The Association Between Gender and Clinical Outcomes in Patients With Moderate to Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis.

INTRODUCTION: Traumatic brain injuries (TBIs) are a significant cause of morbidity and mortality in the United States. but have a disproportionate impact on patients based on gender. This systematic review and meta-analysis aim to compare gender differences in clinical outcomes between male and female adult trauma patients with moderate and severe TBI. METHODS: Studies assessing gender differences in outcomes following TBIs on PubMed, Google Scholar, EMBASE, and ProQuest were searched. Meta-analysis was performed for outcomes including in-hospital mortality, hospital length of stay, intensive care unit length of stay, and Glasgow outcome scale (GOS) at 6 mo. RESULTS: Eight studies were included for analysis with 26,408 female and 63,393 male patients. Meta-analysis demonstrated that males had a significantly lower risk of mortality than females (RR: 0.88; 95% CI 0.78, 0.99; P = 0.0001). Females had a shorter hospital length of stay (mean difference -1.4 d; 95% CI - 1.6 d, -1.2 d). No significant differences were identified in intensive care unit length of stay (mean difference -3.0 d; 95% CI -7.0 d, 1.1 d; P = 0.94) or GOS at 6 mo (mean difference 0.2 d; 95% CI -0.9 d, 1.4 d; P = 1). CONCLUSIONS: Compared to male patients, female patients with moderate and severe TBI had a significantly higher in-hospital mortality risk. There were no significant differences in long-term outcomes between genders based on GOS at 6 mo. These findings warrant further investigation into the etiology of these gender disparities and their impact on additional clinical outcome measures.

National Analysis of Outcomes for Adult Trauma Patients With Isolated Severe Blunt Traumatic Brain Injury Following Venous Thromboembolism Prophylaxis.

INTRODUCTION: We aim to evaluate the association of early versus late venous thromboembolism (VTE) prophylaxis on in-hospital mortality among patients with severe blunt isolated traumatic brain injuries. METHODS: Data from the American College of Surgeons Trauma Quality Program Participant Use File for 2017-2021 were analyzed. The target population included adult trauma patients with severe isolated traumatic brain injury (TBI). VTE prophylaxis types (low molecular weight heparin and unfractionated heparin) and their administration timing were analyzed in relation to in-hospital complications and mortality. RESULTS: The study comprised 3609 patients, predominantly Caucasian males, with an average age of 48.5 y. Early VTE prophylaxis recipients were younger (P < 0.01) and more likely to receive unfractionated heparin (P < 0.01). VTE prophylaxis later than 24 h was associated with a higher average injury severity score and longer intensive care unit stays (P < 0.01). Logistic regression revealed that VTE prophylaxis later than 24 h was associated with significant reduction of in-hospital mortality by 38% (odds ratio 0.62, 95% confidence interval 0.40-0.94, P = 0.02). Additionally, low molecular weight heparin use was associated with decreased mortality odds by 30% (odds ratio 0.70, 95% confidence interval 0.55-0.89, P < 0.01). CONCLUSIONS: VTE prophylaxis later than 24 h is associated with a reduced risk of in-hospital mortality in patients with severe isolated blunt TBI, as opposed to VTE prophylaxis within 24 h. These findings suggest the need for timely and appropriate VTE prophylaxis in TBI care, highlighting the critical need for a comprehensive assessment and further research concerning the safety and effectiveness of VTE prophylaxis in these patient populations.

Clinical Outcomes of Splenic Artery Embolization Versus Splenectomy in the Management of Hemodynamically Stable High-Grade Blunt Splenic Injuries: A National Analysis.

INTRODUCTION: This study aims to compare the outcomes of splenic artery embolization (SAE) versus splenectomy in adult trauma patients with high-grade blunt splenic injuries. METHODS: This retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database (2017-2021) compared SAE versus splenectomy in adults with blunt high-grade splenic injuries (grade ≥ IV). Patients were stratified first by hemodynamic status then splenic injury grade. Outcomes included in-hospital mortality, intensive care unit length of stay (ICU-LOS), and transfusion requirements at four and 24 h from arrival. RESULTS: Three thousand one hundred nine hemodynamically stable patients were analyzed, with 2975 (95.7%) undergoing splenectomy and 134 (4.3%) with SAE. One thousand eight hundred sixty five patients had grade IV splenic injuries, and 1244 had grade V. Patients managed with SAE had 72% lower odds of in-hospital mortality (odds ratio [OR] 0.28; P = 0.002), significantly shorter ICU-LOS (7 versus 9 d, 95%, P = 0.028), and received a mean of 1606 mL less packed red blood cells at four h compared to those undergoing splenectomy. Patients with grade IV or V injuries both had significantly lower odds of mortality (IV: OR 0.153, P < 0.001; V: OR 0.365, P = 0.041) and were given less packed red blood cells within four h when treated with SAE (2056 mL versus 405 mL, P < 0.001). CONCLUSIONS: SAE may be a safer and more effective management approach for hemodynamically stable adult trauma patients with high-grade blunt splenic injuries, as demonstrated by its association with significantly lower rates of in-hospital mortality, shorter ICU-LOS, and lower transfusion requirements compared to splenectomy.

