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

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

Venous thromboembolism chemoprophylaxis in geriatric trauma patients with isolated severe traumatic brain injury.

PURPOSE: Low-molecular-weight-heparin (LMWH) has been shown to be associated with a decreased risk of venous thromboembolism (VTE) and mortality compared to unfractionated heparin (UH) in severe traumatic brain injury (TBI). The aim of this study was to see if this association persists among a subset of patients, namely elderly patients with isolated TBI. METHODS: This Trauma Quality Improvement Project (TQIP) database study included patients ≥ 65 years old with severe TBI (Abbreviated injury score [AIS] ≥ 3) that received either LMWH or UH for VTE prophylaxis. Patients with associated severe injuries (extracranial AIS ≥ 3), transferals, deaths < 72-h, hospitalization < 2 days, VTE chemoprophylaxis other than UH or LMWH, or with a history of bleeding diathesis were excluded. The association between VTE, deep vein thrombosis (DVT), and pulmonary embolism (PE) with VTE chemoprophylaxis was analyzed with multivariable analysis, subset analyses of different grades of AIS-head injury, and a 1:1 matched LWMH:UH cohort of patients. RESULTS: Out of 14,926 patients, 11,036 (73.9%) received LMWH. Multivariate analysis showed that patients receiving LMWH had a decreased risk of mortality (OR 0.81, 95% CI 0.67-0.97, p < 0.001) but a similar risk of VTE (OR 0.83, 95% CI 0.63-1.08). Analysis according to head-AIS showed that LMWH was associated with a decreased risk of PE in patients AIS-3 but not in AIS 4 or 5. In a 1:1 matched cohort of LMWH:UH patients, the risk of PE, DVT and VTE were all similar but LMWH continued to be associated with a decreased risk of mortality (OR 0.81, CI 0.67-0.97, p = 0.023). CONCLUSION: LMWH was associated with a decreased risk of overall mortality and reduced risk of PE compared to UH among geriatric patients with a severe head injury.

Risk factors for thromboembolic complications in isolated severe head injury.

PURPOSE: Patients with traumatic brain injury (TBI) are at high risk for venous thromboembolism (VTE). The aim of the present study is to identify factors independently associated with VTE events. Specifically, we hypothesized that the mechanism of penetrating head trauma might be an independent factor associated with increased VTE events when compared with blunt head trauma. METHODS: The ACS-TQIP database (2013-2019) was queried for all patients with isolated severe head injuries (AIS 3-5) who received VTE prophylaxis with either unfractionated heparin or low-molecular-weight heparin. Transfers, patients who died within 72 h and those with a hospital length of stay < 48 h were excluded. Multivariable analysis was used as the primary analysis to identify independent risk factors for VTE in isolated severe TBI. RESULTS: A total of 75,570 patients were included in the study, 71,593 (94.7%) with blunt and 3977 (5.3%) with penetrating isolated TBI. Penetrating trauma mechanism (OR 1.49, CI 95% 1.26-1.77), increasing age (age 16-45: reference; age > 45-65: OR 1.65, CI 95% 1.48-1.85; age > 65-75: OR 1.71, CI 95% 1.45-2.02; age > 75: OR 1.73, CI 95% 1.44-2.07), male gender (OR 1.53, CI 95% 1.36-1.72), obesity (OR 1.35, CI 95% 1.22-1.51), tachycardia (OR 1.31, CI 95% 1.13-1.51), increasing head AIS (AIS 3: reference; AIS 4: OR 1.52, CI 95% 1.35-1.72; AIS 5: OR 1.76, CI 95% 1.54-2.01), associated moderate injuries (AIS = 2) of the abdomen (OR 1.31, CI 95% 1.04-1.66), spine (OR 1.35, CI 95% 1.19-1.53), upper extremity (OR 1.16, CI 95% 1.02-1.31), lower extremity (OR 1.46, CI 95% 1.26-1.68), craniectomy/craniotomy or ICP monitoring (OR 2.96, CI 95% 2.65-3.31) and pre-existing hypertension (OR 1.18, CI 95% 1.05-1.32) were identified as independent risk factors for VTE complications in isolated severe head injury. Increasing GCS (OR 0.93, CI 95% 0.92-0.94), early VTE prophylaxis (OR 0.48, CI 95% 0.39-0.60) and LMWH compared to heparin (OR 0.74, CI 95% 0.68-0.82) were identified as protective factors for VTE complications. CONCLUSION: The identified factors independently associated with VTE events in isolated severe TBI need to be considered in VTE prevention measures. In penetrating TBI, an even more aggressive VTE prophylaxis management may be justified as compared to that in blunt.

