Incidence and characteristics of vascular trauma at a level 2 trauma center.

OBJECTIVE: Despite the significant number of trauma patients treated at level 2 trauma centers (L2TCs) in the United States, most of the literature describing vascular trauma is from level 1 trauma centers (L1TCs). Currently, trauma center designation criteria do not require vascular surgery as a necessary component service. METHODS: A retrospective chart review was performed for all trauma patients with a vascular surgery consultation seen at our L2TC between 2013 and 2018. Patient demographics, injury characteristics, and outcomes were collected and analyzed with descriptive statistics. RESULTS: Of the 3062 trauma patients evaluated at our L2TC, 110 (3.6%) had a vascular surgery consultation. Operative intervention was performed in 35.2% of consults, and 1.0% of all trauma patients had a vascular intervention. Average age was 57 years, and the majority were male (n = 75; 68.2%). Mean Injury Severity Score was 12.0 ± 9.6, and blunt injury (n = 77; 87.5%) was more common than penetrating (n = 11; 12.5%). The most common location of injury was the lower extremity (n = 23; 74.2%), followed by upper extremity (n = 3; 9.7%), chest (n = 2; 6.5%), neck (n = 2; 6.5%), and pelvis (n = 1; 3.2%). Endovascular interventions were performed by the vascular surgery service in 67.7% (n = 21) of all injuries. There was one amputation (3.2%) and one postoperative mortality (3.2%). CONCLUSIONS: At our L2TC, postoperative morbidity and mortality rates at 30 days were substantially lower compared with previously reported data. However, mean injury severity score and the incidence of penetrating and polytrauma were also lower at our institution. Most patients were managed nonoperatively, but when they did require an operation, endovascular therapies were more commonly implemented. Vascular surgery should be considered an integral service in trauma level designation, and there is a need for further investigation of these outcomes in L2TCs.

Risk factors for stroke in penetrating cerebrovascular injuries.

OBJECTIVE: Penetrating cerebrovascular injuries (PCVI) are associated with a high incidence of mortality and neurological events. The optimal treatment strategy of PCVI, especially when damage control measures are required, remains controversial. The aim of this study was to describe the management of PCVI and patient outcomes at a level 1 trauma center where vascular injuries are managed predominantly by trauma surgeons. METHODS: An institutional trauma registry was queried for patients with PCVI from 2011 to 2021. Patients with common carotid artery (CCA), internal carotid artery (ICA), or vertebral artery injuries were included for analysis. The primary outcome was in-hospital stroke. The secondary outcomes were in-hospital mortality and in-hospital stroke or death. A subgroup analysis was completed of arterial repair (primary repair or interposition graft) vs ligation or embolization vs temporary intravascular shunting at the index procedure. RESULTS: We analyzed 54 patients with PCVI. Overall, the in-hospital stroke rate was 17% and in-hospital mortality was 26%. Twenty-one patients (39%) underwent arterial interventions for PCVI. Ten patients underwent arterial repair, six patients underwent ligation or embolization, and five patients underwent intravascular shunting as a damage control strategy with a plan for delayed repair. The rate of in-hospital stroke was 30% after arterial repair, 0% after arterial ligation or embolization, and 80% after temporary intravascular shunting. There was a significant difference in the stroke rate between the three subgroups (P = .015). Of the 32 patients who did not have an intervention to the CCA, ICA, or vertebral artery, 1 patient with ICA occlusion and 1 patient with CCA intimal injury developed in-hospital stroke. The mortality rate was 0% after arterial repair, 50% after ligation or embolization, and 60% after intravascular shunting. The rate of stroke or death was 30% in the arterial repair group, 50% in the ligation or embolization group, and 100% in the temporary intravascular shunting group. CONCLUSIONS: High rates of stroke and mortality were seen in patients requiring damage control after PCVI. In particular, temporary intravascular shunting was associated with a high incidence of in-hospital stroke and a 100% rate of stroke or death. Further investigation is needed into the factors related to these finding and whether the use of temporary intravascular shunting in PCVI is an advisable strategy.

Screening for Intimate Partner Violence in Trauma: Results of a Quality Improvement Project.

