Morbidity and Mortality of Trauma Patients 55 and Older: A Study of Nontrauma Risk Factors.

Introduction: The American College of Surgeons (ACS) recommends that special considerations be made during triage of trauma patients aged ≥55 due to an observed increase in morbidity and mortality in this population. The geriatric population aged ≥65 represents 30% of all trauma patients. Our objective was to assess which pre-existing conditions (PECs) are associated with worse outcomes in trauma patients aged ≥55. Methods: Study population was selected from the local trauma registry (2020-22). Bi-variate analysis compared PEC status with outcomes controlling for each Injury Severity Score (ISS) category. Injury Severity Score was defined as mild (1-8), moderate (9-15), severe (16-24), and critical (≥25). Results: A total of 5,168 patients were identified (54.9% female, 56.7% age ≥75, 49.1% mild injury). Patients who had chronic renal failure (CRF) were at increased odds of mortality after adjusting for mild (adjusted odds ratio [aOR]: 2.63), moderate (aOR: 2.97), severe (aOR: 2.84), and critical (aOR: 2.62) injuries. Patients who had cirrhosis or congestive heart failure (CHF) were at increased odds of mortality after adjusting for mild (aOR: 3.03, 1.61), moderate (aOR: 3.63, 2.14), and severe (aOR: 3.46, 1.93) injuries, respectively. In addition, there was a relationship between having chronic obstructive pulmonary disease (COPD), dementia, anticoagulant therapy, or diabetes with unplanned intensive care unit (ICU) admission and development of acute kidney injury (AKI). Discussion: There is an association between certain pre-exiting conditions and worse outcomes. Early identification of these factors could provide a foundation for better interdisciplinary management, prevention of complications and associated mortality.

Outcomes of Tracheostomy on Burn Inhalation Injury.

Background: Tracheostomy has been proposed for patients with expected prolonged intubation. This study aims to determine the outcomes of tracheostomy on patients with burn inhalation injuries requiring mechanical ventilation. Methods: This study is a retrospective review from 2011 to 2019. Inclusion criteria were recording of inhalation injury, ventilator support (at least 24 hours), and total body surface area of <15%. The patients were stratified into 2 groups: tracheostomy (group 1) versus no tracheostomy (group 2). The outcome measures were in-hospital mortality rate, hospital length of stay, intensive care unit length of stay, ventilator days, and ventilator- associated pneumonia (VAP). Results: A total of 33 burn patients met our inclusion criteria. Group 1 consisted of 10 patients and group 2 of 23 patients. There was no statistically significant difference in terms of percent total body surface area. There was a higher intensive care unit length of stay at 23.8 days in group 1 compared with 3.16 days in group 2, a higher hospital length of stay at 28.4 days in group 1 compared with 5.26 days in group 2, and higher ventilator days in group 1 with 20.8 days compared with 2.5 days in group 2. There was no statistically significant difference between the 2 groups in terms of mortality. The incidence of VAP was also significantly higher in group 1 than in group 2. Conclusions: The ideal timing and implementation of tracheostomy with inhalation injury has yet to be determined. In this study, tracheostomy was associated with much longer lengths of stay and pneumonia. The impact of the underlying lung injury versus the tracheostomy itself on these observations is unclear. The challenge of characterizing the severity of an inhalation injury based on early visual inspection remains.

Hospital Volume of Emergency General Surgery and its Impact on Inpatient Mortality for Geriatric Patients: Analysis From 3994 Hospitals.

BACKGROUND: Previous investigations have shown a positive association between hospital volume of operations and clinical outcomes. However, it is unclear whether such relationships also apply to emergency surgery. We sought to examine the association between hospital case volume and inpatient mortality for 7 common emergency general surgery (EGS) operations among geriatric patients. METHODS: This is a population based retrospective cohort study using the Centers of Medicare and Medicaid Services (CMS) Limited Dataset Files (LDS) from 2011 to 2013. The 7 most common emergency surgeries included (1) partial colectomy, (2) small-bowel resection (SBR), (3) cholecystectomy, (4) appendectomy, (5) lysis of adhesions (LOA), (6) operative management of peptic ulcer disease (PUD), and (7) laparotomy with the primary outcome being inpatient mortality. Risk-adjusted inpatient mortality was plotted against operative volume. Subsequently an operative volume threshold was calculated using a best fit regression method. Based on these estimates, high- and low-volume hospitals were compared to examine significance of outcomes. Significance was defined as P-value < .05. RESULTS: The final cohort comprised of 414 779 patients from 3994 hospitals. The standardized mortality ratio (SMR) for high-volume centers were lower in 6 out of 8 surgeries examined. Small-bowel resection and partial colectomy operations had a significant decrease in mortality based on a volume threshold. CONCLUSION: We observed decreased mortality with higher surgical volume for small-bowel resection and partial colectomy operations. Such differences may be related to practice patterns during the perioperative period, as complications related to the perioperative care were significantly lower for high-volume centers.

