Validating the ATLS Shock Classification for Predicting Death, Transfusion, or Urgent Intervention.

BACKGROUND: The Advanced Trauma Life Support (ATLS) shock classification has been accepted as the conceptual framework for clinicians caring for trauma patients. We sought to validate its ability to predict mortality, blood transfusion, and urgent intervention. MATERIALS AND METHODS: We performed a retrospective review of trauma patients using the 2014 National Trauma Data Bank. Using initial vital signs data, patients were categorized into shock class based on the ATLS program. Rates for urgent blood transfusion, urgent operative intervention, and mortality were compared between classes. RESULTS: 630,635 subjects were included for analysis. Classes 1, 2, 3, and 4 included 312,404, 17,133, 31, and 43 patients, respectively. 300,754 patients did not meet criteria for any ATLS shock class. Of the patients in class 1 shock, 2653 died (0.9%), 3123 (1.0%) were transfused blood products, and 7115 (2.3%) underwent an urgent procedure. In class 2, 219 (1.3%) died, 387 (2.3%) were transfused, and 1575 (9.2%) underwent intervention. In class 3, 7 (22.6%) died, 10 (32.3%) were transfused, and 13 (41.9%) underwent intervention. In class 4, 15 (34.9%) died, 19 (44.2%) were transfused, and 23 (53.5%) underwent intervention. For uncategorized patients, 21,356 (7.1%) died, 15,168 (5.0%) were transfused, and 23,844 (7.9%) underwent intervention. CONCLUSIONS: Almost half of trauma patients do not meet criteria for any ATLS shock class. Uncategorized patients had a higher mortality (7.1%) than patients in classes 1 and 2 (0.9% and 1.3%, respectively). Classes 3 and 4 only accounted for 0.005% and 0.007%, respectively, of patients. The ATLS classification system does not help identify many patients in severe shock.

Alcohol/Illicit Substance Use in Fatal Motorcycle Crashes.

BACKGROUND: The objective of the current study is to determine how alcohol and illicit substance use contributes to motorcycle crash fatalities by examining the relationship between toxicology levels found postmortem and the behavior of riders and passengers in fatal motorcycle crashes. MATERIALS AND METHODS: All motorcycle fatalities in Miami-Dade County, FL, from 2009 to 2014 were reviewed using the Miami-Dade County Medical Examiner's toxicology reports and the corresponding crash reports. RESULTS: Positive alcohol/illicit substance detection was found in 44% of our population of 227 fatalities. When compared with those with a negative alcohol/illicit substance detection, those with a positive alcohol/illicit substance detection were more likely to be found at fault of the crash (77% versus 50%, P < 0.001), more likely to be in a single-vehicle crash (47% versus 21%, P < 0.001) and less likely to wear a helmet (44% versus 64%, P = 0.002). However, there was no significant relationship between speeding and alcohol/illicit substance detection (29% versus 33%, P = 0.748). In addition, a regression analysis demonstrated that there was less helmet use and more single-vehicle crashes with higher blood alcohol concentration. CONCLUSIONS: In fatal motorcycle crashes, alcohol and illicit substance use had a significantly negative impact on the risk aversion of motorcycle fatalities in regard to fault, helmet use, and single-vehicle crashes.

Hidden Costs of Hospitalization After Firearm Injury: National Analysis of Different Hospital Readmission.

