Pain in Trauma Patients: Measurement and Predisposing Factors.

INTRODUCTION: Acute pain is common after injury. This study intended to evaluate the feasibility of quantifying pain experience over an entire admission using "area under the pain curve" and to identify factors associated with increased pain. METHODS: This retrospective single-center study included all trauma patients admitted from 2013 to 2020. Maximum pain scores were extracted for each day. Pain was defined as area under the curve (AUC) of maximum pain scores/day plotted against time. Injury patterns were analyzed by dichotomizing Abbreviated Injury Scale (AIS) scores (AIS < 3 versus AIS ≥ 3) for each body region. Urinary drug screen results were collected from admission data. A general linear model was used to determine which injury patterns, mechanisms, and age groups were predictive of increased AUC in all patients together and separate by operative and nonoperative groups. RESULTS: We identified 21,640 patients, of which 70% were male and 83% had suffered blunt injury. Overall injury severity was associated with increased pain experience. Serious head injury, younger age, and older age (compared to 45-49 y) were associated with decreased pain. Spinal injuries, thoraco-abdominal injuries, and combined thoracic and lower extremity injuries were predictive of increased pain. Compared to patients with no positive test for illicit substances or documentation of prehospital narcotic medications, the pain experience was greater for both, those who had been administered a narcotic in the prehospital setting and those who tested positive for illicit substances. CONCLUSIONS: This study extends the concept of total pain experience using AUC methodology. Our results demonstrate associations between increased pain and certain patterns of injury, ages, and presence of drugs on admission. Measuring total pain experience could assist in comparing pain-management strategies. Future research should focus on validating pain experience against quality-of-life measurements.

Over-transfusion with blood for suspected hemorrhagic shock is not associated with worse clinical outcomes.

BACKGROUND: We evaluated patient outcomes after early, small volume red blood cell (RBC) transfusion in the setting of presumed hemorrhagic shock. We hypothesized that transfusion with even small amounts of blood would be associated with more complications. STUDY DESIGN AND METHODS: Retrospective review of trauma patients admitted to a Level 1 trauma center between 2016-2021. Patients predicted to require massive transfusion who survived ≥72 h were categorized according to units of RBCs transfused in the first 24 h. A Cox regression model stratified by dichotomized ISS and adjusted for SBP <90 mm Hg and pulse >120 bpm on arrival was used to estimate hazard ratios (HRs) for outcomes of interest. RESULTS: A total of 3121 (24%) received RBC transfusion within the first 24 h. Massive transfusion protocol (MTP) was activated in 38% (1188/3121): 17% received no RBCs, 27.4% 1-3 units, 32.4% 4-9 units, and 22.7% ≥10 units. Mean ISS increased with each category of RBC transfusion. There was no difference in the risk of acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), infection, cardiac arrest, venous thromboembolism or stroke for patients receiving 1-3 units compared to the non-transfused group or 4-9 units group (p > 0.05). Compared to those receiving ≥10 units, the 1-3 units group had a significantly lower risk of AKI, ARDS, and cardiac arrest. DISCUSSION: Early empiric RBC transfusion for presumed hemorrhagic shock may subject patients to potential over-transfusion and end-organ damage. Among patients meeting clinical triggers for MTP, 1-3 units of allogeneic RBCs is not associated with worse outcomes.

Low albumin levels are independently associated with neonatal acute kidney injury: a report from AWAKEN Study Group.

