An Assessment of the Impact of SARS-CoV-2 on a Level 1 Trauma Center Including Subgroup Analysis of Orthopedic Injuries and Mechanism of Injury.

Background and objective There is a paucity of medical literature describing the preparedness of hospital institutions to withstand the population effects of a pandemic. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19), has had a global impact on all facets of medicine, which has ultimately affected the medical community in a significant manner. Furthermore, there is a scarcity of research regarding the effects of COVID-19 on trauma and acute care surgery injury and admission rates. We conducted this study to examine the effects of the COVID-19 pandemic on both pediatric and adult trauma admissions, injury types, and mechanisms of injury. Materials and methods Data from the Trauma Registry was extracted for all adult (>15 years) and pediatric (<15 years) patients who consulted trauma surgery, acute care surgery, or orthopedic surgery at our center in the year immediately prior to the pandemic (March 1, 2019-February 29, 2020) and during the COVID-19 pandemic (March 1, 2020-February 28, 2021). Patient demographics, cause of injury, injury type and mechanism, and procedures performed were recorded. Results We documented a 4.2% increase in adult encounters compared to the preceding year. There was a significant difference in the distribution of mechanism of injury of adult patients between the two time periods, with the most changes seen in motor-vehicle auto, gunshot, and other vehicle injuries. However, no significant difference was seen in trauma type or intent (assault, self-inflicted, unintentional). Pediatric encounters increased by 6.4% during the COVID-19 pandemic compared to the pre-COVID-19 period. Overall, there was no detectable association between the distribution of encounters by the mechanism of injury and the time period for pediatric encounters. Conclusion This retrospective review of trauma encounters through both pre-COVID-19 and COVID-19 periods outlines the differences in factors such as demographics, injury mechanisms, and injury types between the two time periods. Overall, we expected a decrease in orthopedic-related trauma admissions during the COVID-19 pandemic; however, there was actually an increase of 4.1% in adult encounters and that of 6.4% in pediatric encounters. Our study lays out possible trends in injury patterns that can be correlated with the COVID-19 pandemic and the lockdown period. This information is useful for the healthcare system in that it demonstrates that resources should not be cut down or removed from surgical specialties. At level I facilities, resources need to be allocated for and continued to be provided to emergency rooms and operative services, including supplies and staffing. These departments need to be well-equipped to handle an increased number of trauma patients.

Retrospective analysis of small intracranial hemorrhage in trauma: Is acute care surgery team management alone safe?

Background: The Brain Injury Guidelines (BIG) provide a validated framework for categorizing patients with small intracranial haemorrhages (ICH) who could be managed by acute care surgery without neurosurgical consultation or repeat head computed tomography in the absence of neurological deterioration. This replication study retrospectively applied BIG criteria to ICH subjects and only included BIG1 and BIG2 subjects.Methods: The trauma registry was queried from 2014 to 2019 for subjects with a traumatic ICH <1 cm, Glasgow Coma Scale score of 14/15 and not on anticoagulation therapy. Patients were then categorized under BIG 1 or BIG2 and outcomes were evaluated.Results: Two hundred fourteen subjects were reviewed (88 BIG1 and 126 BIG2). Twenty-three subjects had worse repeat imaging, but only one had worsening exam that resolved spontaneously. None required neurosurgical intervention. One died of non-neurological causes.Conclusions: Retrospective analysis supported our hypothesis that patients categorized as BIG1 or BIG2 could have been safely managed by acute care surgeons without neurosurgical consultation or repeat head imaging. A review of minor worsening on repeat imaging without changes in neurological exams and no need for neurosurgical interventions supports this evidence-based approach to the management of small intracranial haemorrhages.

The impact of clinical crisis management on trauma team outcomes following a prolonged strike by nursing, technical, and support staff.

There is a paucity of literature describing the preparation of hospital institutions prior to a nursing strike and the quality outcomes during and after a prolonged nursing strike. No published study was found describing the effects of a prolonged strike on quality outcomes specific to trauma patients. The American College of Surgeons (ACS) suggests specific critiques and complications data that each trauma program may choose to track as quality indicators, and those metrics are submitted to regional, state and national databanks and closely examined during site accreditations. This research study analyzed data from three equal time periods following a multiservices strike involving both nurses and service/technical staff lasting 63 days. The purposes of this study were to (1) evaluate the effects of prestrike organizational leadership and crisis management planning on organizational staffing and emergency management to reduce health care risk during the strike, (2) describe outcomes data from three equal time periods: prestrike, strike, and poststrike, and (3) specifically compare the trauma program's selected ACS trauma metrics for critiques and complication rates for our high-risk/high-volume population as a level 1 trauma center.

