Levetiracetam or Phenytoin as Prophylaxis for Status Epilepticus: Secondary Analysis of the "Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial" (ADAPT) Dataset, 2014-2017.

OBJECTIVES: To compare levetiracetam and phenytoin as prophylaxis for the short-term development of status epilepticus (SE) during care of pediatric patients with acute severe traumatic brain injury (TBI). DESIGN: Nonprespecified secondary analysis using propensity score matching. SETTING: We used the Approaches and Decisions in Acute Pediatric TBI Trial (ADAPT NCT04077411) dataset (2014-2017). SUBJECTS: Patients less than 18 years old with Glasgow Coma Scale Score less than or equal to 8 who received levetiracetam or phenytoin as a prophylactic anticonvulsant therapy. INTERVENTION: None. MEASUREMENT AND MAIN RESULTS: Of the 516 total patients who qualified for the case-control study, 372 (72.1%) patients received levetiracetam, and 144 (27.9%) received phenytoin. After propensity score matching, the pair-matched analysis with 133 in each group failed to identify an association between levetiracetam versus phenytoin use and occurrent of SE (3.8% vs. 0.8%, p = 0.22), or mortality (i.e., in-hospital, 30-d and 60-d). However, on closer inspection of the statistical testing, we cannot exclude the possibility that selecting levetiracetam rather than phenytoin for prophylaxis was associated with the following: up to a mean difference of 7.3% greater prevalence of SE; up to a mean difference of 13.9%, 12.1%, and 13.9% greater mortality during the hospital stay, and 30-, and 60-days after hospital arrival, respectively. Last, analysis of 6 months Glasgow Outcome Scale Extended score in those without premorbid comorbidities, there was an association between favorable outcomes and use of phenytoin rather than levetiracetam prophylaxis. CONCLUSIONS: In ADAPT, the decision to use prophylactic levetiracetam versus phenytoin failed to show an association with occurrence of subsequent SE, or mortality. However, we are unable to exclude the possibility that selecting levetiracetam rather than phenytoin for prophylaxis was associated with greater prevalence of SE and mortality. We are unable to make any recommendation about one prophylactic anticonvulsant medication over the other, but recommend that further larger, contemporary studies in severe pediatric TBI are carried out.

Factors associated with pediatric trauma patients leaving against medical advice.

BACKGROUND: Discharge against medical advice (AMA) leads to worse patient outcomes, increased readmission rates, and higher cost. However, AMA discharge has received limited study, particularly in pediatric trauma patients. Our objective was to explore the risk factors associated with leaving AMA in pediatric trauma patients. METHODS: We performed a retrospective analysis on pediatric trauma patients from 2017 to 2019 using the National Trauma Data Bank. We examined patient characteristics including age (<18 years), race, sex, Glasgow Coma Scale, trauma type, primary payment methods, and Abbreviated Injury Scale. Multiple Logistic Regression models were utilized to determine characteristics associated with leaving AMA. RESULTS: Of the 224,196 pediatric patients included in the study, 238 left AMA (0.1%). Our study showed black pediatric trauma patients were more likely to leave AMA compared to nonblack patients (OR 1.987, 95% CI 1.501 to 2.631). Patients with self-pay coverage were more likely to leave AMA than those with other insurance coverages (OR 1.759, 95% CI 1.183 to 2.614). Blunt trauma patients were more likely to leave AMA than those with penetrating trauma (OR 1.683, 95% CI 1.216 to 2.330). Every one-year increase in age led to 15% increase in odds of AMA discharge (OR 1.150, 95% CI 1.115 to 1.186). Pediatric patients with severe abdominal injuries were less likely to leave AMA compared to those with mild abdominal injuries (OR 0.271, 95% CI 0.111 to 0.657). Patients with severe lower extremity injury were less likely to leave AMA compared to those with mild lower extremity injuries (OR 0.258, 95% CI 0.127 to 0.522). CONCLUSION: Race, insurance, injury type, and age play a role in AMA discharge of pediatric trauma patients. Black pediatric trauma patients have ∼ double the AMA discharge rate of nonblack patients. AMA discharge remains relevant, and addressing racial and socioeconomic factors provide opportunities for future interventions in pediatric trauma care. LEVEL OF EVIDENCE: III, retrospective study.