Race and Insurance Status Disparities in Post-discharge Disposition After Hospitalization for Major Trauma.

BACKGROUND: Investigations detailing predictive measures of hospital disposition after traumatic injury are scarce. We aim to examine the discharge practices among trauma centers in the US and to identify factors that may influence post-hospital disposition. METHODS: A retrospective analysis of trauma patients using the American College of Surgeons-Trauma Quality Improvement Program dataset from 2007-2017. Primary study outcome was hospital disposition (including long term care facility [LTC], others). Secondary outcomes included: Intensive Care Unit (ICU)-length of stay (LOS), complications, others). RESULTS: 6 899 538 patients were analyzed. Odds of LTC discharge was significantly higher for Black patients (aOR = 1.30, 95% CI:1.24-1.37), abbreviated injury score (AIS) ≥3 (aOR = 4.22, 95% CI: 4.05-4.39), and higher injury severity score (ISS) (aOR = 9.41, 95% CI:9.03-9.80). Significantly more self-pay patients were discharged home compared to other insurance types (P < .0001). Significantly longer hospital- and ICU-LOS were experienced by those who had an AIS ≥3 (hospital: 4.8 days (±7.1) vs. 7.9 (±10.1); ICU: 4.6 (±6.9) vs. 5.9 (±7.9), P < .0001) and had a high ISS (hospital: 4.5 days (±5.9) vs. 16.8 (±17.9); ICU: 3.6 (±5.0) vs. 10.2 (±11.5), P < .0001). CONCLUSIONS: Patient race, insurance status, and injury severity were predictive of post-hospitalization care discharge. Self-pay and Black patients were less likely to be discharged to secondary care facilities. These findings have the potential to improve in-hospital patient management and predict discharge secondary care needs, and necessitate the need for future research to investigate the extent of inequalities in access to trauma care.

Nationwide Analysis of the Distribution of Level 1 and Level 2 Trauma Centers Per Population Growth and Motor Vehicle Collision Injuries/Fatalities Utilizing Geographic Information Systems Mapping Technology: Toward Optimizing Access to Trauma Care.

BACKGROUND: Trauma centers (TCs) improve patient outcomes. Few investigations detail the US geographical distribution of Level 1 and 2 TCs (L1TCs, L2TCs) regarding motor vehicle collision (MVC) injuries/fatalities. OBJECTIVE: We utilized Geographic Information Systems mapping to investigate the distribution of L1TCs and L2TCs in relation to population growth, MVC injuries, and MVC fatalities at the county and regional level to identify any disparities in access to trauma care. METHODS: A cross-sectional analysis of L1TC and L2TC distribution, MVC injuries/fatalities, and population growth from 2010 to 2018. Information was gathered at the county and region level for young adults (aged 15-44), middle-aged adults (45-64), and elderly (≥65). RESULTS: A total of 263 L1TCs across 46 states and 156 counties and 357 L2TCs across 44 states and 255 counties were identified. The mean distance between L1TCs and L2TCs is 28.3 miles and 31.1 miles, respectively. Seven counties were identified as being at-risk, all in the Western and Southern US regions that experienced ≥10% increase in population size, upward trends in MVC injuries, and upward trends MVC fatalities across all age groups. CONCLUSIONS: Seven US counties containing ≤2 ACSCOT-verified and/or state-designated L1TCs or L2TCs experienced a 10% increase in population, MVC injuries, and MVC fatalities across young, middle-aged and elderly adults from 2010 to 2018. This study highlights chronic disparities in access to trauma care for MVC patients. Evaluation of state limitations regarding the distribution of L1TCs and L2TCs, frequent evaluation of local and regional trauma care needs, and strategic interventions to improve access to trauma care may improve patient outcomes for heavily burdened counties.