Patient Experiences of Acute and Postacute Care After Trauma.

INTRODUCTION: Traumatic injury can transform a healthy, independent individual into a patient with complex health needs. Little is known about how injured patients understand their health and healthcare needs during postacute recovery, limiting our ability to optimize care. This multiple-methods study explored injured patients' experiences of care up to 30 days after discharge. METHODS: Injured adults admitted to an urban, Level I trauma center August 1, 2019-November 30, 2020 were sampled purposively to balance blunt and penetrating injuries. Patient experience and health status were assessed at baseline and 30 days postdischarge using the Quality of Trauma Care Patient-Reported Experience Measure. Fifteen qualitative interviews were conducted with a purposive subset and analyzed using qualitative content analysis. RESULTS: Of 67 participants (76% male, 73% Black, 51% penetrating, median age 34 years), 37 completed follow-up surveys. Quality of acute care was rated 9-10/10 by 81% of the sample for acute and 65% for postacute care (P = 0.09). Thirty percent described fair or poor mental health, but only mental health concerns were addressed for only 2/3. Pain control was inadequate in 31% at baseline and for 46% at follow-up (P = 0.09). Qualitative analysis revealed general satisfaction with acute care but challenges in recovery with unmet needs for communication and care coordination. CONCLUSIONS: Trauma patients appreciated the quality of their acute care experiences but identified opportunities for improvement in prognostic communication, pain management, and mental health support. Unmet mental and physical care needs persist at least 1 month after hospital discharge and reinforce the need for interventions that optimize postacute trauma care.

Traumatic Brain Injury, Electrolyte Levels, and Associated Outcomes: A Systematic Review.

INTRODUCTION: Although it has been established that electrolyte abnormalities are a consequence of traumatic brain injury (TBI), the degree to which electrolyte imbalances impact patient outcomes has not been fully established. We aim to determine the impact of sodium, potassium, calcium, and magnesium abnormalities on outcomes in patients with TBI. METHODS: Four databases were searched for studies related to the impact of electrolyte abnormalities on outcomes for TBI patients. Outcomes of interest were rates of mortality, Glasgow Outcome Scale (GOS), and intensive care unit length of stay (ICU-LOS). The search included studies published up to July 21, 2022. Articles were then screened and included if they met inclusion and exclusion criteria. RESULTS: In total, fourteen studies met inclusion and exclusion criteria for analysis in this systematic review. In patients with TBI, an increased mortality rate was associated with hypernatremia, hypokalemia, and hypocalcemia in the majority of studies. Both hyponatremia and hypomagnesemia were associated with worse GOS at 6 months. Whereas, both hyponatremia and hypernatremia were associated with increased ICU-LOS. There was no evidence to suggest other electrolyte imbalances were associated with either GOS or ICU-LOS. CONCLUSIONS: Hyponatremia and hypomagnesemia were associated with worse GOS. Hypernatremia was associated with increased mortality and ICU-LOS. Hypokalemia and hypocalcemia were associated with increased mortality. Given these findings, future practice guidelines should consider the effects of electrolytes' abnormalities on outcomes in TBI patients prior to establishing management strategies.

Postoperative antiplatelet and/or anticoagulation use does not impact complication or reintervention rates after vein repair of arterial injury: A PROOVIT study.