INTRODUCTION: Intimate partner violence (IPV) is common, especially among patients presenting with traumatic injury. We implemented an IPV screening program for patients admitted after trauma. We sought to determine whether specific demographic or clinical characteristics were associated with being screened or not screened for IPV and with IPV screen results. METHODS: Retrospective cohort study evaluating all patients admitted after trauma from July 2020-July 2022 in an Adult Level 1 Trauma Center. RESULTS: There were 4147 admissions following traumatic injury, of which 70% were men and 30% were women. The cohort was 46% White, 20% Asian, 15% Black, and 17% other races. Twenty-three percent were Hispanic or Latino/a. Seventy-seven percent were admitted for blunt injuries and 16% for penetrating injuries. Thirteen percent (n = 559) of the cohort was successfully screened for IPV. Screening rates did not differ by gender, race, or ethnicity. After adjustment for demographic and clinical factors, patients admitted to the intensive care unit were significantly less likely to be screened. Of the screened patients, 30% (165) screened positive. These patients were more commonly Hispanic or Latino/a, insured by Medicaid and presented with a penetrating injury. There were no differences in injury severity in patients who screened positive versus those who screened negative. CONCLUSIONS: There are significant barriers to universal screening for IPV, including injury acuity, in patients admitted following trauma. However, the 30% rate of positive screens for IPV in patients admitted following trauma highlights the urgent need to understand and address barriers to screening in trauma settings to enable universal screening.

The Use of Parenteral Nutrition and Disparities in Its Allocation Following Traumatic Injury.

INTRODUCTION: Severe traumatic injury requires rapid and extensive deployment of resources to save the lives of the critically injured. The sequelae of traumatic injuries frequently require extensive intervention obligating patients to a complicated recovery process devoid of meaningful nutrition. In this setting, parenteral nutrition (PN) is key in enabling appropriate wound healing, recovery, and rehabilitation. We sought to examine the use of PN in adult trauma management and to highlight any disparities in the utilization of PN in adult trauma patients. METHODS: We queried the 2017-2019 Trauma Quality Improvement Program (TQIP) for adult patients (aged > 18 y) who sustained blunt or penetrating traumatic injuries and received PN as part of their hospitalization. We compared time to PN administration based on demographics. We then used a multivariable logistic regression model to identify factors associated with the use of PN. We hypothesized that PN would be less commonly employed in the uninsured and minority groups. RESULTS: We identified 2,449,498 patients with sufficient data for analysis. Of these, 1831 patients were treated with PN. On univariate analysis, PN patients were more commonly male (74.7% PN versus 60.2% non-PN; P < 0.001). PN use was more frequent in the Black population (24.3% PN versus 15.5% non-PN; P < 0.001) and less frequent in the White population (72.7% PN versus 81.2% non-PN; P < 0.001). PN use was also much more common among patients covered by Medicaid. Penetrating trauma was over twice as common among PN recipients relative to non-PN patients (% PN versus % non-PN). PN patients had higher injury severity scores (ISSs), more intensive care unit days, longer hospitalizations, and increased mortality compared to non-PN patients. PN patients were half as likely to discharge home and twice as likely to discharge to a long-term care facility. Multivariable analysis including age, race, trauma mechanism, primary payer, and ISS, demonstrated an association of PN use with increasing age (OR 1.01, P < 0.001), cases of penetrating trauma (odds ratio [OR], 2.47; P < 0.001), and patients with high ISS (OR, 0.1.06; P < 0.001). There was decreased use in Uninsured patient (OR, 0.54; P < 0.001). CONCLUSIONS: PN use following traumatic injury is rarely required. Patients treated with PN typically have a resource-intense hospital course. More severe injuries, penetrating trauma, and increased age are more likely to result in PN use. Variations in PN use are apparent based on insurance payer, further examination into allocation of hospital and intensive care resources, as it pertains to patient socioeconomic status, is warranted in light of these findings.

Nationwide Analysis of Firearm Injury Versus Other Penetrating Trauma: It's Not All the Same Caliber.

INTRODUCTION: Ballistic injuries cause both a temporary and permanent cavitation event, making them far more destructive and complex than other penetrating trauma. We hypothesized that global injury scoring and physiologic parameters would fail to capture the lethality of gunshot wounds (GSW) compared to other penetrating mechanisms. METHODS: The 2019 American College of Surgeons Trauma Quality Programs participant use file was queried for the mortality rate for GSW and other penetrating mechanisms. A binomial logistic regression model ascertained the effects of sex, age, hypotension, tachycardia, mechanism, Glasgow Coma Scale, ISS, and volume of blood transfusion on the likelihood of mortality. Subgroup analyses examined isolated injuries by body regions. RESULTS: Among 95,458 cases (82% male), GSW comprised 46.4% of penetrating traumas. GSW was associated with longer hospital length of stay (4 [2-9] versus 3 [2-5] days), longer intensive care unit length of stay (3 [2-6] versus 2 [2-4] days), and more ventilator days (2 [1-4] versus 2 [1-3]) compared to stab wounds, all P < 0.001. The model determined that GSW was linked to increased odds of mortality compared to stab wounds (odds ratio 4.19, 95% confidence interval 3.55-4.93). GSW was an independent risk factor for acute kidney injury, acute respiratory distress syndrome, venous thromboembolism, sepsis, and surgical site infection. CONCLUSIONS: Injury scoring systems based on anatomical or physiological derangements fail to capture the lethality of GSW compared to other mechanisms of penetrating injury. Adjustments in risk stratification and reporting are necessary to reflect the proportion of GSW seen at each trauma center. Improved classification may help providers develop quality processes of care. This information may also help shape public discourse on this highly lethal mechanism.

