Outcome of Hypotensive Trauma Patients by Time and Day of Arrival.

BACKGROUND: Although most studies of trauma patients have not demonstrated a "weekend" or "night" effect on mortality, outcomes of hypotensive (systolic blood pressure <90 mm Hg) patients have not been studied. We sought to evaluate whether outcomes of hypotensive patients were associated with admission time and day. METHODS: We retrospectively analyzed patients from Pennsylvania Level 1 and Level 2 trauma centers with systolic blood pressure of <90 mm Hg over 5 y. Patients were stratified into four groups by arrival day and time: Group 1, weekday days; Group 2, weekday nights; Group 3, weekend days; and Group 4, weekend nights. Patient characteristics and outcomes were compared for the four groups. Adjusted mortality risks for Groups 2, 3, and 4 with Group 1 as the reference were determined using a generalized linear mixed effects model. RESULTS: After exclusions, 27 trauma centers with a total of 4937 patients were analyzed. Overall mortality was 44%. Compared with patients arriving during the day (Groups 1 and 3), those arriving at night (Groups 2 and 4) were more likely to be younger, to be male, to have lower Glasgow Coma Scale scores and blood pressures, to have penetrating injuries, and to die in the emergency room. Controlled for admission variables, odds ratios (95% confidence intervals) for Groups 2, 3, and 4 were 0.92 (0.72-1.17), 0.89 (0.65-1.23), and 0.76 (0.56-1.02), respectively, for mortality with Group 1 as reference. CONCLUSIONS: Patients arriving in shock to Pennsylvania Level 1 and Level 2 trauma centers at night or weekends had no increased mortality risk compared with weekday daytime arrivals.

Nonoperative management of splenic injuries: significance of age.

BACKGROUND: In the nonoperative management (NOM) of blunt splenic injuries (BSI), the clinical relevance of age as a risk factor has not been well studied. METHODS: Using the 2011 National Trauma Data Bank data set, age was analyzed both as a continuous variable and a categorical variable (group 1 [13-54 y], group 2 [55-74 y], and group 3 [≥75 y]). BSI severity was stratified by abbreviated injury scale (AIS): group 1 (AIS ≤2), group 2 (AIS 3), and group 3 (AIS ≥4). A semiparametric proportional odds model was used to model NOM outcomes and effects due to age and BSI severity. RESULTS: Of 15,113 subjects, 15.3% failed NOM. The odds of failure increased by a factor of 1.014 for each year of age, or factor of 1.5 for groups 2 and 3 each. BSI severity groups 2 and 3 had increases in the odds of failure by factors of 3.9 and 13, respectively, compared with those of group 1. Most failures occurred by 48 h irrespective of age. The effect of age was most pronounced in age groups 2 and 3 with the most severe BSI, where a NOM failure rate of >50% was seen. Both age and failure of NOM were independent predictors of mortality. CONCLUSIONS: Age is associated with failure of NOM but its effect seems more clinically relevant only in high-grade BSI. Factors that could influence NOM success in elderly patients with high-grade injuries deserve further study.

Advanced Practitioners Are Peers in Trauma Performance Improvement Peer Review.

Advanced practitioners (APs) have been successfully integrated into the clinical care of injured patients. Given the expanding role of APs in trauma care, we hypothesized that APs can perform Performance Improvement and Patient Safety (PIPS) peer review at a level comparable with trauma surgeons. For Phase 1, cases previously reviewed by a trauma surgeon were randomly selected by the PIPS coordinator and peer reviewed by an AP. The trauma surgeons' and APs' reviews were compared. For Phase 2, cases requiring concurrent review were peer reviewed by both an AP and an MD, who were blinded to each other's review. Both the APs' and trauma surgeons' reviews of the same medical record were presented at a bimonthly performance improvement (PI) meeting. In Phase 1, 46 PI cases were reviewed including 22 deaths. Trauma surgeons and APs had high concordance (96.0%) regarding appropriateness or inappropriateness of care (κ = 0.774). Among disagreements, APs were 3 times more likely than trauma surgeons to determine care to be inappropriate. Trauma surgeons and APs had similarly high concordance (95.5%) regarding preventability of mortality (κ = 0.861). In Phase 2, 38 PI cases were reviewed, including 31 deaths. Trauma surgeons and APs had high concordance (89.0%) regarding appropriateness or inappropriateness of care (κ = 0.585). Among disagreements, trauma surgeons and APs had similarly high concordance (86.2%) regarding preventability of mortality (κ = 0.266). We found that APs had high concordance with trauma surgeons regarding medical record reviews and are thus able to effectively review medical records for the purposes of PIPS.

