Predictors of Massive Transfusion Protocol Initiation Among Trauma Patients Transported From the Scene Via Flight Emergency Management Services.

OBJECTIVE: Early identification of the subset of trauma patients with acute hemorrhage who require resuscitation via massive transfusion protocol (MTP) initiation is vital because such identification can ensure the availability of resuscitation products immediately upon hospital arrival and result in improved clinical outcomes, including reduced mortality. However, there are currently few studies on the predictors of MTP in the unique setting of flight transport. METHODS: This was a retrospective study of adult trauma patients transported from the scene via flight to 6 trauma centers between March 1, 2019, and January 21, 2021. Patients were included if they had emergency medical service vitals documented. The variables collected included demographics, comorbidities, cause of injury, body regions injured, in-flight treatments, and transport vitals. The primary outcome was MTP initiated by the receiving hospital. RESULTS: A total of 212 patients were included, of whom 16 (8%) had MTP initiated. During flight transport, 24 (11%) received whole blood, 9 (4%) received packed red blood cells, 11 (5%) had a tourniquet placed, and 5 (2%) received tranexamic acid. In adjusted analyses, receiving whole blood during transport (odds ratio [OR] = 8.52, P < .01), systolic blood pressure ≤ 90 mm Hg (OR = 8.07, P < .01), and a Glasgow Coma Scale score < 13 (OR = 8.38, P < .01) were independently associated with MTP. CONCLUSIONS: This retrospective cohort study showed that 3 factors readily available in the flight setting-receipt of whole blood, systolic blood pressure, and Glasgow Coma Scale score-are strong predictors of MTP at the receiving facility, particularly when considered in aggregate.

Recalibrating the Glasgow Coma Score as an Age-Adjusted Risk Metric for Neurosurgical Intervention.

BACKGROUND: The Glasgow Coma Scale (GCS) score is the most frequently used neurologic assessment in traumatic brain injury (TBI). The risk for neurosurgical intervention based on GCS is heavily modified by age. The objective is to create a recalibrated Glasgow Coma Scale (GCS) score that accounts for an interaction by age and determine the predictive performance of the recalibrated GCS (rGCS) compared to the standard GCS for predicting neurosurgical intervention. METHODS: This retrospective cohort study utilized the National Trauma Data Bank and included all patients admitted from 2010-2015 with TBI (ICD9 diagnosis code 850-854.19). The study population was divided into 2 subsets: a model development dataset (75% of patients) and a model validation dataset (remaining 25%). In the development dataset, logistic regression models were used to calculate conditional probabilities of having a neurosurgical intervention for each combination of age and GCS score, to develop a point-based risk score termed the rGCS. Model performance was examined in the validation dataset using area under the receiver operating characteristic (AUROC) curves and calibration plots. RESULTS: There were 472,824 patients with TBI. The rGCS ranged from 1-15, where rGCS 15 denotes the baseline risk for neurosurgical intervention (4.4%) and rGCS 1 represents the greatest risk (62.6%). In the validation dataset there was a statistically significant improvement in predictive performance for neurosurgical intervention for the rGCS compared to the standard GCS (AUROC: 0.71 versus 0.67, difference, -0.04, P<0.001), overall and by trauma level designation. The rGCS was better calibrated than the standard GCS score. CONCLUSIONS: The relationship between GCS score and neurosurgical intervention is significantly modified by age. A revision to the GCS that incorporates age, the rGCS, provides risk of neurosurgical intervention that has better predictive performance than the standard ED GCS score.

Examining emergency medical services' prehospital transport times for trauma patients during COVID-19.

INTRODUCTION: Longer prehospital times were associated with increased odds for survival in trauma patients. The purpose of this study was to determine how the COVID-19 pandemic affected emergency medical services (EMS) prehospital times for trauma patients. METHODS: This retrospective cohort study compared trauma patients transported via EMS to six US level I trauma centers admitted 1/1/19-12/31/19 (2019) and 3/16/20-6/30/20 (COVID-19). Outcomes included: total EMS pre-hospital time (dispatch to hospital arrival), injury to dispatch time, response time (dispatch to scene arrival), on-scene time (scene arrival to scene departure), and transportation time (scene departure to hospital arrival). Fisher's exact, chi-squared, or Kruskal-Wallis tests were used, alpha = 0.05. All times are presented as median (IQR) minutes. RESULTS: There were 9400 trauma patients transported by EMS: 79% in 2019 and 21% during the COVID-19 pandemic. Patients were similar in demographics and transportation mode. Emergency room deaths were also similar between 2019 and COVID-19 [0.6% vs. 0.9%, p = 0.13].There were no differences between 2019 and during COVID-19 for total EMS prehospital time [44 (33, 63) vs. 43 (33, 62), p = 0.12], time from injury to dispatch [16 (6, 55) vs. 16 (7, 77), p = 0.41], response time [7 (5, 12) for both groups, p = 0.27], or on-scene time [16 (12-22) vs. 17 (12,22), p = 0.31]. Compared to 2019, transportation time was significantly shorter during COVID-19 [18 (13, 28) vs. 17 (12, 26), p = 0.01]. CONCLUSION: The median transportation time for trauma patients was marginally significantly shorter during COVID-19; otherwise, EMS prehospital times were not significantly affected by the COVID-19 pandemic.

