Deterioration Index in Critically Injured Patients: A Feasibility Analysis.

INTRODUCTION: Continuous prediction surveillance modeling is an emerging tool giving dynamic insight into conditions with potential mitigation of adverse events (AEs) and failure to rescue. The Epic electronic medical record contains a Deterioration Index (DI) algorithm that generates a prediction score every 15 min using objective data. Previous validation studies show rapid increases in DI score (≥14) predict a worse prognosis. The aim of this study was to demonstrate the utility of DI scores in the trauma intensive care unit (ICU) population. METHODS: A prospective, single-center study of trauma ICU patients in a Level 1 trauma center was conducted during a 3-mo period. Charts were reviewed every 24 h for minimum and maximum DI score, largest score change (Δ), and AE. Patients were grouped as low risk (ΔDI <14) or high risk (ΔDI ≥14). RESULTS: A total of 224 patients were evaluated. High-risk patients were more likely to experience AEs (69.0% versus 47.6%, P = 0.002). No patients with DI scores <30 were readmitted to the ICU after being stepped down to the floor. Patients that were readmitted and subsequently died all had DI scores of ≥60 when first stepped down from the ICU. CONCLUSIONS: This study demonstrates DI scores predict decompensation risk in the surgical ICU population, which may otherwise go unnoticed in real time. This can identify patients at risk of AE when transferred to the floor. Using the DI model could alert providers to increase surveillance in high-risk patients to mitigate unplanned returns to the ICU and failure to rescue.

Dehydrated Human Amniotic-Chorionic Membrane Reduces Incisional Hernia Formation in an Animal Model.

BACKGROUND: Currently there are no standard of care treatment strategies for IH prevention (IHP). Dehydrated human amnion-chorion (dHACM) is a healing adjunct that elutes growth factors including several that have reduced IH in animal models. We therefore performed a double-blinded, prospective randomized controlled trial (RCT) to test the hypothesis that dHACM significantly reduces IH formation in a well-studied animal model of acute IH. MATERIAL AND METHODS: Forty 16-week-old male Sprague-Dawley rats were randomized to one of four groups: No Treatment vs. dHACM Sheet (Group A), and Saline vs. dHACM Injection (Group B). Each animal underwent a 5-cm midline laparotomy which was incompletely closed with 5-0 plain gut sutures; this was performed by a surgeon blinded to treatment group (first blind). After 28 days, the primary endpoints of IH formation and hernia size were determined by study staff blinded to treatment (second blind). Secondary endpoints included healed fascia tensile strength as determined by tensiometry, systemic and local inflammatory markers as measured by ELISA, and fascial scar collagen I/III ratios per Western blotting. RESULTS: In Group A, No Treatment developed IH at 87.5% vs. 62.5% for Sheet (P = 0.28). Hernias that formed in the Sheet group were significantly smaller (P = 0.036). In Group B, Injection and Saline yielded identical IH rates of 77.8%. Molecular characterization of fascial scar demonstrated non-inferior tensile strength, collagen I/III ratios, and inflammatory markers in dHACM-treated animals. CONCLUSIONS: dHACM sheets significantly reduced the size of IH following laparotomy when compared to no treatment.

Stop the Bleed Training: Rescuer Skills, Knowledge, and Attitudes of Hemorrhage Control Techniques.

