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.

Prospective validation and application of the Trauma-Specific Frailty Index: Results of an American Association for the Surgery of Trauma multi-institutional observational trial.

BACKGROUND: The frailty index is a known predictor of adverse outcomes in geriatric patients. Trauma-Specific Frailty Index (TSFI) was created and validated at a single center to accurately identify frailty and reliably predict worse outcomes among geriatric trauma patients. This study aims to prospectively validate the TSFI in a multi-institutional cohort of geriatric trauma patients. METHODS: This is a prospective, observational, multi-institutional trial across 17 American College of Surgeons Levels I, II, and III trauma centers. All geriatric trauma patients (65 years and older) presenting during a 3-year period were included. Frailty status was measured within 24 hours of admission using the TSFI (15 variables), and patients were stratified into nonfrail (TSFI, ≤0.12), prefrail (TSFI, 0.13-0.25), and frail (TSFI, >0.25) groups. Outcome measures included index admission mortality, discharge to rehabilitation centers or skilled nursing facilities (rehab/SNFs), and 3-month postdischarge readmissions, fall recurrences, complications, and mortality among survivors of index admission. RESULTS: A total of 1,321 geriatric trauma patients were identified and enrolled for validation of TSFI (nonfrail, 435 [33%]; prefrail, 392 [30%]; frail, 494 [37%]). The mean ± SD age was 77 ± 8 years; the median (interquartile range) Injury Severity Score was 9 (5-13). Overall, 179 patients (14%) had a major complication, 554 (42%) were discharged to rehab/SNFs, and 63 (5%) died during the index admission. Compared with nonfrail patients, frail patients had significantly higher odds of mortality (adjusted odds ratio [aOR], 1.93; p = 0.018), major complications (aOR, 3.55; p < 0.001), and discharge to rehab/SNFs (aOR, 1.98; p < 0.001). In addition, frailty was significantly associated with higher adjusted odds of mortality, major complications, readmissions, and fall recurrence at 3 months postdischarge ( p < 0.05). CONCLUSION: External applicability of the TSFI (15 variables) was evident at a multicenter cohort of 17 American College of Surgeons trauma centers in geriatric trauma patients. The TSFI emerged as an independent predictor of worse outcomes, both in the short-term and 3-month postdischarge. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

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.

Intentional foreign object ingestions: need for endoscopy and surgery.

BACKGROUND: Intentional ingestion of foreign objects (IIFO) is common in the incarcerated population. This study was undertaken in order to better define clinical patterns of IIFO among prisoners. We sought to determine factors associated with the need for endoscopic and surgical therapy for IIFO. METHODS: After obtaining permission to conduct IIFO research in incarcerated populations, study patients were identified by ICD-9 codes. Patient charts were reviewed for demographics; past medical history; IIFO characteristics; and diagnostic, endoscopic, and surgical findings. Univariate and multivariate analyses were performed using statistical software. RESULTS: Thirty patients with 141 episodes of IIFO were identified. The mean number of ingested items per episode was 4.60. Endoscopy was performed in 97 of 141 IIFO instances, with failure to retrieve the ingested object in 21 of 97 cases (22%). Eleven instances (7.8%) required surgical intervention. On multivariate analyses, hospital admission was associated with elevated white blood cell count (odds ratio [OR] 1.4, P < 0.05) and number of items ingested (OR 1.3, P < 0.05). The need for endoscopy was independently associated with ingestion of multiple objects (OR 3.3, P < 0.05) and elevated white blood cell count (OR 1.3, P < 0.05). Surgical therapy was significantly associated with elevated white blood cell count (OR 1.6, P < 0.01) and with increasing number of ingested items (OR 1.07 per item, P < 0.05). Endoscopy is associated with significantly lower odds of surgery (OR 0.13, P < 0.01). CONCLUSIONS: Intentional ingestion of foreign objects continues to pose a significant human and economic burden. The need for admission or therapy is frequently associated with leukocytosis. Further investigation is warranted into resource-appropriate triage of patients who present with IIFO.

