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OBJECTIVE: Blunt thoracic aortic injury (BTAI) is a major cause of morbidity and mortality in trauma patients. Although outcomes for BTAI have been described in younger patient populations, elderly patients may present with different patterns of injury and have unique factors contributing to morbidity and mortality. This study aims to describe patterns of presentation and management in elderly patients presenting with BTAI using a nationwide database. METHODS: Patients aged 65 years and older with BTAI from 2007 through 2016 were identified from the American College of Surgeons Trauma Quality Improvement Program database. Baseline demographics, initial physiologic variables, and clinical outcomes were extracted from the database. Our primary outcome was in-hospital mortality. An adjusted Poisson generalized regression model was used to compare rates of mortality for thoracic endovascular aortic repair (TEVAR), open repair, and nonoperative management. RESULTS: During the study period, 1322 patients aged 65 years and over sustained BTAI and survived past triage. Mean age was 74.7 years, and 60% were male. There were low incidence rates of concomitant major head (9.4%), spine (3.1%), and abdominal (5.7%) injuries. Three hundred fifty (26.5%) underwent TEVAR, 58 (4.4%) open repair, and 914 (69.1%) were managed nonoperatively. Utilization of TEVAR increased from 13.1% to 32.7% from 2007 to 2015, with subsequent decline to 19.9% in 2016 in favor of nonoperative management. Age, gender, and mean Injury Severity Scores (ISS) did not significantly differ by management. In-hospital mortality for the entire cohort was 37.9%. In an adjusted Poisson generalized regression model using inverse probability of treatment weighting controlling for age, race, gender, ISS, and hypotension, TEVAR was associated with the lowest mortality rate (1.31 deaths/100 person-years; 95% confidence interval [CI], 1.17-1.46) compared with open repair (2.53; 95% CI, 2.32-2.75; P < .001) and nonoperative management (3.91; 95% CI, 3.60-4.25; P < .001). There was a higher incidence of acute kidney injury, acute respiratory distress syndrome, and surgical site infection in the TEVAR group. CONCLUSIONS: This study describes the management of and outcomes for BTAI in the elderly population. The majority of patients did not undergo operative repair, which was associated with a higher risk of in-hospital mortality. In an adjusted analysis, TEVAR was associated with the lowest mortality rate, compared with open repair and nonoperative management.
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Implante de Prótese Vascular , Procedimentos Endovasculares , Traumatismos Torácicos , Lesões do Sistema Vascular , Ferimentos não Penetrantes , Humanos , Masculino , Idoso , Idoso de 80 Anos ou mais , Feminino , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/cirurgia , Aorta Torácica/lesões , Procedimentos Endovasculares/efeitos adversos , Aorta/cirurgia , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/cirurgia , Implante de Prótese Vascular/efeitos adversos , Traumatismos Torácicos/diagnóstico por imagem , Traumatismos Torácicos/cirurgia , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Fatores de RiscoRESUMO
OBJECTIVE: There is paucity of data about prevalence of pediatric acute respiratory distress syndrome (PARDS) in children with pulmonary contusion (PC). We intend to evaluate PC in children with chest trauma and the association between PC and PARDS. DESIGN: Retrospective review of Institutional Trauma Registry for patients with trauma. SETTING: Level 1 trauma center. PATIENTS: Age 18 years and younger with a diagnosis of PC. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 1916 children with trauma, 50 (2.6%) had PC. Patients with PC and PARDS had lower Glasgow Coma Scale (GCS) score (7 [3-15] vs 15 [15-15], P = .0003), higher Injury Severity Scale (ISS) score (29 [22-34] vs 19 [14-22], P = .004), lower oxygen saturations (96 [93-99] days vs 99 [98-100] days, P = .0009), higher FiO2 (1 [1-1] vs 0.21 [0.21-0.40], P < .0001), lower oxygen saturation/FiO2 (S/F) ratios (97 [90-99] vs 457 [280-471], P < .0001), need for invasive mechanical ventilation (IMV; 86% vs 23%, P < .0001), and mortality (28% vs 0%, P = .006) compared to those without PARDS. Forty-two percent (21/50) of patients needed IMV, of these 61% (13/21) had PARDS. Patients who needed IMV had significantly lower GCS score (8 [3-11] vs 15 [15-15], P < .0001), higher ISS score (27 [22-34] vs 18 [14-22], P = .002), longer length of stay (LOS; 7.5 [4-14] days vs 3.3 [2-5] days, P = .003), longer hospital LOS (18 [7.0-25] vs 5 [4-11], P = .008), higher PARDS rate (62% vs 7%, P < .0001), and lower S/F ratios (99 [94-190] vs 461 [353-471], P < .0001) compared to those who did not require IMV. Lower GCS score was independently associated with both PARDS and need for IMV. CONCLUSIONS: Pediatric ARDS in children with PC is independently associated with lower GCS score, and its presence significantly increased morbidity and mortality. Further larger studies are needed to explore association of lower GCS and higher injury score in children with PARDS and PC.
