Outcomes of severely injured pregnant trauma patients: a multicenter analysis.

Nearly 10% of pregnant women suffer traumatic injury. Clinical outcomes for pregnant trauma patients (PTPs) with severe injuries have not been well studied. We sought to describe outcomes for PTPs presenting with severe injuries, hypothesizing that PTPs with severe injuries will have higher rates of complications and mortality compared to less injured PTPs. A post-hoc analysis of a multi-institutional retrospective study at 12 Level-I/II trauma centers was performed. Patients were stratified into severely injured (injury severity score [ISS] > 15) and not severely injured (ISS < 15) and compared with bivariate analyses. From 950 patients, 32 (3.4%) had severe injuries. Compared to non-severely injured PTPs, severely injured PTPs were of similar maternal age but had younger gestational age (21 vs 26 weeks, p = 0.009). Penetrating trauma was more common in the severely injured cohort (15.6% vs 1.4%, p < 0.001). The severely injured cohort more often underwent an operation (68.8% vs 3.8%, p < 0.001), including a hysterectomy (6.3% vs 0.3%, p < 0.001). The severely injured group had higher rates of complications (34.4% vs 0.9%, p < 0.001), mortality (15.6% vs 0.1%, p < 0.001), a higher rate of fetal delivery (37.5% vs. 6.0%, p < 0.001) and resuscitative hysterotomy (9.4% vs. 0%, p < 0.001). Only approximately 3% of PTPs were severely injured. However, severely injured PTPs had a nearly 40% rate of fetal delivery as well as increased complications and mortality. This included a resuscitative hysterotomy rate of nearly 10%. Significant vigilance must remain when caring for this population.

Predictors of fetal delivery in pregnant trauma patients: A multicenter study.

BACKGROUND: Pregnant trauma patients (PTPs) undergo observation and fetal monitoring following trauma due to possible fetal delivery (FD) or adverse outcome. There is a paucity of data on PTP outcomes, especially related to risk factors for FD. We aimed to identify predictors of posttraumatic FD in potentially viable pregnancies. METHODS: All PTPs (≥18 years) with ≥24-weeks gestational age were included in this multicenter retrospective study at 12 Level-I and II trauma centers between 2016 and 2021. Pregnant trauma patients who underwent FD ((+) FD) were compared to those who did not deliver ((-) FD) during the index hospitalization. Univariate analyses and multivariable logistic regression were performed to identify predictors of FD. RESULTS: Of 591 PTPs, 63 (10.7%) underwent FD, with 4 (6.3%) maternal deaths. The (+) FD group was similar in maternal age (27 vs. 28 years, p = 0.310) but had older gestational age (37 vs. 30 weeks, p < 0.001) and higher mean injury severity score (7.0 vs. 1.5, p < 0.001) compared with the (-) FD group. The (+) FD group had higher rates of vaginal bleeding (6.3% vs. 1.1%, p = 0.002), uterine contractions (46% vs. 23.5%, p < 0.001), and abnormal fetal heart tracing (54.7% vs. 14.6%, p < 0.001). On multivariate analysis, independent predictors for (+) FD included abdominal injury (odds ratio [OR], 4.07; confidence interval [CI], 1.11-15.02; p = 0.035), gestational age (OR, 1.68 per week ≥24 weeks; CI, 1.44-1.95; p < 0.001), abnormal FHT (OR, 12.72; CI, 5.19-31.17; p < 0.001), and premature rupture of membranes (OR, 35.97; CI, 7.28-177.74; p < 0.001). CONCLUSION: The FD rate was approximately 10% for PTPs with viable fetal gestational age. Independent risk factors for (+) FD included maternal and fetal factors, many of which are available on initial trauma bay evaluation. These risk factors may help predict FD in the trauma setting and shape future guidelines regarding the recommended observation of PTPs. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Significant variation in computed tomography imaging of pregnant trauma patients: a retrospective multicenter study.

