Optimal Timing of Tracheostomy in the Setting of COVID-19 and Associated Pneumothorax.

Introduction At the beginning of the 2020 pandemic, no criteria were in place regarding the timing of tracheostomy placement in intubated COVID-19 patients, nor were there any data pertaining to pneumothorax incidence in this population. This study examines the timing of tracheostomy placement and its correlation with patient outcomes, along with pneumothorax incidence in COVID-19 patients who underwent a tracheostomy.  Methods We performed a multi-institutional retrospective study of intubated COVID-19 patients admitted to intensive care units (ICUs) in North and South Dakota between April 2020 and December 2020. The timing of the tracheostomy was assessed, with primary outcomes being mortality, successful ventilator weaning, discharge to a long-term care facility, and overall length of stay. Patients were grouped by age, gender, ethnicity, and comorbidities. Pre- and post-tracheostomy pneumothorax was extracted from this dataset. Results We identified 85 patients who were intubated with COVID-19 and underwent a tracheostomy. The timing of tracheostomy varied widely, ranging from five to 53 days with an average time to tracheostomy being 17.3 days. Thirty-four of the patients expired, 32 patients were discharged to a long-term care hospital (LTCH), and 11 patients were discharged to an inpatient rehabilitation facility. Only three patients were discharged home. Regression analysis did not reveal statistically significant differences between patients who survived (N = 51) and patients who expired (N = 34) for almost all variables analyzed. Sixteen of the 85 patients were diagnosed with pneumothorax during their hospital stay. Half of these patients were diagnosed after a tracheostomy was placed. Conclusion This study did not demonstrate statistically significant differences in overall mortality or incidence of pneumothorax when it pertains to the timing of placement of tracheostomy. Variation in mortality was identified, in which younger patients were more likely to survive than older patients, a finding that was echoed in other studies. Considering this evidence, we cannot conclude that an association between the timing of tracheostomy and mortality from COVID-19; therefore, tracheostomy in the setting of COVID-19 can be performed at the provider's discretion.

A Call for Help: A Retrospective National Study of Self-Inflicted Trauma Among American Indians and Alaskan Natives.

Background Self-inflicted injury accounts for approximately 312,000 emergency department visits annually. American Indians/Alaskan Natives (AIAN) have significantly higher rates of suicide. The National Trauma Data Bank (NTDB) was analyzed for the incidence of self-inflicted trauma. Methods Data were obtained from the NTDB 2012-2017. Patients were selected using ICD codes for self-inflicted trauma. Categorical and continuous variables were tested for significance. Results AIAN patients accounted for 1,176 of the 78,668 patients. The AIAN patients were younger, had lower injury severity score (ISS) scores, were more female, utilized Medicaid more frequently, were more likely to present with a cut or piercing injury, and had higher rates of positive alcohol and drug tests. AIAN patients had shorter lengths of stay in the ICU and overall hospital stay. Conclusion Despite a higher rate of suicide completion, the AIAN population had lower rates of presentation to the hospital and lower ISS scores. AIAN patients were younger, had higher rates of drug use, and utilized cutting/stabbing. This discrepancy could indicate a physical manifestation of a "call for help".

Changes in Patterns of Trauma Injuries in the Dakotas Region During the COVID-19 Pandemic.

BACKGROUND: The aim of this study is to compare impact of COVID-19 on trauma volume and characteristics on a set of trauma centers with a rural catchment area. The COVID-19 pandemic has affected different parts of the country quite differently, both in case volume and in local responses. State-wide responses have varied considerably, including variations in local mask mandates, school closures, and social distancing measures. METHODS: This was a retrospective trauma registry review of patients who were admitted to three of the tertiary care trauma centers in North and South Dakota between 2014 through 2022. RESULTS: In the analysis of 36,397 patients, we found a significant increase in trauma patient volume during the COVID-19 pandemic, with an increased percentage of patients presenting with a mechanism of injury secondary to abuse or assault. This increase in patient volume continued to rise during 2021 and 2022. CONCLUSIONS: Our study demonstrates how the COVID-19 pandemic impacted trauma center admissions in the rural and frontier Midwest differently from more urban areas, and the importance of including a variety of settings in trauma research.

Inhaled Nitroglycerin for Pulmonary Edema in Air Medical Services: A Retrospective Pilot Study.

