A Stitch in Time Saves Clots: Venous Thromboembolism Chemoprophylaxis in Traumatic Brain Injury.

BACKGROUND: Venous thromboembolism chemoprophylaxis (VTE-CHEMO) is often delayed in patients with traumatic brain injury because of the concern for intracranial hemorrhage (ICH) progression. We hypothesize that (1) late time to VTE-CHEMO (≥48 h) is associated with higher incidence of VTE, and (2) VTE-CHEMO use does not correlate with ICH progression. MATERIALS AND METHODS: This is a multiinstitutional retrospective study of patients with traumatic brain injury admitted between 2014 and 2016. Inclusion criteria were head Abbreviated Injury Code ≥2, ICH present on initial head computed tomography, and two or more head computed tomography scans after admission. The primary outcome was VTE, and the secondary outcome was ICH progression. Patients were classified as receiving VTE-CHEMO early (<48 h) or late (≥48 h). Multivariable analysis with Cox proportional hazards regression was performed. RESULTS: Overall, 1803 patients were included. Patients with VTE (n = 137) were more likely to have spinal cord injury, blunt cerebrovascular injury, pelvic or femur fractures, and missed VTE-CHEMO doses. After multivariable regression, body mass index >30 (hazard ratio [HR], 1.05; P = 0.002), Injury Severity Score (HR, 1.004; P < 0.001), pelvic or femur fractures (HR, 1.05; P < 0.0001), spinal cord injury (HR, 1.28; P = 0.02), and missed VTE-CHEMO doses (HR, 1.08; P = 0.01) were significant predictors of VTE. In those who required neurosurgery, late VTE-CHEMO predicted VTE (HR, 1.21; P = 0.0001). Overall, 32% patients experienced ICH progression, which did not correlate with VTE-CHEMO use or timing. CONCLUSIONS: This multicenter study highlights benefits from early VTE-CHEMO and identifies high-risk groups who may benefit from more aggressive prophylaxis. These data also emphasize risk to patients by withholding VTE-CHEMO.

The Effect of Frailty in Predicting Outcomes of Rib Fractures Among Elderly Patients.

INTRODUCTION: Rib fractures are consequential injuries for geriatric trauma patients. Frailty has been associated with adverse outcomes in this population. The Rib Fracture Frailty Index (RFF) and 5-factor modified Frailty Index (mFI) are 2 validated frailty metrics. Research assessing inclusion of frailty metrics in geriatric rib fractures triage protocols is limited. METHODS: A retrospective cohort study was performed for trauma patients ≥50 years old with rib fractures admitted to a Level I trauma center, which currently uses percent predicted forced vital capacity (FVC%) to triage rib fractures patients. Frailty metrics (RFF & mFI) were calculated retrospectively, stratifying patients as low, moderate, or severe frailty. Unfavorable discharge disposition (UDD) was defined as discharge to facility or death. Unadjusted and adjusted odds ratios were used to assess frailty with outcome variables. RESULTS: In total, 834 patients were included from August 2018 - May 2023, with mean age of 69.1. A majority had low frailty (64.0 vs 40.3%), followed by moderate frailty (21.1 vs 30.7%), then severe frailty (14.9 vs 29.0%) for RFF and mFI, respectively. Age, sex, and ISS differed between groups. For RFF, increased frailty was associated with longer hospital and ICU length of stay. Neither frailty metric was associated with unplanned ICU transfer or intubation. In the adjusted analysis, frail patients were more likely to have UDD (OR 8.9, CI 3.4-23.0, P < .0001). CONCLUSION: While both frailty metrics were predictive of UDD, neither was associated with ICU transfer or intubation, suggesting that frailty does not enhance the accuracy of our current protocol using FVC%.

A novel preoperative score to predict severe acute cholecystitis.

