Glasgow Coma Scale Intubation Thresholds and Outcomes of Patients With Traumatic Brain Injury: The Need for Tailored Practice Management Guidelines.

INTRODUCTION: This study aims to re-evaluate the GCS threshold for intubation in patients presenting to the ED with a traumatic brain injury to optimize outcomes and provide evidence for future practice management guidelines. METHODS: We retrospectively reviewed the ACS-TQIP-Participant Use File (PUF) 2015-2019 for adult trauma patients 18 years and older who experienced a blunt traumatic head injury and received computerized tomography. Multivariable regressions were performed to assess associations between outcomes and GCS intubation thresholds of 5, 8, and 10. RESULTS: In patients with a GCS ≤5, there were no differences in mortality (GCS ≤5: 26.3% vs GCS >5: 28.3%, adjusted P = .08), complication rates (GCS ≤5: 9.1% vs GCS >5: 10.3%, adjusted P = .91), or ICU length of stay (GCS ≤5: 5.4 vs GCS >5: 4.7, adjusted P = .36) between intubated and non-intubated patients. Intubated patients at GCS thresholds ≤8 (26.2% vs 19.1%, adjusted P < .0001) and ≤10 (25.6% vs 15.8%, adjusted P < .0001) had significantly higher mortality rates than non-intubated patients. Intubation at all GCS thresholds >5 resulted in higher rates of complications, H-LOS, and ICU-LOS when compared to non-intubated patients with the same GCS score. CONCLUSION: A GCS ≤5 was the threshold at which intubation in TBI patients conferred an additional benefit in disposition without worsened outcomes of mortality, H-LOS, or ICU-LOS. Trauma societies and hospital institutions should consider revisiting existing guidelines and protocols concerning the appropriate GCS threshold for safer intubation and better outcomes among these patient population.

Trends in disparities research on trauma and acute care surgery outcomes: A 10-year systematic review of articles published in The Journal of Trauma and Acute Care Surgery.

ABSTRACT: This is a 10-year review of The Journal of Trauma and Acute Care Surgery (JTACS) literature related to health care disparities, health care inequities, and patient outcomes. A retrospective review of articles published in JTACS between January 1, 2013, and July 15, 2022, was performed. Articles screened included both adult and pediatric trauma populations. Included articles focused on patient populations related to trauma, surgical critical care, and emergency general surgery. Of the 4,178 articles reviewed, 74 met the inclusion criteria. Health care disparities related to gender (n = 10), race/ethnicity (n = 12), age (n = 14), income status (n = 6), health literacy (n = 6), location and access to care (n = 23), and insurance status (n = 13) were described. Studies published on disparities peaked in 2016 and 2022 with 13 and 15 studies respectively but dropped to one study in 2017. Studies demonstrated a significant increase in mortality for patients in rural geographical regions and in patients without health insurance and a decrease in patients who were treated at a trauma center. Gender disparities resulted in variable mortality rates and studied factors, including traumatic brain injury mortality and severity, venous thromboembolism, ventilator-associated pneumonia, firearm homicide, and intimate partner violence. Under-represented race/ethnicity was associated with variable mortality rates, with one study demonstrating increased mortality risk and three finding no association between race/ethnicity and mortality. Disparities in health literacy resulted in decreased discharge compliance and worse long-term functional outcomes. Studies on disparities in JTACS over the last decade primarily focused on location and access to health care, age, insurance status, and race, with a specific emphasis on mortality. This review highlights the areas in need of further research and funding in the Journal of Trauma and Acute Care Surgery regarding health care disparities in trauma aimed at interventions to reduce disparities in patient care, ensure equitable care, and inform future approaches targeting health care disparities. LEVEL OF EVIDENCE: Systematic Review; Level IV.

Cost-Effectiveness of Cell Salvage in Trauma Blood Transfusions.