INTRODUCTION: The use of antiplatelet (AP) and anticoagulation (AC) therapy after autogenous vein repair of traumatic arterial injury is controversial. The hypothesis in this study was that there is no difference in early postoperative outcomes regardless of whether AC, AP, both, or neither are used. METHODS: The American Association for the Surgery of Trauma (AAST) PROspective Observational Vascular Injury Treatment (PROOVIT) registry was queried from November, 2013, to January, 2019, for arterial injuries repaired with a vein graft. Demographics and injury characteristics were compared. Need for in-hospital reoperation was the primary outcome in this four-arm study, assessed with two ordinal logistic regression models (1. no therapy vs. AC only vs. AC and AP; 2. no therapy vs. AP only vs. AC and AP). RESULTS: 373 patients (52 no therapy, 88 AP only, 77 AC only, 156 both) from 19 centers with recorded Injury Severity Scores (ISS) were identified. Patients who received no therapy were younger than those who received AP (27.0 vs. 34.2, p = 0.02), had higher transfusion requirement (p < 0.01 between all groups) and a different distribution of anatomic injury (p < 0.01). After controlling for age, sex, ISS, platelet count, hemoglobin, pH, lactate, INR, transfusion requirement and anatomic location, there was no association with postoperative medical therapy and in-hospital operative reintervention, or any secondary outcome, including thrombosis (p = 0.67, p = 0.22). CONCLUSIONS: Neither AC nor AP alone, nor in combination, impact complication rate after arterial repair with autologous vein. These patients can be safely treated with or without antithrombotics, recognizing that this study did not demonstrate a beneficial effect.

Predictors of Readmission Following Treatment for Traumatic Hemothorax.

INTRODUCTION: Retained-hemothorax after trauma can be associated with prolonged hospitalization, empyema, pneumonia, readmission, and the need for additional intervention. The purpose of this study is to reduce patient morbidity associated with retained-hemothorax by defining readmission rates and identifying predictors of readmission after traumatic hemothorax. METHODS: The Nationwide Readmission Database for 2017 was queried for patients with an index admission for traumatic hemothorax during the first 9 mo of the year. Deaths during the index admission were excluded. Data collected includes demographics, injury mechanism, outcomes and interventions including chest tube, video-assisted thoracoscopic surgery, and thoracotomy. Chest-related readmissions (CRR) were defined as hemothorax, pleural effusion, pyothorax, and lung abscess. Univariate and multivariate analysis were used to identify predictors of readmission. RESULTS: There were 13,903 patients admitted during the study period with a mean age of 53 ± 21, 75.2% were admitted after blunt versus 18.3% penetrating injury. The overall 90-day readmission rate was 20.8% (n = 2896). The 90-day CRR rate was 5.7% (n = 794), with 80.5% of these occurring within 30 d. Of all CRR, 62.3% (n = 495) required an intervention (chest tube 72.7%, Thoracotomy 26.9%, video-assisted thoracoscopic surgery 0.4%). Mortality for CRR was 6.2%. Predictors for CRR were age >50, pyothorax or pleural effusion during the index admission and discharge to another healthcare facility or skilled nursing facility. CONCLUSIONS: Majority of CRR after traumatic hemothorax occur within 30 d of discharge and frequently require invasive intervention. These findings can be used to improve post discharge follow-up and monitoring.

The Association Between Early Versus Late Physical Therapy Initiation and Outcomes of Trauma Patients With and Without Traumatic Brain Injuries.

BACKGROUND: There is a lack of literature regarding the most effective timing to initiate physical therapy (PT) among traumatically injured patients. We aim to evaluate the association between early PT/mobilization versus delayed or late PT/mobilization and clinical outcomes of trauma patients. METHODS: A retrospective cohort analysis of an urban level-I trauma center from 2014 to 2019 was performed. Univariate analyses and multivariable logistic regression were performed with significance defined as P < 0.05. RESULTS: A total of 11,937 patients were analyzed. Among patients without a traumatic brain injury (TBI), late PT initiation times were associated with 60% lower odds of being discharged home without services (P < 0.05), significantly increased hospital and ICU length of stay (H-LOS, ICU-LOS) (P < 0.05), and significantly higher odds of complications (VTE, pneumonia, pressure ulcers, ARDS) (P < 0.001). Among patients with a TBI, late PT initiation time had 76% lower odds of being discharged home without services (P < 0.05) and significantly longer H-LOS and ICU-LOS (P < 0.05) however did not experience significantly higher odds of complications (P > 0.05). CONCLUSIONS: Among traumatically injured patients, early PT is associated with decreased odds of complications, shorter H-LOS and ICU-LOS, and a favorable discharge disposition to home without services. Adoption of early PT initiation/mobilization protocols and establishment of prophylactic measures against complications associated with delayed PT is critical to maximize quality of care and trauma patient outcomes. Multi-center prospective studies are needed to ascertain the impact of PT initiation times in greater detail and to minimize trauma patient morbidity.

