Lower Extremity Vascular Injury in the Pediatric Trauma Patient: Management and Outcomes at an Adult Level I Trauma Center.

BACKGROUND: Traumatic vascular injuries of the lower extremity in the pediatric population are uncommon but can result in significant morbidity. The objective of this study is to demonstrate our experience with these injuries by describing patterns of traumatic vascular injury, the initial management, and data regarding early outcomes. METHODS: In total, 506 patients presented with lower extremity vascular injury between January 1, 2009 and January 1, 2021 to Grady Memorial Hospital, an urban, adult Level I trauma center in Atlanta, Georgia. Thirty-two of the 506 patients were aged less than 18 years and were evaluated for a total of 47 lower extremity vascular injuries. To fully elucidate the injury patterns and clinical course in this population, we examined patient demographics, mechanism of injury, type of vessel injured, surgical repair performed, and early outcomes and complications. RESULTS: The median (interquartile range) age was 16 (2) years (range, 3-17 years), and the majority were male (n = 29, 90.6%). Of the vascular injuries identified, 28 were arterial and 19 were venous. Of these injuries, 14 patients had combined arterial-venous injuries. The majority of injuries were the result of a penetrating injury (n = 28, 87.5%), and of these, all but 2 were attributed to gunshot wounds. Twenty-seven vascular interventions were performed by nonpediatric surgeons: 11 by trauma surgeons, 13 by vascular surgeons, 2 by orthopedic surgeons, and 1 by an interventional radiologist. Two patients required amputation: 1 during the index admission and 1 delayed at 3 months. Overall survival was 96.9%. CONCLUSIONS: Vascular injuries as the result of trauma at any age often require early intervention, and we believe that these injuries in the pediatric population can be safely managed in adult trauma centers with a multidisciplinary team composed of trauma, vascular, and orthopedic surgeons with the potential to decrease associated morbidity and mortality from these injuries.

Death by the minute: Inequities in trauma care for victims of firearm violence.

BACKGROUND: Gunshot wounds (GSWs) remain a significant source of mortality in the United States. Timely delivery of trauma care is known to be critical for survival. We sought to understand the relationship of predicted transport time and death after GSW. Given large racial disparities in firearm violence, we also sought to understand disparities in transport times and death by victim race, an unstudied phenomenon. METHODS: Firearm mortality data were obtained from the Boston Police Department 2005 to 2023. Firearm incidents were mapped using ArcGIS. Predicted transport times for each incident to the closest trauma center were calculated in ArcGIS. Spatial autoregressive models were used to understand the relationship between victim race, transport time to a trauma center, and mortality associated with the shooting incidents. RESULTS: There were 4,545 shooting victims with 758 deaths. Among those who lived, the median transport time was 9.4 minutes (interquartile range, 5.8-13.8) and 10.5 minutes (interquartile range, 6.4-14.6; p = 0.003) for those who died. In the multivariable logistic regression, increased transport time to the nearest trauma center (odds ratio, 1.024; 95% confidence interval, 1.01-1.04) and age (odds ratio, 1.016; 95% confidence interval, 1.01-1.02) were associated with mortality. There was a modest difference in median transport time to the nearest trauma center by race with non-Hispanic Black at 10.1 minutes, Black Hispanic 9.2 minutes, White Hispanic 8.5 minutes, and non-Hispanic White 8.3 minutes ( p < 0.001). CONCLUSION: Our results highlight the relationship of transport time to a trauma center and death after a GSW. Non-White individuals had significantly longer transport times to a trauma center and predicted mortality would have been lower with White victim transport times. These data underscore the importance of timely trauma care for GSW victims and can be used to direct more equitable trauma systems. LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level III.

Injury Patterns and Treatment Strategies in Civilian and Military Isolated Abdominal Gunshot Wounds.

