Does time to surgery for traumatic hip fracture impact the efficacy of fascia iliaca blocks? A brief report.

Objectives: Outcomes after traumatic hip fracture have shown to be significantly improved with timely surgical management. This study determined whether there were differences in efficacy of fascia iliaca compartment block (FICB) on pain outcomes in patients with hip fracture, once stratified by time to surgery. Methods: Trauma patients (55-90 years) admitted to five Level I/II trauma centers within 12 hours of hip fracture were included. Patients with coagulopathy, significant multi-trauma (injury severity score >16), bilateral hip fractures, and postoperative FICBs were excluded. The primary exposure was analgesia modality: adjunctive FICB or systemic analgesics (no FICB). Study endpoints were incidence of delirium through 48 hours postoperatively (%), preoperative and postoperative oral morphine equivalents (OMEs), and preoperative and postoperative pain (0-10 scale). Adjusted regression models were used to examine the effect of FICB on outcomes; all models were stratified by time from arrival to surgery, ≤24 hours (earlier surgery; n=413) and >24 hours (later surgery; n=143). Results: FICB use was similar with earlier and later surgery (70.2% vs 76.2%), and there were no demographic differences by utilization of FICB, by time to surgery. In the earlier surgery group, preoperative pain was lower for patients with FICB versus no FICB (3.6 vs 4.5, p<0.001), with no difference by FICB for delirium (OR 1.00, p>0.99) or OMEs (p=0.75 preoperative, p=0.91 postoperative). In the later surgery group, there was a nearly twofold reduction in preoperative OMEs with FICB than no FICB (25.5 mg vs 45.2 mg, p=0.04), with no differences for delirium (OR 4.21, p=0.18), pain scores (p=0.25 preoperative, p=0.27 postoperative), and postoperative OMEs (p=0.34). Conclusions: Compared with systemic analgesia, FICB resulted in improved pain scores at the preoperative assessment among patients with earlier surgery, whereas FICB reduced opioid consumption over the preoperative period only when surgery was later than 24 hours from arrival. Level of evidence: II, prospective, therapeutic.

Associations of Smoking With Delirium and Opioid Use in Older Adults With Traumatic Hip Fracture.

INTRODUCTION: Cigarette smoking is a risk factor for hip fractures, while risk factors for developing delirium include older age and preexisting cognitive impairment. We sought to determine whether smoking status is independently associated with delirium and pain outcomes. METHODS: This was a prospective, observational cohort study of 442 older adults (65 to 90 years) admitted for traumatic hip fracture at five trauma centers. The primary exposure was smoking status (n = 43, 10%). Additional risk factors included demographics, injury characteristics, and medical interventions. Delirium (primary) and analgesia-related complications were examined with multivariable logistic regression, while analysis of covariance models were used to examine preoperative and postoperative pain scores and opioid consumption (oral morphine equivalents). RESULTS: Smokers had significantly worse outcomes compared with nonsmokers: delirium incidence was 16.3% versus 5.0% (adjusted odds ratio, 4.23; P = 0.005), analgesia complications developed in 30.2% versus 14.8% (adjusted odds ratio, 2.63; P = 0.01), and postoperative opioid consumption was greater (53 mg versus 33 mg, adjusted P = 0.04). Adjusted pain scores were not different between groups. DISCUSSION: Smoking status is associated with markedly worse outcomes in older adults with traumatic hip fracture. Smoking status should be considered in pain management protocols and for early screening and delirium prevention methods. DATA AVAILABILITY: On reasonable request.

A multi-institutional prospective observational study to evaluate fascia iliaca compartment block (FICB) for preventing delirium in adults with hip fracture.

