Non-Binary Trauma Patients: Delineating a Vulnerable, At-Risk Population.

INTRODUCTION: An increasing proportion of the population identifies as non-binary. This marginalized group may be at differential risk for trauma compared to those who identify as male or female, but physical trauma among non-binary patients has not yet been examined at a national level. METHODS: All patients aged ≥ 16 years in the National Trauma Data Bank were included (2021-2022). Demographics, injury characteristics, and outcomes after trauma among non-binary patients were compared to males and females. The goal was to delineate differences between groups to inform the care and future study of non-binary trauma patients. RESULTS: In total, 1,012,348 patients were included: 283 (<1%) non-binary, 610,904 (60%) male, and 403,161 (40%) female patients. Non-binary patients were younger than males or females (median age 44 vs 49 vs 67 years, P < .001) and less likely to be White race/ethnicity (58% vs 60% vs 74%, P < .001). Despite non-binary patients having a lower median Injury Severity Score (5 vs 9 vs 9, P < .001), mortality was highest among non-binary and male patients than females (5% vs 5% vs 3%, P < .001). DISCUSSION: In this study, non-binary trauma patients were younger and more likely minority races/ethnicities than males or females. Despite having a lower injury severity, non-binary patient mortality rates were comparable to those of males and greater than for females. These disparities identify non-binary trauma patients as doubly marginalized, by gender and race/ethnicity, who experience worse outcomes after trauma than expected based on injury severity. This vulnerable patient population deserves further study to identify areas for improved trauma delivery care.

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.

When is it safe to start venous thromboembolism prophylaxis after blunt solid organ injury? A prospective American Association for the Surgery of Trauma multi-institutional trial.

BACKGROUND: The optimal time to initiate venous thromboembolism (VTE) chemoprophylaxis (VTEp) after blunt solid organ injury remains controversial, as VTE mitigation must be balanced against bleeding promulgation. Evidence from primarily small, retrospective, single-center work suggests that VTEp ≤48 hours is safe and effective. This study was undertaken to validate this clinical practice. METHODS: Blunt trauma patients presenting to 19 participating trauma centers in North America were screened over a 1-year study period beginning between August 1 and October 1, 2021. Inclusions were age older than 15 years; ≥1 liver, spleen, or kidney injury; and initial nonoperative management. Exclusions were transfers, emergency department death, pregnancy, and concomitant bleeding disorder/anticoagulation/antiplatelet medication. A priori power calculation stipulated the need for 1,158 patients. Time of VTEp initiation defined study groups: Early (≤48 hours of admission) versus Late (>48 hours). Bivariate and multivariable analyses compared outcomes. RESULTS: In total, 1,173 patients satisfied the study criteria with 571 liver (49%), 557 spleen (47%), and 277 kidney injuries (24%). The median patient age was 34 years (interquartile range, 25-49 years), and 67% (n = 780) were male. The median Injury Severity Score was 22 (interquartile range, 14-29) with Abbreviated Injury Scale Abdomen score of 3 (interquartile range, 2-3), and the median American Association for the Surgery of Trauma grade of solid organ injury was 2 (interquartile range, 2-3). Early VTEp patients (n = 838 [74%]) had significantly lower rates of VTE (n = 28 [3%] vs. n = 21 [7%], p = 0.008), comparable rates of nonoperative management failure (n = 21 [3%] vs. n = 12 [4%], p = 0.228), and lower rates of post-VTEp blood transfusion (n = 145 [17%] vs. n = 71 [23%], p = 0.024) when compared with Late VTEp patients (n = 301 [26%]). Late VTEp was independently associated with VTE (odd ratio, 2.251; p = 0.046). CONCLUSION: Early initiation of VTEp was associated with significantly reduced rates of VTE with no increase in bleeding complications. Venous thromboembolism chemoprophylaxis initiation ≤48 hours is therefore safe and effective and should be the standard of care for patients with blunt solid organ injury. LEVEL OF EVIDENCE: Therapeutic and Care Management; Level III.

Witnessed prehospital traumatic arrest: predictors of survival to hospital discharge.

