Epidemiology and risk factors for fat embolism in isolated lower extremity long bone fractures.

PURPOSE: Fat embolism syndrome (FES) is a serious complication after orthopedic trauma. The aim of this study was to identify risk factors for FES in isolated lower extremity long bone fractures. METHODS: The National Trauma Data Bank "NTDB" study included patients with isolated femoral and tibial fractures. A total of 344 patients with FES were propensity score matched with 981 patients without FES. Multivariate logistical regression was used to identify independent risk factors for FES. RESULTS: FES was diagnosed in 344 (0.03%) out of the 1,251,143 patients in the study populations. In the two matched groups, the mortality was 7% in the FES group and 1% in the No FES group (p < 0.001). FES was associated with an increased risk of ARDS, VTE, pneumonia, AKI, and stroke. Younger age, femur fractures, obesity, and diabetes mellitus were independent predictors of FES. Early operative fixation (≤ 48 h) was protective against FES. CONCLUSION: FES increases mortality by seven times. Young age, obesity, and diabetes mellitus are significant independent risk factors for FES. Early fixation is independently associated with a reduced risk of FES. LEVEL OF EVIDENCE: Level III. STUDY TYPE: Prognostic study.

Pneumopericardium following severe thoracic trauma.

BACKGROUND: Traumatic pneumopericardium (PPC) is a rare clinical entity associated with chest trauma, resulting from a pleuropericardial connection in the presence of a pneumothorax, interstitial air tracking along the pulmonary perivascular sheaths from ruptured alveoli to the pericardium, or direct trachea-bronchial-pericardial communication.  Our objectives were to describe the modern management approach to PPC and to identify variables that could improve survival with severe thoracic injury. METHODS: We conducted a retrospective study of the trauma registry between 2015 and 2022 at a Level I verified adult trauma center for all patients with PPC. Demographics, injury patterns, and treatment characteristics were compared between blunt and penetrating trauma. This study focused on the management strategies and the physiologic status regarding PPC and the development of tension physiology. The main outcome measure was operative versus nonoperative management. RESULTS: Over a seven-year period, there were 46,389 trauma admissions, of which 488 patients had pneumomediastinum. Eighteen patients were identified with PPC at admission. Median age was 39.5 years (range, 18-77 years), predominantly male (n = 16, 89 %), Black (n = 12, 67 %), and the majority from blunt trauma (78 %). Half had subcutaneous emphysema on presentation while 39 % had recognizable pneumomediastinum on chest x-ray. Tube thoracostomy was the most common intervention in this cohort (89 %). Despite tube thoracostomy, tension PPC was observed in three patients, two mandating emergent pericardial windows for progression to tension physiology, and the remaining requiring reconstruction of a blunt tracheal disruption. The majority of PPC patients recovered with expectant management (83 %), and no deaths were directly related to PPC. CONCLUSIONS: Traumatic PPC is a rare radiographic finding with the majority successfully managed conservatively in a monitored ICU setting. These patients often have severe thoracic injury with concomitant injuries requiring thoracostomy alone; however, emergent surgical intervention may be required when PPC progresses to tension physiology to improve overall survival.

Proximal protective diverting ostomy following colon anastomosis for penetrating trauma may not be protective: A matched cohort study.

INTRODUCTION: Despite the shift toward liberal primary anastomosis in penetrating colon injuries, some surgeons recommend a protective diverting ostomy (DO) proximal to the anastomosis. This study evaluates the effect of DO on outcomes in patients undergoing colon resection and anastomosis following penetrating trauma. METHODS: The TQIP database (2013-2018) was queried for penetrating colon injuries undergoing colectomy and anastomosis. Patients receiving DO were propensity matched to patients without diverting ostomy (woDO) (1:3). Outcomes were compared between groups. RESULTS: After matching, 89 DO patients were analyzed. The DO group had more surgical site infections (32 â€‹% vs. 21 â€‹%; p â€‹< â€‹0.05) and longer hospital stay (20 [13-27] vs. 15 [9-25]; p â€‹< â€‹0.05) compared to the woDO group. Mortality and unplanned operations were similar between groups. CONCLUSIONS: Diverting ostomy after colon resection and anastomosis is associated with increased infectious complications without decreasing unplanned operations or mortality. Its routine role in penetrating colon trauma needs reassessment.

