Injury patterns and outcomes in motorcycle driver crashes in the United States: The effect of helmet use.

BACKGROUND: Motorcycle crashes pose a persistent public health problem with disproportionate rates of severe injuries and mortality. This study aims to analyze injury patterns and outcomes with regard to helmet use. We hypothesized that helmet use is associated with fewer head injuries and does not increase the risk of cervical spine injuries. METHODS: The National Trauma Data Bank was queried for all motorcycle driver crashes between 2007-2017. Univariable analysis was used to compare demographics, clinical data, injury patterns using abbreviated injury scale, and outcomes between helmeted motorcycle drivers and non-helmeted motorcycle drivers who were injured in traffic crashes. Independent factors associated with mortality were determined by regression analysis after adjustment for potential confounders. RESULTS: A total of 315,258 patients were included for analysis, 66 % of these patients were helmeted. The sample was 92.5 % male and the median age was 41 years. Non-helmeted motorcycle drivers were more likely to sustain severe head trauma (head abbreviated injury scale ≥ 3: 28.5 % vs. 13.3 %, p < 0.001), had higher intensive care unit-admission (38 % vs. 30.2 %, p<0.001), mechanical ventilation (20.1 % vs. 13 %, p<0.001) and overall mortality rates (6.2 % vs. 3.9 %, p<0.001). Cervical spine injuries occurred in 10.6 % of non-helmeted motorcycle drivers and in 9.5 % of helmeted motorcycle drivers (p<0.001). Helmet use was identified as an independent factor associated with lower mortality [OR 0.849 (0.809-0.891), p<0.001]. CONCLUSION: Helmet use is protective for severe head injuries and associated with decreased mortality. Helmet use was not associated with increased rates of cervical spine injuries. On the contrary, fewer injuries were observed in helmeted motorcycle drivers. Public health initiatives should be aimed at enforcement of universal helmet laws within the United States and across the world.

Injury patterns and outcomes in motorcycle passengers.

INTRODUCTION: Contemporary trauma literature on injuries to motorcycle passengers is scarce. The aim of this study was to examine the injury patterns and outcomes of motorcycle passengers with regard to helmet use. We hypothesized that helmet utilization affects both injury type and outcomes. METHODS: The National Trauma Data Bank was queried for all motorcycle passengers who were injured in traffic accidents. Participants were stratified according to helmet utilization into helmeted (HM) and nonhelmeted (NHM) groups. Univariate and multivariate analyses were performed to compare the injury patterns and outcomes between the groups. RESULTS: A total of 22,855 patients were included for analysis, of which 57.1% (13,049) used helmet. The median age was 41 years (IQR 26-51), 81% were female, and 16% of patients required urgent operation. NHM had higher risk of major trauma (ISS > 15: 26.8% vs 31.6%, p < 0.001). The most frequently injured body region in NHM was the head (34.6% vs 56.9%, p < 0.001), whereas in HM patients was the lower extremities (65.3% vs 56.7%, p < 0.001). NHM patients were more likely to require admission to the ICU, mechanical ventilation, and had significantly higher mortality rate (3.0% vs 6.3%, p < 0.001). The strongest predictors of mortality were GCS < 9 on admission, hypotension on admission, and severe head injury. Helmet utilization was associated with decreased odds of death (OR 0.636; 95% CI 0.531-0.762; p < 0.001). CONCLUSION: Motorcycle collisions can lead to significant injury burden and high mortality in motorcycle passengers. Middle-age females are disproportionally affected. Traumatic brain injury is the leading cause of death. Helmet use is associated with decreased risk of head injury and death.

Manhandling injuries during legal interventions.

INTRODUCTION: Data concerning injuries resulting from physical force during legal interventions are scarce. The purpose of this study was to examine manhandling injuries occurring in both civilian suspects and law enforcement officials (LEO). METHODS: Retrospective cross-sectional study using data from the National Trauma Data Bank. All patients who sustained manhandling injuries during legal interventions were identified using ICD-10 e-codes. The study groups were injured civilian suspects and LEO. The primary outcomes were type and severity of injuries among the groups. RESULTS: A total of 507 patients were included in the study, 426 (84.0%) civilians and 81 (16.0%) LEO. Overall, median age was 37 years (IQR: 28-48) and 90.3% were male. The median ISS was higher in civilians compared to LEO (5 [4-10] vs 4 [4-9], p = 0.023). Civilians were more likely to sustain injuries to the face (49.8% vs 35.9%, p = 0.024) and abdomen (8.3% vs 1.3%, p = 0.028). LEO were more likely to sustain tibia/fibula fractures (3.5% vs 9.9%, p = 0.019). The mortality was 1.2% (5/426) in civilians and there were no deaths in LEO. The overall complication rates and hospital length of stay were similar between the groups. CONCLUSION: Injury patterns and severity of injuries sustained from the use of physical force during legal interventions are different in civilians and law enforcement officials. Further research and more comprehensive data are warranted to better understand and prevent these injuries.

