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.

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.

Final Lifelines: The Implications and Outcomes of Thoracic Damage Control Surgeries.

INTRODUCTION: There is a lack of data on the outcomes of thoracic damage control surgery (TDCS). This study aimed to describe the characteristics and outcomes of patients undergoing TDCS. METHODS: This is a retrospective analysis of the American College of Surgeons-Trauma Quality Improvement Program database (2017-2021). All trauma patients who underwent emergency thoracotomy and packing with temporary closure were included. Patients were stratified based on the age groups (pediatric [<18 y], adults [18-64 y], and older adults [≥65 y]). Our primary outcome measures included 6-h, 24-h, and in-hospital mortality. Secondary outcomes were major complications. RESULTS: We identified 14,192 thoracotomies, out of which 213 underwent TDCS (pediatric [n = 17], adults [n = 175], and older adults [n = 21]). The mean (SD) age was 37 (18), and 86% were male. The mean shock index was 1.1 (0.4) on presentation with a median [IQR] Glasgow Coma Scale of 4 [3-14], and 22.1% had a prehospital cardiac arrest. The study population was profoundly injured with a median injury severity scoreand chest-abbreviated injury scale of 26 [17-38] and 4 [3-5], respectively, with lung (76.5%) being the most injured intrathoracic organs. Overall, the rates of 6-h, 24-h, and in-hospital mortality were 22.5%, 33%, and 53%, respectively, and 51% developed major complications. There was no significant difference in terms of in-hospital mortality (P = 0.800) and major complications (0.416) among pediatrics, adults, and older adults. CONCLUSIONS: One in three patients undergoing TDCS die within the first 24 h, and more than half of them develop major complications and die in the hospital, with no difference among pediatric, adults, and older adults. Future efforts should be directed to improve the survival of these severely injured, metabolically depleted, challenging patients.

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.

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.

Trauma Laparotomy for the Cirrhotic Patient: An Outcome-Based Analysis.

INTRODUCTION: There is a lack of large-scale data on outcomes of cirrhotic patients undergoing trauma laparotomy. We aimed to compare outcomes of cirrhotic versus noncirrhotic trauma patients undergoing laparotomy. METHODS: We analyzed 2018 American College of Surgeons Trauma Quality Improvement Program. We included blunt trauma patients (≥18 y) who underwent a laparotomy. Patients who were transferred, dead on arrival, or had penetrating injuries were excluded. Patients were matched in a 1:2 ratio (cirrhotic and noncirrhotic). Outcomes included mortality, complications, failure to rescue, transfusion requirements, and hospital and intensive care unit (ICU) lengths of stay. Multivariable backward stepwise regression analysis was performed. RESULTS: Four hundred and seventy-one patients (cirrhotic, 157; noncirrhotic, 314) were matched. Mean age was 57 ± 15 y, 78% were male, and median injury severity score was 24. Cirrhotic patients had higher rates of mortality (60% versus 30%, P value <0.001), complications (49% versus 37%; P value = 0.01), failure to rescue (66% versus 36%, P value<0.001), and pRBC (units, median, 11 [7-18] versus 7 [4-11], P value <0.001) transfusion requirements. There were no significant differences in hospital and intensive care unit (ICU) lengths of stay (P value ≥0.05). On multivariate analysis, increasing age (adjusted odds ratio [aOR] 1.02, P value <0.001), Glasgow Coma Scale score ≤8 at presentation (aOR 3.3, P value <0.001), and total splenectomy (aOR 5.7, P value <0.001) were associated with higher odds of mortality. Platelet transfusion was associated with lower odds of mortality (aOR 0.84, P value = 0.044). CONCLUSIONS: On a national scale, mortality following trauma laparotomy is twice as high for cirrhotic patients compared to noncirrhotic patients with higher rates of major complications and failure to rescue. Our finding of a protective effect of platelet transfusion may be explained by the platelet dysfunction associated with cirrhosis. Liver cirrhosis among trauma patients warrants heightened surveillance.

