Are geriatric transfer patients with traumatic brain injury at risk for worse outcomes compared to non-geriatric? Propensity-matched study.

OBJECTIVE: To compare outcomes between geriatric and non-geriatric patients with traumatic brain injury (TBI) transferred to trauma center and effects of anticoagulants/antiplatelets (AC/AP) and reversal therapy. METHODS: A retrospective review of 1,118 patients with TBI transferred from acute care facilities to level 1 trauma center compared in groups: geriatric versus non-geriatric, geriatric with AC/AP therapy versus without, and geriatric AC/AP with AC/AP reversal therapy versus without. RESULTS: Patients with TBI constituted 54.4% of trauma transfers. Mean transfer time was 3.9 h. Propensity matched by Injury Severity Score and Abbreviated Injury Score (AIS) head geriatric compared to non-geriatric patients had more AC/AP use (53.9% vs 8.8%), repeat head computed tomography (93.7% vs 86.1%), intensive care unit (ICU) admissions (57.4% vs 45.7%) and mortality (9.8% vs 3.2%), all p < 0.004. Patients on AC/AP versus without had more ICU admissions (69.1% vs 51.8%, p < 0.001). Patients with AC/AP reversals compared to without reversals had more AIS head 5 (32.0% vs 13.1%), brain surgeries (17.8% vs 3.5%) and ICU admissions (84.8% vs 57.1%), all p < 0.001. CONCLUSION: TBI constituted half of trauma transfers and 10% required surgery. Based on higher ICU admissions, mortality, and prevalence of AC/AP therapy requiring reversal, geriatric patients with TBI on anticoagulants/antiplatelets should be considered for direct trauma center admission.

Stop exsanguination by inflation: management of aorta-esophageal fistula bleeding.

Aortoesophageal fistula is rare and typically presents itself to the emergency department as Chiari's Triad of mid-thoracic pain, sentinel arterial hemorrhage, and exsanguination after a symptom-free interval. However, fatal bleeding may be the first and last presentation of an aortoesophageal fistula. When a patient experiences massive hematemesis without witnesses, EMS may assume that bleed is of a traumatic mechanism. We present a case of a 59-year-old male with no previous medical history who was transported to a trauma center unconscious and with massive bleeding of unknown origin. Computed tomography revealed a thoracic aortic aneurysm and an aortoesophageal fistula. Bleeding was not controlled and the patient expired. Trauma bay personnel should follow an algorithm which includes a prompt tamponade of the bleed using a Sengstaken-Blakemore tube or esophageal balloon paralleled by massive transfusion and obtaining an early computed tomography scan to manage patients with massive gastroesophageal bleeding until appropriate surgical interventions can be initiated.

Nonfatal Injuries Sustained in Mass Shootings in the US, 2012-2019: Injury Diagnosis Matrix, Incident Context, and Public Health Considerations.

INTRODUCTION: The epidemic of gun violence in the United States (US) is exacerbated by frequent mass shootings. In 2021, there were 698 mass shootings in the US, resulting in 705 deaths and 2,830 injuries. This is a companion paper to a publication in JAMA Network Open, in which the nonfatal outcomes of victims of mass shootings have been only partially described. METHODS: We gathered clinical and logistic information from 31 hospitals in the US about 403 survivors of 13 mass shootings, each event involving greater than 10 injuries, from 2012-19. Local champions in emergency medicine and trauma surgery provided clinical data from electronic health records within 24 hours of a mass shooting. We organized descriptive statistics of individual-level diagnoses recorded in medical records using International Classification of Diseases codes, according to the Barell Injury Diagnosis Matrix (BIDM), a standardized tool that classifies 12 types of injuries within 36 body regions. RESULTS: Of the 403 patients who were evaluated at a hospital, 364 sustained physical injuries-252 by gunshot wound (GSW) and 112 by non-ballistic trauma-and 39 were uninjured. Fifty patients had 75 psychiatric diagnoses. Nearly 10% of victims came to the hospital for symptoms triggered by, but not directly related to, the shooting, or for exacerbations of underlying conditions. There were 362 gunshot wounds recorded in the Barell Matrix (1.44 per patient). The Emergency Severity Index (ESI) distribution was skewed toward higher acuity than typical for an emergency department (ED), with 15.1% ESI 1 and 17.6% ESI 2 patients. Semi-automatic firearms were used in 100% of these civilian public mass shootings, with 50 total weapons for 13 shootings (Route 91 Harvest Festival, Las Vegas. 24). Assailant motivations were reported to be associated with hate crimes in 23.1%. CONCLUSION: Survivors of mass shootings have substantial morbidity and characteristic injury distribution, but 37% of victims had no GSW. Law enforcement, emergency medical systems, and hospital and ED disaster planners can use this information for injury mitigation and public policy planning. The BIDM is useful to organize data regarding gun violence injuries. We call for additional research funding to prevent and mitigate interpersonal firearm injuries, and for the National Violent Death Reporting System to expand tracking of injuries, their sequelae, complications, and societal costs.