PURPOSE: Following motor vehicle collisions (MVCs), patients often undergo extensive computed tomography (CT) imaging. However, pregnant trauma patients (PTPs) represent a unique population where the risk of fetal radiation may supersede the benefits of liberal CT imaging. This study sought to evaluate imaging practices for PTPs, hypothesizing variability in CT imaging among trauma centers. If demonstrated, this might suggest the need to develop specific guidelines to standardize practice. METHODS: A multicenter retrospective study (2016-2021) was performed at 12 Level-I/II trauma centers. Adult (≥18 years old) PTPs involved in MVCs were included, with no patients excluded. The primary outcome was the frequency of CT. Chi-square tests were used to compare categorical variables, and ANOVA was used to compare the means of normally distributed continuous variables. RESULTS: A total of 729 PTPs sustained MVCs (73% at high speed of ≥ 25 miles per hour). Most patients were mildly injured but a small variation of injury severity score (range 1.1-4.6, p < 0.001) among centers was observed. There was a variation of imaging rates for CT head (range 11.8-62.5%, p < 0.001), cervical spine (11.8-75%, p < 0.001), chest (4.4-50.2%, p < 0.001), and abdomen/pelvis (0-57.3%, p < 0.001). In high-speed MVCs, there was variation for CT head (12.5-64.3%, p < 0.001), cervical spine (16.7-75%, p < 0.001), chest (5.9-83.3%, p < 0.001), and abdomen/pelvis (0-60%, p < 0.001). There was no difference in mortality (0-2.9%, p =0.19). CONCLUSION: Significant variability of CT imaging in PTPs after MVCs was demonstrated across 12 trauma centers, supporting the need for standardization of CT imaging for PTPs to reduce unnecessary radiation exposure while ensuring optimal injury identification is achieved.

The Effect of 2019 Coronavirus Stay-at-Home Order on Geriatric Trauma Patients in Southern California.

BACKGROUND: California issued stay-at-home (SAH) orders to mitigate COVID-19 spread. Previous studies demonstrated a shift in mechanisms of injuries (MOIs) and decreased length of stay (LOS) for the general trauma population after SAH orders. This study aimed to evaluate the effects of SAH orders on geriatric trauma patients (GTPs), hypothesizing decreased motor vehicle collisions (MVCs) and LOS. METHODS: A post-hoc analysis of GTPs (≥65 years old) from 11 level-I/II trauma centers was performed, stratifying patients into 3 groups: before SAH (1/1/2020-3/18/2020) (PRE), after SAH (3/19/2020-6/30/2020) (POST), and a historical control (3/19/2019-6/30/2019) (CONTROL). Bivariate comparisons were performed. RESULTS: 5486 GTPs were included (PRE-1756; POST-1706; CONTROL-2024). POST had a decreased rate of MVCs (7.6% vs 10.6%, P = .001; vs 11.9%, P < .001) and pedestrian struck (3.4% vs 5.8%, P = .001; vs 5.2%, P = .006) compared with PRE and CONTROL. Other mechanisms of injury, LOS, mortality, and operations performed were similar between cohorts. However, POST had a lower rate of discharge to skilled nursing facility (SNF) (20% vs 24.5%, P = .001; and 20% vs 24.4%, P = .001). CONCLUSION: This retrospective multicenter study demonstrated lower rates of MVCs and pedestrian struck for GTPs, which may be explained by decreased population movement as a result of SAH orders. Contrary to previous studies on the generalized adult population, no differences in other MOIs and LOS were observed after SAH orders. However, there was a lower rate of discharge to SNF, which may be related to a lack of resources due to the COVID-19 pandemic, and thus potentially negatively impacted recovery of GTPs.Keywords.

Outcomes for advanced aged (35 and older) versus younger aged pregnant trauma patients: A multicenter study.

BACKGROUND: Effects of advanced maternal age (AMA) pregnancies (defined as ≥35 years) on pregnant trauma patients (PTPs) are unknown. This study compared AMA versus younger PTPs, hypothesizing AMA PTPs have increased risk of fetal delivery (FD). METHODS: A retrospective (2016-2021) multicenter study included all PTPs. Multivariable logistic regression was used to evaluate risk of FD after trauma. RESULTS: A total of 950 PTPs were included. Both cohorts had similar gestational age and injury severity scores. The AMA group had increased injuries to the pancreas, bladder, and stomach (p < 0.05). There was no difference in rate or associated risk of FD between cohorts (5.3% vs. 11.4%; OR 0.59, CI 0.19-1.88, p > 0.05). CONCLUSION: Compared to their younger counterparts, some intra-abdominal injuries (pancreas, bladder, and stomach) were more common among AMA PTPs. However, there was no difference in rate or associated risk of FD in AMA PTPs, thus they do not require increased observation.