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Contusões , Lesão Pulmonar , Síndrome do Desconforto Respiratório , Adolescente , Criança , Contusões/complicações , Escala de Coma de Glasgow , Humanos , Lesão Pulmonar/complicações , Respiração Artificial , Síndrome do Desconforto Respiratório/etiologia , Estudos RetrospectivosRESUMO
OBJECTIVE: Traumatic popliteal artery injury is associated with an increased propensity for limb loss, morbidity, and mortality above an already elevated baseline risk to life and limb. Previous studies of outcomes in this patient group have been limited by selection bias. This study analyzed outcomes after blunt popliteal artery injury using propensity matching to reduce confounding variables associated with multiple mechanisms of traumatic vascular injury and to identify factors associated with amputation. METHODS: A retrospective review was conducted of prospectively collected data from the National Trauma Data Bank. Patients were identified using International Classification of Diseases, Ninth Revision codes related to patterns of blunt injury associated with popliteal arterial injury or intervention. Using Trauma Quality Improvement Program variables as a reference, specific characteristics were collected. Variables found significant on univariate analysis were used to generate propensity-matched amputation and nonamputation cohorts. Multivariate logistic regression was used to assess for risk factors associated with amputation and inpatient mortality. RESULTS: In total, 3029 patients with blunt popliteal artery injury were identified; 628 (20.7%) underwent amputation. Patients who underwent amputation presented with more frequent hypotension (systolic blood pressure of 0-99 mm Hg, 22.7% vs 12.8%; P < .001) and tachycardia (heart rate >120 beats/min, 28.5% vs 14.5%; P < .001). Limb loss was also associated with concurrent popliteal vein injury (18.3% vs 8.7%; P < .001) and tibial nerve injury (5.3% vs 1.3%; P < .001) as well as with elevated Injury Severity Score (median, 13 vs 9; P < .001) and lower extremity Abbreviated Injury Scale score (3 vs 2; P < .001). Subsequently, 794 patients were divided into equal number propensity-matched amputation and nonamputation cohorts. Regression analysis revealed that patients with diabetes mellitus (odds ratio [OR], 1.763; P = .049), popliteal vein injury (OR, 1.657; P = .012), or tibial nerve injury (OR, 3.537; P = .007) were more likely to undergo amputation. Further regression analysis with patients matched for Injury Severity Score revealed that age ≥86 years (OR, 38.092; P = .009), patellar fracture (OR, 3.445; P = .036), and elevated Abbreviated Injury Scale score (OR, 1.101; P < .001) were associated with higher risk of inpatient death. CONCLUSIONS: Trauma patients who sustain blunt popliteal artery injury are at an increased risk of amputation. Propensity-matched analysis revealed that concurrent popliteal vein and tibial nerve injury but not severity of tissue injury predicted limb loss.
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Amputação Cirúrgica , Artéria Poplítea/cirurgia , Lesões do Sistema Vascular/cirurgia , Ferimentos não Penetrantes/cirurgia , Adulto , Amputação Cirúrgica/efeitos adversos , Amputação Cirúrgica/mortalidade , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Artéria Poplítea/diagnóstico por imagem , Artéria Poplítea/lesões , Pontuação de Propensão , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/mortalidade , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/mortalidade , Adulto JovemRESUMO
INTRODUCTION: Conflicting evidence exists regarding the role of inferior vena cava filters (IVCFs) in the prevention of pulmonary embolism. The aim of this study was to review an institutional policy of prophylactic IVCF placement in all operative pelvic and acetabular fractures as a means of preventing PE by comparing it to a historical prepolicy period of significantly less aggressive IVCF placement. METHODS: The trauma registry of a single level 1 trauma center was retrospectively queried for all pelvic or acetabular fractures for the prepolicy and intervention periods as defined as January 2003-December 2008 and January 2009-December 2014, respectively-yielding 231 patients for analysis. The primary and secondary outcomes measured were the incidence of PE and deep vein thrombosis. RESULTS: The rate of prophylactic IVCF insertion significantly increased during the study period (p < 0.001). The incidence of pulmonary embolism (1.8% vs. 5.1%, p = 0.351) and DVT (19.3% vs. 10.3%, p = 0.231) were not significantly different when comparing the prepolicy and intervention cohorts. In patients with operative fractures, a nonsignificant trend of increasing incidence of DVTs was appreciated in patients with a prophylactic IVCF versus those without prophylactic IVCF (13 vs. 2, p = 0.222). DISCUSSION: A policy of increased use of prophylactic IVCFs in patients with operative pelvic and acetabular fractures failed to reduce the incidence of PE or DVT. In contrast, several case reports and institutional series have published several risks associated with IVCF placement including failure to retrieve temporary IVCF. CONCLUSION: The benefit of prophylactic IVCF in this patient population is unclear.