BACKGROUND: Bystanders play a significant role in the immediate management of life-threatening hemorrhage. The Stop the Bleed (STB) program was designed to train lay rescuers (LRs) to identify and control life-threatening bleeding. The aim of this study was to evaluate the efficacy of STB training for rescuers from different backgrounds. We hypothesized that STB training would be appropriate to increase skills and knowledge of bleeding control techniques for all providers, regardless of level of medical training. STUDY DESIGN: Course participants anonymously self-reported confidence in six major areas. A five-point Likert scale was used to quantitate participant's self-reported performance. Results were stratified into medical rescuers (MR) and LRs. Students' ability to perform STB skills were objectively assessed using an internally validated 15-point objective assessment tool. Data were pooled and analyzed using Student's t-test and chi-Squared test with P < 0.05 considered significant. Results are presented as average with standard deviation (SD) unless otherwise stated. RESULTS: A total of 1974 participants were included in the study. Precourse confidence was lowest for both groups in management of active severe bleeding and ability to pack a bleeding wound. Postcourse confidence improved significantly for both groups in all 6 core areas measured (P < 0.001). The most significant increases were reported in the two previous areas of lowest precourse confidence-management of active severe bleeding-LRs 2.0 (SD 1.2) versus 4.2 (SD 0.9) and MRs 2.6 (SD 1.4) versus 4.6 (SD 0.6), P < 0.001-and ability to pack a bleeding wound-LR 2.1 (SD 1.3) versus 4.4 (SD 0.8) and MR 2.7 (SD 1.3) versus 4.7 (SD 0.05), P < 0.001. Objective assessment of LR skills at the end of the course demonstrated combined 99.3% proficiency on postcourse objective assessments. CONCLUSIONS: This study provides quantitative evidence that Stop the Bleed training is effective, with both LRs and MRs demonstrating improved confidence and skill proficiency after a 1-h course. Future program development should focus on building a pool of instructors, continued training of LRs, and determining how often skills should be recertified.

Incidence, Risk Factors, and Outcomes of Intra-Abdominal Hypertension in Critically Ill Patients-A Prospective Multicenter Study (IROI Study).

OBJECTIVES: To identify the prevalence, risk factors, and outcomes of intra-abdominal hypertension in a mixed multicenter ICU population. DESIGN: Prospective observational study. SETTING: Fifteen ICUs worldwide. PATIENTS: Consecutive adult ICU patients with a bladder catheter. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Four hundred ninety-one patients were included. Intra-abdominal pressure was measured a minimum of every 8 hours. Subjects with a mean intra-abdominal pressure equal to or greater than 12 mm Hg were defined as having intra-abdominal hypertension. Intra-abdominal hypertension was present in 34.0% of the patients on the day of ICU admission (159/467) and in 48.9% of the patients (240/491) during the observation period. The severity of intra-abdominal hypertension was as follows: grade I, 47.5%; grade II, 36.6%; grade III, 11.7%; and grade IV, 4.2%. The severity of intra-abdominal hypertension during the first 2 weeks of the ICU stay was identified as an independent predictor of 28- and 90-day mortality, whereas the presence of intra-abdominal hypertension on the day of ICU admission did not predict mortality. Body mass index, Acute Physiology and Chronic Health Evaluation II score greater than or equal to 18, presence of abdominal distension, absence of bowel sounds, and positive end-expiratory pressure greater than or equal to 7 cm H2O were independently associated with the development of intra-abdominal hypertension at any time during the observation period. In subjects without intra-abdominal hypertension on day 1, body mass index combined with daily positive fluid balance and positive end-expiratory pressure greater than or equal to 7 cm H2O (as documented on the day before intra-abdominal hypertension occurred) were associated with the development of intra-abdominal hypertension during the first week in the ICU. CONCLUSIONS: In our mixed ICU patient cohort, intra-abdominal hypertension occurred in almost half of all subjects and was twice as prevalent in mechanically ventilated patients as in spontaneously breathing patients. Presence and severity of intra-abdominal hypertension during the observation period significantly and independently increased 28- and 90-day mortality. Five admission day variables were independently associated with the presence or development of intra-abdominal hypertension. Positive fluid balance was associated with the development of intra-abdominal hypertension after day 1.

Massive bleeding following severe blunt trauma: the first minutes that can change everything.

The first hour following a major trauma with massive bleeding is certainly the most decisive period in global trauma care. Most of it takes place during the prehospital care. Those prehospital minutes are thus determinant as they can be used to correctly identified patient's clinical condition, initiate organization of the in-hospital needed resources and initiate specific therapies in the very early phase after trauma. Significant recent advances in this aspect of care have been made and but evidence to support some of those strategies is still lacking.

Risk Factors for Empyema Following Penetrating Diaphragmatic Injuries.