Disparities in Care Among Gunshot Victims: A Nationwide Analysis.

INTRODUCTION: Given the well-known healthcare disparities most pronounced in racial and ethnic minorities, trauma healthcare in underrepresented patients should be examined, as in-hospital bias may influence the care rendered to patients. This study seeks to examine racial differences in outcomes and resource utilization among victims of gunshot wounds in the United States. METHODS: This is a retrospective review of the National Trauma Data Bank (NTDB) conducted from 2007 to 2017. The NTDB was queried for patients who suffered a gunshot wound not related to accidental injury or suicide. Patients were stratified according to race. The primary outcome for this study was mortality. Secondary outcomes included racial differences in resource utilization including air transport and discharge to rehabilitation centers. Univariate and multivariate analyses were used to compare differences in outcomes between the groups. RESULTS: A total of 250,675 patients were included in the analysis. After regression analysis, Black patients were noted to have greater odds of death compared to White patients (odds ratio [OR] 1.14, confidence interval [CI] 1.037-1.244; P = 0.006) and decreased odds of admission to the intensive care unit (ICU) (OR 0.76, CI 0.732-0.794; P < 0.001). Hispanic patients were significantly less likely to be discharged to rehabilitation centers (Hispanic: 0.78, CI 0.715-0.856; P < 0.001). Black patients had the shortest time to death (median time in minutes: White 49 interquartile range [IQR] [9-437] versus Black 24 IQR [7-205] versus Hispanic 39 IQR [8-379] versus Asian 60 [9-753], P < 0.001). CONCLUSIONS: As society carefully examines major institutions for implicit bias, healthcare should not be exempt. Greater mortality among Black patients, along with differences in other important outcome measures, demonstrate disparities that encourage further analysis of causes and solutions to these issues.

Falls from scaffolds: a nationwide analysis.

INTRODUCTION: Falls from scaffolds are a common cause of occupational injuries and fatalities, however, the data concerning these injuries are scarce. The purpose of this study was to characterize the epidemiology, injury patterns, and outcomes of falls from scaffolds. METHODS: Retrospective cohort study using data from the National Trauma Data Bank (2007-2017). All adult patients who sustained injuries following falls from scaffolds and as a comparator, falls from ladders, were identified using the external cause of injury codes. The primary outcome was differences in the type and severity of injuries between the groups. RESULTS: A total of 183,853 patients were analyzed. Of these, 18,189 (9.9%) fell from scaffolds and 165,664 (90.1%) from ladders. Patients who fell from scaffolds were younger, more often male, and more likely to sustain severe trauma (ISS > 15: 24.1% vs 17.3%, p < 0.001). Falls from scaffolds resulted in more severe head injuries (head AIS ≥ 3: 18.6% vs 14.7%, p < 0.001) and more spinal fractures (30.3% vs 25.2%, p < 0.001). Falls from scaffolds were associated with higher mortality (2.5% vs 1.8%, p < 0.001), higher ICU admission rate (25.0% vs 21.5%, p < 0.001), and longer hospitalization. On multivariable analysis, the strongest predictors of mortality were GCS < 9 and hypotension on admission, severe (AIS ≥ 3) head injury, and age > 65 years. CONCLUSION: Falls from scaffolds are associated with more severe injuries and worse outcomes compared to ladder falls. Males in the fourth decade of life were disproportionally affected. Further research on fall prevention is warranted to decrease this important cause of death and disability.

Race does matter: venous thromboembolism in trauma patients with isolated severe pelvic fractures.