The combined effects of alcohol and marijuana use prior to traumatic brain injury on mortality.

BACKGROUND: Alcohol (ETOH) intoxication is a common comorbidity in traumatic brain injury (TBI), and marijuana (THC) has been implicated as a major risk factor for trauma. The objective this study was to investigate the combined effects of ETOH and THC on mortality after TBI. MATERIALS AND METHODS: A retrospective review of patient data was performed to assess adult (>18 years) patients with brain injuries between January 2012 and December 2018. Included patients sustained TBI (Abbreviated Injury Scale (AIS 1-6)) and were divided into two groups: No Substances and THC + ETOH. RESULTS: 1085 (median age 52 years [range: 18-97 years]; 33.5% female (364/1085)) patients met the inclusion criteria. Significant differences for mortality at discharge were found between groups (p = 0.0025) with higher mortality in the No Substances group. On multiple logistic regression, a positive test for both ETOH + THC was found not to independently predict mortality at discharge, while age, Glasgow Coma Scale, intensive care unit stay, Injury Severity Score, length of hospital stay, and days on ventilator were independent predictors. CONCLUSIONS: After controlling for confounding variables, positive ETOH + THC screens were not found to be independent predictors of mortality at discharge. Therefore, our results indicated no survival benefit for TBI patients with concomitant ETOH and THC use prior to injury.

Is There a Need for Abdominal CT Scan in Trauma Patients With a Low-Risk Mechanism of Injury and Normal Vital Signs?

Background Clinically significant injuries are often missed in trauma patients with low-risk mechanisms of injury and lack of "red flags," such as abnormal vital signs. The purpose of this retrospective analysis was to evaluate the efficacy of computed axial tomography (CT) for identifying occult injuries in a high-volume trauma center. Methods Records from our institutional trauma registry were retrospectively extracted, examining encounters from January 2015 to October 2019. Those patients between the ages of 18 and 65 who were referred to the trauma team with a CT scan of the abdomen and had low-risk mechanisms of injury, a Glasgow Coma Scale (GCS) score of 15, and normal vital signs at presentation were included. Patients in the lowest trauma categorization (Level Three, Consult) met the study definition for the low-risk mechanism of injury. Demographic and clinical data were abstracted for all patients. For this analysis, patients were divided into two groups based on age (18 - 40 years or 40 - 65 years). Injuries found on CT, their clinical significance, and the likelihood of being missed without CT were determined. Results Of 2,103 blunt trauma patients that received a CT scan of the abdomen from January 2015 to October 2019, 134/2,103 (6.4%) met the inclusion criteria (mean age: 44.6 years; 72.3% male). Patients between the ages of 40 and 65 years comprised 61.2% (82/134) of the study population. Of the included patients, 17.2% (23/134) had at least one acute traumatic injury identified after CT imaging of the torso. Occult injuries found on CT included rib fracture with associated lung injuries (10/23, 43.5%), splenic laceration (4/23, 17.4%), liver laceration (3/23, 13.0%), gluteal hematoma with active bleeding (1/23, 4.3%), sternal fractures (3/23, 13.0%), and thoracic or lumbar spine fractures (2/23, 8.7%). An independent review of the medical records determined that 9.0% (12/134) of these patients had traumatic injuries that would have been missed based on clinical examination without CT. Conclusions Based on our experience, utilizing CT imaging of at least the abdomen as a routine screening measure for all trauma consults - even low-risk patients with normal vital signs - can rapidly and accurately identify clinically significant injuries that would have been otherwise missed in a notable portion of the population.

Emergency Department Boarding of Non-Trauma Patients Adversely Affects Trauma Patient Length of Stay.

Introduction Emergency Department (ED) boarding delays initiation of time-sensitive protocols for trauma patients and makes them susceptible to increased mortality and morbidity. In this study, we compared the ED boarding times of non-trauma patients and ED length of stay (LOS) of trauma patients. Methods This was a single-center retrospective cohort study in a Level 1 trauma center. The median boarding time among non-trauma patients and ED LOS among trauma patients was determined by month between the period of April 2018 to March 2019. Linear regression and Pearson correlation coefficient were used to express the magnitude and direction of the relationship between these two variables. Results During the study period, the mean number of non-trauma patients admitted in our ED per month was 1,154 and trauma patients was 89. The mean of the median boarding time per month for non-trauma patients was 76 minutes, and the mean of the median ED LOS per month for trauma patients was 198 minutes. There was a significant positive correlation between boarding time for non-trauma patients and ED LOS for trauma patients (Pearson correlation coefficient: 0.73; p = 0.007). Conclusion The long boarding times for non-trauma patients is associated with ED LOS for trauma patients, indicating that the total patient volume in the hospital contributes to the trauma patient's stay in the ED. Thus, ED LOS of trauma patients can be minimized by improving overall ED and hospital flow, including non-trauma patients.