Association of Designated Pediatric Trauma Center and Outcomes of Severely Injured Children Who Were Mechanically Ventilated and Underwent Tracheostomy: A Propensity-Matched Analysis.

OBJECTIVES: The purpose of the study is to examine the outcomes of care delivered at the pediatric trauma center (PTC) in severely injured children who were intubated, mechanically ventilated, and underwent tracheostomy. METHODS: The study data were obtained from the Trauma Quality Improvement Program database for the calendar years 2017 to 2019. All children aged ≤17 years who sustained severe injury, required intubation and mechanical ventilation for more than 96 hours, and underwent tracheostomy were included in the study. Patients' characteristics, injury severity, and outcomes were compared between the care provided at the PTCs (level I or level II) and nonpediatric trauma centers (NPTCs). The propensity score matching methodology was used to perform the analysis. All P values are 2-sided, and a P value of <0.0.5 is considered statistically significant. RESULTS: Of 2164 patients who were qualified for the study, 1288 (59%) of the patients were treated at PTCs, and 876 (40.5%) of the patients were treated at NPTCs. Propensity matching created 876 pairs of patients. There were no significant differences found between the 2 groups on patients' characteristics except for age. Patients who were treated at PTCs had a median age of 14 (10-16) versus 15 (11-17) years ( P < 0.001) when compared with care provided at NPTCs. A longer hospital stay was found in the PTC group when compared with the NPTC group (24 [23, 25] vs 22 [21, 24], P = 0.008). Patients who were treated at PTC were found to have significantly less sepsis occurrence (0.9% vs 2.2%), and a higher proportion of patients were discharged home without needing additional support (26.2% vs 18.5%). CONCLUSIONS: Care at the PTC was associated with a lower occurrence of sepsis complications. A higher number of patients were discharged home without additional services when the care was provided at PTC.

Resuscitative Endovascular Balloon Occlusion of The Aorta (REBOA) And Mortality in Hemorrhagic Shock Associated with Severe Pelvic Fracture: a National Data Analysis.

BACKGROUND: The purpose of the study was to evaluate the mortality of patients who received Resuscitative Endovascular Balloon Occlusion of The Aorta (REBOA) in severe pelvic fracture with hemorrhagic shock. METHODS: The American College of Surgeon Trauma Quality Improvement Program (ACS-TQIP) database for the calendar years 2017-2019 was accessed for the study. The study included all patients aged 15 years and older who sustained severe pelvic fractures, defined as an injury with an abbreviated injury scale (AIS) score of ≥ 3, and who presented with the lowest systolic blood pressure (SBP) of < 90 mmHg. Patients with severe brain injury were excluded from the study. Propensity score matching was used to compare the patients who received REBOA with similar characteristics to patients who did not receive REBOA. RESULTS: Out of 3,186 patients who qualified for the study, 35(1.1%) patients received REBOA for an ongoing hemorrhagic shock with severe pelvic fracture. The propensity matching created 35 pairs of patients. The pair-matched analysis showed no significant differences between the group who received REBOA and the group that did not receive REBOA regarding patients' demography, injury severity, severity of pelvic fractures, lowest blood pressure at initial assessment and laparotomies. There was no significant difference found between REBOA versus no REBOA group in overall in-hospital mortality (34.3% vs. 28.6, P = 0.789). CONCLUSION: Our study did not identify any mortality advantage in patients who received REBOA in hemorrhagic shock associated with severe pelvic fracture compared to a similar cohort of patients who did not receive REBOA. A larger sample size prospective study is needed to validate our results. CASE-CONTROL RETROSPECTIVE STUDY: Level of Evidence IV.

Decision tree learning in Neo4j on homogeneous and unconnected graph nodes from biological and clinical datasets.

