Associations between hollow viscus injury and acute kidney injury in blunt abdominal trauma: A national trauma data bank analysis.

PURPOSE: It is well established that hollow viscus perforation leads to sepsis and acute kidney injury (AKI) in non-trauma patients. However, the relationship between traumatic hollow viscus injury (HVI) and AKI is not well understood. Utilizing data from the National Trauma Data Bank, we investigated whether HVI serves as a risk factor for AKI. Additionally, we examined the characteristics of AKI in stable patients who underwent conservative treatment. METHODS: We reviewed blunt abdominal trauma (BAT) cases from 2012 to 2015, comparing patients with and without AKI. Significant factors from univariate analysis were tested in a multivariate logistic regression (MLR) to identify independent AKI determinants. We also analyzed subsets: patients without HVI and stable patients given conservative management. RESULTS: Out of the 563,040 BAT patients analyzed, 9073 (1.6%) developed AKI. While a greater proportion of AKI patients had HVI than those without AKI (13.3% vs. 5.2%, p < 0.001), this difference wasn't statistically significant in the MLR (p = 0.125). Notably, the need for laparotomy (odds = 3.108, p < 0.001) and sepsis (odds = 13.220, p < 0.001) were identified as independent risk factors for AKI. For BAT patients managed conservatively (systolic blood pressure >90 mmHg, without HVI or laparotomy; N = 497,066), the presence of sepsis was a significant predictor for the development of AKI (odds = 16.914, p < 0.001). CONCLUSIONS: While HVI wasn't a significant risk factor for AKI in BAT patients, the need for laparotomy was. Stable BAT patients managed conservatively are still at risk for AKI due to non-peritonitis related sepsis.

Comparison of Outcomes in Below-Knee Amputation Between Vascular, General, and Orthopedic Surgeons.

INTRODUCTION: General surgeons (GS), orthopedic surgeons (OS), and vascular surgeons (VS) can perform below-knee amputation (BKA) operations. We compared the outcomes of BKA patients among the three specialties. METHODS: Adult patients who underwent a BKA were identified from the 2016-2018 National Surgical Quality Improvement Project database. Statistical data for orthopedic and vascular BKA cases were then compared with GS cases using logistic regression analysis. Outcomes included mortality, length of hospital stay, and complications. RESULTS: There were 9619 BKA cases. VS had the highest volume of BKA with 58.9% of the cases, compared to GS at 22.9% and OS at 18.1%. 4.4% of general surgery patients had severe frailty compared to OS (3.3%) and VS (3.4%, P < 0.001). VS has the lowest rates of emergency cases (11.9% versus 16.1 for GS versus 15.8% versus OS) and the most favorable wound classification (38.3%, versus 48.7% for GS and VS). Peripheral vascular disease was notably highest in VS (34.0% versus. 20.6% for GS and 9.9% for OS, P < 0.001). Compared to GS, VS was more likely to have a prolonged length of stay (odds ratio) (OR)(1.409), 95% CI 1.265-1.570) while OS was less likely (OR 0.650, 95% CI 0.561-0.754). OS had a lower risk of complications (OR 0.781, 95% CI 0.674-0.904). Mortality was not significantly different among the three specialties. CONCLUSIONS: The National Surgical Quality Improvement Project retrospective analysis of BKA cases suggested that mortality was not statistically different when performed by VS, GS, and OS. There were fewer overall complications when OS performed a BKA, but this is more likely a result of operating upon a generally healthier patient population with lower incidence of preoperative comorbid conditions.

The Role of Open Cardiopulmonary Resuscitation in Chest Trauma Patients with No Sign of Life: A National Trauma Data Bank Study.