BACKGROUND: Combat-related gunshot wounds (GSW) may differ from those found in civilian trauma centers. Missile velocity, resources, logistics, and body armor may affect injury patterns and management strategies. This study compares injury patterns, management, and outcomes in isolated abdominal GSW between military (MIL) and civilian (CIV) populations. METHODS: The Department of Defense Trauma Registry (DoDTR) and TQIP databases were queried for patients with isolated abdominal GSW from 2013 to 2016. MIL patients were propensity score matched 1:3 based on age, sex, and extraabdominal AIS. Injury patterns and in-hospital outcomes were compared. Initial operative management strategies, including selective nonoperative management (SNOM) for isolated solid organ injuries, were also compared. RESULTS: Of the 6435 patients with isolated abdominal GSW, 183 (3%) MIL were identified and matched with 549 CIV patients. The MIL group had more hollow viscus injuries (84% vs. 66%) while the CIV group had more vascular injuries (10% vs. 21%) (p < .05 for both). Operative strategy differed, with more MIL patients undergoing exploratory laparotomy (95% vs. 82%) and colectomy (72% vs. 52%) (p < .05 for both). However, no difference in ostomy creation was appreciated. More SNOM for isolated solid organ injuries was performed in the CIV group (34.1% vs. 12.5%; p < 0.05). In-hospital outcomes, including mortality, were similar between groups. CONCLUSIONS: MIL abdominal GSW lead to higher rates of hollow viscus injuries compared to CIV GSW. MIL GSW are more frequently treated with resection but with similar ostomy creation compared to civilian GSW. SNOM of solid organ injuries is infrequently performed following MIL GSW.

Which Method of Transportation Is Associated With Better Outcomes for Patients With Firearm Injuries to the Head and Neck?

BACKGROUND: In firearm injuries (FI), rapid transportation is important for survival. Information regarding different methods of transportation for head and neck FI is limited. PURPOSE: The purpose of the study was to measure the association between method of transportation and the need for tracheostomy and/or intensive care unit (ICU). STUDY DESIGN, SETTING, SAMPLE: This retrospective cross-sectional study reviewed patients in Trauma Registry at Grady Memorial Hospital (GMH) in Atlanta, Georgia, from January 2016 to June 2021. Patients ≥18 years old who sustained FI to the head and neck and were transported via ground emergency medical services (GEMS) or helicopter emergency medical services (HEMS) were included. Patients who arrived at the hospital by foot, private vehicle, or transported from a different hospital were excluded. PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE: The primary predictor variable was method of transportation (GEMS: ambulance transportation to GMH vs HEMS: helicopter transportation to GMH helipad). MAIN OUTCOME VARIABLE(S): The primary outcome variables were tracheostomy (yes/no) and ICU admission (yes/no). COVARIATES: Patient, injury, and hospital-related covariates were collected. ANALYSES: Univariate analysis, χ2 test for categorical variables, and independent t test for continuous variables were calculated. Statistical significance was P < .05. RESULTS: Of total, 609 patients met the inclusion criteria. There were 560 patients (483 males) with a mean age of 33.6 years old (range, 18 to 90) transported by GEMS. There were 49 patients (40 males) with a mean age of 44 years old (range, 18 to 82) transported by HEMS. Patients transported by HEMS were statistically more likely to have longer transportation time in minutes [13.2 (range, 5 to 132) versus 24.2 (range, 9 to 46), P= <.001], lower Glasgow Coma Scale score [9.9 (range, 3 to 15) versus 6.3 (range, 3 to 15); P= <.001], higher Injury Severity Score [19.3 (range, 3.7 to 98) versus 24.2 (range, 10.3 to 98); P = .007], require transfusion [195 (34.8%); versus 26 (53.1%); P = .013], tracheostomy [46(8.2%) versus 13 (26.5%); P = <.001], and/or admitted to ICU [169, 30.2% versus 24 (49%); P = .007]. CONCLUSION AND RELEVANCE: HEMS was positively associated with more tracheostomy and/or ICU admission. Additionally, patients transported by HEMS experienced longer transportation time and severe injuries. HEMS triage criteria specific for FI to the head and neck should be developed.

The association between childhood opportunity index and pediatric hospitalization for firearm injury or motor vehicle crash.