PURPOSE: Studies in non-trauma populations have shown that Black patients have a higher risk of venous thromboembolism (VTE) compared to other races. We sought to determine whether this association exists in trauma patients. The incidence of VTE is particularly high following severe pelvic fractures. To limit confounding factors associated with additional injuries, we examined patients with isolated blunt severe pelvic fractures. METHODS: The TQIP database (2013-2017) was queried for all patients who sustained isolated blunt severe pelvic fractures (AIS ≥ 3) and received VTE prophylaxis (VTEp) with either unfractionated heparin or low molecular weight heparin. The study groups were Asian, Black, and White race as defined by TQIP. The primary outcome was differences in the rate of thromboembolic events. RESULTS: A total of 9491 patients were included in the study. Of these, 232 (2.4%) were Asian, 1238 (13.0%) Black, and 8021 (84.5%) White. There was no significant difference in the distribution of pelvis AIS 3,4,5 between the groups. Black patients had a significantly higher incidence of VTE, DVT and PE compared to Asians and Whites. After adjusting for differences between the groups, Black patients had higher odds of developing pulmonary embolism (OR 1.887, 95% CI 1.101-3.232, p = 0.021) compared to White patients. CONCLUSIONS: In this nationwide study of trauma patients with severe pelvic fractures, Black patients were more likely to develop pulmonary embolism compared to White patients. Further research to identify the determinants of racial disparities in trauma-related VTE is warranted, to target interventions that can improve VTE outcomes for all patients.

Falls from ladders: Injury patterns and outcomes.

BACKGROUND: Our contemporary understanding of the impact of falls from ladders remains limited. The purpose of this study was to examine the injury patterns and outcomes of falls from ladders. Our hypothesis was that age affects both injury type and outcomes. METHODS: The National Trauma Data Bank was queried for all patients who fell from a ladder (January 2007 to December 2017). Participants were stratified into four groups according to age: 15 years or younger, 16 years to 50 years, 51 years to 65 years, and older than 65 years. Univariate and multivariate analyses were performed to compare the injury patterns and outcomes between the groups. RESULTS: A total of 168,227 patients were included for analysis. Median age was 56 years (interquartile range, 45-66 years), 86.1% were male, and median ISS was 9 (interquartile range, 4-13). Increasing age was associated with a higher risk of severe trauma (ISS > 15: 8.8% vs. 13.7% vs. 17.5% vs. 22.0%; p < 0.001). Head injuries followed a U-shaped distribution, with pediatric and elderly patients representing the most vulnerable groups. Overall, fractures were the most common type of injury, in the following order: lower extremity, 27.3%; spine, 24.9%; rib, 23.1%; upper extremity, 20.1%; and pelvis, 10.3%. The overall intensive care unit admission rate was 21.5%; however, it was significantly higher in the elderly (29.1%). In-hospital mortality was 1.8%. The risk of death progressively increased with age with a mortality rate of 0.3%, 0.9%, 1.5%, and 3.6%, respectively ( p < 0.001). Strong predictors of mortality were Glasgow Coma Scale score of 8 or lower on admission (odds ratio, 29.80; 95% confidence interval, 26.66-33.31; p < 0.001) and age >65 years (odds ratio 4.07; 95% confidence interval, 3.535-4.692; p < 0.001). Only 50.8% of the elderly patients were discharged home without health services, 16.5% were discharged to nursing homes, and 15.2% to rehabilitation centers. CONCLUSION: Falls from ladders are associated with considerable morbidity and mortality, especially in the elderly. Head injuries and fractures are common and often severe. An intensified approach to safe ladder use in the community is warranted. LEVEL OF EVIDENCE: Therapeutic/care management; Level III.

The trauma pelvic X-ray: Not all pelvic fractures are created equally.

BACKGROUND: The primary aim of this study was to evaluate the role of the initial pelvic X-ray in identifying significant pelvic fractures, which could result in changes in the management of the patient. METHODS: Patients admitted to a level I trauma center (2010-2019) with a severe blunt pelvic fracture (AIS ≥3) were identified. Included in the analysis were patients who underwent emergency department pelvic X-ray followed by CT scan. A control group of patients without pelvic fractures was also included in the study. All investigations were reviewed by a blinded attending trauma radiologist. Pelvic X-ray findings and CT scan reports were compared according to the specific pelvic fracture location, and severity. RESULTS: Overall, pelvic X-ray was diagnosed 252 of the 285 pelvic fractures (sensitivity 88.4%) and wrongly diagnosed a facture in 3 of 97 patients without a fracture (specificity 96.9%). In 29/184 (15.8%) of patients with pelvic fracture AIS 3, the pelvic X-ray was read as normal, missing the fracture, compared with 4/101 (4.0%) in the AIS 4/5 group (p = 0.003). Pelvic X-ray had the lowest sensitivity in ischial (10.7%), iliac (28.7%), acetabular (42.4%), and sacral fractures (49.1%) and was best for detecting symphysis diastasis (89.8%). CONCLUSION: Pelvic X-ray is useful in identifying pubic symphysis diastasis. However, it misses or underestimates a significant number of fractures. CT scan evaluation should be performed in patients with a suspicious mechanism or clinical suspicion of pelvic fracture.