PURPOSE: The effectiveness of open cardiopulmonary resuscitation (OCPR) remains controversial for trauma patients. In this current study, the role of OCPR in managing chest trauma patients is evaluated using nationwide real-world data. METHODS: From 2014 to 2015, the National Trauma Data Bank was retrospectively queried for chest trauma patients with out-of-hospital cardiac arrest status. The emergency department (ED) and overall survival of patients without signs of life were analyzed. Multivariate logistic regression (MLR) analysis was performed to evaluate independent factors of mortality for the target group. Furthermore, a subset group of patients who survived after the ED were studied, focusing on the duration of survival after leaving the ED. RESULTS: A total of 911 patients were enrolled in this study (OCPR vs. non-OCPR: 161 patients vs. 750 patients). The average overall mortality rate was 98.6% (N = 898). Among penetrating chest trauma patients, non-survivors in the ED had significantly higher proportions of gunshot injuries (83.9% vs. 69.7%, p = 0.001) and lower proportions of OCPR (20.7% vs. 44.4%, p < 0.001). MLR analysis showed that gunshot injuries and non-OCPR were significantly related to ED mortality in penetrating trauma patients without signs of life (odds ratio = 2.039, p = 0.006 and odds ratio = 2.900, p < 0.001, respectively). However, the overall survival rate of patients after ED survival (n = 99) was 9.9%, and only 21.2% (n = 21) of them survived more than 1 day after leaving the ED. CONCLUSION: OCPR could be considered in situations where appropriate indications exist. The survival benefit was observed in critically ill patients with penetrating chest trauma who show no signs of life. By enhancing ED survival, OCPR may also contribute to overall survival improvement.

Validation of the Twenty-Four-Hour Threshold for Bladder Repair: Impact on Infection Rates Using the National Trauma Data Bank.

PURPOSE: This study aimed to validate the previously reported association between delayed bladder repair and increased infection rates using the National Trauma Data Bank (NTDB). METHODS: Bladder injury patients with bladder repair in the NTDB from 2013 to 2015 were included. Propensity score matching (PSM) was used to compare mortality, infection rates, and hospital length of stay (LOS) between patients who underwent bladder repair within 24 h and those who underwent repair after 24 h. Linear regression and multivariate logistic regression analyses were also performed. RESULTS: A total of 1658 patients were included in the study. Patients who underwent bladder repair after 24 h had significantly higher infection rates (5.4% vs. 1.2%, p = 0.032) and longer hospital LOS (17.1 vs. 14.0 days, p = 0.032) compared to those who underwent repair within 24 h after a well-balanced 1:1 PSM (N = 166). Linear regression analysis showed a positive correlation between time to bladder repair and hospital LOS for patients who underwent repair after 24 h (B-value = 0.093, p = 0.034). Multivariate logistic regression analysis indicated that bladder repair after 24 h increased the risk of infection (odds = 3.162, p = 0.018). Subset analyses were performed on patients who underwent bladder repairs within 24 h and were used as a control group. These analyses showed that the time to bladder repair did not significantly worsen outcomes. CONCLUSIONS: Delayed bladder repair beyond 24 h increases the risk of infection and prolongs hospital stays. Timely diagnosis and surgical intervention remain crucial for minimizing complications in bladder injury patients.

Is Maxillofacial Gunshot Wound Location Associated With Operative Intervention?

PURPOSE: Gunshot wound (GSW) injuries are an important public health concern in the United States. The study purpose was to measure the association between GSW location and need for operative treatment. METHODS: This was a retrospective cohort study. Sample consisted of all patients treated for maxillofacial gunshot wound injuries at Cook County Health from 2008 to 2018. The sample data were collected through a retrospective charts review and review of computed tomography imaging. The predictor variable was the region of the face involved with the GSW and it was divided into 3 levels, upper face (UF), middle face (MF), and lower face (LF). The outcome variable was whether operative intervention was rendered or not (operative vs no intervention). Other variables of interest collected included patient demographics, the type of surgical intervention, disposition (home vs rehab/morgue), rate of intracranial injury, and need for blood transfusion. Data analysis was performed using Chi-square for proportions and relative risk (RR) with 95% confidence interval (CI). RESULTS: A total of 180 patients were identified to have sustained GSW injuries to the face during abovementioned time frame. Of those, 120 patients had isolated GSW injuries with no other organs involvement. The median age was 25 years. Majority of the patients were males (94%). The involved facial region appeared to influence the need for operative management and this reached statistical significance (Chi-square 22.703, P < .001). GSW injuries to LF were 2.94 times more likely to require operative intervention than injuries to the MF (RR = 2.94, 95% CI = 1.625-5.327). Injuries of the UF were 2 times more likely to require operative intervention than injuries of the MF (RR = 2.03, 95% CI 1.023-4.008). Injuries to the UF were more likely to be associated with intracranial injuries (Chi-square = 20.522, P < .001). CONCLUSIONS: In patients with facial GSW injuries, there is an association between injury location and the need for operative intervention. Injuries to the LF were most likely to require surgical intervention followed by the UF and MF, respectively.

