Surgical stabilization of rib fractures-Does race matter?

BACKGROUND: Advances in medical technology have widened the gaps and exposed disparities in medical treatments. The prevalence of surgical stabilization for rib fractures is rising despite its controversial indications for this treatment modality. In situations of equipoise, surgeons may find themselves choosing patients for surgery, revealing potential implicit biases. We hypothesize that there exists an inequity in surgical stabilization for rib fractures performed based on race. METHODS: Data were obtained from the American College of Surgeons 2013-2021 Trauma Quality Improvement Program database. Study participants were divided into race groups according to Trauma Quality Improvement Program data registry. To assess the association between race and surgical stabilization for rib fractures, a Poisson regression model was used. Potential confounding adjusted include race, age, sex, highest abbreviated injury severity score in each region, flail chest, sternum fracture, pneumothorax, hemothorax, pulmonary contusion, and comorbidities. RESULT: Black patients were more often treated at a level 1 trauma center (74%) (P < .001). Flail chest was most common in White (3.2%) and American Indian (3.4%) patients compared with other races (P = .012). After adjusting for potential confounding in the Poisson regression analyses, Black patients were 26% less likely to undergo surgical stabilization for rib fractures (adjusted incident rate ratio [95% confidence interval]: 0.74 [0.64-0.85], P < .001) and Asian were 40% less likely to undergo surgical stabilization for rib fractures (adjusted incident rate ratio [95% confidence interval]: 0.60 [0.43-0.81], P = .001) than White patients. CONCLUSION: There is a disparity in the delivery of surgical stabilization for rib fractures in patients with rib fractures. Black and Asian patients undergo surgical stabilization for rib fractures at a significantly lower rate than their White counterparts. This discrepancy in the delivery of care is concerning and requires further study.

Hybrid 1 randomized controlled trial of an integrated stepped-care mental health intervention for traumatic injury patients.

BACKGROUND: Annually, nearly 3 million individuals in the US are hospitalized after experiencing a traumatic injury (e.g., serious automobile crash, gunshot wound, stab injury). Many traumatically injured patients experience a trajectory of resilience. However, 20-40 % develop mental health problems such as posttraumatic stress disorder and depression; population estimates exceed 600,000 patients annually. Most trauma centers do not provide direct services to address mental health recovery, but the 2022 American College of Surgeons guidelines have established this as a priority. Cost-effective interventions are needed that meet the needs of patients at each stage of the recovery process while achieving sustainability at the level of implementation. This protocol paper describes a study that rigorously tests the Trauma Resilience and Recovery Program (TRRP), a scalable, sustainable technology-enhanced intervention to support the mental health recovery of patients who have experienced a traumatic injury. METHODS: We describe a randomized controlled trial with 1-year follow up of TRRP vs. enhanced usual care with 350 traumatically injured patients, including recruitment and retention procedures, assessment, implementation and fidelity monitoring, and statistical plans. CONCLUSION: Novel components of our design include integration of technology-based elements, use of a stepped-care model, and implementation in a trauma center that did not previously have a mental health program. Data collected address the impact of TRRP and inform improvements to the model and its implementation in preparation for large-scale testing and implementation initiatives. This body of work is critical to informing the field as it continues to move toward national standards and recommendations. TRIAL REGISTRATION: NCT05497115Clinicaltrials.gov.

Time to surgical stabilization of rib fractures: does it impact outcomes?