OBJECTIVE: To compare the risk factors and costs associated with readmission after firearm injury nationally, including different hospitals. BACKGROUND: No national studies capture readmission to different hospitals after firearm injury. METHODS: The 2013 to 2014 Nationwide Readmissions Database was queried for patients admitted after firearm injury. Logistic regression identified risk factors for 30-day same and different hospital readmission. Cost was calculated. Survey weights were used for national estimates. RESULTS: There were 45,462 patients admitted for firearm injury during the study period. The readmission rate was 7.6%, and among those, 16.8% were readmitted to a different hospital. Admission cost was $1.45 billion and 1-year readmission cost was $131 million. Sixty-four per cent of those injured by firearms were publicly insured or uninsured. Readmission predictors included: length of stay >7 days [odds ratio (OR) 1.43, P < 0.01], Injury Severity Score >15 (OR 1.41, P < 0.01), and requiring an operation (OR 1.40, P < 0.01). Private insurance was a predictor against readmission (OR 0.81, P < 0.01). Predictors of readmission to a different hospital were unique and included: initial admission to a for-profit hospital (OR 1.52, P < 0.01) and median household income ≥$64,000 (OR 1.48, P < 0.01). CONCLUSIONS: A significant proportion of the national burden of firearm readmissions is missed by not tracking different hospital readmission and its unique set of risk factors. Firearm injury-related hospitalization costs $791 million yearly, with the largest fraction paid by the public. This has implications for policy, benchmarking, quality, and resource allocation.

Appendicitis in Pregnancy: A Post-Hoc Analysis of an EAST Multicenter Study.

Objective: To compare the presentation, management, and outcomes of appendicitis in pregnant and non-pregnant females of childbearing age (18-45 years). Methods: This was a post-hoc analysis of a prospectively collected database (January 2017-June 2018) from 28 centers in America. We compared pregnant and non-pregnant females' demographics, clinical presentation, laboratory data, imaging findings, management, and clinical outcomes. Results: Of the 3,597 subjects, 1,010 (28%) were of childbearing age, and 41 were pregnant: The mean age of the pregnant subjects was 30 ± 8 years at a median gestational age of 15 (range 10-23) weeks. The two groups had similar demographics and clinical presentation, but there were differences in management and outcomes. For example, in pregnant subjects, abdominal ultrasound scans (US) plus magnetic resonance imaging (MRI) was the most frequently used imaging method (41%) followed by MRI alone (29%), US alone (22%), computed tomography (CT) (5%), and no imaging (2%). Despite similar American Association for the Surgery of Trauma Emergency General Surgery Clinical and Imaging Grade at presentation, pregnant subjects were more likely to be treated with antibiotics alone (15% versus 4%; p = 0.008). Pregnant subjects were less likely to have simple appendicitis and were more likely to have complicated (perforated or gangrenous) appendicitis or a normal appendix. With the exception of index hospital length of stay, there were no significant differences between the groups in clinical outcomes at index hospitalization or at 30 days. Conclusion: Almost 1 in 20 women of childbearing age presenting with appendicitis is pregnant. Appendicitis most commonly affects women in early to mid-pregnancy. Compared with non-pregnant women of childbearing age, pregnant women presenting with appendicitis undergo non-operative management more often and are less likely to have simple appendicitis. Compared with non-pregnant patients, they have similar clinical outcomes at both index hospitalization and 30 days after discharge.

Use of Predictive Equations for Energy Prescription Results in Inaccurate Estimation in Trauma Patients.

BACKGROUND: Overfeeding and underfeeding are associated with poor clinical outcomes. In the absence of indirect calorimetry (IC), the Society of Critical Care Medicine/ASPEN recommend prescribing 25-30 kcal/kg. The Harris-Benedict equation (HBE) multiplied by a stress factor is commonly applied in critically ill patients. We describe the difference between estimated and actual energy needs in critically injured patients. METHODS: From March to November 2018, we collected demographics and energy needs determined by continuous IC (started within 4 days) in intubated adults. Ideal or adjusted body weight was used for 25-30 kcal/kg, and HBE was multiplied by a 1.3 stress factor (1.3HBE). Daily requirements up to 14 days, extubation, or death were calculated using all 3 methods and compared with IC. RESULTS: Fifty-five subjects were included. Median age was 38 [27-58] years, 38 (69%) were male, body mass index was 28 [25-33] kg/m2 , and Acute Physiology and Chronic Health Evaluation II score was 17 [14-24] Mechanism of injury was blunt (38, 69%), penetrating (9, 16%), and burn (8, 15%). By day 14, compared with measured energy requirements by IC, the other methods could result in a cumulative 1827-kcal (+7%) surplus (1.3HBE), a 1313-kcal (-5%) deficit (25 kcal/kg), or a 3950-kcal (+14%) surplus (30 kcal/kg) per patient over a median 9 days. CONCLUSION: In critically injured patients, predictive equations for energy needs do not account for dynamic metabolic changes over time and could result in underfeeding or overfeeding. Adjusting daily prescription based on continuous IC may result in better individualized treatment.