The effects of alcohol and marijuana on survival after severe traumatic brain injury: A retrospective cohort study.

BACKGROUND: Alcohol (ETOH) and marijuana (THC) use have previously shown to improve outcomes after Traumatic Brain Injury (TBI). However, whether TBI severity impacts outcomes among patients tested positive for both ETOH and THC remains unclear. MATERIALS AND METHODS: A retrospective review from the Northern Ohio Regional Trauma Registry, which includes deidentified data from six regional hospitals, including three Level 1 and three Level 3 trauma centers, was performed to assess adult (>18 years) patients with severe TBI (head Abbreviated Injury Score ≥ 3) between January 2012 and December 2018 having an alcohol and drug toxicology screen and data regarding outcome at discharge. Patients were divided into two groups: 1) patients with a negative ETOH and drug test, and 2) patients positive for ETOH + THC. Mortality at discharge was the primary outcome measure and multiple logistic regression was used to assess predictors of mortality at discharge. RESULTS: A total of 854 (median age: 51 years [range: 18-72]; 34.4% female [294/854]) patients were included. On multiple logistic regression, age (p = 0.003), days in intensive care unit (ICU) (p < 0.001), Glasgow Coma Scale (GCS) (p < 0.001), Injury Severity Score (ISS) (p < 0.001), length of stay (LOS) (p < 0.001), and days on ventilator support (p = 0.032) were significant predictors of mortality at discharge. Blood alcohol content (BAC), cause of TBI, drug class, and sex were not significant predictors of mortality at discharge. CONCLUSIONS: After severe TBI, positive THC and BAC screening did not predict mortality at discharge after controlling for confounding variables, indicating no survival benefit for patients with severe TBI.

The right team at the right time - Multidisciplinary approach to multi-trauma patient with orthopedic injuries.

Integrated, multidisciplinary team approach to the multiply injured patient can help optimize care, minimize morbidity, and reduce mortality. It also provides a framework for accelerated postinjury rehabilitation course. The characteristics and potential benefits of this approach, including team dynamics and interactions, are discussed in this brief review. Emphasis is placed on synergies provided by specialty teams working together in the framework of care coordination, timing of surgical and nonsurgical interventions, and injury/physiologic considerations. REPUBLISHED WITH PERMISSION FROM: Bach JA, Leskovan JJ, Scharschmidt T, Boulger C, Papadimos TJ, Russell S, Bahner DP, Stawicki SPA. Multidisciplinary approach to multi-trauma patient with orthopedic injuries: the right team at the right time. OPUS 12 Scientist 2012;6(1):6-10.

Anion gap as a predictor of trauma outcomes in the older trauma population: correlations with injury severity and mortality.

The relationship among traumatic injury, the associated metabolic/physiologic responses, and mortality is well established. Tissue hypoperfusion and metabolic derangement may not universally correlate with initial clinical presentation. We hypothesized that anion gap (AG) could be a useful gauge of trauma-related physiologic response and mortality in older patients with relatively lower injury acuity. We retrospectively analyzed data from 711 trauma patients older than 45 years. Parameters examined included demographics, injury characteristics, laboratories, morbidity, and mortality. Univariate and survival analyses were performed using PASW 18. A stepwise correlation exists between increasing Injury Severity Score and AG. Although AG less than 8 to 15 was not associated with a significant increase in mortality, greater mortality was seen for AG greater than 16 with further stepwise increases for AGs greater than 22. Anion gap correlated moderately with serum lactate and poorly with base excess. Increasing AG also correlated with morbidity and greater incidence of intensive care admissions. The presence of any complication increased from 28.6 per cent for patients with AG 12 or less to 45.5 per cent for patients with AG 22 or greater (P < 0.04). These findings support the contention that "low acuity" trauma patients with high AGs may not appear acutely ill but may harbor significant underlying metabolic and physiologic disturbances that could contribute to morbidity and mortality. Higher AG values (i.e., greater than 16) may be associated with worse clinical outcomes.