OBJECTIVE: The use of traditional inhaled pulmonary vasodilators, such as nitric oxide, to treat symptomatic pulmonary edema is not practical in the air medical or prehospital environment because of difficulty with administration. A hospital-based critical care air medical transport service initiated a pilot study to investigate the use of inhaled nitroglycerin (iNTG) as an alternative pulmonary vasodilator. METHODS: For this pilot study, iNTG was administered using a jet nebulizer setup and concentrated nitroglycerin, both of which are widely available in acute care settings. In conjunction with medical oversight, transport personnel identified patients with respiratory distress secondary to pulmonary edema. Twenty-two months after initiating the protocol, a retrospective chart review was conducted. Data for patients receiving iNTG were retrospectively abstracted through a medical record search and manual chart review. RESULTS: Twelve patients received iNTG during the pilot study. Basic demographics, medical comorbidities, concurrent medications, laboratory values, and radiographic studies were collected for each patient. Basic statistics were performed to identify any potential trends. CONCLUSION: The administration of iNTG is feasible in an air medical transport setting and may provide a useful adjunct to treating patients with pulmonary edema and respiratory distress. Because iNTG delivery targets the pulmonary vasculature, this may be of particular benefit in patients with a poor hemodynamic profile. Larger randomized controlled or cohort studies are needed to specifically analyze and compare hemodynamics, diagnostics, and patient outcomes.

"Blunt adrenal injury does not affect outcomes in the pediatric population with isolated abdominal injury- a National Trauma Data Bank Review®."

BACKGROUND: The incidence of blunt abdominal injury (BAI) in the adult population has been estimated to be between 0.03% and 4.95%. However, the impact of BAI on the pediatric population remains unknown. METHODS: We conducted a retrospective review of National Trauma Data Bank datasets for the years 2017-2019. We included patients under the age of 18 who experienced blunt trauma and had suffered a blunt abdominal injury with an Abbreviated Injury Scale (AIS) severity score of 2 or higher. RESULTS: Out of the 8064 pediatric patients with isolated abdominal trauma, 134 patients also suffered from BAI. We found no difference in the outcomes of patients with blunt adrenal injury in terms of mortality, length of stay in the intensive care unit (ICU) and hospital, and the number of ventilator days. Within poly-trauma patients BAI was associated with worst patient outcomes. CONCLUSIONS: This study demonstrates that BAI has minimal clinical impact on patient outcomes in isolation. However it is associated with worst outcomes in poly trauma patients suggesting correlation with increased trauma burden. LEVEL OF EVIDENCE: III.

Tractor Injuries in the Upper Midwestern United States: a retrospective analysis of four trauma centers.

OBJECTIVES: The purpose of the present study was to characterize the incidence, injury characteristics, and outcomes of patients presented to four trauma facilities located in the upper Midwest with tractor-related agricultural injuries. METHODS: We performed a retrospective review of the facility level trauma registries of four trauma centers located in North Dakota, South Dakota, and Minnesota between January 1, 2010 and December 31, 2021. We characterized the incidence, severity and outcomes of traumatic tractor-related agricultural injuries for pediatric and adult patients. We described the nature of these injuries by severity, anatomical site, type, age, sex, and length of stay (LoS). Injury severity was evaluated using Injury Severity Score (ISS) and Abbreviated Injury Scale (AIS). RESULTS: Findings indicated that farmers aged 65 and older experience polytraumatic, severe tractor-related agricultural injuries and fatalities. Of the 177 tractor patients analyzed, 40 patients were between the ages of 65 and 74 years and 45 patients were 75 and over. Male farmers aged 65 and older are injured year-round, many are discharged to skilled nursing facilities for additional care, are spending more time in the hospital, and have the highest rate of critical injuries out of all age groups. Moreover, the patients who died as a result of tractor-related agricultural injuries were men over 65 years. The most common tractor-related agricultural injuries include falls from tractors (n = 53), struck by object falling/propelled from tractor (n = 25), rollovers (n = 26), and runovers (n = 24). Falls from tractors accounted for 33% of all tractor-related upper extremity fractures, 36% of head injuries and 29% of chest injuries. CONCLUSION: The findings from this study indicate that tractor-related agricultural injuries represent a significant problem in the upper Midwest. Older, male farm workers experience a higher incidence of tractor-related agricultural injuries, and all tractor-related fatalities occurred in individuals 65 years of age and older. These results underscore the need for further investigation into aging-related farm safety issues.

Using Partnerships and Multiple Data Sources to Surveil Agricultural Injuries: Considerations and Recommendations.