Two surgical pathways for isolated hip fractures: A comparative study.

BACKGROUND: Hip fractures (HF) are common among the aging population, and surgery within 48 h is recommended. Patients can be hospitalized for surgery through different pathways, either trauma or medicine admitting services. AIM: To compare management and outcomes among patients admitted through the trauma pathway (TP) vs medical pathway (MP). METHODS: This Institutional Review Board-approved retrospective study included 2094 patients with proximal femur fractures (AO/Orthopedic Trauma Association Type 31) who underwent surgery at a level 1 trauma center between 2016-2021. There were 69 patients admitted through the TP and 2025 admitted through the MP. To ensure comparability between groups, 66 of the 2025 MP patients were propensity matched to 66 TP patients by age, sex, HF type, HF surgery, and American Society of Anesthesiology score. The statistical analyses included multivariable analysis, group characteristics, and bivariate correlation comparisons with the χ² test and t-test. RESULTS: After propensity matching, the mean age in both groups was 75-years-old, 62% of both groups were females, the main HF type was intertrochanteric (TP 52% vs MP 62%), open reduction internal fixation was the most common surgery (TP 68% vs MP 71%), and the mean American Society of Anesthesiology score was 2.8 for TP and 2.7 for MP. The majority of patients in TP and MP (71% vs 74%) were geriatric (≥ 65-years-old). Falls were the main mechanism of injury in both groups (77% vs 97%, P = 0.001). There were no significant differences in pre-surgery anticoagulation use (49% vs 41%), admission day of the week, or insurance status. The incidence of comorbidities was equal (94% for both) with cardiac comorbidities being dominant in both groups (71% vs 73%). The number of preoperative consultations was similar for TP and MP, with the most common consultation being cardiology in both (44% and 36%). HF displacement occurred more among TP patients (76% vs 39%, P = 0.000). Time to surgery was not statistically different (23 h in both), but length of surgery was significantly longer for TP (59 min vs 41 min, P = 0.000). Intensive care unit and hospital length of stay were not statistically different (5 d vs 8 d and 6 d for both). There were no statistical differences in discharge disposition and mortality (3% vs 0%). CONCLUSION: There were no differences in outcomes of surgeries between admission through TP vs MP. The focus should be on the patient's health condition and on prompt surgical intervention.

Outcomes among trauma patients with duodenal leak following primary versus complex repair of duodenal injuries: An Eastern Association for the Surgery of Trauma multicenter trial.

BACKGROUND: Duodenal leak is a feared complication of repair, and innovative complex repairs with adjunctive measures (CRAM) were developed to decrease both leak occurrence and severity when leaks occur. Data on the association of CRAM and duodenal leak are sparse, and its impact on duodenal leak outcomes is nonexistent. We hypothesized that primary repair alone (PRA) would be associated with decreased duodenal leak rates; however, CRAM would be associated with improved recovery and outcomes when leaks do occur. METHODS: A retrospective, multicenter analysis from 35 Level 1 trauma centers included patients older than 14 years with operative, traumatic duodenal injuries (January 2010 to December 2020). The study sample compared duodenal operative repair strategy: PRA versus CRAM (any repair plus pyloric exclusion, gastrojejunostomy, triple tube drainage, duodenectomy). RESULTS: The sample (N = 861) was primarily young (33 years) men (84%) with penetrating injuries (77%); 523 underwent PRA and 338 underwent CRAM. Complex repairs with adjunctive measures were more critically injured than PRA and had higher leak rates (CRAM 21% vs. PRA 8%, p < 0.001). Adverse outcomes were more common after CRAM with more interventional radiology drains, prolonged nothing by mouth and length of stay, greater mortality, and more readmissions than PRA (all p < 0.05). Importantly, CRAM had no positive impact on leak recovery; there was no difference in number of operations, drain duration, nothing by mouth duration, need for interventional radiology drainage, hospital length of stay, or mortality between PRA leak versus CRAM leak patients (all p > 0.05). Furthermore, CRAM leaks had longer antibiotic duration, more gastrointestinal complications, and longer duration until leak resolution (all p < 0.05). Primary repair alone was associated with 60% lower odds of leak, whereas injury grades II to IV, damage control, and body mass index had higher odds of leak (all p < 0.05). There were no leaks among patients with grades IV and V injuries repaired by PRA. CONCLUSION: Complex repairs with adjunctive measures did not prevent duodenal leaks and, moreover, did not reduce adverse sequelae when leaks did occur. Our results suggest that CRAM is not a protective operative duodenal repair strategy, and PRA should be pursued for all injury grades when feasible. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

The timing and value of early postoperative computed tomography after head surgery in traumatic brain injury patients.