Empyema resulting as a complication of penetrating diaphragmatic injuries is a subject that requires further investigation, and the aim of this study was to determine the risk factors associated with empyema in patients with penetrating trauma. Consecutive adult trauma patients from a level 1 trauma center were searched for penetrating diaphragm injuries. Data were collected on patient demographics, pre-existing conditions, injury type and severity, hospital interventions, in-hospital complications, and outcomes. Patients were stratified by empyema formation and univariant analyses were performed. 164 patients were identified, and 17 patients (10.4%) developed empyema. Empyema was associated with visible abdominal contamination (35.3% vs 15%, P = .04), thoracotomy (35.5% vs 13.6%, P = .03), pneumonia (41.2% vs 14.3%, P = .01), sepsis (35.3% vs 8.8%, P = .006), increased hospital length of stay (25.5 vs 10.1 days, p =<.001), increased intensive care unit length of stay (9.6 vs 4.3 days, P = .01), and decreased in-hospital mortality (0% vs 20.4%, P = .04).

Venovenous Extracorporeal Membrane Oxygenation Usage Following Bullet Embolism to the Pulmonary Artery.

Background: Pulmonary artery embolus is a rare complication following gunshot wounds that creates a unique and serious challenge for trauma surgeons. While the majority of bullets that embolize through the vascular system end in the peripheral circulation, approximately one-third enter the central venous circulation. Case Report: We present the case of a bullet embolus to the left pulmonary artery following gunshot wounds to the right chest and the abdomen, with the abdominal ballistic traversing the liver before entering the vena cava and embolizing. The patient's course was complicated by the development of severe acute respiratory distress syndrome that was successfully managed by venovenous extracorporeal membrane oxygenation. Conclusion: Venovenous extracorporeal membrane oxygenation support for severe acute respiratory distress syndrome after bullet embolization to the pulmonary tree and surgical embolectomy is a viable option in appropriately selected patients.

Prehospital Needle Decompression of Suspected Tension Pneumothorax: Outcomes and Consequences.

Tension pneumothorax (TPT) identified in the prehospital setting requires prehospital needle decompression (PHND). This study aimed to evaluate complications from PHND when it was performed without meeting clinical criteria. A retrospective review was performed of patients undergoing (PHND) from 2016 through 2022 at a level 1 trauma center. Patient data who received PHND were reviewed. Of 115 patients, 85 did not meet at least one clinical criterion for PHND. The majority of patients in this cohort 76 (89%) required a chest tube and 22 (25%) had an iatrogenic pneumothorax from PHND. 5 patients (6%) were admitted due to iatrogenic PHND. Two vascular injuries in this population were directly due to PHND and required emergency operative repair. This study shows the negative consequences of PHND when performed without clear indications. Several patients underwent unnecessary procedures with significant clinical consequences.

The Impact of Pre-Trauma Steroid Use on Wound Healing and Outcomes.

This study presents data on pre-trauma steroid use, a topic underrepresented in the trauma literature. Long-term steroid use has been linked to impaired wound healing, compromised immune responses, and hindrance of bone healing, alongside the potential for adrenal insufficiency during traumatic events. The aim of this study was to conduct a retrospective analysis of clinical outcomes for trauma patients with chronic steroid use. Examining adult trauma cases with pre-trauma steroid use at a level 1 trauma center (January 2016-September 2023), we identified 18 patients (58.6 ± 19.4 years, 55.6% males). All were on prednisone prior to trauma activation and 66.7% had autoimmune disease. Complications included orthopedic fractures (72.2%), ICU admissions (16.7%), and low mortality (5.6%). Future larger, multi-center studies are needed to determine the impact of immunosuppression and pre-trauma steroids on clinical outcomes.

Does the use of double hormone replacement therapy for trauma patient organ donors improve organ recovery for transplant.