The Impact of the Affordable Care Act on Trauma Outcomes in At-Risk Groups: An Interrupted Time Series Analysis with Control Group.

OBJECTIVE: Analyze the impact of the Affordable Care Act (ACA) on trauma outcomes at a population level and within at-risk subgroups. BACKGROUND: Trauma disproportionately affects the uninsured. Compared to the insured, uninsured patients have worse functional outcomes and increased mortality. The goal of the ACA was to increase access to insurance. METHODS: An interrupted time series was conducted using data from the National Inpatient Sample database between 2011 and 2016. Data from Alberta, Canada was used as a control group. Mortality, length of stay, and probability of discharge home with or without home health care was examined using monthly time intervals, with January 2014 as the intervention time. Single and multiple group interrupted time series were conducted. Subgroup analyses were conducted using income quartiles and race. RESULTS: After the intervention, there was a monthly reduction in mortality of 0.0148% ( P < 0.01) in the American cohort: there was no change in the Canadian cohort. The White subgroup experienced a mortality reduction: the non-White subgroup did not. There was no significant change in length of stay or discharge home rate at a population level. There was a monthly increase in the probability of discharge with home health (0.0247%: P < 0.01); this was present in the lower-income quartiles and both race groups. The White subgroup had a higher rate of utilization of home health pre-ACA, and this discrepancy persisted post-ACA. CONCLUSIONS: The ACA is associated with improved mortality and increased use of home health services. Discrepancies amongst racial groups and income quartiles are present.

The effect of transarterial embolization versus nephrectomy on acute kidney injury in blunt renal trauma patients.

PURPOSE: The impact of transarterial embolization (TAE) and nephrectomy on acute kidney injury (AKI) in blunt renal trauma patients remains unclear, and we used the National Trauma Data Bank (NTDB) to investigate this issue. METHODS: Adult patients from the NTDB between 2007 and 2015 who survived traumatic events with blunt injuries were eligible for inclusion. The exclusion criteria were those without outcome information, who required dialysis, or with chronic renal failure prior to the traumatic injury. Patients sustaining hepatic, splenic, or pelvic fractures or who had bilateral nephrectomy were also excluded. The patients were divided into three treatment groups, including conservative treatment, TAE, and nephrectomy. Two statistical models, logistic regression (LR) and inverse probability treatment weighting (IPTW), were used to clarify the AKI predictors. RESULTS: The study included 10,096 patients. There were 9697 (96.0%), 202 (2.0%) and 197 (2.0%) patients in the conservative, TAE and nephrectomy groups, respectively. Nephrectomy was a statistically significant predictor of AKI in blunt renal trauma patients in the standard LR (odds ratio [OR], 4.58; 95% confidence interval [CI] 1.92-10.38; p < 0.001) and IPTW (OR, 5.16; 95% CI 1.07-24.85; p = 0.023) models. In addition, TAE was not a risk factor for AKI in blunt renal trauma patients (p > 0.05 in all models). CONCLUSION: AKI is less likely affect patients with blunt renal trauma with TAE than those with nephrectomy. Nephrectomy is a risk factor for AKI in blunt renal trauma patients. TAE should be considered first when blunt renal trauma patients need a hemostatic procedure.

The American Association for the Surgery of Trauma (AAST) Liver Injury Grade Does Not Equally Predict Interventions in Blunt and Penetrating Trauma.