Objectives: Rib fractures are common, morbid, and potentially lethal. Intuitively, if interventions to mitigate downstream effects of rib fractures can be implemented early, likelihood of developing these complications should be reduced. Surgical stabilization of rib fractures (SSRF) is one therapeutic intervention shown to be useful for mitigating complications of these common fractures. Our aim was to investigate for association between time to SSRF and complications among patients with isolated rib fractures undergoing SSRF. Methods: The 2016-2019 American College of Surgeons Trauma Quality Improvement Program (TQIP) database was queried to identify patient >18 years with isolated thoracic injury undergoing SSRF. Patients were divided into three groups: SSRF ≤2 days, SSRF >2 days but <3 days, and SSRF >3 days. Poisson regression, and adjusting for demographic and clinical covariates, was used to evaluate the association between time to SSRF and the primary endpoint, in-hospital complications. Quantile regression was used to evaluate the effects of time to SSRF on the secondary endpoints, hospital and intensive care unit (ICU) length of stay (LOS). Results: Out of 2185 patients, 918 (42%) underwent SSRF <2 days, 432 (20%) underwent SSRF >2 days but <3 days, and 835 (38%) underwent SSRF >3 days. Hemothorax was more common among patients undergoing SSRF >3 days, otherwise all demographic and clinical variables were similar between groups. After adjusting for potential confounding, SSRF >3 days was associated with a threefold risk of composite in-hospital complications (adjusted incidence rate ratio: 3.15, 95% CI 1.76 to 5.62; p<0.001), a 4-day increase in total hospital LOS (change in median LOS: 4.09; 95% CI 3.69 to 4.49, p<0.001), and a nearly 2-day increase in median ICU LOS (change in median LOS: 1.70; 95% CI 1.32 to 2.08, p<0.001), compared with SSRF ≤2 days. Conclusion: Among patients undergoing SSRF in TQIP, earlier SSRF is associated with less in-hospital complications and shorter hospital stays. Standardization of time to SSRF as a trauma quality metric should be considered. Level of evidence: Level II, retrospective.

Orthopedic Frailty Score and adverse outcomes in patients with surgically managed isolated traumatic spinal injury.

Background: With an aging global population, the prevalence of frailty in patients with traumatic spinal injury (TSI) is steadily increasing. The aim of the current study is to evaluate the utility of the Orthopedic Frailty Score (OFS) in assessing the risk of adverse outcomes in patients with isolated TSI requiring surgery, with the hypothesis that frailer patients suffer from a disproportionately increased risk of these outcomes. Methods: The Trauma Quality Improvement Program database was queried for all adult patients (18 years or older) who suffered an isolated TSI due to blunt force trauma, between 2013 and 2019, and underwent spine surgery. Patients were categorized as non-frail (OFS 0), pre-frail (OFS 1), or frail (OFS ≥2). The association between the OFS and in-hospital mortality, complications, and failure to rescue (FTR) was determined using Poisson regression models, adjusted for potential confounding. Results: A total of 43 768 patients were included in the current investigation. After adjusting for confounding, frailty was associated with a more than doubling in the risk of in-hospital mortality (adjusted incidence rate ratio (IRR) (95% CI): 2.53 (2.04 to 3.12), p<0.001), a 25% higher overall risk of complications (adjusted IRR (95% CI): 1.25 (1.02 to 1.54), p=0.032), a doubling in the risk of FTR (adjusted IRR (95% CI): 2.00 (1.39 to 2.90), p<0.001), and a 10% increase in the risk of intensive care unit admission (adjusted IRR (95% CI): 1.10 (1.04 to 1.15), p=0.004), compared with non-frail patients. Conclusion: The findings indicate that the OFS could be an effective method for identifying frail patients with TSIs who are at a disproportionate risk of adverse events. Level of evidence: Level III.

Timing to surgery in elderly patients with small bowel obstruction: An insight on frailty.