BACKGROUND: Data from adult and pediatric literature have shown an association between albumin levels and AKI. Whether hypoalbuminemia and neonatal AKI are associated has not been studied. METHODS: We evaluated the association of albumin with early (during the first postnatal week) and late (after the first postnatal week) AKI for 531 neonates from the Assessment of Worldwide AKI Epidemiology in Neonates (AWAKEN) database and for 3 gestational age (GA) subgroups: < 29, 29 to < 36, and ≥ 36 weeks GA. RESULTS: Low albumin levels were associated with increased odds of neonatal AKI; for every 0.1 g/dL decrease in albumin, the odds of late AKI increased by 12% on continuous analysis. After adjustment for potential confounders, neonates with albumin values in the lowest quartiles (< 2.2 g/dL) had an increased odds of early [Adjusted Odd Ratio (AdjOR) 2.5, 95% CI = 1.1-5.3, p < 0.03] and late AKI [AdjOR 13.4, 95% CI = 3.6-49.9, p < 0.0001] compared to those with albumin in the highest quartile (> 3.1 g/dL). This held true for albumin levels 2.3 to 2.6 g/dL for early [AdjOR 2.5, 95% CI = 1.2-5.5, p < 0.02] and late AKI [AdjOR 6.4, 95% CI = 1.9-21.6, p < 0.01]. Albumin quartiles of (2.7 to 3.0 g/dL) were associated with increased odds of late AKI. Albumin levels of 2.6 g/dL and 2.4 g/dL best predicted early (AUC = 0.59) and late AKI (AUC = 0.64), respectively. Analysis of albumin association with AKI by GA is described. CONCLUSIONS: Low albumin levels are independently associated with early and late neonatal AKI. Albumin could be a potential modifiable risk factor for neonatal AKI.

An ecological study regarding the association between paraquat exposure and end stage renal disease.

BACKGROUND: Persons who experience paraquat poisoning rapidly develop damage to a variety of organ systems including acute kidney injury (AKI), the occurrence of which is associated with an increased risk of death. However, little is known about the effects of chronic paraquat exposure on renal function and the onset of chronic renal disease. The objective of the current study is to assess the association between paraquat exposure and the incidence of end stage renal disease (ESRD) in the United States. METHODS: Data on the incidence of ESRD for the period 2010 through 2017 and kilograms of paraquat use per square mile for each county in the conterminous United States was obtained from the United States Renal Data System (USRDS) and the National Water Quality Assessment (NAWQA) Program, respectively. Negative binomial regression was used to estimate rate ratios (RRs) and 95% confidence intervals (CIs) for the association between quartiles of paraquat exposure and the incidence of ESRD. RESULTS: The incidence of ESRD increased with increasing paraquat density. Based on a 20-year exposure lag, those in the highest paraquat density quartile had a 21% higher rate of ESRD compared to the lowest quartile whereas for a 15-year lag the increase was 26%. Adjusted associations were attenuated though still followed an increasing linear trend across quintiles. CONCLUSIONS: The results of this study are consistent with a large number of studies documenting a high incidence of AKI and a small number of studies chronic renal disease following acute and chronic paraquat exposure, respectively. While the pathophysiological mechanisms underlying kidney injury following paraquat poisoning are well understood, more research is necessary to understand the natural history of chronic kidney disease due to chronic paraquat exposure.

Institutional Adherence to Current Mohs Surgery Appropriate Use Criteria With Reasons for Nonadherence and Recommendations for Future Versions.

BACKGROUND: The appropriate use criteria (AUC) were established to optimize the use of Mohs micrographic surgery (MMS) and confer the highest possible clinical benefit to the patient. OBJECTIVE: We documented our adherence to AUC and review reasons for nonadherence regarding lesions classified as inappropriate, in the hopes of informing future versions of the AUC. MATERIALS AND METHODS: A retrospective review of 1,000 consecutive patients who underwent MMS at a single institution. A total of 1,318 biopsy-proven nonmelanoma skin cancers were treated with MMS, and each skin cancer that underwent MMS was classified as appropriate, uncertain, or inappropriate based on the AUC. RESULTS: Data were collected on 1,318 lesions with 1,237 (93.9%) categorized as appropriate, 59 (4.5%) uncertain, and 22 (1.7%) not appropriate. The primary variables that determined appropriateness were type of cancer (p = .001), size (p < .001), and area of body (p < .001). CONCLUSION: Institutional adherence to AUC was high, with 93.9% of treated tumors classified as appropriate, 4.5% as uncertain and 1.7% as inappropriate. By far the most commonly reported reason for performing MMS on an inappropriate lesion in our review was the treatment of adjacent lesions in 1 session.

