Focused assessment with sonography for trauma exam for diagnosis of pericardial effusion in penetrating thoracic trauma - A retrospective review from a level 1 trauma center.

INTRODUCTION: Point of care ultrasound has long been used in the trauma setting for rapid assessment and diagnosis of critically ill patients. Its utility for diagnosis of pericardial effusion in the setting of penetrating thoracic trauma has more recently been a topic of consideration, given the rapid decompensation that these patients can experience. OBJECTIVES: This study aims to identify the diagnostic accuracy of point of care ultrasound in the diagnosis of pericardial effusion among patients with penetrating thoracic trauma. METHODS: Retrospective review of 2099 patients brought to the trauma bay between the years 2016 and 2021 were analyzed for diagnosis of pericardial effusion. Patients who were diagnosed with a pericardial effusion were investigated for point of care ultrasound findings. Descriptive statistics were performed to identify sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS: Prevalence was calculated to be 26.7 cases of pericardial effusion per 1000 patients presenting with penetrating thoracic trauma. Incidence was estimated to be 3.8 cases of pericardial effusion per 1000 person-years. Calculation of diagnostic capabilities of ED POCUS revealed a sensitivity of 96.36 â€‹%, a specificity of 100 â€‹%, PPV of 100 â€‹%, and NPV of 99.90 â€‹%. CONCLUSIONS: Point of Care cardiac ultrasonography is a reliable tool for the rapid diagnosis of pericardial effusion in penetrating thoracic trauma patients. Patients with ultrasound suggestive of this condition should receive rapid surgical management to prevent decompensation.

Every minute matters: Improving outcomes for penetrating trauma through prehospital advanced resuscitative care.

INTRODUCTION: Prehospital resuscitation with blood products is gaining popularity for patients with traumatic hemorrhage. The MEDEVAC trial demonstrated a survival benefit exclusively among patients who received blood or plasma within 15 minutes of air medical evacuation. In fast-paced urban EMS systems with a high incidence of penetrating trauma, mortality data based on the timing to first blood administration is scarce. We hypothesize a survival benefit in patients with severe hemorrhage when blood is administered within the first 15 minutes of EMS patient contact. METHODS: This was a retrospective analysis of a prospective database of prehospital blood (PHB) administration between 2021 and 2023 in an urban EMS system facing increasing rates of gun violence. PHB patients were compared to trauma registry controls from an era before prehospital blood utilization (2016-2019). Included were patients with penetrating injury and SBP ≤ 90 mmHg at initial EMS evaluation that received at least one unit of blood product after injury. Excluded were isolated head trauma or prehospital cardiac arrest. Time to initiation of blood administration before and after PHB implementation and in-hospital mortality were the primary variables of interest. RESULTS: A total of 143 patients (PHB = 61, controls = 82) were included for analysis. Median age was 34 years with no difference in demographics. Median scene and transport intervals were longer in the PHB cohort, with a 5-minute increase in total prehospital time. Time to administration of first unit of blood was significantly lower in the PHB vs. control group (8 min vs 27 min; p < 0.01). In-hospital mortality was lower in the PHB vs. control group (7% vs 29%; p < 0.01). When controlling for patient age, NISS, tachycardia on EMS evaluation, and total prehospital time interval, multivariate regression revealed an independent increase in mortality by 11% with each minute delay to blood administration following injury (OR 1.11, 95%CI 1.04-1.19). CONCLUSION: Compared to patients with penetrating trauma and hypotension who first received blood after hospital arrival, resuscitation with blood products was started 19 minutes earlier after initiation of a PHB program despite a 5-minute increase in prehospital time. A survival for early PHB use was demonstrated, with an 11% mortality increase for each minute delay to blood administration. Interventions such as PHB may improve patient outcomes by helping capture opportunities to improve trauma resuscitation closer to the point of injury. LEVEL OF EVIDENCE: Prospective, Level IV.

Faster refill in an urban emergency medical services system saves lives: A prospective preliminary evaluation of a prehospital advanced resuscitative care bundle.