BACKGROUND: Graph databases enable efficient storage of heterogeneous, highly-interlinked data, such as clinical data. Subsequently, researchers can extract relevant features from these datasets and apply machine learning for diagnosis, biomarker discovery, or understanding pathogenesis. METHODS: To facilitate machine learning and save time for extracting data from the graph database, we developed and optimized Decision Tree Plug-in (DTP) containing 24 procedures to generate and evaluate decision trees directly in the graph database Neo4j on homogeneous and unconnected nodes. RESULTS: Creation of the decision tree for three clinical datasets directly in the graph database from the nodes required between 0.059 and 0.099 s, while calculating the decision tree with the same algorithm in Java from CSV files took 0.085-0.112 s. Furthermore, our approach was faster than the standard decision tree implementations in R (0.62 s) and equal to Python (0.08 s), also using CSV files as input for small datasets. In addition, we have explored the strengths of DTP by evaluating a large dataset (approx. 250,000 instances) to predict patients with diabetes and compared the performance against algorithms generated by state-of-the-art packages in R and Python. By doing so, we have been able to show competitive results on the performance of Neo4j, in terms of quality of predictions as well as time efficiency. Furthermore, we could show that high body-mass index and high blood pressure are the main risk factors for diabetes. CONCLUSION: Overall, our work shows that integrating machine learning into graph databases saves time for additional processes as well as external memory, and could be applied to a variety of use cases, including clinical applications. This provides user with the advantages of high scalability, visualization and complex querying.

The results of rapid source control laparotomy or open abdomen for acute diverticulitis.

INTRODUCTION: Rapid source control laparotomy (RSCL) for the management of non-traumatic intra-abdominal emergencies has increased over the past 25 years when it was advocated for trauma patients. Little data, however, support its widespread use. We hypothesize that the patients with RSCL will have poorer outcomes than those treated with primary fascial closure (PFC). METHODS: Patients operated for acute diverticulitis from 2014 to 2016 using The American College of Surgeons sponsored National Surgical Quality Improvement Program (NSQIP) data were reviewed. Two groups were identified: PFC, patients with their closed fascia but skin left open (PFC) and RSCL, patients with their left open fascia after the initial operation. The primary outcome of the study was 30-day mortality, with secondary analyses evaluating complications, discharge location and length of stay. Univariate analysis was initially performed followed by propensity score matching. RESULTS: A total of 460 patients were surgically treated for Hinchey IV diverticulitis of whom 101 (21.9%) had RSCL. The length of stay of the RSCL patients was significantly longer (15 versus 12 days, p, 0.02) than patients in the PFC group. Similarly, the discharge destination for the PFC group was twice as likely to be discharged home as the RSCL group. CONCLUSION: RSCL for acute diverticulitis is a widely used but is associated with prolonged hospitalizations resulting in high rates of discharge to skilled nursing or rehabilitation facilities. Its routine use for diverticulitis should be limited.

Post-traumatic thrombotic microangiopathy: What trauma surgeons need to know?

Thrombotic microangiopathy (TMA) is characterized by systemic microvascular thrombosis, target organ injury, anemia and thrombocytopenia. Thrombotic thrombocytopenic purpura, atypical hemolytic uremic syndrome and Shiga toxin E-coli-related hemolytic uremic syndrome are the three common forms of TMAs. Traditionally, TMA is encountered during pregnancy/postpartum period, malignant hypertension, systemic infections, malignancies, autoimmune disorders, etc. Recently, the patients presenting with trauma have been reported to suffer from TMA. TMA carries a high morbidity and mortality, and demands a prompt recognition and early intervention to limit the target organ injury. Because trauma surgeons are the first line of defense for patients presenting with trauma, the prompt recognition of TMA for these experts is critically important. Early treatment of post-traumatic TMA can help improve the patient outcomes, if the diagnosis is made early. The treatment of TMA is also different from acute blood loss anemia namely in that plasmapheresis is recommended rather than platelet transfusion. This article familiarizes trauma surgeons with TMA encountered in the context of trauma. Besides, it provides a simplified approach to establishing the diagnosis of TMA. Because trauma patients can require multiple transfusions, the development of disseminated intravascular coagulation must be considered. Therefore, the article also provides different features of disseminated intravascular coagulation and TMA. Finally, the article suggests practical points that can be readily applied to the management of these patients.