BACKGROUND: With an ongoing demand for transplantable organs, optimization of donor management protocols, specifically in trauma populations, is important for obtaining a high yield of viable organs per patient. Endocrine management of brain-dead potential organ donors (BPODs) is controversial, leading to heterogeneous clinical management approaches. Previous studies have shown that when levothyroxine was combined with other treatments, including steroids, vasopressin, and insulin, BPODs had better organ recovery and survival outcomes were increased for transplant recipients. AIM: To determine if levothyroxine use in combination with steroids in BPODs increased the number of organs donated in trauma patients. METHODS: A retrospective review of adult BPODs from a single level 1 trauma center over ten years was performed. Exclusion criteria included patients who were not solid organ donors, patients who were not declared brain dead (donation after circulatory death), and patients who did not receive steroids in their hospital course. Levothyroxine and steroid administration, the number of organs donated, the types of organs donated, and demographic information were recorded. Univariate analyses were performed with P < 0.05 considered to be statistically significant. RESULTS: A total of 88 patients met inclusion criteria, 69 (78%) of whom received levothyroxine and steroids (ST/LT group) vs 19 (22%) receiving steroids without levothyroxine (ST group). No differences were observed between the groups for gender, race, pertinent injury factors, age, or other hormone therapies used (P > 0.05). In the ST/LT group, 68.1% (n = 47) donated a high yield (3-5) of organ types per donor compared to 42.1% (n = 8) in the ST group (P = 0.038). There was no difference in the total number of organ types donated between the groups (P = 0.068). CONCLUSION: This study suggests that combining levothyroxine and steroid administration increases high-yield organ donation per donor in BPODs in the trauma patient population. Limitations to this study include the retrospective design and the relatively small number of organ donors who met inclusion criteria. This study is unique in that it mitigates steroid administration as a confounding variable and focuses specifically on the adjunctive use of levothyroxine.

Traumatic Abdominal Wall Hernia: Management Using a Standardized Approach.

Traumatic abdominal wall hernias are a rare complication of high energy blunt trauma. There exist several studies evaluating and outlining potential management options but still no generalized consensus on management. This series was meant to evaluate the diagnosis and management of traumatic abdominal wall hernias. A prospectively maintained database was used to identify patients with TAWH from 2021 to 2022. The primary outcome was operative management. Secondary outcomes included: time to diagnosis and post-operative outcomes. Of the 19 patients in this case series, 100% (n = 19/19) were secondary to blunt trauma with a mean ISS of 21. Exploratory laparotomy was performed in 17 cases. 14 cases had concomitant traumatic injuries to visceral structures. Complications were found in nearly half of the patients with 3 experiencing wound dehiscence. Future studies should be aimed at standardizing management approach taking into account nature of the mechanism and concomitant injuries.

Discrepancies in Mass Shootings and Access to Trauma Care Across the United States, 2014-2018.

INTRODUCTION: The United States has one of the highest rates of gun violence and mass shootings. Timely medical attention in such events is critical. The objective of this study was to assess geographic disparities in mass shootings and access to trauma centers. METHODS: Data for all Level I and II trauma centers were extracted from the American College of Surgeons and the Trauma Center Association of America registries. Mass shooting event data (4+ individuals shot at a single event) were taken from the Gun Violence Archive between 2014 and 2018. RESULTS: A total of 564 trauma centers and 1672 mass shootings were included. Ratios of the number of mass shootings vs trauma centers per state ranged from 0 to 11.0 mass shootings per trauma center. States with the greatest disparity (highest ratio) included Louisiana and New Mexico. CONCLUSION: States in the southern regions of the US experience the greatest disparity due to a high burden of mass shootings with less access to trauma centers. Interventions are needed to increase access to trauma care and reduce mass shootings in these medically underserved areas.

Chest Tube Size Selection: Evaluating Provider Practices, Treatment Efficacy, and Complications in Management of Thoracic Trauma.

BACKGROUND: The standard for managing traumatic pneumothorax (PTX), hemothorax (HTX), and hemopneumothorax (HPTX) has historically been large-bore (LB) chest tubes (>20-Fr). Previous studies have shown equal efficacy of small-bore (SB) chest tubes (≤19-Fr) in draining PTX and HTX/HPTX. This study aimed to evaluate provider practice patterns, treatment efficacy, and complications related to the selection of chest tube sizes for patients with thoracic trauma. METHODS: A retrospective chart review was performed on adult patients who underwent tube thoracostomy for traumatic PTX, HTX, or HPTX at a Level 1 Trauma Center from January 2016 to December 2021. Comparison was made between SB and LB thoracostomy tubes. The primary outcome was indication for chest tube placement based on injury pattern. Secondary outcomes included retained hemothorax, insertion-related complications, and duration of chest tube placement. Univariate and multivariate analyses were performed. RESULTS: Three hundred and forty-one patients were included and 297 (87.1%) received LB tubes. No significant differences were found between the groups concerning tube failure and insertion-related complications. LB tubes were more frequently placed in patients with penetrating MOI, higher average ISS, and higher average thoracic AIS. Patients who received LB chest tubes experienced a higher incidence of retained HTX. DISCUSSION: In patients with thoracic trauma, both SB and LB chest tubes may be used for treatment. SB tubes are typically placed in nonemergent situations, and there is apparent provider bias for LB tubes. A future randomized clinical trial is needed to provide additional data on the usage of SB tubes in emergent situations.