Gunshot wounds sustained during legal intervention versus those inflicted by civilians: A comparative analysis.

BACKGROUND: Existing data demonstrate that injuries sustained during legal intervention (LI) differ from those incurred during civilian interpersonal violence (CIV), but gunshot wounds (GSWs) have not yet been specifically examined. This study was undertaken to provide an in-depth analysis of patients shot during LI versus CIV. METHODS: Patients injured by GSW and captured by the National Trauma Data Bank (2007-2017) were included. Exclusions were transfer from outside hospital or self-inflicted, accidental, or undetermined injury intent GSWs. Study groups were defined by injury circumstances: GSWs sustained during LI versus CIV. Univariable analysis compared demographics, clinical/injury data, and outcomes. RESULTS: In total, 248,726 patients met inclusion/exclusion criteria: 98% (n = 243,150) CIV versus 2% (n = 5,576) LI. Race varied significantly between study groups (p < 0.001). White patients were the most commonly injured race after LI (n = 2,176, 39%). Black patients were the most commonly injured race after CIV (n = 139,067, 57%). Psychiatric disease (9% vs. 2%, p < 0.001) was more common among LI GSWs. The LI patients were more frequently tachycardic (18% vs. 13%, p < 0.001), hypotensive (26% vs. 14%, p < 0.001), and comatose (34% vs. 15%, p < 0.001). The LI patients had higher Injury Severity Scores (13 vs. 9, p < 0.001), required emergent surgical intervention (39% vs. 28%, p < 0.001) and intensive care unit admission (47% vs. 32%, p < 0.001) more often, and had longer hospital stay (4 vs. 3 days, p < 0.001). Mortality was higher after LI (27% vs. 14%, p < 0.001). CONCLUSION: Significant racial and injury severity differences exist between patients shot during LI and CIV. White patients were the most commonly injured race after LI, while Black patients were the most commonly injured race during CIV. In addition, Black patients were overrepresented in both groups when compared with their proportion in the US population. LI patients were more significantly injured, as quantified by clinical, injury, and outcomes variables including increased mortality. Further study of patients shot during LI is needed to better understand this increased burden of injury. LEVEL OF EVIDENCE: Prognostic and epidemiological, level IV.

Damage Control Laparotomy in the Cirrhotic Trauma Patient is Highly Lethal: A Matched Cohort Study.

INTRODUCTION: Damage control laparotomy (DCL) has revolutionized trauma care and is considered the standard of care for severely injured patients requiring laparotomy. The role of DCL in cirrhotic patients has not been investigated. METHODS: A matched cohort study using American College of Surgeons Trauma Quality Improvement Program database including patients undergoing DCL within 24 hours of admission. A 1:2 cohort matching of cirrhotic vs. non-cirrhotic patients was matched for the following criteria: age (>55, ≤55 years), gender, mechanism of injury (blunt and penetrating), injury severity score (ISS) (≤25, >25), head/face/neck Abbreviated Injury Scale (AIS) (<3, ≥3), chest AIS (<3, ≥3), abdominal AIS (<3, ≥3), and overall comorbidities. Outcomes between the 2 cohorts were subsequently compared with univariable analysis. RESULTS: Overall, 1151 patients with DCL within 24 hours were identified, 29 (2.5%) with liver cirrhosis. Six cirrhotic patients were excluded because there were no suitable matching controls. The remaining 23 cirrhotic patients were matched with 46 non-cirrhotic patients. Overall mortality in the cirrhotic group was 65% vs. 26% in the non-cirrhotic group (P = .002). The higher mortality rate in cirrhotic vs. non-cirrhotic patients was accentuated in the group with ISS >25 (83% vs. 33%; P = .005). 40% of the deaths in cirrhotic patients occurred after 10 days of admission, compared to only 8% in non-cirrhotic patients (P = .091). The total blood product use within 24 hours was significantly higher in cirrhotic than non-cirrhotic patients [33 (14-46) units vs. 19.9 (4-32) units; P = .044]. CONCLUSION: Cirrhotic trauma patients undergoing DCL have a very high mortality. A significant number of deaths occur late and alternative methods of physiological support should be considered.