BACKGROUND: In a large multicenter trial, The Parkland Grading Scale (PGS) for acute cholecystitis outperformed other grading scales and has a positive correlation with complications but is limited in its inability to preoperatively predict high-grade cholecystitis. We sought to identify preoperative variables predictive of high-grade cholecystitis (PGS 4 or 5). METHODS: In a six-month period, patients undergoing cholecystectomy at a single institution with prospectively graded PGS were analyzed. Stepwise logistic regression models were constructed to predict high-grade cholecystitis. The relative weight of the variables was used to derive a novel score, the Severe Acute Cholecystitis Score (SACS). This score was compared with the Emergency Surgery Acuity Score(ESS), American Association for the Surgery of Trauma (AAST) preoperative score and Tokyo Guidelines (TG) for their ability to predict high-grade cholecystitis. Severe Acute Cholecystitis Score was then validated using the database from the AAST multicenter validation of the grading scale for acute cholecystitis. RESULTS: Of the 575 patients that underwent cholecystectomy, 172 (29.9%) were classified as high-grade. The stepwise logistic regression modeling identified seven independent predictors of high-grade cholecystitis. From these variables, the SACS was derived. Scores ranged from 0 to 9 points with a C statistic of 0.76, outperforming the ESS ( C statistic of 0.60), AAST (0.53), and TG (0.70) ( p < 0.001). Using a cutoff of 4 or more on the SACS correctly identifies 76.2% of cases with a specificity of 91.3% and a sensitivity of 40.7%. In the multicenter database, there were 464 patients with a prospectively collected PGS. The C statistic for SACS was 0.74. Using the same cutoff of 4, SACS correctly identifies 71.6% of cases with a specificity of 83.8% and a sensitivity of 52.2%. CONCLUSION: The Severe Acute Cholecystitis Score can preoperatively predict high-grade cholecystitis and may be useful for counseling patients and assisting in surgical decision making. LEVEL OF EVIDENCE: Diagnostic Test/Criteria; Level III.

Prevalence and Outcomes of High versus Low Ratio Plasma to Red Blood Cell Resuscitation in a Multi-Institutional Cohort of Severely Injured Children.

BACKGROUND: The benefit of targeting high ratio fresh frozen plasma (FFP):red blood cell (RBC) transfusion in pediatric trauma resuscitation is unclear as existing studies are limited to patients who retrospectively met criteria for massive transfusion. The purpose of this study is to evaluate the use of high ratio FFP:RBC transfusion and the association with outcomes in children presenting in shock. METHODS: A post-hoc analysis of a 24-institution prospective observational study (4/2018-9/2019) of injured children <18 years with elevated age-adjusted shock index was performed. Patients transfused within 24 hours were stratified into cohorts of low (<1:2) or high (>1:2) ratio FFP:RBC. Nonparametric Kruskal-Wallis and chi-square were used to compare characteristics and mortality. Competing risks analysis was used to compare extended (≥75th percentile) ventilator, intensive care, and hospital days while accounting for early deaths. RESULTS: Of 135 children with median (IQR) age 10 (5,14) years and weight 40 (20,64) kg, 85 (63%) received low ratio transfusion and 50 (37%) high ratio despite similar activation of institutional massive transfusion protocols (MTP; low-38%, high-46%, p = .34). Most patients sustained blunt injuries (70%). Median injury severity score was greater in high ratio patients (low-25, high-33, p = .01); however, hospital mortality was similar (low-24%, high-20%, p = .65) as was the risk of extended ventilator, ICU, and hospital days (all p > .05). CONCLUSION: Despite increased injury severity, patients who received a high ratio of FFP:RBC had comparable rates of mortality. These data suggest high ratio FFP:RBC resuscitation is not associated with worst outcomes in children who present in shock. MTP activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers. LEVEL OF EVIDENCE: Prospective cohort study, Level II.

High-grade liver injuries with contrast extravasation managed initially with interventional radiology versus observation: A secondary analysis of a WTA multicenter study.

BACKGROUND: High-grade liver injuries with extravasation (HGLI â€‹+ â€‹Extrav) are associated with morbidity/mortality. For low-grade injuries, an observation (OBS) first-strategy is beneficial over initial angiography (IR), however, it is unclear if OBS is safe for HGLI â€‹+ â€‹Extrav. Therefore, we evaluated the management of HGLI â€‹+ â€‹Extrav patients, hypothesizing IR patients will have decreased rates of operation and mortality. METHODS: HGLI â€‹+ â€‹Extrav patients managed with initial OBS or IR were included. The primary outcome was need for operation. Secondary outcomes included liver-related complications (LRCs) and mortality. RESULTS: From 59 patients, 23 (39.0%) were managed with OBS and 36 (61.0%) with IR. 75% of IR patients underwent angioembolization, whereas 13% of OBS patients underwent any IR, all undergoing angioembolization. IR patients had an increased rate of operation (13.9% vs. 0%, p â€‹= â€‹0.049), but no difference in LRCs (44.4% vs. 43.5%) or mortality (5.6% vs. 8.7%) versus OBS patients (both p â€‹> â€‹0.05). CONCLUSION: Over 60% of patients were managed with IR initially. IR patients had an increased rate of operation yet similar rates of LRCs and mortality, suggesting initial OBS reasonable in appropriately selected HGLI â€‹+ â€‹Extrav patients.

