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.

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.

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.

The Association of Payer Status and Injury Patterns in Pediatric Bicycle Injuries.

BACKGROUND: Bicycle injuries continue to cause significant morbidity in the United States. How insurance status affects outcomes in children with bicycle injuries has not been defined. We hypothesized that payer status would not impact injury patterns or outcomes in pediatric bicycle-related accidents. METHODS: The National Trauma Data Bank was used to identify pediatric (≤18 y) patients involved in bicycle-related crashes admitted in year 2016. Patients with private insurance were compared with all others (uninsured, Medicaid, and Medicare). RESULTS: There were 5619 patients that met study criteria. Of these, 2500 (44%) had private insurance. Privately insured were older (12 y versus 11, P < 0.001), more likely to be white (77% versus 56%, P < 0.001), and more likely to wear a helmet (26% versus 9%, P < 0.001). On multivariate analysis, factors associated with traumatic brain injury included age (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.06-1.08; P < 0.001) and helmet use (OR, 0.64; 95% CI, 0.55-0.74; P < 0.001). Patients without private insurance were significantly less likely to wear a helmet (OR, 0.52; 95% CI, 0.44-0.63; P < 0.001). Uninsured patients had significantly higher odds of a fatal injury (OR, 4.43; 95% CI, 1.52-12.92; P = 0.006). CONCLUSIONS: Uninsured children that present to a trauma center after a bicycle accident are more likely to die. Although helmet use reduced the odds of traumatic brain injury, minorities and children without private insurance were less likely to be helmeted. Public health interventions should increase helmet access to children without private insurance, especially uninsured children.

Did the Affordable Care Act Reach Penetrating Trauma Patients?

BACKGROUND: The benefits of the Affordable Care Act (ACA) for trauma patients have been well established. However, the ACA's impact on penetrating trauma patients (PTPs), a population that is historically young and uninsured, has not been defined. We hypothesized that PTPs in the post-ACA era would have better outcomes. MATERIAL AND METHODS: The National Trauma Data Bank (NTDB) was queried for all PTPs from 2009 (pre-ACA) and 2011-2014 (post-ACA). Subset analysis was performed in patients aged 19-25 y, as this group was eligible for the ACA's dependent care provision (DCP). RESULTS: There were 9,714,471 patients in the study, with 2,053,501 (21.1%) pre-ACA and 7,660,970 (78.9%) post-ACA. When compared to pre-ACA, patients in the post-ACA cohort were more likely to have commercial/private insurance, less likely to have Medicaid, and more likely to be uninsured. On logistic regression, the pre-ACA era was associated with mortality (HR: 1.02, 95% CI: 1.01-1.04, P = 0.004). Being uninsured was associated with mortality (HR: 1.89, 95% CI: 1.87-1.92, P < 0.001). On subset analysis of the DCP age group, post-ACA patients were more likely to be uninsured (24.1% versus 17.6%; P < 0.001). In addition, for the DCP age group, pre-ACA era was not associated with mortality (HR: 1.03, 95% CI: 0.99-1.06, P = 0.20). CONCLUSIONS: Although the ACA provided a survival benefit to PTPs overall, it did not increase insurance coverage for this population. In addition, the DCP of the ACA did not improve insurance access for PTP in the eligible age group. Further efforts are needed to extend insurance access to this population.