INTRODUCTION: Despite the increasing amount of evidence supporting its use, cell salvage (CS) remains an underutilized resource in operative trauma care in many hospitals. We aim to evaluate the utilization of CS in adult trauma patients and associated outcomes to provide evidence-based recommendations. METHODS: A systematic review was conducted using PubMed, Google Scholar, and CINAHL. Articles evaluating clinical outcomes and the cost-effectiveness of trauma patients utilizing CS were included. The primary study outcome was mortality rates. The secondary outcomes included complication rates (sepsis and infection) and ICU-LOS. The tertiary outcome was the cost-effectiveness of CS. RESULTS: This systematic review included 9 studies that accounted for a total of 1119 patients that received both CS and allogeneic transfusion (n = 519), vs allogeneic blood transfusions only (n = 601). In-hospital mortality rates ranged from 13% to 67% in patients where CS was used vs 6%-65% in those receiving allogeneic transfusions only; however, these findings were not significantly different (P = .21-.56). Similarly, no significant differences were found between sepsis and infection rates or ICU-LOS in those patients where CS usage was compared to allogeneic transfusions alone. Of the 4 studies that provided comparisons on cost, 3 found the use of CS to be significantly more cost-effective. CONCLUSIONS: Cell salvage can be used as an effective method of blood transfusion for trauma patients without compromising patient outcomes, in addition to its possible cost advantages. Future studies are needed to further investigate the long-term effects of cell salvage utilization in trauma patients.

Traumatic Brain Injury, Electrolyte Levels, and Associated Outcomes: A Systematic Review.

INTRODUCTION: Although it has been established that electrolyte abnormalities are a consequence of traumatic brain injury (TBI), the degree to which electrolyte imbalances impact patient outcomes has not been fully established. We aim to determine the impact of sodium, potassium, calcium, and magnesium abnormalities on outcomes in patients with TBI. METHODS: Four databases were searched for studies related to the impact of electrolyte abnormalities on outcomes for TBI patients. Outcomes of interest were rates of mortality, Glasgow Outcome Scale (GOS), and intensive care unit length of stay (ICU-LOS). The search included studies published up to July 21, 2022. Articles were then screened and included if they met inclusion and exclusion criteria. RESULTS: In total, fourteen studies met inclusion and exclusion criteria for analysis in this systematic review. In patients with TBI, an increased mortality rate was associated with hypernatremia, hypokalemia, and hypocalcemia in the majority of studies. Both hyponatremia and hypomagnesemia were associated with worse GOS at 6 months. Whereas, both hyponatremia and hypernatremia were associated with increased ICU-LOS. There was no evidence to suggest other electrolyte imbalances were associated with either GOS or ICU-LOS. CONCLUSIONS: Hyponatremia and hypomagnesemia were associated with worse GOS. Hypernatremia was associated with increased mortality and ICU-LOS. Hypokalemia and hypocalcemia were associated with increased mortality. Given these findings, future practice guidelines should consider the effects of electrolytes' abnormalities on outcomes in TBI patients prior to establishing management strategies.

National analysis of motorcycle associated injuries and fatalities: Wearing helmet saves lives.

INTRODUCTION: Riding a motorcycle without a helmet represents a public health risk that can result in disabling injuries or death. We aim to provide a comprehensive analysis of the impact of helmet use on motorcycle injuries, injury types, and fatalities, to highlight areas requiring future intervention. METHODS: We performed a retrospective cohort study utilizing the American College of Surgeons Trauma Quality Program Participant Use File between 2017 and 2020 analyzing motorcycle associated injuries and fatalities in adult patients with moderate and severe injury severity score in relation to helmet use. Multivariable regressions were utilized and adjusted for potential confounders. A subset analysis was performed for patients presenting with abbreviated injury scale (AIS) head ≥3 and all other body regions ≤2. RESULTS: 43,225 patients met study criteria, of which 24,389 (56.4%) were helmet users and 18,836 (43.6%) were not. Helmet use was associated with a 35% reduction in the relative risk of expiring in the hospital due to motorcycle-related injuries (aOR 0.65; 95% CI [0.59-0.70]; p < 0.001) and a decreased intensive care unit length of stay (ICU-LOS) by half a day (B = -0.50; 95% CI [-0.77, -0.24]; p < 0.001). CONCLUSION: Motorcycle riders without a helmet had significantly greater odds of increased in-hospital mortality and longer stays in the ICU than those who used a helmet. The results of this nationwide study support the need for continued research exploring the significance of helmet use and interventions aimed at improving helmet usage among motorcyclists. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

Analysis of Racial and Gender Distribution of US MD Graduates Entering Into General Surgery and Surgical Subspecialties Residencies: The Need for Effective & Sustainable Diversity, Equity, and Inclusion Strategies.

