Urban thoracic trauma: diagnosis and initial treatment of non-cardiac injuries in adults.

This comprehensive review aims to delineate the prevailing non-cardiac thoracic injuries occurring in urban environments following initial on-site treatment and subsequent admission to hospital emergency departments. Our study involved a rigorous search within the PubMed database, employing key phrases and their combinations, including "thoracic injury," "thoracic trauma," "haemothorax," "lung contusion," "traumatic pneumothorax," "rib fractures," and "flail chest." We focused on original research articles and reviews. Non-cardiac thoracic injuries exhibit a high prevalence, often affecting poly-trauma patients, and contributing to up to 35% of polytrauma-related fatalities. Furthermore, severe thoracic injuries can result in a substantial 5% mortality rate. This review provides insights into clinical entities such as lung contusion, traumatic haemothorax, pneumothorax, rib fractures, and sternal fractures. Thoracic injuries represent a frequent and significant clinical concern for emergency department physicians and thoracic surgeons, warranting thorough understanding and timely intervention.

Stop the Bleed-Wait for the Ambulance or Get in the Car and Drive? A Post Hoc Analysis of an EAST Multicenter Trial.

Background: The Stop the Bleed campaign gives bystanders an active role in prehospital hemorrhage control. Whether extending bystanders' role to private vehicle transport (PVT) for urban penetrating trauma improves survival is unknown, but past research has found benefit to police and PVT. We hypothesized that for penetrating trauma in an urban environment, where prehospital procedures have been proven harmful, PVT improves outcomes compared to any EMS or advanced life support (ALS) transport.Methods: Post-hoc analysis of an EAST multicenter trial was performed on adult patients with penetrating torso/proximal extremity trauma at 25 urban trauma centers from 5/2019-5/2020. Patients were allocated to PVT and any EMS or ALS transport using nearest neighbor propensity score matching. Univariate analyses included Wilcoxon signed rank or McNemar's Test and logistic regression.Results: Of 1999 penetrating trauma patients in urban settings, 397 (19.9%) had PVT, 1433 (71.7%) ALS transport, and 169 (8.5%) basic life support (BLS) transport. Propensity matching yielded 778 patients, distributed equally into balanced groups. PVT patients were primarily male (90.5%), Black (71.2%), and sustained gunshot wounds (68.9%). ALS transport had significantly higher ED mortality (3.9% vs 1.9%, P = 0.03). There was no difference in in-hospital mortality rate, hospital LOS, or complications for all EMS or ALS only transport patients.Conclusion: Compared to PVT, ALS, which provides more prehospital procedures than BLS, provided no survival benefit for penetrating trauma patients in urban settings. Bystander education incorporating PVT for early arrival of penetrating trauma patients in urban settings to definitive care merits further investigation.

A Single-Center Review of Radiologically Diagnosed Maxillofacial Fractures: Etiology and Distribution.

The etiology of fractures of the maxillofacial skeleton varies among studies, with motor vehicle accidents and assaults oftentimes the most common. The number of males outnumbers females throughout most studies. Fractures of the zygoma, orbit, and mandible are usually cited as most common fracture types. This study examines a single center's experience with regards to etiology and distribution of fractures. A retrospective review of all radiologically confirmed facial fractures in a level 1 trauma center in an urban environment was performed for the years 2000 to 2012. Patient demographics, etiology of injury, and location of fractures were collected. During this time period, 2,998 patients were identified as having sustained a fracture of the facial skeleton. The average age was 36.9 years, with a strong male predominance (81.5%). The most common etiologies of injury were assault (44.9%) and motor vehicle accidents (14.9%). Throughout the study period, the number of fractures as a result of assault remained relatively constant, whereas the number as a result of motor vehicle accidents decreased slightly. The most common fracture observed was of the orbit, followed by mandible, nasal bones, zygoma, and frontal sinus. Patients sustaining a fracture as a result of assault were more likely to have a mandible fracture. Patients in motor vehicle accidents were more likely to suffer fractures of the maxilla, orbit, and frontal sinus. Mandible fractures are more common in cases of assault. Motor vehicle accidents convey a large force, which, when directed at the craniofacial skeleton, can cause a variety of fracture patterns. The decreasing number of fractures as a result of motor vehicle accidents may represent improved safety devices such as airbags.

Urban versus rural trauma recidivism: is there a difference?

