epidural analgesia.

BACKGROUND: Adequate pain control is a critical component of rib fracture management. Our study aimed to evaluate the in-hospital and post-discharge outcomes of geriatric rib fracture patients who received paravertebral nerve block (PVNB) versus epidural analgesia (EA) on a national level. METHODS: We performed a 5-year (2011-15) retrospective analysis of the Nationwide Readmission database. We included all the geriatric (≥65 years) blunt trauma patients with rib fractures who received a paravertebral nerve block (PVNB) or Epidural analgesia (EA) for chest injuries. We excluded patients who were dead on arrival, those with head AIS≥3, spine AIS >0, and those with cognitive impairment. Patients were stratified into two groups (PVNB and EA). A propensity score matching (1:2) was performed, and the two groups were compared. Our outcomes included delirium, hospital length of stay (LOS), 90-day readmissions, 90-day mechanical ventilation, and initial and 90-day mortality. RESULTS: A total of 2,855 geriatric rib fracture patients were identified, out of which 352 (12 %) received PVNB and 2,503 (87 %) received EA. The mean (SD) age was 78 (8) years and 53 % were female. A total of 1,041 patients were matched (PVNB=347, EA=694 patients). The median [IQR] Injury severity score was 9 [3-15], median chest AIS was 3 [2-4], and 70 % had ≥3 rib fractures. The total mortality during index admission was 6 %, 13 % experienced delirium, and the median hospital LOS was 6 [4-10] days. There was no difference in the primary outcomes of the two groups including rates of index admission mortality (PVNB: 5.2% vs. EA:6.3 %, p = 0.548) and delirium (PVNB: 12.4% vs. EA:12.9 %, p = 0.862). We also found no statistically significant difference between these groups in terms of 90-day respiratory complications (p = 1.000), 90-day readmission (p = 0.111), 90-day mortality (p = 0.718), and 90-day need for mechanical ventilation (p = 1.000). CONCLUSION: The use of PVNB in geriatric trauma patients with multiple rib fractures is associated with comparable in-hospital and post-discharge outcomes relative to EA. PVNB is relatively easy to perform and has a better side effect profile. The use of PVNB as part of rib fracture management protocols warrants further consideration. LEVEL OF EVIDENCE: III STUDY TYPE: Therapeutic/Care Management.

Decreased Glycocalyx Shedding on Presentation in Hemorrhaging Geriatric Trauma Patients.

INTRODUCTION: Plasma levels of syndecan-1 (Sdc-1), a biomarker of endothelial glycocalyx (EG) damage, correlate with worse outcomes in trauma patients. However, EG injury is not well characterized in injured older adults (OA). The aims of this study were to characterize Sdc-1 shedding in OA trauma patients relative to younger adults (YA) and determine associations with putative regulators of EG sheddases. METHODS: We performed a secondary analysis of data from the Pragmatic, Randomized Optimal Platelet, and Plasma Ratios (PROPPR) trial, stratifying bluntly injured subjects into OA and YA groups based on upper age quartile (57 y). Plasma Sdc-1 levels were compared in OA and YA at hospital arrival through postinjury day 3, and the independent association between age and Sdc-1 level at arrival was determined after adjusting for differences in gender, shock index (SI), and pre-existing comorbidities. In a follow-up analysis, case-control matching was used to create populations of OA and YA with equivalent SI and injury severity score. Levels of Sdc-1 were compared between these matched groups, and the relationships with candidate regulators of EG shedding were assessed. RESULTS: Of 680 subjects in the Pragmatic, Randomized Optimal Platelet, and Plasma Ratios trial, 350 (51%) had blunt injuries, and 92 (26.3%) of these were OA. Plasma Sdc-1 levels at arrival, 2 h, and 6 h were significantly lower in OA compared to YA (all P < 0.05). After adjusting for sex, pre-existing morbidities and SI, age was associated with decreased Sdc-1 levels at arrival. In the matched analyses, Sdc-1, high-mobility group box 1 and tissue inhibitor of metalloproteinase-2 levels were lower in OA compared to YA. Both high-mobility group box-1 and tissue inhibitor of metalloproteinase-2 significantly correlated with arrival Sdc-1 and were inversely associated with age. CONCLUSIONS: This study indicates that increased age is independently associated with decreased Sdc-1 levels among patients with blunt injuries. Suppressed plasma levels of sheddases in relation to diminished Sdc-1 shedding suggest that mechanisms regulating EG cleavage may be impaired in injured older adults. These findings provide novel insight into the age-dependent impact of injury on the vascular endothelium, which could have important implications for the clinical management of older adults following trauma.