INTRODUCTION: We aim to investigate disparities & inequities based on race, sex, graduating age, and the number of peer-reviewed publications among allopathic U.S. Doctor of Medicine graduates who reported entering a surgical training program over a span of 5 y. METHODS: A retrospective cohort analysis of the Association of American Medical Colleges student records system and Electronic Residency Application Service for graduates entering a surgical specialty residency during graduate medical education training cycles 2015-2020. RESULTS: African American, Asian, and Hispanic applicants each accounted for less than 1% of graduates who reported entering a surgical training program. Asians (OR = 0.58, P = 0.01) and those identifying as other races (OR = 0.74, P = 0.01) were significantly less likely to enter a surgical subspecialty when compared to Caucasians. Orthopedic surgery contained the lowest proportion of minorities; African Americans 0.5% (n = 18), Asians 0.3% (n = 11), Hispanics 0.1% (n = 4), and others with 2% (n = 68). Females who reported entering Orthopedic surgery training represented the smallest female population in surgical specialties (17%, n = 527). The number of peer-reviewed publications was significantly associated with male sex (ß = 0.28, P < 0.01), age between 30 and 32 at graduation (ß = 1.76, P < 0.01), and identification as other races (ß = 1.53, P < 0.01). CONCLUSIONS: Racial minorities represented only 5.1% of graduates who reported entering a surgical specialty graduate medical education training program. Minority races and females were significantly less likely to enter a surgical subspecialty training program compared to Caucasian graduates and males, especially in orthopedic surgery. Implementation of specialty-specific programs and diversity, equity, and inclusion departments that promote mentorship and guidance toward residency programs is needed to combat continued race and sex disparities.

Outcomes of Transfusion With Whole Blood, Component Therapy, or Both in Adult Civilian Trauma Patients: A Systematic Review and Meta-Analysis.

INTRODUCTION: This systematic review and meta-analysis was conducted to compare outcomes, including transfusion volume, complications, intensive care unit length of stay, and mortality for adult civilian trauma patients transfused with whole blood (WB), components (COMP), or both (WB + COMP). METHODS: A systematic review and meta-analysis were conducted using studies that evaluated outcomes of transfusion of WB, COMP, or WB + COMP for adult civilian trauma patients. A search of PubMed, Embase, and Cochrane from database inception to March 3, 2022 was conducted. The search resulted in 18,400 initial articles with 16 studies remaining after the removal of duplicates and screening for inclusion and exclusion criteria. RESULTS: This study identified an increased risk of 24-h mortality with COMP versus WB + COMP (relative risk: 1.40 [1.10, 1.78]) and increased transfusion volumes of red blood cells with COMP versus WB at 6 and 24 h, respectively (-2.26 [-3.82, -0.70]; -1.94 [-3.22, -0.65] units). There were no differences in the calculated rates of infections or intensive care unit length of stay between WB and COMP, respectively (relative risks: 1.35 [0.53, 3.46]; -0.91 [-2.64, 0.83]). CONCLUSIONS: Transfusion with WB + COMP is associated with lower 24-h mortality versus COMP and transfusion with WB is associated with a lower volume of red blood cells transfused at both 6 and 24 h. Based on these findings, greater utilization of whole blood in civilian adult trauma resuscitation may lead to improved mortality and reduced transfusion requirements.

Outcomes of Pigtail Catheter Placement versus Chest Tube Placement in Adult Thoracic Trauma Patients: A Systematic Review and Meta-Analysis.