Decreasing High-risk Exposures for Healthcare Workers Through Universal Masking and Universal Severe Acute Respiratory Syndrome Coronavirus 2 Testing on Entry to a Tertiary Care Facility.

We describe the impact of universal masking and universal testing at admission on high-risk exposures to severe acute respiratory syndrome coronavirus 2 for healthcare workers. Universal masking decreased the rate of high-risk exposures per patient-day by 68%, and universal testing further decreased those exposures by 77%.

Low hemoglobin levels are independently associated with neonatal acute kidney injury: a report from the AWAKEN Study Group.

BACKGROUND: Studies in adults showed a relationship between low hemoglobin (Hb) and acute kidney injury (AKI). We performed this study to evaluate this association in newborns. METHODS: We evaluated 1891 newborns from the Assessment of Worldwide AKI Epidemiology in Neonates (AWAKEN) database. We evaluated the associations for the entire cohort and 3 gestational age (GA) groups: <29, 29-<36, and ≥36 weeks' GA. RESULTS: Minimum Hb in the first postnatal week was significantly lower in neonates with AKI after the first postnatal week (late AKI). After controlling for multiple potential confounders, compared to neonates with a minimum Hb ≥17.0 g/dL, both those with minimum Hb ≤12.6 and 12.7-14.8 g/dL had an adjusted increased odds of late AKI (aOR 3.16, 95% CI 1.44-6.96, p = 0.04) and (aOR 2.03, 95% CI 1.05-3.93; p = 0.04), respectively. This association was no longer evident after controlling for fluid balance. The ability of minimum Hb to predict late AKI was moderate (c-statistic 0.68, 95% CI 0.64-0.72) with a sensitivity of 65.9%, a specificity of 69.7%, and a PPV of 20.8%. CONCLUSIONS: Lower Hb in the first postnatal week was associated with late AKI, though the association no longer remained after fluid balance was included. IMPACT: The current study suggests a possible novel association between low serum hemoglobin (Hb) and neonatal acute kidney injury (AKI). The study shows that low serum Hb levels in the first postnatal week are associated with increased risk of AKI after the first postnatal week. This study is the first to show this relationship in neonates. Because this study is retrospective, our observations cannot be considered proof of a causative role but do raise important questions and deserve further investigation. Whether the correction of low Hb levels might confer short- and/or long-term renal benefits in neonates was beyond the scope of this study.

Evaluation of Injury Recidivism Using the Electronic Medical Record.

BACKGROUND: Traumatic injuries remain one of the leading causes of death in the United States. Patients who survive traumatic injuries but return to the emergency department with repeat injuries are said to suffer from injury recidivism. Numerous studies have described trends in injury recidivism using trauma registry and survey data. To our knowledge, no prior study has leveraged electronic medical record (EMR) data to characterize injury recidivism. The EMR is potentially more comprehensive as it contains details of patients who visited the emergency department after injury but did not meet the criteria for inclusion in the trauma registry. Such injuries could be predictive of future recidivism. We therefore aimed to describe patterns of injury recidivism seen at a Level 1 trauma center using the EMR. METHODS: A retrospective review was conducted of all injury-related encounters between January 2016 and December 2019. Manual review was conducted of all recidivistic encounters with < 11 months between encounters to ensure the recidivistic encounter was not a sequela of the index visit. A general estimating equation logistic regression adjusted for age, race, sex, and insurance payor, estimated odds ratios (ORs) and 95% confidence intervals (CIs) for the association between injury mechanism and odds of recidivistic encounter. RESULTS: A total of 20,566 index encounters was included during the study period. Of the 20,566 encounters, 7.6% (n = 1570) had a recidivistic encounter during the study period, half of which (n = 781) occurred within the first year of the index encounter. An over two-fold increased odds of recidivism was observed for blunt assault encounters (OR 2.53, 95% CI 2.03-3.15) and unintentional falls (OR 2.10, 95% CI 1.76-2.52). For both mechanisms, this increase was observed across the three years following the index encounter. CONCLUSIONS: Our study found that patients with assault injuries have the highest odds of injury recidivism and assault-related recidivistic encounters. These results demonstrate the feasibility and utility of incorporating EMR data, and suggest that the development of targeted interventions focused on mitigating assault injuries, such as hospital-based violence intervention programs, should be considered in our region.