Objectives: Until recently, systemic opioids have been standard care for acute pain management of geriatric hip fracture; however, opioids increase risk for delirium. Fascia Iliaca compartment blocks (FICB) may be favored to systemic analgesia for reducing delirium, but this has not been well demonstrated. We evaluated the efficacy of adjunctive FICB versus systemic analgesia on delirium incidence, opioid consumption, and pain scores. Methods: This prospective, observational cohort study was performed in patients (55-90 years) with traumatic hip fracture admitted to five trauma centers within 12 hours of injury, enrolled between January 2019 and November 2020. The primary end point was development of delirium, defined by the Confusion Assessment Method tool, from arrival through 48 hours postoperatively, and analyzed with multivariate Firth logistic regression. Secondary end points were analyzed with analysis of covariance models and included preoperative and postoperative oral morphine equivalents and pain numeric rating scale scores. Results: There were 517 patients enrolled, 381 (74%) received FICB and 136 (26%) did not. Delirium incidence was 5.4% (n=28) and was similar for patients receiving FICB versus no FICB (FICB, 5.8% and no FICB, 4.4%; adjusted OR: 1.2 (95% CI 0.5 to 3.0), p=0.65). Opioid requirements were similar for patients receiving FICB and no FICB, preoperatively (p=0.75) and postoperatively (p=0.51). Pain scores were significantly lower with FICB than no FICB, preoperatively (4.2 vs 5.1, p=0.002) and postoperatively (2.9 vs 3.5, p=0.04). Conclusions: FICB demonstrated significant benefit on self-reported pain but without a concomitant reduction in opioid consumption. Regarding delirium incidence, these findings suggest clinical equipoise and the need for a randomized trial. Level of evidence: II-prospective, therapeutic.

Severe fungal infections following blunt traumatic injuries: A 5-year multicenter descriptive study.

INTRODUCTION: The aggressive and timely treatment of post-traumatic fungal infections is the most efficacious way to reduce morbidity and mortality. Compared to the military trauma population, studies reporting on fungal infections in civilian trauma are not well described. The purpose of this study was to describe characteristics of civilian trauma patients who developed fungal infections and to identify common risk factors and report any delays between injury and treatment. METHODS: This was a five-year (1/1/2013-3/1/2018) retrospective, descriptive study across six level 1 trauma centers. All consecutively admitted trauma patients (≥18 years) with laboratory-confirmed fungal wound infections were included. Patients with solely candida wound isolates were excluded. Patient demographics, clinical wound and infection characteristics, organisms cultured, treatment modalities, length of stay, in-hospital mortality, and any diagnostic or treatment delays were described. RESULTS: Of the 54,521 trauma patients screened for fungal infection, 12 were identified. All patients suffered major injuries after blunt trauma (abbreviated injury score 3-5) and sustained wound contamination, and in nine patients, the cause of injury was motor vehicle. Six had open wounds/fractures on admission. The geographical region with the highest rate of fungal infection was Texas (n = 7), followed by Kansas (N = 3), then Missouri (N = 2). First symptoms of infection (leukocytosis or fever (n = 10)) presented a median of 6.3 (4.1-9.8) days after injury. Wound management entailed a combination of debridements (n = 8), negative pressure wound therapy (n = 9), amputation (n = 6), and antifungal treatment (n = 10). All fungal isolates identified from the wound site were hyphomycetes. A median of 2.1 (1.8-4.0) days passed from diagnosis to first antifungal treatment, and 3 patients died. CONCLUSIONS: Our study shows the challenges surrounding diagnosis and treatment of fungal infections secondary to trauma. Non-specific fungal infection symptoms, such as leukocytosis and fever, typically presented a week after injury. Vigilance for investigating risk factors and infection symptoms may help clinicians with more timely management of trauma patients with a severe fungal infection.

PA student assessment of body mass index in children using visual cues.