INTRODUCTION: Military experience has demonstrated mortality improvement when advanced resuscitative care (ARC) is provided for trauma patients with severe hemorrhage. The benefits of ARC for trauma in civilian emergency medical services (EMS) systems with short transport intervals are still unknown. We hypothesized that ARC implementation in an urban EMS system would reduce in-hospital mortality. METHODS: This was a prospective analysis of ARC bundle administration between 2021 and 2023 in an urban EMS system with 70,000 annual responses. The ARC bundle consisted of calcium, tranexamic acid, and packed red blood cells via a rapid infuser. Advanced resuscitative care patients were compared with trauma registry controls from 2016 to 2019. Included were patients with a penetrating injury and systolic blood pressure ≤90 mm Hg. Excluded were isolated head trauma or prehospital cardiac arrest. In-hospital mortality was the primary outcome of interest. RESULTS: A total of 210 patients (ARC, 61; controls, 149) met the criteria. The median age was 32 years, with no difference in demographics, initial systolic blood pressure or heart rate recorded by EMS, or New Injury Severity Score between groups. At hospital arrival, ARC patients had lower median heart rate and shock index than controls ( p ≤ 0.03). Fewer patients in the ARC group required prehospital advanced airway placement ( p < 0.001). Twenty-four-hour and total in-hospital mortality were lower in the ARC group ( p ≤ 0.04). Multivariable regression revealed an independent reduction in in-hospital mortality with ARC (odds ratio, 0.19; 95% confidence interval, 0.05-0.68; p = 0.01). CONCLUSION: Early ARC in a fast-paced urban EMS system is achievable and may improve physiologic derangements while decreasing patient mortality. Advanced resuscitative care closer to the point of injury warrants consideration. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Association Between Markers of Structural Racism and Mass Shooting Events in Major US Cities.

Importance: The root cause of mass shooting events (MSEs) and the populations most affected by them are poorly understood. Objective: To examine the association between structural racism and mass shootings in major metropolitan cities in the United States. Design, Setting, and Participants: This cross-sectional study of MSEs in the 51 largest metropolitan statistical areas (MSAs) in the United States analyzes population-based data from 2015 to 2019 and the Gun Violence Archive. The data analysis was performed from February 2021 to January 2022. Exposure: Shooting event where 4 or more people not including the shooter were injured or killed. Main Outcome and Measures: MSE incidence and markers of structural racism from demographic data, Gini income coefficient, Black-White segregation index, and violent crime rate. Results: There were 865 MSEs across all 51 MSAs from 2015 to 2019 with a total of 3968 injuries and 828 fatalities. Higher segregation index (ρ = 0.46, P = .003) was associated with MSE incidence (adjusted per 100 000 population) using Spearman ρ analysis. Percentage of the MSA population comprising Black individuals (ρ = 0.76, P < .001), children in a single-parent household (ρ = 0.44, P < .001), and violent crime rate (ρ = 0.34, P = .03) were other variables associated with MSEs. On linear regression, structural racism, as measured by percentage of the MSA population comprising Black individuals, was associated with MSEs (ß = 0.10; 95% CI, 0.05 to 0.14; P < .001). Segregation index (ß = 0.02, 95% CI, -0.03 to 0.06; P = .53), children in a single-parent household (ß = -0.04, 95% CI, -0.11 to 0.04; P = .28), and Gini income coefficient (ß = -1.02; 95% CI, -11.97 to 9.93; P = .93) were not associated with MSEs on linear regression. Conclusions and Relevance: This study found that major US cities with higher populations of Black individuals are more likely to be affected by MSEs, suggesting that structural racism may have a role in their incidence. Public health initiatives aiming to prevent MSEs should target factors associated with structural racism to address gun violence.

Thromboembolic Outcomes in Tetrahydrocannabinol-Positive Trauma Patients With Traumatic Brain Injury.