Heads Up: Describing and Implementing a Time-Saving Head Strike Protocol at a Level II Trauma Center.

Head strikes can be fatal for patients taking blood thinners (anticoagulants or antiplatelets). Our trauma center instituted the "head strike protocol" to provide uniform and expedited care for adult trauma patients taking preinjury anticoagulants and antiplatelet medications with suspected head injury. The purpose of this article is to describe the development and implementation of the head strike protocol and compare time metrics and outcomes before and after implementing the protocol. Per the head strike protocol, patients with suspected traumatic intracranial hemorrhage (tICH) were screened for anticoagulants or antiplatelet medications by emergency medical service personnel/at first contact, activated as a Level II trauma and received a computed tomographic scan of the head within 30 min of arrival, and started reversal of blood products within 30 min of tICH confirmation. Compared with patients admitted before establishing the head strike protocol, patients treated postimplementation were significantly more likely to have trauma team activation (77% preprotocol vs. 89% postprotocol) and expeditious initiation of reversal agents (68 min preprotocol vs. 21 min postprotocol) and to survive their head injury for patients taking anticoagulants (42% preprotocol vs. 21% postprotocol). There were no differences in mortality for patients taking antiplatelet agents. This comprehensive nurse-driven reversal protocol presents an algorithm for managing patients with suspected tICH taking any preinjury blood thinners, allowing "ownership" by the nursing staff to ensure there are no delays in initiating blood products. This protocol may be particularly salient with the aging of the trauma population and parallel increase in the use of blood thinners.

Occurrence, Predictors, and Prognosis of Alcohol Withdrawal Syndrome and Delirium Tremens Following Traumatic Injury.

OBJECTIVES: We sought to determine occurrence, predictors, and prognosis of alcohol withdrawal syndrome and delirium tremens in patients with traumatic injury. DESIGN: Retrospective multicenter cohort study. SETTING: Three U.S. trauma centers. PATIENTS: Twenty-eight thousand one hundred one trauma patients admitted from 2010-2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Measures included occurrence of alcohol withdrawal syndrome and delirium tremens, injury characteristics, risk factors for alcohol withdrawal syndrome, clinical outcomes, pharmacologic treatment for alcohol withdrawal syndrome, and Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) scores. Alcohol withdrawal syndrome severity was defined by CIWA-Ar score as minimal (< 10), moderate (10-20), and severe (> 20). Alcohol withdrawal syndrome developed in 0.88% (n = 246), including 12% minimal, 36% moderate, and 53% severe. Alcohol withdrawal syndrome progressed to delirium tremens in 11%. Before adjustment, alcohol withdrawal syndrome severity was associated with injury severity, hypokalemia, baseline CIWA-Ar score, and established alcohol withdrawal syndrome risk factors. Logistic regression identified the following predictors of delirium tremens: baseline CIWA-Ar score greater than or equal to 10 (odds ratio, 6.05; p = 0.02) and age greater than or equal to 55 (odds ratio, 3.24; p = 0.03). In patients with severe alcohol withdrawal syndrome, severe head injury also predicted progression to delirium tremens (odds ratio, 6.08; p = 0.01), and hypokalemia was borderline significant (odds ratio, 3.23; p = 0.07). Clinical outcomes of hospital length of stay, ICU length of stay, and alcohol withdrawal syndrome complications differed significantly by alcohol withdrawal syndrome severity and were worse with more severe manifestations of alcohol withdrawal syndrome. Mortality also significantly differed by alcohol withdrawal syndrome severity but was only greater in patients who progressed to delirium tremens (11.1%; p = 0.02); otherwise, there were no differences in mortality by severity (4%, 4%, and 0% by minimal, moderate, and severe alcohol withdrawal syndrome). CONCLUSIONS: Trauma patients with alcohol withdrawal syndrome experience a high occurrence of delirium tremens that is associated with significant mortality. These data demonstrate the predictive ability of baseline CIWA-Ar score, age, and severe head injury for developing delirium tremens.

Lights and Siren Transport and the Need for Hospital Intervention in Trauma Patients.