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Fraturas Ósseas/cirurgia , Ossos Pélvicos/cirurgia , Filtros de Veia Cava , Trombose Venosa/prevenção & controle , Adulto , Idoso , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/etiologia , Estudos Retrospectivos , Fatores de Tempo , Trombose Venosa/epidemiologiaRESUMO
BACKGROUND: Ground-level falls (GLFs) are the predominant mechanism of injury in US trauma centers and accompany a spectrum of comorbidities, injury severity, and physiologic derangement. Trauma center levels define tiers of capability to treat injured patients. We hypothesized that risk-adjusted observed-to-expected mortality (O:E) by trauma center level would evaluate the degree to which need for care was met by provision of care. MATERIALS AND METHODS: This retrospective cohort study used National Trauma Data Bank files for 2007-2014. Trauma center level was defined as American College of Surgeons (ACS) level I/II, ACS III/IV, State I/II, and State III/IV for within-group homogeneity. Risk-adjusted expected mortality was estimated using hierarchical, multivariable regression techniques. RESULTS: Analysis of 812,053 patients' data revealed the proportion of GLF in the National Trauma Data Bank increased 8.7% (14.1%-22.8%) over the 8 y studied. Mortality was 4.21% overall with a three-fold increase for those aged 60 y and older versus younger than 60 y (4.93% versus 1.46%, P < 0.001). O:E was lowest for ACS III/IV, (0.973, 95% CI: 0.971-0.975) and highest for State III/IV (1.043, 95% CI: 1.041-1.044). CONCLUSIONS: Risk-adjusted outcomes can be measured and meaningfully compared among groups of trauma centers. Differential O:E for ACS III/IV and State III/IV centers suggests that factors beyond case mix alone influence outcomes for GLF patients. More work is needed to optimize trauma care for GLF patients across the spectrum of trauma center capability.
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Acidentes por Quedas/mortalidade , Centros de Traumatologia/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Despite mostly favorable past evidence for use of intracranial pressure monitoring (ICPM), more recent data question not only the indications but also the utility of ICPM. The Fourth Edition Brain Trauma Foundation guidelines offer limited indications for ICPM. Evidence supports ICPM for reducing mortality in patients with severe traumatic brain injury (TBI) and cites decreased survival in elderly patients. METHODS: All patients ≥ 18 years of age with isolated TBI, head Abbreviated Injury Scale (AIS) ≥ 3, and a Glasgow Coma Scale (GCS) ≤ 8 between 2008 and 2014 were included from the National Trauma Data Bank. Exclusion criteria were head AIS = 6 and death within 24 hours. Patients with and without ICPM were compared using TBI-specific variables. Patients were then matched via propensity-score matching (PSM), and the odds ratio (OR) of death with ICPM was determined using logistic regression modeling for 8 different age strata. RESULTS: A total of 23,652 patients with a mean age of 56 years, median head AIS of 4, median GCS of 3, and overall mortality of 29.2% were analyzed. After PSM, ICPM was associated with death beginning at the age stratum of 56-65 years. Intracranial pressure monitoring was associated with survival beginning at the age-group 36-45 years. DISCUSSION: Based on a large propensity-matched sample of TBI patients, ICPM was not associated with improved survival for TBI patients above 55 years of age. Until level 1 evidence is available, this age threshold should be considered for further prospective study in determining indications for ICPM.
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Lesões Encefálicas Traumáticas , Pressão Intracraniana , Adulto , Idoso , Lesões Encefálicas Traumáticas/diagnóstico , Escala de Coma de Glasgow , Humanos , Pessoa de Meia-Idade , Monitorização Fisiológica , Pontuação de Propensão , Estudos ProspectivosRESUMO
BACKGROUND: During early spring 2020, New York City (NYC) rapidly became the first US epicenter of the COVID-19 pandemic. With an unparalleled strain on health care resources, we sought to investigate the impact of the pandemic on trauma visits and mortality in the United States' largest municipal hospital system. METHODS: We conducted a retrospective multicenter cohort study of the five level 1 trauma centers in NYC's public health care system, New York City's Health and Hospitals Corporation. Clinical characteristics, mechanism of injury, and mortality of trauma patients presenting during the early pandemic (March 1, 2020, to May 31, 2020) were compared with a similar period in the previous 2 years. To account for important patient and hospital-level confounding variables, we created a propensity score for treatment and applied inverse probability weighting. RESULTS: In March to May 2020, there was a 25% decrease in median number of monthly trauma visits (693 vs. 528; p = 0.02) but a 50% increase (15% vs. 22%; p = <0.001) in patients presenting for penetrating injuries, compared with the same period for 2018 and 2019. Injured patients with COVID were significantly more likely to die compared with those without COVID-19 (10.5% vs. 3.6%; p < 0.001). Overall, there was no significant difference in mortality for non-COVID-injured New Yorkers cared for in 2020 compared with 2018 and 2019. Less severely injured non-COVID patients (Injury Severity Score, <15), however, were significantly more likely to die compared with this same subgroup in 2018 and 2019 (adjusted relative risk, 2.7 [95% confidence interval, 1.5-4.7]). CONCLUSION: Despite a decline in overall trauma visits during the early part of the COVID pandemic in NYC, there was a significant increase in the proportion of penetrating mechanisms. Less-injured non-COVID patients experienced an increase in mortality in the early pandemic, possibly from a depletion of human and hospital resources from the large influx of COVID patients. These data lend support to the safeguarding of trauma system resources in the event of a future pandemic. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level III.