OBJECTIVE: To analyze the timing of the early postoperative computed tomography (CT) in traumatic brain injury (TBI) patients, and compare CT and neurological examination (NE) findings. METHODS: Retrospective analysis included 353 TBI patients admitted to two level 1 trauma centers (2016-2020) who underwent head surgery and postoperative CT within 24 h. Analyzed variables: age, Injury Severity Score (ISS), Glasgow Coma Score (GCS), Abbreviated Injury Scale head (AISh), comorbidities, CT and NE findings and timing, head surgery type, and mortality. RESULTS: Patients mean age was 61.9 years, ISS 25.1, GCS 11.0, AISh 4.7. Postoperatively, mean time to first positive CT was 6.1 h and to first positive NE was 13.2 h. Positive CT alone was more accurate in identifying need for 2nd head surgery than positive NE alone (21.8 % vs 6.0 %, p = 0.04). There was no difference between patients with CT done earlier than 6 h compared to patients with CT done after 6 h in mortality (26.1 % vs 22.0 %, p = 0.4) or 2nd surgery rate (12.2 % vs 12.2 %, p = 1.0). Reversal of postoperative CT findings occurred in 1/6 of patients and was more common when CT was done earlier than 6 h compared to CT done later (25.7 % vs 0.8 %, p < 0.001). Early CT within 1 h rarely leads to the change of management but often is followed by another CT within 12 h. CONCLUSION: In TBI patients postoperative CT was more effective than NE in predicting a need for 2nd head surgery. Postoperative head CT at 6 h is recommended to allow timely detection of intracranial deterioration, reduce the number of CTs and reversal findings as it does not increase 2nd surgery rates and mortality.

Acute cardiac tamponade secondary to nonpenetrating injury from gunshot with beanbag round: A case report and literature review.

Over the past twenty years, "less-lethal" munitions have caused a variety of significant, life-threatening injuries. However, evidence of blunt cardiac injury due to these weapons is sparse. A healthy 44-year old man presented with hemodynamic instability due to cardiac tamponade after he was shot with a beanbag, ultimately requiring operative intervention. This case report describes a unique clinical presentation of blunt cardiac injury and the diagnostic and therapeutic steps that the trauma surgery team took to appropriately manage this rare injury.

Injury Characteristics, Outcomes, and Health Care Services Use Associated With Nonfatal Injuries Sustained in Mass Shootings in the US, 2012-2019.

Importance: Civilian public mass shootings (CPMSs) in the US result in substantial injuries. However, the types and consequences of these injuries have not been systematically described. Objective: To describe the injury characteristics, outcomes, and health care burden associated with nonfatal injuries sustained during CPMSs and to better understand the consequences to patients, hospitals, and society at large. Design, Setting, and Participants: This retrospective case series of nonfatal injuries from 13 consecutive CPMSs (defined as ≥10 injured individuals) from 31 hospitals in the US from July 20, 2012, to August 31, 2019, used data from trauma logs and medical records to capture injuries, procedures, lengths of stay, functional impairment, disposition, and charges. A total of 403 individuals treated in hospitals within 24 hours of the CPMSs were included in the analysis. Data were analyzed from October 27 to December 5, 2021. Exposures: Nonfatal injuries sustained during CPMSs. Main Outcomes and Measures: Injuries and diagnoses, treating services, procedures, hospital care, and monetary charges. Results: Among the 403 individuals included in the study, the median age was 33.0 (IQR, 24.5-48.0 [range, 1 to >89]) years, and 209 (51.9%) were women. Among the 386 patients with race and ethnicity data available, 13 (3.4%) were Asian; 44 (11.4%), Black or African American; 59 (15.3), Hispanic/Latinx; and 270 (69.9%), White. Injuries included 252 gunshot wounds (62.5%) and 112 other injuries (27.8%), and 39 patients (9.7%) had no physical injuries. One hundred seventy-eight individuals (53.1%) arrived by ambulance. Of 494 body regions injured (mean [SD], 1.35 [0.68] per patient), most common included an extremity (282 [57.1%]), abdomen and/or pelvis (66 [13.4%]), head and/or neck (65 [13.2%]), and chest (50 [10.1%]). Overall, 147 individuals (36.5%) were admitted to a hospital, 95 (23.6%) underwent 1 surgical procedure, and 42 (10.4%) underwent multiple procedures (1.82 per patient). Among the 252 patients with gunshot wounds, the most common initial procedures were general and trauma surgery (41 [16.3%]) and orthopedic surgery (36 [14.3%]). In the emergency department, 148 of 364 injured individuals (40.7%) had 199 procedures (1.34 per patient). Median hospital length of stay was 4.0 (IQR, 2.0-7.5) days; for 50 patients in the intensive care unit, 3.0 (IQR, 2.0-8.0) days (13.7% of injuries and 34.0% of admissions). Among 364 injured patients, 160 (44.0%) had functional disability at discharge, with 19 (13.3%) sent to long-term care. The mean (SD) charges per patient were $64 976 ($160 083). Conclusions and Relevance: Civilian public mass shootings cause substantial morbidity. For every death, 5.8 individuals are injured. These results suggest that including nonfatal injuries in the overall burden of CPMSs may help inform public policy to prevent and mitigate the harm caused by such events.