Geriatric Patients on Antithrombotic Agents Who Fall: Does Trauma Team Activation Improve Outcomes?

Despite the incorporation of anticoagulant and antiplatelet (ACAP) drugs in our trauma triage criteria, it is unclear whether trauma team activation (TTA) impacts outcomes in geriatric patients on ACAP drugs sustaining falls. We hypothesized that TTA in this cohort was associated with improved outcomes. The hospital electronic database was queried to identify normotensive, awake patients aged ≥65 years on ACAP agent from 2014 to 2018 presenting to the emergency department after falls. The outcome was in-hospital mortality. The association between TTA and mortality was examined using logistic regression analysis and 1:1 propensity score matching analysis. In this study, 4540 patients on ACAP drugs were analyzed, with TTA occurring in 500 (11%). TTA occurred in younger but more severely injured patients with lower Glasgow Coma Score. Logistic regression revealed that TTA was not associated with mortality (odds ratio [95% confidence intervals], 2.04 [0.89-4.25]). The 1:1 propensity score analysis revealed similar mortality for the matched groups (non-TTA, 1.6% vs TTA, 2.2%, P = 0.64). In the elderly patients on ACAP agents, the current triage criteria resulted in the appropriate use of TTA for more severely injured patients. The lack of outcome benefit suggests that ACAP drug use as a criterion for TTA should be re-evaluated.

Success Of An Expedited Emergency Department Triage Evaluation System For Geriatric Trauma Patients Not Meeting Trauma Activation Criteria.

BACKGROUND: Geriatric patients are at increased risk of injury following low-energy mechanisms and are less tolerant of injury. Current criteria for trauma team activation (TTA) often miss these injuries. We evaluated a novel triage process for an expedited Emergency Medicine Physician evaluation protocol (T3) for at-risk geriatric sub-populations not meeting trauma team activation (TTA) criteria. METHODS: Retrospective review of injured patients (≥65 years) from a Level II Trauma Center with an Injury Severity Score (ISS < 16), prior to (Pre-T3, Jan 2007-Oct 2009), and after (Post-T3, Jan 2010-Oct 2012), implementation of T3, as well as a contemporary period (CP, Jan 2013-Oct 2015). Demographics, physiologic variables, and timeliness of care were measured. Rates of ICU admission, operative procedures and lengths of stay and in-hospital mortality were compared for all periods. Logistic regression analysis determined variables independently associated with mortality. RESULTS: Post-T3, 49.2% of geriatric registry patients underwent T3 with a reduction in key time intervals. Median time to evaluation (42.1 mins vs 61.7 min, p<0.001), median time to CT (161.3 mins vs 212.9 mins, p<0.001) and EDLOS (364.6 mins vs 451.5 mins, p=0.023) were all reduced compared to non-expedited evaluations. There was no change in mortality after the implementation of the protocol. CONCLUSION: The T3 protocol expedited patient evaluation of at-risk geriatric patients that would not otherwise meet TTA criteria. The new process met the goals of the American College of Surgeons Trauma Quality Improvement Program while conserving resources.

Is clinician assessment accurate or is routine pan-body CT needed in the stable intoxicated trauma patient?

