Obesity Does Not Increase Risk for Mortality in Severe Sepsis Trauma Patients.

INTRODUCTION: The prevalence of obesity in the United States is up to 40% in adults. Obese patients with severe sepsis have a lower mortality rate compared with normal body mass index (BMI) patients. We hypothesized that trauma patients with severe sepsis and obese BMI will have a decreased mortality risk in comparison with normal BMI patients. METHODS: The Trauma Quality Improvement Program (2017) was queried for adult trauma patients with documented BMI and severe sepsis. Patients were grouped based on BMI: non-obese trauma patients (nOTP) BMI <30 kg/m2 and obese trauma patients (OTP) ≥30 kg/m2. A multivariable logistic regression model was used for analysis of mortality. RESULTS: From 1246 trauma patients with severe sepsis, 566 (42.4%) were nOTP and 680 (57.6%) were OTP. OTP had increased length of stay (LOS) (19 vs 21 days, P < .001), intensive care unit (ICU) LOS (13 vs 18 days, P < .001) and ventilator days (10 vs 11 days, P < .001). After adjusting for covariates, when compared to normal BMI patients, patients who were overweight (OR 1.11 CI .875-1.41 P = .390), obese (OR .797 CI .59-1.06 P = .126), severely obese (OR .926 CI .63-1.36 P = .696) and morbidly obese (OR 1.448 CI 1.01-2.07 P = .04) all had a similar associated risk for mortality compared to patients with normal BMI. CONCLUSION: In adult trauma patients with severe sepsis, this national analysis demonstrated OTP had increased LOS, ICU LOS, and ventilator days compared to nOTP. However, patients with increasing degrees of obesity had similar associated risk of mortality compared to trauma patients with severe sepsis and a normal BMI.

Emergency medicine (EM) can safely manage geriatric trauma patients sustaining ground level falls: Fostering EM autonomy while safely offloading a busy trauma service.

OBJECTIVE: Limited data exists regarding different specialties care of geriatric (>74 years-old) trauma patients (GTPs). We created a "Tier-III" designation for ground-level fall (GLF) GTPs to be managed by EM, with a trauma consult as needed. MATERIALS AND METHODS: A single-center comparison of PRE (1/1/2013-4/30/2016) versus POST (5/1/2016-11/30/2019) Tier-III GTP GLFs. The primary outcome was mortality. Secondary outcomes included admissions, trauma bay procedures and length of stay (LOS). RESULTS: 1,652 patients (314-PRE vs. 1,338-POST) were included. The admission rate was lower in the POST (56.9% vs. 88.9%, p < 0.001) cohort. There were no differences in LOS or trauma bay procedures between cohorts (p > 0.05). On multivariable analysis there was similar associated risk of mortality between groups (p = 0.68). CONCLUSION: The associated risk of mortality was similar between GLF GTP cohorts managed initially by EM and trauma surgeons, however the admission rate was lower in the POST group suggesting EM management may improve hospital bed utilization.

Comparative Outcomes for Trauma Patients in Prison and the General Population.

BACKGROUND: Prisoners are a vulnerable population, and there are few contemporary studies that consider trauma patient outcomes within the prisoner population. Therefore, we sought to provide a descriptive analysis of prisoners involved in trauma and evaluate whether a healthcare disparity exists. We hypothesized that prisoners and non-prisoners have a similar risk of mortality and in-hospital complications after trauma. METHODS: The Trauma Quality Improvement Program (2015-2016) was queried for trauma patients based upon location inside or outside of prison at the time of injury. A multivariable logistic regression analysis was performed to compare these groups for risk of mortality-the primary outcome. RESULTS: From 593,818 trauma patients, 1115 were located in prison. Compared to non-prisoners, prisoner trauma patients had no significant difference in mortality (5.1 vs 6.0%, P = .204). However, after adjusting for covariates, prisoners had a shorter length of stay (LOS) (mean days, 6.3 vs 7.8, P < .001), shorter intensive care unit (ICU) LOS (mean days, 5.44 vs 5.89, P = .004), and fewer complications, including lower rates of drug/alcohol withdrawal (.4% vs 1.1%, P = .030), pneumonia (.5 vs 1.6%, P = .004), and urinary tract infections (.0 vs 1.1%, P < .001). Upon performing a multivariable logistic regression model, prisoner trauma patients had a similar associated risk of mortality compared to non-prisoners (OR 1.61, CI .52-4.94, P = .409). DISCUSSION: Our results suggest that prisoner trauma patients at least receive equivalent treatment in terms of mortality and may have better outcomes when considering some complications. Future prospective studies are needed to confirm these results and explore other factors, which impact prisoner patient outcomes.