Early Abnormal Vital Signs Predict Poor Outcomes in Normotensive Patients Following Penetrating Trauma.

INTRODUCTION: Because trauma patients in class II shock (blood loss of 15%-30% of total blood volume) arrive normotensive, this makes the identification of shock and subsequent prognostication of outcomes challenging. Our aim was to identify early predictive factors associated with worse outcomes in normotensive patients following penetrating trauma. We hypothesize that abnormalities in initial vital signs portend worse outcomes in normotensive patients following penetrating trauma. METHODS: A retrospective review was performed from 2006 to 2021 using our trauma database and included trauma patients presenting with penetrating trauma with initial normotensive blood pressures (systolic blood pressure ≥90 mmHg). We compared those with a narrow pulse pressure (NPP ≤25% of systolic blood pressure), tachycardia (heart rate ≥100 beats per minute), and elevated shock index (SI ≥ 0.8) to those without. Outcomes included mortality, intensive care unit admission, and ventilator use. Chi-squared, Mann-Whitney tests, and regression analyses were performed as appropriate. RESULTS: We identified 7618 patients with penetrating injuries and normotension on initial trauma bay assessment. On univariate analysis, NPP, tachycardia, and elevated SI were associated with increases in mortality compared to those without. On multivariable logistic regression, only NPP and tachycardia were independently associated with mortality. Tachycardia and an elevated SI were both independently associated with intensive care unit admission. Only an elevated SI had an independent association with ventilator requirements, while an NPP and tachycardia did not. CONCLUSIONS: Immediate trauma bay NPP and tachycardia are independently associated with mortality and adverse outcomes and may provide an opportunity for improved prognostication in normotensive patients following penetrating trauma.

Patients Lost to Follow-up After Injury: Who are They and What are Their Long-Term Outcomes?

INTRODUCTION: Trauma patients are at high risk for loss to follow-up (LTFU) after hospital discharge. We sought to identify risk factors for LTFU and investigate associations between LTFU and long-term health outcomes in the trauma population. METHODS: Trauma patients with an Injury Severity Score ≥9 admitted to one of three Level-I trauma centers, 2015-2020, were surveyed via telephone 6 mo after injury. Univariate and multivariate analyses were performed to assess factors associated with LTFU and several long-term outcomes. RESULTS: Of 3609 patients analyzed, 808 (22.4%) were LTFU. Patients LTFU were more likely to be male (71% versus 61%, P = 0.001), Black (22% versus 14%, P = 0.003), have high school or lower education (50% versus 42%, P = 0.003), be publicly insured (23% versus 13%, P < 0.001), have a penetrating injury (13% versus 8%, P = 0.006), have a shorter length of stay (3.64 d ± 4.09 versus 5.06 ± 5.99, P < 0.001), and be discharged home without assistance (79% versus 50%, P < 0.001). In multivariate analyses, patients who followed up were more likely to require assistance at home (6% versus 11%; odds ratio [OR] 2.23, 1.26-3.92, P = 0.005), have new functional limitations (11% versus 26%; OR 2.91, 1.97-4.31, P = < 0.001), have daily pain (30% versus 48%; OR 2.11, 1.54-2.88, P = < 0.001), and have more injury-related emergency department visits (7% versus 10%; OR 1.93, 1.15-3.22, P = 0.012). CONCLUSIONS: Vulnerable populations are more likely to be LTFU after injury. Clinicians should be aware of potential racial and socioeconomic disparities in follow-up care after traumatic injury. Future studies investigating improvement strategies in follow-up care should be considered.

Trauma Laparotomy for the Cirrhotic Patient: An Outcome-Based Analysis.