PURPOSE: Trauma patients are rapidly transported to the hospital for definitive care. Nonetheless, some are alive upon Emergency Medical Services (EMS) arrival but arrest on-scene or during transport. The study objective was to examine EMS-witnessed traumatic arrests to define patients who survived hospital discharge. METHODS: Patients sustaining EMS-witnessed traumatic arrest and entered into the National Trauma Data Bank were included (2007-2018). Mortality defined groups: survival to hospital discharge vs. in-hospital death vs. death in ED/declared dead on arrival (DOA). ANOVA/Chi-square compared cohorts. Multivariable analysis established factors associated with survival out of ED and to hospital discharge. RESULTS: After exclusions, 14,177 patients met the criteria: 10% survived, 22% died in hospital, and 68% died in ED/DOA. Survivors tended to be female (33% vs. 23% vs. 23%, p < 0.001), blunt traumas (71% vs. 56% vs. 60%, p < 0.001), have higher scene GCS (15 [7-15] vs. 3 [3-11] vs. 3 [3-7], p < 0.001), and lower injury severity (ISS 13 [7-26] vs. 27 [18-41] vs. 25 [10-30], p < 0.001), particularly of the head (AIS 0 [0-2] vs. 0 [0-4] vs. 1 [0-4], p < 0.001). Survival to hospital discharge was independently associated with higher field GCS (OR 1.252, p < 0.001) and SBP (OR 1.006, p < 0.001), and Head AIS scores (OR 1.073, p < 0.001). Increasing age (OR 0.984, p < 0.001), higher ISS (OR 0.975, p < 0.001), male sex (OR 0.695, p < 0.001), and penetrating mechanism of injury (OR 0.537, p < 0.001) were associated with reduced survival to discharge. CONCLUSION: After EMS-witnessed traumatic cardiac arrest, survivors were more likely to be young, female, injured by blunt trauma, and less hypotensive/comatose on-scene. These findings may have implications for ED resuscitation or declaration of care futility and should be further investigated with a prospective multicenter study.

Effects of prone positioning on ARDS outcomes of trauma and surgical patients: a systematic review and meta-analysis.

BACKGROUND: Prone position is an option for rescue therapy for acute respiratory distress syndrome. However, there are limited relevant data among trauma and surgical patients, who may be at increased risk for complications following position changes. This study aimed to identify the benefits and risks of proning in this patient subgroup. METHODS: Follow the PRISMA 2020, MEDLINE and EMBASE database searches were conducted. Additional search of relevant primary literature and review articles was also performed. A random effects model was used to estimate the PF ratio, mortality rate, mechanical ventilator days, and intensive care unit length of stay using Review Manager 5.4.1 software. RESULTS: Of 1,128 studies, 15 articles were included in this meta-analysis. The prone position significantly improved the PF ratio compared with the supine position (mean difference, 79.26; 95% CI, 53.38 to 105.13). The prone position group had a statistically significant mortality benefit (risk ratio [RR], 0.48; 95% CI, 0.35 to 0.67). Although there was no significant difference in the intensive care unit length of stay, the prone position significantly decreased mechanical ventilator days (-2.59; 95% CI, -4.21 to -0.97). On systematic review, minor complications were frequent, especially facial edema. There were no differences in local wound complications. CONCLUSIONS: The prone position has comparable complications to the supine position. With its benefits of increased oxygenation and decreased mortality, the prone position can be considered for trauma and surgical patients. A prospective multicenter study is warranted.

Effect of noninvasive respiratory support on interstitial lung disease with acute respiratory failure: A systematic review and meta-analysis.

Background: Primary studies have demonstrated the effectiveness of noninvasive respiratory supports, including noninvasive positive pressure ventilation (NIPPV) and high flow nasal cannula (HFNC), for improving oxygenation and ventilation in patients with interstitial lung diseases (ILDs) and acute respiratory failure (ARF). These studies have not been synthesized and are not included in current practice guidelines. This systematic review with meta-analysis synthesizes studies that compared the effectiveness of NIPPV, HFNC and conventional oxygen therapy (COT) for improving oxygenation and ventilation in ILD patients with ARF. Methods: MEDLINE, EMBASE and the Cochrane Library searches were conducted from inception to August 2023. An additional search of relevant primary literature and review articles was also performed. A random effects model was used to estimate the PF ratio (ratio of arterial oxygen partial pressure to fractional inspired oxygen), PaCO2 (partial pressure of carbon dioxide), mortality, intubation rate and hospital length of stay. Results: Ten studies were included in the systematic review and meta-analysis. Noninvasive respiratory supports demonstrated a significant improvement in PF ratio compared to conventional oxygen therapy (COT); the mean difference was 55.92 (95% CI [18.85-92.99]; p=0.003). Compared to HFNC, there was a significant increase in PF ratio in NIPPV (mean difference 0.45; 95% CI [0.12-0.79]; p=0.008). There were no mortality and intubation rate benefits when comparing NIPPV and HFNC; the mean difference was 1.1; 95% CI [0.83-1.44]; p=0.51 and 1.86; 95% CI [0.42-8.33]; p=0.42, respectively. In addition, there was a significant decrease in hospital length of stay in HFNC compared to NIPPV (mean difference 9.27; 95% Cl [1.45 - 17.1]; p=0.02). Conclusions: Noninvasive respiratory supports might be an alternative modality in ILDs with ARF. NIPPV demonstrated a potential to improve the PF ratio compared to HFNC. There was no evidence to support the benefit of NIPPV or HFNC in terms of mortality and intubation rate.

Examining the independent risk factors for withdrawal of life sustaining treatment in trauma patients.