BACKGROUND: Community-level factors can profoundly impact children's health, including the risk of violent injury. This study's objective was to understand the relationship between the Childhood Opportunity Index and pediatric firearm injury owing to interpersonal violence compared with a motor vehicle crash. METHODS: All pediatric patients (<18 years) who presented with an initial encounter with a firearm injury or motor vehicle crash between 2016 to 2021 were identified from 35 children's hospitals included in the Pediatric Health Information System database. The child-specific community-level vulnerability was determined by the Childhood Opportunity Index, a composite score of neighborhood opportunity level data specific to pediatric populations. RESULTS: We identified 67,407 patients treated for injuries related to motor vehicle crashes (n = 61,527) or firearms (n = 5,880). The overall cohort had a mean age of 9.3 (standard deviation 5.4) years; 50.0% were male patients, 44.0% non-Hispanic Black, and were 60.8% publicly insured. Compared with motor vehicle crash injuries, patients with firearm-related injuries were older (12.2 vs 9.0 years), more likely to be male patients (77.7% vs 47.4%), non-Hispanic Black (63.5% vs 42.1%), and had public insurance (76.4 vs 59.3%; all P < .001). In multivariable analysis, children living in communities with lower Childhood Opportunity Index levels were more likely to present with firearm injury than those living in communities with a very high Childhood Opportunity Index. The odds increased as the Childhood Opportunity Index level decreased (odds ratio 1.33, 1.60, 1.73, 2.00 for high, moderate, low, and very low Childhood Opportunity Index, respectively; all P ≤ .001). CONCLUSION: Children from lower-Childhood Opportunity Index communities are disproportionately impacted by firearm violence, and these findings have important implications for both clinical care and public health policy.

Using the Field Artificial Intelligence Triage (FAIT) tool to predict hospital critical care resource utilization in patients with truncal gunshot wounds.

BACKGROUND: Tiered trauma triage systems have resulted in a significant mortality reduction, but models have remained unchanged. The aim of this study was to develop and test an artificial intelligence algorithm to predict critical care resource utilization. METHODS: We queried the ACS-TQIP 2017-18 database for truncal gunshot wounds(GSW). An information-aware deep neural network (DNN-IAD) model was trained to predict ICU admission and need for mechanical ventilation (MV). Input variables included demographics, comorbidities, vital signs, and external injuries. The model's performance was assessed using the area under receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC). RESULTS: For the ICU admission analysis, we included 39,916 patients. For the MV need analysis, 39,591 patients were included. Median (IQR) age was 27 (22,36). AUROC and AUPRC for predicting ICU need were 84.8 ± 0.5 and 75.4 ± 0.5, and the AUROC and AUPRC for MV need were 86.8 ± 0.5 and 72.5 ± 0.6. CONCLUSIONS: Our model predicts hospital utilization outcomes in patients with truncal GSW with high accuracy, allowing early resource mobilization and rapid triage decisions in hospitals with capacity issues and austere environments.

Abdominal Injuries from Civilian Conflicts: An Emerging Global Health Challenge in Rural Southeast Nigeria.

Background: In recent time, incidence of abdominal injuries continues to increase steadily in most major regions of West Africa due to emergence of various religious, social and political conflicts. Indeed, violence and social conflicts constitute major global public health challenges that commonly lead to injuries and long-term physical and mental health problems. In our setting, increasing cases of abdominal trauma resulting from civilian violence led to additional workload in the general surgery unit and the audit of our experiences is presented in this paper. Objective: To analyze the etiological spectrum, trend and management outcome of abdominal injuries from civilian violence in our setting. Methods: This was a multicenter prospective study of adult patients with abdominal injuries from civilian conflicts managed at three selected district hospitals in Southeast Nigeria between January 2013 to December 2020. Findings: Of 398 patients evaluated, 359 (90.2%) sustained penetrating while 39 (9.8%) had blunt abdominal injuries. Gunshot was the most common mechanism, accounting for 248 (62.3%) cases, followed by stab wound (95, 23.9%). Armed robbery attack (68, 27.4%) was the main source of gunshot wounds. Overall, annual rates showed a four-fold rise over an eight-year period from 24 cases (6.0%) in 2013 to 96 (24.1%) in 2020. Majority (365, 91.7%) had operative management (OM); the rest (33, 8.3%) were treated non-operatively. Morbidity and mortality rates for operative cases were 29.6% and 12.1% respectively. The main factors associated with increased mortality rates were delayed presentation (p = 0.002), bowel resection (p = 0.006), gunshot wounds (p = 0.013), advanced age (p = 0.033), multiple visceral injury (p = 0.034) and ASA score ≥ III (p = 0.001). Conclusion: Abdominal trauma from civilian violence is on the steady rise in our setting. The main etiologic factors are armed-robbery, communal clashes, political thuggery and cultism perpetrated predominantly through gunshots and stab wounds. Advancing age, gunshot wounds, delayed presentation, bowel resection and multiple injuries were associated with increased mortality.

Epidemiological characteristics and comparative outcome of blast versus gunshot injuries of the extremities in Somalia.

