Incidence and Outcomes of Pregnant Trauma Patients With Positive Urine Toxicology: A Southern California Multicenter Study.

Background: The use of illicit substances during pregnancy has increased 4-fold in the past two decades, negatively impacting both mother and fetus. The rate and clinical outcomes of substance use in pregnant trauma patients (PTPs) are not well studied. We sought to evaluate clinical outcomes of PTPs with positive urine toxicology, hypothesizing a higher rate of in-hospital maternal complications for PTPs with a positive urine toxicology ((+)Utox) compared to those testing negative ((-)Utox). Methods: PTPs (≥18 years old) were included in this multicenter retrospective study between 2016 and 2021. We included patients with known urine toxicology results and compared (+)Utox vs (-)Utox PTPs. Results: From 852 PTPs, 84 (9.8%) had a (+)Utox with the most common illicit substance being THC (57%) followed by methamphetamine (44%). (+)Utox PTPs had higher rates of blunt head injury (9.5% vs 4.2%, P = .028), extremity injury (14.3% vs 6.5%, P = .009), domestic violence (21.4% vs 5.9%, P < .001), suicide attempt (3.6% vs 0.3%, P < .001), and uterine contractions (46% vs 23.5%, P < .001). Abnormal fetal heart tracing, premature rupture of membranes and placental injury were similar between groups (all P > .05). The rate of maternal complications was similar in both groups (all P > .05). Conclusion: In this study, the rate of (+)Utox in PTPs was 9.8%. The (+)Utox group had similar rates of maternal complications but more commonly experienced uterine contractions which may be related to the physiology of drugs such as methamphetamines. PTPs with (+)Utox also more commonly were victims of domestic violence and suicide attempt, which merits further prevention research efforts.

Prehospital Intervention Among Black Patients With Traumatic Injury in Los Angeles County.

This cohort study examined the differences in prehospital treatment received by patients with traumatic injury belonging to different racial and ethnic groups between 2013 and 2020 in Los Angeles County.

Sex-based utilization and outcomes of cold-stored whole blood for trauma resuscitation: Analysis of a prospective multicenter study.

BACKGROUND: Resuscitation with cold-stored whole blood (WB) has outcome benefits, but benefits varied by patient sex is unknown. There are also concerns about alloimmunization risk for premenopausal females given WB, leading to some protocols excluding this cohort. We sought to analyze WB utilization, outcomes, and disparities by patient sex. METHODS: This is a secondary analysis of a prospective multicenter study of WB resuscitation. Patients were stratified by sex and compared by transfusion strategy of WB or component therapy (CT). Generalized estimated equation models using inverse probability of treatment weighting were utilized. RESULTS: There were 1,617 patients (83% male; 17% female) included. Females were less likely to receive WB versus males (55% vs. 76%; p < 0.001), with wide variability between individual centers (0%-33% female vs. 66%-100% male, p < 0.01). Male WB had more blunt trauma (45% vs. 31%) and higher shock index (1.0 vs. 0.8) compared with the male CT cohort (all p < 0.05) but similar Injury Severity Score. The female WB cohort was older (53 vs. 36) and primarily blunt trauma (77% vs. 62%) compared with the female CT cohort (all p < 0.05) but had similar shock index and Injury Severity Score. Male WB had lower early and overall mortality (27% vs. 42%), but a higher rate of acute kidney injury (16% vs. 6%) vs. the male CT cohort (all p < 0.01). Female cohorts had no difference in mortality, but the WB cohort had higher bleeding complications. Whole blood use was independently associated with decreased mortality (OR, 0.6; p < 0.01) for males but not for females (OR, 0.9; p = 0.78). CONCLUSION: Whole blood was independently associated with a decreased mortality for males with no difference identified for females. Whole blood was significantly less utilized in females and showed wide variability between centers. Further study of the impact of patient sex on outcomes with WB and WB utilization is needed. LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level IV.

Surgical trends and outcomes of open, laparoscopic, and robotic colostomy reversal for benign disease.