The Synergy Factor: Trauma and Cancer.

INTRODUCTION: Trauma and cancer are the leading causes of death in the US. There is a paucity of data describing the impact of cancer on trauma patients. We aimed to determine the influence of cancer on outcomes of trauma patients. METHODS: In this retrospective analysis of American College of Surgeons-Trauma Quality Improvement Program 2019-2021, we included all adult trauma patients (≥18 y) and excluded patients with severe head injuries and nonmelanomatous skin cancers. Patients were stratified into cancer (C), and no cancer (No-C). Propensity score matching (1:3) was performed. Outcomes were complications and mortality. RESULTS: A matched cohort of 3236 patients (C, 809; No-C, 2427) was analyzed. The mean age was 70 y, 50.5% were males, and the median injury severity score was 8 (4-10). There were no differences in terms of receiving thromboprophylaxis (C 51%: No-C 50%, P = 0.516). Compared to No-C group, the C group had higher rates of deep vein thrombosis (C 1.1% versus No-C 0.3%, P = 0.004), but there was no difference in terms of overall complications. Patients in the C group had higher mortality (C 7.5% versus No-C 2.7%, P < 0.001). CONCLUSIONS: Trauma patients with cancer have nearly 4 times higher odds of deep vein thrombosis and 3 times higher odds of mortality. Developing pathways specific to cancer patients might be necessary to improve the outcomes of trauma patients with cancer.

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.

The Bottom Line: Trauma Center Viability During COVID-19.

INTRODUCTION: The COVID-19 pandemic was a potential threat to the viability of trauma centers and health systems in general. We sought to answer the question of how COVID-19 was associated with patient characteristics as well as trauma center volume, finances, and viability. METHODS: We reviewed 6375 patients admitted to our verified Level 1 trauma center during two time periods: pre-COVID (February 2019-February 2020) and COVID (March 2020-March 2021). Three thousand ninety-nine patients were admitted pre-COVID and 3276 were admitted during COVID. Data including case-mix index (CMI), total contribution margin, insurance status, age, race, gender, ethnicity, and injury mechanism were collected from the trauma registry and finance databases and analyzed. A P < 0.05 was considered significant. RESULTS: Trauma admissions decreased initially during COVID but returned to and ultimately surpassed admission trends pre-COVID. Trauma revenue and patient acuity increased significantly along with a decrease in the number of underinsured patients during COVID. When evaluating all service lines, the trauma center was the highest contributor to overall hospital revenue. CONCLUSIONS: Despite a decrease in admissions for other service lines and a pause in elective surgeries during the pandemic, the trauma center remained unaffected. In addition, trauma was the most significant contributor to the bottom line of the health system. These findings underscore the need to maintain and even increase trauma center resources and staffing to ensure that optimal care is provided to critically ill and injured patients.

Increased Complications of Emergent Surgical Procedures During the First Wave of COVID-19.

INTRODUCTION: Based on recommendations by CMS elective surgery was stopped during the first wave of COVID-19. Despite hospitals being open for emergent surgery, there were some studies that showed a decrease in surgical volume. METHODS: A retrospective analysis for all surgeries from 185 affiliated hospitals from the first wave of the COVID-19 pandemic (March 2020 to May 2020) and as a comparison the previous year, March 2019 to May 2019 were obtained. Five surgeries were further analyzed: appendectomies, cholecystectomies, craniotomies, exploratory laparotomies, and endoscopic retrograde cholangiopancreatographies (ERCPs). RESULTS: Between March 2019 and May 2019, 326,726 surgeries were performed, and between March 2020 and May 2020, 237,809 surgeries were performed. The highest specialty for both years was gastroenterology. In 2020, 15.7% of the patients were admitted to the ICU versus 13.7% in 2019. For appendectomies, cholecystectomies, craniotomies, exploratory laparotomies and ERCPs, there was an increase from 2019 to 2020 in acute kidney injuries rate, infection, systemic inflammatory response syndrome (SIRS), and sepsis. All the changes in surgical volumes for the five surgeries from 2019 to 2020 were significant. For appendectomy, the statistically significant complications were infection and SIRS and sepsis. CONCLUSIONS: Across the board, there was a decrease in surgical volume during the COVID-19 pandemic first wave. There was a statistically significant decrease in appendectomy, cholecystectomy, exploratory laparotomy, craniotomy, and ERCP. For all five surgeries, we did see an increase in mortality rates and several complications. The only statistically significant complications were infection and SIRS and sepsis, for appendectomy.