Emergent ambulance transportation is associated with increased risk of collision, injury, and death for EMS professionals, patients, and the general public. Time saved using lights and siren (L&S) is typically small, and often provides minimal clinical benefit. Our objective was to investigate the frequency of L&S transports, describe the precision of the decision to employ L&S to predict the need for a time critical hospital intervention (TCHI) within 15 minutes of hospital arrival, identify clinical predictors of a TCHI, and compare clinical outcomes in patients transported by Emergency Medical Services (EMS) with and without L&S in a trauma-specific population. EMS patient care reports and trauma registry data were retrospectively reviewed for trauma patients consecutively transported from the field by three EMS agencies to three trauma centers within urban and suburban settings over a two-year period. TCHIs were collaboratively developed by the study team. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were utilized to report the precision of the decision to employ L&S to predict the need of a TCHI. Univariate and multivariate analyses determined predictors of a TCHI and compared clinical outcomes. 2,091 patients were included in the study. Of the 19.8% of patients transported with L&S, 22.9% received a TCHI. The most common TCHI was airway or respiratory procedures (87.2% of all TCHI's). The sensitivity and specificity of L&S to predict the need for a TCHI was 87.2% (95% CI 79.4-92.8) and 84.0% (95% CI 82.2-85.5), respectively. PPV was 23.0% (95% CI 23.53-38.01); NPV was 99.2% (95% CI 98.6-99.6). L&S was predictive for the need for a TCHI (p < 0.001), as was abnormal Glasgow Coma Score (p < 0.001), abnormal systolic blood pressure and age (p < 0.05 for all). Among patients that received a TCHI, over a third that were transported with L&S (36.8%) expired, compared with two of 14 patients (14.3%) not transported L&S. EMS professionals in this study demonstrated a high ability to discern which trauma patients did not require L&S. Nevertheless, L&S transport resulted in a TCHI less than one quarter of the time, suggesting an opportunity for further reduction of L&S transports in trauma patients.

Age ≥80 Years Is Not a Contraindication for Intra-Arterial Therapy after Ischemic Stroke.

BACKGROUND: Clinical trials confirmed the safety and efficacy of intra-arterial therapy (IAT) in the management of ischemic stroke. At a community hospital, we compared outcomes in patients aged ≥80 and patients in the age range 55-79 years receiving IAT following ischemic stroke. METHODS: Data were retrospectively abstracted for ischemic stroke patients ≥55 years treated with IAT at an urban comprehensive stroke center between 2010 and 2013. Baseline demographics, incidence of symptomatic intracranial hemorrhage (sICH), in-hospital mortality, discharge modified Rankin scale (mRS) score (favorable ≤2) and improvement in National Institutes of Health Stroke Scale Score (NIHSS; decreased score at discharge) were compared between patients in the age range 55-79 and patients ≥80 years. Data were analyzed using univariate analyses and multivariate logistic regression. RESULTS: IAT was performed in 239 patients with ischemic stroke; 63 (26.4%) were ≥80 years. When compared to patients aged 55-79, the elderly patients were more often female and non-smokers, with a history of atrial fibrillation. No differences were observed in those ≥80 years compared to patients in the age range 55-79 years for sICH (10 vs. 5%, p = 0.23), mortality (24 vs. 18%, p = 0.28), favorable discharge mRS score (13 vs. 19%, p = 0.27), or improvement in NIHSS (83 vs. 92%, p = 0.10). The nonsignificant association of age with the outcomes persisted after adjusting for covariates and when analyzing the subset of patients who received IAT only. CONCLUSIONS: These findings suggest that in a cohort not subject to the criteria of a clinical trial, age ≥80 years should not be a contraindication to IAT.

Pilot study examining anti-factor Xa levels for heparin monitoring and outcomes in patients with cerebral venous thrombosis.

Objective: There are no studies to date that examine the association between anti-factor-Xa (AFXa)-based heparin monitoring and clinical outcomes in the setting of cerebral venous thrombosis (CVT). Methods: This pilot study included adults aged ≥18 admitted with CVT between 1 January 2018 and 1 January 2021, who were treated with unfractionated heparin (UFH) and were monitored via AFXa-based nomogram within 24 h of arrival. Comparisons were made between patients with AFXa levels within the target therapeutic range (0.25-0.5 IU/mL) and patients whose levels were not within the therapeutic range within 24 h of arrival; the time (hours) from arrival to reach the therapeutic range was also examined. Outcomes were length of stay (LOS) in the hospital, major (actionable) bleeding events, and discharge home (vs. higher acuity location). Continuous data are reported in the form of the median (interquartile range). Results: Among 45 patients, treatment with UFH was initiated 2 (1-11) h after arrival, and the majority (84%) of UFH infusions did not need dose adjustment. AFXa assays were conducted every 6 (5.5-7) h. Thirty patients (67%) fell within the therapeutic range. Outcomes were similar for patients with levels within the therapeutic range vs. not: major bleeding events, 10% vs. 0% (p = 0.54); discharge home, 77% vs. 80% (p = 1.0); LOS, 5 days in each group (p = 0.95). There was also no association between outcomes and time to reach the therapeutic range. Conclusion: Our findings demonstrate the practicability of monitoring UFH based on AFXa values in this population of patients with CVT, but reaching target AFXa levels within 24 h of arrival may not necessarily be prognostic.