OBJECTIVE: Pediatric weight or body mass index often is underestimated by providers when relying solely upon visual cues. This study sought to determine physician assistant (PA) students' and recent graduates' ability to accurately assess BMI for age in patients ages 3 to 5 years using visual cues. METHODS: PA students and recent graduates visually assessed pictures of three children ages 3 to 5 years-one obese, one overweight, and one with healthy weight-for BMI categorization via online survey. Responses were scored for accuracy. RESULTS: Ninety-eight PA students and recent graduates completed the assessment. Accuracy for BMI categorization was low, especially in the obese and overweight children for visual assessment alone. Accuracy improved slightly when height and weight data were provided. CONCLUSIONS: PA student and recent graduate visual assessment for categorization of BMI is unreliable, similar to studies with other providers. PAs should be aware of discrepancy and not rely on visual assessment to determine weight-related interventions.

Treatment provider is most predictive of ED dismissal in minimally-injured trauma patients: a retrospective review.

BACKGROUND: Secondary triage protocols have been described in the literature as physiologic (first-tier) criteria and mechanism-related (second-tier) criteria to determine the level of trauma activation. There is debate as to the efficiency of triage decisions based on mechanism of injury which may result in overtriage and overuse of limited trauma resources. Our institution developed and implemented an advanced three-tier trauma alert system in which stable patients presenting with blunt traumatic mechanism of injury would be evaluated by the emergency department (ED) physician rather than the trauma surgeon. The American College of Surgeons Committee on Trauma (ACSCOT) requires that operational changes be monitored and evaluated for patient safety and performance. The primary aim of this study was to evaluate the process, as well as outcomes, of patient care pre and post implementation of the new triage protocol. The secondary aim was to determine predictor variables that were associated with ED dismissal. METHODS: A retrospective blinded pre/post process change implementation explicit chart review was conducted to compare process and outcomes of minimally injured trauma patients who were field triaged by mechanism of injury. Generalized linear modeling was performed to determine which predictor variables were associated with ED dismissal. RESULTS: There were no significant differences in minutes to physician evaluation, CT scan, OR/ICU disposition, readmission rates, safety or quality. Significant differences only occurred in time to chest x-ray, length of stay in ED, and ED dismissal rates. Trauma surgeon and ED physician patient groups did not differ on ISS, age, or sex. The only significant predictor for ED dismissal was treatment provider, with ED physicians 3.6 times more likely to dismiss the patient from the emergency department. CONCLUSIONS: ED physicians provided compble care as measured by safety, timeliness, and quality in minimally-injured patients triaged to our trauma center based only on mechanism of injury. Moreover, ED physicians were more likely to dismiss patients from the ED. A three-tiered internal triaging protocol can redirect resource usage to reduce the burden on the trauma service. This may be increasingly beneficial in trauma models in which the trauma surgeons also serve as critical care intensivists.

Patient satisfaction with surgeons in a trauma population: testing a structural equation model using perceptions of interpersonal and technical care.

BACKGROUND: Research has shown that interpersonal care is positively associated with patient satisfaction. The literature is not as clear concerning patient perceptions of technical care. Evaluating patient satisfaction requires understanding the influence of patient perceptions of interpersonal and technical aspects of care. METHODS: This prospective, cross-sectional telephone survey examined the relationship between patient satisfaction, interpersonal care, and technical care. Respondents were asked to recall the trauma surgeon and then rate them for satisfaction with interpersonal and technical care. Patients were also asked to rate their global satisfaction (GS) with the healthcare. RESULTS: Structural equation modeling indicated that there was a significant direct effect of Interpersonal Care on Technical Care and Technical Care and Interpersonal Care on GS. Interpersonal care also had an indirect effect on GS though Technical Care. Fit indices showed that the hypothesized paths significantly improved the model. CONCLUSIONS: There were strong positive relationships between patient's perceptions of interpersonal care and technical care and GS. Patients that are unacquainted with technical aspects of care may make judgments based on satisfaction with interpersonal aspects of care. It is important that surgeons, even in a trauma environment, are aware of the strong relationship between patients' perceptions of interpersonal and technical care. Making efforts to focus on relationship-centered care will improve both personal and institutional satisfaction ratings. LEVEL OF EVIDENCE: III, epidemiological study.