The Role of Pericardial Window Techniques in the Management of Penetrating Cardiac Injuries in the Hemodynamically Stable Patient: Where Does It Fit in the Current Trauma Algorithm?

INTRODUCTION: Penetrating cardiac injuries (PCIs) have high in-hospital mortality rates. Guidelines regarding the use of pericardial window (PW) for diagnosis and treatment of suspected PCIs are not universally established. The objective of this review was to provide a critical appraisal of the current literature to determine the effectiveness and safety of PW as both a diagnostic and therapeutic technique for suspected PCIs in patients with hemodynamic stability. METHODS: A review was conducted using PubMed/MEDLINE, Google Scholar, and Embase to identify literature evaluating the accuracy and therapeutic efficacy of PW and its role in a hemodynamically stable patient with penetrating thoracic or thoracoabdominal trauma. RESULTS: Eleven studies evaluating diagnostic PW and two studies evaluating therapeutic PW were included. These studies ranged from (y) 1977 to 2018. Existing literature indicates that PW is highly sensitive (92%-100%) and specific (96%-100%) for the diagnosis of suspected PCIs. PW and drainage, when compared with sternotomy, may be associated with decreased total hospital stay (4.1 versus 6.5 d; P < 0.001) and intensive care unit stay (0.25 versus 2.04 d; P < 0.001) along with similar mortality and complication rates after the management of hemopericardium. CONCLUSIONS: In a hemodynamically stable patient presenting with penetrating cardiac trauma with a high suspicion for PCI, PWs can (1) facilitate prompt diagnosis in the event of equivocal ultrasonography findings and (2) serve as an effective therapeutic modality with the benefit of potentially avoiding more invasive procedures. Subxiphoid, transdiaphragmatic, and laparoscopic approaches for PW have been shown to have similar efficacy and safety.

Preoperative and Postoperative Cognitive Assessment in Geriatric Patients Following Acute Traumatic Injuries: Towards Improving Geriatric Trauma Outcomes.

INTRODUCTION: A growing percentage of the US population is over the age of 65, and geriatrics account for a large portion of trauma admissions, expected to reach nearly 40% by 2050. Cognitive status is important for operative management, especially in elderly populations. This study aims to investigate preoperative and postoperative cognitive function assessment tools in geriatric patients following acute trauma and associated outcomes, including functional status, postdischarge disposition, mortality, and hospital length of stay (H-LOS). METHODS: A literature search was conducted using Medline/PubMed, Google Scholar, Embase, JAMA Networks, and Cochrane databases for studies investigating the use of cognitive assessment tools for geriatric patients with acute trauma. The last literature search was conducted on November 13, 2021. RESULTS: Ten studies were included in this review, of which five focused on preoperative cognitive assessment and five focused on postoperative. The evidence suggests patients with preoperative cognitive impairment had worse functional status, mortality, and postdischarge disposition along with increased LOS. Acute trauma patients with postoperative cognitive impairment also had worse functional status, mortality, and adverse postdischarge disposition. CONCLUSIONS: Preoperative and postoperative cognitive impairment is common in geriatric patients with acute trauma and is associated with worse outcomes, including decreased functional status, increased LOS, and adverse discharge disposition. Cognitive assessment tools such as MMSE, MoCA, and CAM are fast and effective at detecting cognitive impairment in the acute trauma setting and allow clinicians to address preoperative or postoperative cognitive impairments to improve patient outcomes.

The Impact of Seatbelt Use on Trauma Outcomes in Adult Motor Vehicle Collision Patients With Rib Fractures: A National ACS-TQP-PUF Database Analysis.

BACKGROUND: Motor vehicle collisions (MVCs) are a leading cause of morbidity and mortality. However, there is limited evidence examining the effects seatbelt use has on MVC-related injuries and outcomes in patients with rib fractures. We aim to assess how seatbelt use affects associated injuries and outcomes in adult MVC patients with ≥2 rib fractures. METHODS: This retrospective study utilized the American College of Surgeons (ACS) Trauma Quality Programs (TQP) Participant Use File (PUF) Database. Drivers/passengers who sustained ≥2 rib fractures following an MVC and had an AIS ≤2 for extra-thoracic body regions were analyzed. Patients were then subdivided by presence of flail chest into two cohorts, which were subdivided according to injury severity score (ISS) and seatbelt use. Logistic and linear regression was used to assess the impact of seatbelt use on outcomes. RESULTS: Among both low and intermediate ISS classifications, restrained patients in the non-flail chest cohort had decreased incidence of pneumothorax, pulmonary contusion, and liver injury (P < 0.001). After adjusting for confounders, restrained patients (versus unrestrained) had decreased odds of pneumothorax (aOR = 0.91, P = <0.001) and acute respiratory distress syndrome (aOR=0.65, P = 0.02), while having increased odds of splenic laceration (aOR = 1.18, P = 0.003) (intermediate ISS group). Compared to unrestrained patients, restrained non-flail chest patients had a significantly decreased hospital length of stay (LOS) and intensive care unit LOS (P < 0.05). CONCLUSIONS: Seatbelt use may be protective against serious injuries in patients with ≥2 rib fractures, resulting in improved outcomes. Education programs should be developed to bolster seatbelt compliance.