Injury patterns and outcomes in motorcycle driver crashes in the United States: The effect of helmet use.

BACKGROUND: Motorcycle crashes pose a persistent public health problem with disproportionate rates of severe injuries and mortality. This study aims to analyze injury patterns and outcomes with regard to helmet use. We hypothesized that helmet use is associated with fewer head injuries and does not increase the risk of cervical spine injuries. METHODS: The National Trauma Data Bank was queried for all motorcycle driver crashes between 2007-2017. Univariable analysis was used to compare demographics, clinical data, injury patterns using abbreviated injury scale, and outcomes between helmeted motorcycle drivers and non-helmeted motorcycle drivers who were injured in traffic crashes. Independent factors associated with mortality were determined by regression analysis after adjustment for potential confounders. RESULTS: A total of 315,258 patients were included for analysis, 66 % of these patients were helmeted. The sample was 92.5 % male and the median age was 41 years. Non-helmeted motorcycle drivers were more likely to sustain severe head trauma (head abbreviated injury scale ≥ 3: 28.5 % vs. 13.3 %, p < 0.001), had higher intensive care unit-admission (38 % vs. 30.2 %, p<0.001), mechanical ventilation (20.1 % vs. 13 %, p<0.001) and overall mortality rates (6.2 % vs. 3.9 %, p<0.001). Cervical spine injuries occurred in 10.6 % of non-helmeted motorcycle drivers and in 9.5 % of helmeted motorcycle drivers (p<0.001). Helmet use was identified as an independent factor associated with lower mortality [OR 0.849 (0.809-0.891), p<0.001]. CONCLUSION: Helmet use is protective for severe head injuries and associated with decreased mortality. Helmet use was not associated with increased rates of cervical spine injuries. On the contrary, fewer injuries were observed in helmeted motorcycle drivers. Public health initiatives should be aimed at enforcement of universal helmet laws within the United States and across the world.

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

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

Propensity Score Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta: Zone-1 Versus Zone-3 Resuscitative Endovascular Balloon Occlusion of the Aorta Odds of Mortality.

INTRODUCTION: There are two zones for the placement of a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in trauma patients: above the mesenteric vessels (Zone-1) or below the renal arteries (Zone-3). Zone-1 REBOA diverts blood away from the visceral organs which leads to a systemic inflammatory response and reperfusion injury. We hypothesized that patients undergoing Zone-1 REBOA placement had a higher odds of mortality. METHODS: The 2017-2019 Trauma Quality Improvement Program database was queried for patients undergoing either Zone-1 or Zone-3 REBOA. We excluded all patients with prehospital cardiac arrest. We compared Zone-1 versus Zone-3 REBOA using a 1:2 propensity-score model, matching for age, mechanism, sex, hypotension, tachycardia, blunt solid organ injury grade, pelvic fracture, and injuries to the aorta, iliac artery, iliac vein, and inferior vena cava. RESULTS: We matched 130 Zone-1 REBOA patients to 260 Zone-3 REBOA patients. There were no statistically significant differences in the matched variables (P > 0.05). Compared to Zone-3 REBOA, patients with Zone-1 REBOA who survived ≥48 h had similar rates of acute kidney injury (18.6% versus 10.9%, P = 0.19). Zone-1 REBOA patients had a higher mortality rate (71.4% versus 48.8%, P = 0.002) and mortality odds ratio (OR) (OR 1.85, OR 1.18-2.89, P = 0.007). Zone-1 REBOA remained associated with a higher odds of mortality after controlling for traumatic brain injury and injury severity score (OR 1.86, OR 1.18-2.92, P = 0.007). CONCLUSIONS: Compared to Zone-3, using a REBOA in Zone-1 is associated with higher odds of mortality. The use of REBOA Zone-1 deployment should be done with caution.

Mild traumatic brain injury: not always a mild injury.