Impact of Rural Hospital Closures on Health-Care Access.

BACKGROUND: Access to health care is an important issue, particularly in remote areas. Since 2010, 106 rural hospital have closed in the United States, potentially limiting geographic access to health care. The aim of this study was to evaluate the impact of these hospital closures on the proportion of the population who can reach a secondary care facility, by road, within 15, 30, 45, or 60 min. METHODS: Geographical information system analysis, using population data obtained from the 2010 U.S. Census Bureau and hospital data between 2010 and 2019 from the Center for Medicare and Medicaid Services, created 15-, 30-, 45-, and 60-min drive time isochrones (areas from which a central location can be reached within a set time). RESULTS: Rural hospital closures resulted in 0%-0.97% of the population no longer being able to access a hospital within 15 min. The most marked changes were in the East South Central (0.97%, 178,478 residents) and West South Central (0.54%, 197,660 residents) divisions. Lesser degrees of change were noted for longer drive times. The changes were more marked when the rural population was analyzed exclusively. CONCLUSIONS: Recent closures of rural hospitals in the United States have impacted population access to hospital care, although the extent varies. There are regions, such as the Southern and Southeastern United States, which demonstrate greater and potentially more concerning losses in population coverage, probably because of the greater number of closures. Future work should evaluate clinical implications of hospital closures and loss of population coverage.

How Does Mission Ground Time Impact on Population Coverage of Aeromedical Retrieval Systems?

BACKGROUND: Aeromedical retrieval is an essential component of contemporary emergency care systems. However, in many locations, ground emergency medical services are dispatched to the scene of an incident first to assess the patient and then call for a helicopter if needed. The time to definitive care therefore includes the helicopter's flight to the scene, flight to the trauma center, and nonflying time. Mission ground time (MGT) includes the time required to get the helicopter airborne, as well as time spent at the scene, packaging and loading the casualty into the aircraft. Estimates of MGT typically vary from 10 to 30 min. The impact of MGT duration on population coverage-the number of residents that could be taken to a trauma center within a set time-is not known. The aim of this study was to compare population coverage for different durations of MGT in a single state. METHODS: Coverage was calculated using elliptical coverage areas ("isochrones") based on the location of helicopter bases and Level I and Level II trauma centers. The calculations were performed using Microsoft Excel, assuming a cruising speed of 133 knots (246 km/h), and mapped using arcGIS. The access time threshold was set at 60 min, and we evaluated MGTs of 10, 15, 20, 25, and 30 min. RESULTS: MGT has a marked impact on population coverage. The effect is, furthermore, not linear. When considering the state's three Level I trauma centers, decreasing MGT from 30 to 10 min increased population coverage from 61.2% to 84.2%. When also considering Level II centers, decreasing MGT from 30 min to 10 min increased coverage by 20%. CONCLUSIONS: Elliptical isochrones, with allowance for MGT, provide realistic estimates of population coverage. MGT significantly impacts the proportion of the population that can be taken to a Level I and/or Level II Trauma Center within a set time. The impact is not linear, reflecting the uneven distribution of the population. Consideration should be given to minimizing MGT to preserve the benefits of aeromedical retrieval.

Quantifying Pain Associated With Rib Fractures.