PURPOSE: Understanding the characteristics of trauma recidivists may allow trauma centers to tailor prevention programs. We hypothesized that there would be an increased incidence of violent injuries and falls in the urban vs. rural recidivists, respectively. METHODS: Trauma admissions from 2000 to 2011 were queried for incidences of recidivism. Age (<65 or ≥65 years), gender, Injury Severity Score (ISS, <9 or ≥9), mortality, and injury cause (fall, violence, or other) were analyzed with univariate analyses to test for differences between urban and rural patients. Significant variables were then included in a binary logistic model and further stratified based on environment. RESULTS: There were a total of 19,600 trauma admissions from 2000 to 2011, representing 18,711 unique patients, with 1,690 admissions (8.6 %) attributed to 801 recidivists (4.3 %). The overall percentages of recidivist trauma admissions attributed to urban and rural patients were 8.6 and 6.9 %, respectively (p < 0.001). When adjusting for age ≥65 years as well as falls and violent injuries, patients from urban environments were at 1.12 times higher odds of being a recidivist than their rural counterparts [odds ratio (OR) 1.12; 95 % confidence interval (CI) 1.01-1.25; p = 0.039]. When stratified into rural and urban groups, falls and violent injuries were significant in both groups of recidivist admissions; however, age ≥65 years was only significant in rural recidivist admissions. CONCLUSION: An urban trauma admission had 12 % higher odds of being attributed to a recidivist than its rural counterpart, when controlling for age and mechanism of injury (MOI). Age ≥65 years was a significant variable in rural but not urban recidivist admissions. Characterizing the recidivist may allow for targeted prevention and intervention programs to decrease repeat hospital visits.

A comparison of rural versus urban trauma care.

OBJECTIVE: We compared the survival of trauma patients in urban versus rural settings after the implementation of a novel rural non-trauma center alternative care model called the Model Rural Trauma Project (MRTP). MATERIALS AND METHODS: We conducted an observational cohort study of all trauma patients brought to eight rural northern California hospitals and two southern California urban trauma centers over a one-year period (1995-1996). Trauma patients with an injury severity score (ISS) of >10 were included in the study. We used logistic regression to assess disparities in odds of survival while controlling for Trauma and Injury Severity Score (TRISS) parameters. RESULTS: A total of 1,122 trauma patients met criteria for this study, with 336 (30%) from the rural setting. The urban population was more seriously injured with a higher median ISS (17 urban and 14 rural) and a lower Glasgow Coma Scale (GCS) (GCS 14 urban and 15 rural). Patients in urban trauma centers were more likely to suffer penetrating trauma (25% urban versus 9% rural). After correcting for differences in patient population, the mortality associated with being treated in a rural hospital (OR 0.73; 95% CI 0.39 to 1.39) was not significantly different than an urban trauma center. CONCLUSION: This study demonstrates that rural and urban trauma patients are inherently different. The rural system utilized in this study, with low volume and high blunt trauma rates, can effectively care for its population of trauma patients with an enhanced, committed trauma system, which allows for expeditious movement of patients toward definitive care.

Pre-hospital transport times and survival for Hypotensive patients with penetrating thoracic trauma.

BACKGROUND: Achieving definitive care within the "Golden Hour" by minimizing response times is a consistent goal of regional trauma systems. This study hypothesizes that in urban Level I Trauma Centers, shorter pre-hospital times would predict outcomes in penetrating thoracic injuries. MATERIALS AND METHODS: A retrospective cohort study was performed using a statewide trauma registry for the years 1999-2003. Total pre-hospital times were measured for urban victims of penetrating thoracic trauma. Crude and adjusted mortality rates were compared by pre-hospital time using STATA statistical software. RESULTS: During the study period, 908 patients presented to the hospital after penetrating thoracic trauma, with 79% surviving. Patients with higher injury severity scores (ISS) were transported more quickly. Injury severity scores (ISS) ≥16 and emergency department (ED) hypotension (systolic blood pressure, SBP <90) strongly predicted mortality (P < 0.05 for each). In a logistic regression model including age, race, and ISS, longer transport times for hypotensive patients were associated with higher mortality rates (all P values <0.05). This was seen most significantly when comparing patient transport times 0-15 min and 46-60 min (P < 0.001). CONCLUSION: In victims of penetrating thoracic trauma, more severely injured patients arrive at urban trauma centers sooner. Mortality is strongly predicted by injury severity, although shorter pre-hospital times are associated with improved survival. These results suggest that careful planning to optimize transport time-encompassing hospital capacity and existing resources, traffic patterns, and trauma incident densities may be beneficial in areas with a high burden of penetrating trauma.