BACKGROUND: Despite the increasing use of minimally invasive surgeries, the outcome benefits of adopting minimally invasive surgery for colostomy reversal remain unclear. We aimed to analyze nationwide trends in the use of minimally invasive surgery for colostomy reversal and compare patient outcomes between different surgical approaches. METHODS: The National Inpatient Sample was queried for patients who underwent colostomy reversal for benign disease from 2015 to 2021. National trends in the use of minimally invasive surgery for colostomy reversal were analyzed by Cochran-Armitage tests. Multivariable linear and logistic regressions accounting for hospital sample weights were developed to examine the association between operative approach (open, laparoscopic, and robotic) and patient outcomes, including hospital complications, length of stay, and hospital charges. RESULTS: A total of 23,260 patients underwent colostomy reversal: 18,880 (81.2%) open, 3,245 (14.0%) laparoscopic, and 1,135 (4.9%) robotic surgery. From 2015 to 2021, the proportion of robotic approaches increased >5-fold (range 2.1-12.5%; Ptrend < .001), whereas the increase in laparoscopic approaches was not significant (range 11.5-16.2%; Ptrend = .34). Multivariable analysis showed that the laparoscopic approach was associated with a lower incidence of pulmonary complications (adjusted odds ratio, 0.49; 95% confidence interval, 0.28-0.87), surgical-site infection (odds ratio, 0.37; 95% CI, 0.19-0.72), peritonitis/abdominal abscess (odds ratio, 0.45; 95% confidence interval, 0.26-0.78), and paralytic ileus (odds ratio, 0.67; 95% confidence interval, 0.48-0.92). The robotic approach was associated with a lower incidence of paralytic ileus (odds ratio, 0.58; 95% confidence interval, 0.33-0.99). Laparoscopic and robotic approaches were associated with 22.9% and 29.9% shorter length of stay, respectively. The robotic approach was associated with 33.0% greater hospital charge. CONCLUSIONS: This study observed a significant trend toward the increased use of robotics in colostomy reversal and potential clinical benefits with minimally invasive surgery. Robotic colostomy reversal, along with laparoscopic approach, may provide better postoperative recovery compared with the open approach; however, the utility of robotic surgeries needs to be reevaluated in the future, given the limited clinical benefits despite greater hospital charges.

Outcomes Following Surgical and Nonsurgical Treatment for Uncomplicated Appendicitis in Older Adults.

Importance: The optimal treatment of acute uncomplicated appendicitis in older adults with frailty is not defined. Objective: To examine outcomes associated with treatment strategies for acute uncomplicated appendicitis in older adults with or without frailty. Design, Setting, and Participants: This retrospective cohort study used National Inpatient Sample data from adults 65 years or older with a diagnosis of uncomplicated appendicitis from January 1, 2016, to December 31, 2018. Data were analyzed from July to November 2023. The National Inpatient Sample database approximates a 20% stratified sample of all inpatient hospital discharges in the US. Exposures: Study patients were categorized into 3 groups: nonoperative management, immediate operation, and delayed operation. Main Outcomes and Measures: Clinical outcomes, including hospital complications and in-hospital mortality, were assessed among older adults with and without frailty, identified using an adapted claims-based frailty index. Results: A total of 24 320 patients were identified (median [IQR] age, 72 [68-79] years; 50.9% female). Of those, 7290 (30.0%) were categorized as having frailty. Overall, in-hospital mortality was 1.4%, and the incidence of complications was 37.3%. In patients with frailty, multivariable analysis showed both nonoperative management (odds ratio [OR], 2.89; 95% CI, 1.40-5.98; P < .001) and delayed appendectomy (OR, 3.80; 95% CI, 1.72-8.43; P < .001) were associated with increased in-hospital mortality compared with immediate appendectomy. In patients without frailty, immediate appendectomy was associated with increased hospital complications compared with nonoperative management (OR, 0.77; 95% CI, 0.64-0.94; P = .009) and lower hospital complications compared with delayed appendectomy (OR, 2.05; 95% CI, 1.41-3.00; P < .001). Conclusions and Relevance: In this cohort study of older adults with uncomplicated appendicitis, outcomes differed among management strategies based on frailty status. Routine frailty assessments incorporated in the care of older adult patients may help guide discussions for shared decision-making.

Unhoused and Injured: Injury Characteristics and Outcomes in Unhoused Trauma Patients.