All about the Benjamins: Efficacy of a modified triage protocol for trauma activation in geriatric patients.

BACKGROUND: The geriatric triage protocol at the study institution was modified from SBP <90 mmHg to SBP <110 mmHg and then to SBP <100 mmHg. The purpose of this study is to evaluate the impact of adjusting geriatric triage protocols on patient outcomes. METHODS: A single-center retrospective review was conducted on trauma patients 65 years or older. Three study periods with different geriatric specific trauma team activation (TTA) protocols (Group 1-SBP<90 mmHg; Group 2-SBP<110 mmHg; Group 3-SBP<100 mmHg) were compared. RESULTS: 2016 patients were included. There were no differences in mortality rates or need for trauma intervention (NFTI) rates among the three groups. The SBP <100 mmHg and SBP <110 mmHg groups had similar under-triage rates. The NFTI over-triage rate in the SBP <100 mmHg group was lower than the SBP <110 mmHg group. CONCLUSION: Using SBP <100 mmHg threshold for TTA criteria in geriatric trauma patients improves over-triage without leading to under-triage.

STRAUMA: A Novel Alert System for a Combined Stroke and Trauma.

INTRODUCTION: Cerebrovascular accident (CVA) can lead to traumatic injury. While timely administration of tissue plasminogen activator (tPA) can be lifesaving in CVAs, it is contraindicated with active bleeding. A STRAUMA is a combined stroke and highest-level trauma activation for patients with suspected CVA and signs of trauma. The purpose of this study is to evaluate the impact of the STRAUMA activation on time to CT and patient outcomes. METHODS: A retrospective review was conducted on adult patients presenting to a Level 1 trauma and comprehensive stroke center with signs of CVA between 01/2019 and 09/2020. Patients who had a STRAUMA activation were compared to patients who had a stroke alert. RESULTS: Five hundred and eighty patients met the inclusion criteria. Of these, 111 had STRAUMA activations and 469 had stroke alerts. There were no differences in age, gender, or anticoagulation use. The STRAUMA group had a higher NIH stroke scale (NIHSS) (11 vs 5, P<.0001). The STRAUMA group had a longer time to CT (23.1 min vs 16.9 min, P<.0001) and a lower rate of tPA (13.5% vs 27.9%, P = .001). Time to tPA and thrombectomy were similar. The STRAUMA group had a 15% rate of traumatic injury with a median injury severity score of 9. Mortality was higher in the STRAUMA group (14.4% vs 6.0%, P = .003). Multivariable logistic regression identified NIHSS and time to CT as predictors of mortality. STRAUMA did not predict mortality. CONCLUSION: The novel STRAUMA activation allows for an evaluation of both stroke and trauma to facilitate safe and timely administration of lifesaving interventions.

Optimal Trauma Activation Criteria for "Found Down" Patients.

INTRODUCTION: Patients who are found down (FD) with unknown mechanism of injury pose a triage dilemma. At the study institution, this population with any "suspicion of trauma" criteria were previously triaged as a trauma team activation (TTA) but due to high rates of mis-triage was modified to "signs of trauma." The purpose of this study is to compare injured and uninjured FD patients to identify patient characteristics and outcomes, and to evaluate triage accuracy of signs of trauma. METHODS: A single-center retrospective review was conducted on adult patients who were FD between 1/2019 and 4/2021. Based on injury severity score (ISS), FD patients were categorized as injured or uninjured and these groups were compared. Sensitivity and specificity were calculated for signs and suspicion of trauma as triage criteria, where suspicion of trauma included altered mental status, confusion, seizures, intoxication, or dementia. Signs of trauma were defined as abrasions, lacerations, ecchymosis, contusions, hematomas, deformity, pain, and crepitus. RESULTS: 415 FD patients were identified with 273 (65.8%) sustaining injury and 142 (34.2%) uninjured. There were no differences in age, gender, Glasgow Coma Scale (GCS) score, or vital signs. Signs of trauma had high sensitivity (96.0%) and moderate specificity (82.4%) for injury, whereas suspicion of trauma had low sensitivity (2.2%) and specificity (37.3%). CONCLUSION: Injured and uninjured FD trauma patients had similar characteristics on arrival including GCS and vitals, emphasizing the challenge of identifying patients with injury requiring trauma evaluation. Signs of trauma represent a valuable indicator of injury in the FD population.