Impact of early methadone initiation in critically injured burn patients: a pilot study.

Numerous studies have identified strategies to reduce mechanical ventilation duration by targeting appropriate sedation levels. However, applicability of these strategies to critically injured patients with burn injury has not been established. At our medical center, methadone is commonly used early in the care of burn patients to treat background pain and limit the development of opioid tolerance. The aim of this study is to evaluate the effect of early methadone initiation in critically injured burn patients requiring mechanical ventilation. This retrospective study compared patients who received early methadone with patients who did not while mechanically ventilated with the primary outcome of ventilator-free days in a 28-day period. Those who received methadone within 4 days of intubation and remained ventilated for 2 days after the first dose were included in the methadone group. Propensity scores were used to match up to three control patients to each methadone patient. Seventy patients (18 methadone and 52 matched control patients) were included in the final evaluation. Patients in the methadone group averaged 16.5 ventilator-free days compared with 11.5 in the control group (P = .03). There was no statistical difference in the duration of intensive care unit or hospital length of stay between groups. Our results suggest that early methadone initiation may have a significant effect on ventilator outcomes in critically injured patients with burn injury. However, further research is warranted.

Comorbidity-polypharmacy scoring facilitates outcome prediction in older trauma patients.

OBJECTIVES: To determine the association between comorbidity-polypharmacy score (CPS) and clinical outcomes in a large sample of older trauma patients, focusing on outcome prognostication. DESIGN: The CPS combines number of preinjury medications and comorbidities to more objectively quantify the severity of comorbid conditions. SETTING: An urban tertiary care level 1 trauma center in the Midwest. PARTICIPANTS: Trauma patients aged 45 and older. METHODS: Participants were stratified into four groups according to CPS ranges. Survival analyses were performed using Kaplan-Meier/Mantel-Cox testing. Factors influencing mortality, complications, and survivor discharge destination were evaluated using analysis of covariance and multivariate logistic regression. RESULTS: Records for 469 individuals (mean age 62.1, mean injury severity score 9.3) were reviewed. Higher CPS is associated with greater mortality, complications, longer hospital and intensive care unit stay, and need for discharge to a facility. Higher CPS is associated with lower 90-day survival (Mantel-Cox, P < .001). Mortality was independently associated with older age (odds ratio (OR) = 1.06 per year), higher injury severity score (OR = 1.19 per point), and higher CPS (OR = 1.11 per point) in multivariate analysis (all P < .01). Complications and need for discharge to a facility were independently associated with older age and higher injury severity score and CPS. CONCLUSION: CPS can be readily determined in the era of medication reconciliation. Trauma patients with CPS of 15 or greater are at greater risk of poor clinical outcomes. CPS constitutes a useful adjunct to currently available injury severity scoring tools as a predictor of morbidity, mortality, hospital resource utilization, and postdischarge disposition in older trauma patients.

Dynamic changes in respiratory frequency/tidal volume may predict failures of ventilatory liberation in patients on prolonged mechanical ventilation and normal preliberation respiratory frequency/tidal volume values.