Frailty is Not Associated with Worse Outcomes following Lower Extremity Angiograms for Limb Ischemia in Nonagenarians.

BACKGROUND: Endovascular interventions are performed routinely with minimal risk in younger populations. The safety and efficacy of endovascular interventions in nonagenarians is under examined. We sought to examine the following (1) mortality and limb salvage rates in the nonagenarian population and (2) whether frailty was associated with outcomes following lower extremity (LE) interventions for both acute limb ischemia (ALI) and chronic limb threatening ischemia (CLTI). METHODS: A retrospective review of patients ≥90 years who underwent a LE angiogram for ALI or CLTI over a 12-year period at a single institution was performed. Primary outcomes were 30-day and 12-month limb salvage and mortality rates. Patient demographics, 30-day complications, and 12-month target vessel reintervention (TVR) were reviewed. Frailty scores were calculated using the 11-factor modified frailty index (MFI-11). RESULTS: From 2009 to 2021, 76 patients (36% male) with a mean age of 93 (range: 90-102) underwent endovascular procedures for ALI (n = 13) and CLTI (n = 63). 30-day amputation and mortality rates were 6% and 8%, respectively. Patient demographics, preoperative functional status, and TVR rates were not different between patients who had early amputation (≤30 days) and those who achieved limb salvage. Seventy-two patients (94%) had follow-up data at 30 days. There was an 8% mortality rate at 30 days. Of those alive at 30 days, 94% of patients had successful limb salvage. Fifty-eight patients had complete follow-up data at 12 months. Of the patients alive at 12-month follow-up (75%), the limb salvage rate was 98%. Patients with amputation at 30 days had a significantly higher mortality rate at 12 months compared to those who did not (83% vs. 19%; P < 0.01). Based on MFI-11 scoring, 35% of the population was considered frail (≥0.27). Frail patients did not have significantly different 30-day outcomes (limb salvage: 94% vs. 88%; mortality 8% vs. 9%, P = 0.41 and 0.94, respectively) or 12-month outcomes (limb salvage: 82% vs. 94%; mortality: 32% vs. 22%, P = 0.28 and 0.39, respectively). CONCLUSIONS: Endovascular procedures can be done safely in nonagenarians with low mortality and amputation rates. Patients with early amputation are at significantly higher risk of death at 12 months. Frailty, as measured by a validated index, was not associated with early or late outcomes. When compared to immediate amputation, nonagenarian patients and their families should be counseled as to the benefit from a minimally invasive endovascular procedure.

Impact of a pharmacy department-wide transitions-of-care program on inappropriate oral antibiotic prescribing at hospital discharge.

Objective: To evaluate oral antibiotic prescribing for common infections at hospital discharge before and after implementation of a pharmacist-driven transitions-of-care (TOC) program. Design: Single-center before-and-after study. Setting: Acute-care, academic, community hospital in Santa Barbara, California. Patients: Eligible adult patients prescribed oral antibiotics at hospital discharge for community-acquired pneumonia, skin and soft-tissue infections, and urinary tract infections between September 2019 and December 2019 (preimplementation period) and between March 2021 and May 2021 (postimplementation period). Intervention: Antimicrobial stewardship-initiated, department-wide, TOC program requiring all clinical pharmacists to review discharge antibiotic prescriptions in real time. Results: In total, 260 antibiotic prescriptions were assessed for appropriateness: 140 before implementation and 120 after implementation. After implementation, the number of prescriptions considered inappropriate significantly decreased by 18% (52% vs 34%; P = .005). Inappropriate rates decreased in all assessment categories: dosing (15% vs 2%; P < .001), treatment duration (42% vs 31%; P = .08), antibiotic selection based on infection type or microbiology (8% vs 4%; P = .33), and antibiotics not indicated (16% vs 10%; P = .18). Median total antibiotic days decreased by 1 day after implementation (10 days vs 9 days; P = .67), and 30-day readmission rates were similar between both phases. Conclusions: A real-time, pharmacist-driven, TOC program for oral antibiotic prescriptions had a significant impact in reducing inappropriate prescribing of antibiotics at hospital discharge for common infections. Incorporating discharge antibiotic prescription review into pharmacist daily workflow may be a sustainable approach to outpatient antimicrobial stewardship in a setting with limited resources.