PURPOSE: In general, risk of mortality after trauma correlates with injury severity. Despite arriving in relatively stable clinical condition, however, some patients are at risk of death following mild traumatic brain injury (TBI). The study objective was delineation of patients who die in-hospital following mild isolated TBI in order to inform Emergency Department (ED) disposition and care discussions with patients and families. METHODS: In this retrospective cohort study, patients from the National Trauma Data Bank (NTDB) (2007-2018) were included if they were injured by blunt trauma and sustained a mild TBI (defined as Head Abbreviated Injury Scale [AIS] score of 1 or 2 and arrival Glasgow Coma Scale [GCS] score of 13-15). Exclusions were severe associated injuries (extracranial AIS > 2); transfers; and missing data. Patients were defined by in-hospital mortality: Survivors vs. Mortalities. Demographics, clinical/injury data, and the outcomes were collected and compared with univariate analysis. Multivariate analysis established independent factors associated with in-hospital mortality following mild TBI. RESULTS: In total, 932,107 patients (10% of NTDB population) met study criteria: 928,542 (99.6%) Survivors and 3,565 (0.4%) Mortalities. In general, comorbidities (including home anticoagulation, cardiac disease, and diabetes mellitus) were significantly more common among patients who died (p < 0.001), although drug and alcohol intoxication on arrival were more common among Survivors (16% vs. 7%, p < 0.001; 13% vs. 10%, p < 0.001). In terms of insurance status, Private/Commercial insurance was more common among Survivors (39% vs. 20%, p < 0.001) while Governmental Insurance was more common among Mortalities (55% vs. 36%, p < 0.001). On multivariate analysis, age ≥ 65 was most strongly associated with death (OR 26.43, p < 0.001), followed by ED intubation (OR 10.08, p < 0.001), admission hypotension (OR 4.55, p < 0.001), and comorbidities, particularly end-stage renal disease (ESRD) (OR 3.03, p < 0.001) and immunosuppression (OR 2.18, p < 0.001). CONCLUSIONS: Survivors differed substantially from Mortalities after mild TBI in terms of comorbidities, intoxicants, and insurance status. Independent variables most strongly associated with in-hospital death following mild head injury included age ≥ 65, intubation in the ED, admission hypotension, and comorbidities (particularly ESRD and immunosuppression). Increased clinical vigilance, including a mandatory period of clinical observation, for patients with these risk factors should be considered to optimize outcomes and potentially mitigate death after mild TBI.

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

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

Understanding the Impact of Trauma Admissions to Nonsurgical Services.

BACKGROUND: The American College of Surgeons Committee on Trauma (ACS COT) delineates trauma center standards, one of which limits the number of injured patients admitted to nonsurgical services. Performance improvement review of nonsurgical admissions (NSAs), particularly those with Injury Severity Score (ISS) > 9, is required. OBJECTIVE: To examine trauma patients with NSA for appropriateness of admission and any potential clinical effect as a result of NSA. METHODS: All trauma patients presenting to our ACS COT-verified level 1 trauma center in Southern California (05/2021-04/2022) were retrospectively screened. Nonsurgical admissions with ISS > 9 were included without exclusions. Appropriateness and clinical impact of NSA were assessed by the Trauma Medical Director (TMD) and Associate TMD. RESULTS: Forty patients met study criteria, with a mean age of 54 years (range 5 d-99 y). The mean ISS was 19 (range 10-30). Nonsurgical admissions most commonly sustained traumatic brain injury (TBI) (n = 27, 68%) after ground level falls (GLF) (n = 32, 80%). All NSAs were evaluated by ≥1 surgical service, commonly neurosurgery (n = 33, 83%) and trauma surgery (n = 13, 33%). Sixteen patients (40%) died, 75% (n = 12) of which were secondary to catastrophic TBI. Upon detailed review, all NSAs were deemed appropriate and without potential clinical impact. CONCLUSIONS: All NSAs in this study were appropriate admissions without clinical effect from lack of surgical admission. Nonsurgical admissions were typically elderly patients with head injuries after GLF. With the anticipated increase in geriatric trauma due to our aging population, NSA with surgical consultation may be an important way to manage trauma admissions without compromising care of injured patients.

Undertriage of Severely Injured Trauma Patients.