BACKGROUND: We sought to determine if clinician suspicion of injury was useful in predicting injuries found on pan-body computed tomography (PBCT) in clinically intoxicated patients. METHODS: We prospectively enrolled awake, intoxicated patients with low-energy mechanism of injury. For each of four body regions (head/face, neck, thorax and abdomen/pelvis), clinician suspicion for injury was recorded as "low index" or "more than a low index". The reference standard was the presence of any pre-defined significant finding (SF) on CT. Sensitivity, specificity, positive (LR+) and negative (LR-) likelihood ratios were calculated. RESULTS: Enrollment of 103 patients was completed. Sensitivity, specificity, LR+ and LR-for clinician index of suspicion were: 56%, 68%, 1.75, 0.64 (head/face), 50%, 92%, 6.18, 0.54 (neck), 10%, 96%, 2.60, 0.94 (thorax) and 67%, 93%, 9.56, 0.36 (abdomen/pelvis). CONCLUSION: Clinician judgement was most useful to guide need for CT imaging in the neck and abdomen/pelvis. Routine PBCT may not be necessary. SUMMARY: For awake, stable intoxicated patients after falls and assaults, clinician index of suspicion was most useful to guide the need for CT imaging in the neck and abdomen/pelvis. Our findings support selective use of CT if the index of suspicion is low. Routine PBCT may not be necessary.

Fall downs should not fall out: Blunt cerebrovascular injury in geriatric patients after low-energy trauma is common.

BACKGROUND: There are limited data examining the impact of screening for blunt cerebrovascular injury (BCVI) in the geriatric population sustaining falls. We hypothesize that BCVI screening in this cohort would rarely identify injuries that would change management. METHODS: A retrospective study (2012-2016) identified patients 65 years or older with Abbreviated Injury Scores for the head and neck region or face region of 1 or greater after falls of 5 ft or less. Patients who met the expanded Denver criteria for BCVI screening were included for analysis. Outcomes were change in management (defined as the initiation of medical, surgical or endovascular therapy for BCVI), stroke attributable to BCVI, in-hospital mortality and acute kidney injury. Univariate analysis was performed where appropriate. A p value less than 0.05 was considered significant. RESULTS: Of 997 patients, 257 (26%) met criteria for BCVI screening after exclusions. The BCVI screening occurred in 100 (39%), using computed tomographic angiography for screening in 85% of patients. Patients who were not screened (n = 157) were more likely to be on preinjury antithrombotic drugs and to have worse renal function compared with the screened group. There were 23 (23%) BCVIs diagnosed in the screened group while one (0.7%) in the nonscreened group had a delayed diagnosis of BCVI. Of the 24 patients with BCVI, 15 (63%) had a change in management, consisting of the initiation of antiplatelet therapy. Comparing the screened to the nonscreened groups, 14% versus 0.7% (p < 0.0001) had a change in management. The screened group had a higher 30-day stroke rate (7% vs. 1%, p = 0.03) but there were no differences in the stroke rate attributable to BCVI (1% vs. 0.7%, p = 0.99), mortality (6% vs. 8%, p = 0.31) or acute kidney injury (5% vs. 6%, p = 0.40). CONCLUSION: In geriatric patients with low-energy falls meeting criteria for BCVI screening, BCVIs were commonly diagnosed when screened, and the majority of those with BCVI had a change in management. These findings support BCVI screening in this geriatric cohort. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Is it safe to discharge geriatric trauma patients with anemia?

INTRODUCTION: The consequences of discharging anemic geriatric trauma patients are not well studied. We hypothesize that anemia at discharge is associated with adverse outcomes. METHODS: A 1-year retrospective review of patients ≥65 years was performed. Hemoglobin levels at admission (HbA), discharge (HbD) and the lowest inpatient level (HbL) were recorded. Severity of anemia was categorized as mild (Hb ≥ 10.0 g/dl), moderate (Hb < 10.0 and ≥ 8.5 g/dl) and severe (Hb < 8.5 g/dl). The study endpoint was death or unplanned readmission 60 days following discharge. Univariate and multivariable analysis were used to determine if anemia predicted the outcome. A p value of 0.05 was considered significant. RESULTS: 550 patients were included. Moderate and severe anemia for HbA each predicted the study endpoint. Both HbD and HbL were highly correlated with HbA but did not predict the study endpoint. CONCLUSION: The degree of discharge anemia was not predictive of 60-day mortality or unplanned admissions in geriatric trauma patients.