Early risk stratification of in hospital mortality following a ground level fall in geriatric patients with normal physiological parameters.

BACKGROUND: The purpose of this study was to identify risk factors of mortality for geriatric patients who fell from ground level at home and had a normal physiological examination at the scene. METHODS: Patients aged 65 and above, who sustained a ground level fall (GLF) with normal scene Glasgow Coma Scale (GCS) score 15, systolic blood pressure (SBP) > 90 and <160 mmHg, heart rate ≥ 60 and ≤100 beats per minute) from the 2012-2014 National Trauma Data Bank (NTDB) data sets were included in the study. Patients' characteristics, existing comorbidities [history of smoking, chronic kidney disease (CKD), cerebrovascular accident (CVA), diabetes mellitus (DM), and hypertension (HTN) requiring medication], injury severity scores (ISS), American College of Surgeons' (ACS) trauma center designation level, and outcomes were examined for each case. Risks factors of mortality were identified using bivariate analysis and logistic regression modeling. RESULTS: A total of 40,800 patients satisfied the study inclusion criteria. The findings of the logistic regression model for mortality using the covariates age, sex, race, SBP, ISS, ACS trauma level, smoking status, CKD, CVA, DM, and HTN were associated with a higher risk of mortality (p < .05). The fitted model had an Area under the Curve (AUC) measure of 0.75. CONCLUSION: Cases of geriatric patients who look normal after a fall from ground level at home can still be associated with higher risk of in-hospital death, particularly those who are older, male, have certain comorbidities. These higher-risk patients should be triaged to the hospital with proper evaluation and management.

Early Colectomy Saves Lives in Toxic Megacolon Due to Clostridium difficile Infection.

OBJECTIVE: The purpose of the study was to evaluate whether early colectomy in patients who have toxic megacolon due to Clostridium difficile colitis reduces mortality. METHODS: The study was performed using the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2016. All patients 18 to 89 years of age who underwent colectomy for toxic megacolon resulting from C. difficile colitis were included in the study. Other variables included in the study were patient demography, comorbidities, and outcomes. Patients who underwent colectomy before the presentation of septic shock (early group) were compared with patients who underwent colectomy after the onset of septic shock (late group). The main outcome of the study is 30-day all-cause mortality. Because there were some significant differences found in patient baseline characteristics in the univariate analysis, the propensity score of each patient was calculated and pair-matched analysis was performed. All P values are reported as 2-sided, and P < 0.05 was considered statistically significant. RESULTS: One hundred sixty-three patients met the inclusion criteria of the study. Approximately 85% of the patients underwent total abdominal colectomy. The average age of the patients was 65 years old, 51% of the patients were female, and 66% of the patients were white. The overall 30-day mortality was approximately 39%. The mortality rate of patients who underwent colectomy early compared to late was 13 (21%) vs 28 (45%), P = 0.009. The absolute risk difference was 0.24 with 95% CI: 0.07-0.42. CONCLUSIONS: There was a reduction of 24% in 30-day mortality when colectomies were performed before the development of septic shock.

Risk factors associated with splenectomy following a blunt splenic injury in pediatric patients.

PURPOSE: The purpose of the study was to identify the factors associated with splenectomy in pediatric trauma patients. METHOD: Pediatric Trauma quality improvement program (P-TQIP) database calendar year 2014-2016 was accessed for the study. All patients, age ≤ 18 years old, who sustained splenic injury due to blunt mechanism, were included in the study. The primary outcome of the study was to identify the risk factors associated with splenectomy. Univariate followed by multivariate analyses were performed. A p value of < 0.05 was considered an indication of statistical significance. RESULTS: Of 1297 trauma victims, who fulfilled the inclusion criteria, 57 (4.4%) patients underwent total splenectomy. In Univariate analysis, there were significant differences found, in many variables, between the groups who underwent splenectomy versus those who did not have splenectomy. A multivariate logistic regression analysis showed use of blood transfusion within 4 h and severity of splenic injury were the two variables associated with splenectomy. The area under the curve (AUC) value was 0.892 and the 95% confidence intervals were [0.859, 0.923]. CONCLUSION: Blood transfusion within 4 h of patient's arrival to the hospital and high-grade splenic injury were main factors for splenectomy in the pediatric population.