Adolescent Trauma During the COVID Pandemic: Just Like Adults, Children, or Someone Else?

COVID-19 stay-at-home (SAH) orders were impactful on adolescence, when social interactions affect development. This has the potential to change adolescent trauma. A post-hoc multicenter retrospective analysis of adolescent (13-17 years-old) trauma patients (ATPs) at 11 trauma centers was performed. Patients were divided into 3 groups based on injury date: historical control (CONTROL:3/19/2019-6/30/2019, before SAH (PRE:1/1/2020-3/18/2020), and after SAH (POST:3/19/2020-6/30/2020). The POST group was compared to both PRE and CONTROL groups in separate analyses. 726 ATPs were identified across the 3 time periods. POST had a similar penetrating trauma rate compared to both PRE (15.8% vs 13.8%, P = .56) and CONTROL (15.8% vs 14.5%, P = .69). POST also had a similar rate of suicide attempts compared to both PRE (1.2% vs 1.5%, P = .83) and CONTROL (1.2% vs 2.1%, P = .43). However, POST had a higher rate of drug positivity compared to CONTROL (28.6% vs 20.6%, P = .032), but was similar in all other comparisons of alcohol and drugs to PRE and POST periods (all P > .05). Hence ATPs were affected differently than adults and children, as they had a similar rate of penetrating trauma, suicide attempts, and alcohol positivity after SAH orders. However, they had increased drug positivity compared to the CONTROL, but not PRE group.

Decreased hospital length of stay and intensive care unit admissions for non-COVID blunt trauma patients during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic overwhelmed hospitals, forcing adjustments including discharging patients earlier and limiting intensive care unit (ICU) utilization. This study aimed to evaluate ICU admissions and length of stay (LOS) for blunt trauma patients (BTPs). METHODS: A retrospective review of COVID (3/19/20-6/30/20) versus pre-COVID (3/19/19-6/30/19) BTPs at eleven trauma centers was performed. Multivariable analysis was used to identify risk factors for ICU admission. RESULTS: 12,744 BTPs were included (6942 pre-COVID vs. 5802 COVID). The COVID cohort had decreased mean LOS (3.9 vs. 4.4 days, p = 0.029), ICU LOS (0.9 vs. 1.1 days, p < 0.001), and rate of ICU admission (22.3% vs. 24.9%, p = 0.001) with no increase in complications or mortality compared to the pre-COVID cohort (all p > 0.05). On multivariable analysis, the COVID period was associated with decreased risk of ICU admission (OR = 0.82, CI 0.75-0.90, p < 0.001). CONCLUSIONS: BTPs had decreased LOS and associated risk of ICU admission during COVID, with no corresponding increase in complications or mortality.

Effects of the COVID-19 pandemic on pediatric trauma in Southern California.

PURPOSE: The COVID-19 pandemic resulted in increased penetrating trauma and decreased length of stay (LOS) amongst the adult trauma population, findings important for resource allocation. Studies regarding the pediatric trauma population are sparse and mostly single-center. This multicenter study examined pediatric trauma patients, hypothesizing increased penetrating trauma and decreased LOS after the 3/19/2020 stay-at-home (SAH) orders. METHODS: A multicenter retrospective analysis of trauma patients ≤ 17 years old presenting to 11 centers in California was performed. Demographic data, injury characteristics, and outcomes were collected. Patients were divided into three groups based on injury date: 3/19/2019-6/30/2019 (CONTROL), 1/1/2020-3/18/2020 (PRE), 3/19/2020-6/30/2020 (POST). POST was compared to PRE and CONTROL in separate analyses. RESULTS: 1677 patients were identified across all time periods (CONTROL: 631, PRE: 479, POST: 567). POST penetrating trauma rates were not significantly different compared to both PRE (11.3 vs. 9.0%, p = 0.219) and CONTROL (11.3 vs. 8.2%, p = 0.075), respectively. POST had a shorter mean LOS compared to PRE (2.4 vs. 3.3 days, p = 0.002) and CONTROL (2.4 vs. 3.4 days, p = 0.002). POST was also not significantly different than either group regarding intensive care unit (ICU) LOS, ventilator days, and mortality (all p > 0.05). CONCLUSIONS: This multicenter retrospective study demonstrated no difference in penetrating trauma rates among pediatric patients after SAH orders but did identify a shorter LOS.