Underestimation of Unplanned Readmission after Colorectal Surgery: A National Analysis.

BACKGROUND: A significant proportion of postoperative readmission occurs at a different hospital and is therefore missed by current benchmarking. There are no national studies tracking readmission at different hospitals after colorectal surgery. This study aimed to determine the national burden of postoperative colorectal readmission, including readmission to a different hospital. STUDY DESIGN: The 2013 to 2014 Nationwide Readmissions Database was queried for adults undergoing colorectal surgery. The outcome of interest was 30-day unplanned readmission. Risk factors were identified. RESULTS: There were 79,098 patients admitted during the study period, with 7.1% (n = 5,591) readmitted and of those, 10.2% (n = 569) readmitted to a different hospital. Risk factors for readmission to a different hospital included admission to a high-volume hospital (odds ratio [OR] 1.49 [95% CI 1.17 to 1.91], p < 0.01), teaching hospital (OR 1.26 [95% CI 1.01 to 1.59], p = 0.04), nonmetropolitan hospital (OR 2.75 [95% CI 1.95 to 3.89], p < 0.01), hospitalization more than 7 days (OR 1.67 [95% CI 1.33 to 2.10], p < 0.01), and elective admission (OR 1.57 [95% CI 1.22 to 2.02], p < 0.01). Predictors of readmission to a different hospital were different than predictors of readmission. The most common reason for readmission was infection (28.4%). CONCLUSIONS: The burden of readmission to a different hospital after colorectal surgery is significant and disproportionately affects high-volume hospitals. Current quality metrics underestimate readmission, failing to capture the subpopulation readmitted to a different hospital. Interventions designed to prevent readmission need to be tailored to the unique risk factors described for different hospital readmission. Benchmarking not measuring different hospital readmission is inaccurate and should be modified.

Effect of time to operation on mortality for hypotensive patients with gunshot wounds to the torso: The golden 10 minutes.

INTRODUCTION: Timely hemorrhage control is paramount in trauma; however, a critical time interval from emergency department arrival to operation for hypotensive gunshot wound (GSW) victims is not established. We hypothesize that delaying surgery for more than 10 minutes from arrival increases all-cause mortality in hypotensive patients with GSW. METHODS: Data of adults (n = 309) with hypotension and GSW to the torso requiring immediate operation from January 2004 to September 2013 were retrospectively reviewed. Patients with resuscitative thoracotomies, traumatic brain injury, transfer from outside institutions, and operations occurring more than 1 hour after arrival were excluded. Survival analysis using multivariate Cox regression models was used for comparison. Hazard ratios (HRs) and 95% confidence intervals (CIs) are reported. Statistical significance was considered at p ≤ 0.05. RESULTS: The study population was aged 32 ± 12 years, 92% were male, Injury Severity Score was 24 ± 15, systolic blood pressure was 81 ± 29 mm Hg, Glasgow Coma Scale score was 13 ± 4. Overall mortality was 27%. Mean time to operation was 19 ± 13 minutes. After controlling for organ injury, patients who arrived to the operating room after 10 minutes had a higher likelihood of mortality compared with those who arrived in 10 minutes or less (HR, 1.89; 95% CI, 1.10-3.26; p = 0.02); this was also true in the severely hypotensive patients with systolic blood pressure of 70 mm Hg or less (HR, 2.67; 95% CI, 0.97-7.34; p = 0.05). The time associated with a 50% cumulative mortality was 16 minutes. CONCLUSIONS: Delay to the operating room of more than 10 minutes increases the risk of mortality by almost threefold in hypotensive patients with GSW. Protocols should be designed to shorten time in the emergency department. Further prospective observational studies are required to validate these findings. LEVEL OF EVIDENCE: Therapeutic study, level IV.