Does frailty impact failure-to-rescue in geriatric trauma patients?

BACKGROUND: Failure-to-rescue (FTR), defined as death following a major complication, is a metric of trauma quality. The impact of patient frailty on FTR has not been fully investigated, especially in geriatric trauma patients. This study hypothesized that frailty increased the risk of FTR in geriatric patients with severe injury. METHODS: A retrospective cohort study was conducted using the TQIP database between 2015 and 2019, including geriatric patients with trauma (age ≥65 years) and an Injury Severity Score (ISS) > 15, who survived ≥48 hours postadmission. Frailty was assessed using the modified 5-item frailty index (mFI). Patients were categorized into frail (mFI ≥ 2) and nonfrail (mFI < 2) groups. Logistic regression analysis and a generalized additive model (GAM) were used to examine the association between FTR and patient frailty after controlling for age, sex, type of injury, trauma center level, ISS, and vital signs on admission. RESULTS: Among 52,312 geriatric trauma patients, 34.6% were frail (mean mFI: frail: 2.3 vs. nonfrail: 0.9, p < 0.001). Frail patients were older (age, 77 vs. 74 years, p < 0.001), had a lower ISS (19 vs. 21, p < 0.001), and had a higher incidence of FTR compared with nonfrail patients (8.7% vs. 8.0%, p = 0.006). Logistic regression analysis revealed that frailty was an independent predictor of FTR (odds ratio, 1.32; confidence interval, 1.23-1.44; p < 0.001). The GAM plots showed a linear increase in FTR incidence with increasing mFI after adjusting for confounders. CONCLUSION: This study demonstrated that frailty independently contributes to an increased risk of FTR in geriatric trauma patients. The impact of patient frailty should be considered when using FTR to measure the quality of trauma care. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Case volume and rate are associated with outcomes in geriatric trauma: A case for geriatric trauma centers?

BACKGROUND: Increased morbidity and mortality in geriatric trauma patients are usually due to decreased physiologic reserve and increased comorbidities. It is unclear whether geriatric trauma case volume and rates correlate with survival. We hypothesized that geriatric patients would have increased survival when treated in high-case volume and rate trauma centers. METHODS: A retrospective cohort study was conducted using the Trauma Quality Improvement Program database between 2015 and 2019. Geriatric trauma patients (≥65 years) with severe injury (Injury Severity Score ≥16) were included. Geriatric case volume (GCV) was defined as the mean annual number of treated geriatric trauma patients, while geriatric case rate (GCR) was the mean annual number of elderly trauma patients divided by all trauma patients in each center. Trauma centers were classified into low-, medium-, and high-volume and rate facilities based on GCV and GCR. The association of GCV and GCR with in-hospital mortality and complication rates was assessed using the generalized additive model (GAM) and multivariate generalized linear mixed model adjusted for patient characteristics (age, sex, Injury Severity Score, Revised Trauma Score, and Modified Frailty Index) as fixed-effect variables and hospital characteristics as random effect variables. RESULTS: A total of 164,818 geriatric trauma patients from 812 hospitals were included in the analysis. The GAM plots showed that the adjusted odds of in-hospital mortality decreased as GCV and the GCR increased. The generalized linear mixed model revealed that both high GCV and high GCR hospitals had lower mortality rates than low GCV and GCR hospitals (adjusted odds ratio [95% confidence interval], high GCV and high GCR centers; 0.82 [0.72-0.92] and 0.81 [0.73-0.90], respectively). CONCLUSION: Both high geriatric trauma volume and rates were associated with decreased mortality of geriatric trauma patients. Consolidation of care for elderly patients with severe injury in specialized high-volume centers may be considered. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Variability of extracorporeal cardiopulmonary resuscitation practice in patients with out-of-hospital cardiac arrest from the emergency department to intensive care unit in Japan.