INTRODUCTION: Traumatic brain injury (TBI) is a significant source of morbidity and mortality in the United States. Recent shifts in state legislation have increased the use of recreational and medical marijuana. While cannabinoids and tetrahydrocannabinol (THC) have known anti-inflammatory effects, the impact of preinjury THC use on clinical outcomes in the setting of severe TBI is unknown. We hypothesized that preinjury THC use in trauma patients suffering TBI would be associated with decreased thromboembolic events and adverse outcomes. METHODS: The American College of Surgeons Trauma Quality Improvement Program was used to identify patients aged ≥18 y with TBI and severe injury (Injury Severity Score ≥ 16) in admit year 2017. Patients with smoking or tobacco history or missing or positive toxicology tests for drug and/or alcohol use other than THC were excluded. Propensity score matching was used to compare THC+ patients to similar THC- patients. RESULTS: A total of 13,266 patients met inclusion criteria, of which 1669 were THC+. A total of 1377 THC+ patients were matched to 1377 THC- patients. No significant differences were found in in-hospital outcomes, including mortality, length of stay, cardiac arrest, pulmonary embolism, deep vein thrombosis, or acute respiratory distress syndrome. No patients had ischemic stroke, and THC+ patients had significantly decreased rates of hemorrhagic stroke (0.5% versus 1.5%, P = 0.02, odds ratio 0.41 [95% confidence interval 0.18-0.86]). CONCLUSIONS: Preinjury THC use may be associated with decreased hemorrhagic stroke in severely injured patients with TBI, but there was no difference in thromboembolic outcomes. Further research into pathophysiological mechanisms related to THC are needed.

How Does Insurance Status Correlate With Trauma Mechanisms and Outcomes? A Retrospective Study at a Level 1 Trauma Center.

OBJECTIVE: Studies showed that a lack of insurance is associated with worse trauma outcomes. We examine insurance status and trauma mortality in a diverse metropolitan city and hypothesize that the higher risk of mortality in uninsured patients is due to insurance status and other factors. METHODS: A retrospective analysis of patients admitted to a Level 1 Trauma center for emergent surgery in a diverse metropolitan city from Jan 2016-May 2020 was conducted. Patients of different insurance statuses were analyzed for their injury mechanism and surgical intervention outcomes. Multivariate logistic regression was performed and the results were presented as odds ratio with 95% confidence intervals and P values. Statistical significance was set at P < .05. RESULTS: 738 patients met study criteria. Medicaid patients made up the largest proportions of injury mechanisms: 65.1% of gunshot wound cases, sharp object (41.7%), and falls (32.5%). Private insurance (OR = .13, 95% CI: .05-.35, P = .000), Medicaid (OR = .19, 95% CI: .10-.35, P = .000), Medicare (OR = .65, 95% CI: 0.28-1.51, P = .31), and other insurance (OR = .44, 95% CI 0.22-.87, P = .01) were associated with survival. Uninsured patients had the highest mortality rate resulting from trauma at 32.6% (P < .001), and the lowest mortality rate belonged to the private insurance cohort (6.3%, P < .001). Uninsured patients accounted for 10.5% of gunshot wound cases, 8.5% of motor vehicle accident cases, 25% of sharp object cases, and 6.6% of falls. CONCLUSION: Being uninsured was independently associated with mortality, while having insurance improved outcomes. Underlying mechanisms should be further elucidated to improve health equity and trauma outcomes in diverse patient populations.

New Injury Severity Score and Trauma Injury Severity Score are superior in predicting trauma mortality.