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COVID-19 , COVID-19/epidemiologia , Estudos de Coortes , Humanos , Cidade de Nova Iorque/epidemiologia , Pandemias , Estudos Retrospectivos , Centros de Traumatologia , Estados UnidosRESUMO
Importance: Although most massive transfusion protocols incorporate cryoprecipitate in the treatment of hemorrhaging injured patients, minimal data exist on its use in children, and whether its addition improves their survival is unclear. Objective: To determine whether cryoprecipitate use for injured children who receive massive transfusion is associated with lower mortality. Design, Setting, and Participants: This retrospective cohort study included injured patients examined between January 1, 2014, and December 31, 2017, at one of multiple centers across the US and Canada participating in the Pediatric Trauma Quality Improvement Program. Patients were aged 18 years or younger and had received massive transfusion, which was defined as at least 40 mL/kg of total blood products in the first 4 hours after emergency department arrival. Exclusion criteria included hospital transfer, arrival without signs of life, time of death or hospital discharge not recorded, and isolated head injuries. To adjust for potential confounding, a propensity score for treatment was created and inverse probability weighting was applied. The propensity score accounted for age, sex, race/ethnicity, injury type, payment type, Glasgow Coma Scale score, hypoxia, hypotension, assisted respirations, chest tube status, Injury Severity Score, total volume of blood products received, hemorrhage control procedure, hospital size, academic status, and trauma center designation. Data were analyzed from December 11, 2019, to August 31, 2020. Exposures: Cryoprecipitate use within the first 4 hours of emergency department arrival. Main Outcomes and Measures: In-hospital 24-hour and 7-day mortality. Results: Of the 2387 injured patients who received massive transfusion, 1948 patients were eligible for analysis. The median age was 16 years (interquartile range, 9-17 years), 1382 patients (70.9%) were male, and 807 (41.4%) were White. A total of 541 patients (27.8%) received cryoprecipitate. After propensity score weighting, patients who received cryoprecipitate had a significantly lower 24-hour mortality when compared with those who did not (adjusted difference, -6.9%; 95% CI, -10.6% to -3.2%). Moreover, cryoprecipitate use was associated with a significantly lower 7-day mortality but only in children with penetrating trauma (adjusted difference, -9.2%; 95% CI, -15.4% to -3.0%) and those transfused at least 100 mL/kg of total blood products (adjusted difference, -7.7%; 95% CI, -15.0% to -0.5%). Conclusions and Relevance: In this cohort study, early use of cryoprecipitate was associated with lower 24-hour mortality among injured children who required massive transfusion. The benefit of cryoprecipitate appeared to persist for 7 days only in those with penetrating trauma and in those who received extremely large-volume transfusion.
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Transfusão de Sangue , Fator VIII/uso terapêutico , Fibrinogênio/uso terapêutico , Hemorragia/terapia , Ferimentos não Penetrantes/terapia , Ferimentos Penetrantes/terapia , Adolescente , Criança , Feminino , Hemorragia/etiologia , Humanos , Masculino , Pontuação de Propensão , Estudos Retrospectivos , Taxa de Sobrevida , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/mortalidade , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/mortalidadeRESUMO
BACKGROUND: During the coronavirus disease 2019 pandemic, New York instituted a statewide stay-at-home mandate to lower viral transmission. While public health guidelines advised continued provision of timely care for patients, disruption of safety-net health care and public fear have been proposed to be related to indirect deaths because of delays in presentation. We hypothesized that admissions for emergency general surgery (EGS) diagnoses would decrease during the pandemic and that mortality for these patients would increase. METHODS: A multicenter observational study comparing EGS admissions from January to May 2020 to 2018 and 2019 across 11 NYC hospitals in the largest public health care system in the United States was performed. Emergency general surgery diagnoses were defined using International Classification Diseases, Tenth Revision, codes and grouped into seven common diagnosis categories: appendicitis, cholecystitis, small/large bowel, peptic ulcer disease, groin hernia, ventral hernia, and necrotizing soft tissue infection. Baseline demographics were compared including age, race/ethnicity, and payor status. Outcomes included coronavirus disease (COVID) status and mortality. RESULTS: A total of 1,376 patients were admitted for EGS diagnoses from January to May 2020, a decrease compared with both 2018 (1,789) and 2019 (1,668) (p < 0.0001). This drop was most notable after the stay-at-home mandate (March 22, 2020; week 12). From March to May 2020, 3.3%, 19.2%, and 6.0% of EGS admissions were incidentally COVID positive, respectively. Mortality increased in March to May 2020 compared with 2019 (2.2% vs. 0.7%); this difference was statistically significant between April 2020 and April 2019 (4.1% vs. 0.9%, p = 0.045). CONCLUSION: Supporting our hypothesis, the coronavirus disease 2019 pandemic and subsequent stay-at-home mandate resulted in decreased EGS admissions between March and May 2020 compared with prior years. During this time, there was also a statistically significant increase in mortality, which peaked at the height of COVID infection rates in our population. LEVEL OF EVIDENCE: Epidemiological, level IV.