BACKGROUND: War conflicts and terror-related injuries constitute a significant public health problem in Somalia. We aim to characterize and compare the injury characteristics of gunshot and blast injuries of the extremities. METHODS: The data of 333 patients with gunshot and blast injuries of the extremities over three years were retrospectively reviewed. The demographics, injury characteristics, and outcomes were analyzed. RESULTS: Most of the patients had injuries due to gunshot casualties compared with blast victims (n = 222, 66.7% vs. n = 111, 33.3%). Patients with gunshot wounds (GSW) had a more significant proportion of males than those with blast wounds (BW) (95.5% vs. 85.6%, P < 0.001). There were more open extremity fractures in GSW casualties (96.4% vs. 81.1%). The BW victims had significantly higher associated injuries (52.3% vs. 18.5%, P < 0.001). The BW group had a higher injury severity score (ISS ≥ 16 in 55%, P < 0.001). The need for an intensive care unit (ICU) admission was significantly higher in the BW patients (18% vs. 6.3%, P < 0.001); as well as the length of hospital stay (LOS) was higher in the BW group compared with the GW patients (> 2-week hospital stay in 31% vs. 19%, P < 0.04). About a 2.7% mortality rate was observed in BW (P < 0.014). CONCLUSION: Gunshot and explosion injuries comprise the majority of war and terror-related trauma of the extremities. These injury mechanisms differ in the body regions involved, the severity of the injury, duration of hospital stay, need for ICU admission, and mortality. Assessment and management of such devastating casualties require a complex and multidisciplinary approach.

Mental Health Care Utilization Among Children and Adolescents With a Firearm Injury.

Importance: Firearm injuries are a leading cause of morbidity and mortality among US children and adolescents. Despite evidence demonstrating mental health sequelae for children and adolescents who have experienced a firearm injury, little is known about mental health care utilization after a firearm injury. Objective: To evaluate mental health care utilization in the 12 months after a firearm injury among Medicaid-insured and commercially insured children and adolescents compared with propensity score-matched controls. Design, Setting, and Participants: This propensity score-matched retrospective cohort analysis assessed 2127 children and adolescents, aged 0 to 17 years, with a firearm injury that occurred between January 1, 2016, and December 31, 2017, compared with 2127 matched controls using MarketScan Medicaid and commercial claims data. Claims data were analyzed 12 months before and after injury, with the total study period spanning from January 1, 2015, to December 31, 2018. Exposure: Nonfatal firearm injury. Main Outcomes and Measures: The primary outcome of interest was a dichotomous variable representing any mental health care utilization in the 12 months after injury. Secondary outcomes included psychotherapy utilization, substance use-related utilization, and a psychotropic medication prescription. Logistic regression modeling was used to estimate relative risks with adjusted analyses of dichotomous outcomes. Results: The overall cohort consisted of 4254 children and adolescents, of whom 2127 (mean [SD] age, 13.5 [4.1] years; 1722 [81.0%] male) had an initial encounter for a firearm injury and an equal number of matched controls (mean [SD] age, 13.5 [4.1] years; 1720 [80.9%] male). Children and adolescents with a firearm injury had a 1.40 times greater risk (95% CI, 1.25-1.56; P < .001) of utilizing mental health services in the 12 months after their injury compared with children and adolescents without a firearm injury, after controlling for potential confounders. Children and adolescents with a firearm injury had a 1.23 times greater risk (95% CI, 1.06-1.43; P = .007) of utilizing psychotherapy and a 1.40 times greater risk (95% CI, 1.19-1.64; P < .001) of substance use-related utilization. Among those who experienced a firearm injury, Black children and adolescents were 1.64 times more likely (95% CI, 1.23-2.19; P < .001) to utilize mental health care compared with White children and adolescents. Conclusions and Relevance: This propensity score-matched cohort study found that children and adolescents with a firearm injury had a greater risk of utilizing mental health services in the 12 months after their injury compared with those without an injury, and significant racial disparities were associated with use of mental health services. The findings suggest that health care practitioners should be aware of this increased risk and ensure adequate mental health follow-up for these patients.

Long-term functional, psychological, emotional, and social outcomes in pediatric victims of violence.