Association of sex and aspirin use with postoperative bleeding in patients with lower extremity long bone fractures.

Objective: The perioperative management of patients on antiplatelet drugs is a rising challenge in orthopedic trauma because antiplatelet drugs are frequently encountered and carry an increased risk of hemorrhagic consequences. The study objective was to examine the effect of aspirin on bleeding outcomes for patients with lower extremity fractures. Methods: This retrospective study included patients requiring surgical fixation of traumatic hip, femur, and tibia fractures from January 1, 2018, to March 1, 2020. Patients were excluded if they had a significant head injury, were on chronic anticoagulant therapy, or they did not receive venous thromboembolism chemoprophylaxis. Comparisons between aspirin users (patients on aspirin therapy preinjury) and non-aspirin users were examined using χ2 tests, Cochran-Mantel-Haenszel tests, and multivariate logistic regression. The primary outcome was an overt, actionable bleed (eg, blood transfusion for surgical site hemorrhage) within 24 hours postoperative. Results: There were 864 patients with lower extremity long bone fractures and 24% were aspirin users. The incidence of postoperative bleeding was 8.8% and significantly differed for patients taking aspirin versus not (13.6% vs 7.3%, p=0.01). However, biological sex at birth (M/F) was a significant effect modifier (interaction p=0.04). Among women, there were significantly more postoperative bleeds for aspirin users (17.8% aspirin vs 7.4% no aspirin, adjusted OR (AOR): 2.48 (1.28-4.81), p=0.01). Among men, there were similar postoperative bleeding events by aspirin use (5.6% aspirin vs 7.2% no aspirin, AOR: 0.50 (0.14-1.82), p=0.30). Postoperative hemoglobin values <8 g/dL were more frequent among female aspirin users (21.5% aspirin vs 12.5% no aspirin, p=0.01), but this association was not observed in men (p=0.43). Conclusion: Women taking aspirin who suffer lower extremity fractures have greater than twofold greater odds of a postoperative bleeding event. These findings suggest adequate perioperative planning to ensure blood availability, and increased awareness to monitor closely for hemorrhage in the 24-hour postoperative window for women taking aspirin preinjury. Level of evidence: IV.

Operative Management Improves Near-term Survival of Patients With Odontoid Type II Fractures: A Propensity-matched National Registry Analysis.

STUDY DESIGN: National Trauma Data Bank (NTDB) review and propensity-matched analysis. OBJECTIVE: To evaluate differences in clinical outcomes by operative management. SUMMARY OF BACKGROUND DATA: Odontoid type II fractures are the most prevalent cervical fracture. Operative intervention on these fractures is frequently debated; surgical risks are compounded by clinical severity, patient age, and comorbidities. METHODS: This registry review included index admissions for odontoid type II fractures [International Classification of Diseases (ICD)-10 codes beginning with S12.11] from 1/1/2017 to 1/1/2020; patients who died in the emergency department (ED) were excluded. Propensity score techniques were used to match patients 1:1 by surgical management, using a caliper distance of 0.05, after matching on the following covariates that differed significantly between surgical and nonsurgical patients: age, sex, race, cause of injury, transfer status, injury severity score, ED Glasgow coma score, ED systolic blood pressure, presence of transverse ligamentous injury, cervical dislocation, and 8 comorbidities. The following outcomes were analyzed with McNemar tests and Wilcoxon signed-rank tests: near-term survival (discharged from the hospital to locations other than morgue or hospice), intensive care unit (ICU) admission, hospital complications, median hospital length of stay (LOS), and median ICU LOS. RESULTS: There were 16,607 patients, 2916 (17.6%) were operatively managed and 13,691 were nonoperatively managed. Before matching, survival was greater for patients managed operatively compared with nonoperatively (95.0% vs. 88.2%). The matched population consisted of 5334 patients: 2667 patients in the operative group (91.5% of this population) and 2667 well-matched patients in the nonoperative group. After matching, there was a survival benefit for patients who were operatively managed compared with nonoperative management (94.8% vs. 91.4% P <0.001). However, operative management was associated with greater development of complications, ICU admission, and longer hospital and ICU LOS. CONCLUSION: Compared with nonoperative management, operative management demonstrated a significant near-term survival benefit for patients with odontoid type II fractures in select patients. LEVEL OF EVIDENCE: III.