INTRODUCTION: A debate currently exists regarding the efficacy of pigtail catheters vs chest tubes in the management of thoracic trauma. This meta-analysis aims to compare the outcomes of pigtail catheters vs chest tubes in adult trauma patients with thoracic injuries. METHODS: This systematic review and meta-analysis were conducted using PRISMA guidelines and registered with PROSPERO. PubMed, Google Scholar, Embase, Ebsco, and ProQuest electronic databases were queried for studies comparing the use of pigtail catheters vs chest tubes in adult trauma patients from database inception to August 15th, 2022. The primary outcome was the failure rate of drainage tubes, defined as requiring a second tube placement or VATS, unresolved pneumothorax, hemothorax, or hemopneumothorax requiring additional intervention. Secondary outcomes were initial drainage output, ICU-LOS, and ventilator days. RESULTS: A total of 7 studies satisfied eligibility criteria and were assessed in the meta-analysis. The pigtail group had higher initial output volumes vs the chest tube group, with a mean difference of 114.7 mL [95% CI (70.6 mL, 158.8 mL)]. Patients in the chest tube group also had a higher risk of requiring VATS vs the pigtail group, with a relative risk of 2.77 [95% CI (1.50, 5.11)]. CONCLUSIONS: In trauma patients, pigtail catheters rather than chest tubes are associated with higher initial output volume, reduced risk of VATS, and shorter tube duration. Considering the similar rates of failure, ventilator days, and ICU length-of-stay, pigtail catheters should be considered in the management of traumatic thoracic injuries. STUDY TYPE: Systematic Review and meta-analysis.

Standardized Medical Coding Curriculum in Surgical Graduate Medical Education.

INTRODUCTION: Despite the increasing importance of coding and billing in healthcare as a whole and calls from the Accreditation Council for Graduate Medical Education (ACGME) to emphasize systems-based practice, many surgical training programs have not prioritized coding and billing within their curricula. We aim to evaluate the performance of surgical residents and early career surgeons in coding and billing and to appraise interventions to improve coding and billing abilities within this group. METHODS: A literature search from conception to March 15th, 2022 utilizing PubMed, Google Scholar, and EMBASE was conducted to search for studies that evaluate surgical resident coding practices and interventions to improve practice management and financial competency. RESULTS: Discrepancies in coding and billing ability are prominent between residents, surgeons, and professional coders. One study demonstrated coding accuracy of 76.5% for professional coders, 62.1% for surgical attendings, and 54.1% for surgical residents, whereas another study reported a 52.82% coding accuracy and residents. Resident performance in coding and billing was inferior to their more experienced surgical attending counterparts and professional coders. Surgical residents and fellows demonstrated significantly improved knowledge and confidence in coding following the administration of either individual or longitudinal educational interventions. CONCLUSION: Coding and billing discrepancies among students, residents, and surgeons persist due to a lack of formalized training. Integration of standardized and mandated medical coding curricula and interventions within residency programs has great potential to improve surgical coding practices and should be a mandatory component of graduate medical education.

Beta-Blocker Therapy in Patients With Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis.

INTRODUCTION: Traumatic brain injury (TBI), a leading cause of morbidity and mortality among trauma patients worldwide, poses the risk of secondary neurological insult due to significant catecholamine surge. We aim to investigate the effectiveness and outcomes of beta-blocker administration in patients with severe TBI. METHODS: A search through PubMed, EMBASE, JAMA network, and Google Scholar databases was conducted for relevant peer-reviewed original studies published before February 15, 2022. A standard random-effects model was used, as justified by a high Cohen's Q test. RESULTS: Twelve studies met inclusion criteria and were included in the meta-analysis. Severe TBI patients who were administered beta-blockers had a significantly reduced incidence of in-hospital mortality compared to the non-beta-blocker group (14.5% vs 19.2%). However, the beta-blocker group was reported to have a significantly greater number of ventilator days (5.58 vs 2.60 days). Similarly, intensive care unit (9.00 vs 6.84 days) and hospital (17.30 vs 11.02 days) lengths of stay (LOS) were increased in the beta-blocker group compared to those who were not administered beta-blocker therapy, but only the difference in hospital-LOS was significant. CONCLUSIONS: Beta-blockers have significantly decreased in-hospital mortality in patients with severe TBI despite being associated with an increase in ventilator days and hospital-LOS. The administration of beta-blocker therapy in the management of severe TBI may be warranted and should be discussed in future guidelines.