INTRODUCTION: The unhoused population is known to be at high risk for traumatic injury. However, there are scarce data regarding injury patterns and outcomes for this patient group. This study aims to investigate any differences in injury characteristics and hospital outcomes between unhoused and housed patients presenting with traumatic injuries. METHODS: We conducted a 3-y retrospective cohort study at a level 1 trauma center in a metropolitan area with a large unhoused population. All adult trauma patients who were identified as unhoused or housed underinsured (HUI) were included in the study. Injury characteristics, comorbidities, and hospital outcomes were compared between the two groups. RESULTS: A total of 8450 patients were identified, of which 7.5% were unhoused. Compared to HUI patients, unhoused patients were more likely to sustain minor injuries (65.2% versus 59.1%, P = 0.003) and more likely to be injured by assault (17.9% versus 12.4%, P < 0.001), stab wound (17.7% versus 10.8%, P < 0.001), and automobile versus pedestrian or bike (21.0% versus 15.8% P < 0.001). We found that unhoused patients had higher odds of mortality (adjusted odds ratio [AOR]: 1.93, 95% confidence interval [CI]: 1.10-3.36, P = 0.021), brain death (AOR: 5.40, 95% CI: 2.11-13.83, P < 0.001), bacteremia/sepsis (AOR: 4.36, 95% CI: 1.20-15.81, P = 0.025), and increased hospital length of stay (regression coefficient: 0.08, 95% CI: 0.03-0.12, P = 0.003). CONCLUSIONS: This study observed significant disparities in injury characteristics and hospital outcomes between the unhoused and HUI groups. Our results suggest that these disparities are impacted by social determinants of health unique to the unhoused population.

Who needs a tourniquet? And who does not? Lessons learned from a review of tourniquet use in the Russo-Ukrainian war.

BACKGROUND: Extremity tourniquets have proven to be lifesaving in both civilian and military settings and should continue to be used by first responders for trauma patients with life-threatening extremity bleeding. This is especially true in combat scenarios in which both the casualty and the first responder may be confronted by the imminent threat of death from hostile fire as the extremity hemorrhage is being treated. Not every extremity wound, however, needs a tourniquet. One of the most important aspects of controlling life-threatening extremity bleeding with tourniquets is to recognize what magnitude of bleeding requires this intervention and what magnitude of bleeding does not. Multiple studies, both military and civilian, have shown that tourniquets are often applied when they are not medically indicated. Overuse of extremity tourniquets has not caused excess morbidity in either the recent conflicts in Iraq and Afghanistan or in the US urban civilian setting. In the presence of prolonged evacuation, however, applying a tourniquet when it is not medically indicated changes tourniquet application from being a lifesaving intervention to one that may cause an avoidable amputation and the development of an array of metabolic derangements and acute kidney injury collectively called prolonged tourniquet application syndrome. METHODS: The recent literature was reviewed for papers that documented the complications of tourniquet use resulting from the prolonged casualty evacuation times being seen in the current Russo-Ukrainian war. The literature was also reviewed for the incidence of tourniquet application that was found to not be medically indicated, in both the US civilian setting and from Ukraine. Finally, an in-person meeting of the US/Ukraine Tourniquet Working Group was held in Warsaw, Poland, in December of 2023. RESULTS: Unnecessary loss of extremities and life-threatening episodes of prolonged tourniquet application syndrome are currently occurring in Ukrainian combat forces because of nonindicated tourniquet use combined with the prolonged evacuation time seen in the Russo-Ukrainian war. Specific numbers of the complications experienced as a result of tourniquet use by Ukrainian forces in the current conflict are treated as classified information and are not available, but multiple sources from the Ukrainian military medical personnel and from the US advisors providing medical assistance to Ukraine have all agreed that the problem is substantial. CONCLUSION: Unnecessary tourniquet morbidity might also occur in US forces in a variety of potential future combat scenarios in which evacuation to surgical care is delayed. Prehospital trauma training programs, including but not limited to tactical combat casualty care, place insufficient emphasis on the need to avoid leaving tourniquets in place when they are not medically indicated. This aspect of training should receive emphasis in future Tactical Combat Casualty Care (TCCC) and civilian first responder curriculum development. An interim ad hoc training solution on this topic is available at the websites noted in this articles. Additional training modalities may follow in the near future. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

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.

Pediatric trauma patients with isolated grade III blunt splenic injuries may be safely managed without intensive care unit admission.