Acute Kidney Injury in Hypotensive Trauma Patients Following Resuscitative Endovascular Balloon Occlusion of the Aorta Placement.

BACKGROUND: ER-Resuscitative Endovascular Balloon Occlusion of the Aorta (ER-REBOA) is an adjunct tool to achieve hemostasis in trauma patients with non-compressible torso hemorrhage. The development of the partial REBOA (pREBOA) allows for distal perfusion of organs while maintaining occlusion of the aorta. The primary aim of this study was to compare rates of acute kidney injury (AKI) in trauma patients who had placement of either a pREBOA or ER-REBOA. METHODS: A retrospective chart review of adult trauma patients who underwent REBOA placement between September 2017 and February 2022 was performed. Baseline demographics, information on REBOA placement, and post-procedure complications including AKI, amputations, and mortality were recorded. Chi-squared and T-test analyses were performed with P < .05 considered to be significant. RESULTS: A total of 68 patients met study inclusion criteria with 53 patients (77.9%) having an ER-REBOA. 6.7% of patients treated with pREBOA had a resulting AKI, while 40% of patients treated with ER-REBOA had a resulting AKI, and this difference was significant (P < .05). The rates of rhabdomyolysis, amputations, and mortality were not significantly different between the two groups. CONCLUSION: The results from this case series suggest that patients treated with pREBOA have a significantly lower incidence of developing an AKI compared to ER-REBOA. There were no significant differences in rates of mortality, and amputations. Future prospective studies are needed to further characterize the indications and optimal use for pREBOA.

Perioperative Fluid Management in Surgical Patients: A Review.

Intravenous (IV) fluids are one of the most widely prescribed medications. Despite their frequent usage, IV fluids are often not used appropriately. High-quality evidence to guide the surgeon in the perioperative period is sparse. A plethora of choices for IV fluids exists with limited evidence to help guide the surgeon in specific patient populations and situations. To address this, the authors have set out to provide a critical review of commonly used IV fluids to treat surgical patients. Gaps in the existing literature for the surgical population will also be discussed as potential target areas for future research.

Surgical stabilization of multiple rib fractures in an Asian population: a systematic review and meta-analysis.

Background: There is no consensus on the effectiveness of surgical stabilization in multiple rib fractures in Asia, especially among patients with a non-flail rib fracture pattern. We aim to synthesize the evidence on the effectiveness of surgical stabilization of rib fractures (SSRF) in an Asian population with multiple non-flail rib fractures. Methods: The MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Database of Systematic Reviews were searched in this systematic literature review and meta-analysis to identify studies conducted in Asia that included patients with multiple non-flail rib fractures in at least one of their treatment groups. The intervention of interest was SSRF, and the comparator was a nonoperative treatment. The duration of mechanical ventilation (DMV) was the primary outcome. Posttreatment pain score, pneumonia, atelectasis, intensive care unit length of stay (ICU LOS), hospital length of stay (HLOS), need for tracheostomy, respiratory function, functional outcomes, quality of life (QoL), and mortality were identified as the secondary outcomes. A random effects model (REM) was used to pool data for outcomes reported in two or more studies. Results: A total of 12 studies (n=2,440 patients) were included. There was a significantly shorter DMV {mean difference (MD): -5.23 [95% confidence interval (CI): -9.64 to -0.81], P=0.02}, lower 4-week post-treatment pain score [standard mean difference (SMD): -2.24 (95% CI: -3.18 to -1.31), P<0.00001], lower risk for pneumonia [risk ratio (RR): 0.46 (95% CI: 0.23 to 0.95), P=0.04], lower risk for atelectasis [RR: 0.44, (95% CI: 0.29 to 0.65), P<0.0001], shorter ICU LOS [MD: -4.00 (95% CI: -6.33 to -1.66), P=0.0008], and shorter HLOS [MD: -6.54 (95% CI: -9.28 to -3.79), P<0.00001] in favor of SSRF. Effect estimates for the need for tracheostomy [RR: 0.67 (95% CI: 0.42 to 1.08), P=0.10] and mortality [RR: 0.94 (95% CI: 0.37 to 2.41), P=0.90] were nonsignificant. Conclusions: In the Asian population with mainly non-flail rib fracture patterns, SSRF was associated with shorter DMV, ICU LOS, and HLOS as well as lower risks for atelectasis and pneumonia, and pain scores after 4 weeks. The risk of mortality was comparable between treatment groups.