Impact of time to surgery on mortality in hypotensive patients with noncompressible torso hemorrhage: An AAST multicenter, prospective study.

BACKGROUND: Death from noncompressible torso hemorrhage (NCTH) may be preventable with improved prehospital care and shorter in-hospital times to hemorrhage control. We hypothesized that shorter times to surgical intervention for hemorrhage control would decrease mortality in hypotensive patients with NCTH. METHODS: This was an AAST-sponsored multicenter, prospective analysis of hypotensive patients aged 15+ years who presented with NCTH from May 2018 to December 2020. Hypotension was defined as an initial systolic blood pressure (SBP) ≤ 90 mm Hg. Primary outcomes of interest were time to surgical intervention and in-hospital mortality. RESULTS: There were 242 hypotensive patients, of which 48 died (19.8%). Nonsurvivors had higher mean age (47.3 vs. 38.8; p = 0.02), higher mean New Injury Severity Score (38 vs. 29; p < 0.001), lower admit systolic blood pressure (68 vs. 79 mm Hg; p < 0.01), higher incidence of vascular injury (41.7% vs. 21.1%; p = 0.02), and shorter median (interquartile range, 25-75) time from injury to operating room start (74 minutes [48-98 minutes] vs. 88 minutes [61-128 minutes]; p = 0.03) than did survivors. Multivariable Cox regression showed shorter time from emergency department arrival to operating room start was not associated with improved survival (p = 0.04). CONCLUSION: Patients who died arrived to a trauma center in a similar time frame as did survivors but presented in greater physiological distress and had significantly shorter times to surgical hemorrhage intervention than did survivors. This suggests that even expediting a critically ill patient through the current trauma system is not sufficient time to save lives from NCTH. Civilian prehospital advance resuscitative care starting from the patient first contact needs special consideration. LEVEL OF EVIDENCE: Prognostic/Epidemiologic, Level III.

Blunt Cardiac Injury in Patients With Sternal Fractures.

Background Blunt cardiac injury (BCI) is a possible consequence of sternal fractures (SF). There is a scarcity of studies addressing BCI in patients with different types of SF and with pre-existing cardiac conditions. The goal of this study was to delineate diagnostic patterns of BCI in different cohorts of SF patients. Methods This retrospective cohort study included 380 blunt trauma patients admitted to two level 1 trauma centers between January 2015 and March 2020 with radiologically confirmed SF. Electrocardiography, cardiac enzymes and echocardiography were evaluated for BCI diagnosis. Analyzed variables included: age, comorbidities, injury severity score, Glasgow coma score, type of SF (isolated, combined, displaced), incidence of traumatic brain injury, co-injuries, retrosternal hematoma, intensive care unit admissions, hospital lengths of stay, and mortality. Results In 380 SF patients there were 250 (66%) females and 130 (34%) males and the mean age was 63 years old. Electrocardiography was done in all patients, cardiac enzymes in 234 (62%) and echocardiography in 181 (48%). BCI was diagnosed in 19 (5%) of patients, all having combined SF. BCI patients had higher injury severity score (mean 18.4) and 14 (74%) had pulmonary co-injuries. Multivariable analysis confirmed pulmonary co-injuries as a statistically significant predictor of BCI (p<0.001). BCI patients compared to no BCI patients had all three tests (electrocardiography, cardiac enzymes and echocardiography) performed statistically more often (90% vs 36%, p<0.001). SF patients with pre-injury cardiac comorbidities had similar incidence of BCI as without cardiac comorbidities (5% vs 6%, p=0.6). In SF patients with traumatic brain injury, cardiac enzymes (troponin, creatine kinase) were elevated significantly more often compared to patients without traumatic brain injury (58% vs 38%, p=0.02). SF displacement or retrosternal hematoma presence were not associated with BCI. Mortality in SF patients with BCI versus without was not statistically different (16 vs 9%, p=0.4). Conclusions Blunt cardiac injury is rare in patients with SF. Higher degree of BCI suspicion must be applied in combined SF patients, especially those with pulmonary co-injuries. Cardiac comorbidities did not affect the rate of BCI. Echocardiography for BCI diagnosis is essential in SF patients with traumatic brain injury, as cardiac enzymes may be less informative, however is less important in isolated SF patients. Performing all three diagnostic tests in combined SF patients improves the accuracy of BCI diagnosis.

Sternal fractures in blunt trauma patients.