BACKGROUND: Non-operative management is the standard of care for pediatric blunt splenic injury. The American Pediatric Surgical Association recommends intensive care unit monitoring only for grade IV/V blunt splenic injury; however, variation remains regarding this practice. We hypothesized that pediatric trauma patients with near-isolated grade III blunt splenic injuries admitted to a non-intensive care unit setting would have similar outcomes to those admitted to the intensive care unit. METHODS: The 2017 to 2019 Trauma Quality Improvement Program database was queried for blunt pediatric trauma patients (≤16 years) with near-isolated grade III blunt splenic injuries. Patients with systolic blood pressure <90 mmHg or heart rate >90 were excluded. Pediatric trauma patients admitted to the intensive care unit were compared to non-intensive care unit admissions. The primary outcome was splenectomy. Bivariate analyses were performed. RESULTS: Of 461 pediatric trauma patients with near-isolated grade III blunt splenic injuries, 186 (40.3%) were admitted to the intensive care unit. Intensive care unit patients were older than their non-intensive care unit counterparts (15 vs 14 years, P = .03). Intensive care unit and non-intensive care unit patients had a similar rate of splenectomy (0.5% vs 0.7%, P = .80) and time to surgery (19.7 vs 19.8 hours, P = .98). Patients admitted to the intensive care unit had a longer length of stay (4 vs 3 days, P < .001). There were no significant complications or deaths in either group. CONCLUSION: This national analysis demonstrated that hemodynamically stable pediatric trauma patients with near-isolated grade III blunt splenic injuries admitted to the floor or intensive care unit had a similar rate of splenectomy without complications or deaths. This aligns with American Pediatric Surgical Association recommendations that pediatric trauma patients with grade III blunt splenic injuries be managed in non-intensive care unit settings. Widespread adoption is warranted and should lead to decreased healthcare expenditures.

Intra-abdominal infections survival guide: a position statement by the Global Alliance For Infections In Surgery.

Intra-abdominal infections (IAIs) are an important cause of morbidity and mortality in hospital settings worldwide. The cornerstones of IAI management include rapid, accurate diagnostics; timely, adequate source control; appropriate, short-duration antimicrobial therapy administered according to the principles of pharmacokinetics/pharmacodynamics and antimicrobial stewardship; and hemodynamic and organ functional support with intravenous fluid and adjunctive vasopressor agents for critical illness (sepsis/organ dysfunction or septic shock after correction of hypovolemia). In patients with IAIs, a personalized approach is crucial to optimize outcomes and should be based on multiple aspects that require careful clinical assessment. The anatomic extent of infection, the presumed pathogens involved and risk factors for antimicrobial resistance, the origin and extent of the infection, the patient's clinical condition, and the host's immune status should be assessed continuously to optimize the management of patients with complicated IAIs.

The Aging Surgeon: Considerations for Navigating a Successful and Satisfying Career.

Our careers as surgeons are some of the busiest and perhaps most sought after in existence. We have all put in countless years of tenacious effort, at times blood, frequent sweat, and occasional tears, to have the privilege to care for others and correct their ailments. Many of us are like freight trains rolling down the tracks indefinitely. But all too often we finish our training and head down those tracks without considering what stops we should make along the way, which forks in the tracks we should consider taking, and perhaps most often, we do not consider how we are going to eventually stop the train. Most of us have been witness to colleagues who keep working beyond their prime, be it for lack of alternative opportunities, lack of hobbies to retire to, or for lack of insight into their own decline. From these observations was born this presidential panel. As you can see, it is a collection of past presidents of So Cal ACS, with the exception for Dr Freischlag (who we all know would have served as president at some point had she never relocated away from Southern California). Each of these speakers has unique experience from their own careers that they will share with us so we can take pause and consider their insights and wisdom for how to navigate a successful and satisfying career.

Building Geriatric Trauma Programs in Resource-Constrained Environments: Trauma Quality Improvement Program Guideline Implementation at Two Safety Net Hospitals in Southern California.