Help a mother out: The impact of acute care surgeon response in postpartum hemorrhage.

INTRODUCTION: A Code White (CW) activation is a hospital-wide alert for postpartum hemorrhage (PPH) and acute care surgeons (ACS) were added to the response team to assist in resuscitation. A multidisciplinary training program was also implemented. This study aimed to evaluate the impact of ACS involvement and training on maternal outcomes. METHODS: A retrospective review was performed on all CW activations from 1/1/2015-8/31/2022. Three groups-pre-ACS response, ACS response, and ACS response â€‹+ â€‹training (R&T)-were compared. RESULTS: 218 patients had CW activations. ACS response increased MTP activations (50.0%vs76.5%vs76.2%, p â€‹= â€‹0.014) and TXA administration (50.0%vs96.5%vs93.3%, p â€‹< â€‹0.0001). The ACS R&T had the highest ACS presence (53.6%vs72.9%vs96.2%, p â€‹< â€‹0.0001), shortest operation (99 vs 67 vs 53min, p â€‹= â€‹0.002), lowest crystalloid use (2000 vs 1110 vs 800 â€‹ml, p â€‹= â€‹0.003), and lowest transfusion requirements. Mortality decreased from 17.9% in pre-ACS to 2.4% in ACS response and 0% in ACS R&T (p â€‹< â€‹0.0001). CONCLUSION: ACS assistance in CW activations and multidisciplinary PPH education led to the prevention of maternal mortality. ACS are a valuable resource in this unique population.

Imaging acute cholecystitis, one test is enough.

BACKGROUND: Patients with right upper quadrant pain are often imaged using multiple modalities with no established gold standard. A single imaging study should provide adequate information for diagnosis. METHODS: A multicenter study of patients with acute cholecystitis was queried for patients who underwent multiple imaging studies on admission. Parameters were compared across studies including wall thickness (WT), common bile duct diameter (CBDD), pericholecystic fluid and signs of inflammation. Cutoff for abnormal values were 3 mm for WT and 6 mm for CBDD. Parameters were compared using chi-square tests and Intra-class correlation coefficients (ICC). RESULTS: Of 861 patients with acute cholecystitis, 759 had ultrasounds, 353 had CT and 74 had MRIs. There was excellent agreement for wall thickness (ICC = 0.733) and bile duct diameter (ICC = 0.848) between imaging studies. Differences between wall thickness and bile duct diameters were small with nearly all <1 mm. Large differences (>2 mm) were rare (<5%) for WT and CBDD. CONCLUSIONS: Imaging studies in acute cholecystitis generate equivalent results for typically measured parameters.

Predictors of initial management failure in traumatic hemothorax: A prospective multicenter cohort analysis.