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COVID-19/prevenção & controle , Emergências/epidemiologia , Mortalidade Hospitalar/tendências , Admissão do Paciente/estatística & dados numéricos , Doença Aguda/mortalidade , Doença Aguda/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Apendicite/diagnóstico , Apendicite/mortalidade , Apendicite/cirurgia , COVID-19/diagnóstico , COVID-19/epidemiologia , COVID-19/transmissão , Colecistite/diagnóstico , Colecistite/mortalidade , Colecistite/cirurgia , Serviço Hospitalar de Emergência , Hérnia Inguinal/diagnóstico , Hérnia Inguinal/mortalidade , Hérnia Inguinal/cirurgia , Hérnia Ventral/diagnóstico , Hérnia Ventral/mortalidade , Hérnia Ventral/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Necrose/diagnóstico , Necrose/mortalidade , Necrose/cirurgia , New York/epidemiologia , Pandemias/prevenção & controle , Admissão do Paciente/tendências , Úlcera Péptica/diagnóstico , Úlcera Péptica/mortalidade , Úlcera Péptica/cirurgia , Estudos Retrospectivos , SARS-CoV-2/isolamento & purificação , Infecções dos Tecidos Moles/diagnóstico , Infecções dos Tecidos Moles/mortalidade , Infecções dos Tecidos Moles/cirurgia , Tempo para o Tratamento/estatística & dados numéricos , Tempo para o Tratamento/tendências , Adulto JovemRESUMO
INTRODUCTION: There is a paucity of research addressing the morbidity and mortality associated with polytrauma in elderly patients. This study aimed to compare the outcomes of elderly trauma patients with an isolated lower extremity fracture, to patients lower extremity fractures and associated musculoskeletal injuries. METHODS: This study is a retrospective review from the National Trauma Database (NTDB) between 2008 and 2014. ICD 9 codes were used to identify patients 65 years and older with lower extremity fractures. Patients were categorize patients into three sub groups: patients with isolated lower extremity fractures (ILE), patients with two or more (multiple) lower extremity fractures (MLE) and, patients with at least one upper and at least one lower extremity fracture (ULE). Groups were stratified into patients age 65-80 and patients >80 years of age. RESULTS: A total 420,066 patients were included in analysis with 356,120 ILE fracture patients, 27,958 MLE fracture patients, and 35,988 ULE fracture patients. The MLE group reported the highest dispatch to ACS level 1 trauma centers at 31.8% followed by the ULE group at 28.5% and the ILE group at 24.7% of patients (p<0.001). The overall rate of complications was highest in the MLE group followed by the ULE and then the ILE group (41.4%, 40.3%, 36.1%, respectively p<0.001). Motility rates in patients >80 years old in the MLE group and ULE group were similar (1.483 vs 1.4432). However, in the 65-80 year group the odds of mortality was 1.260 in the MLE group and 1.450 in the ULE group (p<0.001), such that the odds of mortality after sustaining a MLE fracture increases with age, whereas this effect was not seen in the ULE group. CONCLUSION: Patients who sustained MLE and ULE fractures, had increased mortality, complications and in hospital care requirements as compared to patients with isolated lower extremity injuries. These outcomes are comparable between ULE and MLE fracture patients over the age of 80 however patients 65-80 with ULE fractures had increased mortality as compared patients 65-80 with MLE fractures. Understanding the unique considerations and requirements of elderly trauma patients is vital to providing successful outcomes.