BACKGROUND: Trauma scores are used to give clinicians appropriate quantitative context in making decisions. Studies show that anatomical trauma scores predicted intensive care unit admission better, while physiological trauma scores predicted mortality better. We hypothesize that trauma scores have a hierarchy of efficacies at predicting mortality and operative decision making. METHODS: We performed a retrospective analysis of our trauma patient database at a level 1 trauma center from 2016 to 2020 and calculated the following trauma scores: Glasgow Coma Scale, Revised Trauma Score, Trauma Injury Severity Score, Injury Severity Score, Shock Index, and New Trauma Injury Severity Score (NISS). Receiver operating characteristic curves were used to evaluate the sensitivity and specificity of trauma scores for predicting mortality. RESULTS: A total of 738 patients were included (mean ± SD age, 35.7 ± 15.6 years). Area under the curve (AUC) results from the DeLong test showed that NISS predicted mortality the best compared with other trauma scores. New Trauma Injury Severity Score was superior in predicting mortality for penetrating trauma (AUC, 0.86 ± 0.02; p < 0.001) compared with blunt trauma (AUC, 0.73 ± 0.04; p < 0.001). Trauma Injury Severity Score was the best predictor of mortality for patients with gunshot wounds (AUC, 0.83; 95% confidence interval [CI], 0.73-0.92; p < 0.001), motor vehicle accidents (AUC, 0.80; 95% CI, 0.61-1.00; p = 0.01), and falls (AUC, 0.73; 95% CI, 0.61-0.85; p = 0.007). CONCLUSION: New Trauma Injury Severity Score was the best scoring index for predicting mortality in trauma patients, especially for penetrating trauma. Clinicians should consider incorporating other trauma scores, especially NISS and Trauma Injury Severity Score, in determining injury severity and the likelihood of mortality. These scores can help physicians determine the best course of action in patient management. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; level IV.

Elevated K/iCa ratio is an ancillary predictor for mortality in patients with severe hemorrhage: A decision tree analysis.

INTRODUCTION: Trauma patients receiving massive transfusion protocol (MTP) are at risk of citrate-induced hypocalcemia and hyperkalemia. Here we evaluate potassium (K), ionized calcium (iCa), and K/iCa ratio as predictors of mortality. METHODS: This retrospective study includes all adult trauma patients who received MTP within 1 h at our level I trauma center between 2014 and 2019. Receiver operating characteristic curve analysis assessed predictive accuracy of K/iCa ratio at admission on 120-day mortality. RESULTS: Of 614 patients, 146 received MTP within 1 h and 38 expired. Patients who expired had higher K/iCa ratio than survivors (median [IQR] = 5.7 [3.8-7.2] vs 3.7 [3.1-4.9], p < 0.001). Area under the curve of K/iCa was 0.72 (95%CI = 0.62-0.82, p < 0.001) with sensitivity = 63.2% and specificity = 77.6%. At the optimum K/iCa cutoff (5.07), patients with high ratios had 4 times higher mortality risk (HR = 3.97, 95%CI = 1.89-8.32, p < 0.001). CONCLUSION: Elevated K/iCa ratio was an independent predictor of mortality in trauma patients managed with MTP.

Surgical stabilization of traumatic rib fractures is associated with reduced readmissions and increased survival.

BACKGROUND: Surgical stabilization for rib fractures (SSRF) in trauma patients remains controversial, with guidelines currently suggesting the procedure for only select patient groups. How surgical stabilization for rib fractures affect hospital readmission in patients with traumatic rib fractures is unknown. We hypothesized that surgical stabilization for rib fractures would not decrease the risk of readmission. METHODS: The National Readmission Database was examined for adults with any rib fractures from 2010 to 2017. Readmission up to 90 days was examined. Patients receiving surgical stabilization for rib fractures were compared with those receiving nonoperative treatment. RESULTS: In total, 864,485 patients met criteria, with 13,701 (1.6%) receiving SSRF. For patients receiving SSRF, 338 (1.5%) were readmitted. Readmitted patients had higher Charlson Comorbidity Index and were more likely to have flail chest. On multivariate propensity score-matched analysis, SSRF (Hazard Ratio [HR]: 0.55, 95% confidence interval [CI] 0.33-0.92, P = .022) was associated with reduced readmission. Addition of surgical stabilization for rib fractures to video-assisted thoracoscopic surgery (VATS) (Odds Ratio [OR]: 0.95, 95% CI 0.52-1.73, P = .86) or thoracotomy (OR: 1.97, 95% CI 0.83-4.70, P = .13) was not associated with increased readmission. On further propensity matched analysis, VATS + SSRF when compared with SSRF alone (HR: 0.75, 95% CI 0.18-3.20, P = .696), and VATS + SSRF when compared with VATS alone (HR: 0.49, 95% CI 0.11-2.22, P = .355) was also not associated with increased readmission. SSRF on primary admission was associated with increased in-hospital survival (HR: 0.27, 95% CI 0.22-0.32, P < .001). For patients with retained hemothorax who underwent VATS, addition of SSRF did not improve survival (HR = 0.92, 95% CI 0.58-1.46, P = .72). However, for patients requiring thoracotomy for retained hemothorax, concomitant SSRF was associated with improved survival (HR = 0.14, 95% CI 0.06-0.32, P < .001). CONCLUSION: Surgical stabilization for rib fractures is associated with reduced readmission risk while also being associated with improved survival. Patients who had a thoracotomy for retained hemothorax appear to especially benefit from concomitant surgical stabilization for rib fractures.