Emergency Resuscitative Thoracotomy for Civilian Thoracic Trauma in the Field and Emergency Department Settings: A Systematic Review and Meta-Analysis.

BACKGROUND: Emergency department resuscitative thoracotomy (ED-RT) or prehospital resuscitative thoracotomy (PH-RT) is performed for trauma patients with impending or full cardiovascular collapse. This systematic review and meta-analysis analyze outcomes in patients with thoracic trauma receiving PH-RT and ED-RT. METHODS: PubMed, JAMA Network, and CINAHL electronic databases were searched to identify studies published on ED-RT or PH-RT between 2000-2020. Patients were grouped by location of procedure and type of thoracic injury (blunt versus penetrating). RESULTS: A total of 49 studies met the criteria for qualitative analysis, and 43 for quantitative analysis. 43 studies evaluated ED-RT and 5 evaluated PH-RT. Time from arrival on scene to PH-RT >5 min was associated with increased neurological complications and time from the initial encounter to PH-RT or ED-RT >10 min was associated with increased mortality. ISS ≥ 25 and absent signs of life were also associated with increased mortality. There was higher mortality in all PH-RT (93.5%) versus all ED-RT (81.8%) (P = 0.02). Among ED-RTs, a significant difference was found in mortality rate between patients with blunt (92.8%) versus penetrating (78.7%) injuries (P < 0.001). When considering only blunt or penetrating injury types, no significant difference in RT mortality rate was found between ED-RT and PH-RT (P = 0.65 and P = 0.95, respectively). CONCLUSIONS: ED-RT and PH-RT are potentially life-saving procedures for patients with penetrating thoracic injuries in extremis and with signs of life. The efficacy of this procedure is time sensitive. Moreover, there appears to be a greater mortality risk for patients with thoracic trauma receiving RT in the PH setting compared to the ED setting. More studies are needed to determine the significance of PH-RT mortality.

Effect of Nighttime on Prehospital Care and Outcomes of Road Traffic Injuries in Asia: A Cross-Sectional Study of Data from the Pan-Asian Trauma Outcomes Study (PATOS).

Introduction: Emergency response to a road traffic injury (RTI) plays a crucial role in patient survival, and the quality of the emergency response should be consistent regardless of the time of day. The aim of this study was to investigate prehospital care and survival outcomes compared between emergency response to RTI during the day and emergency response to RTI at night in Asia.Method: This cross-sectional study used data from the Pan-Asian Trauma Outcome Study (PATOS) that was conducted during 2015-2018. We included RTI patients who were transported to the emergency department (ED) by ground ambulance. That group was then categorized according to the time that the ambulance arrived on-scene. On-scene arrival during 8:00 am to 7:59 pm was defined as the daytime group, and arrival during 8:00 pm to 7:59 am was defined as the nighttime group. Multiple logistic regression was employed to identify factors associated with nighttime prehospital interventions and survival outcomes after adjustment for age, alcohol consumption, and injury severity score (ISS).Results: The final analysis included 20,105 RTI patients. Of those, 12,043 (60%) accidents occurred during the daytime, and 8,062 (40%) occurred at night. RTI patients at night were younger (mean age: 35.7 ± 17.3 vs. 39.5 ± 20.7; p < 0.001), had more alcohol consumption (15.0% vs. 4.2%; p < 0.001), and had more severe injuries (mean ISS: 6.5 ± 7.5 vs. 5.8 ± 7.0; p < 0.001) compared to the daytime group. The nighttime group had increased prehospital immobilization (adjusted odds ratio [aOR]: 1.22, 95% confidence interval [CI]: 1.14-1.31) and more prehospital intravenous (IV) access (aOR 1.36, 95%CI: 1.22-1.51). There was no significant difference in either basic or advanced airway management between the daytime and nighttime groups. The nighttime group had decreased survival in the ED (aOR: 0.80, 95%CI: 0.65-0.98); however, nighttime on-scene arrival did not impact survival to discharge (aOR: 1.10, 95%CI: 0.91-1.33).Conclusion: In the PATOS community, RTI patients that sustained their injuries at night received significantly more prehospital immobilization and IV access, and they had significantly decreased survival in the ED. The results of this study can be used to develop and enhance strategies to improve the care and outcomes of nighttime RTI in Asia.