Injury Patterns and Treatment Strategies in Civilian and Military Isolated Abdominal Gunshot Wounds.

BACKGROUND: Combat-related gunshot wounds (GSW) may differ from those found in civilian trauma centers. Missile velocity, resources, logistics, and body armor may affect injury patterns and management strategies. This study compares injury patterns, management, and outcomes in isolated abdominal GSW between military (MIL) and civilian (CIV) populations. METHODS: The Department of Defense Trauma Registry (DoDTR) and TQIP databases were queried for patients with isolated abdominal GSW from 2013 to 2016. MIL patients were propensity score matched 1:3 based on age, sex, and extraabdominal AIS. Injury patterns and in-hospital outcomes were compared. Initial operative management strategies, including selective nonoperative management (SNOM) for isolated solid organ injuries, were also compared. RESULTS: Of the 6435 patients with isolated abdominal GSW, 183 (3%) MIL were identified and matched with 549 CIV patients. The MIL group had more hollow viscus injuries (84% vs. 66%) while the CIV group had more vascular injuries (10% vs. 21%) (p < .05 for both). Operative strategy differed, with more MIL patients undergoing exploratory laparotomy (95% vs. 82%) and colectomy (72% vs. 52%) (p < .05 for both). However, no difference in ostomy creation was appreciated. More SNOM for isolated solid organ injuries was performed in the CIV group (34.1% vs. 12.5%; p < 0.05). In-hospital outcomes, including mortality, were similar between groups. CONCLUSIONS: MIL abdominal GSW lead to higher rates of hollow viscus injuries compared to CIV GSW. MIL GSW are more frequently treated with resection but with similar ostomy creation compared to civilian GSW. SNOM of solid organ injuries is infrequently performed following MIL GSW.

Injury patterns and outcomes in motorcycle passengers.

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

Epidemiology and Post-Discharge Resource Utilization of Isolated Traumatic Brain Injury in Geriatric Patients.

Benchmark data on traumatic brain injury (TBI) are potentially confounded by morbidity and rehabilitation needs associated with coincident extracranial injuries. Using data on isolated head injuries from 13 trauma centers in Georgia over 3 years, we studied the epidemiology and natural history of isolated TBI in geriatric vs non-geriatric patients in order to identify potential areas for quality improvement. We identified 8 512 patients, 3 895 of whom were geriatric. Geriatric patients had higher baseline comorbidity burden, mostly presented after ground level falls, had higher mortality despite equivalent ICU admission rates, and had higher rates of post-discharge resource utilization than non-geriatric counterparts. Geriatric patients are more likely to require post-discharge services and/or facility placement, regardless of pre-injury functional status. These data highlight the importance of streamlined protocols that place an early focus on post-discharge needs and goals of care, informed by cohort-specific prognosis data.

Blunt Traumatic Abdominal Wall Hernias: An Indicator for Emergent Laparotomy?

BACKGROUND: Traumatic abdominal wall hernias (TAWH) are relatively uncommon; however, the shearing force that results in fascial disruption could indicate an increased risk of visceral injury. The aim of our study was to evaluate whether the presence of a TAWH was associated with intra-abdominal injury requiring emergent laparotomy. METHODS: The trauma registry was queried over an 8-year period (7/2012-7/2020) for adult patients with blunt thoracoabdominal trauma diagnosed with a TAWH. Those patients who were identified with a TAWH and greater than 15 years of age were included in the study. Demographics, mechanism of injury, ISS, BMI, length of stay, TAWH size, type of TAWH repair, and outcomes were analyzed. RESULTS: Overall, 38,749 trauma patients were admitted over the study period, of which 64 (.17%) had a TAWH. Patients were commonly male (n = 42, 65.6%); the median age was 39 years (range 16-79 years) and a mean ISS of 21. Twenty-eight percent had a clinical seatbelt sign. Twenty-seven (42.2%) went emergently to the operating room, the majority for perforated viscus requiring bowel resection (n = 16, 25.0%), and 6 patients (9.4%) who were initially managed nonoperatively underwent delayed laparotomy. Average ventilator days was 14 days, with a mean ICU LOS of 14 days and mean hospital LOS of 18 days. About half of the hernias were repaired at the index operation, 6 of which were repaired primarily and 10 with mesh. CONCLUSION: The presence of a TAWH alone was an indication for immediate laparotomy to evaluate for intra-abdominal injury. In the absence of other indications for exploration, nonoperative management may be safe.