A joinpoint analysis examining trends in firearm injuries at six us trauma centers from 2016 to 2022.

BACKGROUND: There is an epidemic of firearm injuries in the United States since the mid-2000s. Thus, we sought to examine whether hospitalization from firearm injuries have increased over time, and to examine temporal changes in patient demographics, firearm injury intent, and injury severity. METHODS: This was a multicenter, retrospective, observational cohort study of patients hospitalized with a traumatic injury to six US level I trauma centers between 1/1/2016 and 6/30/2022. ICD-10-CM cause codes were used to identify and describe firearm injuries. Temporal trends were compared for demographics (age, sex, race, insured status), intent (assault, unintentional, self-harm, legal intervention, and undetermined), and severity (death, ICU admission, severe injury (injury severity score ≥ 16), receipt of blood transfusion, mechanical ventilation, and hospital and ICU LOS (days). Temporal trends were examined over 13 six-month intervals (H1, January-June; H2, July-December) using joinpoint regression and reported as semi-annual percent change (SPC); significance was p < 0.05. RESULTS: Firearm injuries accounted for 2.6% (1908 of 72,474) of trauma hospitalizations. The rate of firearm injuries initially declined from 2016-H1 to 2018-H2 (SPC = - 4.0%, p = 0.002), followed by increased rates from 2018-H2 to 2020-H1 (SPC = 9.0%, p = 0.005), before stabilizing from 2020-H1 to 2022-H1 (0.5%, p = 0.73). NH black patients had the greatest hospitalization rate from firearm injuries (14.0%) and were the only group to demonstrate a temporal increase (SPC = 6.3%, p < 0.001). The proportion of uninsured patients increased (SPC = 2.3%, p = 0.02) but there were no temporal changes by age or sex. ICU admission rates declined (SPC = - 2.2%, p < 0.001), but ICU LOS increased (SPC = 2.8%, p = 0.04). There were no significant changes over time in rates of death (SPC = 0.3%), severe injury (SPC = 1.6%), blood transfusion (SPC = 0.6%), and mechanical ventilation (SPC = 0.6%). When examined by intent, self-harm injuries declined over time (SPC = - 4.1%, p < 0.001), assaults declined through 2019-H2 (SPC = - 5.6%, p = 0.01) before increasing through 2022-H1 (SPC = 6.5%, p = 0.01), while undetermined injuries increased through 2019-H1 (SPC = 24.1%, p = 0.01) then stabilized (SPC = - 4.5%, p = 0.39); there were no temporal changes in unintentional injuries or legal intervention. CONCLUSIONS: Hospitalizations from firearm injuries are increasing following a period of declines, driven by increases among NH Black patients. Trauma systems need to consider these changing trends to best address the needs of the injured population.

Developing a rural trauma outreach program: the experience of a major health care network.

This study describes the process undertaken by a private health care network to develop and implement an outreach program for rural level III to V trauma centers. The program provided individualized trauma program support to 18 rural out-of-network facilities. A case study and participant satisfaction survey demonstrate the experiences of rural trauma nurse coordinators working with the program. The Trauma Outreach Program presents a solution to enhance the effectiveness of regional trauma systems, lift the burden on rural facilities, and improve care for the injured patient.

Network Analysis Examining Intrahospital Traffic of Patients With Traumatic Hip Fracture.

INTRODUCTION: Increased intrahospital traffic (IHT) is associated with adverse events and infections in hospitalized patients. Network science has been used to study patient flow in hospitals but not specifically for patients with traumatic injuries. METHODS: This retrospective analysis included 103 patients with traumatic hip fractures admitted to a level I trauma center between April 2021 and September 2021. Associations with IHTs (moves within the hospital) were analyzed using R (4.1.2) as a weighted directed graph. RESULTS: The median (interquartile range) number of moves was 8 (7-9). The network consisted of 16 distinct units and showed mild disassortativity (-0.35), similar to other IHT networks. The floor and intensive care unit (ICU) were central units in the flow of patients, with the highest degree and betweenness. Patients spent a median of 20-28 hours in the ICU, intermediate care unit, or floor. The number of moves per patient was mildly correlated with hospital length of stay (ρ = 0.26, p = .008). Intrahospital traffic volume was higher on weekdays and during daytime hours. Intrahospital traffic volume was highest in patients aged <65 years ( p = .04), but there was no difference in IHT volume by dependent status, complications, or readmissions. CONCLUSIONS: Network science is a useful tool for trauma patients to plan IHT, flow, and staffing.