PURPOSE: Sternal fractures (SF) are commonly associated with other injuries and their incidence is on the rise. The aim was to evaluate injury characteristics and outcomes in patients with all types of SF after blunt trauma. METHODS: Retrospective analysis of 380 SF patients from two Level 1 trauma centers was performed. Patients were compared in various combinations: geriatric versus non-geriatric, isolated sternal fractures (ISF) versus combined sternal fractures (CSF), sternal body versus manubrium, displaced versus non-displaced, and with retrosternal hematoma versus without. Analyzed variables included: age, gender, race, comorbidities, mechanism of injury (MOI), injury severity score (ISS), Glasgow Coma Score (GCS), type and location of SF, concomitant fractures of ribs, vertebrae, clavicles and scapulae, co-injuries, rates of surgical stabilization, mechanical ventilation requirements, intensive care unit (ICU) admission, ICU length of stay (ICULOS), hospital LOS (HLOS), complications, and mortality. RESULTS: ISF constituted 17.9% of all patients with no mortality. CSF patients constituted 82.1%, had more ICU admissions, longer ICULOS/HLOS and 9.3% mortality (all p < 0.001). Geriatric SF had more concomitant rib fractures and 12.9% mortality. Concomitant fractures of ribs were present in 56.7% and had higher ICU admissions, ICULOS and complications compared to SF patients with concomitant vertebrae fractures diagnosed in 38.2%. CONCLUSION: SF are present in 2.1% of admissions to trauma centers. Geriatric patients account for half of SF patients and have higher mortality. Concomitant fractures of ribs are present in half and vertebrae fractures in one-third of the SF patients. CSF portend higher mortality and pulmonary co-injuries. The high incidence of concomitant rib and vertebra fractures requires additional diagnostic and treatment considerations.

Comparison of Geriatric Versus Non-geriatric Trauma Patients With Palliative Care Consultations.

BACKGROUND: Palliative care in trauma patients is still evolving. The goal was to compare characteristics, outcomes, triggers and timing for palliative care consultations (PCC) in geriatric (≥65 y.o.) and non-geriatric trauma patients. MATERIALS AND METHODS: Retrospective study included 432 patients from two level 1 trauma centers who received PCC between December 2012 and January 2019. Non-geriatric (n = 61) and geriatric (n = 371) groups were compared for: mechanism of injury (MOI), Injury Severity Score (ISS), Revised Trauma Score (RTS), Glasgow Coma Score (GCS), Do-Not-Resuscitate (DNR) orders, futile interventions (FI), duration of mechanical ventilation (DMV), ICU admissions, ICU and hospital lengths of stay (ICULOS; HLOS), timing to PCC, and mortality. Further propensity matching (PM) analysis compared 59 non-geriatric to 59 Geriatric patients matched by ISS, GCS, and DNR. RESULTS: Geriatric patients were older (85.2 versus 49.7), with falls as predominant MOI. Non-geriatric patients comprised 14.1% of all patients with PCC and were more severely injured than Geriatrics: with statistically higher ISS (24.1 versus 18.5), lower RTS (5.4 versus 7.0), GCS (7.1 versus 11.5), with predominant MOI being traffic accidents, all P < 0.01. Non-Geriatrics had more ICU admissions (96.7% versus 88.1%), longer ICULOS (10.2 versus 4.7 days), DMV (11.1 versus 4.1 days), less DNR (57.4% versus 73.9%), higher in-hospital mortality (12.5% versus 2.6%), but double the time admission-PCC (11.3 versus 4.3 days) compared to Geriatrics, all P < 0.04. In PM comparison, despite same injury severity, Non-geriatrics had triple the time to PCC, five times the HLOS of geriatrics, and more FI (25.4% versus 3.4%), all P < 0.001. CONCLUSIONS: PCC remains underutilized in non-geriatric trauma patients. Despite higher injury severity, non-geriatrics received more aggressive treatment, and had three times longer time to PCC, resulting in higher rate of FI than in Geriatrics.

Reduction in Potentially Inappropriate Interventions in Trauma Patients following a Palliative Care Consultation.

Background: Palliative care is expanding as part of treatment, but remains underutilized in trauma settings. Palliative care consultations (PCC) have shown to reduce nonbeneficial, potentially inappropriate interventions (PII), as decision for their use should always be made in the context of both the patient's prognosis and the patient's goals of care. Objective: To characterize trauma patients who received PCC and to analyze the effect of PCC and do-not-resuscitate (DNR) orders on PII in severely injured patients. Setting/Subjects: Retrospective cohort study of 864 patients admitted to two level 1 trauma centers: 432 patients who received PCC (PCC group) were compared with 432 propensity score match-controlled (MC group) patients who did not receive PCC. Measurements: PCC in a consultative palliative care model, PII (including tracheostomy and percutaneous endoscopic gastrostomy) rate and timing, DNR orders. Results: PCC rate in trauma patients was 4.3%, with a 5.3-day average time to PCC. PII were done in 9.0% of PCC and 6.0% of MC patients (p = 0.09). In the PCC group, 74.1% of PII were done before PCC, and 25.9% after. PCC compared with MC patients had significantly higher mechanical ventilation (60.4% vs. 18.1%, p < 0.001) and assisted feeding requirements (14.1% vs. 6.7%, p < 0.001). We observed a statistically significant reduction in PII after PCC (p = 0.002). Significantly less PCC than MC patients had PII following DNR (26.3% vs. 100.0%, p = 0.035). Conclusions: PCC reduced PII in severely injured trauma patients by factor of two. Since the majority of PII in PCC patients occurred before PCC, a more timely administration of PCC is recommended. To streamline goals of care, PCC should supplement or precede a DNR discussion.