BACKGROUND: Traumatic hemothorax is common, and management failure leads to worse outcomes. We sought to determine predictive factors and understand the role of trauma center performance in hemothorax management failure. METHODS: We prospectively examined initial hemothorax management (observation, pleural drainage, surgery) and failure requiring secondary intervention in 17 trauma centers. We defined hemothorax management failure requiring secondary intervention as thrombolytic administration, tube thoracostomy, image-guided drainage, or surgery after failure of the initial management strategy at the discretion of the treating trauma surgeon. Patient-level predictors of hemothorax management failure requiring secondary intervention were identified for 2 subgroups: initial observation and immediate pleural drainage. Trauma centers were divided into quartiles by hemothorax management failure requiring secondary intervention rate and hierarchical logistic regression quantified variation. RESULTS: Of 995 hemothoraces in 967 patients, 186 (19%) developed hemothorax management failure requiring secondary intervention. The frequency of hemothorax management failure requiring secondary intervention increased from observation to pleural drainage to surgical intervention (12%, 22%, and 35%, respectively). The number of ribs fractured (odds ratio 1.12 per fracture; 95% confidence interval 1.00-1.26) and pulmonary contusion (odds ratio 2.25, 95% confidence interval 1.03-4.91) predicted hemothorax management failure requiring secondary intervention in the observation subgroup, whereas chest injury severity (odds ratio 1.58; 95% confidence interval 1.17-2.12) and initial hemothorax volume evacuated (odds ratio 1.10 per 100 mL; 95% confidence interval 1.05-1.16) predicted hemothorax management failure requiring secondary intervention after pleural drainage. After adjusting for patient characteristics in the logistic regression model for hemothorax management failure requiring secondary intervention, patients treated at high hemothorax management failure requiring secondary intervention trauma centers were 6 times more likely to undergo an intervention after initial hemothorax management failure than patients treated in low hemothorax management failure requiring secondary intervention trauma centers (odds ratio 6.18, 95% confidence interval 3.41-11.21). CONCLUSION: Failure of initial management of traumatic hemothorax is common and highly variable across trauma centers. Assessing patient selection for a given management strategy and center-level practices represent opportunities to improve outcomes from traumatic hemothorax.

To observe or not to observe: Evaluation of the modified brain injury guideline management of small volume intracranial hemorrhage.

INTRODUCTION: Patients with small volume intracranial hemorrhage (ICH) are categorized as modified Brain Injury Guidelines (mBIG) 1 and are managed with a 6-h emergency department (ED) observation period. The current study aimed to describe the mBIG 1 patient population and determine the utility of the ED observation period. METHODS: A retrospective analysis was performed on trauma patients with small volume ICH. Exclusion criteria were Glasgow Coma Scale (GCS) < 13 and penetrating injuries. RESULTS: 359 patients were identified over the 8-year study period. The most common ICH was SDH (52.7%) followed by SAH (50.1%). Two patients (0.56%) had neurologic deterioration, but neither had radiographic progression. Overall, 14.3% of the cohort had radiographic progression; none required neurosurgical intervention. Four patients (1.1%) had readmission related to TBI from the index admission. CONCLUSION: There were no patients with small volume ICH that required neurosurgical intervention despite a small subset of patients having radiographic or clinical deterioration. Patients who meet the mBIG 1 criteria may be managed safely without an ED observation period.

Prospective validation and application of the Trauma-Specific Frailty Index: Results of an American Association for the Surgery of Trauma multi-institutional observational trial.

BACKGROUND: The frailty index is a known predictor of adverse outcomes in geriatric patients. Trauma-Specific Frailty Index (TSFI) was created and validated at a single center to accurately identify frailty and reliably predict worse outcomes among geriatric trauma patients. This study aims to prospectively validate the TSFI in a multi-institutional cohort of geriatric trauma patients. METHODS: This is a prospective, observational, multi-institutional trial across 17 American College of Surgeons Levels I, II, and III trauma centers. All geriatric trauma patients (65 years and older) presenting during a 3-year period were included. Frailty status was measured within 24 hours of admission using the TSFI (15 variables), and patients were stratified into nonfrail (TSFI, ≤0.12), prefrail (TSFI, 0.13-0.25), and frail (TSFI, >0.25) groups. Outcome measures included index admission mortality, discharge to rehabilitation centers or skilled nursing facilities (rehab/SNFs), and 3-month postdischarge readmissions, fall recurrences, complications, and mortality among survivors of index admission. RESULTS: A total of 1,321 geriatric trauma patients were identified and enrolled for validation of TSFI (nonfrail, 435 [33%]; prefrail, 392 [30%]; frail, 494 [37%]). The mean ± SD age was 77 ± 8 years; the median (interquartile range) Injury Severity Score was 9 (5-13). Overall, 179 patients (14%) had a major complication, 554 (42%) were discharged to rehab/SNFs, and 63 (5%) died during the index admission. Compared with nonfrail patients, frail patients had significantly higher odds of mortality (adjusted odds ratio [aOR], 1.93; p = 0.018), major complications (aOR, 3.55; p < 0.001), and discharge to rehab/SNFs (aOR, 1.98; p < 0.001). In addition, frailty was significantly associated with higher adjusted odds of mortality, major complications, readmissions, and fall recurrence at 3 months postdischarge ( p < 0.05). CONCLUSION: External applicability of the TSFI (15 variables) was evident at a multicenter cohort of 17 American College of Surgeons trauma centers in geriatric trauma patients. The TSFI emerged as an independent predictor of worse outcomes, both in the short-term and 3-month postdischarge. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Rates and risk factors for anastomotic leak following blunt trauma-associated bucket handle intestinal injuries: a multicenter study.