Operative management and outcomes of colorectal injuries after gunshot wounds in the deployed military setting versus civilian trauma centers.

INTRODUCTION: Colon and rectal injuries have been diverted at higher rates in military trauma compared with civilian injuries. However, in the last few years, there has been a shift to more liberal primary anastomosis in wartime injuries. The purpose of this study was to compare the management and outcomes in colorectal gunshot wounds (GSWs) between military and civilian settings. METHODS: The study included Department of Defense Trauma Registry and Trauma Quality Improvement Program database patients who sustained colorectal GSWs, during the period 2013 to 2016. Department of Defense Trauma Registry patients were propensity score matched 1:3 based on age, sex, grade of colorectal injury, and extra-abdominal Abbreviated Injury Scale. Patients without signs of life, transfers from an outside hospital, and nonspecific colorectal Organ Injury Scale were excluded. Operative management and outcomes were compared between the two groups. Subanalysis was performed on the military cohort to identify any differences in the use primary repair, colectomy, or fecal diversion based upon military affiliation or North Atlantic Treaty Organization status. RESULTS: Overall, there were 2,693 patients with colorectal GSWs; 60 patients in the military group were propensity score matched with 180 patients in the civilian group. Overall, colectomy was the most common procedure performed (72.1%) and was used more frequently in the military group (83.3% vs. 68.3%; p < 0.05). However, the rate of fecal diversion was similar in the two groups (23.3% vs. 27.8%; p = 0.500). Among those in the military group, no difference was seen in primary repair, colectomy, or fecal diversion based upon military affiliation or North Atlantic Treaty Organization status. The rates of in-hospital compilations and mortality were similar between the military and civilian groups. CONCLUSION: The severity of GSW colorectal injuries in military and civilian trauma was comparable. There was no significant difference in terms of fecal diversion, mortality, and complications between groups. Military personnel are treated similarly regardless of affiliation. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Titratable partial aortic occlusion: Extending Zone I endovascular occlusion times.

BACKGROUND: Extending the time to definitive hemorrhage control in noncompressible torso hemorrhage (NCTH) is of particular importance in the battlefield where transfer times are prolonged and NCTH remains the leading cause of death. While resuscitative endovascular balloon occlusion of the aorta is widely practiced as an initial adjunct for the management of NCTH, concerns for ischemic complications after 30 minutes of compete aortic occlusion deters many from zone 1 deployment. We hypothesize that extended zone 1 occlusion times will be enabled by novel purpose-built devices that allow for titratable partial aortic occlusion. METHODS: This is a cross-sectional analysis describing pREBOA-PRO zone 1 deployment characteristics at seven level 1 trauma centers in the United States and Canada (March 30, 2021, and June 30, 2022). To compare patterns of zone 1 aortic occlusion, the AORTA registry was used. Data were limited to adult patients who underwent successful occlusion in zone 1 (2013-2022). RESULTS: One hundred twenty-two patients pREBOA-PRO patients were included. Most catheters were deployed in zone 1 (n = 89 [73%]) with a median zone 1 total occlusion time of 40 minutes (interquartile range, 25-74). A sequence of complete followed by partial occlusion was used in 42% (n = 37) of zone 1 occlusion patients; a median of 76% (interquartile range, 60-87%) of total occlusion time was partial occlusion in this group. As was seen in the prospectively collected data, longer median total occlusion times were observed in the titratable occlusion group in AORTA compared with the complete occlusion group. CONCLUSION: Longer zone 1 aortic occlusion times seen with titratable aortic occlusion catheters appear to be driven by the feasibility of controlled partial occlusion. The ability to extend safe aortic occlusion times may have significant impact to combat casualty care where exsanguination from NCTH is the leading source of potentially preventable deaths. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Case Series of Patients With Intermediate-High Risk Pulmonary Embolism in the Setting of Trauma Undergoing Mechanical Thrombectomy.

