Impact of Trauma Resuscitation Emergency Care Nurse Deployment in Trauma Activations in a Rural Trauma Center.

BACKGROUND: Although the role of a dedicated trauma nurse has been implemented in an urban setting, it has not been studied in the rural trauma setting. We instituted a trauma resuscitation emergency care (TREC) nurse role to respond to trauma activations at our rural trauma center. OBJECTIVE: This study aims to determine the impact of TREC nurse deployment on the timeliness of resuscitation interventions in trauma activations. METHODS: This pre- and postintervention study at a rural Level I trauma center compared the time to resuscitation interventions before (August 2018 to July 2019) and after (August 2019 to July 2020) deploying TREC nurses to trauma activations. RESULTS: A total of 2,593 participants were studied, of which 1,153 (44%) were in the pre-TREC group and 1,440 (56%) in the post-TREC group. After TREC deployment, the median (interquartile range [IQR]) emergency department times within the first hour decreased from 45 (31.23-53) to 35 (16-51) min ( p = .013). The median (IQR) time to the operating room within the first hour decreased from 46 (37-52) to 29 (12-46) min ( p = .001), and within the first 2 hr, decreased from 59 (43.8-86) to 48 (23-72) min ( p = .014). CONCLUSION: Our study found that TREC nurse deployment improved resuscitation intervention timeliness during the first 2 hr (early phase) of trauma activations.

Before Disaster Strikes: A Pilot Intervention to Improve Pediatric Trainees' Knowledge of Disaster Medicine.

OBJECTIVE: Because training in pediatric disaster medicine (PDM) is neither required nor standardized for pediatric residents, we designed and integrated a PDM course into the curriculum of a pediatric residency program and assessed if participation increased participants' knowledge of managing disaster victims. METHODS: We adapted and incorporated a previously studied PDM course into a small-sized pediatric residency program. The curriculum consisted of didactic lectures and experiential learning via simulation with structured debriefing. With IRB approval, the authors conducted a longitudinal series of pretests and posttests to assess knowledge and perceptions. RESULTS: Sixteen eligible residents completed the intervention. Before the course, none of the residents reported experience treating disaster victims. Pairwise comparison of scores revealed a 35% improvement in scores immediately after completing the course (95% confidence interval, 22.73%-47.26%; P < 0.001) and a 23.73% improvement 2 months later (95% confidence interval, 7.12%-40.34%; P < 0.01). CONCLUSIONS: Residents who completed this course increased their knowledge of PDM with moderate retention of knowledge gained. There was a significant increase in perceived ability to manage patients in a disaster situation after this educational intervention and the residents' confidence was preserved 2 months later. This PDM course may be used in future formulation of a standardized curriculum.

Comparative Analysis of State Trauma Triage Criteria vs. Paramedic Discretion.

OBJECTIVE: The Florida Adult Trauma Triage Criteria (FATTC) define specific parameters concerning injury mechanism and physiologic data that prompt paramedics to initiate a trauma alert and necessitate transport to a trauma center. In the state of Florida, paramedics are also given discretion to bring patients to the trauma center who do not meet those criteria. Our aim was to compare the injury characteristics and outcomes of adult patients who were evaluated in our trauma center after activation due to FATTC criteria vs. paramedic discretion (PD) and to identify predictors of PD. METHODS: This retrospective study included all patients 18 years and older evaluated in our trauma center from January 1, 2007, to December 31, 2014. Descriptive statistics were computed for all variables. Bivariate and multivariate analyses were performed to compare demographic, injury severity, and outcome differences between groups. RESULTS: A total of 13,963 patients met FATTC during the study period, and 1,811 were brought in by PD. PD patients had lower injury severity and crude mortality. Regression modeling of demographic and injury variables found that only the combination of older age and higher heart rate predicted PD when both were lower than FATTC alone. CONCLUSIONS: While PD patients were less seriously injured and had lower mortality, they experienced similar lengths of stay and resource utilization after presentation. Paramedics may be able to identify patients at risk for poor outcomes who would otherwise not be captured by FATTC.

An evaluation of trauma outcomes related to insurance status in patients requiring prehospital helicopter transport.