INTRODUCTION: There is a lack of large-scale data on outcomes of cirrhotic patients undergoing trauma laparotomy. We aimed to compare outcomes of cirrhotic versus noncirrhotic trauma patients undergoing laparotomy. METHODS: We analyzed 2018 American College of Surgeons Trauma Quality Improvement Program. We included blunt trauma patients (≥18 y) who underwent a laparotomy. Patients who were transferred, dead on arrival, or had penetrating injuries were excluded. Patients were matched in a 1:2 ratio (cirrhotic and noncirrhotic). Outcomes included mortality, complications, failure to rescue, transfusion requirements, and hospital and intensive care unit (ICU) lengths of stay. Multivariable backward stepwise regression analysis was performed. RESULTS: Four hundred and seventy-one patients (cirrhotic, 157; noncirrhotic, 314) were matched. Mean age was 57 ± 15 y, 78% were male, and median injury severity score was 24. Cirrhotic patients had higher rates of mortality (60% versus 30%, P value <0.001), complications (49% versus 37%; P value = 0.01), failure to rescue (66% versus 36%, P value<0.001), and pRBC (units, median, 11 [7-18] versus 7 [4-11], P value <0.001) transfusion requirements. There were no significant differences in hospital and intensive care unit (ICU) lengths of stay (P value ≥0.05). On multivariate analysis, increasing age (adjusted odds ratio [aOR] 1.02, P value <0.001), Glasgow Coma Scale score ≤8 at presentation (aOR 3.3, P value <0.001), and total splenectomy (aOR 5.7, P value <0.001) were associated with higher odds of mortality. Platelet transfusion was associated with lower odds of mortality (aOR 0.84, P value = 0.044). CONCLUSIONS: On a national scale, mortality following trauma laparotomy is twice as high for cirrhotic patients compared to noncirrhotic patients with higher rates of major complications and failure to rescue. Our finding of a protective effect of platelet transfusion may be explained by the platelet dysfunction associated with cirrhosis. Liver cirrhosis among trauma patients warrants heightened surveillance.

Primary Repair Versus Resection for AAST Grade I and II Colon Injuries: Does the Type of Repair Matter?

INTRODUCTION: The management of traumatic colon injuries has evolved over the past two decades. Recent evidence suggests that primary repair or resection over colostomy may decrease morbidity and mortality. Data comparing patients undergoing primary repair versus resection are lacking. We sought to compare the outcomes of patients undergoing primary repair versus resection for low-grade colon injuries. METHODS: A retrospective review of all patients who presented with American Association for the Surgery of Trauma grade I and II traumatic colon injuries to our Level I trauma center between 2011 and 2021 was performed. Patients were further dichotomized based on whether they underwent primary repair or resection with anastomosis. Outcome measures included length of stay data, infectious complications, and mortality. RESULTS: A total of 120 patients met inclusion criteria. The majority of patients (76.7%) were male, and the average age was 35.6 ± 13.1 y. Most patients also underwent primary repair (80.8%). There were no statistically significant differences between the groups in arrival physiology or in injury severity score. Length of stay data including hospital length of stay, intensive care unit length of stay, and ventilator days were similar between groups. Postoperative complications including pneumonia, surgical site infections, fascial dehiscence, the development of enterocutaneous fistulas, and unplanned returns to the operating room were also all found to be similar between groups. The group who underwent resection with anastomosis did demonstrate a higher rate of intra-abdominal abscess development (3.1% versus 26.1%, P < 0001). Mortality between both groups was not found to be statistically significant (7.2% versus 4.3%, P = 0.4) CONCLUSIONS: For low-grade (American Association for the Surgery of Trauma I and II) traumatic colon injuries, patients undergoing primary repair demonstrated a decreased rate of intra-abdominal abscess development when compared to patients who underwent resection with anastomosis.

Trauma Laparoscopy: Time Efficient, Cost Effective, and Safe.

INTRODUCTION: Laparoscopy has demonstrated improved outcomes in abdominal surgery; however, its use in trauma has been less compelling. In this study, we hypothesize that laparoscopy may be observed to have lower costs and complications with similar operative times compared to open exploration in appropriately selected patients. METHODS: We retrospectively reviewed adult patients undergoing abdominal exploration after blunt and penetrating trauma at our level 1 center from 2008 to 2020. Data included mechanism, operative time, length of stay (LOS), hospital charges, and complications. Patients were grouped as follows: therapeutic and nontherapeutic diagnostic laparoscopy and celiotomy. Therapeutic procedures included suture repair of hollow viscus organs or diaphragm, evacuation of hematoma, and hemorrhage control of solid organ or mesenteric injury. Unstable patients, repair of major vascular injuries or resection of an organ or bowel were excluded. RESULTS: Two hundred ninety-six patients were included with comparable demographics. Diagnostic laparoscopy had shorter operative times, LOS, and lower hospital charges compared to diagnostic celiotomy controls. Similarly, therapeutic laparoscopy had shorter LOS and lower hospital costs compared to therapeutic celiotomy. The operative time was not statistically different in this comparison. Patients in the celiotomy groups had more postoperative complications. The differences in operative time, LOS and hospital charges were not statistically significant in the diagnostic laparoscopy compared to diagnostic laparoscopy converted to diagnostic celiotomy group, nor in the therapeutic laparoscopy compared to the diagnostic laparoscopy converted to therapeutic laparoscopy group. CONCLUSIONS: Laparoscopy can be used safely in penetrating and blunt abdominal trauma. In this cohort, laparoscopy was observed to have shorter operative times and LOS with lower hospital charges and fewer complications.