Established Primary Care Provider Improves Odds of Survival to Discharge for Injured Patients.

INTRODUCTION: The average age and number of comorbidities is increasing among trauma patients. Primary care providers (PCPs) provide pre-injury diagnosis and management of comorbidities that may affect outcomes for injured patients. The role of primary care in trauma systems is currently unknown. METHODS: Observational retrospective review of an institutional trauma databank from 2013 - 2019. PCP was extracted from the electronic medical record and combined with trauma data. Case-control matching was performed to compare outcomes between patients with and without primary care based on age, injury severity score, sex, and injury mechanism. Mann-Whitney U test, chi-square test, and multivariate regression described differences between subgroups. Primary outcome was difference in mortality rate for injured patients with and without PCPs. RESULTS: Within the study period, 19,096 patients were included. 6,626 (34.7%) had a PCP recorded. Of these, 2,158 were matched in a case-control design. Patients with PCPs had a lower mortality rate (1.6%) compared to patients without PCPs (3.6%, P < 0.01). PCP retention was associated with longer length of stay overall, equivalent rates of complications (5.4% vs. 5.7%, P = 0.63), and similar numbers of ICU and ventilator days. Multivariate logistic regression controlling for case-control factors, insurance, and comorbidities conferred an odds ratio of 2.58 (95% Confidence Interval: 1.59 - 4.19, P < 0.001) for survival to discharge. CONCLUSION: Pre-injury primary care significantly improves the odds of survival to discharge for injured patients. Prospective study of this relationship may identify strategies to promote primary care within health systems.

Utility of the Marshall & Rotterdam Classification Scores in Predicting Outcomes in Trauma Patients.

BACKGROUND: Traumatic Brain Injury (TBI) is a leading cause of mortality in the trauma population. Accurate prognosis remains a challenge. Two common Computed Tomography (CT)-based prognostic models include the Marshall Classification and the Rotterdam CT Score. This study aims to determine the utility of the Marshall and Rotterdam scores in predicting mortality for adult patients in coma with severe TBI. METHOD: Retrospective review of our Level 1 Trauma Center's registry for patients ≥ 18 years of age with blunt TBI and a Glasgow Coma Scale (GCS) of 3-5, with no other significant injuries. Admission Head CT was evaluated for the presence of extra-axial blood (SDH, EDH, SAH, IVH), intra-axial blood (contusions, diffuse axonal injury), midline shift and mass effect on basilar cisterns. Rotterdam and Marshall scores were calculated for all patients; subsequently patients were divided into two groups according to their score (< 4, ≥ 4). RESULTS: 106 patients met inclusion criteria; 75.5% were males (n = 80) and 24.5% females (n = 26). The mean age was 52. The odds ratio (OR) of dying from severe TBI for patients in coma with a Rotterdam score of ≥ 4 compared to < 4 was OR = 17 (P < 0.05). The odds of dying from severe TBI for patients in coma with a Marshall score of ≥ 4 versus < 4 was OR = 11 (P < 0.05). CONCLUSION: Higher scores in the Marshall classification and the Rotterdam system are associated with increased odds of mortality in adult patients in come from severe TBI after blunt injury. The results of our study support these scoring systems and revealed that a cutoff score of < 4 was associated with improved survival.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Use in Animal Trauma Models.