INTRODUCTION: Disparities in access to medical care and outcomes of medical treatment related to insurance status are documented. However, little attention has been given to the effect of health care funding status on outcomes in trauma patients. Hypothesis/Problem This study evaluated if adult trauma patients who arrived by air transport to a trauma center had different clinical outcomes based on their health insurance status. METHODS: A retrospective analysis was performed of all adult trauma patients arriving by prehospital flight services to a Level I Trauma Center over a 5-year period. Patients were classified as unfunded or funded based on health insurance status. Injury severity scores (ISS) were compared, while the end points evaluated in the study included duration of stay in the intensive care unit (ICU), duration of hospitalization, and mortality. RESULTS: A total of 1,877 adult patients met inclusion criteria for the study, with 14% (n = 259) classified as unfunded and 86% (n = 1,618) classified as funded. Unfunded patients compared to funded patients had a significantly lower average ISS (12.82 vs 15.56; P < .001) but a significantly higher mortality rate (16.6% vs 10.7%; P < .01) and a 1.54 relative risk of death (95% CI, 1.136-2.098). Neither mean ICU stay (3.44 days vs 4.98 days; P = .264) nor duration of hospitalization (11.18 days vs 13.34 days; P = .382) was significantly different when controlling for ISS. CONCLUSION: Unfunded health insurance status is associated with worse outcomes following less significant injury. Further investigation of baseline health disparities for identification and early intervention may improve outcomes. Additionally, these findings may have implications for the health systems of other countries that lack universal health care coverage.

Assessing Futile Trauma Transfers in Rural Appalachia Following a Regional Health Care System Consolidation.

This study sought to define and analyze rates of futile trauma transfers (FTTs) after the consolidation of two rural level 1 trauma centers into one. Data was extracted from the regional trauma registry for a period of 5 years (2017-2022) for all trauma patients transferred into our level 1 trauma center (n = 3369). An FTT was defined as a transfer that (1) received no major interventions and (2) died or was discharged to a hospice facility within 72 hours. Out of the 3369 transfer patients analyzed during the 33-month pre-consolidation and 33-month post-consolidation periods, 34 patients met the criteria of an FTT within the transfer-to-discharge window. The pre-consolidation category contained 12, and the post-consolidation category contained 22. Chi-square analysis indicated no significant difference in FTT rate between categories. Furthermore, the post-consolidation FTT rate of 1.1% remained consistent with the estimated national average of 1.5%.

Operative Management and Outcome of Idiopathic Rectal Necrosis in an Octogenarian.

Idiopathic acute rectal necrosis (IARN) is a rare condition due to a robust rectal blood supply. This report describes an 83-year-old man presenting with septic shock due to distal sigmoid and complete rectal necrosis with perforation. He underwent emergent exploratory laparotomy, sigmoid and proximal rectum resection, and end sigmoid colostomy creation with delayed distal rectal evaluation. Bedside proctoscopy revealed pale, viable-appearing distal rectal mucosa on postoperative day 3. The patient had a protracted, complicated hospital stay but required no further operative intervention. Subsequent colostomy reversal was done 8 months postoperatively, and the patient did well and has been discharged with normal gastrointestinal function. Our successful conservative operative management of IARN deviates from previously described management in the literature which is emergent abdominoperineal resection. This conservative surgical strategy appears to have contributed to the patient's positive outcomes, highlighting the importance of considering a similar approach for future IARN cases.

Evaluation of Secondary Overtriage at a Rural Level 1 Trauma Center.

OBJECTIVE: To retrospectively assess the prevalence of secondary overtriage (SO) within a rural regional Appalachian health care system. METHODS: Trauma registry data was extracted for all trauma activation transfer patients from 2017 to 2022. Transferred patients were then stratified into two groups, non-secondary overtriage (non-SO) or SO. Patients were considered SO if they met three criteria following transfer: an Injury Severity Score (ISS) of less than 15, no required operative intervention, and discharge within 48 hours of arrival. Descriptive statistics were compared for age, length of stay (LOS), ICU LOS, and ISS. Surgical subspecialty consultations were compared between the two groups. Patients in the SO group were further assessed by body region of injury and Abbreviated Injury Score (AIS). RESULTS: Among 3,291 trauma activation transfer patients, 43% (1,407) were considered SO transfers. Patients in the SO group were significantly younger, had shorter average hospital and ICU LOS, and lower ISS compared to the non-SO group. Additionally, 25.7% of patients in the SO group had injuries to the head or neck of which 8.96% have an AIS ≥3. 21% of patients had injuries to the face, with 0.14% having an AIS ≥3. CONCLUSIONS: 43% of transfer patients in this study met our definition of SO. Although no optimal rate of SO has been universally established, limiting SO stands to benefit both patients and trauma systems. This study highlights how institutional analysis of transfer patients may help inform transfer protocols to reduce secondary overtriage and overutilization of scarce resources.