Endovascular Versus Open Repair in Adolescent Patients With Difficult-to-Access Vascular Injuries.

INTRODUCTION: Management of subclavian artery injuries (SAI) and iliac artery injuries (IAI) in adolescent trauma patients poses a considerable challenge due to their complex anatomical locations. The aim of our study was to determine the association between the injury mechanism and type of repair with the outcomes of patients with traumatic SAI and IAI. METHODS: In this retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database2017-2020, adolescent (<18 y) patients with SAI and IAI undergoing either endovascular or open repair were included. Patients were stratified by mechanism (blunt versus penetrating) and type of repair (endovascular [E] versus open [O]) and compared. Outcomes measured were mortality and major complications. Multivariable logistic regression analyses were performed. RESULTS: Over 4 y, 170 pediatric patients were identified, of which 73 (43%) sustained an SAI and 97 (57%) had IAI. The mean age was 15 and 79% were male. Overall, 39% were managed endovascularly. Both groups had comparable median injury severity score (E: 23 versus O: 25, P = 0.278). For patients with blunt injury (n = 60), the type of repair was neither associated with major complications (E: 39% versus O: 33%, P = 0.694) nor mortality (E: 2.6% versus O: 4.8%, P = 0.651). For patients with penetrating injuries (n = 110), the endovascular repair had significantly lower morbidity (19% versus 41%, P = 0.034) and mortality (3.7% versus 21%, P = 0.041). On multivariable logistic regression, endovascular repair was identified as the only modifiable risk factor associated with reduced mortality (adjusted odds ratio: 0.201, 95% confidence interval [0.14-0.76], P = 0.038). CONCLUSIONS: Difficult-to-access vascular injuries result in significant morbidity and mortality. Endovascular repair was found to be the only modifiable factor associated with decreased mortality of patients with penetrating injury, whereas the type of repair was not associated with mortality in those with blunt injury.

The Relationship Between the COVID-19 Pandemic and Pediatric Trauma.

INTRODUCTION: The COVID-19 pandemic created difficulties in access to care. There was also increased penetrating trauma in adults, which has been attributed to factors including increased firearm sales and social isolation. However, less is known about the relationship between the pandemic and pediatric trauma patients (PTPs). This study aimed to investigate the national incidence of penetrating trauma in PTPs, hypothesizing a higher rate with onset of the pandemic. We additionally hypothesized increased risk of complications and death in penetrating PTPs after the pandemic versus prepandemic. METHODS: We included all PTPs (aged ≤17-years-old) from the 2017-2020 Trauma Quality Improvement Program database, dividing the dataset into two eras: prepandemic (2017-2019) and pandemic (2020). We performed subset analyses of the pandemic and prepandemic penetrating PTPs. Bivariate analyses and a multivariable logistic regression analysis were performed. RESULTS: Of the 474,524 PTPs, 123,804 (26.1%) were from the pandemic year. The pandemic era had increased stab wounds (3.3% versus 2.8%, P > 0.001) and gunshot wounds (5.5% versus 4.0%, P < 0.001) compared to the prepandemic era. Among penetrating PTPs, the rates and associated risk of in-hospital complications (2.6% versus 2.8%, P = 0.23) (odds ratio 0.90, confidence interval 0.79-1.02, P = 0.11) and mortality (4.9% versus 5.0%, P = 0.58) (odds ratio 0.90, confidence interval 0.78-1.03, P = 0.12) were similar between time periods. CONCLUSIONS: This national analysis confirms increased penetrating trauma, particularly gunshot wounds in pediatric patients following onset of the COVID-19 pandemic. Despite this increase, there was no elevated risk of death or complications, suggesting that trauma systems adapted to the "dual pandemic" of COVID-19 and firearm violence in the pediatric population.

Blunt Adrenal Injury is Not Associated With Worse Outcomes in Adult Trauma Patients.