Outcomes in patients with late debridement of open long bone fractures of the lower extremities in penetrating trauma: a retrospective review of the National Trauma Data Bank.

BACKGROUND: The morbidity and mortality associated with open long bone fractures have been greatly reduced due to antibiotics and early surgical washout and debridement. Guidelines recommend early washout and debridement within 6-8 h; however, newer studies have shown that delaying surgical washout and debridement up to 24 h can be done safely without an increase in surgical site infection, wound nonunion or sepsis. All studies thus far have looked at combined blunt and penetrating open long bone fractures, without distinguishing between mechanism or type of injury. Our study looked specifically at open long bone fractures of the lower extremity caused by a penetrating mechanism of injury. METHODS: We utilized the US National Trauma Data Bank and included patients who had diagnosis of lower extremity open long bone fracture from a penetrating mechanism and underwent irrigation and debridement (I&D) within 24 h of arriving to the hospital. RESULTS: A total of 1014 patients qualified for the study. Of those, 736 (72.6%) patients underwent an I&D within 8 h and 278 (27.4%) underwent an I&D between 8 and 24 h after hospital arrival. When examining the patient outcomes, there were few cases and no significant differences in the occurrence of surgical site infections, sepsis or wound disruptions between the two groups. CONCLUSION: The majority of the open long bone fractures were due to firearm injury. I&D of penetrating open long bone fracture can be performed within 24 h without any added infective morbidity.

Risk stratification of survival in injured patients with cardiopulmonary resuscitation within the first hour of arrival to trauma centre: retrospective analysis from the national trauma data bank.

BACKGROUND: The purpose of this study was to evaluate overall survival and associated survival factors for patients with trauma who had cardiopulmonary resuscitation (CPR) within 1 hour after arrival to a hospital. METHODS: Retrospective patient data was retrieved from the 2007-2010 edition of the US National Trauma Data Bank. Inhospital survival was the primary outcome; only patients with a known outcome were included in the analysis. Summary statistics and univariate analyses were first reported. Eighty per cent of the patients were then randomly selected and used for multivariate logistic regression analysis. The identified risk factors were further assessed for discrimination and calibration with the remaining patients with trauma using area under the curve (AUC) analysis and a Hosmer-Lemeshow test. RESULTS: From 19 310 total cases that were reviewed, only 2640 patients required CPR within 1 hour of hospital arrival and met the additional inclusion criteria. Of these patients, 2309 (87.5%) died and 331 (12.5%) survived to discharge. There were statistical differences for race (p=0.003), initial systolic BP (p<0.001), initial pulse (p<0.001), cause of injury (p<0.001), presence of head injury (p=0.02), Injury Severity Score (ISS) (p<0.001), Glasgow Coma Scale (GCS) total score (p<0.001) and GCS motor score (p<0.001); though not all were clinically significant. The multiple logistic regression model (AUC=0.72) identified lower ISS, higher GCS motor score, Caucasian race, American College of Surgeons (ACS) level 2 trauma designation and higher initial SBP as the most predictive of survival to hospital discharge. CONCLUSION: Approximately 13% of patients who had CPR within an hour of arrival to a trauma centre survived their injury. Therefore, implementation of an aggressive first hour in-hospital resuscitation strategy may result in better survival outcomes for this patient population.

Survival of Trauma Victims Transported by Helicopter Who Required Cardiopulmonary Resuscitation Within the First Hour of Hospital Arrival.