BACKGROUND: Small bowel obstruction (SBO) frequently necessitates emergency surgical intervention. The impact of frailty and age on operative outcomes is uncertain. This study evaluated postoperative outcomes of SBO surgery based on patient's age and frailty and explore the optimal timing to operation in elderly and/or frail patients. METHODS: Patients who underwent SBO surgery were identified in American College of Surgeons National Surgical Quality Improvement Program database 2005 to 2021. Patients aged ≥65 years were defined as elderly. Patients with 5-Factor Modified Frailty Index≥2 were defined as frail. Multivariable logistic regression was used to compare 30-day postoperative outcomes between elderly frail versus nonfrail patients, as well as between nonfrail young versus elderly patients. RESULTS: There were 49,344 patients who had SBO surgery, with 7,089 (14.37%) patients classified as elderly frail, 17,821 (36.12%) as elderly nonfrail, and 21,849 (44.28%) as young nonfrail. Elderly frail patients had higher mortality (adjusted odds ratio, 1.541; p < 0.01) and postoperative complications compared with their elderly nonfrail counterparts; these patients also had longer wait until definitive operation ( p < 0.01). Among nonfrail patients, when compared with young patients, the elderly had higher mortality (adjusted odds ratio, 2.388; p < 0.01) and complications, and longer time to operation ( p < 0.01). In elderly nonfrail patients, a higher mortality was observed when surgery was postponed after 2 days. Mortality risk for frail elderly patients is heightened from their already higher baseline when surgery is delayed after 4 days. CONCLUSION: When SBO surgery is postponed for more than 2 days, elderly nonfrail patients have an increased mortality risk. Consequently, upon admission, these patients should be placed under a nasogastric tube and undergo an initial gastrograffin challenge. If there is no contrast in colon, they should be operated on within 2 days. Conversely, elderly frail patients with SBO have a higher mortality risk when surgery is delayed beyond 4 days. Thus, following the same scheme, they should be operated on before 4 days if gastrograffin challenge fails. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Comparison of law enforcement officer- versus emergency medical services-placed tourniquets.

INTRODUCTION: Tourniquet use for hemorrhage control is a core skill for many law enforcement officers (LEOs) and all emergency medical services (EMS) providers. However, LEO tourniquet training is not as intensive as EMS. Overuse of tourniquet can result in overtriage. We hypothesize that LEOs are more liberal than EMS with tourniquet placement. METHODS: A 7-year retrospective, single-center study of adult patients who had a tourniquet placed in the field was conducted. Data were stratified by provider who placed the tourniquet. Patient demographics, body location where the tourniquet was placed, hospital location where the tourniquet was removed, incidence of recurrent bleeding and need for operative control of bleeding, and name of injured vessel were recorded. Data were analyzed using Student's t and χ 2 tests. RESULTS: A total of 192 patients had 197 tourniquets placed (LEO, 77 [40%]; EMS, 120 [63%]). Most tourniquets were placed on the thigh. There was no difference in body mass index, but the EMS cohort had a higher Injury Severity Score (9.4 vs. 6.5, p = 0.03) and extremity Abbreviated Injury Scale severity score (2.4 vs. 1.9, p = 0.007). The LEO-placed tourniquets were more commonly removed in the trauma bay (83% vs. 73%, p = 0.03). The EMS-placed tourniquets were more likely to require operative control of bleeding (23% vs. 6%, p = 0.003). There were no complications related to tourniquet use in either arm. CONCLUSION: Law enforcement officers are more likely than EMS to place tourniquets without injury to a named vessel or the presence of severe bleeding. Law enforcement officers need better training to determine when a tourniquet is needed. Emergency medical services should be allowed to remove tourniquet if appropriate. Studies on the impact of overtriage based on tourniquet use are needed. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Four-factor prothrombin complex concentrate is not inferior to andexanet alfa for the reversal or oral factor Xa inhibitors: An Eastern Association for the Surgery of Trauma multicenter study.

