A 12-year experience in the management of blunt thoracic aortic injury in Otautahi Christchurch.

BACKGROUND: Blunt thoracic aortic injury (BTAI) is associated with a high mortality and is the second most common cause of death from trauma. The approach to major trauma, imaging technology and advancement in endovascular therapy have revolutionised the management of BTAI. Endovascular therapy has now become the gold standard technique replacing surgery with its high mortality and morbidity in unstable patients. We aim to assess the outcomes following management of BTAI. METHOD: This is a retrospective study of all patients with BTAI between 1 January 2010 and 1 January 2022. Data were obtained from electronic health records. The grading of BTAI severity was done based on the Society of Vascular Surgery (SVS) Criteria. RESULTS: Fifty patients were included in the study analysis. The most common cause of BTAI was due to high-speed motor vehicle accidents (MVA) (36 patients, 72%). Grade 1 and grade 3 BTAI injuries were mostly encountered in 40% and 30% of the study cohort, respectively. Twenty-three patients (46%) underwent thoracic endovascular aortic repair (TEVAR). There was no secondary aortic re-intervention, conversion to open surgery or aortic-related deaths at 30 days or at most recent follow-up. CONCLUSION: Management of BTAI in our centre compares well with currently published studies. Long-term studies are warranted to guide clinicians in areas of controversy in BTAI management.

Mortality of traumatic chest injury and its predictors across sub-saharan Africa: systematic review and meta-analysis, 2024.

INTRODUCTION: Globally, chest trauma remain as a prominent contributor to both morbidity and mortality. Notably, patients experiencing blunt chest trauma exhibit a higher mortality rate (11.65%) compared to those with penetrating chest trauma (5.63%). AIM: This systematic review and meta-analysis aimed to assess the mortality rate and its determinants in cases of traumatic chest injuries. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist guided the data synthesis process. Multiple advanced search methods, encompassing databases such as PubMed, Africa Index Medicus, Scopus, Embase, Science Direct, HINARI, and Google Scholar, were employed. The elimination of duplicate studies occurred using EndNote version X9. Quality assessment utilized the Newcastle-Ottawa Scale, and data extraction adhered to the Joanna Briggs Institute (JBI) format. Evaluation of publication bias was conducted via Egger's regression test and funnel plot, with additional sensitivity analysis. All studies included in this meta-analysis were observational, ultimately addressing the query, what is the pooled mortality rate of traumatic chest injury and its predictors in sub-Saharan Africa? RESULTS: Among the 845 identified original articles, 21 published original studies were included in the pooled mortality analysis for patients with chest trauma. The determined mortality rate was nine (95% CI: 6.35-11.65). Predictors contributing to mortality included age over 50 (AOR 3.5; 95% CI: 1.19-10.35), a time interval of 2-6 h between injury and admission (AOR 3.9; 95% CI: 2.04-7.51), injuries associated with the head and neck (AOR 6.28; 95% CI: 3.00-13.15), spinal injuries (AOR 7.86; 95% CI: 3.02-19.51), comorbidities (AOR 5.24; 95% CI: 2.93-9.40), any associated injuries (AOR 7.9; 95% CI: 3.12-18.45), cardiac injuries (AOR 5.02; 95% CI: 2.62-9.68), the need for ICU care (AOR 13.7; 95% CI: 9.59-19.66), and an Injury Severity Score (AOR 3.5; 95% CI: 10.6-11.60). CONCLUSION: The aggregated mortality rate for traumatic chest injuries tends to be higher in sub-Saharan Africa. Factors such as age over 50 years, delayed admission (2-6 h), injuries associated with the head, neck, or spine, comorbidities, associated injuries, cardiac injuries, ICU admission, and increased Injury Severity Score were identified as positive predictors. Targeted intervention areas encompass the health sector, infrastructure, municipality, transportation zones, and the broader community.

Recent Changes in the Management of High-Grade Blunt Pancreatic Injury in Children: A Nationwide Trend Analysis.

BACKGROUND: The optimal management of pediatric patients with high-grade blunt pancreatic injury (BPI) involving the main pancreatic duct remains controversial. This study aimed to assess the nationwide trends in the management of pediatric high-grade BPI at pediatric (PTC), mixed (MTC), and adult trauma centers (ATC). STUDY DESIGN: This is a retrospective observational study of the National Trauma Data Bank. We included pediatric patients (age 16 years or less) sustaining high-grade BPI (Abbreviated Injury Scale 3 or more) from 2011 to 2021. Patients who did not undergo pancreatic operation were categorized into the nonoperative management (NOM) group. Trauma centers were defined as PTC (level I/II pediatric only), MTC (level I/II adult and pediatric), and ATC (level I/II adult only). Primary outcome was the proportion of patients undergoing NOM, and secondary outcomes included the use of ERCP and in-hospital mortality. A Cochran-Armitage test was used to analyze the trend. RESULTS: A total of 811 patients were analyzed. The median age was 9 years (interquartile range 6 to 13), 64% were male patients, and the median injury severity score was 17 (interquartile range 10 to 25). During the study period, there was a significant upward linear trend in the use of NOM and ERCP among the overall cohort (range 48% to 66%; p trend = 0.033, range 6.1% to 19%; p trend = 0.030, respectively). The significant upward trend for NOM was maintained in the subgroup of patients at PTC and MTC (p trend = 0.037), whereas no significant trend was observed at ATC (p trend = 0.61). There was no significant trend in in-hospital mortality (p trend = 0.38). CONCLUSIONS: For the management of pediatric patients with high-grade BPI, this study found a significant trend toward increasing use of NOM and ERCP without mortality deterioration, especially at PTC and MTC.