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.

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.

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.

Impact of resuscitation adjuncts on postintubation hypotension in patients with isolated traumatic brain injury.

INTRODUCTION: Postintubation hypotension (PIH) is a risk factor of endotracheal intubation (ETI) after injury. For those with traumatic brain injury (TBI), one episode of hypotension can potentiate that injury. This study aimed to identify the resuscitation adjuncts that may decrease the incidence of PIH in this patient population. METHODS: This is a 4-year (2019-2022) prospective observational study at a level I trauma center. Adult (18 years or older) patients with isolated TBI requiring ETI in the trauma bay were included. Blood pressures were measured 15 minutes preintubation and postintubation. Primary outcome was PIH, defined as a decrease in systolic blood pressure of ≥20% from baseline or to ≤80 mm Hg, or any decrease in mean arterial pressure to ≤60 mm Hg. Multivariable logistic regression was performed to identify the associations of preintubation vasopressor, hypertonic saline (HTS), packed red blood cell, and crystalloids on PIH incidence. RESULTS: Of the 490 enrolled patients, 16% had mild (head AIS, ≤2), 35% had moderate (head AIS, 3-4), and 49% had severe TBI (head AIS, ≥5). The mean ± SD age was 42 ± 22 years, and 71% were male. The median ISS, head AIS, and Glasgow Coma Scale were 26 (19-38), 4 (3-5), and 6 (3-11), respectively. The mean ± SD systolic blood pressure 15 minutes preintubation and postintubation were 118 ± 46 and 106 ± 45, respectively. Before intubation, 31% received HTS; 10%, vasopressors; 20%, crystalloids; and 14%, at least 1 U of packed red blood cell (median, 2 [1-2] U). Overall, 304 patients (62%) developed PIH. On multivariable regression analysis, preintubation use of vasopressors and HTS was associated with significantly decreased odds of PIH independent of TBI severity, 0.310 (0.102-0.944, p = 0.039) and 0.393 (0.219-0.70, p = 0.002), respectively. CONCLUSION: Nearly two thirds of isolated TBI patients developed PIH. Preintubation vasopressors and HTS are associated with a decreased incidence of PIH. Such adjuncts should be considered prior to ETI in patients with suspected TBI. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

When Every Minute Counts: REBOA Before Surgery Is Independently Associated With a 15-Minute Delay in Time to Definitive Hemorrhage Control.

INTRODUCTION: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a temporizing hemorrhage control intervention, but its inevitable effect on time to operating room (OR) has not been assessed. The aim of our study is to assess the impact of undergoing REBOA before surgery (RBS) on time to definitive hemorrhage control surgery. METHODS: In this retrospective analysis of 2017-2021 ACS-TQIP database, all adult (≥18 years) patients who underwent emergency hemorrhage control laparotomy (≤4 hours of admission) and received early blood products (≤4 hours) were included, and patients with severe head injury (Head-abbreviated injury score > 2) were excluded. Patients were stratified into those who did (RBS) vs those who did not undergo REBOA before surgery (No-RBS). Primary outcome was time to laparotomy. Secondary outcomes were complications and mortality. Multivariable linear and binary logistic regression analyses were performed to identify the independent associations between RBS and outcomes. RESULTS: A total of 32,683 patients who underwent emergency laparotomy were identified (RBS: 342; No-RBS: 32,341). The mean age was 39 (16) years, 78% were male, mean SBP was 107 (34) mmHg, and the median injury severity score was 21 [14-29]. The median time to emergency hemorrhage control surgery was 50 [32-85] minutes. Overall complication rate was 16% and mortality was 19%. On univariate analysis, RBS group had longer time to surgery (RBS 56 [41-89] vs No-RBS 50 [32-85] minutes, P < 0.001). On multivariable analysis, RBS was independently associated with a longer time to hemorrhage control surgery (ß + 14.5 [95%CI 7.8-21.3], P < 0.001), higher odds of complications (aOR = 1.72, 95%CI = 1.27-2.34, P < 0.001), and mortality (aOR = 3.42, 95%CI = 2.57-4.55, P < 0.001). CONCLUSION: REBOA is independently associated with longer time to OR for hemorrhaging trauma patients with an average delay of 15 minutes. Further research evaluating center-specific REBOA volume and utilization practices, and other pertinent system factors, may help improve both time to REBOA as well as time to definitive hemorrhage control across US trauma centers. LEVEL OF EVIDENCE: III. STUDY TYPE: Epidemiologic.