INTRODUCTION: The American College of Surgeons (ACS) delineates trauma team activation (TTA) criteria to identify seriously injured trauma patients in the field. Patients are deemed to be severely undertriaged (SU), placing them at risk for adverse outcomes, when they do not meet TTA criteria but nonetheless sustain significant injuries (Injury Severity Score [ISS] ≥25). OBJECTIVES: Delineate patient demographics, injuries, and outcomes after SU. PARTICIPANTS: Trauma patients presenting to our ACS-verified Level 1 trauma center with ISS ≥25 were included (11/2015-03/2022). Transfers and private vehicle transports were excluded. Patients were dichotomized and compared by trauma arrival level: TTA (Appropriately Triaged, AT) vs routine consults (SU). RESULTS: Study criteria were satisfied by 1653 patients: 1375 (83%) AT and 278 (17%) SU. Severely undertriaged patients were older than AT patients (47 vs 36 years, P < .001). Severely undertriaged occurred almost exclusively following blunt trauma (96% vs 71%, P < .001). Injury Severity Score was lower following SU than AT (29 vs 32, P < .001). The most common severe injuries (Abbreviated Injury Scale score [AIS] ≥3) among the SU group were in the Chest (n = 179, 64%). Severely undertriaged patients necessitated emergent intubation (n = 34, 12%), surgery (n = 59, 21%), and angioembolization (n = 22, 8%) at high rates. Severely undertriaged mortality was n = 40, 14%. CONCLUSION: Severely undertriaged occurred among a substantial proportion of ISS ≥25 patients, predominately following blunt trauma. Severe chest injuries were most likely to evade capture. Rates of intubation, emergent intervention, and in-hospital mortality were high after SU. Efforts should be made to identify such patients in the field as they may benefit from TTA.

Injury patterns and outcomes in motorcycle passengers.

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

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

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

Manhandling injuries during legal interventions.

INTRODUCTION: Data concerning injuries resulting from physical force during legal interventions are scarce. The purpose of this study was to examine manhandling injuries occurring in both civilian suspects and law enforcement officials (LEO). METHODS: Retrospective cross-sectional study using data from the National Trauma Data Bank. All patients who sustained manhandling injuries during legal interventions were identified using ICD-10 e-codes. The study groups were injured civilian suspects and LEO. The primary outcomes were type and severity of injuries among the groups. RESULTS: A total of 507 patients were included in the study, 426 (84.0%) civilians and 81 (16.0%) LEO. Overall, median age was 37 years (IQR: 28-48) and 90.3% were male. The median ISS was higher in civilians compared to LEO (5 [4-10] vs 4 [4-9], p = 0.023). Civilians were more likely to sustain injuries to the face (49.8% vs 35.9%, p = 0.024) and abdomen (8.3% vs 1.3%, p = 0.028). LEO were more likely to sustain tibia/fibula fractures (3.5% vs 9.9%, p = 0.019). The mortality was 1.2% (5/426) in civilians and there were no deaths in LEO. The overall complication rates and hospital length of stay were similar between the groups. CONCLUSION: Injury patterns and severity of injuries sustained from the use of physical force during legal interventions are different in civilians and law enforcement officials. Further research and more comprehensive data are warranted to better understand and prevent these injuries.

Asymptomatic Covid-19 Trauma Patients Have Worse Outcomes and Resource Utilization: A Matched Cohort Study.

OBJECTIVE: To evaluate the impact of COVID-19 positivity on outcomes and resource utilization in the trauma population. INTRODUCTION: COVID-19 infection worsens outcomes of trauma patients, but it is not known if asymptomatic COVID-19 trauma patients have different outcomes from COVID-19-negative patients. METHODS: All trauma patients admitted to an urban level 1 trauma center between March 2020 and October 2021 were collected and reviewed for COVID-19 status. COVID-19-positive patients with symptoms or initial chest radiographs consistent with infections were excluded. Propensity score model 1:3 matched asymptomatic COVID-19-positive to COVID-19-negative trauma patients for their age, body mass index, MOA, injury severity score, SBP<90, GCS<9, and comorbidities. Outcomes included mortality, complications, and resource utilization. RESULTS: A total of 185 asymptomatic COVID-19-positive patients were matched with 554 COVID-19-negative patients. Asymptomatic COVID-19 -positive patients had higher rates of myocardial infarction and cardiac arrest (3.2% vs. 0.9%, P =0.023), higher ventilator days (3.33 vs. 1.49 days, P <0.001), ICU-length of stay [LOS (4.92 vs. 3.41 d, P =0.034)], overall LOS (11.41 vs. 7.24 d, P <0.001), and hospital charges ($ 176.505.80 vs. 107.591.93, P =0.002). CONCLUSION: Asymptomatic COVID-19 trauma patients have significantly higher rates of cardiac events, longer LOS, and higher hospital charges when compared with similar trauma patients who are COVID-19-negative.

