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.

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.

What Is Going on in Our Schools? Review of Injuries Among School Children Across the United States.

INTRODUCTION: Children spend most of their time at school and participate in many activities that have the potential for causing injury. This study aims to describe the nationwide epidemiology of pediatric trauma sustained in school settings in the United States. METHODS: In the 3-y analysis of 2017-2019 American College of Surgeons-Trauma Quality Program, all pediatric trauma patients (≤18 y) injured in a school setting were included and stratified based on place of injury, into elementary, middle, and high school (HS) groups. Descriptive statistics and multivariable logistic regression analysis were performed to identify the independent predictors of intentional injuries. RESULTS: 23,215 pediatric patients were identified, of which 15,264 patients were injured at elementary (57.6%), middle (17.5%), and high (25%) schools. The mean age was 9.5 y, 66.9% were male, 63.9% were white, the median injury severity score was 2 [1-4], and 95.6% had a blunt injury. Elementary school students were more likely to sustain falls (85%) and humerus fractures (43%) whereas HS students were more likely to be injured by assaults (17%). Overall, 7% of the students sustained intentional injuries. On multivariable logistic regression, male gender (odds ratio [OR] 1.54), Black race (OR 2.94), American Indian race (OR 1.88), Hispanic ethnicity (OR 1.77), positive drug screen (OR 4.9), middle (OR 5.2), and HSs (OR 10.6) were identified as independent predictors of intentional injury (all P < 0.01). CONCLUSIONS: Injury patterns vary across elementary, middle, and HSs. Racial factors appear to influence intentional injuries along with substance abuse. Further studies to understand these risk factors and efforts to reduce school injuries are warranted to provide a safe learning environment for children.

Drugs, Delirium, and Trauma: Substance Use and Incidence of Delirium After Traumatic Brain Injury.

INTRODUCTION: There is a paucity of data on the effect of preinjury substance (alcohol, drugs) abuse on the risk of delirium in patients with traumatic brain injury (TBI). This study aimed to assess the incidence of delirium among patients with blunt TBI in association with different substances. METHODS: We analyzed the 2020 American College of Surgeons-Trauma Quality Improvement Program. We included all adult (≥18 y) patients with blunt TBI who had a recorded substance (drugs and alcohol) screening. Our primary outcome was the incidence of delirium. RESULTS: A total of 72,901 blunt TBI patients were identified. The mean (standard deviation) age was 56 (20) years and 68.0% were males. The median (interquartile range) injury severity score was 17 (10-25). Among the study population, 23.1% tested positive for drugs (Stimulants: 3.0%; Depressants: 2.9%, hallucinogens: 5.1%, Cannabinoids: 13.4%, TCAs: 0.1%), and 22.8% tested positive for Alcohol. Overall, 1856 (2.5%) experienced delirium. On univariate analysis, patients who developed delirium were more likely to have positive drug screening results. On multivariable regression analyses, positive screen tests for isolated stimulants (adjusted odds ratio [aOR]: 1.340, P = 0.018), tricyclic antidepressants (aOR: 3.107, P = 0.019), and cannabinoids (aOR: 1.326, P ≤ 0.001) were independently associated with higher odds of developing delirium. CONCLUSIONS: Nearly one-fourth of adult patients with blunt TBI had an initial positive substance screening test. Patients with positive results for isolated stimulants, tricyclic antidepressants, and cannabinoids were at a higher risk of developing delirium, whereas this association was not evident with other drugs and alcohol-positive tests. These findings emphasize the need for early drug screening in TBI patients and close monitoring of patients with positive screening tests.

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.

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.

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.

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.

Emergency Department Shock Index Outperforms Prehospital and Delta Shock Indices in Predicting Outcomes of Trauma Patients.

INTRODUCTION: Multiple shock indices (SIs), including prehospital, emergency department (ED), and delta (ED SI - Prehospital SI) have been developed to predict outcomes among trauma patients. This study aims to compare the predictive abilities of these SIs for outcomes of polytrauma patients on a national level. METHODS: This was a retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program (2017-2018). We included adult (≥18 y) trauma patients and excluded patients who were transferred, had missing vital signs, and those with severe head injuries (Head-Abbreviated Injury Scale>3). Outcome measures were 24-h and in-hospital mortality, 24-h packed red blood cells transfusions, and intensive care unit and hospital length of stay. Predictive performances of these SIs were evaluated by the Area Under the Receiver Operating Characteristics for the entire study cohort and across all injury severities. RESULTS: A total of 750,407 patients were identified. Meanstandard deviation age and lowest systolic blood pressure were 53 ± 21 y, and 81 ± 32 mmHg, respectively. Overall, 24-h and in-hospital mortality were 1.2% and 2.5%, respectively. On multivariable analysis, all three SIs were independently associated with higher rates of 24-h and in-hospital mortality, blood product requirements, intensive care unit and hospital length of stay (P < 0.001). ED SI was superior to prehospital and delta SIs (P < 0.001) for all outcomes. On subanalysis of patients with moderate injuries, severe injuries, and positive delta SI, the results remained the same. CONCLUSIONS: ED SI outperformed both prehospital and delta SIs across all injury severities. Trauma triage guidelines should prioritize ED SI in the risk stratification of trauma patients who may benefit from earlier and more intense trauma activations.