Nonoperative Management for Low-Grade Blunt Thoracic Aortic Injury.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) is the standard of care for the treatment of blunt thoracic aortic injury (BTAI) requiring intervention. Data suggest that low-grade BTAI (grade I [intimal tears] or grade II [intramural hematoma]) will resolve spontaneously if treated with nonoperative management (NOM) alone. There has been no comparison specifically between the use of NOM vs TEVAR for low-grade BTAI. We hypothesize that these low-grade injuries can be safely managed with NOM alone. STUDY DESIGN: Retrospective analysis of all patients with a low-grade BTAI in the Aortic Trauma Foundation Registry from 2016 to 2021 was performed. The study population was 1 primary outcome was mortality. Secondary outcomes included complications, ICU length of stay, and ventilator days. RESULTS: A total of 880 patients with BTAI were enrolled. Of the 269 patients with low-grade BTAI, 218 (81%) were treated with NOM alone (81% grade I, 19% grade II), whereas 51 (19%) underwent a TEVAR (20% grade I, 80% grade II). There was no difference in demographic or mechanism of injury in patients with low-grade BTAI who underwent NOM vs TEVAR. There was a difference in mortality between NOM alone and TEVAR (8% vs 18%, p = 0.009). Aortic-related mortality was 0.5% in the NOM group and 4% in the TEVAR group (p = 0.06). Hospital and ICU length of stay and ventilator days were not different between the 2 groups. CONCLUSIONS: NOM alone is safe and appropriate management for low-grade BTAI, with lower mortality and decreased rates of complication when compared with routine initial TEVAR.

Cardiac risk stratification and adverse outcomes in surgically managed patients with isolated traumatic spine injuries.

INTRODUCTION: As the incidence of traumatic spine injuries has been steadily increasing, especially in the elderly, the ability to categorize patients based on their underlying risk for the adverse outcomes could be of great value in clinical decision making. This study aimed to investigate the association between the Revised Cardiac Risk Index (RCRI) and adverse outcomes in patients who have undergone surgery for traumatic spine injuries. METHODS: All adult patients (18 years or older) in the 2013-2019 TQIP database with isolated spine injuries resulting from blunt force trauma, who underwent spinal surgery, were eligible for inclusion in the study. The association between the RCRI and in-hospital mortality, cardiopulmonary complications, and failure-to-rescue (FTR) was determined using Poisson regression models with robust standard errors to adjust for potential confounding. RESULTS: A total of 39,391 patients were included for further analysis. In the regression model, an RCRI ≥ 3 was associated with a threefold risk of in-hospital mortality [adjusted IRR (95% CI): 3.19 (2.30-4.43), p < 0.001] and cardiopulmonary complications [adjusted IRR (95% CI): 3.27 (2.46-4.34), p < 0.001], as well as a fourfold risk of FTR [adjusted IRR (95% CI): 4.27 (2.59-7.02), p < 0.001], compared to RCRI 0. The risk of all adverse outcomes increased stepwise along with each RCRI score. CONCLUSION: The RCRI may be a useful tool for identifying patients with traumatic spine injuries who are at an increased risk of in-hospital mortality, cardiopulmonary complications, and failure-to-rescue after surgery.

Readmission after thoracic endovascular aortic repair following blunt thoracic aortic injury.

