The impact of preinjury anticoagulants and prescription antiplatelet agents on outcomes in older patients with traumatic brain injury.

BACKGROUND: Anticoagulants and prescription antiplatelet (ACAP) agents widely used by older adults have the potential to adversely affect traumatic brain injury (TBI) outcomes. We hypothesized that TBI patients on preinjury ACAP agents would have worse outcomes than non-ACAP patients. METHODS: This was a 5.5-year retrospective review of patients 55 years and older admitted to a Level I trauma center with blunt force TBI. Patients were categorized as ACAP (warfarin, clopidogrel, dipyridamole/aspirin, enoxaparin, subcutaneous heparin, or multiple agents) or non-ACAP. ACAP patients were further stratified by class of agent (anticoagulant or antiplatelet). Initial and subsequent head computerized tomographic results were examined for type and progression of TBI. Patient preadmission living status and discharge destination were identified. Primary outcome was in-hospital mortality. Secondary outcomes were progression of initial TBI, development of new intracranial hemorrhage (remote from initial), and the need for an increased level of care at discharge. RESULTS: A total of 353 patients met inclusion criteria: 273 non-ACAP (77%) and 80 ACAP (23%). Upon exclusion of three patients taking a combination of agents, 350 were available for advanced analyses. ACAP status was significantly related to in-hospital mortality. After adjustment for patient and injury characteristics, anticoagulant users were more likely than non-ACAP patients to show progression of initial hemorrhage and develop a new hemorrhagic focus. However, compared with non-ACAP users, antiplatelet users were more likely to die in the hospital. Among survivors to discharge, anticoagulant users were more likely to be discharged to a care facility, but this finding was not robust to adjustment. CONCLUSION: Older TBI patients on preinjury ACAP agents experience a comparatively higher rate of inpatient mortality and other adverse outcomes caused by the effects of antiplatelet agents. Our findings should inform decision making regarding prognosis and caution against grouping anticoagulant and antiplatelet users together in considering outcomes. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Gunshot wounds and blast injuries to the face are associated with significant morbidity and mortality: results of an 11-year multi-institutional study of 720 patients.

BACKGROUND: Gunshot wounds and blast injuries to the face (GSWBIFs) produce complex wounds requiring management by multiple surgical specialties. Previous work is limited to single institution reports with little information on processes of care or outcome. We sought to determine those factors associated with hospital complications and mortality. METHODS: We performed an 11-year multicenter retrospective cohort analysis of patients sustaining GSWBIF. The face, defined as the area anterior to the external auditory meatuses from the top of the forehead to the chin, was categorized into three zones: I, the chin to the base of the nose; II, the base of the nose to the eyebrows; III, above the brows. We analyzed the effect of multiple factors on outcome. RESULTS: From January 1, 2000, to December 31, 2010, we treated 720 patients with GSWBIF (539 males, 75%), with a median age of 29 years. The wounding agent was handgun in 41%, explosive (shotgun and blast) in 20%, rifle in 6%, and unknown in 33%. Prehospital or resuscitative phase airway was required in 236 patients (33%). Definitive care was rendered by multiple specialties in 271 patients (38%). Overall, 185 patients died (26%), 146 (79%) within 48 hours. Of the 481 patients hospitalized greater than 48 hours, 184 had at least one complication (38%). Factors significantly associated with any of a total of 207 complications were total number of operations (p < 0.001), Revised Trauma Score (RTS, p < 0.001), and head Abbreviated Injury Scale (AIS) score (p < 0.05). Factors significantly associated with mortality were RTS (p < 0.001), head AIS score (p < 0.001), total number of operations (p < 0.001), and age (p < 0.05). An injury located in Zone III was independently associated with mortality (p < 0.001). CONCLUSION: GSWBIFs have high mortality and are associated with significant morbidity. The multispecialty involvement required for definitive care necessitates triage to a trauma center and underscores the need for an organized approach and the development of effective guidelines. LEVEL OF EVIDENCE: Therapeutic/care management, level III.

The changing nature of death on the trauma service.