INTRODUCTION: The AAST liver injury grade has a validated association with mortality and need for operation. AAST liver injury grade is the same regardless of the mechanism of trauma. METHODS: A 5-year retrospective review of all liver injuries at an urban, level-one trauma center was performed. RESULTS: Totally, 315 patients were included (29% blunt, 71% penetrating). In blunt trauma, AAST grade was associated with need for laparotomy (0%, 7%, 5%, 33%, 29%, Grade 1-5, p = 0.01), angiography (0%, 7%, 25%, 40%, 57%, p < 0.001), embolization (0%, 7%, 15%, 33%, 43%, p = 0.01), and percutaneous drainage procedures (13% use in Grade 4, otherwise 0%, p = 0.04), but not ERCP (0% for all grades). In penetrating trauma, AAST grade was associated with need for angiography (7%, 4%, 15%, 24%, 30%, p < 0.01) and percutaneous drainage (7%, 2%, 14%, 18%, 26%, p = 0.03) and had a marginal association with embolization (0%, 4%, 11%, 13%, 22%, p = 0.06). Laparotomy, ERCP, sphincterotomy, and stenting rates increased with AAST grade, but this was not statistically significant. CONCLUSION: AAST grade is associated with the need for surgical hemostasis, angioembolization, and percutaneous drainage in both penetrating and blunt trauma. Operative, endoscopic, and percutaneous procedures are utilized more in penetrating trauma. Angioembolization was used more in blunt trauma. Mechanism should be considered when using AAST grade to guide management of liver injuries.

Can the 5-item Modified Frailty Index Predict Outcomes in Geriatric Trauma? A National Database Study.

BACKGROUND: Frailty results in increased vulnerability to adverse outcomes following trauma. We investigated the association between the 5-item modified frailty index (mFI-5) and outcomes in geriatric trauma patients. METHODS: The 2011-2016 Trauma Quality Improvement Program database was used to study outcomes in patients ≥ 65 years old. The mFI-5 was measured and categorized into no frailty (mFI-5 = 0), moderate frailty (mFI-5 = 0.2), and severe frailty (mFI-5 ≥ 0.4). Multivariable logistic regression analyses were performed to identify independent factors of mortality and complications. RESULTS: 26,963 cases met the inclusion criteria, of whom 25.5% were not frail, 38% were moderately frail, and 36.6% were severely frail. Mean age (± SD) was 76 ± 7 years, 61.5% were male, and 97.8% sustained blunt injuries. Median Injury Severity Score (ISS) was 17 (IQR = 10-26), and the median Glasgow Coma Scale was 15 (IQR = 12-15). Overall mortality was 30.6%. Factors independently associated with mortality were age (OR = 1.07 per year, 95%CI 1.06-1.07), blunt trauma (OR = 1.44, 95%CI 1.19 -1.75), ISS (OR = 1.04 per unit increase in ISS, 95%CI 1.03-1.04), and severe frailty (OR = 1.23, 95%CI 1.15-1.32). Interestingly, male sex and GCS appeared to be protective factors with OR of 0.88 (95%CI 0.83 - 0.93) and 0.89 per point change in GCS (95%CI 0.88-0.9), respectively. Moderate (OR = 1.27, 95%CI 1.19-1.25) and severe frailty (OR = 1.49, 95%CI 1.-1.59) were significantly associated with in-hospital complications. CONCLUSION: Moderate and severe frailty were significant predictors of complications. Only severe frailty was associated with short-term mortality. The mFI-5 can be used as an objective measure to stratify risks in geriatric trauma.

The Geriatric Nutritional Risk Index Is an Independent Predictor of Adverse Outcomes for Total Joint Arthroplasty Patients.