Comparison of rampage and non-rampage mass shootings in the U.S.: A 5-year demographic analysis.

BACKGROUND: Rampage mass shootings (RMS) are a subset of mass shootings occurring in public involving random victims. Due to rarity, RMS are not well-characterized. We aimed to compare RMS and NRMS. We hypothesized that RMS and NRMS would be significantly different with respect to time/season, location, demographics, victim number/fatality rate, victims being law enforcement, and firearm characteristics. STUDY DESIGN: Mass shootings (4 or more victims shot at a single event) from 2014-2018 were identified in the Gun Violence Archive (GVA). Data were collected from the public domain (e.g. news). Crude comparisons between NRMS and RMS were performed using Chi-squared or Fisher's exact tests. Parametric models of victim and perpetrator characteristics were conducted at the event level using negative binomial regression and logistic regression. RESULTS: There were 46 RMS and 1626 NRMS. RMS occurred most in businesses (43.5%), whereas NRMS occurred most in streets (41.1%), homes (28.6%), and bars (17.9%). RMS were more likely to occur between 6AM-6PM (OR=9.0 (4.8-16.8)). RMS had more victims per incident (23.6 vs. 4.9, RR: 4.8 (4.3,5.4)). Casualties of RMS were more likely to die (29.7% vs. 19.9%, OR: 1.7 (1.5,2.0)). RMS were more likely to have at least one police casualty (30.4% versus 1.8%, OR: 24.1 (11.6,49.9)) or police death (10.9% versus 0.6%, OR: 19.7 (6.4,60.3)). RMS had significantly greater odds that casualties were adult (OR: 1.3 (1.0,1.6)) and female (OR: 1.7 (1.4,2.1)). Deaths in RMS were more likely to be female (OR: 2.0 (1.5,2.5)) and White (OR: 8.6 (6.2,12.0) and less likely to be children (OR: 0.4 (0.2,0.8)). Perpetrators of RMS were more likely to die by suicide (34.8%), be killed by police (28.3%), or be arrested at the scene (26.1%), while more than half of perpetrators from NRMS escaped without death or apprehension (55.8%). Parametric models of perpetrator demographics indicated significant increases in the odds that a RMS shooter was White (OR: 13.9 (7.3,26.6)) or Asian (OR: 16.9 (3.7,78.4)). There was no significant difference in weapon type used (p=0.35). CONCLUSION: The demographics, temporality, and location differ between RMS and NRMS, suggesting that they are dissimilar and require different preventive approaches.

The COVID-19 pandemic and its impacts on mass shootings in six major US cities.