Minimally Invasive Surgery for Genitourinary Trauma: A Nationwide Outcomes-Based Analysis.

INTRODUCTION: Bladder and ureteral injuries are uncommon in trauma patients but are associated with increased morbidity and mortality. Patients presenting with such injuries may undergo either open surgical repair or laparoscopic repair. We aimed to compare outcomes of open surgical approach and laparoscopy in trauma patients with isolated bladder and ureteral injury. We hypothesized that laparoscopy is associated with improved outcomes. METHODS: We performed a 2017 review of American College of Surgeons Trauma Quality Improvement Program and identified trauma patients with bladder and ureteral injury who underwent open surgical repair or laparoscopy. A 1:1 propensity score matching was performed adjusting for demographics, emergency department vitals (systolic blood pressure, heart rate, Glasgow Coma Scale), mechanism of injury, Injury Severity Score, each body region Abbreviated Injury Scale score, and transfusion units. Outcomes were rates of in-hospital major complications and mortality. RESULTS: Of the 1,004,440 trauma patients, 384 patients (open: 192 and laparoscopy: 192) were matched and included. The mean age was 36 ± 15 y, Injury Severity Score was 27 [27-48], 77% were males, and 56% of patients had a blunt mechanism of injury, and 44% had penetrating injuries. Overall mortality was 7.3%. On univariate analysis, mortality was lower in the open group as compared to the laparoscopy group (10.4% versus 4.2%, P = 0.019) and survivor-only hospital length of stay was longer in the open group (8 [8-9] versus 7 [5-11], P = 0.008). There was no difference in overall major complications (23% versus 21%, P = 0.621). On multivariate analysis, open surgical repair was independently associated with lower odds of mortality (adjusted odds ratio: 0.405, 95% confidence interval: [0.17-0.95], P-value = 0.038) CONCLUSIONS: In our analysis open surgical repair of bladder and ureteral injuries was associated with lower mortality with other outcomes being similar when compared to laparoscopy. Laparoscopic surgical repair may not have an advantage over the open surgical repair for bladder and ureteral injuries. Further prospective studies are needed to delineate the ideal surgical approach for these injuries.

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.

It is not all black and white: The effect of increasing severity of frailty on outcomes of geriatric trauma patients.

BACKGROUND: Frailty is associated with poor outcomes in trauma patients. However, the spectrum of physiologic deficits, once a patient is identified as frail, is unknown. The aim of this study was to assess the dynamic association between increasing frailty and outcomes among frail geriatric trauma patients. METHODS: This is a secondary analysis of the American Association of Surgery for Trauma Frailty Multi-institutional Trial. Patients 65 years or older presenting to one of the 17 trauma centers over 3 years (2019-2022) were included. Frailty was assessed within 24 hours of presentation using the Trauma-Specific Frailty Index (TSFI) questionnaire. Patients were stratified by TSFI score into six groups: nonfrail (<0.12), Grade I (0.12-0.19), Grade II (0.20-0.29), Grade III (0.30-0.39), Grade IV (0.40-0.49), and Grade V (0.50-1). Our Outcomes included in-hospital and 3-month postdischarge mortality, major complications, readmissions, and fall recurrence. Multivariable regression analyses were performed. RESULTS: There were 1,321 patients identified. The mean (SD) age was 77 years (8.6 years) and 49% were males. Median [interquartile range] Injury Severity Score was 9 [5-13] and 69% presented after a low-level fall. Overall, 14% developed major complications and 5% died during the index admission. Among survivors, 1,116 patients had a complete follow-up, 16% were readmitted within 3 months, 6% had a fall recurrence, 7% had a complication, and 2% died within 3 months postdischarge. On multivariable regression, every 0.1 increase in the TSFI score was independently associated with higher odds of index-admission mortality and major complications, and 3 months postdischarge mortality, readmissions, major complications, and fall recurrence. CONCLUSION: The frailty syndrome goes beyond a binary stratification of patients into nonfrail and frail and should be considered as a spectrum of increasing vulnerability to poor outcomes. Frailty scoring can be used in developing guidelines, patient management, prognostication, and care discussions with patients and their families. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

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.

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.

Finding The Sweet Spot: The Association Between Whole Blood to Red Blood Cells Ratio and Outcomes of Hemorrhaging Civilian Trauma Patients.