INTRODUCTION: Blunt adrenal injury is rare. Given production of hormones including catecholamines, adrenal injury may lead to worse outcomes. However, there is a paucity of literature on this topic. As such, we compared blunt trauma patients (BTPs) with and without adrenal injuries, hypothesizing similar mortality and complications between cohorts. METHODS: The 2017-2019 Trauma Quality Improvement Program database was queried for adult (≥18-year-old) BTPs. Patients with penetrating trauma, traumatic brain injury, severe thoracic injury, or who were transferred from another hospital were excluded. Patients with adrenal injury were compared to those without using a 1:2 propensity score model. Matched variables included patient age, comorbidities, vitals on admission and concomitant injuries (i.e., liver, spleen, kidney, pancreas, and hollow viscus). Univariable logistic regression was then performed for associated risk of mortality. RESULTS: 2287 (0.2%) BTPs had an adrenal injury, with 1470 patients with adrenal injury matched to 2940 without adrenal injury. The rate of all complications including sepsis (0.1% versus 0.0%) was similar between cohorts (all P > 0.05). Patients with adrenal injury had a lower rate of mortality (0.1% versus 0.6%, P = 0.035) but increased length of stay (4 [3-6] versus 3 [2-5] days, P = 0.002). However, there was no difference in associated risk of mortality for patients with and without adrenal injury (odds ratio = 0.234; confidence interval = 0.54-1.015; P = 0.052). CONCLUSIONS: Blunt adrenal injury occurred in <1% of patients. After propensity matching, there was a similar associated rate of complications but longer hospital length of stay for patients with adrenal injury. Adrenal injury was not associated with an increased risk of mortality.

Outcomes of penetrating carotid artery injuries: A South African multicentre study.

BACKGROUND: This multicenter study examines the contemporary management of penetrating carotid artery injury (PCAI) to identify trends in management, outcomes, and to determine prognostic factors for stroke and death. METHODS: Data from three large urban trauma centers in South Africa were retrospectively reviewed for patients who presented with PCAI from 2012 to 2020. RESULTS: Of 149 identified patients, 137 actively managed patients were included. Twenty-four patients (17.9%) presented in coma and 12 (9.0%) with localizing signs (LS). CT angiography was performed on admission for 120 (87.6%) patients. Thirty patients (21.9%) underwent nonoperative management, 87 (63.5%) open surgery, and 20 (14.6%) endovascular stenting. Eighteen patients (13.1%) died, and 15 (12.6%) surviving patients had strokes. Ligation was significantly related to death and reperfusion to survival. A mechanism of gunshot wound, occlusive injuries, a threatened airway, a systolic blood pressure <90 mmHg, hard signs of vascular injury, a low GCS, coma, a CT brain demonstrating infarct, a high injury severity score and shock index, a low pH or HCO3, and an elevated lactate were significant independent prognostic factors for death. Ligation was unsurvivable in all patients with severe neurological deficits, whereas reperfusion procedures resulted in survival in 63% (12/19) patients with coma and 78% (7/9) with LS although with high stroke rates (coma: 25.0%, LS: 85.7%). CONCLUSIONS: Outcomes in PCAI, including patients with severe neurological deficit and stroke, are better when reperfused. Reperfusion holds the best promise of survival and ligation should be reserved for technically inaccessible bleeding injuries.

Late video-assisted thoracoscopic surgery versus thoracostomy tube reinsertion for retained hemothorax after penetrating trauma, a prospective randomized control study.

BACKGROUND: Early video-assisted thoracoscopic surgery (VATS) is the recommended treatment of choice for retained hemothorax (RH). A prospective single-center randomized control study was conducted to compare outcomes between VATS and thoracostomy tube (TT) reinsertion for patients with RH after penetrating trauma in a resource constrained unit. Our hypothesis was that patients with a RH receiving VATS instead of TT reinsertion would have a shorter hospital stay and lesser complications. MATERIALS AND METHODS: From January 2014 to November 2019, stable patients with thoracic penetrating trauma complicated with retained hemothoraces were randomized to either VATS or TT reinsertion. The outcomes were length of hospital stay (LOS) and complications. RESULTS: Out of the 77 patients assessed for eligibility, 65 patients were randomized and 62 analyzed: 30 in the VATS arm and 32 in the TT reinsertion arm. Demographics and mechanisms of injury were comparable between the two arms. Length of hospital stay was: preprocedure: VATS 6.8 (+/-2.8) days and TT 6.6 (+/- 2.4) days (p = 0.932) and postprocedure: VATS 5.1 (+/-2.3) days, TT 7.1 (+/-6.3) days (p = 0.459), total LOS VATS 12 (+/- 3.9) days, and TT 14.4 (+/-7) days (p = 0.224). The TT arm had 15 complications compared to the VATS arm of four (p = 0.004). There were two additional procedures in the VATS arm and 10 in the TT arm (p = 0.014). CONCLUSION: VATS proved to be the better treatment modality for RH with fewer complications and less need of additional procedures, while the LOS between the two groups was not statistically different.

