An Abdominal Seat Belt Sign is Associated With Similar Incidence of Hollow Viscus Injury but Increased In-Hospital Mortality in Older Adult Trauma Patients: A PCSA Multicenter Study.

BACKGROUND: The abdominal seat belt sign (SBS) is associated with an increased risk of hollow viscus injury (HVI). Older age is associated with worse outcomes in trauma patients. Thus, older trauma patients ≥65 years of age (OTPs) may be at an increased risk of HVI with abdominal SBS. Therefore, we hypothesized an increased incidence of HVI and mortality for OTPs vs younger trauma patients (YTPs) with abdominal SBS. STUDY DESIGN: This post hoc analysis of a multi-institutional, prospective, observational study (8/2020-10/2021) included patients >18 years old with an abdominal SBS who underwent abdominal computed tomography (CT) imaging. Older trauma patients were compared to YTPs (18-64 years old) with bivariate analyses. RESULTS: Of the 754 patients included in this study from nine level-1 trauma centers, there were 110 (14.6%) OTPs and 644 (85.4%) YTPs. Older trauma patients were older (mean 75.3 vs 35.8 years old, P < .01) and had a higher mean Injury Severity Score (10.8 vs 9.0, P = .02). However, YTPs had an increased abdominal abbreviated-injury scale score (2.01 vs 1.63, P = .02). On CT imaging, OTPs less commonly had intraabdominal free fluid (21.7% vs 11.9%, P = .02) despite a similar rate of abdominal soft tissue contusion (P > .05). Older trauma patients also had a statistically similar rate of HVI vs YTPs (5.5% vs 9.8%, P = .15). Despite this, OTPs had increased mortality (5.5% vs 1.1%, P < .01) and length of stay (LOS) (5.9 vs 4.9 days P < .01). CONCLUSION: Despite a similar rate of HVI, OTPs with an abdominal SBS had an increased rate of mortality and LOS. This suggests the need for heightened vigilance when caring for OTPs with abdominal SBS.

Traumatic Brain Injuries After Falls From Height vs Falls at the US-Mexico Border Wall.

This cohort study examines the incidence, severity, and mortality of fall-related injuries among migrants at the US-Mexico border in San Diego, California.

Two-center analysis of cannabis on venous thromboembolism risk after traumatic injury: A matched analysis.

BACKGROUND: Conflicting evidence exists evaluating associations between cannabis (THC) and post-traumatic DVT. METHODS: Retrospective analysis (2014-2023) of patients ≥15yrs from two Level I trauma centers with robust VTE surveillance and prophylaxis protocols. Multivariable hierarchical regression assessed the association between THC and DVT risk. THC â€‹+ â€‹patients were direct matched to other drug use categories on VTE risk markers and hospital length of stay. RESULTS: Of 7365 patients, 3719 were drug-, 575 were THC â€‹+ â€‹only, 2583 were other drug+, and 488 were TCH+/other drug+. DVT rates by exposure group did not differ. TCH â€‹+ â€‹only patients had higher GCS scores, shorter hospital length of stay, and the lowest pelvic fracture and mortality rates. A total of 458 drug-, 453 other drug+, and 232 THC+/other drug â€‹+ â€‹patients were matched to 458, 453, and 232 THC â€‹+ â€‹only patients. There were no differences in DVT event rates in any paired sub-cohort set. Additionally, iteratively adjusted paired models did not show an association between THC and DVT. CONCLUSIONS: THC does not appear to be associated with increased DVT risk in patients with strict trauma chemoprophylaxis. Toxicology testing is useful for identifying substance abuse intervention opportunities, but not for DVT risk stratification in THC â€‹+ â€‹patients.

Deaths After Readmissions are Mostly Attributable to Failure-to-Rescue in EGS Patients.