Outcome of Seatbelt Education and Safety Program Among Teenagers.

Despite the effectiveness of seatbelts, concerns persist about compliance, especially among teenagers. Survey data from a local high school and registry data from a level 1 trauma center were used to observe seatbelt and motor vehicle accident trends. The survey data was analyzed to gauge student's sentiments on seatbelt education. The trauma center data was analyzed to identify characteristics and trends among teenage motor vehicle accidents. Social media was the most common strategy selected for seatbelt safety awareness. Random seatbelt checks performed over 4 months revealed seatbelt compliance rates of 90%, 93.55%, and 96.94% after education intervention. Trauma center data showed that lack of seatbelt usage resulted in greater morbidity. These findings emphasize the need for targeted interventions. This study provides insights into creating effective education campaigns that can be used to enhance safety belt compliance and potentially reduce injury.

Antithrombotics in the Fall Patient: Appropriateness and Risk-Benefit Analysis.

Falls are the leading cause of hospitalizations following trauma nationwide, resulting in over 3 million admissions in 2020. This population is typically aged, and many are prescribed antithrombotic (AT) therapy. In this prospective study, we aimed to analyze fall history while assessing appropriateness of AT regimen relative to fall risk. Patients presenting following ground level fall (GLF) and meeting inclusion criteria during the study period were enrolled. Primary outcome was the relationship between AT therapy necessity (CHA2DS2-VASc) and fall risk (Morse Fall Risk). The cohort of 30 patients had an average age of 77. CHA2DS2-VASc and Morse Fall Risk showed a moderate-positive correlation (r = 0.47; P = 0.012); however, 17% of patients categorized as high fall risk had a <5% 1-year risk of VTE. This study demonstrates that risks of hemorrhage may outweigh thromboembolism prophylaxis in a significant number of patients and sheds light on the astonishing fall volume in this population.

Trends of Self-Inflicted Firearm Injuries at a Rural Level 1 Trauma Center.

Firearm injuries are a major public health concern with much focus on injuries due to violent crimes in urban areas. Less focus has been on self-inflicted injuries and rural settings. This study included 201 patients, of which 124 (61.7%) were accidental and 77 (38.3%) were intentional self-inflicted gunshot wounds (GSWs) sustained over 6 years at a rural level 1 trauma center. Injury severity scores (P < .001), hospital days (P < .001), and mortality (P < .001) were significantly higher among intentional self-inflicted GSWs. Injuries to the head were the most common injury among patients with intentional self-inflicted GSWs (P < .001).Accidental and intentional self-inflicted GSWs make up a large portion of firearm injuries seen at our rural level 1 trauma center, and defining these injuries can facilitate the need for targeted gun safety and injury prevention efforts.

Application of the Geriatric Trauma Outcome Score in a Rural Setting.

OBJECTIVE: To retrospectively apply the Geriatric Trauma Outcome (GTO) score to the patient population of a rural South Central Appalachian level 1 trauma center and identify the potential utility of the GTO score in guiding goals of care discussions. METHODS: Trauma registry data was extracted for 5,627 patients aged 65+ from 2017 to 2021. GTO score was calculated for each patient. Descriptive statistics were calculated for age, Injury Severity Score (ISS), GTO score, receipt of red blood cells, discharge status, and code status. A simple logistic regression model was used to determine the relationship between GTO score and discharge status. The probability of mortality was then calculated using GTO score, and the distribution of code status among patients with ≤50, 51-75%, and >75% probability of mortality was examined. RESULTS: For every 10-point increase in GTO score, odds of mortality increased by 79% (OR = 1.79; P < .001). Patients had an estimated 50% probability of mortality with a GTO score of 156, 75% with 174, and 99% with a score of 234, respectively. Seventeen patients had a GTO score associated with >75% probability of mortality. Of those 17 patients, four retained a full code status. CONCLUSIONS: Our analysis demonstrates that the GTO score is a validated measure in a rural setting and can be an easily calculated metric to help determine a geriatric patient's probability of mortality following a trauma. The results of our study also found that GTO score can be used to inform goals of care discussions with patients.