AIM: A lack of known guidelines for the provision of extracorporeal cardiopulmonary resuscitation (ECPR) to patients with out-of-hospital cardiac arrest (OHCA) has led to variability in practice between hospitals even in the same country. Because variability in ECPR practice has not been completely examined, we aimed to describe the variability in ECPR practice in patients with OHCA from the emergency department (ED) to the intensive care units (ICU). METHODS: An anonymous online questionnaire to examine variability in ECPR practice was completed in January 2020 by 36 medical institutions who participated in the SAVE-J II study. Institutional demographics, inclusion and exclusion criteria, initial resuscitation management, extracorporeal membrane oxygenation (ECMO) initiation, initial ECMO management, intra-aortic balloon pumping/endotracheal intubation/management during coronary angiography, and computed tomography criteria were recorded. RESULTS: We received responses from all 36 institutions. Four institutions (11.1%) had a hybrid emergency room. Cardiovascular surgery was always involved throughout the entire ECMO process in only 14.7% of institutions; 60% of institutions had formal inclusion criteria and 50% had formal exclusion criteria. In two-thirds of institutions, emergency physicians carried out cannulation. Catheterization room was the leading location of cannulation (48.6%) followed by ED (31.4%). The presence of formal exclusion criteria significantly increased with increasing ECPR volume (P for trend <0.001). Intra-aortic balloon pumping was routinely initiated in only 25% of institutions. Computed tomography was routinely carried out before coronary angiography in 25% of institutions. CONCLUSIONS: We described the variability in ECPR practice in patients with OHCA from the ED to the ICU.

Medicine at mass gatherings: current progress of preparedness of emergency medical services and disaster medical response during 2020 Tokyo Olympic and Paralympic Games from the perspective of the Academic Consortium (AC2020).

Mass gatherings are events characterized by "the concentration of people at a specific location for a specific purpose over a set period of time that have the potential to strain the planning and response resources of the host country or community." Previous reports showed that, as a result of the concentration of people in the limited area, injury and illness occurred due to several factors. The response plan should aim to provide timely medical care to the patients and to reduce the burden on emergency hospitals, and to maintain a daily emergency medical services system for residents of the local area. Although a mass gathering event will place a significant burden on the local health-care system, it can provide the opportunity for long-term benefits of public health-care and improvement of daily medical service systems after the end of the event. The next Olympic and Paralympic Games will be held in Tokyo, during which mass gatherings will occur on a daily basis in the context of the coronavirus disease (COVID-19) epidemic. The Academic Consortium on Emergency Medical Services and Disaster Medical Response Plan during the Tokyo Olympic and Paralympic Games in 2020 (AC2020) was launched 2016, consisting of 28 academic societies in Japan, it has released statements based on assessments of medical risk and publishing guidelines and manuals on its website. This paper outlines the issues and countermeasures for emergency and disaster medical care related to the holding of this big event, focusing on the activities of the academic consortium.

Planned Versus On-Demand Relaparotomy Strategy in Initial Surgery for Non-occlusive Mesenteric Ischemia.

BACKGROUND: There has been insufficient evidence regarding a treatment strategy for patients with non-occlusive mesenteric ischemia (NOMI) due to the lack of large-scale studies. We aimed to evaluate the clinical benefit of strategic planned relaparotomy in patients with NOMI using detailed perioperative information. METHODS: We conducted a multicenter retrospective cohort study that included NOMI patients who underwent laparotomy. In-hospital mortality, 28-day mortality, incidence of total adverse events, ventilator-free days, and intensive care unit (ICU)-free days were compared between groups experiencing the planned and on-demand relaparotomy strategies. Analyses were performed using a multivariate mixed effects model and a propensity score matching model after adjusting for pre-operative, intra-operative, and hospital-related confounders. RESULTS: A total of 181 patients from 17 hospitals were included, of whom 107 (59.1%) were treated using the planned relaparotomy strategy. The multivariate mixed effects regression model indicated no significant differences for in-hospital mortality (61 patients [57.0%] in the planned relaparotomy group vs. 28 patients [37.8%] in the on-demand relaparotomy group; adjusted odds ratio [95% confidence interval] = 1.94 [0.78-4.80]), as well as in 28-day mortality, adverse events, and ICU-free days. Significant reduction in ventilator-free days was observed in the planned relaparotomy group. Propensity score matching analysis of 61 matched pairs with comparable patient severity did not show superiority of the planned relaparotomy strategy. CONCLUSIONS: The planned relaparotomy strategy, compared with on-demand relaparotomy strategy, did not show clinical benefits after the initial surgery of patients with NOMI. Further studies estimating potential subpopulations who may benefit from this strategy are required.

A case of paraplegia that developed 6 years after thoracic endovascular aortic repair for blunt traumatic aortic injury.

Case: Thoracic endovascular aortic repair (TEVAR) is becoming the standard therapy for blunt thoracic aortic injury (BTAI). However, the long-term outcomes of TEVAR for BTAI remain unclear. A 36-year-old man was admitted to our emergency department with dyspnea. He had been involved in a serious traffic accident 6 years earlier, requiring TEVAR for BTAI. Outcome: Acute heart failure and pneumonia were diagnosed on this admission. His respiratory condition improved, but paraplegia developed 10 h after hospitalization. Magnetic resonance imaging showed an intraspinal longitudinal area of signal hyperintensity, and spinal cord infarction was diagnosed. Conclusion: Although the causal relationship between the TEVAR and spinal cord infarction remains unclear, paraplegia as a long-term complication after TEVAR does not appear to have been reported previously, and so represents a potentially important complication.