Disclosure of Conflicts of Interest Among Speakers, Moderators, Presenters, and Discussants at National Trauma Meetings.

BACKGROUND: Official conference participants (OCPs) consisting of speakers, moderators, discussants, and presenters) with conflicts of interest (COI) could negatively influence the audience's ability to fairly evaluate information if their COI is not properly disclosed. We aim to examine the patterns of COI disclosures by OCPs and the nature and extent of financial compensation at 3 annual trauma conferences. METHODS: A retrospective cohort analysis of COI disclosures of OCPs, in the EAST, WTA, and AAST Annual Meetings from 2016 to 2019. The Open Payments Database (OPD) was used to describe the nature and extent of financial compensation. Descriptive statistics and independent sample t-tests were performed with significance defined as P < .05. RESULTS: Eastern Association for the Surgery of Trauma: conflicts of interest ranged from 3.8 to 6.0% of OCPs. Moderators, discussants, and presenters comprised decreasing proportions disclosing COIs, whereas speakers comprised an increasing proportion. Western Trauma Association: conflicts of interest ranged from 1.3 to 6.8% of OCPs. Moderators comprised an increasing proportion whereas speakers comprised a decreasing proportion. American Association for the Surgery of Trauma: conflicts of interest ranged from 3.6 to 5.4% of OCPs. Speakers, moderators, and presenters comprised progressively decreasing proportions, whereas discussants comprised an increasing proportion. Participants who did not disclose a COI comprised the majority of payment recipients in the OPD. CONCLUSION: Official conference participants who disclosed a COI varied between EAST, WTA, and AAST Annual Meetings from 2016 to 2019. Implementation of standardized COI disclosure policies with explicitly communicated definitions/categories can maximize the participants' understanding of the disclosure process, translate into improved COI reporting, and preserve an evidence-based environment that is free from commercial influence for physicians to teach and learn.

Operative Confidence Among U.S General Surgery Residents.

BACKGROUND: General surgery residents (GSRs) must develop operative autonomy skills to practice independently after graduation. We aim to investigate perceived confidence and operative autonomy of GSR physicians in order to identify and address influential factors. METHODS: A 28-question anonymous online survey was distributed to 23 United States general surgery residency programs. Multivariable logistic regression was used for calculating the adjusted odds ratio (aOR) for binary outcomes. Significance was defined as P-values ≤ .05 or 95% confidence intervals (CIs) >1 or <1. RESULTS: There were 120/558 (21.5%) GSR respondents. General surgery residents with >200 overall operative case volume reported significantly higher confidence with minor cases (P = .05) and major cases (P = .02). General surgery residents that performed both minor and major surgeries reported higher confidence with minor cases at 85.7% compared to GSRs that performed mostly minor surgeries (64.7%) and mostly major surgeries (62.5%). General surgery residents who performed >50 minor surgeries during their PGY 1 and 2 were less confident with major cases than GSRs who performed <50 minor surgeries (aOR: 19.98, 95% CI: 1.26, 318). General surgery residents from community teaching hospitals reported higher confidence with major and minor cases than GSRs from university teaching hospitals and combined programs. CONCLUSION: Increased case volume, predominant case type, early surgical experience during PGY 1 and 2 years, and training at community teaching hospitals were identified as the most important factors that positively influence perception of operative confidence and autonomy among GSRs. These may have important implications in the development of future surgeons.

Timing and Type of Venous Thromboembolic Chemoprophylaxis Is Associated with Acute Traumatic Brain Injury Outcomes.