In patients with pulmonary embolism (PE) in the setting of trauma, administration of fibrinolytic therapy is contraindicated due to high risk of hemorrhage. Several studies have demonstrated the safety and efficacy of mechanical thrombectomy among all-comers with PE as an alternative to catheter-directed thrombolytics. However, the risks and benefits of mechanical thrombectomy treatment for pulmonary embolism in a trauma population are not well established. A retrospective analysis was performed in all patients who presented to Level 1 Trauma Center with acute trauma who were found to have a pulmonary embolism (PE) treated with mechanical thrombectomy. From May 2019 to December 2020, six patients were identified. Average age was 54 years, and four patients were male. Four patients had a saddle PE on computed tomography. All patients had an intermediate-high risk PE with troponin I elevation >0.04 ng/mL (average 0.42 ng/mL). Pulmonary Embolism Severity Index (PESI) score in all six patients was class III or IV. In all patients, the mechanical thrombectomy was performed with mean-PA pressure changing from average 40.33 to 31.5 mmHg. Average Intensive Care Unit (ICU) length of stay post-procedure was five days with two patients not requiring ICU stay. No patient had post-operative bleeding during their index stay. Average hemoglobin drop after mechanical thrombectomy was 1.33 g/dL. One patient died <30 days post-procedure due to septic shock and another >90 days later (5 months) from cardiac arrest from recurrent PE. The other four patients were still living >90 days post-procedure. No immediate or delayed postoperative complications were identified. Mechanical thrombectomy appears to be a safe and effective treatment for patients with recent trauma who have an intermediate-high risk pulmonary embolism.

Development of a post-mortem human specimen flow model for advanced bleeding control training.

INTRODUCTION: Prompt and effective hemorrhage control is paramount to improve survival in patients with catastrophic bleeding. In the ever-expanding field of bleeding control techniques, there is a need for a realistic training model to practice these life-saving skills. This study aimed to create a realistic perfused post-mortem human specimen (PMHS) flow model that is suitable for training various bleeding control techniques. MATERIALS AND METHODS: This laboratory study was conducted in the SkillsLab & Simulation Center of Erasmus MC, University Medical Center Rotterdam, the Netherlands. One fresh frozen and five AnubiFiX® embalmed PMHS were used for the development of the model. Subsequent improvements in the exact preparation and design of the flow model were made based on model performance and challenges that occurred during this study and are described. RESULTS: Circulating arteriovenous flow with hypertonic saline was established throughout the entire body via inflow and outflow cannulas in the carotid artery and jugular vein of embalmed PMHS. We observed full circulation and major hemorrhage could be mimicked. Effective bleeding control was achieved by placing a resuscitative endovascular balloon occlusion of the aorta (REBOA) catheter in the model. Regional perfusion significantly reduced the development of tissue edema. CONCLUSION: Our perfused PMHS model with circulating arterial and venous flow appears to be a feasible method for the training of multiple bleeding control techniques. Regional arteriovenous flow successfully reduces tissue edema and increases the durability of the model. Further research should focus on reducing edema and enhancing the durability of the model.

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

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

Preperitoneal Packing for Pelvic Fracture Bleeding Control: A Human Cadaver Study.