BACKGROUND: Andexanet alfa (AA) is the only FDA-approved reversal agent for apixaban and rivaroxaban (DOAC). There are no studies comparing its efficacy with four-factor prothrombin complex concentrate (PCC). This study aimed to compare PCC to AA for DOAC reversal, hypothesizing noninferiority of PCC. METHODS: We performed a retrospective, noninferiority multicenter study of adult patients admitted from July 1, 2018, to December 31, 2019, who had taken a DOAC within 12 hours of injury, were transfused red blood cells (RBCs) or had traumatic brain injury, and received AA or PCC. Primary outcome was PRBC unit transfusion. Secondary outcome with intensive care unit length of stay. MICE imputation was used to account for missing data and zero-inflated Poisson regression was used to account for an excess of zero units of RBC transfused. Two units difference in RBC transfusion was selected as noninferior. RESULTS: Results: From 263 patients at 10 centers, 77 (29%) received PCC and 186 (71%) AA. Patients had similar transfusion rates across reversal treatment groups (23.7% AA vs. 19.5% PCC) with median transfusion in both groups of 0 RBC. According to the Poisson component, PCC increases the amount of RBC transfusion by 1.02 times (95% confidence interval, 0.79-1.33) compared with AA after adjusting for other covariates. The average amount of RBC transfusion (nonzero group) is 6.13. Multiplying this number by the estimated rate ratio, PCC is estimated to have an increase RBC transfusion by 0.123 (95% confidence interval, 0.53-2.02) units compared with AA. CONCLUSION: PCC appears noninferior to AA for reversal of DOACs for RBC transfusion in traumatically injured patients. Additional prospective, randomized trials are necessary to compare PCC and AA for the treatment of hemorrhage in injured patients on DOACs. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Contemporary management of patients with multiple rib fractures: What you need to know.

ABSTRACT: Ten percent of all injured patients and 55% of patients with blunt chest trauma experience rib fractures. The incidence of death due to rib fractures is related to the number of fractured ribs, severity of fractured ribs, and patient age and comorbid conditions. Death due to rib fracture is mostly caused by pneumonia because of inability to expectorate and take deep breaths. Over the last 25 to 30 years, there has been renewed interest in surgical stabilization of rib fractures (SSRF), known colloquially as "rib plating." This review will present what you need to know in regard to triage decisions on whether to admit a patient to the hospital, the location to which they should be admitted, criteria and evidentiary support for SSRF, timing to SSRF, and operative technique. The review also addresses the cost-effectiveness of this operation and stresses nonoperative treatment modalities that should be implemented prior to operation.

Prioritizing patients for hip fracture surgery: the role of frailty and cardiac risk.

Introduction: The number of patients with hip fractures continues to rise as the average age of the population increases. Optimizing outcomes in this cohort is predicated on timely operative repair. The aim of this study was to determine if patients with hip fractures who are frail or have a higher cardiac risk suffer from an increased risk of in-hospital mortality when surgery is postponed >24 h. Methods: All patients registered in the 2013-2021 TQIP dataset who were ≥65 years old and underwent surgical fixation of an isolated hip fracture caused by a ground-level fall were included. Adjustment for confounding was performed using inverse probability weighting (IPW) while stratifying for frailty with the Orthopedic Frailty Score (OFS) and cardiac risk using the Revised Cardiac Risk Index (RCRI). The outcome was presented as the absolute risk difference in in-hospital mortality. Results: A total of 254,400 patients were included. After IPW, all confounders were balanced. A delay in surgery was associated with an increased risk of in-hospital mortality across all strata, and, as the degree of frailty and cardiac risk increased, so too did the risk of mortality. In patients with OFS ≥4, delaying surgery >24 h was associated with a 2.33 percentage point increase in the absolute mortality rate (95% CI: 0.57-4.09, p = 0.010), resulting in a number needed to harm (NNH) of 43. Furthermore, the absolute risk of mortality increased by 4.65 percentage points in patients with RCRI ≥4 who had their surgery delayed >24 h (95% CI: 0.90-8.40, p = 0.015), resulting in a NNH of 22. For patients with OFS 0 and RCRI 0, the corresponding NNHs when delaying surgery >24 h were 345 and 333, respectively. Conclusion: Delaying surgery beyond 24 h from admission increases the risk of mortality for all geriatric hip fracture patients. The magnitude of the negative impact increases with the patient's level of cardiac risk and frailty. Operative intervention should not be delayed based on frailty or cardiac risk.

Investigating the link between frailty and outcomes in geriatric patients with isolated rib fractures.