Effects of Trauma Center Consolidation on Adult Trauma at a Rural Level 1 Trauma Center.

OBJECTIVE: The aim was to determine the impact of consolidation of two rural level 1 trauma centers on adult trauma patients presenting to the remaining level 1 trauma center. To our knowledge, a study assessing the impact of trauma center consolidation on adult trauma patients had yet to be performed. METHODS: A single institution, retrospective study was conducted at a rural level 1 trauma center. Adult trauma patients who presented to our center from January 2017 to January 2022 were included. The cohorts spanned 33 months pre- and post-consolidation. Multiple demographic and outcome measures were gathered. Data were analyzed using the student's t-test and Chi-squared testing. RESULTS: There was a 33% increase in overall trauma activations and 9% increase in transfers from outside facilities post-consolidation. The post-consolidation group was significantly older, had higher mean injury severity score, and decreased hospital-free days. The post-consolidation group also saw an increase in ICU admission and surgical intervention. While there were no significant differences in ICU-free days or ventilator days, patients in the post-consolidation group with the highest level of activation who required both surgical intervention and ICU admission experienced decreased mortality. CONCLUSION: The consolidation of trauma services to a single level 1 trauma center in a rural Appalachian health system led to higher trauma volume and acuity, but most importantly decreased mortality for the most severely injured trauma patients.

Poor Outcomes of Patients From Delayed Care After Ground Level Falls.

BACKGROUND: Ground level falls are a common cause of morbidity and mortality in trauma patients. Delayed presentation in many conditions has been proven to lead to worsened outcomes. Currently, there are limited data on outcomes of those who have a delayed presentation after a ground level fall. MATERIALS AND METHODS: This study was a retrospective analysis of the Trauma Registry at our center. Any adult patient who presented after a ground level fall was grouped based on their time to presentation post-injury: less than or greater than 24 h. Age, gender, hospital length of stay (LOS), intensive care unit (ICU) LOS, mechanical ventilation days, Injury Severity Score, and mortality were patient characteristics gathered. A Student's t-test and Chi-squared testing were utilized to determine the presence of significant differences between the groups. Significance was set at P < .05. RESULTS: Two hundred of 4018 patients had delayed presentation. Those with delayed presentation were more likely to be male (P = .028), younger in age (71 vs 74 years old, P < .01), had greater hospital LOS (6 vs. 5, P < .01), ICU LOS (5 vs. 3, P < .01), and mechanical ventilation days (13 vs. 5 days, P < .01). They also had higher ISS (8 vs. 7, P < .01), and mortality was significantly higher in those who presented after 24 h (P = .034). CONCLUSION: Patients with delayed presentation after a ground level fall have worsened Injury Severity Scores and outcomes to include hospital and ICU LOS, ventilator days, and overall mortality.

Lower Extremity Sandblast Injury: A Rarely Seen Injury Mechanism in the Civilian Population.

Blast injuries are both complex and rare in the civilian population. This combination can often lead to missed opportunities for early, effective intervention. This is a case report of a 31-year-old male who suffered a lower extremity blast injury while using an industrial sandblaster. This blast injury presented as a closed degloving, or Morel-Lavallee lesion, which can easily be mistreated and lead to infection and further disability. Following assessment, identification, and confirmation of the Morel-Lavallee lesion via radiographic imaging, this patient underwent debridement surgery, wound vac therapy, and antibiotic treatment before being discharged home with no major physiologic or neurologic deficits. The purpose of this report is to highlight the importance of assessing for closed degloving injuries when presented with blast injury traumas in the civilian trauma setting, and outlines the process utilized for assessment and treatment.

Sunken Skin Flap Syndrome: Neurological Dysfunction After Decompressive Craniectomy.

Sunken Skin Flap Syndrome (or Syndrome of the Trephined) following a head trauma is rare, but most often results from complications after decompressive craniectomy. This syndrome is most often characterized by neurological dysfunction that improves with cranioplasty. Early diagnosis and treatment are critically important to long term neurological improvement. This is a case report of a 49-year-old male who fell down a flight of stairs and was found unresponsive. Initial imaging revealed extensive head trauma. Neurosurgery performed an emergency decompressive craniectomy, but his post-operative course was complicated by the development of sunken flap syndrome one month after his initial surgery, diagnosed by an acute neurological decline and emergent CT imaging. A review of the literature indicates that this is a rarely documented finding, and this case report discusses the critical components of diagnosis and treatment of this unusual and potentially lethal condition.