INTRODUCTION: We have recently shown that readmission after EGS procedures carries a 4-fold higher mortality rate when compared to those not readmitted. Understanding factors associated with death after readmission is paramount to improving outcomes for EGS patients. We aimed to identify risk factors contributing to failure-to-rescue (FTR) during readmission after EGS. We hypothesized that most post-readmission deaths in EGS are attributable to FTR. METHODS: A retrospective cohort study using the NSQIP database 2013-2019 was performed. Patients who underwent 1 of 9 urgent/emergent surgical procedures representing 80% of EGS burden of disease, who were readmitted within 30 days post-procedure were identified. The procedures were classified as low- and high-risk. Patient characteristics analyzed included age, sex, BMI, ASA score comorbidities, postoperative complications, frailty, and FTR. The population was assessed for risk factors associated with mortality and FTR by uni- and multivariate logistic regression. RESULTS: Of 312,862 EGS cases, 16,306 required readmission. Of those, 10,748 (3.4%) developed a postoperative complication. Overall mortality after readmission was 2.4%, with 90.6% of deaths attributable to FTR. Frailty, high-risk procedures, pulmonary complications, AKI, sepsis, and the need for reoperation increased the risk of FTR. DISCUSSION: Death after a complication is common in EGS readmissions. The impact of FTR could be minimized with the implementation of measures to allow early identification and intervention or prevention of infectious, respiratory, and renal complications.

An Executive Summary of the National Trauma Research Action Plan (NTRAP).

ABSTRACT: The National Trauma Research Action Plan (NTRAP) project successfully engaged multidisciplinary experts to define opportunities to advance trauma research and has fulfilled the recommendations related to trauma research from the National Academies of Sciences, Engineering and Medicine (NASEM) report. These panels identified more than 4,800 gaps in our knowledge regarding injury prevention and the optimal care of injured patients and laid out a priority framework and tools to support researchers to advance this field. Trauma research funding agencies and researchers can use this executive summary and supporting manuscripts to strategically address and close the highest priority research gaps. Given that this is the most significant public health threat facing our children, young adults, and military service personnel, we must do better in prioritizing these research projects for funding and providing grant support to advance this work. Through the Coalition for National Trauma Research (CNTR), the trauma community is committed to a coordinated, collaborative approach to address these critical knowledge gaps and ultimately reduce the burden of morbidity and mortality faced by our patients.

American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma clinical protocol for postdischarge venous thromboembolism prophylaxis after trauma.

ABSTRACT: Trauma patients are at an elevated risk for developing venous thromboembolism (VTE), which includes pulmonary embolism and deep vein thrombosis. In the inpatient setting, prompt pharmacologic prophylaxis is utilized to prevent VTE. For patients with lower extremity fractures or limited mobility, VTE risk does not return to baseline levels postdischarge. Currently, there are limited data to guide postdischarge VTE prophylaxis in trauma patients. The goal of these postdischarge VTE prophylaxis guidelines are to identify patients at the highest risk of developing VTE after discharge and to offer pharmacologic prophylaxis strategies to limit this risk.

Weight-based enoxaparin thromboprophylaxis in young trauma patients: analysis of the CLOTT-1 registry.