BACKGROUND: Malnutrition affects patient outcomes after total joint arthroplasty (TJA). Although hypoalbuminemia has been used as a surrogate, there is no unanimous method for screening and assessing malnutrition. This study aimed to determine if malnutrition, as defined by the Geriatric Nutritional Risk Index (GNRI), is independently correlated with short-term (<30 days) postoperative complications and prognosis in patients undergoing TJA. METHODS: The 2016-2019 American College of Surgeons National Surgical Quality Improvement Program was queried for all patients aged >65 years who underwent TJA. Based on GNRI value, patients were divided into 3 groups: normal nutrition (GNRI >98), moderate malnutrition (GNRI 92-98), and severe malnutrition (GNRI <92). After adjusting for potential confounders, multivariable regression models were used to analyze the association between GNRI and patient outcomes. RESULTS: A total of 191,087 patients were included in the study. Prevalence of malnutrition based on body mass index (<18.5 kg/m2), albumin (<3.5 mg/dL), and GNRI (≤98) was 0.41% (784), 4.17% (7975), and 15.83% (30,258). Adjusted analysis showed that compared with normal nutrition, moderate and severe malnutrition status were associated with a higher rate of transfusion, readmission, and postoperative length of stay over 8 days (P < .05). Severe malnutrition was also associated with pneumonia, surgical site infection, urinary tract infection, sepsis, and revision surgery (P < .05). CONCLUSION: Malnutrition, as defined by GNRI, is an independent predictor of adverse outcomes after TJA, including 30-day readmission, revision surgery, and increased length of stay. GNRI can be used to routinely screen and assess patient nutritional status before TJA and counsel patients and families appropriately. LEVEL OF EVIDENCE: Level 3: Retrospective Cohort Study.

There Is No Weekend Effect in the Trauma Patient.

BACKGROUND: The presence of a "weekend effect", that is, increased morbidity/mortality for patients admitted to the hospital on a weekend, has been reported in numerous studies across many specialties. Postulated causes include reduced weekend staffing, increased time between admission and undergoing procedures/surgery, and decreased subspecialty availability. The aim of this study is to evaluate if a "weekend effect" exists in trauma care in the United States. METHODS: Using the 2012-2015 National In-patient Sample database from the Healthcare Cost and Utilization Project, adults with trauma diagnoses who were admitted nonelectively were analyzed. Using logistic and negative binomial regression adjusted for survey-related discharge weights and statistically significant covariables, mortality and length of stay (LOS) were assessed, respectively. Subgroup analysis was conducted using rural, urban teaching, and urban nonteaching hospital-type subgroups. Additional subgroup analysis of patients who required surgery during admission was also performed. RESULTS: A total of 22,451 patients were identified, with 3.94% admitted to rural and 81.42% to urban hospitals. Weekend admission did not have a statistically significant difference in adjusted-mortality (OR 0.928; 95% CI 0.858-1.003; P = 0.059) or LOS (IRR 0.978; 95% CI 0.945-1.011; P = 0.199). There was also no statistically significant increase in mortality or LOS for weekend admits in any of the hospital subgroups. CONCLUSIONS: There does not appear to be a weekend effect for trauma admission. This may be explained by the nature of trauma care in the United States, in which there is often 24-h in-house coverage regardless of day of the week. Replicating a trauma service coverage schedule may help other services decrease the presence of the weekend effect.

Pediatric Firearm-Related Injuries: Taking Kids Out of Harm's Way Begins with Targeted Prevention.

BACKGROUND: Firearm-related injury is a public health crisis and remains the 3rd most common cause of death from ages 1 15 years. By evaluating events surrounding such injuries, evidence-based intervention strategies efforts may be targeted to maximize impact. MATERIAL AND METHODS: A retrospective chart review was performed for firearm-related injuries in patients 15 years-old and under at an urban Pediatric Level 1 Trauma Center between January 2016 and December 2020. Age, gender, race/ethnicity, injury severity score (ISS), reported cause of injury, timing of injury around school and curfew, and mortality were evaluated. Medical Examiner data identified other deaths that occurred within the hospital's catchment area. RESULTS: There were 195 injuries including 14 from the Medical Examiner. Overall, 82.6% were male with median age of 14 years (range 1-15; IQR 13-15), and median ISS of 5 (IQR 1-10). African-American children comprised 74.9% of the cohort while only representing 35.9% of local schools. Intentional interpersonal injuries comprised 65.6%; 17.4% were bystanders; 7.2% were negligent discharges; and 0.5% suicide. Median age for intentional interpersonal injuries was 14 years (IQR 13-15) compared to 11 years (IQR 8-14, P = 0.03) for negligent discharges. Regarding timing, 6.9% of injuries occurred during school hours; 56.4% after school or during non-school days; and 36.7% were after legal curfew. Mortality rate was 17.4%. CONCLUSIONS: Firearm safety education and community-based violence intervention should start in the pre-teen years. Pediatric firearm-related injury prevention strategies must be multifaceted addressing structural racism, truancy, curfew violation, extra-curricular activities, childcare options, firearm safety education, violence reduction, suicide prevention, and recidivism.