Background: To improve care of geriatric trauma patients, the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) updated guidelines in 2021. Amid geriatrician shortages in Southern California, 2 Los Angeles County safety net hospitals were tasked with creating a strategy to meet geriatric trauma guidelines despite constrained resources. Methods: All trauma patients ≥ 60 years admitted to a safety net hospital in Southern California were enrolled without exclusions (August 2022-April 2023). Primary outcome was frailty screening with documentation to identify older trauma patients at a high risk for adverse outcomes. Results: Needs assessment discovered no standardized process to identify high-risk geriatric patients, no geriatric care guidelines, and no inpatient geriatric consultation service. An action plan composed of a resident-led frailty screen resulted in identification of high-risk patients. Overall, 217 patients met criteria. Ninety-six patients (44%) successfully underwent frailty screening. Frailty screening compliance increased over the study, beginning at 37% capture in the first month and increasing to 81% in the final study month. After achieving nearly uniform frailty screening, a form was developed for the EMR for ease of documentation, data capture/tracking, and compliance monitoring. Discussion: In this study, creativity, collaboration, and resourcefulness allowed TQIP guideline implementation at 2 county hospitals. A systematic process is now in place to identify and triage high-risk geriatric trauma patients based on frailty screen to receive inpatient medicine consultation for medical comorbidity optimization. Continued interdisciplinary and interfacility collaboration will be crucial for continued delivery of the optimal care to older injured patients.

Early Cold Stored Platelet Transfusion Following Severe Injury: A Randomized Clinical Trial.

OBJECTIVE: To determine the feasibility, efficacy, and safety of early cold stored platelet transfusion compared with standard care resuscitation in patients with hemorrhagic shock. BACKGROUND: Data demonstrating the safety and efficacy of early cold stored platelet transfusion are lacking following severe injury. METHODS: A phase 2, multicenter, randomized, open label, clinical trial was performed at 5 US trauma centers. Injured patients at risk of large volume blood transfusion and the need for hemorrhage control procedures were enrolled and randomized. The intervention was the early transfusion of a single apheresis cold stored platelet unit, stored for up to 14 days versus standard care resuscitation. The primary outcome was feasibility and the principal clinical outcome for efficacy and safety was 24-hour mortality. RESULTS: Mortality at 24 hours was 5.9% in patients who were randomized to early cold stored platelet transfusion compared with 10.2% in the standard care arm (difference, -4.3%; 95% CI, -12.8% to 3.5%; P =0.26). No significant differences were found for any of the prespecified ancillary outcomes. Rates of arterial and/or venous thromboembolism and adverse events did not differ across treatment groups. CONCLUSIONS AND RELEVANCE: In severely injured patients, early cold stored platelet transfusion is feasible, safe and did not result in a significant lower rate of 24-hour mortality. Early cold stored platelet transfusion did not result in a higher incidence of arterial and/or venous thrombotic complications or adverse events. The storage age of the cold stored platelet product was not associated with significant outcome differences. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04667468.

Mechanism Matters: Differential benefits of cold-stored whole blood for trauma resuscitation from a prospective multicenter study.

BACKGROUND: Resuscitation with cold-stored low-titre whole blood (LTOWB) has increased despite the paucity of robust civilian data. Most studies are in predominately blunt trauma and lack analysis of specific subgroups or mechanism of injury. We sought to compare outcomes between patients receiving LTOWB vs. balanced component therapy (BCT) after blunt (BL) and penetrating (PN) trauma. METHODS: Secondary analysis of a prospective multicenter study of patients receiving either LTWOB-containing or BCT resuscitation was performed. Patients were grouped by mechanism of injury (BL vs PN). A generalized estimated equations model using inverse probability of treatment weighting was employed. Primary outcome was mortality and secondary outcomes were acute kidney injury, venous thromboembolism, pulmonary complications, and bleeding complications. Additional analyses were performed on non-traumatic brain injury (TBI), severe torso injury, and LTOWB-only resuscitation patients. RESULTS: 1617 patients (BL 47% vs PN 54%) were identified; 1175 (73%) of which received LTOWB. PN trauma patients receiving LTOWB demonstrated improved survival compared to BCT (77% vs. 56%; p<0.01). Interval survival was higher at 6 hrs (95% vs. 88%), 12 hrs (93% vs. 80%) and 24 hrs (88% vs. 57%) (all p<0.05). The survival benefit following LTOWB was also seen across PN non-TBI (83% vs. 52%), and severe torso injuries (75% vs. 43%) (all p <0.05). After controlling for age, sex, injury severity, and trauma center, LTWOB was associated with decreased odds of death (OR .31, p<.05) in PN trauma. However, no difference in overall mortality was seen across the BL groups. Both PN and BL patients receiving LTOWB had more frequent AKI compared to BCT (19% vs. 7% and 12% vs 6%, respectively; p<0.05). CONCLUSIONS: LTOWB resuscitation was independently associated with decreased mortality following PN trauma, but not BL trauma. Further analysis in BL trauma is required to identify subgroups that may demonstrate survival benefit. LEVEL OF EVIDENCE: Therapeutic/Care Management, III.