PURPOSE: Thoracic endovascular aortic repair (TEVAR) is increasingly utilized to treat blunt thoracic aortic injury (BTAI), but post-discharge outcomes remain underexplored. We examined 90-day readmission in patients treated with TEVAR following BTAI. METHODS: Adult patients discharged alive after TEVAR for BTAI in the Nationwide Readmissions Database between 2016 and 2019 were included. Outcomes examined were 90-day non-elective readmission, primary readmission reasons, and 90-day mortality. As a complementary analysis, 90-day outcomes following TEVAR for BTAI were compared with those following TEVAR for acute type B aortic dissection (TBAD). RESULTS: We identified 2085 patients who underwent TEVAR for BTAI. The median age was 43 years (IQR, 29-58), 65% of all patients had an ISS ≥ 25, and 13% were readmitted within 90 days. The main primary causes for readmission were sepsis (8.8%), wound complications (6.7%), and neurological complications (6.5%). Two patients developed graft thrombosis as primary readmission reasons. Compared with acute TBAD patients, BTAI patients had a significantly lower rate of readmission within 90 days (BTAI vs. TBAD; 13% vs. 29%; p < .001). CONCLUSION: We found a significant proportion of readmission in patients treated with TEVAR for BTAI. However, the 90-day readmission rate after TEVAR for BTAI was significantly lower compared with acute TBAD, and the common cause for readmission was not related to residual aortic disease or vascular devices. This represents an important distinction from other patient populations treated with TEVAR for acute vascular conditions. Elucidating differences between trauma-related TEVAR readmissions and non-traumatic indications better informs both the clinician and patients of expected post-discharge course. Level of evidence/study type: IV, Therapeutic/care management.

Nephrectomy Is Not Associated with Increased Risk of Mortality or Acute Kidney Injury after High-Grade Renal Trauma: A Propensity Score Analysis of the Trauma Quality Improvement Program (TQIP).

PURPOSE: Patients with high-grade renal trauma (HGRT) undergoing nephrectomy may be at higher risk for mortality compared to those treated conservatively. However, no study has controlled for degree of hemorrhage as a measure of shock. We hypothesized that after controlling for blood transfusions and other factors, nephrectomy after HGRT would be associated with increased mortality and acute kidney injury (AKI). MATERIALS AND METHODS: We identified adult patients with HGRT (American Association for the Surgery of Trauma grade III-V) in TQIP (2013-2017). Propensity scoring was used to adjust for the probability of nephrectomy. Conditional logistic regression was used to analyze the association between nephrectomy and mortality and AKI. We adjusted for patient characteristics, injury specifics, and physiological factors including blood transfusions. RESULTS: There were 12,780 patients with HGRT, and 1,014 (7.9%) underwent nephrectomy. Mortality was 10.6% and 4.2% in the nephrectomy and nonnephrectomy groups, respectively (p <0.001). In nephrectomy patients, 8.6% experienced AKI vs 2.4% of nonnephrectomy patients (p <0.001). In the adjusted analysis, there was no association between nephrectomy and mortality (OR=0.367, 95% CI 0.09-1.497, p=0.162). There was also no association between nephrectomy and AKI. Increasing age, nonCaucasian race, increasing Injury Severity Score, decreasing Glasgow Coma Score and blood transfusions were associated with higher mortality. For AKI, independent predictors included increasing age, male sex, and blood transfusions. CONCLUSIONS: After adjusting for volume of blood transfused in the first 24 hours, nephrectomy after HGRT was not associated with increased mortality or AKI. As a clinical principle, trauma nephrectomy should be avoided when possible.

How long of a postponement in surgery can a blunt hollow viscus injury patient tolerate? A retrospective study from the National Trauma Data Bank.

BACKGROUND: In the management of patients with blunt abdominal trauma, delayed diagnosis and treatment of hollow viscus injury can occur. We assessed the effect of the time to surgery on the outcomes of blunt hollow viscus injury patients. METHODS: The National Trauma Data Bank was queried from 2012 to 2015 to identify patients with blunt hollow viscus injury for inclusion. Patients with unstable hemodynamics, concomitant intra-abdominal organ injuries, or other severe extra-abdominal injuries were excluded. Inverse probability of treatment weighting and multivariate logistic regression were used to evaluate the effect of the time to surgery on the outcomes. RESULTS: In total, 2,997 patients with blunt hollow viscus injury were studied; the mean time to abdominal surgery was 6.7 hours. Twenty-two hours was selected as a cutoff value for further analyses because of an observed transition zone at that time in the distribution of mortality and severe sepsis rates. After adjustment, patients who underwent surgery within 22 hours had a significantly lower mortality rate (1.2% vs 4.2%), lower sepsis rate (0.9% vs 4.5%), shorter hospital length of stay (8.7 vs 12.0 days), and shorter intensive care unit length of stay (1.4 vs 3.3 days). In patients who underwent surgery within 22 hours, neither mortality nor sepsis were affected significantly by the time to surgery. CONCLUSION: In the management of patients with blunt hollow viscus injury, early surgical treatment is needed. Patients with isolated blunt hollow viscus injury may have a poor outcome if they undergo abdominal surgery more than 22 hours after arrival in the emergency department.

Time is of the Essence: Impact of a More Aggressive Chemical Venous Thromboembolism Prophylaxis Regimen on Trauma Patients.