OBJECTIVES: The purpose of the study was to review the impact on survival of trauma victims who were transported via helicopter ambulance versus ground transportation and who received cardiopulmonary resuscitation (CPR) within 1 hour of hospital arrival. METHODS: A retrospective analysis of the trauma patients who underwent CPR within 1 hour of arrival to the trauma centers and transported either via air or ground ambulances was performed. Data were extracted from the Research Data Set 2007-2010 from the American College of Surgeons National Trauma Data Bank. Patient and hospital characteristics were compared between the groups. Propensity score matching was performed to balance the baseline characteristics and absolute risk reduction was calculated using the McNemar test to evaluate the risk difference of survival at discharge with the mode of transportation. RESULTS: A total of 1269 patients qualified for the final analysis; 314 patients were transported by helicopter and 955 by ground ambulances. There were significant differences in baseline characteristics between the groups regarding age (P = 0.015), Injury Severity Score (P < 0.001), Glasgow Coma Scale (P < 0.001), male sex (P < 0.001), race (P < 0.001), and injury type (blunt vs penetrating, P < 0.001). After propensity score matching, no significant differences were seen on baseline characteristics between the groups. The mean standardized difference was <10% between the groups after matching in all covariates. There was a higher rate of survival of patients who were brought in via helicopter ambulance (absolute risk reduction 0.066, confidence interval 0.008-0.125, P = 0.02). CONCLUSIONS: Higher survival was seen in patients who were transported by helicopter ambulance and received CPR within 1 hour of hospital arrival.

Investigation of the EMG-time relationship of the biceps Brachii muscle during contractions.

[Purpose] This study investigated the changes in the slope of EMG-time curves (relationship) at the maximal and different levels of dynamic (eccentric and concentric) and static (isometric) contractions. [Subjects and Methods] The subject was a 17 year-old male adolescent. The surface EMG signal of the dominant arm's biceps brachii (BB) was recorded through electrodes placed on the muscle belly. [Results] The results obtained during the contractions show that the regression slope was very close to 1.00 during concentric contraction, whereas those of eccentric and isometric contractions were lower. Significant differences were found for the EMG amplitude and time lags among the contractions. [Conclusion] The results show that the EMG signal of the BB varies among the three modes of contraction and the relationship of the EMG amplitude with a time lag gives the best fit during concentric contraction.

Factors Associated With Tracheostomy in Ventilated Pediatric Trauma Patients. A National Trauma Database Study.

PURPOSE: The purpose of the study was to find the factors that were associated with tracheostomy procedures in ventilated pediatric trauma patients. METHODS: The Trauma Quality Improvement Program (TQIP) database of the calendar year 2017 through 2019 was accessed for the study. All patients <18 years old and who were on mechanical ventilation for more than 96 hours were included in the study. Multiple logistic regression analysis was performed to find the factors that were associated with a tracheostomy. RESULTS: Out of 2653 patients, 1907 (71.88%) patients underwent tracheostomy. The patients who underwent tracheostomy had a lower median [IQR] of Glasgow Coma Scale (GCS) (3 [3-8] vs 5 [3-10], P < .001) and had a higher proportion of severe spine injury (On Abbreviated Injury Scale [AIS]≥3) (11.6% vs 8.8%, P = .044) when compared with patients who did not have tracheostomy. Lower GCS scores and severe spine injury were associated with higher odds of tracheostomy, with all P values <.05. Higher proportion of tracheostomy procedures were performed at level I pediatric trauma centers as compared to non-designated pediatric centers (odds ratio [95% CI]: 1.848 [1.524-2.242], P < .001). CONCLUSION: A lower GCS score, severe spine injury and highest level trauma centers were associated with a tracheostomy.

Outcomes of Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome in Pediatric Trauma Patients.