Firearm homicide mortality is influenced by structural racism in US metropolitan areas.

INTRODUCTION: Metropolitan cities in the United States suffer from higher rates of gun violence. However, the specific structural factors associated with increased gun violence are poorly defined. We hypothesized that firearm homicide in metropolitan cities would be impacted by Black-White segregation index. METHODS: This cross-sectional analysis evaluated 51 US metropolitan statistical areas (MSAs) using data from 2013 to 2017. Several measures of structural racism were examined, including the Brooking Institute's Black-White segregation index. Demographic data were derived from the US Census Bureau, US Department of Education, and US Department of Labor. Crime data and firearm homicide mortality rates were obtained from the Federal Bureau of Investigation and the Centers for Disease Control. Spearman ρ and linear regression were performed. RESULTS: Firearm mortality was associated with multiple measures of structural racism and racial disparity, including White-Black segregation index, unemployment rate, poverty rate, single parent household, percent Black population, and crime rates. In regression analysis, percentage Black population exhibited the strongest association with firearm homicide mortality (ß = 0.42, p < 0.001). Black-White segregation index (ß = 0.41, p = 0.001) and percent children living in single-parent households (ß = 0.41, p = 0.002) were also associated with higher firearm homicide mortality. Firearm legislation scores were associated with lower firearm homicide mortality (ß = -0.20 p = 0.02). High school and college graduation rates were not associated with firearm homicide mortality and were not included in the final model. CONCLUSION: Firearm homicide disproportionately impacts communities of color and is associated with measures of structural racism, such as White-Black segregation index. Public health interventions targeting gun violence must address these systemic inequities. Furthermore, given the association between firearm mortality and single-parent households, intervention programs for at-risk youth may be particularly effective. LEVEL OF EVIDENCE: Epidemiological level II.

Surgical stabilization of rib fractures is associated with improved survival but increased acute respiratory distress syndrome.

BACKGROUND: How the surgical stabilization of rib fractures after trauma affects the development of acute respiratory distress syndrome and impacts survival has yet to be determined in a large database. We hypothesized that surgical stabilization of rib fractures would not decrease the incidence of acute respiratory distress syndrome. METHODS: The National Trauma Data Bank was queried for all traumatic rib fractures in 2016. Patients were divided into groups with single rib fractures, multiple rib fractures, and flail chest. Nonoperative therapy was compared with stabilization of rib fractures of 1 to 2 ribs or 3+ ribs. RESULTS: There were 114,972 total patients with rib fractures meeting inclusion criteria, with 5,106 (4.4%) having flail chest, 24,726 (21.5%) having single rib fractures, and 85,140 (74.1%) having multiple rib fractures. Those with flail chest (15.9%) were most likely to get rib plating in comparison to multiple rib fractures (0.9%) and single rib fractures (0.2%); P < .001. On logistic regression, surgical stabilization of rib fractures 1 to 2 ribs (odds ratio: 0.17, 95% confidence interval: 0.10-0.28) or 3+ ribs (odds ratio: 0.17, 95% confidence interval: 0.11-0.28), with nonoperative therapy as the reference was associated with survival. Variables associated with mortality included increasing age, male sex, increasing injury severity score, decreased Glasgow coma scale, requirement of transfusions, and hypotension on admission. Surgical stabilization of rib fractures 3+ ribs (odds ratio: 2.30, 95% confidence interval: 1.58-3.37) was associated with acute respiratory distress syndrome but not 1 to 2 ribs (odd ratio: 1.55, 95% confidence interval: 0.97-2.48). On logistic regression of only patients with flail chest, stabilization of rib fractures was associated with decreased mortality but not increased risk of acute respiratory distress syndrome. CONCLUSION: The increased risk of acute respiratory distress syndrome should be considered in the preoperative assessment for stabilization of rib fractures.