Management of Infected Galactocele and Breast Implant with Uninterrupted Breastfeeding.

Infected breast implants during lactation present a rare but challenging clinical scenario that may result in early cessation of breastfeeding and unnecessary morbidity to mother and infant. We present the case of a 39-year-old African American primigravid woman with a history of bilateral retropectoral textured implants placed three years prior. Five days after delivering a healthy, full-term infant via cesarean section, she sought evaluation for nipple pain and trauma. She was instructed to use a nipple shield and pump every 2-3 hours in addition to breastfeeding, which resulted in iatrogenic hyperlactation. One week postpartum, the patient was started on antibiotics for presumed mastitis. Ultrasound demonstrated a complex fluid collection at the 12 o'clock periareolar position, as well as peri-implant fluid. She subsequently underwent aspirations of a periareolar complex galactocele and aspirations of peri-implant fluid. She continued on antibiotics without improvement. The patient proceeded to implant removal and definitive drainage of the galactocele at four months postpartum. Throughout her course, the patient provided her infant with exclusive breastmilk, including breastfeeding in the perioperative area of the operating room. This case demonstrates an example of safe surgical removal of infected breast implants and management of an infected galactocele without interruption of breastfeeding.

Drug and alcohol positivity of traumatically injured patients related to COVID-19 stay-at-home orders.

Background: COVID-19 related stay-at-home (SAH) orders created many economic and social stressors, possibly increasing the risk of drug/alcohol abuse in the community and trauma population.Objectives: Describe changes in alcohol/drug use in traumatically injured patients after SAH orders in California and evaluate demographic or injury pattern changes in alcohol or drug-positive patients.Methods: A retrospective analysis of 11 trauma centers in Southern California (1/1/2020-6/30/2020) was performed. Blood alcohol concentration, urine toxicology results, demographics, and injury characteristics were collected. Patients were grouped based on injury date - before SAH (PRE-SAH), immediately after SAH (POST-SAH), and a historical comparison (3/19/2019-6/30/2019) (CONTROL) - and compared in separate analyses. Groups were compared using chi-square tests for categorical variables and Mann-Whitney U tests for continuous variables.Results: 20,448 trauma patients (13,634 male, 6,814 female) were identified across three time-periods. The POST-SAH group had higher rates of any drug (26.2% vs. 21.6% and 24.7%, OR = 1.26 and 1.08, p < .001 and p = .035), amphetamine (10.4% vs. 7.5% and 9.3%, OR = 1.43 and 1.14, p < .001 and p = .023), tetrahydrocannabinol (THC) (13.8% vs. 11.0% and 11.4%, OR = 1.30 and 1.25, p < .001 and p < .001), and 3,4-methylenedioxy methamphetamine (MDMA) (0.8% vs. 0.4% and 0.2%, OR = 2.02 and 4.97, p = .003 and p < .001) positivity compared to PRE-SAH and CONTROL groups. Alcohol concentration and positivity were similar between groups (p > .05).Conclusion: This Southern California multicenter study demonstrated increased amphetamine, MDMA, and THC positivity in trauma patients after SAH, but no difference in alcohol positivity or blood concentration. Drug prevention strategies should continue to be adapted within and outside of hospitals during a pandemic.

Shark-Related Injuries in the United States: A National Trauma Data Bank Analysis.

BACKGROUND: Shark-related injuries (SRIs) are a dreaded, but rare, source of injury that have not been well described. The present study aims to examine the incidence, injuries, and outcomes of SRIs presenting to US trauma centers. STUDY DESIGN: The National Trauma Data Bank was queried from 2015 to 2018 to identify SRIs using ICD-10 e-codes W56.41XA, W56.42XA, and W56.49XA. Descriptive analyses were conducted on patient demographics, injuries, hospital course, procedures, and outcomes. RESULTS: Fifty-three patients were identified with a mechanism of injury that was shark-related. The median age was 29 years (range: 3-67) and median injury severity score was 5 (IQR: 3-10). The majority of patients (96%) were admitted to the hospital (median length of stay (LOS): 4.0 days, IQR: 3.0-8.0), 55% went directly to the operating room, and 53% required intensive care unit (ICU) admission (median ICU LOS: 4.5 days, IQR: 1.3-7.0). Extremity injuries were common: 47% suffered lower extremity injuries, 40% had upper extremity injuries, and 13% had both. The majority of patients underwent surgical procedures: 83% had soft tissue injuries requiring debridement, flap coverage, or skin grafting; 28% suffered neurovascular injuries (17% requiring nerve repair and 2% requiring arterial bypass); and 59% required orthopedic intervention. Six patients (11%) required amputation(s). All patients survived to discharge. CONCLUSION: Although an exceedingly rare source of trauma, SRIs are frequently associated with devastating injuries. Given the severity of injuries and associated procedures required, these patients warrant referral to a trauma center capable of providing comprehensive care.