Marijuana use and outcomes in adult and pediatric trauma patients after legalization in California.

BACKGROUND: Marijuana has become legal in eight states since 2012. We hypothesized the incidence of marijuana-positive trauma patients and rate of mortality has increased post-legalization. METHODS: A single level-I trauma center was used to identify patients screening positive for marijuana on urine-toxicology. Patients in the pre-legalization and post-legalization periods were compared. RESULTS: In the pre-legalization cohort 9.4% were marijuana-positive versus 11.0% in the post-legalization cohort (p = 0.001). Marijuana-positive patients post-legalization had higher rates of critical trauma activation (20.0% vs. 15.0%, p = 0.01) and mortality (2.6% vs. 1.2%, p = 0.03). In the pediatric (age 12-17) subgroup, the incidence of marijuana-positive patients did not change after legalization (pre: 39.3%, post: 46.4%, p = 0.24). CONCLUSION: The incidence of marijuana-positive trauma patients increased post-legalization. Adult marijuana-positive trauma patients post-legalization were more likely to meet criteria for critical trauma activation and have a higher mortality rate. A subgroup of pediatric patients had an alarmingly high rate of marijuana use. SUMMARY: The rate of marijuana use among trauma patients increased post-legalization in California. The rate of critical trauma activation also increased as well as the mortality rate.

Non-accidental trauma increases length of stay and mortality in pediatric trauma.

PURPOSE: More than half a million children experience non-accidental trauma (NAT) annually. Historically, NAT has been associated with an increased hospital length of stay (LOS). We hypothesized that in pediatric trauma patients, NAT is associated with longer hospital LOS, independent of injury severity, compared to accidental trauma (AT). METHODS: The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients aged 1-16 years. Patients were stratified into two groups: AT and NAT. The median LOS for the entire cohort was identified and used in a multivariable logistic regression analysis. RESULTS: From 93,089 pediatric trauma patients, 417 (< 0.1%) were involved in NAT. Patients with NAT had a lower median age (3 vs. 9 years, p < 0.001) and higher median injury severity score (10 vs. 5, p < 0.001), compared to patients with AT. After controlling for covariates, patients with NAT were associated with a longer hospital LOS (≥ 2 days), compared to those with AT (OR = 4.99 CI = 3.55-7.01, p < 0.001). In comparison to AT, NAT was also associated with a higher mortality rate (10.3% vs. 0.8%, p < 0.001). CONCLUSION: Pediatric patients presenting after NAT have a prolonged hospital and ICU LOS, even after adjusting for injury severity. Furthermore, pediatric victims of NAT had a higher mortality rate compared to those presenting after AT.

Nosocomial infections in the surgical intensive care unit: a difference between trauma and surgical patients.

In 1970, the Centers for Disease Control and Prevention (CDC) established the National Nosocomial Infection Surveillance System to assist institutions with infection surveillance, data collection, and processing. This facilitates interinstitutional comparison for nosocomial infection rates. Nosocomial infection rates in the surgical intensive care unit have been shown to be different from the medical intensive care unit. Whether there exists a difference in infection rates between trauma and surgical patients in the intensive care unit has not been established. Our objective was to determine whether there is a difference in rates of nosocomial infections between trauma and surgical patients in the surgical intensive care unit. From January 1995 through December 1997, we reviewed 3715 admissions to the surgical intensive care unit and separated them into trauma (1272) or surgical (2443) cases. We documented all nosocomial pneumonias, urinary tract infections, bloodstream infections, and surgical site infections. From these data we determined infection rates per 100 admissions. We also identified all device-related nosocomial infections and calculated infection rate by current CDC standards using number of device infections divided by number of device-days times 1000. We found that the overall trauma patient infection rate was 11.64 per cent compared with 6.43 per cent for surgical patients (P<.001). Using conventional infection rate criteria, trauma patients had higher frequency in the rate of ventilator-associated pneumonia (6.13% vs. 2.50%; P<0.001), urinary tract infection (2.36 versus 1.76; P<0.2), and bloodstream infection (2.52% versus 1.27%; P<0.01). However, when using the CDC guidelines, which correct for the number of device-days for infections, only the difference in rate of pneumonia between the two groups reached statistical significance (23.9 rate for trauma patients vs. 16.7 for the surgery group; P<0.005). We conclude that trauma patients are at higher risk for nosocomial infections than routine surgical patients. Because of this difference, centers should collect and report data separately for trauma and surgical patients in the intensive care unit. Specific attention should be focused on the causes and prevention of increased rates of nosocomial pneumonia in trauma patients.