Timing of venous thromboembolism chemoprophylaxis with major surgery of lower-extremity long bone fractures.

BACKGROUND: There is debate on the need to withhold chemical venous thromboembolism (VTE) prophylaxis in patients requiring major orthopedic surgery. We hypothesized that the incidence of clinically significant hemorrhage (CSH) does not differ by the timing of prophylaxis in such patients. METHODS: This was a multicenter, retrospective cohort study conducted at five US trauma centers that included trauma patients admitted between January 1, 2018, to March 1, 2020, requiring surgical fixation of the femoral shaft, hip, or tibia and received VTE chemoprophylaxis during the hospitalization. Exclusions were major and moderate head or spinal injuries, chronic anticoagulant use, or multiple long bone surgeries. Timing of VTE chemoprophylaxis was examined as four groups: (1) initiated preoperatively without interruption for surgery; (2) initiated preoperatively but held perioperatively; (3) initiated within 12 hours postoperatively; and (4) initiated >12 hours postoperatively. The primary outcome was incidence of CSH (%), defined as overt hemorrhage within 24 hours postoperative that was actionable. Multivariate logistic regression evaluated differences in CSH based on timing of VTE chemoprophylaxis. RESULTS: There were 786 patients, and 65 (8.3%) developed a CSH within 24 hours postoperatively. Nineteen percent of patients received chemoprophylaxis preoperatively without interruption for surgery, 13% had preoperative initiation but dose(s) were held for surgery, 21% initiated within 12 hours postoperatively, and 47% initiated more than 12 hours postoperatively. The incidence and adjusted odds of CSH were similar across groups (11.3%, 9.1%, 7.1%, and 7.3% respectively; overall p = 0.60). The incidence of VTE was 0.9% and similar across groups ( p = 0.47); however, six of seven VTEs occurred when chemoprophylaxis was delayed or interrupted. CONCLUSION: This study suggests that early and uninterrupted VTE chemoprophylaxis is safe and effective in patients undergoing major orthopedic surgery for long bone fractures. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Oxidation­reduction potential parameters worsen following intraarterial therapy in patients with reduced collateral circulation and middle cerebral artery occlusions.

Collateral circulation is important for cerebral perfusion in acute ischemic strokes. Monitoring the oxidation-reduction potential (ORP) may be useful to assess collateral status or treatment efficacy. The objectives of the present study were to determine if the ORP was associated with collateral circulation status in middle cerebral artery (MCA) occlusions and to identify patterns in the ORP and the collateral circulation status among patients treated with intraarterial therapy (IAT) over time. The present pilot study was nested within a prospective cohort study measuring the ORP of the peripheral venous plasma of stroke patients. The population included in the present study were patients with MCA (M1/M2) occlusions. Two ORP parameters were examined: Static ORP (sORP; mV), indicating oxidative stress, and capacity ORP (cORP; µC), indicating antioxidant reserves. Collateral status was retrospectively graded using Miteff's system as good (grade 1) or reduced (grade 2/3). Comparisons were made between collateral status groups (reduced vs. good collaterals) in all patients, within a subset including only patients who received IAT, and between thrombolysis in cerebral infraction scale score (TICI) groups (0-2a vs. 2b/3). The Fisher's exact test, Student's t-test and Wilcoxon tests were used (α<0.20). The 19 patients were categorized based on their collaterals: Good collaterals (53%) and reduced collaterals (47%). The baseline characteristics were similar with the exception that the patients with good collaterals had a lower international normalized ratio (P=0.12) and were more likely to have a stroke on the left side (P=0.18) or to have a mismatch (P=0.05). The admission sORP values were comparable (169.5 vs. 164.2 mV; P=0.65), as was admission cORP (P=0.73). When considering only the patients who received IAT (n=12), admission sORP (P=0.69) and cORP (P=0.90) were also statistically similar. On day 2, after IAT, both groups experienced a worsening in ORP measures; however, the patients with good collaterals had a significantly lower sORP (169.4 vs. 203.5 mV; P=0.02) and a higher cORP (0.2 vs. 0.1 µC; P=0.002) compared with the patients with reduced collaterals. Neither sORP nor cORP were significantly different between TICI score groups on admission or on day 2. Upon discharge, patients with a TICI of 2b-3 had a significantly better sORP (P=0.03) and cORP (P=0.12) compared with those with a TICI of 0-2a. In conclusion, upon patient admission, the ORP parameters were not significantly different between the collateral circulation status groups for MCA occlusions. The ORP parameters worsened after IAT regardless of the collateral circulation status; however, after IAT, on day 2, patients with good collaterals experienced less oxidative stress (sORP) and had higher antioxidant reserves (cORP) than patients with reduced collaterals.