Is barbed better? Evaluation of triclosan-coated barbed suture on wound complications following emergency laparotomy.

INTRODUCTION: Emergent laparotomy is associated with significant wound complications including surgical site infections (SSIs) and fascial dehiscence. Triclosan-coated barbed (TCB) suture for fascial closure has been shown to reduce local complications but primarily in elective settings. We sought to evaluate the effect of TCB emergency laparotomy fascial closure on major wound complications. METHODS: Adult patients undergoing emergency laparotomy were prospectively evaluated over 1 year. Patients were grouped into TCB versus polydioxanone (PDS) for fascial closure. Subanalysis was performed on patients undergoing single-stage laparotomy. Primary outcomes were SSI and fascial dehiscence. Multivariate analysis identified independent factors associated with SSI and fascial dehiscence. RESULTS: Of the 206 laparotomies, 73 (35%) were closed with TCB, and 133 (65%) were closed with PDS. Trauma was the reason for laparotomy in 73% of cases; damage-control laparotomy was performed in 27% of cases. The overall rate of SSI and fascial dehiscence was 18% and 10%, respectively. Operative strategy was similar between groups, including damage-control laparotomy, wound vac use, skin closure, and blood products. Surgical site infection events trended lower with TCB versus PDS closure (11% vs. 21%, p = 0.07), and fascial dehiscence was significantly lower with TCB versus PDS (4% vs. 14%, p < 0.05). Subanalysis of trauma and nontrauma cases showed no difference in SSI or fascial dehiscence. Multivariable analysis found that TCB decreased the likelihood of fascial dehiscence (odds ratio, 0.07; p < 0.05) following emergency laparotomy. Increased odds of fascial dehiscence were seen in damage-control laparotomy (odds ratio, 3.1; p < 0.05). CONCLUSION: Emergency laparotomy fascial closure with TCB showed significantly decreased rates of fascial dehiscence compared with closure with PDS and a strong trend toward lower SSI events. Triclosan-coated barbed suture was independently associated with decreased fascial dehiscence rates after emergency laparotomy. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Identifying Pregnant Patients With Suspected Intimate Partner Violence.

INTRODUCTION: Intimate partner violence (IPV) is the leading cause of death in pregnant women. Although it can be difficult to identify patients experiencing IPV, injuries to the head, neck, or face due to an assault are known to correlate with intentional injury. The objective of this study is to assess the contemporary burden of IPV in pregnancy and describe the patient characteristics. METHODS: The National Inpatient Sample was queried for all pregnant women between January 2016 and December 2019. Patients were divided into two groups: suspected IPV (SIPV) and no-SIPV groups. We defined SIPV as any pregnant patient with an identified head, neck, or face injuries categorized as intentional assault. Multivariable logistic regression analysis was performed to assess the association between SIPV and variables of interest. RESULTS: A total of 28,540 pregnant patients presented with traumatic injuries with 530 (.02%) identified as SIPV. Suspected IPV patients were younger (25 vs 27 years, P = .012), more likely to be of Black race (46% vs 28%, P = .002), more likely to be in the lowest income quartile (51% vs 38%, P = .031), less likely to have private insurance (12% vs 34%, P < .001), and have higher rates of substance use disorder (35% vs 18%, P < .001). Black race and history of substance use disorder were associated with increased odds of SIPV-related injuries (odds ratio [OR]: 2.01, interquartile range [IQR]: 1.27-3.16, P = .003 and OR: 2.30, IQR 1.54-3.43, P < .001, respectively). CONCLUSIONS: Our results suggest that there are significant racial and socioeconomic disparities in potential risk for IPV during pregnancy.

Immediate Operative Trauma Assessment Score: A Simple and Reliable Predictor of Mortality in Trauma Patients Undergoing Urgent/Emergent Surgery.