Association between Torso Gunshot Wound Volumes of Trauma Centers and Outcomes of Torso Gunshot Wound Patients. A Propensity-Matched Nationwide Cohort Study.

Objective: The number and type of patients treated by trauma centers can vary widely because of a number of factors. There might be trauma centers with a high volume of torso GSWs that are not designated as high-level trauma centers. We proposed that, for torso gunshot wounds (GSWs), the treating hospital's trauma volume and not its trauma center level designation drives patient prognosis.Methods: The National Trauma Data Bank was queried for torso GSWs. The characteristics of torso GSWs in trauma centers with different volumes of torso GSWs were compared. The association between torso GSW volumes of trauma centers and the outcomes of torso GSWs were evaluated with propensity score matching (PSM) and multivariate logistic regression (MLR) analysis.Results: There were 618 trauma centers that treated 14,804 torso GSW patients in two years (2014-2015). In 191 level I trauma centers, 82 of them (42.9%, 82/191) treated <1 torso GSW per month. After well-balanced PSM, patients who were treated in higher volume trauma centers (≥9 torso GSWs/month) had a significantly lower mortality rate (7.9% vs. 9.7%). Patients treated in trauma centers with ≥9 torso GSWs/month had a 30.9% (odds ratio = 0.764) lower probability of death than if sent to trauma centers with <9 torso GSWs/month. Treatment in level I or II trauma centers did not significantly affect mortality.Conclusion: There is an uneven distribution of torso GSWs among trauma centers. Torso GSWs treated in trauma centers with ≥9 torso GSWs/month have significantly superior outcomes with regard to survival.

Obesity May Require a Higher Level of Trauma Care: A Propensity-Matched Nationwide Cohort Study.

OBJECTIVE: Stable patients with less severe injuries are not necessarily triaged to high-level trauma centers according to current guidelines. Obese patients are prone to comorbidities and complications. We hypothesized that stable obese patients with low-energy trauma have lower mortality and fewer complications if treated at Level-I/II trauma centers. Methods: Blunt abdominal trauma (BAT) patients with systolic blood pressures ≥90mmHg, Glasgow coma scale ≥14, and respiratory rates at 10-29 were derived from the National Trauma Data Bank between 2013-2015. Per current triage guidelines, these patients are not necessarily triaged to high-level trauma centers. The relationship between obesity and mortality of stable BAT patients was analyzed. A subset analysis of patients with injury severity scores (ISS) <16 was performed with propensity score matching (PSM) to evaluate outcomes between Level-I/II and Level-III/IV trauma centers. Outcomes of obese patients were compared between Level-I/II and Level-III/IV trauma centers. Non-obese patients were analyzed as a control group using a similar PSM cohort analysis. Results: 48,043 stable BAT patients in 707 trauma centers were evaluated. Non-survivors had a significantly higher body mass index (BMI) (28.7 vs. 26.9, p < 0.001) and higher proportion of obesity (35.6% vs. 26.5%, p < 0.001) than survivors. After a PSM (1,502 obese patients: 751 in Level-I/II trauma centers and 751 in Level-III/IV trauma centers), obese patients treated in Level-I/II trauma centers had significantly lower complication rates than obese patients treated in other trauma centers (20.2% vs. 26.6%, standardized difference = 0.151). The complication rate of obese patients treated at Level-I/II trauma centers was 20.6% lower than obese patients treated at other trauma centers. Conclusion: Obesity plays a role in the mortality of stable BAT patients. Obese patients with ISS < 16 have lower complication rates at Level-I/II trauma centers compared to obese patients treated at other trauma centers. Obesity may be a consideration for triaging to Level-I/II trauma centers.

Surviving traumatic cardiac arrest: Identification of factors associated with survival.