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Traumatismos da Perna , Idoso , Idoso de 80 Anos ou mais , Humanos , Traumatismos da Perna/epidemiologia , Extremidade Inferior , Morbidade , Estudos Retrospectivos , Centros de TraumatologiaRESUMO
INTRODUCTION: Ketorolac is useful in acute pain management to avoid opiate-related complications; however, some surgeons fear associated acute kidney injury (AKI) and bleeding despite a paucity of literature on ketorolac use in trauma patients. We hypothesized that our institution's use of intravenous ketorolac for rib fracture pain management did not increase the incidence of bleeding or AKI. METHODS: Rib fracture patients aged 15 years and above admitted between January 2016-June 2018 were identified in our trauma registry along with frequency of bleeding events. AKI was defined as ≥ 1.5x increase in serum creatinine from baseline measured on the second day of admission (after 24 hours of resuscitation) or an increase of ≥ .3 mg/dL over a 48-hour period. Patients receiving ketorolac were compared to patients with no ketorolac use. RESULTS: Two cohorts of 199 control and 205 ketorolac patients were found to be similar in age, gender, admission systolic blood pressure (SBP), injury severity score, intravenous radiocontrast received, and transfusion requirements. Analysis revealed no difference in frequency of AKI using both definitions (8% vs. 7.3%, P = .79) and (19.6% vs. 15.1%, P = .24), respectively, or bleeding events (2.5% vs. 0%, P = .03). Logistic regression demonstrated that ketorolac use was not an independent predictor for AKI but age and admission SBP < 90 were. CONCLUSION: Use of ketorolac in this cohort of trauma patients with rib fractures did not increase the incidence of AKI or bleeding events.
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Injúria Renal Aguda/induzido quimicamente , Anti-Inflamatórios não Esteroides/uso terapêutico , Hemorragia/induzido quimicamente , Cetorolaco/uso terapêutico , Dor Musculoesquelética/tratamento farmacológico , Manejo da Dor/métodos , Fraturas das Costelas/complicações , Injúria Renal Aguda/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Hemorragia/epidemiologia , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Dor Musculoesquelética/etiologia , Manejo da Dor/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Patients who experience traumatic spine injuries remain in spinal precautions (SP) to minimize the risk of devastating cord injury while awaiting definitive management. This study examines the incidence of pneumonia (PNA), urinary tract infection (UTI), deep vein thrombosis (DVT), or pulmonary embolism (PE) in this population. STUDY DESIGN: From 2014 to 2016, 344 patients aged 18 and older with spinal column injuries were identified in a prospectively-collected registry at an urban, level 1 trauma center. After exclusion criteria, 330 patients were reviewed and the following were analyzed: demographics, duration of SP, time to intervention, and rates of PNA, UTI, and DVT or PE. Those patients kept in SP for ≤ 72 h ("prolonged") were compared to patients maintained in SP for > 72 h ("early"). RESULTS: Mean age was 54.6 years (SD, 21.7), median Injury Severity Score (ISS) 10 (IQR, 5-17). The median SP was 4.0 (IQR, 3.0-6.0) days. Fifty-eight (17.6%) patients underwent fixation and 170 (51.5%) received a brace. 102 (30.9%) patients initially awaiting a brace were cleared after MRI. 93 (28.2) patients suffered one of the tracked complications; 51 (15.5%) developed PNA, 35 (10.6%) UTI, 23 (7.0%) DVT, and 5 (1.5%) PE. Rate of overall complications between patients with SP ≤ 72 h versus patients with SP > 72 h was statistically significant (20.5% vs 34.6%, p = 0.005) as was the incidence of UTI (14.5 vs 6.0, p = 0.012). CONCLUSION: Prolonged SP (>72 h) is associated with increased rates of immobility-associated morbidities. Focus should be on prompt, definitive care and early mobilization. LEVEL OF EVIDENCE: III Retrospective review of prospectively-collected data.
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Restrição Física/efeitos adversos , Traumatismos da Medula Espinal/prevenção & controle , Traumatismos da Coluna Vertebral/complicações , Ferimentos e Lesões/complicações , Adulto , Idoso , Braquetes/estatística & dados numéricos , Estudos de Casos e Controles , Feminino , Fixação de Fratura/métodos , Fixação de Fratura/estatística & dados numéricos , Humanos , Doença Iatrogênica/epidemiologia , Incidência , Escala de Gravidade do Ferimento , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Pneumonia/epidemiologia , Embolia Pulmonar/epidemiologia , Restrição Física/estatística & dados numéricos , Estudos Retrospectivos , Traumatismos da Coluna Vertebral/diagnóstico por imagem , Tempo para o Tratamento , Infecções Urinárias/epidemiologia , Trombose Venosa/epidemiologia , Ferimentos e Lesões/epidemiologiaRESUMO
Penetrating cardiac injuries have a pre-hospital mortality of 94% with a subsequent in-hospital mortality of 50% among initial survivors (Leite et al., 2017 [1]). The Western Trauma Association (WTA) guidelines recommend resuscitative thoracotomy (RT) for patients with penetrating torso trauma and less than 15 min of cardiopulmonary resuscitation (CPR) Burlew et al. (2012) [2]. Penetrating cardiac injuries are classically repaired using skin-stapling devices and/or suture repair with or without pledgets (Wall et al., 1997 [3]). In this study, we present a case of penetrating cardiac injury where all the aforementioned techniques failed, and a new approach was explored. A fibrinogen/thrombin patch was used in this clinical setting, which is an off-label use of the product, we here present our encouraging outcome.