INTRODUCTION: Rib fractures are a major problem in trauma patients, and the associated pain is not well understood. Measuring total pain experience, duration, and intensity could facilitate comparisons of treatments. This study was intended to evaluate the feasibility of quantifying pain over the course of an admission and identify factors associated with increased pain experience in adults with rib fractures. METHODS: Patients admitted to a level I trauma center with rib fractures between 2015 and 2017 were included. Maximum pain score (verbal or nonverbal) was captured for each hospital day. Total pain was defined as the sum of the area under the curve (AUC) of the max pain scores plotted against time. A general linear model was used to determine demographic, injury, and clinical predictors of the pain AUC. RESULTS: We identified 3713 patients. Increased pain experienced (greater AUC) was associated with age group 40-59 y compared with 18-39 y (B = 6.1, P = 0.002); Injury Severity Score 9-14 (B = 11.5, P < 0.001) and ≥16 (B = 36.9, P < 0.0001); patients with flail chest versus multiple rib fractures (B = 17.1, P < 0.001); and patients who underwent rib fixation (B = 20.7, P = 0.004). Decreased pain experience was observed for male gender (B = -3.7, P = 0.032) and blunt mechanism of injury (B = -13.7, P < 0.0001). CONCLUSIONS: This study demonstrates the feasibility of measuring patients' total pain experience over the duration of their admission. Pain is a subjective but relevant measure of patients' experience. Our study identifies a number of predictive factors, some expected and some unexpected. Increased overall experience pain following fixation may be the result of severe pain before intervention.

Secondary Overtriage of Trauma Patients: Analysis of Clinical and Geographic Patterns.

BACKGROUND: The purpose of a trauma system is to match patients' needs with hospitals' ability to care for them, recognizing that the highest levels of care cannot be provided in all locations. This means that some patients will need to be transferred from a local facility to a higher level of care. Unnecessary transfers are expensive and inconvenient to patients and families. The aim of this study is to analyze the pattern of secondary transfers in a regional trauma system. METHODS: This is a retrospective analysis. We included patients aged 16 y and older who were transferred to University of Alabama at Birmingham Hospital between 2014 and 2018. We conducted bivariate and multivariate logistic regression analysis to identify clinical and organizational predictors of requiring a critical intervention, early discharge, intensive care unit admission, and mortality. Rather than treating each injury as isolated, we analyzed injury patterns. RESULTS: A total of3824 patients met the inclusion criteria. Of them, 664 patients (17.4%) required a critical intervention, 635 (16.6%) were discharged within 24 h, 1356 (35.5%) were admitted to the intensive care unit, and 172 (4.0%) patients died. Univariate and multivariate analyses revealed many positive associations, with regard to injury pattern, originating center, and insurance status. CONCLUSIONS: There are patterns in the data, and further study is required to understand drivers of secondary overtriage, and how we might be able to address this problem. Reducing the number of unnecessary transfers is a difficult task, which will require engagement at all levels of the trauma system.

Impact of Infectious Disease Consultation on Clinical Management and Mortality in Patients With Candidemia.

Candidemia has a high attributable mortality. The objective of this study was to determine the impact of infectious disease consultation on mortality and clinical outcomes in candidemia. Infectious disease consultation was associated with better adherence to guidelines and improved survival, even in patients with high Acute Physiology and Chronic Health Evaluation II scores.

Complications Associated With Placement of Chest Tubes: A Trauma System Perspective.