Introduction: Optimal venous thromboembolism (VTE) enoxaparin prophylaxis dosing remains elusive. Weight-based (WB) dosing safely increases anti-factor Xa levels without the need for routine monitoring but it is unclear if it leads to lower VTE risk. We hypothesized that WB dosing would decrease VTE risk compared with standard fixed dosing (SFD). Methods: Patients from the prospective, observational CLOTT-1 registry receiving prophylactic enoxaparin (n=5539) were categorized as WB (0.45-0.55 mg/kg two times per day) or SFD (30 mg two times per day, 40 mg once a day). Multivariate logistic regression was used to generate a predicted probability of VTE for WB and SFD patients. Results: Of 4360 patients analyzed, 1065 (24.4%) were WB and 3295 (75.6%) were SFD. WB patients were younger, female, more severely injured, and underwent major operation or major venous repair at a higher rate than individuals in the SFD group. Obesity was more common among the SFD group. Unadjusted VTE rates were comparable (WB 3.1% vs. SFD 3.9%; p=0.221). Early prophylaxis was associated with lower VTE rate (1.4% vs. 5.0%; p=0.001) and deep vein thrombosis (0.9% vs. 4.4%; p<0.001), but not pulmonary embolism (0.7% vs. 1.4%; p=0.259). After adjustment, VTE incidence did not differ by dosing strategy (adjusted OR (aOR) 0.75, 95% CI 0.38 to 1.48); however, early administration was associated with a significant reduction in VTE (aOR 0.47, 95% CI 0.30 to 0.74). Conclusion: In young trauma patients, WB prophylaxis is not associated with reduced VTE rate when compared with SFD. The timing of the initiation of chemoprophylaxis may be more important than the dosing strategy. Further studies need to evaluate these findings across a wider age and comorbidity spectrum. Level of evidence: Level IV, therapeutic/care management.

Identification and management of low-risk isolated traumatic brain injury patients initially treated at a rural level IV trauma center.

STUDY OBJECTIVE: Our goal was to determine if low-risk, isolated mild traumatic brain injury (TBI) patients who were initially treated at a rural emergency department may have been safely managed without transfer to the tertiary referral trauma center. METHODS: This was a retrospective observational analysis of isolated mild TBI patients who were transferred from a rural Level IV Trauma Center to a regional Level I Trauma Center between 2018 and 2022. Patients were risk-stratified according to the modified Brain Injury Guidelines (mBIG). Data abstracted from the electronic medical record included patient presentation, management, and outcomes. RESULTS: 250 patients with isolated mild TBI were transferred out to the Level I Trauma Center. Fall was the most common mechanism of injury (69.2%). 28 patients (11.2%) were categorized as low-risk (mBIG1). No mBIG1 patients suffered a progression of neurological injury, had worsening of intracranial hemorrhage on repeat head CT, or required neurosurgical intervention. 12/28 (42.9%) of mBIG1 patients had a hospital length of stay of 2 days or less, typically for observation. Those with longer lengths of stay were due to medical complications, such as sepsis, or difficulty in arranging disposition. CONCLUSION: We propose that patients who meet mBIG1 criteria may be safely observed without transfer to a referral Level I Trauma Center. This would be of considerable benefit to patients, who would not need to leave their community, and would improve resource utilization in the region.

Analysis of lipid metabolites derived from gut microbiota in ischemia-reperfusion model.

BACKGROUND: Disruption of intestinal barrier caused by intestinal ischemia due to hemorrhagic shock is associated with the pathogenesis of multiple organ dysfunction (MOD) after severe trauma. Mesenteric lymph (ML) plays an important role as a route for transporting inflammatory mediators, including lipids. Postbiotics, such as 10-hydroxy-cis-12-octadecenoic acid (HYA), have received much attention as a treatment option. However, the relationship between postbiotics and MOD has yet to be clarified. The aim of the present study was to analyze lipid metabolites derived from gut microbiota in the intestinal ischemia-reperfusion (IR) rat model. METHODS: Male Sprague-Dawley rats underwent laparotomy, and their ML duct and superior mesenteric artery were exposed. The superior mesenteric artery was clamped for 60 minutes, followed by 120 minutes of reperfusion. The ML and the plasma were collected before and after intestinal IR. Lipids were extracted from plasma and ML, and liquid chromatography-tandem mass spectrometry was performed. RESULTS: The concentration of linoleic acid in plasma samples was not different before and after IR; however, the linoleic acid concentration in the ML samples increased after intestinal IR. Eicosapentaenoic acids and docosahexaenoic related to linoleic acids showed similar changes with IR-induced increase in the ML. The concentration of HYA, a linoleic acid-derived bioactive metabolite produced by gut bacteria, was high in ML samples, while that in plasma samples was low. The relative increase rate of HYA in ML samples after IR was higher than that of the plasma samples (the ML samples: relative increase, 3.23 ± 1.36; the plasma samples: relative increase, 0.95 ± 0.35; n = 3, p = 0.048). CONCLUSION: The present study demonstrated increased linoleic acids and high concentrations of HYA, lipid metabolites derived from gut bacteria in the ML after intestinal IR. These findings may contribute to clarifying the relation between gut microbiota and MOD after severe trauma.