BACKGROUND: To evaluate the long-term functional, psychological, and emotional outcomes in individuals who survived violence-related injuries as children. METHODS: We retrospectively identified all pediatric patients (age <18y at time of injury) treated for a violent traumatic injury (gun-shot wound, stab, or assault) at our institution (1/2011-12/2020). We then prospectively attempted to contact and survey, via telephone, all patients that had reached adulthood (age ≥18y at time of study) using 7 Patient-Reported Outcomes Measurement Information System (PROMIS) instruments and the Primary Care Post Traumatic Stress Disorder (PTSD) screen. RESULTS: Of the 270 patients identified, we attempted to contact 218, successfully contacted 68, and 24 participated in the study. Of participants, 15 (62.5%) sustained gunshot wounds, 8 (33.3%) were stabbed, and 1 (4.2%) was assaulted with a median time from injury of 6.7(3.4) years. Based on PROMIS metrics, Global Physical Health (55.0 vs. 50.0, p = 0.013) and Emotional Support (55.4 vs. 50.0, p = 0.004) were better in participants compared to reference populations. However, a disproportionate number of participants reported substance use in the past 30 days (45.8 vs 13.0%; p < 0.001), 41.7% screened positive for PTSD, and 62.5% requested resources and/or referral for medical care. CONCLUSIONS: Many individuals who survive violent injuries as children continued to experience negative physical and mental outcomes extending into adulthood that required ongoing medical and psychological support. Further resources are needed to better understand the long-term effects of violent injury and to care for the complex needs of this population.

Gunshot wound versus blunt liver injuries: different liver-related complications and outcomes.

PURPOSE: Severe hepatic injury due to gunshot (GSW) compared to blunt mechanism may have significantly different presentation, management, complications, and outcomes. The aim of this study was to identify the differences. METHODS: Retrospective single-center analysis June 1, 2015-June 30, 2020, included all patients with Grade III-V liver injuries due to GSW or blunt mechanism. Clinical characteristics, severity of injury, liver-related complications (rebleeding, necrosis/abscess, bile leak/biloma, pseudoaneurysm, acute liver failure) and overall outcomes (mortality, hospital length of stay, intensive care unit length of stay, and ventilatory days) were compared. RESULTS: Of 879 patients admitted with hepatic trauma, 347 sustained high-grade injury and were included: 81 (23.3%) due to GSW and 266 (76.7%) due to blunt force. A significantly larger proportion of patients with GSW were managed operatively (82.7 vs. 36.1%, p < 0.001). GSW was associated with significantly more liver-related complications (40.7% vs. 27.4%, p = 0.023), specifically liver necrosis/abscess (18.5% vs. 7.1%, p = 0.003) and bile leak/biloma (12.3% vs. 5.3%, p = 0.028). On subgroup analysis, in patients with grade III injury, the incidence of liver necrosis/abscess and bile leak/biloma remained significantly higher after GSW (13.9% vs. 3.1%, p = 0.008 and 11.1% vs. 2.5%, p = 0.018, respectively). In sub analysis of 88 patients with leading severe liver injuries, GSW had a significantly longer hospital length of stay, ICU length of stay, and ventilator days. CONCLUSION: GSW mechanism to the liver is associated with a higher incidence of liver-related complications than blunt force injury.

Tratamiento de las fracturas por herida de arma de fuego: revisión bibliográfica sistematizada / Treatment of gunshot wound fractures: systematic review of the literature / Tratamento de fraturas por arma de fogo: revisão bibliográfica sistematizada

Introducción: Las fracturas por heridas de arma de fuego son un motivo de consulta habitual en nuestro país. Existe gran variabilidad de conductas respecto a su tratamiento. El objetivo principal de este trabajo es analizar los distintos tratamientos y sus indicaciones. Materiales: Se realizó una revisión sistematizada de la literatura en las bases de datos Pubmed y Scielo. Se incluyeron artículos con fracturas por herida de arma de fuego en miembros superiores e inferiores, excluyendo la mano. Se analizó: tratamiento (ortopédico o quirúrgico), debridamiento, antibioticoterapia y complicaciones. Resultados: Se obtuvieron 19 artículos que cumplían los criterios de inclusión y exclusión. Los artículos tuvieron un Nivel de Evidencia tipo 2b, 3 y 4. Conclusiones: Los artículos analizados tienen un bajo nivel de evidencia. La fijación quirúrgica es variable y depende de la topografía ósea, la lesión de partes blandas y las lesiones asociadas. El debridamiento profundo está relacionado con mayores índices de infección. Las fracturas estables de tratamiento ortopédico no deberían debridarse ya que aumenta los índices de infección. Debería realizarse antibioticoterapia intravenosa inicial en todos los pacientes, la terapia posterior es discutida.