IMPORTANCE: Acute respiratory distress syndrome (ARDS) is associated with high mortality and morbidity. Extracorporeal membrane oxygenation (ECMO) is one of the interventions that have been in practice for ARDS for decades. OBJECTIVES: The purpose of the study was to investigate the outcomes of ECMO in pediatric trauma patients who suffered from ARDS. DESIGN: Observational cohort study. SETTING AND PARTICIPANTS: The Trauma Quality Improvement Program database for years 2017 to 2019 and 2021 through 2022 was accessed for the study. All children younger than 18 years old who were admitted to the hospital after trauma and suffered from ARDS were included in the study. Other variables included in the study were patients' demographics, clinical characteristics, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) score, comorbidities, and outcomes. MAIN OUTCOMES AND MEASURES: ECMO is the exposure, and the outcomes are in-hospital mortality and hospital complications (acute kidney injury [AKI], pneumonia and deep vein thrombosis [DVT]). RESULTS: Of 453 patients who qualified for the study, propensity score matching found 50 pairs of patients. There were no significant differences identified between the groups, ECMO+ vs. ECMO- on patients' age in years (16 yr; interquartile range [IQR], 13.25-17 yr vs. 16 yr [14.25-17 yr]), race (White; 62.0% vs. 66.0%), sex (male; 78% vs. 76%), ISS (23 [IQR, 9.25-34] vs. 22 [9.25-32]), and GCS (15 [IQR, 3-15] vs. 13.5 [3-15]), mechanism of injury; and comorbidities. There was no difference between the groups, ECMO+ vs. ECMO-, in-hospital mortality (10.0% vs. 20.0%; p = 0.302), hospital complications (AKI 12.0% vs. 2.0%; p = 0.131), pneumonia (10.0% vs. 20.0%; p = 0.182 > ), and DVT (16% vs. 6%; p = 0.228). CONCLUSIONS AND RELEVANCE: No difference in mortality was observed in injured children who suffered from the ARDS and were placed on ECMO when compared with patients who were not placed on ECMO. Patients with trauma and ARDS who require ECMO have comparable outcomes to those who do not receive ECMO. A larger sample size study is needed to find the exact benefit of ECMO in this patients' cohort.

Trauma centers: an underfunded but essential asset to the community.

Research indicates that specialized trauma centers, especially those of level I and II designation, can generate revenue if financial support is provided, and most importantly provide better outcomes for an injured patient by reducing length of stay and mortality when compared with treatment at hospitals without trauma center designation. Costs associated with trauma center operation have risen over the past few years in association with growing patient volumes and inflation. Documentation regarding costs for trauma center operations is sparse, and there exists a large variance between reported numbers based on their region. In most cases, the greatest proportion of funds are spent on clinical personnel while the smallest fraction is dedicated to educational and prevention programs. Studies confirm that as a product of these rising costs and a lack of state and federal funding that trauma centers remain uniquely financially vulnerable. Multiple strategies have been implemented to mitigate these costs but have proven insufficient. Legislations providing patients with expanded access to healthcare such as the Affordable Healthcare Act have failed to deliver on their intended purposes, and managed care organizations have moved to protect their own interest at the expense of trauma patient mortality. In lieu of concerted federal support, states and municipalities have explored solutions to support trauma centers such as small fees added to fines or encouraging charitable donations, although these programs have not seen ubiquitous implementation. Most trauma centers have begun incorporating activation costs to recoup losses from their low reimbursement rate, but these have continued to inflate, and pose a growing burden on vulnerable patients. Lack of funding from external sources such as state or federal appropriations poses a tangible threat to trauma centers for closure, and with multiple trauma centers acting as critical pillars of healthcare infrastructure for disadvantaged communities as well as the impact of this lack of funding being so broad and systemic, multiple 'trauma deserts' may emerge, leaving communities-especially disadvantaged communities which rely on the safety-net function of many high designation trauma centers-deprived of an essential treatment resource and increasing annual mortalities that could have otherwise been averted.

Outcomes of Repeat Surgery in Pediatric Severe Traumatic Brain Injury: An Analysis from Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial.

BACKGROUND: Early operative intervention, craniotomy, and/or craniectomy are occasionally warranted in severe traumatic brain injury (TBI). Persistent increased intracranial pressure or accumulation of intracranial hematoma postsurgery can result in higher mortality and morbidity. There is a gap in information regarding the outcome of repeat surgery (RS) in pediatric patients with severe TBI. METHODS: An observational cohort study titled Approaches and Decisions in Acute Pediatric TBI Trial data was obtained from the Federal Interagency Traumatic Brain Injury Research Informatics System. All pediatric patients who underwent craniotomy or decompressive craniectomy, survived more than 44 hours and were found to have persistent elevated intracranial pressure >20 mmHg for 2 consecutive hours were included in the study. The purpose of the study was to find the outcomes of RS in pediatric severe TBI. Propensity based matching was used to find the outcomes. The primary outcome was 60-day mortality. RESULTS: Out of 1000 total patients enrolled in the Approaches and Decisions in Acute Pediatric Trial, 160 patients qualified for this study. Propensity score matching created 13 pairs of patients. There were no significant differences found between the groups who had RS versus those who did not have repeat surgery on baseline characteristics. There were no significant differences found between the groups regarding 60-day mortality, median hospital days, median intensive care unit days, and 6-month favorable outcome on Glasgow Outcome Scale Extended score. CONCLUSIONS: There was no difference in mortality between patients who underwent a second surgery and patients who did not have to undergo a second surgery.