BACKGROUND: The insertion of a chest tube is a common procedure in trauma care, and the Advanced Trauma Life Support program teaches the insertion of chest tubes as an essential and life-saving skill. It is also recognized that the insertion of chest tubes is not without risks or complications. The purpose of this study was to evaluate complications of chest tube placement in a level 1 trauma center compared with those placed in surrounding referral hospitals. METHODS: A retrospective matched cohort study of trauma patients was performed between those who underwent chest tube placement at the level 1 trauma center and those with a chest tube placed before transfer to the level 1 center between 2004 and 2013. Conditional logistic regression was used to compare the likelihood of complications and death between chest tube placement groups. RESULTS: Four thousand two hundred and sixteen trauma patients had a chest tube placed at the level 1 center, and 364 patients had a chest tube placed at an outside hospital before transfer. Two hundred and eighty-one patients were matched. Patients with a chest tube placed outside the trauma center had an increased likelihood of malposition (OR 7.2, 95% CI 3.6-14.6), residual hemothorax (OR 6.3, 95% CI 3.4-11.6), residual pneumothorax (OR 6.7, 95% CI 3.9-11.4), and having a second chest tube placed (OR 3.77, 95% CI 2.37-6.01). However, the patients with a chest tube placed outside of the trauma center were also less likely to develop pneumonia (OR 0.32, 95% CI 0.14-0.73). There were no differences in the odds of developing an empyema, the need for video-assisted thoracoscopic surgery, thoracotomy, or death. CONCLUSIONS: There are opportunities for improving the care of patients who require chest tubes at both referring hospitals and the receiving trauma center. Improving the care of patients who require intercostal drainage requires a systems-based approach, focusing on training and quality improvement.

Older Blood Is Associated With Increased Mortality and Adverse Events in Massively Transfused Trauma Patients: Secondary Analysis of the PROPPR Trial.

STUDY OBJECTIVE: The transfusion of older packed RBCs may be harmful in critically ill patients. We seek to determine the association between packed RBC age and mortality among trauma patients requiring massive packed RBC transfusion. METHODS: We analyzed data from the Pragmatic, Randomized Optimal Platelet and Plasma Ratios trial. Subjects in the parent trial included critically injured adult patients admitted to 1 of 12 North American Level I trauma centers who received at least 1 unit of packed RBCs and were predicted to require massive blood transfusion. The primary exposure was volume of packed RBC units transfused during the first 24 hours of hospitalization, stratified by packed RBC age category: 0 to 7 days, 8 to 14 days, 15 to 21 days, and greater than or equal to 22 days. The primary outcome was 24-hour mortality. We evaluated the association between transfused volume of each packed RBC age category and 24-hour survival, using random-effects logistic regression, adjusting for total packed RBC volume, patient age, sex, race, mechanism of injury, Injury Severity Score, Revised Trauma Score, clinical site, and trial treatment group. RESULTS: The 678 patients included in the analysis received a total of 8,830 packed RBC units. One hundred patients (14.8%) died within the first 24 hours. On multivariable analysis, the number of packed RBCs greater than or equal to 22 days old was independently associated with increased 24-hour mortality (adjusted odds ratio [OR] 1.05 per packed RBC unit; 95% confidence interval [CI] 1.01 to 1.08): OR 0.97 for 0 to 7 days old (95% CI 0.88 to 1.08), OR 1.04 for 8 to 14 days old (95% CI 0.99 to 1.09), and OR 1.02 for 15 to 21 days old (95% CI 0.98 to 1.06). Results of sensitivity analyses were similar only among patients who received greater than or equal to 10 packed RBC units. CONCLUSION: Increasing quantities of older packed RBCs are associated with increased likelihood of 24-hour mortality in trauma patients receiving massive packed RBC transfusion (≥10 units), but not in those who receive fewer than 10 units.

Biomarkers associated with bronchopulmonary dysplasia/mortality in premature infants.

BACKGROUND: Bronchopulmonary dysplasia (BPD) portends lifelong organ impairment and death. Our ability to predict BPD in first days of life is limited, but could be enhanced using novel biomarkers. METHODS: Using an available clinical and urine biomarker database obtained from a prospective 113 infant cohort (birth weight ≤1,200 g and/or gestational age ≤31 wk), we evaluated the independent association of 14 urine biomarkers with BPD/mortality. RESULTS: Two of the 14 urine biomarkers were independently associated with BPD/mortality after controlling for gestational age (GA), small for gestational age (SGA), and intubation status. The best performing protein was clusterin, a ubiquitously expressed protein and potential sensor of oxidative stress associated with lung function in asthma patients. When modeling for BPD/mortality, the independent odds ratio for maximum adjusted urine clusterin was 9.2 (95% CI: 3.3-32.8, P < 0.0001). In this model, clinical variables (GA, intubation status, and SGA) explained 38.3% of variance; clusterin explained an additional 9.2%, while albumin explained an additional 3.4%. The area under the curve incorporating clinical factors and biomarkers was 0.941. CONCLUSION: Urine clusterin and albumin may improve our ability to predict BPD/mortality. Future studies are needed to validate these findings and determine their clinical usefulness.