BACKGROUND: Preperitoneal packing (PPP) has been widely accepted as a damage control technique for severe bleeding from pelvic fractures. It is supposed to work by direct compression and tamponade of the bleeding source in the pelvis and it has been suggested to be effective for both venous and arterial bleeding. However, there is little evidence to support its efficacy or the ability to place the laparotomy pads in proximity of the desired location. METHODS: Bilateral PPP was performed on 10 fresh human cadavers, followed by laparotomy and measurements of resultant pad placement in relation to critical anatomic structures. RESULTS: A total of 20 assessments of laparotomy pad placement were performed. Following completion of PPP, a midline laparotomy was performed to determine proximity and closest distance of the laparotomy pads to sites of potential bleeding in pelvic fractures. In almost all cases, the pad placement was not contiguous with the key anatomic structure with mean placement 3.9 + 1.1 cm from the sacroiliac joint, 3.5 + 1.6 cm from the common iliac artery, 1.1 + 1.2 cm from the external iliac artery, 2.8 + 0.8 cm from the internal iliac artery, and 2.3 + 1.2 cm from the iliac bifurcation. Surgeon experience resulted in improved placement relative to the sacroiliac joint, however the pads still did not directly contact the target point. CONCLUSION: This human cadaver study has shown that PPP, even in experienced hands, may not be placed in significant proximity of anatomical structures of interest. The role of PPP needs to be revisited with better clinical or human cadaver studies.

Therapeutic Interventions and Outcomes in Civilian and Military Isolated Gunshot Wounds to the Head: A Department of Defense Trauma Registry and ACS TQIP-matched Study.

OBJECTIVE: The purpose of this study was to compare therapeutic strategies and outcomes, following isolated gunshot wounds of the head, between military and civilian populations. BACKGROUND: Recent military conflicts introduced new concepts in trauma care, including aggressive surgical intervention in severe head trauma. METHODS: This was a cohort-matched study, using the civilian Trauma Quality Improvement Program (TQIP) database of the American College of Surgeons (ACS) and the Department of Defense Trauma Registry (DoDTR), during the period 2013 to 2016. Included in the study were patients with isolated gunshots to the head. Exclusion criteria were dead on arrival, civilians transferred from other hospitals, and patients with major extracranial associated injuries (body area Abbreviated Injury Scale >3). Patients in the military database were propensity score-matched 1:3 with patients in the civilian database. RESULTS: A total of 136 patients in the DoDTR database were matched for age, sex, year of injury, and head Abbreviated Injury Scale with 408 patients from TQIP. Utilization of blood products was significantly higher in the military population ( P <0.001). In the military group, patients were significantly more likely to have intracranial pressure monitoring (17% vs 6%, P <0.001) and more likely to undergo craniotomy or craniectomy (34% vs 13%, P <0.001) than in the civilian group. Mortality in the military population was significantly lower (27% vs 38%, P =0.013). CONCLUSIONS: Military patients are more likely to receive blood products, have intracranial pressure monitoring and undergo craniectomy or craniotomy than their civilian counterparts after isolated head gunshot wounds. Mortality is significantly lower in the military population. LEVEL OF EVIDENCE: Level III-therapeutic.

Nonoperative Management of Blunt Hepatic Trauma: Comparison of Level I and II Trauma Centers.

INTRODUCTION: Most blunt liver injuries are treated with nonoperative management (NOM), and angiointervention (AI) has become a common adjunct. This study evaluated the use of AI, blood product utilization, pharmacological venous thromboembolic prophylaxis (VTEp), and outcomes in severe blunt liver trauma managed nonoperatively at level I versus II trauma centers. METHODS: American College of Surgeons Trauma Quality Improvement Program (TQIP) study (2013-2016), including adult patients with severe blunt liver injuries (AIS score>/= 3) treated with NOM, was conducted. Epidemiological and clinical characteristics, severity of liver injury (AIS), use of AI, blood product utilization, and VTEp were collected. Outcomes included survival, complications, failure of NOM, blood product utilization, and length of stay (LOS). RESULTS: Study included 2825 patients: 2230(78.9%) in level I and 595(21.1%) in level II centers. There was no difference in demographics, clinical presentation, or injury severity between centers. Angiointervention was used in 6.4% in level I and 7.2% in level II centers (P=.452). Level II centers were less likely to use LMWH for VTEp (.003). There was no difference in mortality or failure of NOM. In level II centers, there was a significantly higher 24-hour blood product utilization (PRBC P = .015 and platelets P = .002), longer ventilator days (P = .012), and longer ICU (P< .001) and hospital LOS (P = .024). The incidence of ventilator-associated pneumonia was significantly higher in level II centers (P = .003). CONCLUSION: Utilization of AI and NOM success rates is similar in level I and II centers. However, the early blood utilization, ventilator days, and VAP complications are significantly higher in level II centers.