Venous thromboembolic (VTE) prophylaxis in acute traumatic brain injury (TBI) is a controversial topic with wide practice variations. This study examined the association of VTE chemoprophylaxis with inpatient mortality and VTE events among isolated TBI patients. This was a retrospective cohort study of 87 trauma centers within a large hospital system in the United States analyzing 23,548 patients with isolated TBI, 7977 of whom had moderate-to-severe TBI. Primary outcomes were inpatient mortality and VTE events. The control group received no chemoprophylaxis. Other groups received low-molecular-weight heparin (LMWH), unfractionated heparin (UFH), and combined LMWH and UFH chemoprophylaxis. Multi-variable regression accounted for confounders. Outcomes were stratified by timing of administration, body mass index (BMI), and TBI type. Patients without VTE prophylaxis had the least VTE events. LMWH had the lowest mortality for both all-isolated and moderate-to-severe isolated TBI populations at adjusted odds ratio (aOR) 0.24 (95% confidence interval [CI], 0.14-0.43) and aOR 0.25 (95% CI, 0.14-0.44), respectively. Clinically significant progression of TBI was lowest among the LMWH group (0.1%; p value, 0.001). After stratifying by timing of VTE chemoprophylaxis, only patients with subdural hematoma and LMWH between 6 and 24 h (N = 62), as well as patients with ≥35 BMI and LMWH between 6 and 24 h (N = 65) or >24-48 h (N = 54), had no VTE events. VTE chemoprophylaxis timing may have prevented VTE in certain subgroups of isolated TBI patients. Though VTE chemoprophylaxis did not prevent VTE for most TBI patients, LMWH VTE chemoprophylaxis was associated with reduced mortality.

Survival following devastating penetrating gunshots polytrauma with grade 5 liver injuries requiring multiple massive transfusion protocols: A case report and review of the literature.

INTRODUCTION: A devastating injury to the liver from a gunshot wound (GSW) challenges the most seasoned trauma surgeon. This challenge is intensified when patients develop severe shock with a high-grade injury. We present the case of a patient with a grade 5 liver injury after a GSW treated with operative and interventional radiology (IR) treatment simultaneously. CASE PRESENTATION: A 25-year-old male presented to our Trauma Center with hypotension, after an abdominal GSW. He was taken emergently to the operating room, which revealed a Grade 5 liver injury with massive hemorrhage. Operative intervention was initiated immediately and a non-anatomic left lobectomy with hepatorrhaphy was performed. IR was consulted intra-operatively and performed a left hepatic artery angioembolization. The patient received over 50 units of blood products during the combined procedures, with eventual bleeding control. On post-operative day 33, the patient became acutely hemodynamically unstable, and angiography revealed a splenic artery pseudoaneurysm, which was embolized but re-bled and resulted in splenectomy. The patient eventually recovered and follows up at 1-year revealed a patient doing well. DISCUSSION: High-grade liver injuries carry significant mortality. Mortality worsens when severe shock is present. Operative intervention is the standard approach for patients who remain in shock. To help improve outcomes patients may benefit from a combined approach with the interventional radiology team. CONCLUSION: The acute management of severe liver injuries when presenting with ongoing shock is beneficial to include both trauma surgeons with interventional radiologists. Further studies are needed to determine the best approach for this devastating injury.

Cocaine Use and Incarceration: A Rare Cause of Bowel Ischemia, Perforation, and Gastrointestinal Hemorrhage.

Cocaine use is rising in persons ≥50 years old and in black and socioeconomically disadvantaged communities. Cocaine-induced bowel ischemia and gastrointestinal injury are deadly findings that have been previously described in the literature. In this report, we present a case of small bowel ischemia, perforation, and upper gastrointestinal hemorrhage co-occurring in a 62-year-old incarcerated male with a 15-year history of cocaine use. The patient presented from jail, peritonitic in septic shock, and was promptly taken for emergent surgical exploration. He was found to have massive fecal peritonitis secondary to full-thickness ischemia and perforation of the jejunum and ileum. Immediately postoperatively, the patient developed a large volume of hemorrhage from multiple gastric and duodenal ulcers refractory to endoscopic intervention, ultimately requiring emergent embolization of the gastroduodenal artery. His course was further complicated by severe septic shock with a blunted response to catecholamine vasopressors. Early recognition and aggressive treatment of the gastrointestinal complications and the unique critical care challenges associated with cocaine use facilitated this patient's eventual full recovery.

A rare case of delayed splenic rupture following initial negative CT scan imaging: A case report and review of the literature.