Background: Studies have shown an increased risk of morbidity in elderly patients suffering rib fractures from blunt trauma. The association between frailty and rib fractures on adverse outcomes is still ill-defined. In the current investigation, we sought to delineate the association between frailty, measured using the Orthopedic Frailty Score (OFS), and outcomes in geriatric patients with isolated rib fractures. Methods: All geriatric (aged 65 years or older) patients registered in the 2013-2019 Trauma Quality Improvement database with a conservatively managed isolated rib fracture were considered for inclusion. An isolated rib fracture was defined as the presence of ≥1 rib fracture, a thorax Abbreviated Injury Scale (AIS) between 1 and 5, an AIS ≤1 in all other regions, as well as the absence of pneumothorax, hemothorax, or pulmonary contusion. Based on patients' OFS, patients were classified as non-frail (OFS 0), pre-frail (OFS 1), or frail (OFS ≥2). The prevalence ratio (PR) of composite complications, in-hospital mortality, failure-to-rescue (FTR), and intensive care unit (ICU) admission between the OFS groups was determined using Poisson regression models to adjust for potential confounding. Results: A total of 65 375 patients met the study's inclusion criteria of whom 60% were non-frail, 29% were pre-frail, and 11% were frail. There was a stepwise increased risk of complications, in-hospital mortality, and FTR from non-frail to pre-frail and frail. Compared with non-frail patients, frail patients exhibited a 87% increased risk of in-hospital mortality [adjusted PR (95% CI): 1.87 (1.52-2.31), p<0.001], a 44% increased risk of complications [adjusted PR (95% CI): 1.44 (1.23-1.67), p<0.001], a doubling in the risk of FTR [adjusted PR (95% CI): 2.08 (1.45-2.98), p<0.001], and a 17% increased risk of ICU admission [adjusted PR (95% CI): 1.17 (1.11-1.23), p<0.001]. Conclusion: There is a strong association between frailty, measured using the OFS, and adverse outcomes in geriatric patients managed conservatively for rib fractures.

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.

Contemporary management and outcomes of blunt traumatic American Association for the Surgery of Trauma Organ Injury Scale grades III and IV pancreatic injuries in children: A Trauma Quality Improvement Program analysis.

BACKGROUND: The Trauma Quality Improvement Program (TQIP) database has delineated management strategies and outcomes for adults with American Association for the Surgery of Trauma Organ Injury Scale grades III and IV pancreatic injuries and suggests that nonoperative management (NOM) is a viable option for these injuries. However, management strategies vary for children following significant pancreatic injuries and outcomes for these intermediate/high-grade injuries have not been sufficiently studied. Our aim was to describe the management and outcomes for grades III and IV pancreatic injuries using TQIP. We hypothesize that pediatric patients with intermediate/high-grade injuries can be safely managed with NOM. METHODS: All pediatric patients (younger than 18 years) registered in TQIP between 2013 and 2021 who suffered a grade III or IV pancreatic injury due to blunt trauma were included in the current study. Patient demographics, clinical characteristics, complications, and in-hospital mortality were compared between the different treatment strategies for pancreatic injury: NOM versus drainage and/or pancreatic resection. RESULTS: A total of 580 patients meeting the inclusion criteria were identified. A total of 416 pediatric patients suffered a grade III pancreatic injury; 79% (n = 332) were NOM, 7% (n = 27) received a drain, and 14% (n = 57) underwent a pancreatic resection. A further 164 patients suffered a grade IV pancreatic injury; 77% (n = 126) were NOM, 11% (n = 18) received a drain, and 12% (n = 20) underwent a pancreatic resection. No differences in overall injury severity or demographical data were observed between the treatment groups. No difference in in-hospital mortality was detected between the different management strategies. Patients who received a drain had a longer hospital length of stay. CONCLUSION: The majority of children with American Association for the Surgery of Trauma Organ Injury Scale grades III and IV pancreatic injuries are managed nonoperatively. Nonoperative management is a reasonable strategy for these injuries and results in equivalent in-hospital adverse outcome profiles as pancreatic drainage or resection with a shorter hospital length of stay. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Traumatic injury of an ectopic kidney with iatrogenic ureteral injury and endovascular control of aberrant renal vessel.