Tracheostomy in trauma patients with rib fractures.

PURPOSE: Patients with rib fractures (RF) may require prolonged mechanical ventilation and tracheostomy. Indications for tracheostomy in trauma patients with RF remain debatable. The goal was to delineate characteristics of patients who underwent tracheostomy due to thoracic versus extra-thoracic causes, such as maxillofacial-mandibular injury (MFM), traumatic brain injury (TBI), and cervical vertebrae trauma (CVT), and to analyze clinical outcomes. The predictive values of chest trauma scoring systems for tracheostomy were also evaluated. We hypothesized that tracheostomized patients were more severely injured with more ribs fractured and had more pulmonary co-injuries. METHODS: Retrospective review included 471 patients with RF admitted to two Level 1 trauma centers. Patients with tracheostomy (n = 124, 26.3%) were compared to patients with endotracheal intubation (n = 347, 73.7%). Analyzed variables included age, gender, injury severity score (ISS), Glasgow Coma Scale, number of ribs fractured, total fractures of ribs, prevalence of bilateral rib fractures, flail chest, clavicle fractures, MFM, TBI, CVT, co-injuries, comorbidities, RF treatment options, hospital length of stay (HLOS), intensive care unit LOS (ICULOS), duration of mechanical ventilation (DMV). RESULTS: Tracheostomized compared to intubated patients had statistically higher ISS, more ribs fractured, total fractures of the ribs, bilateral and clavicle fractures, MFM, spine, chest, and orthopedic co-injuries and longer HLOS, ICULOS and DMV. Tracheostomy for thoracic reasons was performed in 64 patients (51.6%) and for extra-thoracic reasons in 60 patients (48.4%). Mean tracheostomy timing was 9.9 days and was significantly shorter in the extra-thoracic compared to the thoracic group (8.0 versus 11.6 days, p < 0.001). All chest trauma scoring system values were significantly higher in tracheostomized patients. Predictive values of scoring systems for tracheostomy increased in patients with thoracic trauma only. CONCLUSIONS: A quarter of mechanically ventilated patients with RF required tracheostomy. Tracheostomized compared to intubated patients were more severely injured with more ribs fractured and were intubated longer. An increased amount of RF was associated with an increase in tracheostomies, especially for thoracic reasons.

Surgical Stabilization of Rib Fractures: Indications, Techniques, and Pitfalls.

Rib fractures are a common thoracic injury that is encountered in 20% to 39% of patients with blunt chest trauma and is associated with substantial morbidity and mortality1,2. Traditionally, the majority of patient with rib fractures have been managed nonoperatively. Recently, the utilization of surgical stabilization of rib fractures has increased considerably because the procedure has shown improved outcomes3-5. DESCRIPTION: Surgical stabilization should be considered in cases of multiple bicortically displaced rib fractures, especially in those with a flail chest and/or a concomitant ipsilateral displaced midshaft clavicular fracture or sternal fracture, as such cases may result in thoracic wall instability. For surgical stabilization of rib fractures, we classify rib fractures by location, type of fracture, and degree of displacement after obtaining thin-sliced chest computed tomography (CT) scans. The incision is selected depending on the fracture location, and the surgical technique is chosen relevant to the type of fracture. Single-lung intubation is preferred if there is no severe contralateral pulmonary contusion. We favor performing video-assisted thoracoscopy if possible to control bleeding, evacuate hematomas, repair a lung, and perform cryoablation of the intercostal nerves. A lateral approach is considered to be the main surgical approach because it allows access to the majority of rib fractures. A curvilinear skin incision is made overlying the fractured ribs. Posterior rib fractures are exposed through a vertical incision within the triangle of auscultation, and anterior fractures, through a transverse inframammary incision. The muscle-sparing technique, splitting alongside fibers without transection, should be utilized if possible and supplemented by muscle retraction. For surgical stabilization of rib fractures, we currently prefer precontoured side and rib-specific plates with threaded holes and self-tapping locking screws. Polymer cable cerclage is used to enhance plating of longitudinal fractures, rib fractures near the spine, osteoporotic ribs, and injuries of rib cartilage. The third to eighth ribs are plated most often. Intercostal muscle deficit, if present, is repaired with a xenograft patch. In comminuted rib fractures, the bone gap is bridged with bone graft. Surgical stabilization of rib fractures is recommended within the first 7 days after trauma, preferably within the first 3 days6-8. ALTERNATIVES: Nonoperative treatment alternatives include (1) epidural analgesia when not contraindicated because of anticoagulant venous thromboembolism prophylaxis9,10; (2) thoracic paravertebral blockage, e.g., serratus anterior or erector spinae plane nerve block11,12; (3) intercostal nerve block; (4) intravenous or enteral analgesics, e.g., opioids, acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs); (5) intrapleural analgesia, e.g., bupivacaine infusion; and (6) multimodal analgesia that incorporates regional techniques, systemic analgesics, and analgesic adjuncts9. RATIONALE: Surgical stabilization of rib fractures is a safe and effective method to treat displaced rib fractures. The procedure provides definitive stabilization of fractures, improves pulmonary function, lessens pain medication requirements, prevents deformity formation, and results in reduced morbidity and mortality.