Objectives: The risk factors for anastomotic leak (AL) after resection and primary anastomosis for traumatic bucket handle injury (BHI) have not been previously defined. This multicenter study was conducted to address this knowledge gap. Methods: This is a multicenter retrospective study on small intestine and colonic BHIs from blunt trauma between 2010 and 2021. Baseline patient characteristics, risk factors, presence of shock and transfusion, operative details, and clinical outcomes were compared using R. Results: Data on 395 subjects were submitted by 12 trauma centers, of whom 33 (8.1%) patients developed AL. Baseline details were similar, except for a higher proportion of patients in the AL group who had medical comorbidities such as diabetes, hypertension, and obesity (60.6% vs. 37.3%, p=0.015). AL had higher rates of surgical site infections (13.4% vs. 5.3%, p=0.004) and organ space infections (65.2% vs. 11.7%, p<0.001), along with higher readmission and reoperation rates (48.4% vs. 9.1%, p<0.001, and 39.4% vs. 11.6%, p<0.001, respectively). There was no difference in intensive care unit length of stay or mortality (p>0.05). More patients with AL were discharged with an ostomy (69.7% vs. 7.3%, p<0.001), and the mean duration until ostomy reversal was 5.85±3 months (range 2-12.4 months). The risk of AL significantly increased when the initial operation was a damage control procedure, after adjusting for age, sex, injury severity, presence of one or more comorbidities, shock, transfusion of >6 units of packed red blood cells, and site of injury (adjusted RR=2.32 (1.13, 5.17)), none of which were independent risk factors in themselves. Conclusion: Damage control surgery performed as the initial operation appears to double the risk of AL after intestinal BHI, even after controlling for other markers of injury severity. Level of evidence: III.

An observation-first strategy for liver injuries with "blush" on computed tomography is safe and effective.

INTRODUCTION: The management of liver injuries in hemodynamically stable patients is variable and includes primary treatment strategies of observation (OBS), angiography (interventional radiology [IR]) with angioembolization (AE), or operative intervention (OR). We aimed to evaluate the management of patients with liver injuries with active extravasation on computed tomography (CT) imaging, hypothesizing that AE will have more complications without improving outcomes compared with OBS. METHODS: This is a prospective, multicenter, observational study. Patients who underwent CT within 2 hours after arrival with extravasation (e.g., blush) on imaging were included. Exclusion criteria included cirrhosis, nontraumatic hemorrhage, transfers from outside facilities, and pregnancy. No hemodynamic exclusion criteria were used. The primary outcome was liver-specific complications. Secondary outcomes include length of stay and mortality. Angioembolization patients were compared with patients treated without AE. Propensity score matching was used to match based on penetrating mechanism, liver injury severity, arrival vital signs, and early transfusion. RESULTS: Twenty-three centers enrolled 192 patients. Forty percent of patients (n = 77) were initially OBS. Eleven OBS patients (14%) failed nonoperative management and went to IR or OR. Sixty-one patients (32%) were managed with IR, and 42 (69%) of these had AE as an initial intervention. Fifty-four patients (28%) went to OR+/- IR. After propensity score matching (n = 34 per group), there was no difference in baseline characteristics between AE and OBS. The AE group experienced more complications with a higher rate of IR-placed drains for abscess or biloma (22% vs. 0%, p = 0.01) and an increased overall length of stay ( p = 0.01). No difference was noted in transfusions or mortality. CONCLUSION: Observation is highly effective with few requiring additional interventions. Angioembolization was associated with higher rate of secondary drain placement for abscesses or biloma. Given this, a trial of OBS and avoidance of empiric AE may be warranted in hemodynamically stable, liver-injured patient with extravasation on CT. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.

Does lower extremity fracture fixation technique influence neurologic outcomes in patients with traumatic brain injury? The EAST Brain vs. Bone multicenter trial.