The management of traumatic injuries in patients with ectopic kidneys presents special challenges. There is a paucity of literature regarding optimal strategies for renal salvage. We describe a case of a patient who presented in hemorrhagic shock after a motor vehicle collision. On initial operative exploration, he was found to have a large retroperitoneal mass. Subsequent imaging demonstrated a large retroperitoneal hematoma and an ectopic kidney. The patient was successfully treated with a combination of open renorrhaphy and endovascular angioembolization. This case demonstrates the importance of a multidisciplinary approach to treating these complex injuries.

An initiative to assess and improve the resources and patient care processes used among Chest Wall Injury Society collaborative centers study (CWIS-CC2).

BACKGROUND: Over the last two decades, the acute management of rib fractures has changed significantly. In 2021, the Chest Wall injury Society (CWIS) began recognizing centers that epitomize their mission as CWIS Collaborative Centers. The primary aim of this study was to determine the resources, surgical expertise, access to care, and institutional support that are present among centers. METHODS: A survey was performed including all CWIS Collaborative Centers evaluating the resources available at their hospital for the treatment of patients with chest wall injury. Data about each chest wall injury center care process, availability of resources, institutional support, research support, and educational offerings were recorded. RESULTS: Data were collected from 20 trauma centers resulting in an 80% response rate. These trauma centers were made up of 5 international and 15 US-based trauma centers. Eighty percent (16 of 20) have dedicated care team members for the evaluation and management of rib fractures. Twenty-five percent (5 of 20) have a dedicated rib fracture service with a separate call schedule. Staffing for chest wall injury clinics consists of a multidisciplinary team: with attending surgeons in all clinics, 80% (8 of 10) with advanced practice providers and 70% (7 of 10) with care coordinators. Forty percent (8 of 20) of centers have dedicated rib fracture research support, and 35% (7 of 20) have surgical stabilization of rib fracture (SSRF)-related grants. Forty percent (8 of 20) of centers have marketing support, and 30% (8 of 20) have a web page support to bring awareness to their center. At these trauma centers, a median of 4 (1-9) surgeons perform SSRFs. In the majority of trauma centers, the trauma surgeons perform SSRF. CONCLUSION: Considerable similarities and differences exist within these CWIS collaborative centers. These differences in resources are hypothesis generating in determining the optimal chest wall injury center. These findings may generate several patient care and team process questions to optimize patient care, patient experience, provider satisfaction, research productivity, education, and outreach. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

Sex disparities in adverse outcomes after surgically managed isolated traumatic spinal injury.

BACKGROUND: Traumatic spinal injury (TSI) encompasses a wide range of injuries affecting the spinal cord, nerve roots, bones, and soft tissues that result in pain, impaired mobility, paralysis, and death. There is some evidence suggesting that women may have different physiological responses to traumatic injury compared to men; therefore, this study aimed to investigate if there are any associations between sex and adverse outcomes following surgically managed isolated TSI. METHODS: Using the 2013-2019 TQIP database, all adult patients with isolated TSI, defined as a spine AIS ≥ 2 with an AIS ≤ 1 in all other body regions, resulting from blunt force trauma requiring spinal surgery, were eligible for inclusion in the study. The association between the sex and in-hospital mortality as well as cardiopulmonary and venothromboembolic complications was determined by calculating the risk ratio (RR) after adjusting for potential confounding using inverse probability weighting. RESULTS: A total of 43,756 patients were included. After adjusting for potential confounders, female sex was associated with a 37% lower risk of in-hospital mortality [adjusted RR (95% CI): 0.63 (0.57-0.69), p < 0.001], a 27% lower risk of myocardial infarction [adjusted RR (95% CI): 0.73 (0.56-0.95), p = 0.021], a 37% lower risk of cardiac arrest [adjusted RR (95% CI): 0.63 (0.55-0.72), p < 0.001], a 34% lower risk of deep vein thrombosis [adjusted RR (95% CI): 0.66 (0.59-0.74), p < 0.001], a 45% lower risk of pulmonary embolism [adjusted RR (95% CI): 0.55 (0.46-0.65), p < 0.001], a 36% lower risk of acute respiratory distress syndrome [adjusted RR (95% CI): 0.64 (0.54-0.76), p < 0.001], a 34% lower risk of pneumonia [adjusted RR (95% CI): 0.66 (0.60-0.72), p < 0.001], and a 22% lower risk of surgical site infection [adjusted RR (95% CI): 0.78 (0.62-0.98), p < 0.032], compared to male sex. CONCLUSION: Female sex is associated with a significantly decreased risk of in-hospital mortality as well as cardiopulmonary and venothromboembolic complications following surgical management of traumatic spinal injuries. Further studies are needed to elucidate the cause of these differences.