Epidemiology of C2 fractures and determinants of surgical management: analysis of a national registry.

Objective: Operative management of axis fractures (C2) usually depend on the stability and location of the break and individual patient characteristics. We sought to describe the epidemiology of C2 fractures and hypothesized that determinants for surgery would differ by fracture diagnosis. Methods: Patients with C2 fractures were identified from the US National Trauma Data Bank from January 1, 2017, to January 1, 2020. Patients were classified by C2 fracture diagnosis: odontoid type II, odontoid types I and III, and non-odontoid fracture (hangman's fracture or fractures through base of the axis). The primary comparison was C2 fracture surgery versus non-operative management. Multivariate logistic regression was used to identify independent associations with surgery. Decision tree-based models were developed to identify determinants for surgery. Results: There were 38 080 patients; 42.7% had an odontoid type II fracture; 16.5% had an odontoid type I/III fracture; and 40.8% had a non-odontoid fracture. All examined patient demographics, clinical characteristics, outcomes, and interventions differed by C2 fracture diagnosis. Overall, 5292 (13.9%) were surgically managed (17.5% odontoid type II, 11.0% odontoid type I/III, and 11.2% non-odontoid; p<0.001). The following covariates increased odds of surgery for all three fracture diagnoses: younger age, treatment at a level I trauma center, fracture displacement, cervical ligament sprain, and cervical subluxation. Determinants of surgery differed by fracture diagnosis: for odontoid type II, age ≤80 years, a displaced fracture, and cervical ligament sprain were determinants; for odontoid type I/III, age ≤85 years, a displaced fracture, and cervical subluxation were determinants; for non-odontoid fractures, cervical subluxation and cervical ligament sprain were the strongest determinants for surgery, by hierarchy. Conclusions: This is the largest published study of C2 fractures and current surgical management in the USA. Odontoid fractures, regardless of type, had age and fracture displacement as the strongest determinants for surgical management, whereas associated injuries were determinants of surgery for non-odontoid fractures. Level of evidence: III.

Propensity matched analysis examining the effect of passive reversal of direct oral anticoagulants on blood loss and the need for transfusions among traumatic geriatric hip fractures.

BACKGROUND: Reversal of direct oral anticoagulants (DOACs) is currently recommended prior to emergent surgery, such as surgical intervention for traumatic geriatric hip fractures. However, reversal methods are expensive and timely, often delaying surgical intervention, which is a predictor of outcomes. The study objective was to examine the effect of DOAC reversal on blood loss and transfusions among geriatric patients with hip fractures. METHODS: This retrospective propensity-matched study across six level I trauma centers included geriatric patients on DOACs with isolated fragility hip fractures requiring surgical intervention (2014-2017). Outcomes included: intraoperative blood loss, intraoperative pRBCs, and hospital length of stay (HLOS). RESULTS: After matching there were 62 patients (31 reversed, 31 not reversed), 29 patients were not matched. The only reversal method utilized was passive reversal (waiting ≥ 24 hours for elimination). Passively reversed patients had a longer time to surgery (mean, 43 vs. 18 hours, p < 0.01). Most patients (92%) had blood loss (90% passively reversed, 94% not reversed); the median volume of blood loss was 100 mL for both those groups, p = 0.97. Thirteen percent had pRBCs transfused (13% passively reversed and 13% not reversed); the median volume of pRBCs transfused was 525 mL for those passively reversed and 314 mL for those not reversed, p = 0.52. The mean HLOS was significantly longer for those passively reversed (7 vs. 5 days, p = 0.001). CONCLUSIONS: Passive DOAC reversal for geriatric patients with isolated hip fracture requiring surgery may be contributing to delayed surgery and an increased HLOS without having a significant effect on blood loss or transfusions. These data suggest that passive DOAC reversal may not be necessary prior to surgical repair of isolated hip fracture.

Development of a geriatric resuscitation protocol, utilization compliance, and outcomes.

Inconsistent application of trauma service resources and underevaluation of risk and resuscitation status in elderly trauma patients are problematic. We describe a geriatric protocol that includes initial lactate determination and trauma surgery admission. Protocol compliance rates were initial lactate determination, 67.9%; trauma service admission for overt or compensated (elevated lactate) shock, 73.6%; and trauma service consultation for nonshock patients, 67.8%. Implementation of this protocol resulted in a trend toward reduced mortality and reduced potentially preventable deaths.