Effects of Trauma Center Consolidation on Pediatric Trauma at an Appalachian Pediatric Hospital.

With the increase in hospital consolidation over the past decade, multiple studies have been performed evaluating patient outcomes after consolidation. To date, there have not been studies performed to assess outcomes in pediatric trauma patients. The goal was to assess pediatric patient outcomes in a children's hospital after consolidation of two Level 1 Trauma centers in a rural Appalachian health system. A retrospective analysis of data from the Trauma Registry between October 2015 - September 2020 was performed. The variables included in analysis were age, injury severity score (ISS), hospital days, intensive care unit days, ventilator days, mortality, discharge disposition, consults, and hospital visit cost. Despite increased ISS, there was no difference in in-patient outcomes. However, these patients were more likely to require orthopedic evaluation and further outpatient care after discharge, suggesting more severely injured patients were evaluated by the trauma service post consolidation.

Antibiotic prophylaxis for tube thoracostomy placement in trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma.

Background: Antibiotic prophylaxis is routinely administered for most operative procedures, but their utility for certain bedside procedures remains controversial. We performed a systematic review and meta-analysis and developed evidence-based recommendations on whether trauma patients receiving tube thoracostomy (TT) for traumatic hemothorax or pneumothorax should receive antibiotic prophylaxis. Methods: Published literature was searched through MEDLINE (via PubMed), Embase (via Elsevier), Cochrane Central Register of Controlled Trials (via Wiley), Web of Science and ClinicalTrials.gov databases by a professional librarian. The date ranges for our literature search were January 1900 to March 2020. A systematic review and meta-analysis of currently available evidence were performed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Results: Fourteen relevant studies were identified and analyzed. All but one were prospective, with eight being prospective randomized control studies. Antibiotic prophylaxis protocols ranged from a single dose at insertion to 48 hours post-TT removal. The pooled data showed that patients who received antibiotic prophylaxis were significantly less likely to develop empyema (OR 0.47, 95% CI 0.25 to 0.86, p=0.01). The benefit was greater in patients with penetrating injuries (penetrating OR 0.25, 95% CI 0.10 to 0.59, p=0.002, vs blunt OR 0.25, 95% CI 0.06 to 1.12, p=0.07). Administration of antibiotic prophylaxis did not significantly affect pneumonia incidence or mortality. Discussion: In adult trauma patients who require TT insertion, we conditionally recommend antibiotic prophylaxis be given at the time of insertion to reduce incidence of empyema. PROSPERO registration number: CRD42018088759.

Emergency airway placement by EMS providers: comparison between the King LT supralaryngeal airway and endotracheal intubation.

INTRODUCTION: The ever-present risk of mass casualties and disaster situations may result in airway management situations that overwhelm local emergency medical services (EMS) resources. Endotracheal intubation requires significant user education/training and carries the risk of malposition. Furthermore, personal protective equipment (PPE) required in hazardous environments may decrease dexterity and hinder timely airway placement. Alternative airway devices may be beneficial in these situations. OBJECTIVE: The objective of this study was to evaluate the time needed to place the King LT Supralaryngeal Airway compared to endotracheal intubation when performed by community EMS personnel with and without PPE. METHODS: Following training, 47 EMS personnel were timed placing both endotracheal tubes and the King LT supralaryngeal airway in a simulator mannikin. The study participants then repeated this exercise wearing PPE. RESULTS: The EMS personnel wearing PPE took significantly longer to place an endotracheal tube than they did without protective equipment (53.4 seconds and 39.5 seconds, p <0.002). The time to place the King LT was significantly faster than the placement of the endotracheal tube without protective equipment (18.4 seconds and 39.5 seconds, respectively, p <0.00003). There also were statistically significant differences between the time required to place the King LT and endotracheal tube in EMS personnel wearing protective equipment (19.7 seconds and 53.4 seconds, p <0.000007). CONCLUSIONS: The King LT Supralaryngeal Airway device may be advantageous in prehospital airway management situations involving multiple patients or hazardous environments. In this study, its insertion was faster than endotracheal intubation when performed by community EMS providers.