RESUMO
Thoracic analgesia plays a key role in management and outcomes of rib fractures and can generally be broken down into oral or parenteral medication administration and regional analgesia. Surgical stabilization of rib fractures (SSRF) may be an underused resource in the management of rib fractures. This study describes recent trends in rib fracture management and outcomes. National Trauma Data Bank datasets from 2008 to 2014 were reviewed. Patients with three or more rib fractures were identified, and the frequencies of epidural analgesia (EA), other regional analgesia, and SSRF were analyzed. Those older than 65 years were more likely to be admitted to the ICU but had shorter ICU length of stay, lower intubation, and need for tracheostomy rates. In addition, those older than 65 years had about 2.5 times higher mortality (6.3% vs 2.6%, P < 0.001). EA was used in only 3 per cent of the population and more commonly in the older than 65 years group (3.7% vs 2.8%, P < 0.001). Regardless of age, SSRF was more commonly performed when compared with the placement of EA (5.8% vs 3%). This difference was even greater in the younger than 65 years group, where 7 per cent underwent SSRF. Utilization of EA remains low nationally. SSRF should be considered not only for chest wall stabilization but also as an analgesic modality in selected patients. A more complete accounting of analgesic care in rib fracture patients is needed to allow a more detailed analysis of analgesia for rib fracture-related pain to elucidate optimal treatment.
Assuntos
Fixação de Fratura , Fraturas das Costelas/cirurgia , Adulto , Idoso , Analgesia Epidural , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fraturas das Costelas/etiologia , Resultado do TratamentoRESUMO
Importance: Although several studies have demonstrated an improvement in mortality for injured adults who receive whole-body computed tomography (WBCT), it is unclear whether children experience the same benefit. Objective: To determine whether emergent WBCT is associated with lower mortality among children with blunt trauma compared with a selective CT approach. Design, Setting, and Participants: A retrospective, multicenter cohort study was conducted from January 1, 2010, to December 31, 2014, using data from the National Trauma Data Bank on children aged 6 months to 14 years with blunt trauma who received an emergent CT scan in the first 2 hours after emergency department arrival. Data analysis was conducted from February 2 to December 29, 2017. Exposures: Patients were classified as having WBCT if they received CT head, CT chest, and CT abdomen/pelvis scans in the first 2 hours and as having a selective CT if they did not receive all 3 scans. Main Outcomes and Measures: The primary outcome was in-hospital mortality in the 7 days after ED arrival. To adjust for potential confounding, propensity score weighting was used. Subgroup analyses were performed for those with the highest mortality risk (ie, occupants and pedestrians involved in motor vehicle crashes, children with a Glasgow Coma Scale score lower than 9, children with hypotension, and those admitted to the intensive care unit). Results: Of the 42â¯912 children included in the study (median age [interquartile range], 9 [5-12] years; 27â¯861 [64.9%] boys), 8757 (20.4%) received a WBCT. Overall, 405 (0.9%) children died within 7 days. After adjusting for the propensity score, children who received WBCT had no significant difference in mortality compared with those who received selective CT (absolute risk difference, -0.2%; 95% CI, -0.6% to 0.1%). All subgroup analyses similarly showed no significant association between WBCT and mortality. Conclusions and Relevance: Among children with blunt trauma, WBCT, compared with a selective CT approach, was not associated with lower mortality. These findings do not support the routine use of WBCT for children with blunt trauma.
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Pontuação de Propensão , Tomografia Computadorizada por Raios X/métodos , Imagem Corporal Total/métodos , Ferimentos não Penetrantes/diagnóstico , Adolescente , Criança , Pré-Escolar , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Lactente , Escala de Gravidade do Ferimento , Masculino , Reprodutibilidade dos Testes , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia , Ferimentos não Penetrantes/mortalidadeRESUMO
BACKGROUND: Hip fractures are primarily a disease of the elderly. Advanced age and associated comorbidities in this patient population can lead to adverse outcomes. We routinely admit our hip fracture patients to the Trauma Service (TS). The goal of this study is to see if this policy has had a positive impact on patient outcome. METHODS: The Jacobi Medical Center Trauma and Operating Room registries were used to identify all patients aged 65 and over who presented with a hip fracture during the 5-year period from January 1, 2000 to December 31, 2004. Patient charts were used for data retrieval. Outcome variables were length of hospital stay (LOS), time from admission to surgery, in-hospital complication, and in-hospital mortality rates. RESULTS: Complete data were available in 255 patients out of a total of 274 admitted in the study period. The mean age was 81.0 years. The median Injury Severity Score was 10 (range, 9-34). Two hundred forty (94.1%) patients were admitted to the TS. The mean time from admission to surgery was 1.9 days and the mean LOS was 10.5 days. In-hospital complication rate and mortality were 35.8% and 2.1%, respectively. CONCLUSION: Our policy of admitting elderly hip fracture patients to the TS has resulted in a mortality and LOS among the lowest reported in the literature. This data suggest that there is a clear benefit to admitting elderly hip fractures to the TS.