Introduction: Fractures due to gunshot wounds are a common reason for consultation in our country. There is great variability of conduct regarding its treatment. The main objective of this work is to analyze the different treatments and their indications. Materials: A systematic review of the literature was carried out in the Pubmed and Scielo databases. Articles with fractures due to gunshot wounds in the upper and lower limbs (excluding the hand) were included. We analyzed: treatment (orthopedic or surgical), debridement, antibiotic therapy and complications. Results: 19 articles were obtained that met the inclusion and exclusion criteria. The articles had a Level of Evidence type 2b, 3 and 4. Conclusions: The articles analyzed have a low level of evidence. Surgical fixation is variable and depends on bone topography, soft tissue injury, and associated injuries. Deep debridement is associated with higher rates of infection. Stable orthopedically treated fractures should not be debrided as this increases infection rates. Initial intravenous antibiotic therapy should be performed in all patients, subsequent therapy is discussed.

Introdução: As fraturas por ferimentos por arma de fogo são motivo comum de consulta em nosso país. Há grande variabilidade de conduta quanto ao seu tratamento. O objetivo principal deste trabalho é analisar os diferentes tratamentos e suas indicações. Materiais: Foi realizada revisão sistemática da literatura nas bases de dados Pubmed e Scielo. Foram incluídos artigos com fraturas por arma de fogo em membros superiores e inferiores, excluindo a mão. Foram analisados: tratamento (ortopédico ou cirúrgico), desbridamento, antibioticoterapia e complicações. Resultados: foram obtidos 19 artigos que atenderam aos critérios de inclusão e exclusão. Os artigos tinham Nível de Evidência tipo 2b, 3 e 4. Conclusões: Os artigos analisados ​​apresentam baixo nível de evidência. A fixação cirúrgica é variável e depende da topografia óssea, lesão de tecidos moles e lesões associadas. O desbridamento profundo está associado a maiores taxas de infecção. Fraturas estáveis ​​tratadas ortopedicamente não devem ser desbridadas, pois isso aumenta as taxas de infecção. A antibioticoterapia intravenosa inicial deve ser realizada em todos os pacientes, a terapia subsequente é discutida.

Clinical characteristics of firearm-related injuries in children in Turkey.

BACKGROUND: A significant number of children are injured by or die from firearm-related incidents every year, although there is a lack of global data on the number of children admitted to pediatric emergency departments (PEDs) and pediatric intensive care units (PICU) with firearm injuries. This study is the most comprehensive analysis of firearm injuries sustained by children in Turkey to date. METHODS: This multicenter, retrospective, cohort study was conducted between 2010 and 2020 with the contributions of the PEDs, PICUs, intensive care units, and surgery departments of university hospitals and research hospitals. RESULTS: A total of 508 children were admitted to hospital with firearm-related injuries in the research period, although the medical records of only 489 could be obtained. Of the total admissions to hospitals, 55.0% were identified as unintentional, 8.2% as homicide, 4.5% as self-harm, and 32.3% as undetermined. The Glasgow Coma Scale (GCS) and ventilation support were found to be the most significant predictors of mortality, while head/neck injury, length of stay (LOS) in the hospital and surgical interventions were found to be the most significant predictors of disability. The overall mortality of firearm-related injuries was 6.3%, and the mortality for children admitted to the PICU was 19.8%. The probability of disability was calculated as 96.0% for children hospitalized with firearm injuries for longer than 75 days. CONCLUSIONS: Head/neck injury, LOS in the hospital, and surgical interventions were found to be the most significant parameters for the prediction of disability. Hospitalization exceeding 6 days was found to be related to disability.

Coming in hot: Police transport and prehospital time after firearm injury.