A heterogenous population of extracellular vesicles mobilize to the alveoli postinjury.

BACKGROUND: Acute lung injury and subsequent resolution following severe injury are coordinated by a complex lung microenvironment that includes extracellular vesicles (EVs). We hypothesized that there is a heterogenous population of EVs recruited to the alveoli postinjury and that we could identify specific immune-relevant mediators expressed on bronchoalveolar lavage (BAL) EVs as candidate biomarkers of injury and injury resolution. METHODS: Mice underwent 30% TBSA burn injury and BAL fluid was collected 4 hours postinjury and compared with sham. Extracellular vesicles were purified and single vesicle flow cytometry (vFC) was performed using fluorescent antibodies to quantify the expression of specific cell surface markers on individual EVs. Next, we evaluated human BAL specimens from injured patients to establish translational relevance of the mouse vFC analysis. Human BAL was collected from intubated patients following trauma or burn injury, EVs were purified, then subjected to vFC analysis. RESULTS: A diverse population of EVs were mobilized to the alveoli after burn injury in mice. Quantitative BAL vFC identified significant increases in macrophage-derived CD44+ EVs (preinjury, 10.8% vs. postinjury, 13%; p < 0.05) and decreases in IL-6 receptor alpha (CD126) EVs (preinjury, 19.3% vs. postinjury, 9.3%, p < 0.05). Bronchoalveolar lavage from injured patients also contained a heterogeneous population of EVs derived from myeloid cells, endothelium, and epithelium sources, with CD44+ EVs being highly detected. CONCLUSION: Injury causes mobilization of a heterogeneous population of EVs to the alveoli in both animal models and injured patients. Defining EV release after injury will be critical in identifying diagnostic and therapeutic targets to limit postinjury acute lung injury.

Development and Validation of a Novel Hollow Viscus Injury Prediction Score for Abdominal Seatbelt Sign: A Pacific Coast Surgical Association Multicenter Study.

BACKGROUND: High-quality CT can exclude hollow viscus injury (HVI) in patients with abdominal seatbelt sign (SBS) but performs poorly at identifying HVI. Delay in diagnosis of HVI has significant consequences necessitating timely identification. STUDY DESIGN: This multicenter, prospective observational study conducted at 9 trauma centers between August 2020 and October 2021 included adult trauma patients with abdominal SBS who underwent abdominal CT before surgery. HVI was determined intraoperatively and physiologic, examination, laboratory, and imaging findings were collected. Least absolute shrinkage and selection operator- and probit regression-selected predictor variables and coefficients were used to assign integer points for the HVI score. Validation was performed by comparing the area under receiver operating curves (AUROC). RESULTS: Analysis included 473 in the development set and 203 in the validation set. The HVI score includes initial systolic blood pressure <110 mmHg, abdominal tenderness, guarding, and select abdominal CT findings. The derivation set has an AUROC of 0.96, and the validation set has an AUROC of 0.91. The HVI score ranges from 0 to 17 with score 0 to 5 having an HVI risk of 0.03% to 5.36%, 6 to 9 having a risk of 10.65% to 44.1%, and 10 to 17 having a risk of 58.59% to 99.72%. CONCLUSIONS: This multicenter study developed and validated a novel HVI score incorporating readily available physiologic, examination, and CT findings to risk stratify patients with an abdominal SBS. The HVI score can be used to guide decisions regarding management of a patient with an abdominal SBS and suspected HVI.

Time-saving effect of real-time ultrasound-guided cannulation for extracorporeal cardiopulmonary resuscitation: A multicenter retrospective cohort study.