OBJECTIVE: This study aimed to determine whether lower extremity fracture fixation technique and timing (≤24 vs. >24 hours) impact neurologic outcomes in TBI patients. METHODS: A prospective observational study was conducted across 30 trauma centers. Inclusion criteria were age 18 years and older, head Abbreviated Injury Scale (AIS) score of >2, and a diaphyseal femur or tibia fracture requiring external fixation (Ex-Fix), intramedullary nailing (IMN), or open reduction and internal fixation (ORIF). The analysis was conducted using analysis of variamce, Kruskal-Wallis, and multivariable regression models. Neurologic outcomes were measured by discharge Ranchos Los Amigos Revised Scale (RLAS-R). RESULTS: Of the 520 patients enrolled, 358 underwent Ex-Fix, IMN, or ORIF as definitive management. Head AIS was similar among cohorts. The Ex-Fix group experienced more severe lower extremity injuries (AIS score, 4-5) compared with the IMN group (16% vs. 3%, p = 0.01) but not the ORIF group (16% vs. 6%, p = 0.1). Time to operative intervention varied between the cohorts with the longest time to intervention for the IMN group (median hours: Ex-Fix, 15 [8-24] vs. ORIF, 26 [12-85] vs. IMN, 31 [12-70]; p < 0.001). The discharge RLAS-R score distribution was similar across the groups. After adjusting for confounders, neither method nor timing of lower extremity fixation influenced the discharge RLAS-R. Instead, increasing age and head AIS score were associated with a lower discharge RLAS-R score (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.002-1.03 and OR, 2.37; 95% CI, 1.75-3.22), and a higher Glasgow Coma Scale motor score on admission (OR, 0.84; 95% CI, 0.73-0.97) was associated with higher RLAS-R score at discharge. CONCLUSION: Neurologic outcomes in TBI are impacted by severity of the head injury and not the fracture fixation technique or timing. Therefore, the strategy of definitive fixation of lower extremity fractures should be dictated by patient physiology and the anatomy of the injured extremity and not by the concern for worsening neurologic outcomes in TBI patients. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Crystalloid volume is associated with short-term morbidity in children with severe traumatic brain injury: An Eastern Association for the Surgery of Trauma multicenter trial post hoc analysis.

OBJECTIVE: This study examined differences in clinical and resuscitation characteristics between injured children with and without severe traumatic brain injury (sTBI) and aimed to identify resuscitation characteristics associated with improved outcomes following sTBI. METHODS: This is a post hoc analysis of a prospective observational study of injured children younger than 18 years (2018-2019) transported from the scene, with elevated shock index pediatric-adjusted on arrival and head Abbreviated Injury Scale score of ≥3. Timing and volume of resuscitation products were assessed using χ 2t test, Fisher's exact t test, Kruskal-Wallis, and multivariable logistic regression analyses. RESULTS: There were 142 patients with sTBI and 547 with non-sTBI injuries. Severe traumatic brain injury patients had lower initial hemoglobin (11.3 vs. 12.4, p < 0.001), greater initial international normalized ratio (1.4 vs. 1.1, p < 0.001), greater Injury Severity Score (25 vs. 5, p < 0.001), greater rates of ventilator (59% vs. 11%, p < 0.001) and intensive care unit (ICU) requirement (79% vs. 27%, p < 0.001), and more inpatient complications (18% vs. 3.3%, p < 0.001). Severe traumatic brain injury patients received more prehospital crystalloid (25% vs. 15%, p = 0.008), ≥1 crystalloid boluses (52% vs. 24%, p < 0.001), and blood transfusion (44% vs. 12%, p < 0.001) than non-sTBI patients. Among sTBI patients, receipt of ≥1 crystalloid bolus (n = 75) was associated with greater ICU need (92% vs. 64%, p < 0.001), longer median ICU (6 vs. 4 days, p = 0.027) and hospital stay (9 vs. 4 days, p < 0.001), and more in-hospital complications (31% vs. 7.5%, p = 0.003) than those who received <1 bolus (n = 67). These findings persisted after adjustment for Injury Severity Score (odds ratio, 3.4-4.4; all p < 0.010). CONCLUSION: Pediatric trauma patients with sTBI received more crystalloid than those without sTBI despite having a greater international normalized ratio at presentation and more frequently requiring blood products. Excessive crystalloid may be associated with worsened outcomes, including in-hospital mortality, seen among pediatric sTBI patients who received ≥1 crystalloid bolus. Further attention to a crystalloid sparing, early transfusion approach to resuscitation of children with sTBI is needed. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

A "GAP" in Activation: A Better Way to Manage Geriatric and Anticoagulated Patients with Head Trauma.