Diagnostic Peritoneal Aspiration Revisited: Its Diagnostic Accuracy for the Detection of Intraabdominal Hemorrhage.

BACKGROUND: The use of Focused Assessment with Sonography for Trauma (FAST) in combination with computed tomography (CT) has become the mainstay of diagnostic workup in patients with suspected intraabdominal hemorrhage (IAH). However, diagnostic peritoneal aspiration (DPA) can be an important adjunct in hemodynamically unstable patients. The aim of this study was to evaluate the utility and diagnostic accuracy of DPA in detecting IAH. METHODS: Retrospective analysis of all patients who presented to the LAC+USC Medical Center and underwent evaluation with DPA between January 2010 and December 2016. Intraoperative, CT, and autopsy findings were used as gold standards in determining the diagnostic accuracy of DPA for the detection of IAH. RESULTS: A total of 73 consecutive patients were included in the study. The median age was 42 years (interquartile range [IQR]: 25-56), median injury severity score was 29 (IQR: 21-41), and 82.2% sustained blunt trauma. The most common indications for DPA were hemodynamically unstable patients with suspected IAH and patients with return of spontaneous circulation following resuscitative thoracotomy. Overall, the positive and negative predictive values of DPA were 89.4% and 88.9%, respectively. In 14 cases (19.2%), DPA correctly identified false positive/negative FAST results. CONCLUSION: Our data suggest that DPA has high diagnostic yield for IAH. The use of DPA should be considered in unstable patients with inconclusive FAST results who cannot safely be evaluated with CT.

Firearm injuries during legal interventions Nationwide analysis.

INTRODUCTION: There is limited literature on firearm injuries during legal interventions. The purpose of this study was to examine the epidemiology, injury characteristics, and outcomes of both civilians and law enforcement officials (LEOs) who sustained firearm injuries over the course of legal action. METHODS: Retrospective observational study using data from the National Trauma Data Bank (2015-2017) was performed. All patients who were injured by firearms during legal interventions were identified using the International Classification of Disease, Tenth Revision, external cause of injury codes. The study groups were injured civilian suspects and police officers. Demographics, injury characteristics, and outcomes were analyzed and compared between the groups. Primary outcomes were the clinical and injury characteristics among the victims. RESULTS: A total of 1,411 patients were included in the study, of which 1,091 (77.3%) were civilians, 289 officers (20.5%), and 31 bystanders (2.2%). Overall, 95.2% of patients were male. Compared with LEOs, civilians were younger (31 vs. 34 years, p = 0.007) and more severely injured (median Injury Severity Score, 13 vs. 10 [p = 0.005]; Injury Severity Score >15, 44.4% vs. 37.1% [p = 0.025]). Civilians were more likely to sustain severe (Abbreviated Injury Scale, ≥3) intra-abdominal injuries (26.8% vs. 16.1%, p < 0.001) and spinal fractures (13.0% vs. 6.9%, p = 0.004). In-hospital mortality and overall complication rate were similar between the groups (mortality: civilians, 24.7% vs. LEOs, 27.3% [p = 0.360]; overall complications: civilians, 10.3% vs. LEOs, 8.4% [p = 0.338]). CONCLUSION: Firearm injuries during legal interventions are associated with significant injury burden and a higher mortality than the reported mortality in gunshot wounds among civilians. The mortality and overall complication rate were similar between civilian suspects and law enforcement officials. LEVEL OF EVIDENCE: Epidemiologic, level IV.

Extracorporeal support for trauma: A trauma quality improvement project (TQIP) analysis in patients with acute respiratory distress syndrome.