INTRODUCTION: The endpoint of resuscitative interventions after traumatic injury resulting in cardiopulmonary arrest varies across institutions and even among providers. The purpose of this study was to examine survival characteristics in patients suffering torso trauma with no recorded vital signs (VS) in the emergency department (ED). METHODS: The National Trauma Data Bank was analyzed from 2007 to 2015. Inclusion criteria were patients with blunt and penetrating torso trauma without VS in the ED. Patients with head injuries, transfers from other hospitals, or those with missing values were excluded. The characteristics of survivors were evaluated, and statistical analyses performed. RESULTS: A total of 24,191 torso trauma patients without VS were evaluated in the ED and 96.6% were declared dead upon arrival. There were 246 survivors (1%), and 73 (0.3%) were eventually discharged home. Of patients who responded to resuscitation (812), the survival rate was 30.3%. Injury severity score (ISS), penetrating mechanism (odds ratio [OR] 1.99), definitive chest (OR 1.59) and abdominal surgery (OR 1.49) were associated with improved survival. Discharge to home (or police custody) was associated with lower ISS (OR 0.975) and shorter ED time (OR 0.99). CONCLUSION: Over a recent nine-year period in the United States, nearly 25,000 trauma patients were treated at trauma centers despite lack of VS. Of these patients, only 73 were discharged home. A trauma center would have to attempt over one hundred resuscitations of traumatic arrests to save one patient, confirming previous reports that highlight a grave prognosis. This creates a dilemma in treatment for front line workers and physicians with resource utilization and consideration of safety of exposure, particularly in the face of COVID-19.

Obesity is Associated with Worse Outcomes Among Abdominal Trauma Patients Undergoing Laparotomy: A Propensity-Matched Nationwide Cohort Study.

INTRODUCTION: Obesity is associated with increased morbidity and mortality in abdominal trauma patients. The characteristics of abdominal trauma patients with poor outcomes related to obesity require evaluation. We hypothesize that obesity is related to increased mortality and length of stay (LOS) among abdominal trauma patients undergoing laparotomies. METHODS: Abdominal trauma patients were identified from the National Trauma Data Bank between 2013 and 2015. Patients who received laparotomies were analyzed using propensity score matching (PSM) to evaluate the mortality rate and LOS between obese and non-obese patients. Patients without laparotomies were analyzed as a control group using PSM cohort analysis. RESULTS: A total of 33,798 abdominal trauma patients were evaluated, 10,987 of them received laparotomies. Of these patients, the proportion of obesity in deceased patients was significantly higher when compared to the survivors (33.1% vs. 26.2%, p < 0.001). Elevation of one kg/m2 of body mass index independently resulted in 2.5% increased odds of mortality. After a well-balanced PSM, obese patients undergoing laparotomies had significantly higher mortality rates [3.7% vs. 2.4%, standardized difference (SD) = 0.241], longer hospital LOS (11.1 vs. 9.6 days, SD = 0.135), and longer intensive care unit LOS (3.5 vs. 2.3 days, SD = 0.171) than non-obese patients undergoing laparotomies. CONCLUSIONS: Obesity is associated with increased mortality in abdominal trauma patients who received laparotomies versus those who did not. Obesity requires a careful evaluation of alternatives to laparotomy in injured patients.

Morbid Obesity's Silver Lining: An Armor for Hollow Viscus in Blunt Abdominal Trauma.

BACKGROUND: Morbid obesity is usually accompanied by both subcutaneous and visceral fat accumulation. Fat can mimic an air bag, absorbing the force of a collision. We hypothesized that morbid obesity is mechanically protective for hollow viscus organs in blunt abdominal trauma (BAT). METHODS: The National Trauma Data Bank (NTDB) was queried for BAT patients from 2013 to 2015. We looked at the rate of gastrointestinal (GI) tract injuries in all BAT patients with different BMIs. A subset analysis of BAT patients with operative GI tract injuries was performed to evaluate the need for abdominal operation. Multivariate analyses were carried out to identify factors independently associated with increased GI tract injuries and associated abdominal operations. RESULTS: A total of 100,459 BAT patients were evaluated in the NTDB. Patients with GI tract injury had a lower proportion of morbidly obese patients [body weight index (BMI) ≥ 40 kg/m2)] (3.7% vs. 4.2%, p = 0.015) and instead had more underweight patients (BMI < 18.5) (5.9% vs. 5.0%, p < 0.001). The risk of GI tract injury decreased 11.6% independently in morbidly obese patients and increased 15.7% in underweight patients. Of the patients with GI tract injuries (N = 11,467), patients who needed a GI operation had a significantly lower proportion of morbidly obese patients (3.2% vs. 5.3%, p < 0.001). The risk of abdominal operation for GI tract injury decreased 57.3% independently in morbidly obese patients. Compared with underweight patients, morbidly obese patients had significantly less GI tract injury (6.0% vs. 13.3%, p < 0.001) and associated abdominal operation rates (65.2% vs. 73.3%, p < 0.001). CONCLUSION: Obesity is protective in BAT. This translates into lower rates of GI tract injury and operation in morbidly obese patients. In contrast, underweight patients appear to suffer a higher rate of GI tract injury and associated GI operations.