BACKGROUND: Extracorporeal cardiopulmonary resuscitation (ECPR), a bridge to treatments for cardiac arrest patients, can be technically challenging and requires expertise. While ultrasound guidance is frequently used for vascular access, its effects on cannulation time in patients treated with ECPR are poorly defined. We hypothesized that real-time ultrasound guidance would contribute to faster and safer cannulation for ECPR. METHODS: This nationwide, multicenter, retrospective study analyzed data from 36 Japanese institutions. Patients who were over age 18 years and underwent ECPR between January 1, 2013, and December 31, 2018, were included. Patients who underwent open surgical vascular access were excluded. Cannulation time and outcomes of patients who underwent real-time ultrasound-guided cannulation (i.e., ultrasound-guided group) were compared to those cannulated without the use of real-time ultrasound guidance (control group) using propensity score matching analysis. RESULTS: The ultrasound-guided group comprised 510 cases, whereas the control group comprised 941 cases. Of those, 443 propensity score-matched pairs were evaluated. Cannulation time in the ultrasound-guided group was 2.5 minutes shorter than in the control group [difference, -2.5 minutes; 95% Confidence interval (CI), -3.7 to -1.3, p < 0.001]. The incidence of catheter-related complications and the incidence of the poor neurological outcomes (Cerebral Performance Category ≥3) did not differ between groups [Odds ratio (OR), 1.51; 95% CI, 0.64-3.74; OR, 1.08; 95% CI, 0.83-1.59]. CONCLUSION: Real-time ultrasound-guided cannulation was associated with shorter cannulation time of ECPR.

A majority of trauma-related deep venous thromboses resolve prior to discharge.

Post-traumatic DVTs present unique challenges in patient populations with specific high-risk injury patterns. Duplex ultrasound (US) can be used to assess evolution of DVTs and may guide treatment for high-risk patients. We hypothesized that many DVTs resolve during the initial admission. Weekly duplex US are ordered on all trauma inpatients regardless of prior DVT at our facility. We reviewed US and outcomes data on all patients with lower extremity DVTs at our Level I trauma center from January 2012-December 2021. 392 patients were diagnosed with lower extremity DVT by US. 261 (67%) patients received follow-up US with a mean time to repeat US of 6 days. Of these, 91 (35%) patients experienced DVT resolution prior to the first follow-up US, and 141 (54%) patients experienced resolution prior to discharge. Mean time to resolution was 10 days. Over 50% of DVTs resolve before discharge and are detected by US. Further studies and post-discharge follow-up are needed to determine if patients with resolved DVTs can be managed without therapeutic anticoagulation.

Novel Association of Blunt Cerebrovascular Injuries with the San Diego-Mexico Border Wall Height Extension.

BACKGROUND: The San Diego-Mexico border wall height extension is associated with increased traumatic injuries and related costs after wall falls. We report previous trends and a neurological injury type not previously associated with border falls: blunt cerebrovascular injuries (BCVIs). METHODS: In this retrospective cohort study, patients who presented to the UC San Diego Health Trauma Center for injuries from border wall falls from 2016 to 2021 were considered. Patients were included if they were admitted before (January 2016 to May 2018) or after (January 2020 to December 2021) the height extension period. Patient demographics, clinical data, and hospital stay data were compared. RESULTS: We identified 383 patients, 51 (68.6% male; mean age, 33.5 years) in the pre-height extension cohort and 332 (77.1% male; mean age, 31.5 years) in the post-height extension cohort. There were 0 and 5 BCVIs in the pre- and post-height extension groups, respectively. BCVIs were associated with increased injury severity scores (9.16 vs. 31.33; P < 0.001), longer intensive care unit lengths of stay (median, 0 days; [interquartile range (IQR), 0-3 days]; vs. median, 5 days [IQR, 2-21 days]; P = 0.022), and increased total hospital charges (median, $163,490 [IQR, $86,578-$282,036]; vs. median, $835,260 [IQR, $171,049-$1,933,996]; P = 0.048). Poisson modeling found BCVI admissions were 0.21 (95% confidence interval, 0.07-0.41; P = 0.042) per month higher after the height extension. CONCLUSIONS: We review the injuries correlating with the border wall extension and reveal an association with rare, potentially devastating BCVIs that were not seen before the border wall modifications. These BCVIs and associated morbidity shed light on the trauma increasingly found at the southern U.S. border, which could be informative for future infrastructure policy decisions.