Resuscitative Endovascular Balloon Occlusion of the Aorta is Associated with Increased Risk of Extremity Compartment Syndrome.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used as a temporizing procedure to control intra-abdominal or pelvic bleeding. Theoretically, occlusion of the aorta and the resulting ischemia-reperfusion of the lower extremities may increase the risk of extremity compartment syndrome (CS). To date, no study has addressed systematically the incidence and risk factors of CS following REBOA intervention. The purpose of this study was to address this knowledge gap. METHODS: Adult trauma patients from the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) database (2016-2019) were included. Patients who received REBOA within 4 h of admission were compared to patients without REBOA after propensity score matching for demographics, vital signs on admission, comorbidities, injury severity of different body regions, pelvic and lower extremity fractures, vascular trauma to the lower extremities, fixation for fractures, angioembolization (AE) for pelvis, preperitoneal pelvic packing (PPP), laparotomy, and venous thromboembolism (VTE) prophylaxis. The primary outcomes were rates of lower extremity CS and fasciotomy and acute kidney injury (AKI). Secondary outcomes included mortality. RESULTS: There were 534 patients who received REBOA matched with 1043 patients without REBOA. Overall, patients in the REBOA group had significantly higher rates of CS than no REBOA patients [5.4% vs 1.1%, p < 0.001, OR: 5.39]. The risk of CS remained significantly higher in the subgroups of patients with or without pelvic or lower extremity fractures, as well as in the subgroup of patients with associated extremity vascular injury [11.2% vs 1.5%, p < 0.001, OR: 8.12].The fasciotomy and AKI rates were significantly higher in the REBOA group (5.8% vs 1.2%, p < 0.001 and 12.9% vs 7.4%, p< 0.001 respectively). CONCLUSION: REBOA use is associated with a higher risk of lower extremity CS, fasciotomy and AKI, especially in patients with associated lower extremity vascular injuries. These complications should be taken into account when considering REBOA use, and close observation for this complication should always be part of the routine monitoring.

Falls from scaffolds: a nationwide analysis.

INTRODUCTION: Falls from scaffolds are a common cause of occupational injuries and fatalities, however, the data concerning these injuries are scarce. The purpose of this study was to characterize the epidemiology, injury patterns, and outcomes of falls from scaffolds. METHODS: Retrospective cohort study using data from the National Trauma Data Bank (2007-2017). All adult patients who sustained injuries following falls from scaffolds and as a comparator, falls from ladders, were identified using the external cause of injury codes. The primary outcome was differences in the type and severity of injuries between the groups. RESULTS: A total of 183,853 patients were analyzed. Of these, 18,189 (9.9%) fell from scaffolds and 165,664 (90.1%) from ladders. Patients who fell from scaffolds were younger, more often male, and more likely to sustain severe trauma (ISS > 15: 24.1% vs 17.3%, p < 0.001). Falls from scaffolds resulted in more severe head injuries (head AIS ≥ 3: 18.6% vs 14.7%, p < 0.001) and more spinal fractures (30.3% vs 25.2%, p < 0.001). Falls from scaffolds were associated with higher mortality (2.5% vs 1.8%, p < 0.001), higher ICU admission rate (25.0% vs 21.5%, p < 0.001), and longer hospitalization. On multivariable analysis, the strongest predictors of mortality were GCS < 9 and hypotension on admission, severe (AIS ≥ 3) head injury, and age > 65 years. CONCLUSION: Falls from scaffolds are associated with more severe injuries and worse outcomes compared to ladder falls. Males in the fourth decade of life were disproportionally affected. Further research on fall prevention is warranted to decrease this important cause of death and disability.

REBOA in trauma and the risk of venous thromboembolic complications: A matched-cohort study.

BACKGROUND: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has been used as a damage control procedure in trauma patients. We hypothesized that REBOA increases risk of venous thromboembolic (VTE) complications. METHODS: This was an American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) database study. Excluded were transfers, deaths within 24 h, and severe head injuries. Included were trauma patients receiving REBOA within 4 h from arrival. Outcomes in the two groups were compared after using propensity score matching (PSM) for demographic and clinical characteristics, body area abbreviated injury scale, injury severity score, pelvis and lower extremity fractures, angiographic intervention, preperitoneal pelvic packing, pharmacological VTE prophylaxis, laparotomy, laparotomy and specific orthopedic procedures. RESULTS: After PSM, 339 REBOA patients were matched with 663 patients with No REBOA. REBOA patients were significantly more likely to develop pulmonary embolism (PE) (5.3% vs. 2.7%, p = .037) and VTE (14.7% vs. 10.0%, p = .025). CONCLUSION: REBOA is associated with an increased risk of PE and VTE complications. Patients managed with REBOA should receive adequate thromboprophylaxis and be monitored closely for VTE complications.

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

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