BACKGROUND: In Philadelphia, PA, police and emergency medical services (EMS) transport patients with firearm injuries. Prior studies evaluating this system have lacked reliable prehospital times. By linking police and hospital data sets, we established a complete timeline from firearm injury to outcome. We hypothesized that police-transported patients have shorter prehospital times that, in turn, are associated with improved survival and increased unexpected survivorship at 6 and 24 hours. METHODS: This retrospective study linked patient-level data from OpenDataPhilly Shooting Victims and the Pennsylvania Trauma Systems Foundation. All adults transported to a Level I or II trauma center after firearm injury in Philadelphia from 2015 to 2018 were included. Patient-level characteristics were compared between cohorts; unexpected survivors were identified using Trauma Score-Injury Severity Score. Multiple regression estimated risk-adjusted associations between transport method, prehospital time, and outcomes. RESULTS: Police-transported patients (n = 977) had significantly shorter prehospital times than EMS-transported patients (n = 320) (median, 9 minutes [interquartile range, 7-12 minutes] vs. 21 minutes [interquartile range, 16-29 minutes], respectively; p < 0.001). Police-transported patients were more often severely injured than those transported by EMS (60% vs. 50%, p = 0.002). After adjusting for confounders, police-transported patients had improved survival relative to EMS on hospital arrival (87% vs. 84%, respectively, p = 0.035), but not at 6 hours (79% vs. 78%, respectively, p = 0.126) or 24 hours after arrival (76% vs. 76%, respectively, p = 0.224). Compared with EMS, police-transported patients were significantly more likely to be unexpected survivors at 6 hours (6% vs. 2%, respectively, p < 0.001) and 24 hours (3% vs. 1%, respectively, p = 0.021). CONCLUSION: Police-transported patients had more severe injuries, shorter prehospital times, and increased likelihood of unexpected survival compared with EMS-transported patients. After controlling for confounders, patient physiology and injury severity represent meaningful determinants of mortality in our mature trauma system, indicating an ongoing opportunity to optimize in-hospital care. Future studies should investigate causes of death among unexpected early survivors to mitigate preventable mortality. LEVEL OF EVIDENCE: Prognostic/Epidemiological, Level III.

Evaluation of firearm injuries by trauma scoring systems in a secondary health care institution.

BACKGROUND: Scoring systems are widely used in trauma patients and are very important in the care of trauma patients. The objective of this study was to investigate the effectiveness of scoring systems in evaluating the patients who were brought to a hospital without a trauma center due to firearm injuries (FIs) using scoring systems, and the efficacy of these systems in identifying patients who should be treated in a trauma center. METHODS: Patients brought to Hakkari Yüksekova State Hospital due to FIs between January 2010 and December 2019 were retrospectively investigated. Patients aged 16 and over were included in the study. Patients who were brought to the hospital while deceased and those who did not respond to cardiopulmonary resuscitation in the hospital were excluded from the study. In addition, patients who underwent simple outpatient medical intervention were not included in the patient group. Patients were evaluated demographically. The mortality predictions of trauma scoring systems, which are widely used in the evaluation of trauma patients, were examined. In addition, the effectiveness of scoring systems in identifying patients who should be treated in trauma centers was investigated. RESULTS: In the study, 331 patients, 96.9% of whom were male, were evaluated. The patient group consisted of young patients and the median age was 27 (IQR, 24-29) years. A total of 74 (22.4%) patients were referred to trauma referral hospitals for diagnosis and treatment. Mortality occurred in 46 (13.9%) patients. Glasgow coma scale, injury severity score (ISS), revised trauma score, new trauma score, and trauma revised ISS were found effective for predicting mortality in patients, and scoring systems were correlated with each other. However, scoring systems were not found effective in distinguishing patients who should be treated in a trauma center. CONCLUSION: Scoring systems are significant in predicting mortality of patients with gunshot wounds. However, trauma scoring systems have not been found to be effective in distinguishing patients who require referral to a trauma center.

Use of whole blood deployment programs for mass casualty incidents: South Texas experience in regional response and preparedness.

INTRODUCTION: Firearm-related deaths have become the leading cause of death in adolescents and children. Since the Sutherland Springs, TX mass casualty incident (MCI), the Southwest Texas Regional Advisory Council for trauma instituted a prehospital whole blood (WB) program and blood deployment program for MCIs. METHODS: The program was adopted statewide by the Texas Emergency Medical Task Force, of which Southwest Texas Regional Advisory Council is the lead for Emergency Medical Task Force 8. The recent active shooter MCI in Uvalde, TX was the first time the MCI blood deployment program had been used. To our knowledge, no other similar programs exist in this or any other country. RESULTS: On May 24, 2022, 19 children and 2 adults were killed at an MCI in Uvalde, TX. The MCI WB deployment protocol was initiated, and South Texas Blood and Tissue Center prepared 15 U of low-titer O-positive whole blood and 10 U of leukoreduced O packed cells. The deployed blood arrived at Uvalde Memorial Hospital within 67 minutes. One of the pediatric patients sustained multiple gunshots to the chest and extremities. The child was hypotensive and received 2 U of leukoreduced O packed cells, one at the initial hospital and another during transport. On arrival, the patient required 2 U of low-titer O-positive whole blood and underwent a successful hemorrhage control operation. The remaining blood was returned to South Texas Blood and Tissue Center for distribution. CONCLUSION: Multiple studies have shown the association of early blood product resuscitation and improved mortality, with WB being the ideal resuscitative product for many. The ongoing efforts in South Texas serve as a model for development of similar programs throughout the country to reduce preventable deaths. This event represents the first ever successful deployment of WB to the site of an MCI related to a school shooting in the modern era. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