BACKGROUND: Trauma patients are at high risk for venous thromboembolism (VTE). Opportunity for chemical VTE prophylaxis improvement was identified and practice was altered to start chemoprophylaxis on admission in most patients. The purpose of this study was to determine if early VTE prophylaxis is safe and reduces VTE. METHODS: The trauma registry was queried over a 12-month period for patients admitted greater than 1 day for traumatic injury. The study spanned 6 months on either side of instituting aggressive chemoprophylaxis. Patients were risk adjusted on demographics, Injury Severity Score, transfusions, procedure type, length of stay, and mortality. Pre-intervention patients were then compared to patients in the aggressive cohort with the primary outcome of VTE. Secondary outcomes included transfusions, mortality, and length of stay (LOS). RESULTS: 1597 patients were identified over the study period with 754 (47%) patients in the aggressive period. There were no differences in age, sex, Injury Severity Score, transfusions, procedures, or LOS between cohorts. Pre-algorithm patients were more likely to have penetrating mechanism (9.3% vs 6.6%; P = .009) and longer time to VTE prophylaxis (23.3 vs 13.9 hours; P < .001). No differences were noted in anticoagulant, VTE rate (2.0% vs 1.2%; P = .195), or mortality. Linear regression analysis identified time to chemical prophylaxis as significant predictor of VTE (ß = 43.9, P < .001). CONCLUSIONS: Early aggressive chemical VTE prophylaxis is safe without increasing transfusions. Venous thromboembolism rates were decreased, but did not reach statistical significance.

Outcomes of thoracic endovascular aortic repair in patients with concomitant blunt thoracic aortic injury and traumatic brain injury from the Aortic Trauma Foundation global registry.

BACKGROUND: Traumatic brain injury (TBI) and blunt thoracic aortic injury (BTAI) are the top two leading causes of death after blunt force trauma. Patients presenting with concomitant BTAI and TBI pose a specific challenge with respect to management strategy, because the optimal hemodynamic parameters are conflicting between the two pathologies. Early thoracic endovascular aortic repair (TEVAR) is often performed, even for minimal aortic injuries, to allow for the higher blood pressure parameters required for TBI management. However, the optimal timing of TEVAR for the treatment of BTAI in patients with concomitant TBI remains an active matter of controversy. METHODS: The Aortic Trauma Foundation international prospective multicenter registry was used to identify all patients who had undergone TEVAR for BTAI in the setting of TBI from 2015 to 2020. The primary outcomes included delayed ischemic or hemorrhagic stroke, in-hospital mortality, and aortic-related mortality. The outcomes were examined among patients who had undergone TEVAR at emergent (<6 vs ≥6 hours) or urgent (<24 vs ≥24 hours) intervals. RESULTS: A total of 100 patients (median age, 43 years; 79% men; median injury severity score, 41) with BTAI (Society for Vascular Surgery BTAI grade 1, 3%; grade 2, 10%; grade 3, 78%; grade 4, 9%) and concomitant TBI who had undergone TEVAR were identified. Emergent repair was performed for 51 patients (51%). Comparing emergent repair (<6 hours) to urgent repair (≥6 hours), no difference was found in delayed cerebral ischemic events (2.0% vs 4.1%; P = .614), in-hospital mortality (15.7% vs 22.4%; P = .389), or aortic-related mortality (2.0% vs 2.0%; P = .996) and no patient had experienced delayed hemorrhagic stroke. Likewise, repairs conducted in an urgent (<24 hours) setting showed no differences compared with those completed in an emergent (≥24 hours) setting regarding delayed ischemic stroke (2.6% vs 4.3%; P = .548), in-hospital mortality (18.2% vs 21.7%; P = .764), or aortic-related mortality (1.3% vs 4.3%; P = .654), and no patient had experienced delayed hemorrhagic stroke. CONCLUSIONS: In contrast to prior retrospective efforts, results from the Aortic Trauma Foundation international prospective multicenter registry have demonstrated that neither emergent nor urgent TEVAR for patients with concomitant BTAI and TBI was associated with delayed stroke, in-hospital mortality, or aortic-related mortality. In these patients, the timing of TEVAR did not have an effect on the outcomes. Therefore, the decision to intervene should be guided by individual patient factors rather than surgical timing.

Mortalidad en hospitalizados con traumatismo torácico: variables asociadas, causas y distribución temporal / Associated variables, causes and time distribution of mortality in thoracic trauma patients