Predictive ability and interobserver reliability of computed tomography findings for angioembolization in patients with pelvic fracture.

BACKGROUND: The purpose of this study was to identify computed tomography (CT) findings that predict the need for angioembolization in patients with pelvic fracture. METHODS: This retrospective cross-sectional study was performed between April 2006 and October 2015 at two urban emergency medical centers in Japan. The study included patients who underwent CT within 3 hours of arrival and were diagnosed with a pelvic fracture. The study outcome was undergoing angioembolization within 24 hours of arrival. Four independent readers blinded to all clinical information interpreted the CT scans for blush, thickness of retroperitoneal hematoma, and diameter and laterality of muscle swelling around the pelvis. Receiver operating characteristics analyses provided area under the receiver-operating characteristic curves (AUROC) and diagnostic indicators at the estimated thresholds including sensitivity, specificity, positive and negative predictive values and diagnostic odds ratio (DOR). The interobserver reliability of all radiographic findings was also evaluated. RESULTS: Fifty-two of 244 eligible patients underwent angioembolization. The predictive ability in terms of DOR was relatively better with blush on CT scan (sensitivity, 0.57; specificity, 0.86; DOR, 8.05) than with laterality of muscle swelling of 12.9 mm or greater (sensitivity, 0.79; specificity, 0.55; DOR, 4.60; AUROC, 0.75) and thickness of retroperitoneal hematoma of 22.7 mm or greater (sensitivity, 0.65; specificity, 0.74; DOR, 5.39; AUROC, 0.73). The interobserver reliability of blush, laterality of muscle swelling, and thickness of retroperitoneal hematoma was 0.43, 0.54, and 0.70, respectively. CONCLUSION: All of the tested CT findings failed to show both sufficient predictive ability and sufficient interobserver agreement. Further diagnostic accuracy studies to validate these findings or establish a prediction model incorporating these findings are expected. LEVEL OF EVIDENCE: Diagnostic, level V.

Pharmaceutical Approach for the Diagnosis and Treatment of Malignant Syndrome: A Case Study.

Since 2012, Matsudo City Hospital has increased the number of pharmacists stationed in the ward on weekday mornings at the emergency care center, the intensive care unit (ICU) and the high care unit (HCU). Multidisciplinary joint meetings and joint conferences are conducted in the emergency care center, and patient and drug information is shared. A 20-year-old man was transferred to our hospital after a traffic accident. He was diagnosed with subarachnoid hemorrhage and brain contusion. He exhibited violent movement and intense restlessness. He was sedated with a continuous intravenous infusion of 5 mg/h midazolam and 20 µg/h fentanyl, with intubation. Propofol was also used intermittently. The midazolam infusion was concluded on day 5 of hospitalization. However, his restlessness recurred so an intravenous drip infusion of 150 mg/h haloperidol was administered. On the 7th day, he developed a high-grade fever, muscle rigidity, perspiration, and leukocytosis, and malignant syndrome or malignant hyperthermia was suspected. For malignant syndrome treatment, he received an intravenous drip infusion of 60 mg dantrolene, followed by the combined oral administration of 100 mg/d dantrolene and 7.5 mg/d bromocriptine. Considering various pharmacological effects, we selected an intravenous drip infusion of 25 mg hydroxyzine hydrochloride as the drug to alleviate restlessness. The patient's course continued without recurrence of malignant syndrome; his symptoms improved because of pharmaceutical care with an awareness of patient benefits through clinical and laboratory findings, consultation with the attending physician, presentation of information on causative and therapeutic drugs, and coordinated planning of a prescription design.

Accidental chest penetration of glass foreign bodies in a 53 year old lady-The challenges with video assisted thoracoscopic extraction.