Penetrating renal injuries: an observational study of non-operative management and the impact of opening Gerota's fascia.

BACKGROUND: Non-operative management has become increasingly popular in the treatment of renal trauma. While data are robust in blunt mechanisms, the role of non-operative management in penetrating trauma is less clear. Additionally, there is a paucity of data comparing gunshot and stab wounds. METHODS: A retrospective review of patients admitted to a high-volume level 1 trauma center (Groote Schuur Hospital, Cape Town) with penetrating abdominal trauma was performed. Patients with renal injuries were identified and compared based on mechanism [gunshot (GSW) vs. stab] and management strategy (operative vs. non-operative). Primary outcomes of interest were mortality and failure of non-operative management. Secondary outcomes of interest were nephrectomy rates, Clavien-Dindo complication rate, hospital length of stay, and overall morbidity rate. RESULTS: A total of 150 patients with renal injuries were identified (82 GSW, 68 stab). Overall, 55.2% of patients required emergent/urgent laparotomy. GSWs were more likely to cause grade V injury and concurrent intra-abdominal injuries (p > 0.05). The success rate of non-operative management was 91.6% (89.9% GSW, 92.8% stab, p = 0.64). The absence of hematuria on point of care testing demonstrated a negative predictive value of 98.4% (95% CI 96.8-99.2%). All but 1 patient who failed non-operative management had associated intra-abdominal injuries requiring surgical intervention. Opening of Gerota's fascia resulted in nephrectomy in 55.6% of cases. There were no statistically significant risk factors for failure of non-operative management identified on univariate logistic regression. CONCLUSIONS: NOM of penetrating renal injuries can be safely and effectively instituted in both gunshot and stab wounds with a very low number of patients progressing to laparotomy. Most patients fail NOM for associated injuries. During laparotomy, the opening of Gerota's fascia may lead to increased risk of nephrectomy. Ongoing study with larger populations is required to develop effective predictive models of patients who will fail NOM.

Mental Health Care Following Firearm and Motor Vehicle-related Injuries: Differences Impacting Our Treatment Strategies.

OBJECTIVE: To compare new mental health diagnoses (NMHD) in children after a firearm injury versus following a motor vehicle collision (MVC). BACKGROUND: A knowledge gap exists regarding childhood mental health diagnoses following firearm injuries, notably in comparison to other forms of traumatic injury. METHODS: We utilized Medicaid MarketScan claims (2010-2016) to conduct a matched case-control study of children ages 3 to 17 years. Children with firearm injuries were matched with up to 3 children with MVC injuries. Severity was determined by injury severity score and emergency department disposition. We used multivariable logistic regression to measure the association of acquiring a NMHD diagnosis in the year postinjury after firearm and MVC mechanisms. RESULTS: We matched 1450 children with firearm injuries to 3691 children with MVC injuries. Compared to MVC injuries, children with firearm injuries were more likely to be black, have higher injury severity score, and receive hospital admission from the emergency department ( P <0.001). The adjusted odds ratio (aOR) of NMHD diagnosis was 1.55 [95% confidence interval (95% CI): 1.33-1.80] greater after firearm injuries compared to MVC injuries. The odds of a NMHD were higher among children admitted to the hospital compared to those discharged. The increased odds of NMHD after firearm injuries was driven by increases in substance-related and addictive disorders (aOR: 2.08; 95% CI: 1.63-2.64) and trauma and stressor-related disorders (aOR: 2.07; 95% CI: 1.55-2.76). CONCLUSIONS: Children were found to have 50% increased odds of having a NMHD in the year following a firearm injury as compared to MVC. Programmatic interventions are needed to address children's mental health following firearm injuries.

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

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