Being Narrow Minded Is Not Always Bad: Focusing on Emergent Interventions in Undertriage Initiatives Improves Mortality Prediction.

The American College of Surgeons Committee on Trauma defines undertriage (UT) as any major trauma patient (injury severity score ≥ 16) not undergoing treatment at the highest level of trauma team activation. This methodology does not account for many important factors that may impact outcome. We performed a retrospective review of the Pennsylvania State Trauma Registry to determine the impact of treatment interventions on mortality. Patients were stratified by triage category as follows: UT, appropriate triage, and overtriage. Multiple prehospital (PH) and ED interventions were assessed. Increased mortality was observed in all triage groups in patients requiring intervention. A logistic regression analysis was performed to assess the independent effect of individual interventions on mortality for patients triaged to partial activation or consult. PH CPR (OR 66.13 [47.07-92.93]), ED CPR (OR 16.87 [8.82-32.27]), PH or ED intubation (OR 16.68 [13.90-20.03]), PH or ED packed red blood cell transfusion (OR 1.89 [1.54-2.33]), emergent operative intervention (OR 3.58 [3.07-4.19]), ED central venous access (OR 5.04 [2.31-10.97]) were all associated with worsening mortality. The American College of Surgeons Committee on Trauma methodology overestimates mortality risk when emergent interventions are not required and underestimates risk where such interventions are necessary. Future methodologies for assessing UT should include these interventions.

Does Antithrombotic Drug Use Mandate Trauma Team Activation in Awake Geriatric Patients with Intracranial Hemorrhage?

Antithrombotic (anticoagulant [AC] and antiplatelet [AP]) drugs have been associated with mortality in geriatric patients with intracranial hemorrhage (ICH). It is unclear whether trauma team activation (TTA) in this cohort impacts outcome. Patients ≥65 years with a Glasgow Coma Scale of ≥13 and ICH over four years were included and were divided into three groups according to type of drug: group 1, AC with or without AP; group 2, AP only and; group 3, no AC or AP. The Rotterdam score was used to characterize the severity of CT findings. The primary outcome was inhospital mortality or transition to comfort measures. The secondary outcome was need for neurosurgical intervention within 48 hours. Logistic regression analysis was performed to evaluate for predictors of each outcome. Of 419 patients, 20.5, 50.4, and 29.1 per cent belonged to groups 1, 2, and 3, respectively, with TTA occurring in 39.5, 18.0, and 32.0 per cent of the respective groups. Within each group, there were no differences for the primary and secondary outcomes whether or not TTA was triggered. TTA patients had shorter times to CT (median, 20 minutes versus 80 minutes, P < 0.0001) and to administration of reversal agents (median, 105 minutes versus 255 minutes, P < 0.0001). Age, head-Abbreviated Injury Score, and the Rotterdam score were predictors for both outcomes by multivariable analysis, whereas antithrombotic drug use and TTA were not. In awake elderly patients on antithrombotic drugs found to have ICH, TTA expedited evaluation and treatment but was not associated with mortality benefit.

Trauma surgeon utilization of computerized tomography scanning: Room for improvement?

BACKGROUND: We aimed to evaluate computerized tomography (CT) utilization and yield rates for trauma team activations (TTA). METHODS: A retrospective review of all TTAs was conducted over nine months. TTAs consisted of two levels--trauma alert (TAL) and trauma response (TR). Yields of CT for significant findings (SF) for four CT types (brain, cervical, chest, abdomen/pelvis) were recorded. RESULTS: 647 patients were included. There was no difference in the utilization rates of CTs except for brain CTs (TAL, 98% vs TR, 94%, p = 0.008). There was no difference in the yield rates except for cervical spine CTs (TAL, 8% vs TR, 4%, p = 0.03). Over 80% received a pan scan regardless of TTA level; 63% who had any CT had no SF. The median ratio of scans with SF to the total number of scans per patient was 0. CONCLUSIONS: Regardless of activation level, CT seems to be over utilized. More selective use of CT should be evaluated.