BACKGROUND: Older age and anticoagulant use have been associated with worse outcomes in trauma. At the study institution, elderly and anticoagulated patients with suspected traumatic brain injury (TBI) were previously triaged as a second tier trauma team activation (TTA) with a high rate of over-triage. A novel "GAP" (Geriatric or Anticoagulated Pathway) alert was created to streamline care delivery to these patients. The purpose of the study is to assess the efficacy and outcomes of the GAP alert. METHODS: A retrospective review was conducted on adult patients presenting to a level-1 trauma center from 1/2018-12/2020. The GAP alert was implemented in 2/2018. The GAP alert group was compared to the second tier TTA group. RESULTS: 1743 patients were identified. 504 (29%) received a GAP alert. GAP alert patients were older (79 years vs 47 years, P < .0001), had a lower injury severity score (ISS) (8.6 vs 9.9, P = .006), and had a higher rate of pre-injury anticoagulant use (28.4% vs 2.5%, P < .0001). The in-hospital mortality was higher in the GAP group (2.4% vs .7%, P = .004). On multivariable logistic regression, GAP alert was not identified as a predictor of mortality. Age, ISS, and pre-injury anticoagulant use predicted mortality. During the study period, the number of GAP alerts increased (B = .15, P = .003) and the number of second tier TTAs decreased (B = -.33, P < .0001). CONCLUSION: Implementation of the GAP alert led to a decrease in trauma resource utilization while providing timely diagnosis and treatment of geriatric patients or those on anticoagulation medication with suspected TBI.

Evaluation of the Nelson Criteria as an Indicator for Nonsurgical Admission in Trauma Patients.

Geriatric patients with complex medical comorbidities who sustain minor injuries may warrant admission to nonsurgical services. The Nelson score provides an objective scoring system that helps identify patients appropriate for nonsurgical admission (NSA). The purpose of this study is to assess the utility of the Nelson criteria in determining the most appropriate admission service. A retrospective review was performed on patients ≥65 years admitted from 12/2016 to 11/2020. 2410 patients met the inclusion criteria. Patients with Nelson score ≥6 were older with more comorbidities, had a lower injury severity score (7.5 vs 12.5, p<0.0001), and a higher rate of NSA (29.2% vs 12.7%, p<0.0001) compared to patients with Nelson score <6. On the multivariable logistic regression, admission service was not identified as an independent predictor of mortality. Utilizing the Nelson criteria may provide an objective measure to stratify and identify patients who would benefit from NSA.

Utilization of Percentage of Predicted Forced Vital Capacity to Stratify Rib Fracture Patients: An Updated Clinical Practice Guideline.

BACKGROUND: Rib fractures are the most common injuries diagnosed after blunt thoracic trauma and are a source of significant morbidity and mortality. Early identification of at-risk patients and initiation of effective analgesia are keys to mitigating complications from these injuries. Multiple tools exist to predict pulmonary decompensation after rib fractures; however, none has found a widespread acceptance. A clinical practice guideline (CPG) utilizing Forced vital capacity (FVC) has been in place at a single institution. The goal of this study is to update the CPG to use percentage of predicted FVC (FVC%) instead of FVC to triage patients with rib fractures. MATERIALS AND METHODS: A retrospective study of 266 patients with rib fractures was conducted. Patients were divided into 3 groups based on FVC of <1000 mL, 1001-1500 mL, or >1500 mL for analysis. Data were analyzed with analysis of variance, and Youden's J Index was used to identify inflection points. RESULTS: Patients in the high-risk category were more likely to be women, older than 65 years, admitted to the intensive care unit (ICU), transferred to the ICU, require intubation, and have overall longer hospital and ICU stays. The updated CPG triage cutoffs for admission to ICU, stepdown, and floor were redefined as FVC% values of <25%, 25-45%, and >45%, respectively. DISCUSSION: The updated CPG using FVC% may more accurately identify patients with compromised physiology and be a better tool to help predict patients who are at risk for decompensation following rib fractures. A validation study for the updated CPG is in progress.