Computed tomography angiography in the "no-zone" approach era for penetrating neck trauma: A systematic review.

BACKGROUND: Penetrating neck trauma (PNT) continues to present a diagnostic dilemma. Practice guidelines advocate the use of computed tomography angiography (CTA) for suspected vascular or aerodigestive injuries in all neck zones. There is also an evolving evidence of "no-zone" approach where the decision to obtain a CTA is guided by physical examination findings and clinical presentation. The aim of this systematic review was to examine existing literature on the diagnostic accuracy of CTA as an integral component of the no-zone approach in stable patients with PNT. METHODS: We performed a systematic review using an electronic search of three databases (PubMed, Medline, Cochrane Review) from 2000 to 2017. RESULTS: A total of 5 prospective and 8 retrospective studies were included. The sensitivity of CTA ranged from 83% to 100%; specificity, from 61% to 100%; positive predictive value, from 30% to 100%; and negative predictive value, from 90% to 100%. Three studies reported high sensitivity and specificity for the detection of vascular injuries but low specificity for aerodigestive tract injuries. When stratified by clinical presentation, CTA had a sensitivity of 89.5% to 100% and specificity of 61% to 100% in stable patients presenting with soft signs (SSs). In a combined group of stable patients with either hard signs (HSs) or SSs, the sensitivity of CTA was 94.4% to 100% and the specificity was 96.7% to 100%. Among patients presenting with HSs, the sensitivity of CTA was 78.6% to 90% and the specificity was 100%. CONCLUSIONS: This is the first systematic review to examine the role of CTA in PNT. In combination with physical examination, CTA demonstrated a reliable high sensitivity and specificity for detecting injuries in PNT in stable patients with SSs of injury and select patients with HSs of injury. These results support the management of PNT using no-zone approach based on physical examination and the use of CTA in stable patients. LEVEL OF EVIDENCE: Systematic review, level IV.

Impact of trauma center volume on major vascular injury: An analysis of the National Trauma Data Bank (NTDB).

BACKGROUND: The association of procedure volume and improved outcomes has been established with infrequently performed elective operations. However, effect of trauma center volume on outcomes in emergency surgery has not been defined. We hypothesized that high volume centers (HVC) would provide better outcomes for operative major vascular injuries (MVI) than low volume centers (LVC). METHODS: The NTDB was queried from 2010 to 2014. Patients with MVI were identified and HVC were compared to LVC. HVC were defined as >480 patients per year with ISS≥15. RESULTS: There were 37,125 patients with MVI, with 16,461 (44.3%) managed operatively. Of these, 15,965 (97%) underwent surgery at HVC and 496 (3%) at LVC. There was no difference in shunt utilization, however, HVC were more likely to utilize endovascular repair (31.0% vs. 21.9%, p < 0.001). Rates of death, amputation, and compartment syndrome were similar. HVC were more likely to develop pneumonia or sepsis. On logistic regression, HVC was not associated with survival (OR: 0.90, 95%CI: 0.60-1.34, p = 0.60). Variables associated with mortality for HVC and LVC included thoracic arterial injury (OR: 1.57, 95%CI: 1.27-1.94, p < 0.001), penetrating mechanism (OR:1.84, 95%CI: 1.57-2.15, p < 0.001), and open repair (OR: 1.95, 95%CI: 1.69-2.26, p < 0.001). Lower ISS (OR: 0.29, 95%CI: 0.24-0.34, p < 0.001) and higher presenting blood pressure (OR: 0.99, 95%CI: 0.99-1.00, p < 0.001) were associated with survival. CONCLUSIONS: Although LVC may have less proficiency with endovascular techniques, trauma center volume does not influence survival in emergency surgery for MVI.