Increased Mortality in Patients Transferred to a Level 1 Trauma Center with Blunt and Penetrating Extremity Vascular Injuries.

BACKGROUND: Trauma care depends on a complex transfer system to ensure timely and adequate management at major trauma centers. Patient outcomes depend on the reliability of triage in local or community hospitals and access to tertiary or quaternary trauma institutions. Patients with polytrauma, extremity trauma, or vascular injuries require multidisciplinary management at trauma hospitals. Our study investigated outcomes in this population at a level one trauma center in San Bernardino County, the largest geographic county in the contiguous United States. METHODS: We conducted a retrospective review of all patients with extremity trauma who presented to a single level 1 trauma center over 10 years. The cohort was divided into following two groups: 1. transferred from another medical center for a higher level of care or 2. those who directly presented. Overall, 19,417 patients were identified, with 15,317 patients presenting directly and 3,830 patients transferred from an outside hospital. Extremity of vascular injuries was observed in 268 patients. Demographic data were ascertained, including the injury severity score, mechanism of injury, response level, arrival method, tertiary center emergency department disposition, and presence of vascular injury in the upper or lower extremities. Univariate and multivariate analyses were performed to assess patient mortality. RESULTS: A total of 268 patients with vascular injuries were analyzed, including 207 nontransferred and 61 transferred patients. In the univariate analysis, injury severity score means were compared at 11.4 in nontransferred patients versus 8.4 in transferred (P < 0.001), 50% of blunt injury in the nontransferred group, and 28% in the transferred group (P < 0.001); in-hospital mortality was 4% in nontransferred patients versus 28% in the transferred group (P < 0.001). Multivariate logistic regression demonstrated that mortality is 8 times more likely if a patient with vascular extremity injuries is transferred from an outside hospital. A 10% mortality rate was observed in patients without blood transfusion within 4 hr of arrival to the trauma center and 3% mortality in transferred patients transfused blood. CONCLUSIONS: Extremity trauma with vascular injury can be lethal if managed appropriately. Patients transferred to our level 1 trauma center had a substantial increase in mortality compared with nontransferred patients. Furthermore, the transfer distance was associated with increased mortality. Further research is required to address this vulnerable patient population.

Outcomes by time-to-OR for penetrating abdominal trauma patients.

INTRODUCTION: Time-To-OR is a critical process measure for trauma performance. However, this measure has not consistently demonstrated improvement in outcome. STUDY DESIGN: Using TQIP, we identified facilities by 75th percentile time-to-OR to categorize slow, average, and fast hospitals. Using a GEE model, we calculated odds of mortality for all penetrating abdominal trauma patients, firearm injuries only, and patients with major complication by facility speed. We additionally estimated odds of mortality at the patient level. RESULTS: Odds of mortality for patients at slow facilities was 1.095; 95% CI: 0.746, 1.608; p = 0.64 compared to average. Fast facility OR = 0.941; 95% CI: 0.780, 1.133; p = 0.52. At the patient-level each additional minute of time-to-OR was associated with 1.5% decreased odds of in-hospital mortality (OR 0.985; 95% CI:0.981, 0.989; p < 0.001). For firearm-only patients, facility speed was not associated with odds of in-hospital mortality (p-value = 0.61). Person-level time-to-OR was associated with 1.8% decreased odds of in-hospital mortality (OR 0.982; 95% CI: 0.977, 0.987; p < 0.001) with each additional minute of time-to-OR. Similarly, failure-to-rescue analysis showed no difference in in-hospital mortality at the patient level (p = 0.62) and 0.4% decreased odds of in-hospital mortality with each additional minute of time-to-OR at the patient level (OR 0.996; 95% CI: 0.993, 0.999; p = 0.004). CONCLUSION: Despite the use of time-to-OR as a metric of trauma performance, there is little evidence for improvement in mortality or complication rate with improved time-to-OR at the facility or patient level. Performance metrics for trauma should be developed that more appropriately approximate patient outcome.

National community disparities in prehospital penetrating trauma adjusted for income, 2020-2021.