Validity of the Braden Scale in grading pressure ulcers in trauma and burn patients.

BACKGROUND: Pressure ulcers are a costly hospital-acquired condition in terms of clinical outcome and expense. The Braden Scale was developed in 1987 as a risk scoring method for pressure ulcers and uses six different risk factors: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. A score of ≤18 is considered high risk. To date, research on the utility of the Braden Scale has focused on general medicine and nontrauma/burn surgery patients. We hypothesize that the Braden Scale does not accurately discriminate who will get a pressure ulcer among trauma and burn patients. METHODS: We collected data from medical records regarding documented Braden scores and presence of pressure ulcers regardless of staging. Patients with ulcers present on admission were excluded from analysis. For each patient, the lowest Braden score documented before the occurrence of the pressure ulcer was determined. A logistic regression was used to estimate odds ratios and associated 95% confidence intervals for the association between pressure ulcer likelihood and lowest Braden Scale measurement. To determine the discriminatory ability of the Braden Scale on pressure ulcer risk, four measures of performance (i.e., sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio) were calculated for four nonmutually exclusive groups: a Braden Scale measurement ≤18, ≤14, ≤12, and ≤9. RESULTS: From 2011 through 2014, a total of 2660 patients were admitted to the trauma/burn intensive care unit. Of these patients, 63 (2.3%) subsequently developed a pressure ulcer. A Braden Scale of ≤18 as the threshold for being at-risk of pressure ulcer had a sensitivity of 100% and specificity of 6%, whereas a Braden Scale of ≤9 had a sensitivity of 28.6% and a specificity of 90%. For all Braden Scale measurements, the positive likelihood ratio never reached the value of 10 that suggests high likelihood of an ulcer. CONCLUSIONS: The Braden scale has mediocre discriminatory ability among the trauma/burn population. In addition, the low positive likelihood ratio suggests that the Braden scale may not be a useful clinical tool as it may result in unnecessary expenditure of time and personnel resources in preventing pressure ulcer formation.

Massive transfusion in pediatric trauma: analysis of the National Trauma Databank.

BACKGROUND: Massive transfusion (MT) in pediatric trauma has been described in combat populations and other single institutions studies. We aim to define the incidence of MT in a large US civilian pediatric trauma population, identify predictive parameters of MT, and the mortality associated with MT. METHODS: Data from the National Trauma Databank (2010-2012), a trauma registry maintained by the American College of Surgeons, were analyzed. We included pediatric trauma patients ≤14 y that underwent MT, as defined by 40 mL/kg of blood products within the first 24 h after admission. We compared the MT group with children receiving any transfusion within the same time frame. Univariate and multivariate analysis were performed. RESULTS: Of 356,583 pediatric trauma patients, 13,523 (4%) received any transfusion in the first 24 h and 173 (0.04%) had a MT. On multivariate analysis, factors predicting MT were: older patients (5-12: OR 2.71, P = 0.006, and ≥12: OR 5.14, P < 0.001), hypothermic patients (temperature <35: OR 2.48, P < 0.025), low Glasgow Coma Scale (Glasgow Coma Scale <8: OR 2.82, P = 0.009), and Injury Severity Scores ≥25 (OR 2.01, P = 0.03). Overall mortality for the entire group, any transfusion group, and MT group were 2.5%, 13.6%, and 50.6%, respectively (P < 0.001). CONCLUSIONS: MT in pediatric trauma is an uncommon event associated with a significant mortality. Patients undergoing MT are older, more likely to be hypothermic and have sustained more severe injuries as measured by traditional trauma scoring systems than transfused trauma patients.