Bicycle lanes: Are we running in circles or cycling in the right direction?

BACKGROUND: The number of urban bicyclists has grown exponentially across the United States. Bike lanes were created to promote a safe environment for both motorist and cyclists, but few studies have specifically addressed the outcomes of these interventions. The aim of this study was to analyze the effect of bike lanes on bicycle usage and safety in a major urban city. METHODS: A retrospective chart review of consecutive adult trauma patients presenting at an urban Level I trauma center due to motor vehicle versus bicycle collisions from January 1, 2007, to January 28, 2017, was performed. Cohorts were stratified into prebicycle and postbicycle lane implementation for analysis. RESULTS: Bicycle use during the study period increased almost three fold (1,672 vs. 6,060, p < 0.0001). There was also a spike in the percent of yearly bicyclists as trauma patients during the 10-year period (0.7% vs. 1.5%, p < 0.05). A total of 184 patients brought to the trauma center were identified. Significant differences between the prebike lane and postbike lane groups were identified for average Injury Severity Score (12.7 ± 1.7 vs. 8.0 ± 0.6 p = 0.0134), Glasgow Coma Scale score on arrival (12.6 ± 0.7 vs. 13.9 ± 0.2, p = 0.0171), proportion of head and face injuries (59.4% to 38.8%, p = 0.047), and patients requiring surgical intervention (100% to 55.9%, p < 0.0001). CONCLUSION: As bicycle lanes become increasing popular in US cities, it is important to review the success of this intervention on improving safety. Preliminary results from this study suggest that the implementation of urban bike lanes improved bicyclist safety. Further studies should focus on specific injury prevention programs, which could help to target areas such as helmet use and riding a bicycle while impaired to help improve overall safety. LEVEL OF EVIDENCE: Prognostic and epidemiological, level IV.

Pediatric firearm incidents: It is time to decrease on-scene mortality.

BACKGROUND: Previous epidemiological studies on pediatric firearm mortality have focused on overall mortality rather than on-scene mortality. Despite advances in trauma care, the number of potentially preventable deaths remains high. This study used the National Emergency Medical Services Information Systems database to characterize patterns of on-scene mortality in order to identify patients who may benefit from changes to prehospital care practices. METHODS: National Emergency Medical Services Information Systems database was searched for all pediatric firearm incidents from 2010 to 2015. Data on demographics, anatomic location of injury, intent and location of incident, and on-scene mortality were analyzed using Student's t test for continuous variables and χ test for categorical variables. A linear regression model was used to calculate independent predictors of mortality. RESULTS: Sixteen thousand eight hundred eight patients were identified, with a mortality rate of 6.1%. Most mortalities suffered cardiac arrest on-scene; 72.6% of these were prior to Emergency Medical Services (EMS) arrival, which carried a significantly higher mortality rate than arrest after EMS arrival. No difference was seen in anatomic location of injury in those who arrested before and after EMS arrival. Compressible injuries were most common with the lowest mortality. Noncompressible injuries together accounted for 25.8% of injuries and 23.5% of mortalities. CONCLUSION: To our knowledge, this is the largest study of on-scene mortality in pediatric firearm injury. Cardiac arrest prior to EMS arrival was a considerable source of on-scene mortality; significantly more of these patients died than those who arrested after EMS arrival. The mortality of compressible injuries was very low, implying that use of compression and tourniquets have been effective in stopping life-threatening extremity bleeding. Noncompressible injury mortality could be decreased with education of bystanders and more aggressive on-scene intervention. Through the evaluation of on-scene mortality specifically, this study offers insight into potential areas of focus to improve prehospital care of pediatric gunshot victims. LEVEL OF EVIDENCE: Therapeutic/Care management, level IV.

Prehospital tourniquet use in penetrating extremity trauma: Decreased blood transfusions and limb complications.