INTRODUCTION: Delayed splenic rupture is an often unpredictable event with high mortality. In this report, we discuss the successful management of delayed splenic rupture, presenting days after index injury, with no commonly associated injuries or blunt abdominal trauma. CASE PRESENTATION: A 50 year old male, not on anticoagulants, presented with blunt trauma after driving his motorcycle into a tree. The patient sustained right 3-5 rib fractures, displaced right midclavicular fracture, 25 % right pneumothorax, T5-9 posterior spinous process fractures, left 2nd-5th metatarsal fractures, and scattered abrasions to the left foot, knee and hand. Focused abdominal sonography for trauma (FAST) and admission abdominal multi-detector CT were negative for any intra-abdominal injuries. On hospital day 5, the patient acutely decompensated. FAST was grossly positive and emergent laparotomy revealed a splenic rupture. After a splenectomy, he recovered. DISCUSSION: The spleen is the most commonly injured organ in blunt abdominal trauma. Although acute injury often presents with imaging findings or sequelae of hemorrhagic shock, complications of splenic trauma have the potential to result in delayed catastrophe. Bedside ultrasonography is a useful tool to assess acute decompensation in trauma patients along with CT imaging. Prompt identification and hemorrhage control are crucial to survival after trauma. CONCLUSION: Repeat CT scans are also important for the identification of delayed splenic rupture and timely intervention. Delayed hemorrhage after blunt trauma should never be ruled out regardless of the injury complexity or length of hospital admission.

Investigation of the Gender Distribution of National Institutes of Health Grants Across Six Surgical Specialties From 2015 to 2020: Toward Promoting Equity in Academic Surgery.

INTRODUCTION: There is a paucity of literature evaluating research-funding differences between male and female surgeons. Our study aims to evaluate possible disparities in the National Institutes of Health (NIH) grant awards by surgeon gender, type of medical degree (MD/DO), and advanced degrees among six surgery specialties: general surgeons, neurosurgeons, urologists, obstetricians/gynecologists, plastic, and orthopedic surgeons, from 2015 to 2020. METHODS: A retrospective cohort study was performed investigating the number of NIH grants received by male and female surgeon-scientists overall and within each listed specialty, 2015-2020. As a surrogate for grants submitted, the proportion of active surgeon-scientists per specialty was used. A priori level of significance was defined as P < 0.05. RESULTS: After adjusting for confounders, male surgeons had a higher mean number of NIH grants and higher grant funding than female surgeons (P < 0.001 for both). Type of medical degree (MD/DO) was not significantly associated with NIH funding. An advanced degree was associated with NIH funding among neurosurgeons only (P < 0.05). Differences in the proportion of active surgeon-scientists and proportion of NIH grants received by male and female surgeon-scientists were found only in the fields of orthopedic surgery (5.8% female surgeons and received 20.7% of grants, P = 0.003) and plastic surgery (17.2% female surgeons and received 33.3% of grants, P = 0.01). CONCLUSIONS: Male surgeons received most of the total surgical NIH grants. However, funding for female surgeons in orthopedic and plastic surgery outpaces that of their male counterparts when compared to gender proportions in their respective field. Future studies should further investigate the effects of additional applicant demographics on securing NIH grant funding.

Trauma Prevalence and Resource Utilization During 4 COVID-19 "Surges": A National Analysis of Trauma Patients From 92 Trauma Centers.

INTRODUCTION: We aim to assess the trends in trauma patient volume, injury characteristics, and facility resource utilization that occurred during four surges in COVID-19 cases. METHODS: A retrospective cohort study of 92 American College of Surgeons (ACS)-verified trauma centers (TCs) in a national hospital system during 4 COVID-19 case surges was performed. Patients who were directly transported to the TC and were an activation or consultation from the emergency department (ED) were included. Trends in injury characteristics, patient demographics & outcomes, and hospital resource utilization were assessed during four COVID-19 case surges and compared to the same dates in 2019. RESULTS: The majority of TCs were within a metropolitan or micropolitan division. During the pandemic, trauma admissions decreased overall, but displayed variable trends during Surges 1-4 and across U.S. regions and TC levels. Patients requiring surgery or blood transfusion increased significantly during Surges 1-3, whereas the proportion of patients requiring plasma and/or platelets increased significantly during Surges 1-2. Patients admitted to the hospital had significantly higher Injury Severity Score (ISS) and mortality as compared to pre-pandemic during Surge 1 and 2. Patients with Medicaid or uninsured increased significantly during the pandemic. Hospital length of stay (LOS) decreased significantly during the pandemic and more trauma patients were discharged home. CONCLUSIONS: Trauma admissions decreased during Surge 1, but increased during Surge 2, 3 and 4. Penetrating injuries and firearm-related injuries increased significantly during the pandemic, patients requiring surgery or packed red blood cells (PRBCs) transfusion increased significantly during Surges 1-3. The number of patients discharged home increased during the pandemic and was accompanied by a decreased hospital length of stay (LOS).