Defining the Problem: 53 Years of Firearm Violence Afflicting America's Schools.

BACKGROUND: Firearm violence and school shootings remain a significant public health problem. This study aimed to examine how publicly available data from all 50 states might improve our understanding of the situation, firearm type, and demographics surrounding school shootings. STUDY DESIGN: School shootings occurring in the US for 53 years ending in May 2022 were analyzed, using primary data files that were obtained from the Center for Homeland Defense and Security. Data analyzed included situation, injury, firearm type, and demographics of victims and shooters. We compared the ratio of fatalities per wounded after stratifying by type of weapon. Rates (among children) of school shooting victims, wounded, and fatalities per 1 million population were stratified by year and compared over time. RESULTS: A total of 2,056 school shooting incidents involving 3,083 victims were analyzed: 2,033 children, 5 to 17 years, and 1,050 adults, 18 to 74 years. Most victims (77%) and shooters (96%) were male individuals with a mean age of 18 and 19 years, respectively. Of the weapons identified, handguns, rifles, and shotguns accounted for 84%, 7%, and 4%, respectively. Rifles had a higher fatality-to-wounded ratio (0.45) compared with shooters using multiple weapons (0.41), handguns (0.35), and shotguns (0.30). Linear regression analysis identified a significant increase in the rate of school shooting victims (ß = 0.02, p = 0.0003), wounded (ß = 0.01, p = 0.026), and fatalities (ß = 0.01, p = 0.0003) among children over time. CONCLUSIONS: Despite heightened public awareness, the incidence of school shooting victims, wounded, and fatalities among children has steadily and significantly increased over the past 53 years. Understanding the epidemic represents the first step in preventing continued firearm violence in our schools.

Role of endovascular management on outcomes in patients with traumatic inferior vena cava injuries.

INTRODUCTION: The aim of this study was to examine the association between the injury mechanism and repair type with outcomes in patients with traumatic inferior vena cava injuries. METHODS: This is a retrospective analysis of the ACS-TQIP database (2017-2020), including patients with traumatic IVC injuries. Patients were stratified by injury mechanism and type of repair and compared. RESULTS: Out of 1334 patients, 5 â€‹% underwent endovascular repair while 95 â€‹% had an open procedure. Overall, 74.7 â€‹% sustained a penetrating injury. On multivariable regression analysis, the type of repair was not associated with mortality and morbidity for patients with penetrating injuries. However, among patients with blunt injuries, endovascular repair was associated with lower odds of in-hospital mortality (aOR:0.35, p â€‹= â€‹0.020) and non-venous thromboembolism (VTE) morbidity (aOR:0.41, p â€‹= â€‹0.015), and higher odds of VTE complications (aOR:6.74, p â€‹< â€‹0.001). CONCLUSIONS: Although the type of repair did not impact morbidity and mortality in patients with penetrating injuries, endovascular repair was identified as the only modifiable predictor of reduced non-VTE morbidity and mortality in patients with blunt injuries.