INTRODUCTION: The use of extracorporeal membrane oxygenation (ECMO) in trauma patients with severe acute respiratory distress syndrome (ARDS) continues to evolve. The objective of this study was to perform a comparative analysis of trauma patients with ARDS who received ECMO to a propensity matched cohort of patients who underwent conventional management. METHODS: The Trauma Quality Improvement Program (TQIP) database was queried from 2013 to 2016 for all patients with ARDS and those who received ECMO. Demographics, as well as clinical, injury, intervention, and outcome data were collected and analyzed. Patients with ARDS were divided into two groups, those who received ECMO and those who did not. A propensity score analysis was performed using the following criteria: age, gender, vital signs (HR, SBP) and GCS on admission, Injury Severity Score (ISS), and Abbreviated Injury Scale (AIS) score in several body regions. Outcomes between the groups were subsequently compared using univariate as well as Cox regression analyses. Secondary outcomes such as hospitalization (HLOS), ICU length-of-stay (LOS) and ventilation days stratified for patient demographics, timing of ECMO and anticoagulation status were compared. RESULTS: Over the 3-year study period, 8990 patients with ARDS were identified from the TQIP registry. Following exclusion, 3680 were included in the final analysis, of which 97 (2.6%) received ECMO. On univariate analysis following matching, patients who underwent ECMO had lower overall hospital mortality (23 vs 50%, p < 0.001) with higher rates of complications (p < 0.005), including longer HLOS. In those undergoing ECMO, early initiation (<7 days) was associated with shorter HLOS, ICU LOS, and fewer ventilator days. No difference was observed between the two groups with regard to anticoagulation. CONCLUSION: Extracorporeal membrane oxygenation use in trauma patients with ARDS may be associated with improved survival, especially for young patients with thoracic injuries, early in the course of ARDS. Anticoagulation while on circuit was not associated with increased risk of hemorrhage or mortality, even in the setting of head injuries. The mortality benefit suggested with ECMO comes at the expense of a potential increase in complication rate and prolonged hospitalization.

Increased Incidence of COVID-19 Infections Amongst Interpersonal Violence Patients.

OBJECTIVE: To investigate whether any specific acute care surgery patient populations are associated with a higher incidence of COVID-19 infection. BACKGROUND: Acute care providers may be exposed to an increased risk of contracting the COVID-19 infection since many patients present to the emergency department without complete screening measures. However, it is not known which patients present with the highest incidence. METHODS: All acute care surgery (ACS) patients who presented to our level I trauma center between March 19, 2020, and September 20, 2020 and were tested for COVID-19 were included in the study. The patients were divided into two cohorts: COVID positive (+) and COVID negative (-). Patient demographics, type of consultation (emergency general surgery consults [EGS], interpersonal violence trauma consults [IPV], and non-interpersonal violence trauma consults [NIPV]), clinical data and outcomes were analyzed. Univariate and multivariate analyses were used to compare differences between the groups. RESULTS: In total, 2177 patients met inclusion criteria. Of these, 116 were COVID+ (5.3%) and 2061 were COVID- (94.7%). COVID+ patients were more frequently Latinos (64.7% versus 61.7%, P = 0.043) and African Americans (18.1% versus 11.2%, P < 0.001) and less frequently Caucasian (6.0% versus 14.1%, P < 0.001). Asian/Filipino/Pacific Islander (7.8% versus 7.2%, P = 0.059) and Native American/Other/Unknown (3.4% versus 5.8%, P = 0.078) groups showed no statistical difference in COVID incidence. Mortality, hospital and ICU lengths of stay were similar between the groups and across patient populations stratified by the type of consultation. Logistic regression demonstrated higher odds of COVID+ infection amongst IPV patients (OR 2.33, 95% CI 1.62-7.56, P < 0.001) compared to other ACS consultation types. CONCLUSION: Our findings demonstrate that victims of interpersonal violence were more likely positive for COVID-19, while in hospital outcomes were similar between COVID-19 positive and negative patients.

Selective Computed Tomography (CT) Imaging is Superior to Liberal CT Imaging in the Hemodynamically Normal Pediatric Blunt Trauma Patient.

BACKGROUND: The optimal imaging strategy in hemodynamically stable pediatric blunt trauma remains to be defined. The purpose of this study was to determine the differences between selective and liberal computed tomography (CT) strategy in a pediatric trauma population with respect to radiation exposure and outcomes. METHODS: We performed a retrospective analysis of hemodynamically stable blunt pediatric trauma patients (≤16 y) who were admitted to a Level I trauma center between 2013-2016. Patients were stratified into selective and liberal imaging cohorts. Univariate and multivariate regression analyses were used to compare outcomes between the groups. Outcomes included radiation dose, hospital and ICU length of stay, complications and mortality. RESULTS: Of the 485 patients included, 176 underwent liberal and 309 selective CT imaging. The liberal cohort were more likely to be severely injured (ISS>15: 34.1 versus 8.4%, P< 0.001). The odds of exposure to a radiation dose of >15 mSv were higher with liberal scanning in patients with both ISS > 15 (OR 2.78, 95% CI 1.76-5.19, P< 0.001) and ISS ≤ 15 (OR 3.41, 95% CI 2.19-8.44, P < 0.001). Adjusted outcomes regarding mortality, ICU length of stay, and complications were similar between the cohorts. CONCLUSION: Selective CT imaging in hemodynamically stable blunt pediatric trauma patients was associated with reduced radiation exposure and similar outcomes when compared to a liberal CT strategy.