PURPOSE: To evaluate the dose-dependent effect of Whole Blood (WB) on the outcomes of civilian trauma patients with hemorrhagic shock. METHODS: We performed a 2-year (2020-2021) retrospective analysis of the ACS-TQIP dataset. Adult (≥18) trauma patients with a shock index (SI) >1 who received at least 5 units of PRBC and one unit of WB within the first 4 hours of admission were included. Primary outcomes were 6-hr, 24-hr, and in-hospital mortality. Secondary outcomes were major complications and hospital and ICU length of stay (LOS). RESULTS: A total of 830 trauma patients with a mean (SD) age of 38 (16) were identified. The median [IQR] 4-hour WB and PRBC requirements were 2[2-4] U and 10[7-15] U, respectively, with a median WB:RBC ratio of 0.2 [0.1-0.3]. Every 0.1 increase in WB:RBC ratio was associated with decreased odds of 24-hour mortality (aOR:0.916, p = 0.035) and in-hospital mortality (aOR:0.878, p < 0.001). Youden's index identified 0.25 (1 U of WB for every 4 U of PRBC) as the optimal WB:PRBC ratio to reduce 24-hour mortality. High ratio (≥0.25) group had lower adjusted odds of 24-hour mortality (aOR:0.678, p = 0.021) and in-hospital mortality (aOR:0.618, p < 0.001) compared to the Low ratio group. CONCLUSIONS: A higher WB:PRBC ratio was associated with improved early and late mortality in trauma patients with hemorrhagic shock. Given the availability of WB in trauma centers across the United States, at least one unit of WB for every four units of PRBC may be administered to improve the survival of hemorrhaging civilian trauma patients.

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.

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.

Interfacility transfer of pediatric trauma patients to higher levels of care: The effect of transfer time and level of receiving trauma center.

BACKGROUND: Interfacility transfer of pediatric trauma patients to pediatric trauma centers (PTCs) after evaluation in nontertiary centers is associated with improved outcomes. We aimed to assess the outcomes of transferred pediatric patients based on their severity of the injury, transfer time, and level of receiving PTCs. METHODS: This is a 3-year (2017-2019) analysis of the American College of Surgeons Trauma Quality Improvement Program database. All children (younger than 15 years) who were transferred from other facilities to Level I or II PTC were included and stratified by level of receiving PTCs and injury severity. Outcome measures were in-hospital mortality and major complications. RESULTS: A total of 67,726 transferred pediatric trauma patients were identified, of which 52,755 were transferred to Level I and 14,971 to Level II. The mean ± SD age and median Injury Severity Score were 7 ± 4 years and 4 (1-6), respectively. Eighty-five percent were transported by ground ambulance. The median transfer time for Levels I and II was 93 (70-129) and 90 (66-128) minutes, respectively ( p < 0.001). On multivariable regression, interfacility transfers to Level I PTCs were associated with decreased risk-adjusted odds of in-hospital mortality among the mildly to moderately injured group (adjusted odds ratio, 0.59; p = 0.037) and severely injured group with a transfer time of less than 60 minutes (adjusted odds ratio, 0.27; p = 0.002). CONCLUSION: Every minute increase in the interfacility transfer time is associated with a 2% increase in risk-adjusted odds of mortality among severely injured pediatric trauma patients. Factors other than the level of receiving PTCs, such as estimated transfer time and severity of injury, should be considered while deciding about transferring pediatric trauma patients to higher levels of care. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Dealing with the elder abuse epidemic: Disparities in interventions against elder abuse in trauma centers.

BACKGROUND: Elder abuse is a major cause of injury, morbidity, and death. We aimed to identify the factors associated with interventions against suspected physical abuse in older adults. METHODS: Analysis of the 2017-2018 ACS TQIP. All trauma patients ≥60 years with an abuse report for suspected physical abuse were included. Patients with missing information on abuse interventions were excluded. Outcomes were rates of abuse investigation initiation following an abuse report and change of caregiver at discharge among survivors with an abuse investigation initiated. Multivariable regression analyses were performed. RESULTS: Of 727,975 patients, 1405 (0.2%) had an abuse report. Patients with an abuse report were younger (mean, 72 vs 75, p < 0.001), and more likely to be females (57% vs 53%, p = 0.007), Hispanic (11% vs 6%, p < 0.001), Black (15% vs 7%, p < 0.001), suffer from dementia (18% vs 11%, p < 0.001), functional disability (19% vs 15%, p < 0.001), have a positive admission drug screen (9% vs 5%, p < 0.001) and had a higher ISS (median [IQR], 9 [4-16] vs 6 [3-10], p < 0.001). Perpetrators were members of the immediate/step/extended family in 91% of cases. Among patients with an abuse report, 1060 (75%) had abuse investigations initiated. Of these, 227 (23%) resulted in a change of caregiver at discharge. On multivariate analysis for abuse investigation initiation, male gender, private insurance, and management at non-level I trauma centers were associated with lower adjusted odds (p < 0.05), while Hispanic ethnicity, positive admission drug screen, and penetrating injury were associated with higher adjusted odds (p < 0.05). On multivariate analysis for change of caregiver, male gender, and private insurance were associated with lower adjusted odds (p < 0.05), while functional disability and dementia were associated with higher adjusted odds (p < 0.05). CONCLUSIONS: Significant gender, ethnic, and socioeconomic disparities exist in the management of physical abuse of older adults. Further studies are warranted to expand on and address the contributing factors underlying these disparities. LEVEL OF EVIDENCE: III. STUDY TYPE: Therapeutic/Care Management.