BACKGROUND: The COVID-19 pandemic has significant impacts on the US socioeconomic structure. Gun violence is a major public health issue and the effects on this area have not been well-elucidated. The objective of this study was to determine the impacts of the pandemic on mass shootings in six major United States cities with historically high rates of gun violence. METHODS: Mass shooting data were extracted from an open-source database, Gun Violence Archive. Mass shooting was defined as four or more people shot at a single event. Data from six cities with the highest incidence of mass shootings were analyzed in 2019 versus 2020 (Baltimore, Chicago, Detroit, New Orleans, Philadelphia, and St. Louis). Geographic data were examined to assess changes in each city's mass shooting geographic distribution over time. Quantitative changes were assessed using the Area Deprivation Index (ADI), and qualitative data were assessed using ArcGIS. RESULTS: In 2020, the overall percentage of mass shootings increased by 46.7% though there was no change in the distribution of these events when assessed quantitatively (no change in average ADI) nor qualitatively (using ArcGIS). In the six cities analyzed, the total proportion of mass shooting events was unchanged during the pandemic (21.8% vs 20.6%, p = 0.64). Chicago, the US city with the highest incidence of mass shootings, did not experience a significant change in 2020 (n = 34/91, 37.3% vs. n = 53/126, 42.1%, p = 0.57). Baltimore had a significant decrease in mass shooting events (n = 18/91, 19.8% vs. 10/126, 7.9%, p = 0.01). The other four cities had no significant change in the number of mass shootings (p>0.05). CONCLUSION: This study is the first to use ArcGIS technology to describe the patterns of mass shooting in six major US cities during the COVID-19 pandemic. The number of mass shootings in six US cities remained largely unchanged which suggests that changes in mass shootings is likely occurring in smaller cities. Future studies should focus on the changing patterns of homicides in at-risk communities and other possible social influences.

Does Vehicle Intrusion Alone Still Predict Injury: A Retrospective Analysis of Mechanism as Trauma Activation Criteria.

Automobile collisions with driver side intrusion >12 inches or >18 elsewhere meet criteria for trauma activation. However, vehicle safety features have improved since this inception. We hypothesized vehicle intrusion (VI) alone as mechanism-of-injury (MOI) criteria inadequately predicts trauma center activation. A retrospective, single-center chart review of adult patients involved in motor vehicle collisions presenting to a level 1 trauma center from July 2016 to March 2022 was performed. Patients were divided by MOI criteria: VI vs. multiple MOI criteria. 2940 patients met inclusion criteria. The VI group reported lower injury severity scores (P = 0.004), higher incidence of ED discharge (P = 0.001), lower ICU admissions (P = 0.004), and fewer in-hospital procedures (P = 0.03). Vehicle intrusion was found to have a positive likelihood ratio of 0.889 for predicting trauma center need. According to current guidelines, these results suggest that VI criteria alone may not be an accurate predictor for trauma center transport and require further investigation.

Development and validation of a pulmonary complications prediction model based on the Yang's index.

Background: Blunt chest trauma patients with pulmonary contusion are susceptible to pulmonary complications, and severe cases may develop respiratory failure. Some studies have suggested the extent of pulmonary contusion to be the main predictor of pulmonary complications. However, no simple and effective method to assess the severity of pulmonary contusion has been available yet. A reliable prognostic prediction model would facilitate the identification of high-risk patients, so that early intervention can be given to reduce pulmonary complications; however, no suitable model based on such an assumption has been available yet. Methods: In this study, a new method for assessing lung contusion by the product of the three dimensions of the lung window on the computed tomography (CT) image was proposed. We conducted a retrospective study on patients with both thoracic trauma and pulmonary contusion admitted to 8 trauma centers in China from January 2014 to June 2020. Using patients from 2 centers with a large number of patients as the training set and patients from the other 6 centers as the validation set, a prediction model for pulmonary complications was established with Yang's index and rib fractures, etc., being the predictors. The pulmonary complications included pulmonary infection and respiratory failure. Results: This study included 515 patients, among whom 188 developed pulmonary complications, including 92 with respiratory failure. Risk factors contributing to pulmonary complications were identified, and a scoring system and prediction model were constructed. Using the training set, models for adverse outcomes and severe adverse outcomes were developed, and area under the curve (AUC) of 0.852 and 0.788 were achieved in the validation set. In the model performance for predicting pulmonary complications, the positive predictive value of the model is 0.938, the sensitivity of the model is 0.563 and the specificity of the model is 0.958. Conclusions: The generated indicator, called Yang's index, was proven to be an easy-to-use method for the evaluation of pulmonary contusion severity. The prediction model based on Yang's index could facilitate early identification of patients at risk of pulmonary complications, yet the effectiveness of the model remains to be validated and its performance remains to be improved in further studies with larger sample sizes.