Pedestrian-motor vehicle trauma: an analysis of injury profiles by age.

BACKGROUND: Pedestrian-motor vehicle trauma (PMVT) is a common mechanism of injury in urban populations. STUDY DESIGN: We performed a retrospective review of 273 PMVT victims (16 percent of all patients with blunt injuries) seen at a Level I trauma center over a three-year period. Patients were analyzed by age and grouped as children (age younger than 16 years), adults (age 16 to 59 years), or elderly (age older than 59 years). RESULTS: Children constituted 27 percent of the patients, adults 54 percent, and elderly 19 percent. This mixture had significantly more children and elderly than the population at large or the entire blunt trauma population at our hospital. The majority of patients (66 percent) were male, with females outnumbering males only in the elderly group. Elderly patients were more frequently admitted to the intensive care unit (ICU) and had significantly longer ICU and hospital stays. Injury Severity Scores were successively higher in each age group and significantly higher in the elderly. Extremity trauma was most common in all three groups, followed by head injuries. The elderly patients were more prone to chest and pelvic injuries and the children most often had femur fractures. Operations were performed in 22 percent of the patients; orthopedic procedures were most frequent. The mortality rate was 6 percent, with 69 percent of the deaths occurring during the initial resuscitation efforts. The mortality rate was significantly higher in the elderly patients (13 percent). The majority of accidents occurred during nighttime hours, especially in the adult group. Half of the accidents occurred on the weekend, with the greatest number on Saturday. One-third of the accidents occurred during the months of October to December. CONCLUSIONS: Pedestrian-motor vehicle trauma is a common injury, with distinct epidemiological features that may be useful in accident prevention strategies.

The laparoscopic learning curve.

To characterize the learning curve for laparoscopic cholecystectomy, we compared the first 47 cases (group A), which were performed by two senior attending surgeons who assisted each other when the procedure was introduced into clinical practice (1990-1991), with the first 46 cases (group R) performed by two surgical chief residents who were assisted by members of the teaching faculty in 1992-1993. The patient groups were comparable in terms of age, sex, and anesthetic class, but pathologically proven acute cholecystitis was more common in group R (33% vs. 9%; p < 0.005). To analyze operative procedures and outcomes, we compared operative time, frequency of successful operative cholangiography (attempted in all cases), frequency of conversion to open cholecystectomy, major complication rate, and days of postoperative stay for all patients and for those without complications. Of these parameters, only operative time for nonacute cases differed significantly between the groups (144 min for group A vs. 114 min for group R; p < 0.05). Complications in group A included one ductal injury and one case of postoperative pancreatitis; group R had one ductal injury and two cases of postoperative bleeding. We conclude that (a) the learning curve has similar structure for senior surgeons and resident trainees; and (b) the resident learning curve is not hazardous when teaching assistants are trained in the procedure, which has implications for safe instruction and proctoring of residents and staff.

Surgical intensive care in the nonagenarian. No basis for age discrimination.

OBJECTIVE: To investigate the effect of extreme age on outcome from surgical intensive care. DESIGN: Prospective data collection. SETTING: A 20-bed noncardiac surgical intensive care unit (SICU) that admits 2200 patients per year from a 1201-bed tertiary medical center. PATIENTS: Nonagenarians were compared with patients under 90 years of age over a 33-month period. Seven patients over age 100 years and 77 nonsurgical patients were excluded. MAIN OUTCOME MEASURES: Mortality and length of stay were determined for both the SICU and the entire hospitalization. The nonagenarian and younger groups were stratified by severity of illness using the first-day Simplified Acute Physiology Score (SAPS). RESULTS: One hundred forty nonagenarian patients (mean +/- SE age, 92.1 +/- 0.2 years) were compared with 5652 younger patients (mean age, 60.1 +/- 0.3 years). The mean SAPS of 11.1 for nonagenarian patients was significantly higher than the SAPS of 8.6 for younger patients (P < .001). Mortality in the SICU was 4.3% for nonagenarian patients vs 2.3% for younger patients (P = .13). SICU mortality rose with increasing SAPS in both groups, but there was no significant difference between nonagenarian and younger patients for any SAPS group. Hospital mortality differed significantly, with 17.1% for nonagenarian patients and 5.3% for younger patients (P < .001). Hospital and SICU length of stay did not differ significantly between the groups. CONCLUSIONS: Nonagenarians do not differ from younger SICU patients in survival from SICU care, although hospital mortality is greater in nonagenarians. Age alone should not be used to make decisions about the utility of SICU care for the elderly. Outcome correlates better with severity of illness, and the measure is valid in young and old alike.