Resuscitating the Endothelial Glycocalyx in Trauma and Hemorrhagic Shock.

The endothelium is lined by a protective mesh of proteins and carbohydrates called the endothelial glycocalyx (EG). This layer creates a negatively charged gel-like barrier between the vascular environment and the surface of the endothelial cell. When intact the EG serves multiple functions, including mechanotransduction, cell signaling, regulation of permeability and fluid exchange across the microvasculature, and management of cell-cell interactions. In trauma and/or hemorrhagic shock, the glycocalyx is broken down, resulting in the shedding of its individual components. The shedding of the EG is associated with increased systemic inflammation, microvascular permeability, and flow-induced vasodilation, leading to further physiologic derangements. Animal and human studies have shown that the greater the severity of the injury, the greater the degree of shedding, which is associated with poor patient outcomes. Additional studies have shown that prioritizing certain resuscitation fluids, such as plasma, cryoprecipitate, and whole blood over crystalloid shows improved outcomes in hemorrhaging patients, potentially through a decrease in EG shedding impacting downstream signaling. The purpose of the following paragraphs is to briefly describe the EG, review the impact of EG shedding and hemorrhagic shock, and begin entertaining the notion of directed resuscitation. Directed resuscitation emphasizes transitioning from macroscopic 1:1 resuscitation to efforts that focus on minimizing EG shedding and maximizing its reconstitution.

Delayed versus early hepatic resection among patients with severe traumatic liver injuries undergoing damage control laparotomy.

INTRODUCTION: We aimed to assess the effect of time to hepatic resection on the outcomes of patients with high-grade liver injuries who underwent damage control laparotomy (DCL). METHODS: This is a 4-year (2017-2020) analysis of the ACS-TQIP. Adult trauma patients with severe liver injuries (AAST-OIS grade â€‹≥ â€‹III) who underwent DCL and hepatic resection were included. We excluded patients with early mortality (<24 â€‹h). Patients were stratified into those who received hepatic resection within the initial operation (Early) and take-back operation (Delayed). RESULTS: Of 914 patients identified, 29% had a delayed hepatic resection. On multivariable regression analyses, although delayed resection was not associated with mortality (aOR:1.060,95%CI[0.57-1.97],p â€‹= â€‹0.854), it was associated with higher complications (aOR:1.842,95%CI[1.38-2.46],p â€‹< â€‹0.001), and longer hospital (ß: +0.129, 95%CI[0.04-0.22],p â€‹= â€‹0.005) and ICU (ß:+0.198,95%CI[0.14-0.25],p â€‹< â€‹0.001) LOS, compared to the early resection. CONCLUSION: Delayed hepatic resection was associated with higher adjusted odds of major complications and longer hospital and ICU LOS, however, no difference in mortality, compared to early resection.

From surveillance to surgery: The delayed implications of non-operative and operative management of pancreatic injuries.

BACKGROUND: Our study compares the delayed outcomes of operative versus nonoperative management of pancreatic injuries. METHODS: We analyzed the 2017 Nationwide Readmissions Database on adult (≥18 years) trauma patients with pancreatic injuries. Patients who died on index admission were excluded. Patients were stratified into operative (OP) and non-operative (NOP) groups and compared for outcomes within 90 days of discharge. Multivariable regression analyses were performed. RESULTS: We identified 1553 patients (NOP â€‹= â€‹1092; OP â€‹= â€‹461). The Mean (SD) age was 39 (17.0) years, 31% of patients were female, and 77% had blunt injuries. Median ISS was 17 [9-25] and 74% had concomitant non-pancreatic intraabdominal injuries. On multivariable analysis, operative management was independently associated with increased odds of 90-day readmissions (aOR â€‹= â€‹1.47; p â€‹= â€‹0.03), intraabdominal abscesses (aOR â€‹= â€‹2.7; p â€‹< â€‹0.01), pancreatic pseudocyst (aOR â€‹= â€‹2.4; p â€‹= â€‹0.04), and need for percutaneous or endoscopic management (aOR â€‹= â€‹5.8; p â€‹< â€‹0.001). CONCLUSION: Operative management of pancreatic injuries is associated with higher rates of delayed complications compared to non-operative management. Surgically treated pancreatic trauma patients may need close surveillance even after discharge.