COVID-19 in trauma: a propensity-matched analysis of COVID and non-COVID trauma patients.

PURPOSE: There is mounting evidence that surgical patients with COVID-19 have higher morbidity and mortality than patients without COVID-19. Infection is prevalent amongst the trauma population, but any effect of COVID-19 on trauma patients is unknown. We aimed to evaluate the effect of COVID-19 on a trauma population, hypothesizing increased mortality and pulmonary complications for COVID-19-positive (COVID) trauma patients compared to propensity-matched COVID-19-negative (non-COVID) patients. METHODS: A retrospective analysis of trauma patients presenting to 11 Level-I and II trauma centers in California between 1/1/2019-6/30/2019 and 1/1/2020-6/30/2020 was performed. A 1:2 propensity score model was used to match COVID to non-COVID trauma patients using age, blunt/penetrating mechanism, injury severity score, Glasgow Coma Scale score, systolic blood pressure, respiratory rate, and heart rate. Outcomes were compared between the two groups. RESULTS: A total of 20,448 trauma patients were identified during the study period. 53 COVID trauma patients were matched with 106 non-COVID trauma patients. COVID patients had higher rates of mortality (9.4% vs 1.9%, p = 0.029) and pneumonia (7.5% vs. 0.0%, p = 0.011), as well as a longer mean length of stay (LOS) (7.47 vs 3.28 days, p < 0.001) and intensive care unit LOS (1.40 vs 0.80 days, p = 0.008), compared to non-COVID patients. CONCLUSION: This multicenter retrospective study found increased rates of mortality and pneumonia, as well as a longer LOS, for COVID trauma patients compared to a propensity-matched cohort of non-COVID patients. Further studies are warranted to validate these findings and to elucidate the underlying pathways responsible for higher mortality in COVID trauma patients.

The coronavirus disease 2019 (COVID-19) stay-at-home order's unequal effects on trauma volume by insurance status in Southern California.

BACKGROUND: The rapid spread of coronavirus disease 2019 in the United States led to a variety of mandates intended to decrease population movement and "flatten the curve." However, there is evidence some are not able to stay-at-home due to certain disadvantages, thus remaining exposed to both coronavirus disease 2019 and trauma. We therefore sought to identify any unequal effects of the California stay-at-home orders between races and insurance statuses in a multicenter study utilizing trauma volume data. METHODS: A posthoc multicenter retrospective analysis of trauma patients presenting to 11 centers in Southern California between the dates of January 1, 2020, and June 30, 2020, and January 1, 2019, and June 30, 2019, was performed. The number of trauma patients of each race/insurance status was tabulated per day. We then calculated the changes in trauma volume related to stay-at-home orders for each race/insurance status and compared the magnitude of these changes using statistical resampling. RESULTS: Compared to baseline, there was a 40.1% drop in total trauma volume, which occurred 20 days after stay-at-home orders. During stay-at-home orders, the average daily trauma volume of patients with Medicaid increased by 13.7 ± 5.3%, whereas the volume of those with Medicare, private insurance, and no insurance decreased. The average daily trauma volume decreased for White, Black, Asian, and Latino patients with the volume of Black and Latino patients dropping to a similar degree compared to White patients. CONCLUSION: This retrospective multicenter study demonstrated that patients with Medicaid had a paradoxical increase in trauma volume during stay-at-home orders, suggesting that the most impoverished groups remain disproportionately exposed to trauma during a pandemic, further exacerbating existing health disparities.

Changes in traumatic mechanisms of injury in Southern California related to COVID-19: Penetrating trauma as a second pandemic.