INTRODUCTION: In rare cases, a foreign body may penetrate the thoracic cavity without the person's awareness. I report a case of the traumatic intrathoracic foreign body of glass implants that the patient did not have awareness about. PRESENTATION OF CASE: The 53-year-old woman was unsteady on her foot and leaned against the sliding door of the glass in a washroom. She fell unto a crashing glass panel sustained chest injury, and then she noticed bleeding from the left chest. Dyspnea and chest pain were emergent gradually. Chest Computed Tomography (CT) showed two foreign bodies which she did not complain of in a left pleural cavity. We performed an emergency video-assisted thoracic surgery by the diagnosis of traumatic hemopneumothorax and the foreign bodies. We could remove two glass pieces. DISCUSSION: I found 15 cases of intrathoracic foreign body without the patient's awareness in a Japanese medical central magazine for the years 1993-2015. In some cases identifying a glass piece on perioperative X-rays may be difficult. Thus, all means for determining the accurate number of glass pieces and their approximate positions should be used, including multi-slice CT. I realize that a preoperative strategy is also important. CONCLUSION: The patients who injured the chest with the glass without awareness of the implant of the foreign body, we take an intrathoracic foreign body by the penetration of the glass piece into consideration, need the search by the imaging. The extraction of the glass foreign bodies by VATS is very useful.

[FIRST REPORTED GENERAL ANESTHESIA SURGERY IN THE FIRST JAPANESE FIELD HOSPITAL].

On April 25th, 2015, a massive 7.8-Mw earthquake occurred 77 km northwest of Kathmandu, the capital of Nepal. Disaster relief medical teams from the Japan International Cooperation Agency (JICA) were sent to Nepal on April 28th. The primary medical team consisted of 46 people, including two trauma surgeons. A meeting was held in Kathmandu by the Nepal Government Ministry of Health and Population and the World Health Organization for the foreign medical teams. The JICA team was asked to provide hub hospital services in Barhabise in the District of Sindhupalchok where some of the greatest damage had occurred. It was not until May 4th that medical supplies for our large medical tents and surgeries arrived in Kathmandu; the supplies were then sent on to Barhabise by road that same day. Our field hospital for both surgery and patient beds was finally operational on May 5th. This was the first time that a Japanese team performed surgery using general anesthesia in a Japanese field hospital. The surgery was for a left Lisfranc joint dislocation with open fracture in a 37-year-old woman. We had patients stay in the field hospital overnight after their surgeries. As the quantity of supplies increases, response times are affected because we have no transportation means such as the armed forces. These problems need to be considered in the future.

Acute abdomen in a patient with cancer pain on oxycodone.

Opioids are a mainstay of treatment for moderate to severe cancer pain. At present, oxycodone has fewer adverse effects compared to morphine and is widely used for cancer pain therapy. The adverse effects of oxycodone are similar to morphine and include constipation, nausea, and sedation. However, acute abdominal pain is rarely seen. Here, we describe a cancer patient presenting with acute abdomen with stercoral diarrhea. A 54-year-old man with squamous cell carcinoma of the external auditory canal had been taking oxycodone for pain relief. The patient had taken oxycodone for several months and had never complained of either diarrhea or constipation. After an increase in the dosage of oxycodone, he complained of abdominal distension and constipation. After being administered a laxative, he complained of diarrhea and severe abdominal pain. He visited the emergency department and was diagnosed with acute colonic obstruction caused by severe constipation. He self-medicated with oxycodone at dosages of up to 180 mg/day, and this abrupt increase of oxycodone caused stercoral diarrhea. Finally, total blockage of stool developed, resulting in acute abdomen.

Effect of pre-existing medical conditions on in-hospital mortality: analysis of 20,257 trauma patients in Japan.

BACKGROUND: The average life expectancy of Japanese individuals is the longest in the world. The mortality rate from injury is increasing among older people. There have been no detailed reports on the relationship between pre-existing medical conditions (PMCs) and mortality from trauma among elderly people in Japan. STUDY DESIGN: We conducted a retrospective analysis using 20,257 cases recorded in the Japan Trauma Data Bank from 2004 to 2007. The subjects were 11,590 hospital inpatients (57.2%) 16 years of age or older. A logistic regression analysis was conducted for the relation between 23 PMCs and in-hospital mortality. RESULTS: Overall in-hospital mortality was 10.8%, and for people 75 years of age and older, was 17.7%. The incidence of PMC was 4,752 (41.0%). Patients with PMCs of cirrhosis, active cancer, chronic obstructive pulmonary disease, hematologic disorders, anticoagulation drugs, dementia or mental retardation, or other conditions had higher in-hospital mortality. The existence of a single PMC did not increase mortality, but with 2 or more PMCs, mortality significantly increased. The existence of 2 or more PMCs in the 50- to 74-year-old age group and in the minor injury group strongly affected the odds ratio for mortality. CONCLUSIONS: The existence of certain PMCs or of 2 or more PMCs increases in-hospital mortality from injury. This effect is particularly conspicuous in middle-aged patients and people with minor injuries, but was not found to be a problem among elderly people. The increased mortality from injury in elderly people in Japan is therefore not affected by the existence of PMCs.