BACKGROUND: Recent innovations in care have improved survival following injury. Coincidentally, the population of elderly injured patients with preexisting comorbidities has increased. We hypothesized that this increase in elderly injured patients may have combined with recent care innovations to alter the causes of death after trauma. METHODS: We reviewed demographics, injury characteristics, and cause of death of in-hospital deaths of patients admitted to our Level I trauma service from 2000 through 2011. Cause of death was classified as acute hemorrhagic shock; severe traumatic brain injury or high spinal cord injury; complications of preexisting medical condition only (PM); survivable trauma combined with complications of preexisting medical condition (TCoM); multiple-organ failure, sepsis, or adult respiratory distress syndrome (MOF/S/ARDS), or trauma not otherwise categorized (e.g., asphyxiation). Major trauma care advances implemented on our service during the period were identified, and trends in the causes of death were analyzed. RESULTS: Of the 27,276 admissions, 819 (3%) eligible nonsurvivors were identified for the cause-of-death analyses. Causes of death were severe traumatic brain injury or high spinal cord injury at 44%, acute hemorrhagic shock at 28%, PM at 11%, TCoM at 10%, MOF/S/ARDS at 2%, and trauma not otherwise categorized at 5%. Mean age at death increased across the study interval (range, 47-57 years), while mean Injury Severity Score (ISS) decreased (range, 28-35). There was a significant increase in deaths because of TCoM (3.3-20.9%) and PM (6.7-16.4%), while deaths caused by MOF/S/ARDS decreased from 5% to 0% by 2007. Compared with year 2000, the annual adjusted mortality rate decreased consistently starting in 2009, after the 2002 to 2007 adoption of four major trauma practice guidelines. CONCLUSION: Mortality caused by preexisting medical conditions has increased, while markedly fewer deaths resulted from the complications of injury. Future improvements in outcomes will require improvement in the management of elderly trauma patients with comorbid conditions.

Student reactions to public safety reports of hate crimes.

This study investigated participant's reactions to hate crime versus nonbiased crime incident reports that included more or less detail about the crime using a 2 (victim race: African American, unstated)×2 (amount of information: vague, detailed) between-subjects factorial design. We hypothesized that participants would be more sympathetic, more distressed, and blame the victim less if the victim was African American (designating a hate crime) and if more detail was included in the incident report. The results generally showed greater psychological impact for a hate crime versus nonbiased crime and when more information was presented than with vague information, and these two manipulations did not interact in influencing participants' reactions. These results indicate that amount of detail provided about a crime should be considered when publishing incident reports.

Limb salvage after complex repairs of extremity arterial injuries is independent of surgical specialty training.

BACKGROUND: Major peripheral vascular trauma is managed by several surgical specialties. The impact of surgical specialty training and certification on outcome has not been evaluated. We hypothesized that general surgeons without specialty training in vascular surgery would have outcomes equivalent to surgeons with vascular training in the management of extremity arterial injuries requiring interposition grafting. METHODS: We performed a multicenter, retrospective study of patients undergoing interposition grafting for peripheral vascular injury between 1995 and 2010. Specialty was defined by training and certification. Outcomes were recorded at the time of discharge from the index hospitalization. Factors affecting limb salvage were determined using logistic regression. RESULTS: From the 11 participating centers, 615 patients were identified. General surgeons performed 69.9%, cardiac/vascular surgeons performed 27.3%, and surgeons of other specialties performed 2.8% of the grafts. There were 32 amputations (5.2%). Outcomes did not differ by institution. Factors associated with amputation were blunt mechanism, older age, female sex, hospital length of stay, and Injury Severity Score (ISS). There was no significant difference in limb salvage among specialty groups (general surgeons, 94%; cardiac/vascular, 95%; other, 100%). CONCLUSION: Limb salvage following major peripheral vascular injury is independent of surgeon specialty training. The majority of complex repairs are performed by general surgeons. LEVEL OF EVIDENCE: Therapeutic/care management, level III.

The value of lower-extremity duplex surveillance to detect deep vein thrombosis in trauma patients.