Resumen Introducción: Los traumatismos están entre las diez principales causas de muerte a nivel mundial y son la primera en jóvenes. El traumatismo torácico (TT) está presente en un alto porcentaje de las muertes por traumatismos y es la segunda causa de muerte después del traumatismo encefalocraneano. Objetivos: Analizar las variables asociadas a mortalidad, las causas principales y la distribución temporal de la mortalidad en hospitalizados fallecidos con TT. Materiales y Método: Estudio observacional de hospitalizados con TT, período enero de 1981 a diciembre de 2018. Revisión de protocolos prospectivos de TT y base de datos. Se consignaron las causas de muerte sindromáticas principales y se realizó una regresión logística para variables asociadas a mortalidad. Se utilizó SPSS25® con pruebas chi-cuadrado para comparar clasificación, tipo de TT y su distribución temporal, considerando significativo p < 0,05. Resultados: Total 4.297 TT, mortalidad global de 120 (2,8%) casos. Las principales variables independientes asociadas a mortalidad fueron el deterioro fisiológico al ingreso, el hemotórax masivo y el TT por arma de fuego. La principal causa de muerte fue el shock hipovolémico, con diferencias significativas según tipo de TT en las primeras 4 y 24 horas. En la distribución temporal se observó que las muertes con TT penetrante y aislado fueron más precoces y no se evidenció un nuevo peak en la mortalidad luego de la primera semana. Conclusiones: Se observaron variables independientes asociadas a mortalidad en hospitalizados con TT, siendo el deterioro fisiológico al ingreso el factor más importante. Además, existen diferencias significativas en las causas de muerte y distribución temporal de la mortalidad entre diferentes subgrupos de hospitalizados con TT.

Background: Trauma is one of the ten leading causes of death worldwide and the first among the youth. Thoracic trauma (TT) is present in a high percentage of deaths due to trauma and is the second leading cause of death after traumatic brain injury. Aim: To analyze the mortality associated variables, major causes and temporal distribution of mortality among dead hospitalized patients with TT. Materials and Method: Observational study in hospitalized patients with TT, period January 1981 to December 2018. Review of prospective TT protocols and data base. Major syndromic causes of death were recorded and a logistic regression for variables associated with mortality was made. SPSS25® with chi-quadrat tests was used to compare classification, type of TT and temporal distribution. A p value < 0,05 was considered significant. Results: Total 4.297 TT and global mortality was 120 (2,8%) cases. The main independent variables associated with mortality were the physiological decline upon admission, massive hemothorax and TT by firearms. The leading cause of death was hypovolemic shock, with significant differences according to the type of TT in the first 4 and 24 hours. In the temporal distribution was observed that, the deaths with penetrating and isolated TT were earlier and that there was no second peak of mortality following the first week. Conclusions: Independent variables associated with mortality were observed among hospitalized patients with TT, being physiological deterioration the most important factor. Besides, there are significant differences in the death causes and temporal distribution of mortality among the different subgroups of hospitalized patients with TT.

Mortality following severe liver trauma is declining at Auckland City Hospital: a 14-year experience, 2006-2020.

INTRODUCTION: Liver injuries sustained in blunt and penetrating abdominal trauma may cause serious patient morbidity and even mortality. AIM: To review the recent experience of liver trauma at Auckland City Hospital, describing the mechanism of injury, patient management, outcomes and complications. METHODS: A retrospective cohort study was performed, including all patients admitted to Auckland City Hospital with liver trauma identified from the trauma registry. Patient clinical records and radiology were systematically examined. RESULTS: Between 2006-2020, 450 patients were admitted with liver trauma, of whom 92 patients (20%) were transferred from other hospitals. Blunt injury mechanisms, most commonly motor-vehicle crashes, predominated (87%). Stabbings were the most common penetrating mechanism. Over half of liver injuries were low risk American Association for the Surgery of Trauma (AAST) grade I and II (56%), whereas 20% were severe grade IV and V. Non-operative management was undertaken in 72% of patients with blunt liver trauma and 92% of patients with penetrating liver trauma underwent surgery. Liver complications occurred in 11% of patients, most commonly bile leaks (7%), followed by delayed haemorrhage (2%). Thirty-two patients died (7%), with co-existing severe traumatic brain injury as the leading cause of death. There was a significant reduction in death from haemorrhage in patients with grade IV and V liver trauma between the first and second half of the study period (p=0.0091). CONCLUSION: Although the incidence and severity of liver trauma at Auckland City Hospital remained stable, there was a reduction in mortality, particularly death as a result of haemorrhage.

Does shock index, pediatric age-adjusted predict mortality by trauma center type?