INTRODUCTION: While Black individuals experienced disproportionately increased firearm violence and deaths during the COVID-19 pandemic, less is known about community level disparities. We sought to evaluate national community race and ethnicity differences in 2020 and 2021 rates of penetrating trauma. METHODS: We linked the 2018-2021 National Emergency Medical Services Information System databases to ZIP Code demographics. We stratified encounters into majority race/ethnicity communities (>50% White, Black, or Hispanic/Latino). We used logistic regression to compare penetrating trauma for each community in 2020 and 2021 to a combined 2018-2019 historical baseline. Majority Black and majority Hispanic/Latino communities were compared to majority White communities for each year. Analyses were adjusted for household income. RESULTS: We included 87,504,097 encounters (259,449 penetrating traumas). All communities had increased odds of trauma in 2020 when compared to 2018-2019, but this increase was largest for Black communities (aOR 1.4, [1.3-1.4]; White communities - aOR 1.2, [1.2-1.3]; Hispanic/Latino communities - aOR 1.1. [1.1-1.2]). There was a similar trend of increased penetrating trauma in 2021 for Black (aOR 1.2, [1.2-1.3]); White (aOR 1.2, [1.1-1.2]); Hispanic/Latino (aOR 1.1, [1.1-1.1]). Comparing penetrating trauma in each year to White communities, Black communities had higher odds of trauma in all years (2018/2019 - aOR 3.0, [3.0-3.1]; 2020 - aOR 3.3, [3.3-3.4]; 2021 - aOR 3.3, [3.2-3.2]). Hispanic/Latino also had more trauma each year but to a lesser degree (2018/2019 - aOR 2.0, [2.0-2.0]; 2020 - aOR 1.8, [1.8-1.9]; 2021 - aOR 1.9, [1.8-1.9]). CONCLUSION: Black communities were most impacted by increased penetrating trauma rates in 2020 and 2021 even after adjusting for income.

Cost-effectiveness analysis of routine computed tomography angiography (CTA) for lower extremity penetrating trauma.

BACKGROUND: Routine evaluation with CTA for patients with isolated lower extremity penetrating trauma and normal ankle-brachial-indices (ABI) remains controversial. While prior literature has found normal ABI's (≥0.9) and a normal clinical examination to be adequate for safe discharge, there remains concern for missed injuries which could lead to delayed surgical intervention and unnecessary morbidity. Our hypothesis was that routine CTA after isolated lower extremity penetrating trauma with normal ABIs and clinical examination is not cost-effective. METHODS: We performed a decision-analytic model to evaluate the cost-effectiveness of obtaining a CTA routinely compared to clinical observation and ABI evaluation in hemodynamically normal patients with isolated penetrating lower extremity trauma. Our base case was a patient that sustained penetrating lower extremity trauma with normal ABIs that received a CTA in the trauma bay. Costs, probability, and Quality-Adjusted Life Years (QALYs) were generated from published literature. RESULTS: Clinical evaluation only (no CTA) was cost-effective with a cost of $2056.13 and 0.98 QALYs gained compared to routine CTA which had increased costs of $7449.91 and lower QALYs 0.92. Using one-way sensitivity analysis, routine CTA does not become the cost-effective strategy until the cost of a missed injury reaches $210,075.83. CONCLUSIONS: Patients with isolated, penetrating lower extremity trauma with normal ABIs and clinical examination do not warrant routine CTA as there is no benefit with increased costs.

Characteristics of blunt and penetrating trauma among victims of physical violence: A retrospective study.

BACKGROUND: A significant number of referrals to the emergency departments is due to violence and conflict leading to serious injuries and death. The increasing number of such cases highlights the urgent need for investigating victimization of physical violence. AIM: The purpose of this study was to determine the frequency of demographic and clinical characteristics in victims of violence and classify them based on penetrating or blunt trauma. METHODS: The data of the patients who had been the victims of violence in 2020 were extracted from the Trauma Registry System(TRS) of the Guilan Road Trauma Research Center(GTRC). All analyses were performed using SPSS software version 24. The significance level was considered less than 0.05. RESULTS: There was a significant difference in the type of violence-related trauma in different age groups (P < 0.001), based on sex (P = 0.002), and marital status (P = 0.012). A significant difference also existed between the trauma type and clinical variables including smoking (P = 0.032), history of alcohol drinking (P = 0.005), and other substance use (P = 0.002), the anatomical location of injury (P < 0.001) and therapeutic interventions (p < 0.001(. CONCLUSION: Most of the clients of the violence suffered from blunt trauma, the severity of which was mild, and they were treated supportively without the need for surgery. Blunt trauma was seen more in women, divorcees, over 40 years and non-smokers. Penetrating trauma was observed more in lower limb injuries and alcohol and amphetamine users. Prevention programs and educational interventions should be programmed for the society long before men alcohol and amphetamine abusers reach their fourth decade of life. Accurately recording the type of physical violence, and the weapon used, and determining the injury severity score in TRS can lead to more reliable results in researching the field of violence issues.