Nationwide Analysis of Motorcycle-Associated Injuries and Fatalities in the United States: Insufficient Prevention Policies or Abandoned Laws?

BACKGROUND: Motorcycle road traffic collisions are a major cause of mortality in the United States. We aimed to analyze the temporal and statewide trends in motorcycle collision fatalities (MCFs) nationwide and their association with state laws regarding motorcycle helmet requirements, lane splitting, speeding, intoxicating driving, and red light cameras. METHODS: A retrospective review of United States MCF/capita from 2015 to 2019 was performed using the Fatality Analysis Reporting System database. MCF/capita was defined as a motorcyclist death per 100 000 motorcyclist registrations. Independent-samples t-test and ANOVA were used to determine differences, with significance defined as P < .05. Linear regression analysis and Pearson's correlation were used to further determine associations between variables. RESULTS: The majority of fatalities occurred in males (n = 21 354, 91.0%), ages 25-54 (n = 13 728, 58.5%), and Caucasians (n = 19 195, 81.8%). A total of 24 states and DC exhibited positive trends in MCF/capita from 2015 to 2019. There was no significant difference in MCF/capita between states who had mandatory helmet laws for all, partial requirements, and states with no law (63.4 vs 54.3 vs 33.6, P = .360). Among fatalities involving alcohol, a significantly greater number of MCF/capita were found above the legal limit of .08 compared to the group with a blood alcohol concentration of .01-.07 (17.8 vs 4.5, P < .001). CONCLUSION: Motorcyclist fatalities continue to pose a public health risk, with 24 states showing an upward trend. Additional interventions and laws are needed to decrease the number of motorcyclist deaths. Further strategy on implementation and enforcement of helmet laws and alcohol consumption may be an essential component.

Analysis of Bicyclist Injuries and Fatalities in The United States: The Need for Effective & Sustainable Prevention Policies.

We aim to investigate nationwide and state trends of bicyclist injuries, fatalities, and associated costs amongst adult and pediatric populations to assess the need for effective and strategic interventions. An epidemiologic study was performed investigating the injury and fatality rate of bicyclists from 2010 to 2020. The fatality rate was higher in adults compared to pediatric bicyclists (0.36 vs. 0.12 per population of 100,000, P < .001), but pediatric bicyclists suffered higher rates of injury (246.19 vs. 102.11 per population of 100,000, P < .001). The medical cost of fatalities for adult bicyclists was $139.1 million compared to $9.0 million for pediatric bicyclists. Bicyclist fatality rates are significantly higher per capita for adult bicyclists. States including Florida, South Carolina, and Louisiana had the highest bicyclist fatalities per capita for both adults and children.

Analysis of Surgical Residents' Salaries and Associated Funding During Eight Residency Training Cycles: Toward Improving Future Residents' Benefits and Compensation.