BACKGROUND: Pediatric trauma patients are treated at adult trauma centers (ATCs), mixed pediatric and ATCs (MTC), or pediatric trauma centers (PTCs). Shock index, pediatric age-adjusted (SIPA) can prospectively identify severely injured children. This study characterized the differences in mortality and hospital length of stay (LOS) among pediatric trauma patients with elevated SIPA (eSIPA) at different trauma centers types. METHODS: Pediatric patients (1-14 years) were queried from the 2013 to 2016 National Trauma Data Bank. Patients with eSIPA were included for analysis. The primary outcome was mortality. Secondary outcomes included rates of splenectomy, computed tomography chest scans, laparotomy, and hospital LOS. Unadjusted frequencies and multivariable regression analyses were performed. An alpha level of 0.01 was used to determine significance. RESULTS: Out of 189,003 pediatric trauma patients, 15,832 were included for analysis. After controlling for age, race, sex, payment method, Injury Severity Score, Glasgow Coma Scale score, hospital teaching status, and number of hospital beds, there was no significant difference in mortality among eSIPA patients at ATCs (odds ratio [OR], 0.753; p = 0.078) and MTCs (OR, 1.051; p = 0.776) when compared with PTCs. This remained true even among the most severely injured eSIPA patients (Injury Severity Score > 25). Splenectomy rates were higher at ATCs (OR, 3.234; p = 0.005), as were computed tomography chest scan rates (ATC OR, 4.423; p < 0.001; MTC OR, 6.070; p < 0.001) than at PTCs. There was a trend toward higher splenectomy rates at MTCs (OR, 2.910; p = 0.030) compared with PTCs, but this did not reach statistical significance. Laparotomy rates and hospital LOS were not significantly different. CONCLUSION: Among eSIPA pediatric trauma patients, there was no difference in mortality between trauma center types. However, other secondary findings indicate that specialty care at PTCs may help optimize the care of pediatric trauma patients. LEVEL OF EVIDENCE: Retrospective cohort study, level IV.

United States military fatalities during Operation New Dawn.

BACKGROUND: Military operations vary by scope, purpose, and intensity, each having unique forces and actions to execute a mission. Evaluation of military operation fatalities guides current and future casualty care. METHODS: A retrospective study was conducted of all US military fatalities from Operation New Dawn in Iraq, 2010 to 2011. Data were obtained from autopsies and other records. Population characteristics, manner of death, cause of death, and location of death were analyzed. All fatalities were evaluated for concomitant evidence of underlying atherosclerosis. Nonsuicide trauma fatalities were also reviewed for injury severity, mechanism of death, injury survivability, death preventability, and opportunities for improvement. RESULTS: Of 74 US military Operation New Dawn fatalities (median age, 26 years; male, 98.6%; conventional forces, 100%; prehospital, 82.4%) the leading cause of death was injury (86.5%). The manner of death was primarily homicide (55.4%), followed by suicide (17.6%), natural (13.5%), and accident (9.5%). Fatalities were divided near evenly between combatants (52.7%) and support personnel (47.3%), and between battle injury (51.4%) and disease and nonbattle injury (48.6%). Natural and suicide death was higher (p < 0.01, 0.02) among support personnel who were older (p = 0.05) with more reserve/national guard personnel (p = 0.01). Total population prevalence of underlying atherosclerosis was 18.9%, with more among support personnel (64.3%). Of 46 nonsuicide trauma fatalities, most died of blast injury (67.4%) followed by gunshot wound (26.1%) and multiple/blunt force injury (6.5%). The leading mechanism of death was catastrophic tissue destruction (82.6%). Most had nonsurvivable injuries (82.6%) and nonpreventable deaths (93.5%). CONCLUSION: Operation New Dawn fatalities were exclusively conventional forces divided between combatants and support personnel, the former succumbing more to battle injury and the latter to disease and nonbattle injury including self-inflicted injury. For nonsuicide trauma fatalities, none died from a survivable injury, and 17.4% died from potentially survivable injuries. Opportunities for improvement included providing earlier blood products and surgery. LEVEL OF EVIDENCE: Therapeutic, level V and epidemiological, level IV.

Association between the initial serum phosphate level and 30-day mortality in blunt trauma patients.

BACKGROUND: Studies on patients with cardiac arrest or sepsis have reported that high initial phosphate levels are associated with poor outcomes. However, no previous study has investigated the association between initial phosphate levels and outcomes in blunt trauma patients. METHODS: This study was a retrospective observational study conducted on blunt trauma patients who had been treated at the single regional trauma center between January 2016 and December 2017. Patients' demographic data, initial vital signs, trauma scores, and laboratory parameters including phosphate levels were collected from the trauma registry. The primary outcome was set to 30-day mortality. The secondary outcomes were the total volume of blood transfused, 30-day hospital-free days, and 30-day intensive care unit-free days. RESULTS: Of the 1,907 included patients, 1,836 were in the survival group, and 71 were in the nonsurvival group. The nonsurvival group had a significantly higher phosphate level than the survival group. Patients in the hyperphosphatemia group had a higher 30-day mortality, fewer 30-day intensive care unit-free days, and higher transfusion volume than those in the other groups. In multivariable logistic regression analysis, hyperphosphatemia was independently associated with 30-day mortality. The receiver operating characteristic curve analysis showed that the area under the curve with the inclusion of phosphate in addition to Injury Severity Score, Revised Trauma Score, and age was 0.911. Area under the curve was also increased when phosphate was simply added to Injury Severity Score and Revised Trauma Score. CONCLUSION: In blunt trauma patients, hyperphosphatemia was associated with an increased 30-day mortality. LEVEL OF EVIDENCE: Prognostic, level III.