0.05% Chlorhexidine Gluconate Irrigation in Trauma/Emergency General Surgical Laparotomy Wounds Closure: A Pilot Study.

INTRODUCTION: Patients who undergo exploratory laparotomy (EL) in an emergent setting are at higher risk for surgical site infections (SSIs) compared to the elective setting. Packaged Food and Drug Administration-approved 0.05% chlorhexidine gluconate (CHG) irrigation solution reduces SSI rates in nonemergency settings. We hypothesize that the use of 0.05% CHG irrigation solution prior to closure of emergent EL incisions will be associated with lower rates of superficial SSI and allows for increased rates of primary skin closure. METHODS: A retrospective observational study of all emergent EL whose subcutaneous tissue were irrigated with 0.05% CHG solution to achieve primary wound closure from March 2021 to June 2022 were performed. Patients with active soft-tissue infection of the abdominal wall were excluded. Our primary outcome is rate of primary skin closure following laparotomy. Descriptive statistics, including t-test and chi-square test, were used to compare groups as appropriate. A P value <0.05 was statistically significant. RESULTS: Sixty-six patients with a median age of 51 y (18-92 y) underwent emergent EL. Primary wound closure is achieved in 98.5% of patients (65/66). Bedside removal of some staples and conversion to wet-to-dry packing changes was required in 27.3% of patients (18/66). We found that most of these were due to fat necrosis. We report no cases of fascial dehiscence. CONCLUSIONS: In patients undergoing EL, intraoperative irrigation of the subcutaneous tissue with 0.05% CHG solution is a viable option for primary skin closure. Further studies are needed to prospectively evaluate our findings.

Predictors of outcomes in geriatric patients with moderate traumatic brain injury after ground level falls.

Introduction: The elderly population constitutes one of the fastest-growing demographic groups globally. Within this population, mild to moderate traumatic brain injuries (TBI) resulting from ground level falls (GLFs) are prevalent and pose significant challenges. Between 50 and 80% of TBIs in older individuals are due to GLFs. These incidents result in more severe outcomes and extended recovery periods for the elderly, even when controlling for injury severity. Given the increasing incidence of such injuries it becomes essential to identify the key factors that predict complications and in-hospital mortality. Therefore, the aim of this study was to pinpoint the top predictors of complications and in-hospital mortality in geriatric patients who have experienced a moderate TBI following a GLF. Methods: Data were obtained from the American College of Surgeons' Trauma Quality Improvement Program database. A moderate TBI was defined as a head AIS ≤ 3 with a Glasgow Coma Scale (GCS) 9-13, and an AIS ≤ 2 in all other body regions. Potential predictors of complications and in-hospital mortality were included in a logistic regression model and ranked using the permutation importance method. Results: A total of 7,489 patients with a moderate TBI were included in the final analyses. 6.5% suffered a complication and 6.2% died prior to discharge. The top five predictors of complications were the need for neurosurgical intervention, the Revised Cardiac Risk Index, coagulopathy, the spine abbreviated injury severity scale (AIS), and the injury severity score. The top five predictors of mortality were head AIS, age, GCS on admission, the need for neurosurgical intervention, and chronic obstructive pulmonary disease. Conclusion: When predicting both complications and in-hospital mortality in geriatric patients who have suffered a moderate traumatic brain injury after a ground level fall, the most important factors to consider are the need for neurosurgical intervention, cardiac risk, and measures of injury severity. This may allow for better identification of at-risk patients, and at the same time resulting in a more equitable allocation of resources.