Objective: Many current trauma mortality prediction tools are either too intricate or rely on data not readily available during a trauma patient's initial evaluation. Moreover, none are tailored to those necessitating urgent or emergent surgery. Our objective was to design a practical, user-friendly scoring tool using immediately available variables, and then compare its efficacy to the widely-known Revised Trauma Score (RTS). Methods: The adult 2017-2021 Trauma Quality Improvement Program (TQIP) database was queried to identify patients ≥18 years old undergoing any urgent/emergent operation (direct from Emergency Department to operating room). Patients were divided into derivation and validation groups. A three-step methodology was used. First, multiple logistic regression models were created to determine risk of death using only variables available upon arrival. Second, the weighted average and relative impact of each independent predictor was used to derive an easily calculated Immediate Operative Trauma Assessment Score (IOTAS). We then validated IOTAS using AUROC and compared it to RTS. Results: From 249 208 patients in the derivation-set, 14 635 (5.9%) died. Age ≥65, Glasgow Coma Scale score <9, hypotension (SBP <90 mmHg), and tachycardia (>120/min) on arrival were identified as independent predictors for mortality. Using these, the IOTAS was structured, offering scores between 0-8. The AUROC for this was .88. A clear escalation in mortality was observed across scores: from 4.4% at score 1 to 60.5% at score 8. For the validation set (250 182 patients; mortality rate 5.8%), the AUROC remained consistent at .87, surpassing RTS's AUROC of .83. Conclusion: IOTAS is a novel, accurate, and now validated tool that is intuitive and efficient in predicting mortality for trauma patients requiring urgent or emergent surgeries. It outperforms RTS, and thereby may help guide clinicians when determining the best course of action in patient management as well as counseling patients and their families.

Non-Binary Trauma Patients: Delineating a Vulnerable, At-Risk Population.

INTRODUCTION: An increasing proportion of the population identifies as non-binary. This marginalized group may be at differential risk for trauma compared to those who identify as male or female, but physical trauma among non-binary patients has not yet been examined at a national level. METHODS: All patients aged ≥ 16 years in the National Trauma Data Bank were included (2021-2022). Demographics, injury characteristics, and outcomes after trauma among non-binary patients were compared to males and females. The goal was to delineate differences between groups to inform the care and future study of non-binary trauma patients. RESULTS: In total, 1,012,348 patients were included: 283 (<1%) non-binary, 610,904 (60%) male, and 403,161 (40%) female patients. Non-binary patients were younger than males or females (median age 44 vs 49 vs 67 years, P < .001) and less likely to be White race/ethnicity (58% vs 60% vs 74%, P < .001). Despite non-binary patients having a lower median Injury Severity Score (5 vs 9 vs 9, P < .001), mortality was highest among non-binary and male patients than females (5% vs 5% vs 3%, P < .001). DISCUSSION: In this study, non-binary trauma patients were younger and more likely minority races/ethnicities than males or females. Despite having a lower injury severity, non-binary patient mortality rates were comparable to those of males and greater than for females. These disparities identify non-binary trauma patients as doubly marginalized, by gender and race/ethnicity, who experience worse outcomes after trauma than expected based on injury severity. This vulnerable patient population deserves further study to identify areas for improved trauma delivery care.

Back on the Streets: Examining Emergency Department Return Rates for Unhoused Patients Discharged After Trauma.

BACKGROUND: The unhoused population is at high risk for traumatic injuries and faces unique challenges in accessing follow-up care. However, there is scarce data regarding differences in Emergency Department (ED) return rates and reasons for return between unhoused and housed patients. METHODS: We conducted a 3-year retrospective cohort study at a level-1 trauma center in a large metropolitan area. All patients who presented to the ED with traumatic injuries and were discharged without hospital admission were included in the study. The primary outcome was ED returns for trauma-related complications or new traumatic events <6 months after discharge. Patient characteristics and study outcomes were compared between housed and unhoused groups. RESULTS: A total of 4184 patients were identified, of which 20.3% were unhoused. Compared to housed, unhoused patients were more likely to return to the ED (18.8% vs 13.9%, P < .001), more likely to return for trauma-related complications (4.6% vs 3.1%, P = .045), more likely to return with new trauma (7.1% vs 2.8%, P < .001), and less likely to return for scheduled wound checks (2.5% vs 4.3%, P = .012). Of the patients who returned with trauma-related complications, unhoused patients had a higher proportion of wound infection (20.5% vs 5.7%, P = .008). In the regression analysis, unhoused status was associated with increased odds of ED return with new trauma and decreased odds of return for scheduled wound checks. CONCLUSIONS: This study observed significant disparities between unhoused and housed patients after trauma. Our results suggest that inadequate follow-up in unhoused patients may contribute to further ED return.