Transcatheter arterial embolization for severe blunt liver injury in hemodynamically unstable patients: a 15-year retrospective study.

BACKGROUND: Transcatheter arterial embolization (TAE) is the first-line nonsurgical treatment for severe blunt liver injury in patients, whereas operative management (OM) is recommended for hemodynamically unstable patients. This study investigated the comparative efficacy of TAE in hemodynamically unstable patients who responded to initial infusion therapy. METHODS: This retrospective study enrolled patients with severe blunt liver injuries, which were of grades III-V according to the American Association for the Surgery of Trauma Organ Injury Scale (OIS). Patients who responded to initial infusion therapy underwent computed tomography to determine the treatment plan. A shock index > 1, despite undergoing initial infusion therapy, was defined as hemodynamic instability. We compared the clinical outcomes and mortality rates between patients who received OM and those who underwent TAE. RESULTS: Sixty-two patients were included (eight and 54 who underwent OM and TAE, respectively; mean injury severity score, 26.6). The overall in-hospital mortality rate was 6% (13% OM vs. 6% TAE, p = 0.50), and the hemodynamic instability was 35% (88% OM vs. 28% TAE, p < 0.01). Hemodynamically unstable patients who underwent TAE had 7% in-hospital mortality and 7% clinical failure. Logistic regression analysis showed that the treatment choice was not a predictor of outcome, whereas hemodynamic instability was an independent predictor of intensive care unit stay ≥7 days (odds ratio [OR], 3.80; p = 0.05) and massive blood transfusion (OR, 7.25; p = 0.01); OIS grades IV-V were predictors of complications (OR, 6.61; p < 0.01). CONCLUSIONS: TAE in hemodynamically unstable patients who responded to initial infusion therapy to some extent has acceptable in-hospital mortality and clinical failure rates. Hemodynamic instability and OIS, but not treatment choice, affected the clinical outcomes.

Case-control analysis of prehospital death and prolonged field care survival during recent US military combat operations.

BACKGROUND: Quantification of medical interventions administered during prolonged field care (PFC) is necessary to inform training and planning. MATERIALS AND METHODS: Retrospective cohort study of Department of Defense Trauma Registry casualties with maximum Abbreviated Injury Scale (MAIS) score of 2 or greater and prehospital records during combat operations 2007 to 2015; US military nonsurvivors were linked to Armed Forces Medical Examiner System data. Medical interventions administered to survivors of 4 hours to 72 hours of PFC and nonsurvivors who died prehospital were compared by frequency-matching on mechanism (explosive, firearm, other), injury type (penetrating, blunt) and injured body regions with MAIS score of 3 or greater. Covariates for adjustment included age, sex, military Service, shock, Glasgow Coma Scale, transport team, MAIS and Injury Severity Score (ISS). Sensitivity analysis focused on US military subgroup with AIS/ISS assigned to nonsurvivors after autopsy. RESULTS: The total inception cohort included 16,202 casualties (5,269 US military, 10,809 non-US military), 64% Afghanistan, 36% Iraq. Of US military, 734 deaths occurred within 30 days, nearly 90% occurred within 4 hours of injury. There were 3,222 casualties (1,111 US military, 2,111 non-US military) documented for prehospital care and died prehospital (691) or survived 4 hours to 72 hours of PFC (2,531). Twenty-five percent (815/3,222) received advanced airway, 18% (583) ventilatory support, 9% (281) tourniquet. Twenty-three percent (725) received blood transfusions within 24 hours. Of the matched cohort (1,233 survivors, 490 nonsurvivors), differences were observed in care (survivors received more warming, intravenous fluids, sedation, mechanical ventilation, narcotics, antibiotics; nonsurvivors received more intubations, tourniquets, intraosseous fluids, cardiopulmonary resuscitation). Sensitivity analysis focused on US military (732 survivors, 379 nonsurvivors) showed no significant differences in prehospital interventions. Without autopsy information, the ISS of nonsurvivors significantly underestimated injury severity. CONCLUSION: Tourniquets, blood transfusion, airway, and ventilatory support are frequently required interventions for the seriously injured. Prolonged field care should direct resources, technology, and training to field technology for sustained resuscitation, airway, and breathing support in the austere environment. LEVEL OF EVIDENCE: Prognostic, Level III.

Novel Trauma Composite Score is superior to Injury Severity Score in predicting mortality across all ages.