This article describes an interprofessional collaboration between Sanford Health and North Dakota State University that strengthens agricultural injury surveillance in the upper Midwest by using multiple sources of health data and geographic information systems (GIS) technology. We provide methodological insights and considerations for using and combining facility-level trauma registry (FLTR) data, national data sets, and GIS to identify areas with disproportionate agricultural injury prevalence. Additionally, we discuss the benefits of FLTR data, how and why it is collected, the data it contains, and how it can be combined with national datasets to fill-in surveillance gaps. Lastly, we offer recommendations for building cross-institutional and interprofessional partnerships.

Benefits of Early Utilization of Palliative Care Consultation in Trauma Patients.

OBJECTIVES: To determine the effects of palliative care consultation if performed within 72 hours of admission on length of stay (LOS), mortality, and invasive procedures. DESIGN: Retrospective observational study. SETTING: Single-center level 1 trauma center. PATIENTS: Trauma patients, admitted to ICU with palliative care consultation. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: The ICU LOS was decreased in the early palliative care (EPC) group compared with the late palliative care (LPC) group, by 6 days versus 12 days, respectively. Similarly, the hospital LOS was also shorter in the EPC group by 8 days versus 17 days in the LPC group. In addition, the EPC group had lower rates of tracheostomy (4% vs 14%) and percutaneous gastrostomy tubes (4% vs 15%) compared with the LPC group. There was no difference in mortality or discharge disposition between patients in the EPC versus LPC groups. It is noteworthy that the patients who received EPC were slightly older, but there were no other significant differences in demographics. CONCLUSIONS: EPC is associated with fewer procedures and a shorter amount of time spent in the hospital, with no immediate effect on mortality. These outcomes are consistent with studies that show patients' preferences toward the end of life, which typically involve less time in the hospital and fewer invasive procedures.

Children and youth agricultural injuries: A retrospective analysis of pediatric trauma admissions in North Dakota.

Introduction: Farm children and youths face unique health risks, including increased risk of agricultural injuries (AI), due to the hazardous machinery, structures and animals on their residential environment. As a result, they experience more severe and complex polytraumatic injuries and longer hospital stays compared to those children injured in homes or residences. A major barrier to the prevention of AI among children and youth residing on farms is a lack of analytic studies about the magnitude and characteristics of these injuries, especially in North Dakota. Methods: We performed a retrospective review of the Sanford Medical Center Fargo trauma registry for pediatric patients (aged 0-19 years) who received care between January 2010 and December 2020 for AI. Patients were grouped for analysis by the age categories of the Agricultural Youth Work Guidelines (AYWG) to compare the mechanisms of injury with the recommended minimum age requirements for specific farm tasks. Results: Of the 41 patients, 26 were male. Mean age was 11 years and one death was reported. The most common mechanism of injury was animals (37%), followed by falls (20%) and machinery (17%). Children under 6 years and youth aged 16 to 19 had the highest number of injuries. Females experienced 53% of animal-related injuries and males accounted for all vehicle-related injuries. Conclusion: The incidence and severity of polytraumatic AI among young children in North Dakota is concerning. Our results underscore the continued need to pursue pediatric injury prevention on farms through educational resources and programs, including the AWYG. Practical applications: Parents require more training on age and ability appropriate farm tasks, especially animal-related interactions. It is imperative that families are given the education and training necessary to integrate children into the farm life while protecting them from injury.

Consistency is Key: Additional Education and Outreach in a Rural Trauma System Reduces Excess Imaging Studies.

BACKGROUND: Repeat imaging for trauma patients is common in rural health care systems after transfer to a tertiary trauma center which subjects patients to increased radiation, excess costs, and delays to definitive care. A previous retrospective review at our regional trauma center found that pre-transfer CT scans were frequently performed with little change in management. To improve this rate, additional emphasis was placed on (1) best imaging practices during Rural Trauma Team Development Courses (RTTDC), (2) management feedback during regional trauma case reviews, and (3) implementation of practice management guidelines for an inter-provider telehealth system. METHODS: Two hundred consecutive adult trauma patients transferred to a regional trauma center were retrospectively evaluated after trauma system improvements were implemented and compared to the previous cohort in the same system as identified by the regional trauma database. RESULTS: 140 (70%) had a pre-transfer CT scan compared to 152 (77.2%) in the prior study (P = .0112). Additionally, 52 (37.1%) of those with pre-transfer CT scans had at least one repeat scan on arrival which decreased from (55.3%) in the prior study (P < .0001). The most common reason for repeat CT scans was incomplete initial imaging. Those with a repeat scan were more likely to have a head injury (51.9% vs 35.8%, P = .0413). DISCUSSION: With regional trauma system maturation and implementation of internal telemedicine guidelines, there was a statistically significant decrease in both pre-transfer as well as repeat CT scans in a rural trauma system. Additional research exploring patient outcomes and cost savings is recommended.