The Association Between Early Versus Late Physical Therapy Initiation and Outcomes of Trauma Patients With and Without Traumatic Brain Injuries.

BACKGROUND: There is a lack of literature regarding the most effective timing to initiate physical therapy (PT) among traumatically injured patients. We aim to evaluate the association between early PT/mobilization versus delayed or late PT/mobilization and clinical outcomes of trauma patients. METHODS: A retrospective cohort analysis of an urban level-I trauma center from 2014 to 2019 was performed. Univariate analyses and multivariable logistic regression were performed with significance defined as P < 0.05. RESULTS: A total of 11,937 patients were analyzed. Among patients without a traumatic brain injury (TBI), late PT initiation times were associated with 60% lower odds of being discharged home without services (P < 0.05), significantly increased hospital and ICU length of stay (H-LOS, ICU-LOS) (P < 0.05), and significantly higher odds of complications (VTE, pneumonia, pressure ulcers, ARDS) (P < 0.001). Among patients with a TBI, late PT initiation time had 76% lower odds of being discharged home without services (P < 0.05) and significantly longer H-LOS and ICU-LOS (P < 0.05) however did not experience significantly higher odds of complications (P > 0.05). CONCLUSIONS: Among traumatically injured patients, early PT is associated with decreased odds of complications, shorter H-LOS and ICU-LOS, and a favorable discharge disposition to home without services. Adoption of early PT initiation/mobilization protocols and establishment of prophylactic measures against complications associated with delayed PT is critical to maximize quality of care and trauma patient outcomes. Multi-center prospective studies are needed to ascertain the impact of PT initiation times in greater detail and to minimize trauma patient morbidity.

The Effects of COVID-19 Pandemic on Trauma Registry and Performance Improvement Operations and Workforce Nationwide: A Survey of Trauma Center Association of America Members.

BACKGROUND: Trauma Centers integrate Trauma Registrars and Performance Improvement Nurses to drive quality care. Delays in their duties could have negative impacts on outcomes and performance. We aim to investigate the impact of COVID-19 pandemic on Trauma Center operations by assessing performance of trauma registry and performance improvement processes across the United States. METHODS: A cross-sectional study was performed utilizing data from two anonymous questionnaires distributed to Trauma Center Association of America members. Descriptive statistics, Fisher's Exact Test, and multivariable logistic regression were performed with statistical significance defined as P < 0.05. RESULTS: Of 90.2% (83) of Trauma Registrars and 85.9% (67) of Performance Improvement personnel reported that their Trauma Centers have treated COVID-19 patients. Among trauma registrars, respondents did not significantly differ in the current status of completing registry cases (P> 0.05), during COVID-19 compared to prior (P> 0.05), or adjusted odds of COVID-19 delaying completion of entries (P> 0.05). Having >2 Performance Improvement Nurses was significantly associated with improved performance during the COVID-19 pandemic (P= 0.03) whereas working at a Trauma Center which treats adults-only or mixed patient population (adult and pediatric) was associated with being 1-3 months behind in closing of performance improvement cases (P= 0.02). CONCLUSIONS: The negative impact of COVID-19 on Trauma Registrars and Performance Improvement Nurses has been minimal. Adequate staffing/experience seem to mitigate delays and decreased performance. Implementation of expanded staffing, improved training, and evidenced-based revision of Trauma Center logistics may help mitigate future disruptions relating to COVID-19 and allow Trauma Centers to recover and improve their operations.

Emergency Resuscitative Thoracotomy for Civilian Thoracic Trauma in the Field and Emergency Department Settings: A Systematic Review and Meta-Analysis.