Rapid shallow breathing index (RSBI, respiratory frequency [f] divided by tidal volume [Vt]) has been used to prognosticate liberation from mechanical ventilation (LMV). We hypothesize that dynamic changes in RSBI predict failed LMV better than isolated RSBI measurements. We conducted a retrospective study of patients who were mechanically ventilated (MV) for longer than 72 hours. Failed LMV was defined as need for reinstitution of MV within 48 hours post-LMV. Ventilatory frequency (f) and Vt (liters) were serially recorded. The instantaneous RSBI (i-RSBI) was defined as f/Vt. Dynamic f/Vt ratio (d-RSBI) was defined as the ratio between two consecutive i-RSBI (f/Vt) measurements ([f(2)/Vt(2)]/[f(1)/Vt(1)]). RSBI Product (RSB-P) was defined as (i-RSBI × d-RSBI). Data from 32 patients were analyzed (Acute Physiology and Chronic Health Evaluation II 13.4, male 69%, mean age 57 years). Mean length of stay was 19.5 days (11.5 ventilator; 14.1 intensive care unit days). For LMV failures, mean time to reinstitution of invasive MV was 20.8 hours. All patients had pre-LMV i-RSBI less than 100. Failed LMVs had higher i-RSBI values (68.9, n = 18) than successful LMVs (44.2, n = 23, P < 0.01). Failures had higher d-RSBI (1.48) than successful LMVs (1.05, P < 0.04). The RSB-P was higher for failed LMVs (118) than for successful LMVs (48.8, P < 0.01) with failures having larger proportion of pre-LMV d-RSBI values greater than 1.5 (39.0 vs 10.7%, P < 0.03). Pre-LMV RSB-P may offer early prediction of failed LMV in patients on MV for longer than 72 hours despite normal pre-LMV i-RSBI. Divergence between RSB-P for successful and failed LMVs occurred earlier than i-RSBI divergence with a greater proportion of pre-LMV d-RSBI greater than 1.5 among failures.

The impact of antiplatelet therapy on pelvic fracture outcomes.

INTRODUCTION: Despite increasing use of antiplatelet agents (APA), little is known regarding the effect of these agents on the orthopedic trauma patient. This study reviews clinical outcomes of patients with pelvic fractures (Pfx) who were using pre-injury APA. Specifically, we focused on the influence of APA on postinjury bleeding, transfusions, and outcomes after Pfx. METHODS: Patients with Pfx admitted during a 37-month period beginning January 2006 were divided into APA and non-APA groups. Pelvic injuries were graded using pelvic fracture severity score (PFSS)-a combination of Young-Burgess (pelvic ring), Letournel-Judet (acetabular), and Denis (sacral fracture) classifications. Other clinical data included demographics, co-morbid conditions, medications, injury severity score (ISS), associated injuries, morbidity/mortality, hemoglobin trends, blood product use, imaging studies, procedures, and resource utilization. Multivariate analyses for predictors of early/late transfusions, pelvic surgery, and mortality were performed. RESULTS: A total of 109 patients >45 years with Pfx were identified, with 37 using preinjury APA (29 on aspirin [ASA], 8 on clopidogrel, 5 on high-dose/scheduled non-steroidal anti-inflammatory agents [NSAID], and 8 using >1 APAs). Patients in the APA groups were older than patients in the non-APA group (70 vs. 63 years, P < 0.01). The two groups were similar in gender distribution, PFSS and ISS. Patients in the APA group had more comorbidities, lower hemoglobin levels at 24 h, and received more packed red blood cell (PRBC) transfusions during the first 24 h of hospitalization (all, P < 0.05). There were no differences in platelet or late (>24 h) PRBC transfusions, blood loss/transfusions during pelvic surgery, lengths of stay, post-ED/discharge disposition, or mortality. In multivariate analysis, predictors of early PRBC transfusion included higher ISS/PFSS, pre-injury ASA use, and lower admission hemoglobin (all, P < 0.03). Predictors of late PRBC transfusion included the number of complications, gender, PFSS, and any APA use (all, P < 0.05). Mortality was associated with pelvic hematoma/contrast extravasation on imaging, number of complications, and higher PFSS/ISS (all, P < 0.04). CONCLUSIONS: Results of this study support the contention that preinjury use of APA does not independently affect morbidity or mortality in trauma patients with Pfx. Despite no clinically significant difference in early postinjury blood loss, pre-injury use of APA was associated with increased likelihood of receiving PRBC transfusion within 24 h of admission. Furthermore, multivariate analyses demonstrated that among different APA, only preinjury ASA (vs. clopidogrel or NSAID) was associated with early PRBC transfusions. Late transfusion was associated with the use of any APA, complications, higher PFSS, and need for pelvic surgery.