Firearms-related injury and sex: a comparative National Trauma Database (NTDB) Study.

Background: Existing study findings on firearms-related injury patterns are largely skewed towards males, who comprise the majority of this injury population. Given the paucity of existing data for females with these injuries, we aimed to elucidate the demographics, injury patterns, and outcomes of firearms-related injury in females compared with males in the USA. Materials and methods: A 7-year (2013-2019) retrospective review of the National Trauma Database was conducted to identify all adult patients who suffered firearms-related injuries. Patients who were males were matched (1:1, caliper 0.2) to patients who were females by demographics, comorbidities, injury patterns and severity, and payment method, to compare differences in mortality and several other post-injury outcomes. Results: There were 196 696 patients admitted after firearms-related injury during the study period. Of these patients, 23 379 (11.9%) were females, 23 378 of whom were successfully matched to a male counterpart. After matching, females had a lower rate of in-hospital mortality (18.6% vs. 20.0%, p<0.001), deep vein thrombosis (1.2% vs. 1.5%, p=0.014), and had a lower incidence of drug or alcohol withdrawal syndrome (0.2% vs. 0.5%, p<0.001) compared with males. Conclusion: Female victims of firearms-related injuries experience lower rates of mortality and complications compared with males. Further studies are needed to elucidate the cause of these differences. Level of evidence: Level III.

Development and Validation of an XGBoost-Algorithm-Powered Survival Model for Predicting In-Hospital Mortality Based on 545,388 Isolated Severe Traumatic Brain Injury Patients from the TQIP Database.

BACKGROUND: Traumatic brain injury (TBI) represents a significant global health issue; the traditional tools such as the Glasgow Coma Scale (GCS) and Abbreviated Injury Scale (AIS) which have been used for injury severity grading, struggle to capture outcomes after TBI. AIM AND METHODS: This paper aims to implement extreme gradient boosting (XGBoost), a powerful machine learning algorithm that combines the predictions of multiple weak models to create a strong predictive model with high accuracy and efficiency, in order to develop and validate a predictive model for in-hospital mortality in patients with isolated severe traumatic brain injury and to identify the most influential predictors. In total, 545,388 patients from the 2013-2021 American College of Surgeons Trauma Quality Improvement Program (TQIP) database were included in the current study, with 80% of the patients used for model training and 20% of the patients for the final model test. The primary outcome of the study was in-hospital mortality. Predictors were patients' demographics, admission status, as well as comorbidities, and clinical characteristics. Penalized Cox regression models were used to investigate the associations between the survival outcomes and the predictors and select the best predictors. An extreme gradient boosting (XGBoost)-powered Cox regression model was then used to predict the survival outcome. The performance of the models was evaluated using the Harrell's concordance index (C-index). The time-dependent area under the receiver operating characteristic curve (AUC) was used to evaluate the dynamic cumulative performance of the models. The importance of the predictors in the final prediction model was evaluated using the Shapley additive explanations (SHAP) value. RESULTS: On average, the final XGBoost-powered Cox regression model performed at an acceptable level for patients with a length of stay up to 250 days (mean time-dependent AUC = 0.713) in the test dataset. However, for patients with a length of stay between 20 and 213 days, the performance of the model was relatively poor (time-dependent AUC < 0.7). When limited to patients with a length of stay ≤20 days, which accounts for 95.4% of all the patients, the model achieved an excellent performance (mean time-dependent AUC = 0.813). When further limited to patients with a length of stay ≤5 days, which accounts for two-thirds of all the patients, the model achieved an outstanding performance (mean time-dependent AUC = 0.917). CONCLUSION: The XGBoost-powered Cox regression model can achieve an outstanding predictive ability for in-hospital mortality during the first 5 days, primarily based on the severity of the injury, the GCS on admission, and the patient's age. These variables continue to demonstrate an excellent predictive ability up to 20 days after admission, a period of care that accounts for over 95% of severe TBI patients. Past 20 days of care, other factors appear to be the primary drivers of in-hospital mortality, indicating a potential window of opportunity for improving outcomes.