BACKGROUND: Despite increasing popularity of prehospital tourniquet use in civilians, few studies have evaluated the efficacy and safety of tourniquet use. Furthermore, previous studies in civilian populations have focused on blunt trauma patients. The objective of this study was to determine if prehospital tourniquet use in patients with major penetrating trauma is associated with differences in outcomes compared to a matched control group. METHODS: An 8-year retrospective analysis of adult patients with penetrating major extremity trauma amenable to tourniquet use (major vascular trauma, traumatic amputation and near-amputation) was performed at a Level I trauma center. Patients with prehospital tourniquet placement (TQ) were identified and compared to a matched group of patients without tourniquets (N-TQ). Univariate analysis was used to compare outcomes in the groups. RESULTS: A total of 204 patients were matched with 127 (62.3%) in the prehospital TQ group. No differences in patient demographics or injury severity existed between the two groups. Average time from tourniquet application to arrival in the emergency department (ED) was 22.5 ± 1.3 minutes. Patients in the TQ group had higher average systolic blood pressure on arrival in the ED (120 ± 2 vs. 112 ± 2, p = 0.003). The TQ group required less total PRBCs (2.0 ± 0.1 vs. 9.3 ± 0.6, p < 0.001) and FFP (1.4 ± 0.08 vs. 6.2 ± 0.4, p < 0.001). Tourniquets were not associated with nerve palsy (p = 0.330) or secondary infection (p = 0.43). Fasciotomy was significantly higher in the N-TQ group (12.6% vs. 31.4%, p < 0.0001) as was limb amputation (0.8% vs. 9.1%, p = 0.005). CONCLUSION: This study demonstrated that prehospital tourniquets could be safely used to control bleeding in major extremity penetrating trauma with no increased risk of major complications. Prehospital tourniquet use was also associated with increased systolic blood pressure on arrival to the ED, decreased blood product utilization and decreased incidence of limb related complications, which may lead to improved long-term outcomes and increased survival in trauma patients. LEVEL OF EVIDENCE: Therapeutic, level IV.

Implementation of a CT scan practice guideline for pediatric trauma patients reduces unnecessary scans without impacting outcomes.

INTRODUCTION: Computed tomography (CT) scans are useful in the evaluation of trauma patients, but are costly and pose risks from ionizing radiation in children. Recent literature has demonstrated the use of CT scan guidelines in the management of pediatric trauma. The study objective is to review our treatment of pediatric blunt trauma patients and evaluate CT use before and after CT-guideline implementation. METHODS: Our Pediatric Level 2 Trauma Center (TC) implemented a CT scan practice guideline for pediatric trauma patients in March 2014. The guideline recommended for or against CT of the head and abdomen/pelvis using published criteria from the Pediatric Emergency Care and Research Network. There was no chest CT guideline. We reviewed all pediatric trauma patients for CT scans obtained during initial evaluation before and after guideline implementation, excluding inpatient scans. The Trauma Registry Database was queried to include all pediatric (age < 15) trauma patients seen in our TC from 2010 to 2016, excluding penetrating mechanism and deaths in the TC. Scans were considered positive if organ injury was detected. Primary outcome was the proportion of patients undergoing CT and percent positive CTs. Secondary outcomes were hospital length of stay, readmissions, and mortality. Categorical and continuous variables were analyzed with χ and Wilcoxon rank-sum tests, respectively. p < 0.05 was considered significant. RESULTS: We identified 1,934 patients: 1,106 pre- and 828 post-guideline. Absolute reductions in head, chest, and abdomen/pelvis CT scans were 17.7%, 11.5%, and 18.8%, respectively (p < 0.001). Percent positive head CTs were equivalent, but percent positive chest and abdomen CT increased after implementation. Secondary outcomes were unchanged. CONCLUSIONS: Implementation of a pediatric CT guideline significantly decreases CT use, reducing the radiation exposure without a difference in outcome. Trauma centers treating pediatric patients should adopt similar guidelines to decrease unnecessary CT scans in children. LEVEL OF EVIDENCE: Therapeutic study, level IV.