BACKGROUND: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) was developed to prevent traumatic exsanguination. We aim to identify the outcomes in animal models with 1) partial versus complete REBOA occlusion and 2) zone 1 versus 2 placements. METHODS: The PRISMA guidelines were followed. We conducted a search of PubMed, EMBASE and Google Scholar for REBOA studies in animal trauma models using the following search terms: "REBOA trauma", "REBOA outcomes" "REBOA complications". SYRCLE's RoB Tool was utilized for the risk of bias and study quality assessment. RESULTS: Our search yielded 14 RCTs for inclusion. Eleven studies directly investigated partial REBOA versus total aortic occlusion. Overall, partial REBOA techniques were associated with similar attainment of proximal MAP but with significantly less ischemic burden. Significant mortality benefit with partial occlusion was observed in three studies. Survival time post-occlusion also was improved with zone 3 placement versus zone 1 (100% versus 33%; P < 0.01). CONCLUSIONS: There appears to be a fine balance between desired proximal arterial pressure and time of occlusion for overall survival and subsequent risk of distal ischemia. Many "partial occlusion" techniques may be superior in attaining such balance over prolonged REBOA inflation where no distal flow is allowed. Tailored zone 3 placement may offer significant mortality and morbidity advantages compared to sustained total occlusion and indiscriminate zone 1 placement strategies. As clear conclusions regarding REBOA are unlikely to be established in animal models, larger randomized investigations utilizing human subjects are needed to describe optimal REBOA technique and applicability in greater detail.

Trauma outcomes for blunt and penetrating injuries by mode of transportation and day/night shift.

BACKGROUND: Effective management of trauma patients is dependent on pre-hospital triage systems and proper in-hospital treatment regardless of time of admission. We aim to investigate any differences in adjusted all-cause mortality between day vs. night arrival for adult trauma patients who were transported to the hospital via ground emergency medical services (GEMS) and helicopter emergency medical services (HEMS) and to determine if care/outcomes are inferior when admitted during the night shift as compared to the day shift. METHODS: Retrospective cohort analysis of adult blunt and penetrating injury patients requiring full team trauma activation at an American College of Surgeons Committee on Trauma (ACSCOT)-verified Level 1 trauma center from 2011 to 2019. Descriptive statistical analyses, chi-square analyses, independent-sample t-tests, and Fisher's exact tests were performed. Primary measurement outcome was adjusted observed/expected (O/E) mortality ratios utilizing TRISS methodology. RESULTS: 8370 patients with blunt injuries and 1216 patients with penetrating injuries were analyzed. There were no significant differences in day vs. night O/Es overall (blunt 0.65 vs. 0.59; p = 0.46) (penetrating 0.88 vs. 0.87; p = 0.97). There also were no significant differences when stratified by GEMS (blunt 0.64 vs. 0.55; p = 0.08) (penetrating 0.88 vs. 1.10; p = 0.09) and HEMS admissions (blunt 0.76 vs. 0.75; p = 0.91) (penetrating 0.88 vs. 0.91; p = 0.85). CONCLUSIONS: At an ACSCOT-verified Level 1 Trauma Center, care/outcomes of patients admitted during the night shift were not inferior to those admitted during the day shift. Trauma Center verification by the ACSCOT and multidisciplinary collaboration may allow for consistent care despite injury type and time of day.

Emergency Resuscitative Thoracotomy: A Nationwide Analysis of Outcomes and Predictors of Futility.

BACKGROUND: Most studies on emergency resuscitative thoracotomy (ERT) suffer from either small sample size or unclear inclusion criteria. We sought to assess ERT outcomes and predictors of futility using a nationwide database. METHODS: Using a novel and comprehensive algorithm of combinations of specific International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision procedure codes denoting the multiple steps of an ERT (e.g., thoracotomy, pericardiotomy, cardiac massage) performed within the first 60 min of patient arrival, we identified ERT patients in the 2010-2016 Trauma Quality Improvement Program database. We defined the primary outcome as survival to discharge and the secondary outcomes as hospital length of stay (LOS), intensive care unit LOS, number of complications, and discharge destination. Univariate then backward stepwise multivariable logistic regression analyses were performed to assess independent predictors of mortality. Multiple imputations by chained equations were performed when appropriate, as additional sensitivity analyses. RESULTS: Of 1,403,470 patients, 2012 patients were included. The median age was 32, 84.0% were males, 66.7% had penetrating trauma, the median Injury Severity Score was 26, and 87.5% presented with signs of life (SOL). Of the 1343 patients with penetrating injury, 72.9% had gunshot wounds and 27.1% had stab wounds. The overall survival rate was 19.9%: 26.0% in penetrating trauma (stab wound 45.6% versus gunshot wound 18.7%; P < 0.001) and 7.6% in blunt trauma. Independent predictors of mortality were aged 60 y and older (odds ratio, 2.71; 95% confidence interval [95% CI], 1.26-5.82; P = 0.011), blunt trauma (odds ratio, 4.03; 95% CI, 2.72-5.98; P < 0.001), prehospital pulse <60 bpm (odds ratio, 3.43; 95% CI, 1.73-6.79; P < 0.001), emergency department pulse <60 bpm (odds ratio, 4.70; 95% CI, 2.47-8.94; P < 0.001), and no SOL on emergency department arrival (odds ratio, 3.64; 95% CI, 1.08-12.24; P = 0.037). Blunt trauma was associated with a higher median hospital LOS compared with penetrating trauma (28 d versus 13 d; P < 0.001), higher median intensive care unit LOS (19 d versus 6 d; P < 0.001), higher median number of complications (2 versus 1; P = 0.006), and more likelihood to be discharged to a rehabilitation facility instead of home (72.6% versus 28.7%; P < 0.001). ERT had the highest survival rates in patients younger than 60 y who present with SOL after penetrating trauma. None of the patients with blunt trauma who presented with no SOL survived. CONCLUSIONS: The survival rates of patients after ERT in recent years are higher than classically reported, even in the patient with blunt trauma. However, ERT remains futile in patients with a blunt trauma presenting with no SOL.