BACKGROUND: Emergency department resuscitative thoracotomy (ED-RT) or prehospital resuscitative thoracotomy (PH-RT) is performed for trauma patients with impending or full cardiovascular collapse. This systematic review and meta-analysis analyze outcomes in patients with thoracic trauma receiving PH-RT and ED-RT. METHODS: PubMed, JAMA Network, and CINAHL electronic databases were searched to identify studies published on ED-RT or PH-RT between 2000-2020. Patients were grouped by location of procedure and type of thoracic injury (blunt versus penetrating). RESULTS: A total of 49 studies met the criteria for qualitative analysis, and 43 for quantitative analysis. 43 studies evaluated ED-RT and 5 evaluated PH-RT. Time from arrival on scene to PH-RT >5 min was associated with increased neurological complications and time from the initial encounter to PH-RT or ED-RT >10 min was associated with increased mortality. ISS ≥ 25 and absent signs of life were also associated with increased mortality. There was higher mortality in all PH-RT (93.5%) versus all ED-RT (81.8%) (P = 0.02). Among ED-RTs, a significant difference was found in mortality rate between patients with blunt (92.8%) versus penetrating (78.7%) injuries (P < 0.001). When considering only blunt or penetrating injury types, no significant difference in RT mortality rate was found between ED-RT and PH-RT (P = 0.65 and P = 0.95, respectively). CONCLUSIONS: ED-RT and PH-RT are potentially life-saving procedures for patients with penetrating thoracic injuries in extremis and with signs of life. The efficacy of this procedure is time sensitive. Moreover, there appears to be a greater mortality risk for patients with thoracic trauma receiving RT in the PH setting compared to the ED setting. More studies are needed to determine the significance of PH-RT mortality.

A national evaluation of emergency department thoracotomy practices: Will a high-risk, low-yield procedure reveal potential management practice bias?

BACKGROUND: Emergency department thoracotomy is often performed on patients in extremis from traumatic exsanguination. Thus, inherent biases may play a role in whether or not the emergency department thoracotomy is performed. We aimed to investigate race, socioeconomic status, and gender disparities in the use of emergency department thoracotomy and to investigate outcomes of these patients to assess for possible surgeon practice bias. METHOD: A nationwide retrospective cohort analysis of the American College of Surgeons Trauma Quality Programs Participant Use Profile 2016-2018. Adult patients who suffered blunt, penetrating, or other injuries secondary to falls/firearms/motor vehicle collision/other mechanisms of injury and presented to a trauma center pulseless, with or without signs of life after injury. Rates of thoracotomy, time to thoracotomy, transfer to operating room, emergency department disposition, intensive care unit length of stay, hospital length of stay, complications, mortality, and hospital disposition. Univariate analyses and adjusted multivariable regression were performed to account for confounders with significance defined as P < .05. RESULTS: A total of 6,453 patients were analyzed. Emergency department thoracotomy and mortality were significantly higher in minorities and uninsured patients, even after risk adjustment. There were no differences in timing among race groups to emergency department thoracotomy. White/Caucasian patients experienced the highest rate of emergency department initial disposition to the intensive care unit (10.3%, P < .0001) and lowest mortality rate (89.2%, P < .0001). CONCLUSION: Surgeon bias was not seen in the practice of emergency department thoracotomy for patients arriving pulseless. However, poorer outcomes were associated with minorities and lower socioeconomic status patients. Thoracotomy rates were higher in minorities and lower socioeconomic status patients due to more penetrating trauma.

Mass Shootings and Their Proximity to a Public or Private School: Protecting the Health and Livelihood of Our Children.

INTRODUCTION: Firearm-related violence occupies the third leading age-adjusted mortality rate among all mechanisms of injury. We aim to analyze the distribution of mass shootings in relation to the distance to the nearest public/private school in the United States. METHODS: A retrospective study investigating mass shootings and proximity to school areas. Information regarding mass shootings was obtained from the Gun Violence Archive. The locations of public/private schools for the 2019-2020 school year were obtained from the National Center for Education Statistics and the Euclidian distance from a mass shooting to the nearest school was measured. RESULTS: There were 417 mass shootings in 2019 and 610 in 2020. The average distance from a mass shooting to the nearest public/private school was 0.52 miles in 2019 and 0.57 miles in 2020. Most mass shootings occurred within 0.30 miles of a school in 2019 and 0.40 miles in 2020. There was no significant association between average distance of a mass shooting to a public/private school and the population density in 2019 (P = .313) or 2020 (P = .351). CONCLUSION: The growing number of mass shootings from 2019-2020 was associated with an average distance of <0.60 miles from the location of a mass shooting to a public or private school, highlighting the danger posed to children living and learning in these areas. Mass shootings are prevalent throughout the country and the close proximity of these events to places of learning warrants further investigation into policies and preventive measures aimed at preventing gun violence occurring near schools.