INTRODUCTION: We aimed to investigate the trends in surgical residents' salaries across the nation and by region from 2014-2015 to 2021-2022 to identify areas for improvement in resident benefits and compensation. METHODS: This is a retrospective study investigating the trends in US medical resident salaries from 2014-2015 to 2021-2022. Residency salary was analyzed over time, by region, and between surgical specialties both unadjusted and adjusted for cost of living. Salary by surgical specialty was collected from available years 2014-2015 to 2019-2020. Trends in residency salaries were also compared to the trends in graduate medical education (GME) Medicare funding. RESULTS: The average resident salary/cost of living ratio did not significantly change over the study period (2014-2015: 0.96, 2020-2021, 0.96, P = 0.654). The South and Midwest had significantly higher average resident salaries than the Northeast (P < 0.001) and West (P < 0.001) after adjusting for the cost of living. The average total GME Medicare funding per resident increased significantly more than the average resident salary ($12,278 versus $4540, P < 0.001). The average general surgery resident salary (2014-2015: $57,000, 2019-2020: $61,500, Δ = $4500) increased significantly less than the average salary of all specialties (2014-2015: $51,586, 2019-2020: $57,191, Δ = $5605, P = 0.001). CONCLUSIONS: Residency salaries have increased marginally from 2014-2015 to 2021-2022 and remain below the average US cost of living. Residency salaries vary significantly between surgical specialties and by region. Discussions aimed at reformulating GME compensation that takes into consideration regional differences in cost of living are needed.

Assessment of Outcomes in Laparotomy vs Laparoscopy: A Propensity Score Matched Analysis of Patients Sustaining Single Penetrating Left Upper Quadrant Injury.

BACKGROUND: We aim to compare outcomes between laparotomy and laparoscopy in trauma patients with single penetrating left upper quadrant injuries. METHODS: Using a 1:1 propensity score match, a retrospective study was conducted utilizing data from the ACS-TQP-PUF between 2016 and 2019. Adults sustaining a single penetrating left upper quadrant injury who received either a laparotomy or laparoscopy were included for analysis. The primary outcome was inpatient mortality. Secondary outcomes included ICU-LOS, H-LOS, and complication rates. Multivariable regression and reliability adjustments were performed to control for confounding. RESULTS: 486 patients receiving laparotomy were matched to 486 patients receiving laparoscopy. No differences in inpatient mortality (1.2% vs 2.9%, aOR: 2.92, 95% CI: .32, 26.31); however, patients undergoing laparotomy experienced higher complication rates (7.0% vs 1.2%, aOR: 9.61, 95% CI: 1.94, 47.48), pRBC transfusions (21.8% vs 6.4%, aOR: 3.19, 95% CI: 1.66, 6.13), and H-LOS (Mean ± SD: 8.1 ± 9.8 vs 3.9 ± 4.0, P = .0002). Lower ISS (1 - 15) undergoing laparotomy had more complications (4.3% vs .7%, aOR: 13.52, 95% CI: 1.39, 131.69), pRBC transfusions (13.9% vs 4.9%, aOR: 3.21, 95% CI: 1.53, 6.75), and H-LOS (Mean ± SD: 6.7 ± 7.1 vs 3.6 ± 3.2, P < .0001). There were no differences in mortality among patients with a lower ISS (1.5% vs .4%, aOR: 77.2, 95% CI: (<.001, >999). CONCLUSIONS: Laparotomy is associated with increased rates of complications for single penetrating LUQ trauma. For patients with low ISS, laparoscopy is associated with better outcomes without increase in mortality.

Analysis of Electric Vehicle Collisions in the United States: An Epidemiological Study.

INTRODUCTION: Despite the increase in electric vehicle sales in the US, their impact on injuries and fatalities is still understudied. We aim to evaluate injuries and fatalities associated with electric vehicle collisions in the US. METHODS: The study utilized electric vehicle injury and fatality data from the Fatality Analysis Reporting System (FARS). All electric vehicle models available within the FARS database and sold in the US from 2014 to 2020 were selected. Electric vehicle models were matched to analogous motor vehicles when possible. RESULTS: No significant increase in electric vehicle fatality per capita (FPC) was found during the study period (2014: .41 vs 2020: 1.42, per 100 000 electric cars, P = .080). However, 82% of all fatalities occurred on non-intersectional local roadways with 46% occurring in the presence of speeding, 14% in the presence of fire, and 38% involving a driver with an elevated blood alcohol content (BAC). The Tesla Model S, Kia Niro, and Hyundai IONIQ accounted for the most fatality per capita (17.89 vs 10.27 vs 8.42, per 100 000 electric cars). Upon comparison of electric vehicles to analogous motor vehicles produced within the same year, the Hyundai IONIQ had a significantly lower FPC compared to the Hyundai Elantra (7.33 vs 23.51, per 100 000 electric cars P = .034). CONCLUSION: While no significant increase in electric vehicle fatality per capita (FPC) was found, the total number of electric vehicle fatalities did increase significantly during the study period (2014-2020). Furthermore, a significant proportion of these fatalities is directly related to speeding, fire, and intoxicated driving.