Palliative Care Consultations in Trauma Patients and Role of Do-Not-Resuscitate Orders: Propensity-Matched Study.

OBJECTIVE: To delineate characteristics of trauma patients associated with a palliative care consultation (PCC) and to analyze the role of do-not-resuscitate (DNR) orders and related outcomes. METHODS: Retrospective study included 864 patients from 2 level one trauma centers admitted between 2012 and 2019.  Level 1 trauma centers are designated for admission of the most severe injured patients. Palliative care consultation group of 432 patients who received PCC and were compared to matched control (MC) group of 432 patients without PCC. Propensity matching covariates included Injury Severity Score, mechanism of injury, gender, and hospital length of stay (HLOS). Analysis included patient demographics, injury parameters, intensive care unit (ICU) admissions, ICU length of stay (ICULOS), duration of mechanical ventilation, timing of PCC and DNR, and mortality. Palliative care consultation patients were further analyzed based on DNR status: prehospital DNR, in-hospital DNR, and no DNR (NODNR). RESULTS: Palliative care consultation compared to MC patients were older, predominantly Caucasian, with more frequent traumatic brain injury (TBI), ICU admissions, and mechanical ventilation. The average time to PCC was 5.3 days. Do-not-resuscitate orders were significantly more common in PCC compared to MC group (71.5% vs 11.1%, P < .001). Overall mortality was 90.7% in PCC and 6.0% in MC (P < .001). In patients with DNR, mortality was 94.2% in PCC and 18.8% in MC. In-hospital DNR-PCC compared to NODNR-PCC patients had shorter ICULOS (5.0 vs 7.3 days, P = .04), HLOS (6.2 vs 13.2 days, P = .006), and time to discharge (1.0 vs 6.3 days, P = .04). CONCLUSIONS: Advanced age, DNR order, and TBI were associated with a PCC in trauma patients and resulted in significantly higher mortality in PCC than in MC patients. Combination of DNR and PCC was associated with shorter ICULOS, HLOS, and time from PCC to discharge.

Intravenous Ibuprofen Reduces Opioid Consumption During the Initial 48 Hours After Injury in Orthopedic Trauma Patients.

OBJECTIVES: To evaluate the efficacy of intravenous (IV) ibuprofen (Caldolor) administration in the management of acute pain in orthopedic trauma patients and to minimize opioid use. DESIGN: Randomized controlled trial, double-blind, parallel, placebo-controlled. SETTING: Level 1 Trauma Center. PATIENTS: A total of 99 consecutive orthopedic trauma patients with fractures of the ribs, face, extremities, and/or pelvis were randomized to receive either 800 mg IV ibuprofen (53 patients) or placebo (44 patients) administered every 6 hours for a total of 8 doses within 48 hours of admission and the same PRN medications along with 20-mg IV/PO Pepcid twice a day. To establish pain reduction efficacy, the analysis was consequently performed in the modified intent-to-treat group that included 74 randomized subjects with a baseline pain score greater than 2. The primary outcomes were reduction in opioid consumption and decrease in pain intensity (PI). INTERVENTION: Administration of study medications. OUTCOME MEASUREMENTS: PI measured by Numerical Rating Scale, opioid consumption adjusted to morphine equivalent dose, and time to first narcotic administration. RESULTS: The 2 groups had comparable baseline characteristics: age, sex distribution, mechanism of injury, type of injury, injury severity score, and PI. IV ibuprofen statistically significantly reduced opioid consumption compared with placebo during the initial 48-hour period (P = 0.017). PI calculated as PI differences was statistically different only at 8-hour interval after Caldolor administration. Time to first narcotic medication was significantly longer in the Caldolor group (hazard ratio: 1.640; 95% confidence interval, 1.009-2.665; P = 0.046). CONCLUSIONS: IV ibuprofen provided adequate analgesia, prolonged time to first narcotic administration, and was opioid-sparing for the treatment of pain in orthopedic trauma patients, which makes Caldolor a recommended candidate for managing acute pain in the diverse orthopaedic trauma population. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of patients with surgically stabilized rib fractures by different scoring systems.