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Serviços de Saúde para Idosos/estatística & dados numéricos , Fraturas do Quadril/epidemiologia , Mortalidade Hospitalar/tendências , Centros de Traumatologia/estatística & dados numéricos , Idoso de 80 Anos ou mais , Cuidados Críticos , Feminino , Fraturas do Quadril/classificação , Fraturas do Quadril/cirurgia , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação , Masculino , Sistemas Computadorizados de Registros Médicos , Cidade de Nova Iorque/epidemiologiaRESUMO
BACKGROUND: Critical administration threshold (≥3 units of packed red blood cells/h or CAT+) has been proposed as a new definition for massive transfusion (MT) that includes volume and rate of blood transfusion. CAT+ has been shown to eliminate survivor bias and be a better predictor of mortality than the traditional MT (>10 units/24h). End-tidal CO2 (ET CO2) negatively correlates with lactate and is an early predictor of shock in trauma patients. We conducted a pilot study to test the hypothesis that low ET CO2 on admission predicts CAT+. METHODS: ET CO2 via capnography and serum lactate were prospectively collected on admission for 131 patients requiring trauma team activation. Demographic data were obtained from patient charts. Excluded were patients with isolated head injuries, traumatic arrests, or pre-hospital intubations. CAT± status was determined for each hour up to 6h from admission as described; likewise, MT± status was determined up to 24h from admission. RESULTS: After exclusion criteria, 67 patients were analyzed. Mean age was 41.2 (SD 18.5). Thirty-three patients had a blunt mechanism of injury (49%), median ISS was 9 (interquartile range 4-19), and there were 6 deaths (9%). ET CO2 and lactate were negatively correlated by Spearman rank-based correlation (rho=-0.41, p=0.0006). Twenty-one (31%) and 8 (12%) patients were CAT+ and traditional MT+, respectively. There were a significantly greater proportion of patients with ISS>15, ET CO2 <35, or who died found to be CAT+. A binomial logistic regression model adjusting for age, SBP <90, HR, and ISS >15 revealed ET CO2 < 35 to be independently predictive of CAT+ (OR 9.24, 95% CI 1.51-56.57, p=0.016). CONCLUSIONS: This pilot study demonstrated that low ET CO2 had strong association with standard indicators for shock and was predictive of patients meeting CAT+ criteria in the first 6h after admission. Further study to verify these results and to elucidate CAT criteria's association with mortality will require a larger sample size.
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Transfusão de Sangue/métodos , Dióxido de Carbono/sangue , Hemorragia/mortalidade , Hipocapnia/mortalidade , Choque Hemorrágico/mortalidade , Centros de Traumatologia , Ferimentos e Lesões/terapia , Adulto , Biomarcadores/sangue , Capnografia/métodos , Protocolos Clínicos , Feminino , Hemorragia/complicações , Mortalidade Hospitalar , Humanos , Hipocapnia/etiologia , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Choque Hemorrágico/etiologia , Choque Hemorrágico/prevenção & controle , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Ferimentos e Lesões/complicações , Ferimentos e Lesões/mortalidadeRESUMO
INTRODUCTION: Frailty is a clinical state of increased vulnerability resulting from aging-associated decline in physiologic reserve. Hip fractures are serious fall injuries that affect our aging population. We retrospectively sought to study the effect of frailty on postoperative outcomes after Total Hip Arthroplasty (THA) and Hemiarthroplasty (HA) for femoral neck fracture in a national data set. METHODS: National Surgical Quality Improvement Project dataset (NSQIP) was queried to identify THA and HA for a primary diagnosis femoral neck fracture using ICD-9 codes. Frailty was assessed using the modified frailty index (mFI) derived from the Canadian Study of Health and Aging. The primary outcome was 30-day mortality and secondary outcomes were 30-day morbidity and failure to rescue (FTR). We used multivariate logistic regression to estimate odds ratio for outcomes while controlling for confounders. RESULTS: Of 3121 patients, mean age of patients was 77.34 ± 9.8 years. The overall 30-day mortality was 6.4% (3.2%-THA and 7.2%-HA). One or more severe complications (Clavien-Dindo class-IV) occurred in 7.1% patients (6.7%-THA vs.7.2%-HA). Adjusted odds ratios (ORs) for mortality in the group with the higher than median frailty score were 2 (95%CI, 1.4-3.7) after HA and 3.9 (95%CI, 1.3-11.1) after THA. Similarly, in separate multivariate analysis for Clavien-Dindo Class-IV complications and failure to rescue 1.6 times (CI95% 1.15-2.25) and 2.1 times (CI95% 1.12-3.93) higher odds were noted in above median frailty group. CONCLUSIONS: mFI is an independent predictor of mortality among patients undergoing HA and THA for femoral neck fracture beyond traditional risk factors such as age, ASA class, and other comorbidities. LEVELS OF EVIDENCE: Level II.