Aggressive Crystalloid Resuscitation Outcomes in Low-Severity Pediatric Trauma.

BACKGROUND: Trauma is the leading cause of death among children. Studies have found that insufficient intravenous (IV) fluid resuscitation contributes significantly to morbidity and mortality in pediatric trauma. While large-volume resuscitation represents a potential solution, overly aggressive fluid management may complicate hospitalizations and recovery. Through this study, we aim to evaluate the impact of aggressive fluid resuscitation on outcomes in pediatric trauma. MATERIALS AND METHODS: This is a retrospective review utilizing our level I trauma center registry for pediatric patients aged <16 y admitted from 2014 to 2017. Patients transferred from our center within 24 h and those who arrived from outside hospitals were excluded. Patients who received blood product transfusions were excluded. Included patients were divided into two crystalloid groups: <60 mL/kg/24 h and ≥60 mL/kg/24 h. Outcome measures included ICU length-of-stay, length-of-hospitalization, complications, and mortality rate. RESULTS: Study sample included 320 patients (<60 mL/kg/24 h = 219; ≥60 mL/kg/24 h = 101). The ≥60 mL/kg/24 h group was younger (9.95 versus 5.27, P = 0.0001). There were no significant differences in GCS on arrival, injury severity score, Abbreviated Injury Scale, Revised Trauma Scores, traumatic brain injury, and operative intervention between groups. Outcome measures showed there was no significant difference in 30-day readmission rate, complications, or mortality. Large-volume crystalloid resuscitation was associated with longer mean ICU length-of-stay (1.5 d versus 0.8 d, P = 0.004). CONCLUSIONS: In this single-institution retrospective database analysis, large-volume crystalloid resuscitation (≥60 mL/kg) was associated with a significant increase in ICU length-of-stay without survival benefit. More research in the form of randomized trials will help determine the optimal rate for fluid resuscitation in pediatric trauma patients while weighing potential critical care complications.

Thoracic Endovascular Aortic Repair Versus Open Repair: Analysis of the National Trauma Data Bank.

BACKGROUND: Blunt thoracic aortic injuries (BTAIs) carry a substantial mortality rate. Our study aimed to compare the outcomes of thoracic endovascular aortic repair (TEVAR) with open repair from trauma centers across the United States using the National Trauma Data Bank-Research Data Set (RDS). MATERIALS AND METHODS: The National Trauma Data Bank-RDS was reviewed for thoracic aortic injures and repair methods. Patients were divided into two groups: TEVAR versus open repair. Demographics and outcomes were compared between groups. Mortality rate was adjusted using the observed/expected mortality (O/E), with TRISS methodology by using the Revised Trauma Score with the Injury Severity Score. Chi-square test and t-test were used with significance defined as P < 0.05. RESULTS: Within the 2016 RDS, there were 275 cases that underwent operative repair for BTAI. Of the 275 operative cases, 62.5% (172/275) had TEVAR and 37.5% (103/275) underwent open repair. Mean age in TEVAR group was 41 and open repair group was 36 (P > 0.05). Mean Injury Severity Score for TEVAR was 36 versus 35 for open repair (P > 0.05). Mean Revised Trauma Score was 6.7 in TEVAR versus 5.5 in open group (P > 0.05). TEVAR patients had significantly lower crude mortality rate versus open repair (11% versus 25.2%, P < 0.005). When adjusted using O/E, the TEVAR group also had significantly less deaths versus open repair (0.40 versus 0.68, P < 0.000008). CONCLUSIONS: For BTAIs, thoracic endovascular aortic repairs were superior to open repair on injury-adjusted, all-cause mortality.