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.

Timing of tracheostomy in patients with severe traumatic brain injuries: The need for tailored practice management guidelines.

INTRODUCTION: Traumatic brain injury (TBI) is one of the leading causes of fatal trauma, and patients often require prolonged ventilation and tracheostomy. There are currently no standardized guidelines regarding the optimal timing of tracheostomy placement for mechanically ventilated patients with severe TBI. This review aims to investigate the impact of tracheostomy timing on the clinical outcomes in patients with severe TBI. METHODS: A literature search was conducted according to PRISMA 2020 guidelines. PubMed, Google Scholar, EMBASE, MedLine, Web of Science, Cochrane, and CINAHL were searched for studies evaluating the impact of early versus late tracheostomy on TBI patient outcomes. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) and Newcastle-Ottawa Scale (NOS) were used for quality of evidence and risk of bias assessment, respectively. RESULTS: A total of nine studies met eligibility criteria. All nine studies investigated tracheostomy timing in severe TBI patients and demonstrated that early tracheostomy is associated with decreased ICU length-of-stay (LOS) and increased ventilator free-days compared to late tracheostomy. CONCLUSION: Current evidence suggests that patients with severe TBI following traumatic injury may benefit from an early tracheostomy due to improved clinical outcomes, including decreased MV duration and ICU-LOS, compared to late tracheostomy. Further multi-institutional studies are needed to develop evidence-based guidelines.

Epidemiological Comparison of ACL Injuries on Different Playing Surfaces in High School Football and Soccer.

Background: Anterior cruciate ligament (ACL) injuries are among the most common serious injuries to athletes in the United States. Among high school sports, the highest rates of ACL injury occur in soccer and football. Purpose: To compare ACL injuries on artificial turf and natural grass using a nationally representative sample of high school athletes participating in football and boys' and girls' soccer. Study Design: Descriptive epidemiology study. Methods: ACL injuries among high school athletes participating in football and soccer were obtained from the High School Reporting Information Online surveillance system during the 2007-08 through 2018-19 school years. National estimates and injury proportion ratios (IPRs) with 95% CIs were calculated for ACL injuries that occurred on artificial turf versus natural grass. Results: A total of 1039 ACL injuries were reported, which represented an estimated 389,320 (95% CI, 358,010-420,630) injuries nationally. There were 74,620 estimated football-related ACL injuries on artificial turf and 122,654 on natural grass. Likewise, 71,877 of the estimated soccer-related ACL injuries occurred on artificial turf and 104,028 on natural grass. A contact-injury mechanism accounted for 50.2% of football-related ACL injuries on artificial turf and 60.8% on natural grass. For soccer-related ACL injuries, a noncontact mechanism predominated on artificial turf (61.5%) and natural grass (66.4%). Among all injuries, ACL injuries were more likely to occur on artificial turf than natural grass in both football (IPR, 1.23 [95% CI, 1.03-1.47]) and girls' soccer (IPR, 1.53 [95% CI, 1.08-2.16]); however, no significant association was found in boys' soccer (IPR, 1.65 [95% CI, 0.99-2.75]). Among lower extremity injuries, ACL injuries were more likely to occur on artificial turf than natural grass in both boys' soccer (IPR, 1.72 [95% CI, 1.03-2.85]) and girls' soccer (IPR, 1.61 [95% CI, 1.14-2.26]); however, the association was not significant in football (IPR, 1.17 [95% CI, 0.98-1.39]). Conclusion: ACL injuries were more likely to occur (ie, had larger IPRs) on artificial turf than natural grass; however, this relationship was not statistically significant for all sports.