BACKGROUND: Injury Severity Score (ISS) is a widely used metric for trauma research and center verification; however, it does not account for age-related physiologic parameters. We hypothesized that a novel age-based injury severity metric would better predict mortality. METHODS: Adult patients (≥18 years) sustaining blunt trauma (BT) or penetrating trauma (PT) were abstracted from the 2010 to 2016 National Trauma Data Bank. Admission vitals, Glasgow Coma Scale, ISS, mechanism, and outcomes were analyzed. Patients with incomplete/non-physiologic vital signs were excluded. For each age: (1) a cut point analysis was used to determine the ISS with the highest specificity and sensitivity for predicting mortality and (2) a linear discriminant analysis was performed using ISS, ISS greater than 16, Trauma and Injury Severity Score, and Revised Trauma Scale to compare each scoring system's mortality prediction. A novel injury severity metric, the trauma component score (TCS), was developed for each age using significant (p < 0.05) variables selected from Abbreviated Injury Scale scores, Glasgow Coma Scale, vital signs, and gender. Receiver operator curves were developed and the areas under the curve were compared between the TCS and other systems. RESULTS: There 777,794 patients studied (BT, 91.1%; PT, 8.9%). Blunt trauma patients were older (53.6 ± 21.3 years vs. 34.4 ± 13.8 years), had higher ISS scores (11.1 ± 8.5 vs. 8.5 ± 8.9), and lower mortality (2.9% vs. 3.4%) than PT patients (p < 0.05). When assessing the entire PT and BT cohort the optimal ISS cut point was 16. The optimal ISS was between 20 and 25 for BT younger than 70 years. For those older than 70 years, the optimal BT ISS steadily declined as age increased PT's cut point was 16 or less for all ages assessed. When the injury metrics were compared by area under the curve, our novel TCS more accurately predicted mortality across all ages in both BT and PT (p < 0.001). CONCLUSION: Injury Severity Score is a poor mortality predictor in older patients and those sustaining penetrating trauma. The age-based TCS is a superior metric for mortality prediction across all ages. LEVEL OF EVIDENCE: Clinical outcomes, Level IV.

DIPLOTRIAENA OBTUSA (NEMATODA: DIPLOTRIAENIDAE) FROM BARN SWALLOWS (HIRUNDO RUSTICA) AND CLIFF SWALLOWS (PETROCHELIDON PYRRHONOTA) COLLECTED DURING MORTALITY EVENTS IN THE UPPER MIDWEST, USA.

Several mortality events involving barn swallows (Hirundo rustica) and cliff swallows (Petrochelidon pyrrhonota) were reported in the Upper Midwestern states in 2017 and 2018. Barn swallow mortality followed unseasonal cold snaps, with the primary cause of death being emaciation with concurrent air sac nematodiasis. Lesions in cliff swallows were consistent with blunt force trauma from suspected car impacts. Examination of air sac nematodes from both bird species revealed morphological characters consistent with Diplotriaena obtusa. Sequence analysis of the partial 18S rRNA gene indicated the samples clustered with other species in the genus Diplotriaena. These nematodes provide a link between morphological specimens and DNA sequence data for D. obtusa.

Nationwide utilization of cardiopulmonary bypass in cardiothoracic trauma: A retrospective analysis of the National Trauma Data Bank.

BACKGROUND: The American College of Surgeons Committee on Trauma requires that all level I trauma centers have cardiopulmonary bypass (CPB) capabilities immediately available. Despite this mandate, there are limited data on the utilization and clinical outcomes among trauma patients requiring CPB in the management of injuries. The aim of this study was to evaluate the current use of CPB in the care of trauma patients. METHODS: This is a retrospective analysis of the National Trauma Data Bank from 2010 to 2015. Adult patients sustaining cardiothoracic injuries who underwent surgical repair within the first 24 hours of admission were included. Propensity score matching was used to compare outcomes (in-hospital mortality, hospital length of stay (LOS), intensive care unit LOS, and complications) between patients who underwent CPB within the first 24 hours of admission and those with similar injuries who did not receive CPB. RESULTS: A total of 28,481 patients who met the inclusion criteria were identified, of whom 319 underwent CPB. Three-hundred three CPB patients were matched to 895 comparison patients who did not undergo CPB. Overall in-hospital mortality was 35%. Patients who were not treated with CPB had a significantly higher in-hospital mortality compared with those treated with CBP (odds ratio, 1.57; 95% confidence interval, 1.16-2.12; p = 0.003); however, complications were significantly lower in those who did not receive CPB (odds ratio, 0.63; 95% confidence interval, 0.47-0.86; p = 0.003). Hospital LOS (non-CPB: mean, 13.4 ± 16.3 days; CPB: mean, 14.7 ± 15.1 days; p = 0.23) and intensive care unit LOS (non-CPB: mean, 9.9 ± 10.7 days; CPB: mean, 10.1 ± 9.7 days; p = 0.08) did not differ significantly between groups. CONCLUSION: The use of CPB in the initial management of select cardiothoracic injuries is associated with a survival benefit. Further investigation is required to delineate which specific injuries would benefit the most from the use of CPB. LEVEL OF EVIDENCE: Therapeutic, level IV.