Prolonged length of stay in the emergency department and increased risk of hospital mortality in patients with sepsis requiring ICU admission.

BACKGROUND AND OBJECTIVES: Delayed patient admission to the intensive care unit (ICU) from the ED is common in China. Patients with severe sepsis or septic shock requiring ICU admission are in need of specialised monitoring and tailored treatment. Delayed admission to the ICU might be associated with adverse clinical outcomes for patients with sepsis. METHODS: Patients with sepsis admitted to the ICU from the ED from January 2010 to April 2018 were retrospectively identified from a clinical data warehouse. The primary endpoint was in-hospital mortality. Length of stay in ED (EDLOS) was compared between survivors and non-survivors. A multivariable regression model was employed to adjust for potential confounding due to patient clinical condition. RESULTS: A total of 1997 patients, including 473 non-survivors and 1524 survivors, were included. The crude mortality rate for patients with EDLOS <6 hours was 21.4%, which was significantly lower than patients with EDLOS of 12-24 hours (31.9%), and those with EDLOS >24 hours (31.8%). After adjusting for PaO2/FiO2, serum creatinine, age, Sequential Organ Failure Assessment, body mass index, lactate, comorbidities and infection site, EDLOS continued to be independently associated with increased risk of hospital mortality. Compared with the group with EDLOS <6 hours, those with EDLOS between 12and24 hours (OR 1.82, 95% CI 1.28 to 2.58) and EDLOS >24 hours (OR 1.79, 95% CI 1.27 to 2.52) showed a significantly increased risk of death. CONCLUSIONS: Our study shows that prolonged EDLOS is independently associated with increased risk of hospital mortality in patients with sepsis requiring ICU admission.

The Effects of Pulmonary Risk Factors and Combination Thoracic Osseous Fractures on Mortality and Outcomes of Surgical Stabilization of Rib Fractures.

BACKGROUND: Rib fixation for traumatic rib fractures is advocated to decrease morbidity and mortality in select patient populations. We intended to investigate the effect of combination osseous thoracic injuries on mortality with the hypothesis that combination injuries will worsen overall mortality and that SSRF will improve outcomes in combination injuries and in high-risk patients. METHODS: Patients with rib fractures were identified from the Trauma Quality Improvement Project registry from 2019. Patients were then divided into rib fracture(s) alone or in combination with sternal, thoracic vertebra, or scapula fracture. Patients were also categorized into those with COPD and smokers. Patients with AIS >3 outside of thorax were excluded. Patients were subcategorized into those who had rib fixation verse nonoperative management for all subgroups. Analysis was performed to evaluate the efficacy of rib fixation. RESULTS: A total of 111,066 patients were included for analysis. The overall mortality was 1.4%. Patients with COPD had over double the mortality risk, with an overall mortality of 3.4%. Combination injuries did not appear to increase mortality. SSRF did not decrease mortality; however, the number of patients in this group was too small to complete statistical analysis. The overall complication rate was 0.43%. There was a trend towards an increase in extrapulmonary complications in the group that underwent surgical fixation. DISCUSSION: Mortality from rib fractures with concomitant osseous thoracic fracture appears to be low. However, mortality is increased in patients with COPD regardless of rib fracture pattern. The number of patients who underwent SSRF was too small to make a statistical comparison.