BACKGROUND: Venous duplex surveillance (VDS) is commonly used in trauma patients considered at risk for deep venous thrombosis. Economic evaluations have not addressed the quality of either the process of care or the outcomes achieved through the use of VDS. We sought to determine the value (quality/cost) of VDS in trauma patients stratified by risk for venous thromboembolism. METHODS: We reviewed records of all trauma patients from July 2006 to December 2010 who received weekly VDS examinations of the lower extremities. Prophylaxis and risk stratification were performed according to the American College of Chest Physicians recommendations. Patients were stratified by level of venous thromboembolism risk according to the results of a systematic review of the literature. The "value" of VDS was expressed as the number of clinically relevant findings divided by the cost (defined as the percent full-time equivalent of a certified vascular technologist performing VDS). RESULTS: A total of 2,169 patients met inclusion criteria and were stratified by deep venous thrombosis risk (218 moderate, 1,173 high, 778 highest). The quality of the process (the percent of sites adequately visualized per VDS) was not clinically different among risk groups. The quality of the outcome (number of clinically relevant findings) was significantly greater, and the work time required per finding was significantly lower in the highest-risk group (p < 0.001). The value of VDS was significantly greater in the highest-risk group compared with high or moderate-risk groups (1,104 vs. 337 vs. 76 findings per percent full-time equivalent, respectively; p < 0.001). CONCLUSION: VDS has significantly greater value in the highest-risk group and is warranted in this group. It is of less value in the moderate risk trauma patient. Calculating the value of specific health care interventions can guide the allocation of limited resources. LEVEL OF EVIDENCE: Prognostic study, level II; value-based evaluation, level III.

Back to the future: reducing reliance on torso computed tomography in the initial evaluation of blunt trauma.

BACKGROUND: Reliance on chest-abdomen-pelvis computed tomography (CAP) in the initial evaluation of blunt trauma is a major source of patient radiation exposure. Our trauma surgeon group (TSG) modified its practice to limit the use of CAP. We evaluated the effect of this practice change on patient radiation exposure and diagnostic accuracy. METHODS: We compared data on blunt injury trauma activations evaluated by the five-member TSG for two 6-month intervals, before (T1) and after (T2) instituting the practice change. Patient demographic and injury data, complications, torso imaging and radiation dosage were collected. Following analysis of T1, the surgeon with the lowest CAP use was identified and found to have no errors or delays in diagnosis. The TSG agreed to adopt that surgeon's focus on findings of the physical examination and Focused Assessment Sonography for Trauma to reduce CAP use in the initial evaluation. T2 was analyzed to assess the effect of implementation of this guideline. RESULTS: There were 897 patients in T1 and 948 in T2. In the two intervals, patients did not differ by age, sex, mortality, or probability of survival. CAP use decreased by 38.5% with a significant drop in mean patient radiation exposure (p < 0.001). There were no missed injuries or delays in diagnosis in either interval. CONCLUSION: The use of CAP and its associated radiation burden in the initial evaluation of blunt trauma can be reduced without diagnostic errors by comparing use and identifying best practice. This process has implications for optimal trauma care. LEVEL OF EVIDENCE: Diagnostic study, level IV; case management study, level IV.

Withdrawal of care: a 10-year perspective at a Level I trauma center.

BACKGROUND: Withdrawal or limitation of care (WLC) in trauma patients has not been well studied. We reviewed 10 years of deaths at our adult Level I trauma center to identify the patients undergoing WLC and to describe the process of trauma surgeon-managed WLC. METHODS: This is a retrospective review of WLC. Each patient was assigned to one of three modes of WLC: care withdrawn, limited or no resuscitation, or organ harvest. Frequency, timing, and circumstances of WLC, including family involvement, ethics committee consultation, palliative care, and hospice, were reviewed. RESULTS: From 2000 through 2009, 375 patients died with WLC (54% of all deaths; 93% at ≥ 24 hours). For age ≥ 65 years, 80% were WLC. Overall, 15% had advance directive documents. Traumatic brain or high cervical spine injury was the cause of death in 63%. Factors associated with WLC included age, comorbidities, injury mechanism and severity, and nontrauma activation status. At time of death, 316 (84%) WLC were under trauma surgeon management. In this group, mode of WLC was care withdrawn in 74%, organ harvest in 20%, and limited or no resuscitation in 6%. Rationale for WLC in non-organ harvest patients was poor neurologic prognosis in 86% and futility in 76%. When family was identified, end-of-life discussions with physicians occurred in 100%. Conflicts over WLC occurred in 6.6% and were not associated with any demographic group. Ethics committee was involved in 2.8%. For care-withdrawn patients, median time to death from first WLC order was 6.6 hours. Palliative care and hospice consults (6% and 9%) increased yearly. CONCLUSIONS: WLC occurred in over 50% of all trauma deaths and exceeded 90% at ≥ 24 hours. Hospice and palliative care were increasingly important adjuncts to WLC. Guidelines for WLC should be developed to ensure quality end-of-life care for trauma patients in whom further care is futile. LEVEL OF EVIDENCE: III, therapeutic study.