Vitamin B6 deficiency: a potential cause of refractory seizures in adults.

OBJECTIVE: In children, vitamin B(6) (pyridoxine) deficiency has been described as a cause of seizures that are refractory to conventional antiepileptic medications. We describe the clinical presentation of 3 adults with refractory seizures (later diagnosed with vitamin B(6) deficiency) that resolved after pyridoxine treatment. DESIGN: Case series. SETTING: Tertiary care surgical intensive care unit. PATIENTS: In the first case, a 54-year-old male with history of alcoholic cirrhosis developed new-onset seizures refractory to phenytoin and levetiracetam 8 days after liver transplantation. In the second case, a 59-year-old male with hepatitis C infection developed intracranial hemorrhage and new-onset seizures refractory to phenytoin, levetiracetam, and pentobarbital. The third patient is a 78-year-old male with a history of alcohol dependence who was admitted for an intraventricular bleed and developed new onset of refractory seizures. INTERVENTIONS: Intravenous pyridoxine followed by oral pyridoxine. MEASUREMENT AND MAIN RESULTS: In all 3 cases, seizures persisted despite escalation of conventional antiepileptic medications but resolved within 2 days of pyridoxine supplementation. In each case, low serum pyridoxal 5'-phosphate concentrations normalized with pyroxidine administration. CONCLUSIONS: Although refractory seizures caused by vitamin B(6) deficiency are rare in adults, it should be considered in critically ill adult patients with refractory seizures.

Does delaying early intravenous fat emulsion during parenteral nutrition reduce infections during critical illness?

BACKGROUND: Because early administration of intravenous fat emulsions (IVFEs) has been linked to infectious complications in trauma patients, we began withholding IVFE for the first seven to ten days of parenteral nutrition (PN) in all surgical intensive care unit (SICU) patients. Prior to this, IVFE had been infused from the start of PN. PURPOSE: To evaluate the influence of delaying IVFE on infectious complications in SICU patients. METHODS: Retrospective review from October 2006 to June 2009 of SICU patients before and after a change in IVFE practice patterns in a 44-bed SICU at an academic medical center. Adult patients who received PN for more than six days were included. Patients receiving PN with IVFE prior to SICU admission or being given other lipid emulsion therapy were excluded. The data collected included demographics, transfusion requirements, nutritional assessments, and laboratory and microbiology results. The infectious complications studied were pneumonia, urinary tract infections (UTIs), blood stream infections (BSIs), and catheter-related blood stream infections (CRBSIs). RESULTS: Sixty-four patients received IVFE; 30 at initiation of PN and 34 starting after seven to ten days. The two groups had similar demographics, severity of illness, transfusion requirements, and duration of PN. Infectious complications occurred in 65.6% of patients (63.3% having immediate IVFE vs. 67.6% having delayed IVFE; p = 0.79). Seventeen patients developed BSI or CRBSI while receiving PN (26.7% immediate IVFE vs. 26.5% delayed IVFE; p > 0.99). The mortality rates were 63.3% and 55.9%, respectively (p = 0.63). CONCLUSIONS: Withholding IVFE therapy during the first seven to ten days of PN did not influence infectious complications or the mortality rate in SICU patients. The benefits of delaying IVFE therefore may not be generalizable to all critically ill patients.

Pre-injury polypharmacy as a predictor of outcomes in trauma patients.