Surgical Outcomes of Epidural Hematoma in Trauma Patients with Absent Pupillary Reactions: A National Trauma Data Analysis.

BACKGROUND: Absent pupillary reaction occasionally heralds a poor prognosis following severe head injury. The purpose of the study was to evaluate the outcome of all patients who underwent acute evacuation of epidural hematoma (EDH) despite absent bilateral pupillary reaction. METHODS: The Trauma Quality Improvement Program (TQIP) database for the calendar years 2017 and 2018 was accessed for the study. Adult patients ≥18 years of age who sustained severe traumatic brain injury (TBI) with the diagnosis of EDH and underwent evacuation of the hematoma were included in the study. The patients' characteristics, injury severity score (ISS), Glasgow Coma Scale (GCS) score, midline shift, and comorbidities were compared between patients who had absence of both pupillary reaction (ABPR) and those who presented with presence of both pupillary reaction (PBPR). The primary outcome of the study was in-hospital mortality. Propensity score matching analyses were performed for the study. RESULTS: No significant differences were found between the ABPR and PBPR groups regarding the median age (37 years [interquartile range (IQR): 26-53] vs. 40 years [IQR: 28-55]), gender (males; 81.9 vs. 79.5%), median ISS (29 [25.5-34] vs. 27 [25-33]), GCS score (3 [3-4] vs. 3 [3-3], presence of significant midline shift (75.9 vs. 79.5%), and comorbidities. The patients who presented with ABPR had a significantly higher mortality (34.9 vs. 10.8%; p = 0.002). A higher number of patients were discharged to skilled nursing and rehabilitation facilities (16.7 vs. 10.8% and 46.3 vs. 41.9%, respectively; p = 0.045). CONCLUSION: Approximately 65% of severe TBI patients survived after the evacuation of the EDH despite the absence of pupillary reaction.

Outcomes of early versus late irrigation and debridement of pediatric open long bone fractures.

BACKGROUND: Open long bone fractures are a major concern for pediatric patients due to the risk of surgical site infection (SSI). Early studies have recommended irrigation and debridement of open fractures within 6 hours-8 hours for the prevention of SSI. According to the American College of Surgeons (ACS) Best Practice Guidelines, in 2015, irrigation and debridement should be done within 24 hours. AIM: To identify whether early irrigation and debridement, within 8 hours, vs late, between 8 hours and 24 hours, for pediatric open long bone fractures impacts rate of SSI. METHODS: Using retrospective data review from the National Trauma Data Bank, Trauma Quality Improvement Project (TQIP) of 2019. TQIP database is own by the ACS and it is the largest database for trauma quality program in the world. Propensity matching analysis was performed for the study. RESULTS: There were 390 pediatric patients with open long bone fractures who were included in the study. After completing propensity score matching, we had 176 patients in each category, irrigation and debridement within 8 hours and irrigation and debridement between 8 hours and 24 hours. We found no significant differences between each group for the rate of deep SSI which was 0.6% for patients who received surgical irrigation and debridement within 8 hours and 1.1% for those who received it after 8 hours [adjusted odd ratio (AOR): 0.5, 95%CI: 0.268-30.909, P > 0.99]. For the secondary outcomes studied, in terms of length of hospital stay, patients who received irrigation and debridement within 8 hours stayed for an average of 3.5 days, and those who received it after 8 hours stayed for an average of 3 days, with no significant difference found, and there were also no significant differences found between the discharge dispositions of the patients. CONCLUSION: Our findings support the recommendation for managing open long bone fractures from the ACS: Complete surgical irrigation and debridement within 24 hours.