American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma clinical protocol for management of acute respiratory distress syndrome and severe hypoxemia.

LEVEL OF EVIDENCE: Therapeutic/Care Management: Level V.

Research priorities in venous thromboembolism after trauma: Secondary analysis of the National Trauma Research Action Plan.

BACKGROUND: Venous thromboembolism (VTE) is a significant cause of morbidity and mortality during recovery from injury and can result in significant health care costs. Despite advances in the past several decades in our approach to VTE prophylaxis after injury, opportunities exist to improve the delivery and implementation of optimal VTE prophylaxis. Here, we aim to identify consensus research questions related to VTE across all National Trauma Research Action Plan (NTRAP) Delphi expert panels to further guide the research agenda aimed at preventing VTE after injury. METHODS: This is a secondary analysis of consensus-based research priorities that were collected using a Delphi methodology by 11 unique NTRAP panels that were charged with unique topic areas across the spectrum of injury care. The database of questions was queried for the keywords "VTE," "venous thromboembo," and "DVT" and then grouped into relevant topic areas. RESULTS: There were 86 VTE-related research questions identified across 9 NTRAP panels. Eighty-five questions reached consensus with 24 rated high priority; 60, medium priority; and 1, low priority. Questions related to the timing of VTE prophylaxis (n = 17) were most common, followed by questions related to risk factors for the development of VTE (n = 16), the effects of tranexamic acid on VTE (n = 11), the approach to dosing of pharmacologic prophylaxis (n = 8), and the pharmacologic prophylactic medication choice for optimal VTE prophylaxis (n = 6). CONCLUSION: National Trauma Research Action Plan panelists identified 85 consensus-based research questions that should drive dedicated extramural research funding opportunities to support quality studies aimed at optimizing VTE prophylaxis after injury. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Falling from new heights: Traumatic fracture burden and resource utilization after border wall height increase.

BACKGROUND: San Diego County hospitals commonly care for patients injured by falls from the United States-Mexico border. From 2018 to 2019, the height of >400 miles of an existing border wall was raised. Prior work has demonstrated a 5-fold increase in traumatic border wall fall injuries after barrier expansion. We aimed to examine the impact of a barrier height increase on fracture burden and resource use. METHODS: We performed a retrospective review of patients admitted to a level 1 trauma center from 2016 to 2021 with lower extremity or pelvic fractures sustained from a border wall fall. We defined the pre-wall group as patients admitted from 2016 to 2018 and the post-wall group as those admitted from 2019 to 2021. We collected demographic and treatment data, hospital charges, weight-bearing status at discharge, and follow-up. RESULTS: A total of 320 patients (pre-wall: 45; post-wall: 275) were admitted with 951 lower extremity fractures (pre-wall: 101; post-wall: 850) due to border wall fall. Hospital resources were utilized to a greater extent post-wall: a 537% increase in hospital days, a 776% increase in intensive care unit days, and a 468% increase in operative procedures. Overall, 86% of patients were non-weight-bearing on at least 1 lower extremity at discharge; 82% were lost to follow-up. CONCLUSION: Traumatic lower extremity fractures sustained from border wall fall rapidly rose after the wall height increase. Hospital resources were used to a greater extent. Patients were frequently discharged with weight-bearing limitations and rarely received scheduled follow-up care. Policymakers should consider the costs of caring for border fall patients, and access to follow-up should be expanded.