Does mortality after trauma team activation peak at shift change?

BACKGROUND: Prior institutional data have demonstrated trauma mortality to be highest between 06:00-07:59 at our center, which is also when providers change shifts (07:00-07:30). The objective was definition of patient, provider, and systems variables associated with trauma mortality at shift change among patients arriving as trauma team activations (TTA). METHODS: All TTA patients at our ACS-verified Level I trauma center were included (01/2008-07/2019), excluding those with undocumented arrival time. Study groups were defined by arrival time: shift change (SC) (06:00-07:59) vs. non-shift change (NSC) (all other times). Univariable/multivariable analyses compared key variables. Propensity score analysis compared outcomes after matching. RESULTS: After exclusions, 6020 patients remained: 229 (4%) SC and 5791 (96%) NSC. SC mortality was 25% vs. 16% during NSC (p < 0.001). More SC patients arrived with SBP <90 (19% vs. 11%, p < 0.001) or GCS <9 (35% vs. 24%, p < 0.001). ISS was higher during SC (43[32-50] vs. 34[27-50], p < 0.001). Time to CT scan (36[23-66] vs. 38[23-61] minutes, p = 0.638) and emergent surgery (94[35-141] vs. 63[34-107] minutes, p = 0.071) were comparable. Older age (p < 0.001), SBP <90 (p < 0.001), GCS <9 (p < 0.001), need for emergent operative intervention (p = 0.044), and higher ISS (p < 0.001) were independently associated with mortality. After propensity score matching, mortality was no different between SC and NSC (p = 0.764). CONCLUSIONS: Early morning is a low-volume, high-mortality time for TTAs. Increased mortality at shift change was independently associated with patient/injury factors but not provider/systems factors. Ensuring ample clinical resource allocation during this high acuity time may be prudent to streamline patient care at shift change.

Pre-injury stimulant use in isolated severe traumatic brain injury: effect on outcomes.

PURPOSE: The aim of this study was to assess the impact of pre-injury stimulant use (amphetamine, cocaine, methamphetamine and/or ecstasy) on outcomes after isolated severe traumatic brain injury (TBI). METHODS: Retrospective 2017 TQIP study, including adult trauma patients (≥16 years old) who underwent drug and alcohol screening on admission and sustained an isolated severe TBI (head AIS ≥3). Patients with significant extracranial trauma (AIS ≥3) were excluded. Epidemiological and clinical characteristics, procedures and outcome variables were collected. Patients with isolated stimulant use were matched 1:1 for age, gender, mechanism of injury, head AIS and overall comorbidities, with patients with negative toxicology and alcohol screen. Outcomes in the two groups were compared with univariable and multivariable regression analysis. RESULTS: 681 patients with isolated TBI and stimulant use were matched with 681 patients with negative toxicology and alcohol screen. The incidence of hypotension and CGS <9 was similar in the two groups. In multivariable regression analysis, stimulant use was not independently associated with mortality (OR 0.95, 95% CI 0.61-1.49). However, stimulant use was associated with longer hospital length of stay (HLOS) (RC 1.13, 95%CI 1.03-1.24). CONCLUSION: Pre-injury stimulant use is common in patients admitted for severe TBI, but was not independently associated with mortality when compared to patients with negative toxicology. However, stimulant use was associated with a significant longer HLOS.