Validity between self-report and biochemical testing of cannabis and drugs among patients with traumatic injury: brief report.

BACKGROUND: The relationship between drug use and traumatic injury is well documented, yet only a small proportion of patients are biochemically tested for cannabis and other substances. The study objective was to determine whether patient self-report can be used as a proxy for biochemical drug testing following traumatic injury. METHODS: This study was a secondary analysis that included 320 patients admitted to four level I trauma centers in Colorado and Texas, primarily involved in motor vehicle crash (89%). If performed, biochemical testing was collected via urine toxicology screen ("tox screen") for cannabis, amphetamines, barbiturates, cocaine, opiates, PCP, and benzodiazepines. All patients were screened for self-reported current drug use, which was evaluated for any drug and specifically for cannabis use. Analyses used to compare results of self-reported drug use and tox screen included sensitivity, specificity, positive, and negative predictive values, and percent agreement. RESULTS: Among 320 patients, 23% (n = 75) self-reported drug use; cannabis was the most frequently reported drug (n = 63). A tox screen was performed in 59% of patients (n = 190); the proportion of patients who had a tox screen was similar for those self-reporting drug use (60.0%) to those who denied using drugs (59.2%), p = 0.90. Among patients who had a tox screen performed, 18% (n = 35) tested positive for any drug, 12% (n = 22) tested positive for THC, and 7% (n = 13) tested positive for opiates. The percent agreement was 80% for any drug and 81% for cannabis. The specificity was 84-85%, indicating a high likelihood that a patient will not have a positive tox screen if they do not report using drugs. Negative predictive values were 90-95%, indicating a negative self-report correctly identified nearly all patients testing negative on tox screen. Sensitivity was only 60% and positive predictive values were 30-47% for cannabis and drugs, respectively. CONCLUSION: These findings may negate the need for biochemical drug testing in this population, particularly as a "rule out" based on self-reporting. Future studies are needed to confirm these findings and should address risk of selection bias.

Predictors of transfer from a remote trauma facility to an urban level I trauma center for blunt splenic injuries: a retrospective observational multicenter study.

BACKGROUND: The decision-making for admission versus emergent transfer of patients with blunt splenic injuries presenting to remote trauma centers with limited resources remains a challenge. Although splenectomy is standard for hemodynamically unstable patients, the specific criterion for non-operative management continues to be debated. Often, lower-level trauma centers do not have interventional radiology capabilities for splenic artery embolization, leading to transfer to a higher level of a care. Thus, the aim of this study was to identify specific characteristics of patients with blunt splenic injuries used for admittance or transfer at a remote trauma center. METHODS: A retrospective observational study was performed to examine the management of splenic injuries at a mountainous and remote Level III trauma center. Trauma patients ≥ 18 years who had a blunt splenic injury and initially received care at a Level III trauma center prior to admittance or transfer were included. Data were collected over 4.5 years (January 1, 2016 - June 1, 2020). Patients who were transferred out in > 24 h were excluded. Patient demographics, injury severity, spleen radiology findings, and clinical characteristics were compared by decision to admit or transfer to a higher level of care ≤ 24 h of injury. Results were analyzed using chi-square, Fisher's exact, or Wilcoxon tests. Multivariable logistic models were used to identify predictors of transfer. RESULTS: Of the 73 patients included with a blunt splenic injury, 48% were admitted and 52% were transferred to a Level I facility. Most patients were male (n = 58), were a median age of 26 (21-42) years old, most (n = 62) had no comorbidities, and 47 had been injured from a ski/snowboarding accident. Compared to admitted patients, transferred patients were significantly more likely to be female (13/38 vs. 3/36, p = 0.007), to have an abbreviated injury scale score ≥ 3 of the chest (31/38 vs. 7/35, p = 0.002), have a higher injury severity score (16 (16-22) vs. 13 (9-16), p = 0.008), and a splenic injury grade ≥ 3 (32/38 vs. 12/35, p < 0.001). After adjustment, splenic injury grade ≥ 3 was the only predictor of transfer (OR: 12.1, 95% CI: 3.9-37.3, p < 0.001). Of the 32 transfers with grades 3-5, 16 were observed, and 16 had an intervention. Compared to patients who were observed after transfer, significantly more who received an intervention had a blush on CT (1/16 vs. 7/16, p = 0.02) and a higher median spleen grade of 4 (3-5) vs. 3 (3-3.5), p = 0.01). CONCLUSIONS: Our data suggest that most patients transferred from a remote facility had a splenic injury grade ≥ 3, with concomitant injuries but were hemodynamically stable and were successfully managed non-operatively. Stratifying by spleen grade may assist remote trauma centers with refining transfer criteria for solid organ injuries.