BACKGROUND: The COVID-19 pandemic resulted in a statewide stay-at-home (SAH) order in California beginning March 19, 2020, forcing large-scale behavioral changes and taking an emotional and economic toll. The effects of SAH orders on the trauma population remain unknown. We hypothesized an increase in rates of penetrating trauma, gunshot wounds, suicide attempts, and domestic violence in the Southern California trauma population after the SAH order. METHODS: A multicenter retrospective analysis of all trauma patients presenting to 11 American College of Surgeons levels I and II trauma centers spanning seven counties in California was performed. Demographic data, injury characteristics, clinical data, and outcomes were collected. Patients were divided into three groups based on injury date: before SAH from January 1, 2020, to March 18, 2020 (PRE), after SAH from March 19, 2020, to June 30, 2020 (POST), and a historical control from March 19, 2019, to June 30, 2019 (CONTROL). POST was compared with both PRE and CONTROL in two separate analyses. RESULTS: Across all periods, 20,448 trauma patients were identified (CONTROL, 7,707; PRE, 6,022; POST, 6,719). POST had a significantly increased rate of penetrating trauma (13.0% vs. 10.3%, p < 0.001 and 13.0% vs. 9.9%, p < 0.001) and gunshot wounds (4.5% vs. 2.4%, p = 0.002 and 4.5% vs. 3.7%, p = 0.025) compared with PRE and CONTROL, respectively. POST had a suicide attempt rate of 1.9% and a domestic violence rate of 0.7%, which were similar to PRE (p = 0.478, p = 0.514) and CONTROL (p = 0.160, p = 0.618). CONCLUSION: This multicenter Southern California study demonstrated an increased rate of penetrating trauma and gunshot wounds after the COVID-19 SAH orders but no difference in attempted suicide or domestic violence rates. These findings may provide useful information regarding resource utilization and a target for societal intervention during the current or future pandemic(s). LEVEL OF EVIDENCE: Epidemiological, level IV.

Towards a more intelligent model of providing pediatric trauma care: identifying temporal variations in trauma team activations.

BACKGROUND: Trauma centers are resource-intensive environments, and pediatric-specific personnel are often limited resources. Identifying the temporal patterns of pediatric traumas can help guide resource allocation strategies to optimize patient care. METHODS: We conducted a retrospective, single-institution analysis of 575 injured patients less than 18 years old that triggered a trauma team activation (TTA). TTA volume according to time of day and day of the week was analyzed using a mixed Poisson regression model and monthly patterns were analyzed using an analysis of variance. Subset analyses were conducted for children and teenagers. RESULTS: Across all days, the 6-hour time frame between 15:00 and 21:00 had significantly more activations than average, encompassing nearly half (47.2%) of all pediatric TTAs (p=0.01). Saturdays had significantly more activations than the daily average (Saturdays: 26.0/year, Other: 14.8/year, p<0.01). A pediatric TTA was 3.6 times more likely to occur between 15:00 and 21:00 on a Saturday than any other time. Volume of activation did not significantly differ by month (p=0.880). CONCLUSION: The volume of pediatric trauma activations varies significantly according to time of day and day of the week. These findings can direct or validate resource allocation strategies such as staffing physicians, nurses, and ancillary personnel according to TTA volume. TYPE OF STUDY: Retrospective cohort study. LEVEL OF EVIDENCE: Level III.

Facial Fractures After Geriatric Ground-Level Falls Are a Marker of Functional Decline and Warrant Trauma Center Admission.

Ground-level falls (GLFs) are a frequent source of injury in the geriatric population. Facial fractures (FFs) are one subsequent injury that can occur and may be an important marker of functional decline. We conducted a retrospective analysis over a 6-year period of patients 65 years and older sustaining one or more FFs due to a GLF (n = 28). Demographics, comorbidities, FF patterns, concomitant injuries, procedures, and outcomes were analyzed. The mean age was 80.0 ± 8.2 years, 64% were male, 12 patients (43%) were on oral anticoagulants prior to injury, and mean injury severity score was 8.3 ± 7.0. Five patients (18%) had LeFort fractures (1 with LeFort I, 4 with LeFort II), and 5 (18%) had isolated mandible fractures (2 were bilateral). Nearly half of all patients suffered neurological injury (concussion: 18%, intracranial hemorrhage: 29%). Average hospital length of stay (LOS) was 4.0 ± 2.9 days. Eight patients (29%) required intensive care unit (ICU) admission with an average ICU-LOS of 2.8 ± 1.2 days. Surgical management was required in 4 patients (14%). More than half of the patients returned home (54%), 25% were discharged to a skilled nursing facility, 4% to rehabilitation, 7% to hospice, and 7% expired. Nearly one-third of patients required discharge to a higher level of care facility than their location prior to injury. GLF-induced FFs are often associated with significant injuries and serve as an indicator of functional decline. These injuries warrant trauma center admission for comprehensive evaluation and management.