Farm Machinery Injuries: A Retrospective Analysis of Admissions at a Level I Trauma Center in North Dakota.

OBJECTIVES: The purpose of the present study was to characterize the incidence, injury characteristics, and outcomes of patients presented to a Level I adult trauma center in Fargo, North Dakota, with farm machinery injuries (FMI). METHODS: We performed a retrospective review of the trauma registry of Sanford Medical Center Fargo (SMCF) between January 2010 and December 2020. We compared admission characteristics of FMI admissions to non-FMI admissions, identified the types of machinery that are most commonly associated with FMI, and described the nature of these injuries by severity, anatomical site, type, age, sex, and length of stay (LoS). Injury severity was evaluated using Injury Severity Score (ISS). RESULTS: Findings indicated that FMI admissions had a higher mean ISS, longer ICU LoS, and a higher mortality rate than non-FMI admissions. The leading cause of fatal and non-fatal FMI in this region are tractors. Males experience 91.2% of tractor injuries, and individuals 65 and over account for nearly 53% of all tractor injuries (n = 18). Males accounted for all deaths, tractor and otherwise. The "other machinery" category was the second most common category and accounted for 50% of female patients. Additionally, 24.5% of all FMI are related to machine maintenance. CONCLUSION: The findings from this study indicate that FMI injuries represent a significant problem in the upper Midwest. Older, male farm workers experience a higher incidence of tractor-related injuries, and all tractor-related deaths occurred in individuals 65 years of age and older. These results underscore the need for further investigation into aging-related farm safety issues.

Stapling Common Enterotomy Does Not Increase Leak Rates in Stapled Anastomoses.

BACKGROUND: Stapled vs handsewn methods of bowel anastomosis have been extensively studied, however, no study has compared the handsewn vs stapled technique of closing the common enterotomy. Anecdotal concerns of higher leak rates due to crossing staple lines has led some to prefer a handsewn technique for closing the common enterotomy. METHODS: Patients undergoing stapled side-to-side enteroenteric and enterocolonic anastomoses in both emergent and elective settings at 1 tertiary center from 2016 to 2020 were studied. 758 patients were included. They were divided into 2 cohorts: Stapled-Stapled (SS) and Stapled-Handsewn (SH) depending on the fashion in which their stapled common enterotomy was closed. Association of anastomotic leak rate overall, in the emergent vs elective setting, and within enteroenteric and enterocolonic anastomotic subgroups was evaluated with both univariate and multivariate analysis. Association with the closure technique, mortality and average operative time was also compared. RESULTS: Multivariate analysis overall leak rates (SS 5.9% vs SH 3.7%, P = .23) and enteroenteric leak rates (SS 2.9 vs SH 4.1, P = .52) were similar between cohorts. Operative times were significantly shorter in the SS cohort (SS 121.8 min vs SH 138.1 min, P = .049), with a difference of 16.3 min on average. No difference in mortality was seen. DISCUSSION: The SH and SS result in similar anastomotic leak rates overall, and the SS technique is significantly faster than the SH technique. We therefore consider the SS technique to be an acceptable, and in the emergent setting, potentially preferred method of anastomotic technique.

79 is the new 70: Left digit bias in craniotomy.

BACKGROUND: Left digit bias is the psychological phenomenon in which the difference between values is perceived as larger due to the value of the first digit. For example, an 80 year old may be perceived as much older than a 79 year old. We sought to determine if left digit bias is present in craniotomy for elderly patients with traumatic brain injury. METHODS: Patients aged 69, 70, 79, and 80 with traumatic brain injury and an abbreviated injury scale severity of a minimum of 3 were included from the National Trauma Data Bank from the years 2012-2019. 38,908 patients were included. A Chi-squared Test was performed to compare the percentage of patients undergoing craniotomy. RESULTS: 79 year olds had higher craniotomy rates than 80 year olds (7.8% vs 6.4%, P < 0.001). There was no difference in craniotomy rates between 69 and 70 year olds (8.2% vs 7.8%, P < 0.2622). CONCLUSION: This study suggests the presence of left digit bias in the decision to perform a craniotomy in patients aged 79 vs 80 with traumatic brain injury.