Intra-Abdominal Hemorrhage Control: The Need for Routine Four-Quadrant Packing Explored.

BACKGROUND: Routine four-quadrant packing (4QP) for hemorrhage control immediately upon opening is a standard practice for acute trauma laparotomy. The aim of this study was to evaluate the utility of 4QP for bleeding control in acutely injured patients undergoing trauma laparotomy. METHODS: Retrospective single-center study (01/2015-07/2019), including adult patients who underwent trauma laparotomy within 4 h of admission. Only patients with active intra-abdominal hemorrhage, defined as bleeding within the peritoneal cavity or expanding retroperitoneal hematoma, were considered for analysis. Bleeding sources were categorized anatomically: liver/retrohepatic inferior vena cava (RIVC), spleen, retroperitoneal zones 1, 2 and 3, mesentery and others. Hemorrhage was further categorized as originating from a single bleeding site (SBS) or from multiple bleeding sites (MBS). The effectiveness of directed versus 4QP was evaluated for bleeding from the liver/RIVC, spleen and retroperitoneal zone 3, areas that are potentially compressible. Directed packing was defined as indicated if the bleeding was restricted to one of the anatomic sites suitable for packing, 4QP was defined as indicated if ≥ 2 of the anatomic sites suitable for packing were bleeding. RESULTS: During the study time frame, 924 patients underwent trauma laparotomy, of which 148 (16%) had active intra-abdominal hemorrhage. Of these, 47% had a SBS and 53% had MBS. The liver/RIVC was the most common bleeding source in both patients with SBS (42%) and in patients with MBS (54%). According to our predefined indications, 22 of 148 patients (15%) would have benefitted from initial 4QP, 90 of 148 patients (61%) from directed packing and 36 of 148 patients (24%) packing would not have been of any value. CONCLUSION: Routine four-quadrant packing is frequently practiced. However, this is only required in a small proportion of patients undergoing trauma laparotomy. Directed packing can be equally effective, saves time and decreases the risk of iatrogenic injury from unnecessary packing.

Timing and Type of Venous Thromboembolic Prophylaxis in Isolated Severe Liver Injury Managed Non-Operatively.

BACKGROUND: The optimal timing and type of pharmacological venous thromboembolic prophylaxis (VTEp) after severe liver injury selected for nonoperative management (NOM) are controversial. The aim of this study was to assess the effect of timing and type of VTEp in severe liver injuries selected for NOM. METHODS: ACS-TQIP database study (2013-17) including patients with blunt isolated severe liver injuries (AIS ≥ 3), selected for NOM, who received VTEp with either unfractionated heparin (UH) or low-molecular-weight heparin (LMWH). Patients who underwent laparotomy or angiointervention within 24 h or prior to the initiation of VTEp were excluded. The study population was stratified according to the timing of VTEp ≤ 48 h (EP) and > 48 h (LP) groups. Univariate and multivariate analyses were used to identify differences between the groups. RESULTS: A total of 4074 patients was included in the study. 2004 (49.2%) received EP and 2070 (50.8%) LP. Patients with more severe injuries were more likely to receive LP than an EP [ISS 24 (19-29) vs 22 (17-27), p < 0.001]. On multivariate analysis (correcting for age, gender, comorbidities, blood pressure, GCS, ISS, type of VTEp), LP was identified as an independent risk factor for thromboembolic events (OR 1.52, p = 0.032) and mortality (OR 2.49, p = 0.031). LMWH was independently associated with lower mortality (OR 0.36, p = 0.007), compared to UH. EP did not increase the risk of laparotomy or angiointervention after starting VTEp, compared to LP (p = 0.992). CONCLUSION: Early VTEp (≤ 48 h) is safe and independently associated with fewer thromboembolic events and a lower mortality after isolated severe liver injuries managed nonoperatively. LMWH was independently associated with improved outcomes when compared with UH.