Facial fractures and associated injuries in high- versus low-energy trauma: all are not created equal.

INTRODUCTION: Facial fractures (FFs) occur after high- and low-energy trauma; differences in associated injuries and outcomes have not been well articulated. OBJECTIVE: To compare the epidemiology, management, and outcomes of patients suffering FFs from high-energy and low-energy mechanisms. METHODS: We conducted a 6-year retrospective local trauma registry analysis of adults aged 18-55 years old that suffered a FF treated at the Santa Barbara Cottage Hospital. Fracture patterns, concomitant injuries, procedures, and outcomes were compared between patients that suffered a high-energy mechanism (HEM: motor vehicle crash, bicycle crash, auto versus pedestrian, falls from height > 20 feet) and those that suffered a low-energy mechanism (LEM: assault, ground-level falls) of injury. RESULTS: FFs occurred in 123 patients, 25 from an HEM and 98 from an LEM. Rates of Le Fort (HEM 12% vs. LEM 3%, P = 0.10), mandible (HEM 20% vs. LEM 38%, P = 0.11), midface (HEM 84% vs. LEM 67%, P = 0.14), and upper face (HEM 24% vs. LEM 13%, P = 0.217) fractures did not significantly differ between the HEM and LEM groups, nor did facial operative rates (HEM 28% vs. LEM 40%, P = 0.36). FFs after an HEM event were associated with increased Injury Severity Scores (HEM 16.8 vs. LEM 7.5, P <0.001), ICU admittance (HEM 60% vs. LEM 13.3%, P <0.001), intracranial hemorrhage (ICH) (HEM 52% vs. LEM 15%, P <0.001), cervical spine fractures (HEM 12% vs. LEM 0%, P = 0.008), truncal/lower extremity injuries (HEM 60% vs. LEM 6%, P <0.001), neurosurgical procedures for the management of ICH (HEM 54% vs. LEM 36%, P = 0.003), and decreased Glasgow Coma Score on arrival (HEM 11.7 vs. LEM 14.2, P <0.001). CONCLUSION: FFs after HEM events were associated with severe and multifocal injuries. FFs after LEM events were associated with ICH, concussions, and cervical spine fractures. Mechanism-based screening strategies will allow for the appropriate detection and management of injuries that occur concomitant to FFs. TYPE OF STUDY: Retrospective cohort study. LEVEL OF EVIDENCE: Level III.

Debris Flow Syndrome: Injuries and Outcomes after the Montecito Debris Flow.

On January 9, 2018, a catastrophic debris flow devastated Montecito, California. A 30-foot wall of boulders, mud, and debris ran down the hillsides at 15 miles per hour injuring dozens and causing 21 prehospital deaths. A retrospective review was conducted of the victims from the debris flow presenting to Cottage Health. Injury patterns, procedures performed, complications, length of stay, and outcomes were analyzed. Twenty-four patients were evaluated; 15 were admitted. Of the patients admitted, the most common presenting symptoms were soft tissue injuries (100%), hypothermia (67%), craniofacial injuries (67%), corneal abrasions (53%), and orthopedic injuries (47%), as well as loss of an immediate family member during the incident (73%). Procedures included skin irrigation (93%), operative soft tissue debridement (47%), body orifice irrigation due to mud impaction (40%), and orthopedic repair of fractures and ligaments (40%). All survived to discharge. "Debris flow syndrome" can be defined as a pattern of injuries, including soft tissue injuries, hypothermia, craniofacial trauma, corneal abrasions, orthopedic injuries, and mud impaction. Managing the debris flow syndrome requires co-ordinated and specialized care.