PURPOSE: Surgical Stabilization (SSRF) is gaining popularity as an alternative to non-operative management (NOM) of patients with rib fractures, however, there are no established guidelines for patients' quantifiable evaluation and for SSRF recommendation. Known rib scoring systems include: Rib Fracture Score (RFS), Chest Wall Trauma Score (CWTS), Chest Trauma Score (CTS) and RibScore (RS), but are underutilized. The purpose was to provide values of scoring systems in SSRF and NOM patients and correlate them with treatment assignment. METHODS: Retrospective cohort study included 87 SSRF and 87 propensity matched NOM patients from two level-1 trauma centers. Clinical variables and score values were compared between two groups. RESULTS: SSRF compared to NOM patients had significantly higher number of total rib fractures, displaced fractures, rates of pulmonary contusion and flail chest. RS and CTS values were significantly higher in SSRF compared to NOM patients (2.3 vs. 1.7, p = 0.001; 5.8 vs. 5.3, p = 0.005, respectively), but RFS and CWTS were similar. CONCLUSIONS: Application of scoring systems could help with patients' objective and standardized assessment and may aid in treatment decisions. RibScore was superior to other scoring systems.

Early Versus Late Tracheostomy in Trauma Patients With Rib Fractures.

BACKGROUND: Patients with blunt chest trauma with multiple rib fractures (RF) may require tracheostomy. The goal was to compare early (≤7 d) versus late (>7 d) tracheostomy patients and to analyze clinical outcomes, to determine which timing is more beneficial. METHODS: This retrospective review included 124 patients with RF admitted to trauma ICU at two level 1 trauma centers who underwent tracheostomy. Analyzed variables included age, gender, injury severity score, Glasgow Coma Scale, number of ribs fractured, total fractures of the ribs, prevalence of bilateral RF, flail chest, maxillofacial injuries, cervical vertebrae trauma, traumatic brain injuries (TBI), coinjuries, epidural analgesia, surgical stabilization of RF, failure to extubate, hospital LOS, intensive care unit LOS (ICULOS), duration of mechanical ventilation, mortality, and timing and type of tracheostomy. RESULTS: Mean number of RF in all tracheostomized patients with blunt chest trauma was 5.2 and 85% of patients had pulmonary co-injuries. Mean tracheostomy timing was 9.9 d. Early tracheostomy (ET) was correlated with statistically significant reduction in ICULOS and duration of mechanical ventilation. The dominant cause of mortality in all groups was TBI and it was more pronounced in the ET patients. Most deaths were encountered between 3 and 5 wk after admission. ET was more often performed in the operating room with an open technique, whereas late tracheostomy was more often implemented with percutaneous technique at bedside. CONCLUSIONS: ET could be beneficial in chest trauma patients with multiple RF as it reduces ICULOS and ventilation requirements. Mortality benefits are not correlated with tracheostomy timing.

Outcome Analysis of Surgical Stabilization of Rib Fractures in Trauma Patients.

OBJECTIVES: To compare outcomes in patients with rib fractures (RFX) who underwent surgical stabilization of rib fractures (SSRF) to those treated nonoperatively. DESIGN: Retrospective cohort study. SETTING: Two Level 1 Trauma Centers. PATIENTS: One hundred seventy-four patients with multiple RFX divided into 2 groups: patients with surgically stabilized RFX (n = 87) were compared with nonoperatively managed patients in the matched control group (MCG) (n = 87). INTERVENTION: SSRF. OUTCOME MEASUREMENTS: Age, sex, injury severity score, RFX, mortality, hospital length of stay (HLOS) and intensive care unit length of stay (ICULOS), duration of mechanical ventilation (DMV), co-injuries, and time to surgery. Patients were further stratified by presence or absence of flail chest and pulmonary contusion (PC). RESULTS: Flail chest, displaced RFX, and PC were present significantly more often in SSRF patients compared with the MCG. Mortality was lower in SSRF group. HLOS and ICULOS were longer in SSRF group compared with the corresponding MCG patients regardless of timing to surgery (P < 0.01 for all). SSRF patients with flail chest had comparable HLOS, ICULOS, and DMV to MCG patients with flail chest (P > 0.3 for all). SSRF patients without flail chest had significantly longer HLOS and ICULOS than MCG patients without flail chest (P < 0.001 for both). Presence of PC did not affect lengths of stay. CONCLUSIONS: SSRF patients had reduced mortality compared with nonoperatively managed patients. HLOS, ICULOS, and DMV were longer in SSRF patients than in MCG. When flail chest was present, lengths of stay were comparable. PC did not seem to affect the surgical outcome. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.