BACKGROUND: One of the hallmarks of modern medicine is the improving management of chronic health conditions. Long-term control of chronic disease entails increasing utilization of multiple medications and resultant polypharmacy. The goal of this study is to improve our understanding of the impact of polypharmacy on outcomes in trauma patients 45 years and older. MATERIALS AND METHODS: Patients of age ≥45 years were identified from a Level I trauma center institutional registry. Detailed review of patient records included the following variables: Home medications, comorbid conditions, injury severity score (ISS), Glasgow coma scale (GCS), morbidity, mortality, hospital length of stay (LOS), intensive care unit (ICU) LOS, functional outcome measures (FOM), and discharge destination. Polypharmacy was defined by the number of medications: 0-4 (minor), 5-9 (major), or ≥10 (severe). Age- and ISS-adjusted analysis of variance and multivariate analyses were performed for these groups. Comorbidity-polypharmacy score (CPS) was defined as the number of pre-admission medications plus comorbidities. Statistical significance was set at alpha = 0.05. RESULTS: A total of 323 patients were examined (mean age 62.3 years, 56.1% males, median ISS 9). Study patients were using an average of 4.74 pre-injury medications, with the number of medications per patient increasing from 3.39 for the 45-54 years age group to 5.68 for the 75+ year age group. Age- and ISS-adjusted mortality was similar in the three polypharmacy groups. In multivariate analysis only age and ISS were independently predictive of mortality. Increasing polypharmacy was associated with more comorbidities, lower arrival GCS, more complications, and lower FOM scores for self-feeding and expression-communication. In addition, hospital and ICU LOS were longer for patients with severe polypharmacy. Multivariate analysis shows age, female gender, total number of injuries, number of complications, and CPS are independently associated with discharge to a facility (all, P < 0.02). CONCLUSION: Over 40% of trauma patients 45 years and older were receiving 5 or more medications at the time of their injury. Although these patients do not appear to have higher mortality, they are at increased risk for complications, lower functional outcomes, and longer hospital and intensive care stays. CPS may be useful when quantifying the severity of associated comorbid conditions in the context of traumatic injury and warrants further investigation.

Tree stands, not guns, are the midwestern hunter's most dangerous weapon.

Although the prevailing stereotype is that most hunting injuries are gunshot wounds inflicted by intoxicated hunting buddies, our experience led us to hypothesize that falls comprise a significant proportion of hunting related injuries. Trauma databases of two Level I trauma centers in central Ohio were queried for all hunting related injuries during a 10-year period. One hundred and thirty patients were identified (90% male, mean age 41.0 years, range 17-76). Fifty per cent of injuries resulted from falls, whereas gunshot wounds accounted for 29 per cent. Most hunters were hunting deer and 92 per cent of falls were from tree stands. Alcohol was involved in only 2.3 per cent, and drugs of abuse in 4.6 per cent. Of gunshots, 58 per cent were self-inflicted, and 42 per cent were shot by another hunter. Tree stand falls were highly morbid, with 59 per cent of fall victims suffering spinal fractures, 47 per cent lower extremity fractures, 18 per cent upper extremity fractures, and 18 per cent closed head injuries. Surgery was required for 81 per cent of fall-related injuries, and 8.2 per cent of fall victims had permanent neurological deficits. In contrast to prevailing beliefs, in our geographic area tree-stand falls are the most common mechanism of hunting related injury requiring admission to a Level 1 trauma center.

Portable ultrasonography in mass casualty incidents: The CAVEAT examination.

Ultrasonography used by practicing clinicians has been shown to be of utility in the evaluation of time-sensitive and critical illnesses in a range of environments, including pre-hospital triage, emergency department, and critical care settings. The increasing availability of light-weight, robust, user-friendly, and low-cost portable ultrasound equipment is particularly suited for use in the physically and temporally challenging environment of a multiple casualty incident (MCI). Currently established ultrasound applications used to identify potentially lethal thoracic or abdominal conditions offer a base upon which rapid, focused protocols using hand-carried emergency ultrasonography could be developed. Following a detailed review of the current use of portable ultrasonography in military and civilian MCI settings, we propose a protocol for sonographic evaluation of the chest, abdomen, vena cava, and extremities for acute triage. The protocol is two-tiered, based on the urgency and technical difficulty of the sonographic examination. In addition to utilization of well-established bedside abdominal and thoracic sonography applications, this protocol incorporates extremity assessment for long-bone fractures. Studies of the proposed protocol will need to be conducted to determine its utility in simulated and actual MCI settings.