INTRODUCTION: Withdrawal of life sustaining treatment (WLST) occurs when medical intervention no longer benefits a patient's acute goals for care. The incidence of WLST in the trauma patient population is not well understood. The purpose of this study was to examine the incidence and independent risk factors associated with WLST. METHODS: The Trauma Quality Improvement Program (2017-2018) was utilized. Patients arrived without signs of life or without mortality or WLST data were excluded. Demographics, injury data, and outcomes were analyzed. Categorical variables are presented as number (percentage) and continuous variables as median [interquartile range]. WLST and non-WLST patients were compared. Early (<24 h) WLST patients were compared to all other WLST patients. RESULTS: Of 749,754 patients, 35,464 (4.7 %) died. Of these, 19,424 (2.6 %) died after WLST, constituting 54.8 % of all deaths. Median age was 67 [50-79], 67.6 % male, 17,557 (90.4 %) blunt injuries, 11,334 (58.4 %) GCS < 9. Median ISS 26 [17-30]. Median head AIS 4 (3-5). The WLST group had a much higher incidence of elderly (60+) patients (65.1% vs 41.0 %), blunt mechanism of injury (90.4% vs 76.9 %) and hypertension (43.5% vs 26.5 %). Black patients (8.2% vs 19.5 %) and Hispanic patients (7.9% vs 12.2 %) were less likely to undergo WLST. On multivariate analysis, patients 80+ years old (OR 12.939, p < 0.001), GCS < 9 (OR 15.621, p < 0.001), and head AIS = 5, head AIS = 6 (OR 3.886, p < 0.001 and OR 5.283, p < 0.001) were independently associated with WLST. GCS < 9 (OR 4.006, p < 0.001) and penetrating injury (OR 2.825, p < 0.001) were independently associated with early WLST within 24 h. CONCLUSIONS: More than half who die from trauma undergo withdrawal of life sustaining treatment. Elderly patients and those with severe TBI and low GCS scores are at high risk of experiencing withdrawal of life sustaining treatment. Further prospective evaluation is warranted.

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.

Surgical mask-to-mouth ventilation as an alternative ventilation technique during CPR: A crossover randomized controlled trial.

INTRODUCTION: Chest compression with rescue breathing improves outcomes in cardiac arrest. However, the efficacy of rescue breathing through surgical masks has not been investigated. OBJECTIVE: We aimed to compare the tidal volume generated by mouth-to-mouth ventilation (MMV) with that generated by surgical mask-to-mouth ventilation (SMV), mouth-to-surgical mask ventilation (MSV), and surgical mask-to-surgical mask ventilation (SSV) in a manikin. METHODS: A crossover randomized controlled trial was conducted in 42 medical personnel volunteers randomly assigned to perform four ventilation techniques: MMV (no protective equipment), SMV (participant wearing a mask), MSV (manikin wearing a mask), and SSV, (both participant and manikin wearing a mask). The average tidal volume and the proportion of adequate ventilation, evaluated using a manikin, were compared across different ventilation methods. RESULTS: The average tidal volume of MMV (828 ± 278 ml) was significantly higher than those of the MSV (648 ± 250 ml, P < 0.001) and SSV (466 ± 301 ml, P < 0.001), but not SMV (744 ± 288 ml, P = 0.054). Adequate ventilation was achieved in 144/168 (85.7%) cases in the MMV group, a proportion significantly higher than in the SMV (77.4%, P = 0.02), MSV (66.7%, P < 0.001) and SSV (39.3%, P < 0.001) groups. The willingness to perform SMV was higher than that to perform MMV. CONCLUSIONS: MMV resulted in a superior average tidal volume when compared to both MSV and SSV. However, SMV achieved a comparable average tidal volume to MMV.

Recent changes in practice patterns and outcomes in patients with severe traumatic brain injury.

BACKGROUND: Despite recent advances in the management of severe traumatic brain injury, the role of decompressive craniectomy remains unclear. The purpose of this study was to compare practice patterns and patient outcomes between 2 study periods over the past decade. METHODS: This is a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Project database. We included patients (age ≥18 years) with isolated severe traumatic brain injury. The patients were divided into the early (2013-2014) and late (2017-2018) groups. The primary outcome was the rate of craniectomy, and secondary outcomes included in-hospital mortality and discharge disposition. A subgroup analysis of patients undergoing intracranial pressure monitoring was also performed. A multivariable logistic regression analysis assessed the association between the early/late period and study outcomes. RESULTS: A total of 29,942 patients were included. In the logistic regression analysis, the late period was associated with decreased use of craniectomy (odds ratio: 0.58, P < .001). Although the late period was associated with higher in-hospital mortality (odds ratio: 1.10, P = .013), it was also associated with a higher likelihood of discharge to home/rehab (odds ratio: 1.61, P < .001). Similarly, the subgroup analysis of patients with intracranial pressure monitoring showed that the late period was associated with a lower craniectomy rate (odds ratio: 0.26, P < .001) and a higher likelihood of discharge to home/rehab (odds ratio:1.98, P < .001). CONCLUSION: The use of craniectomy for severe traumatic brain injury has decreased over the study period. Although further studies are warranted, these trends may reflect recent changes in the management of patients with severe traumatic brain injury.

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.

Epidemiology, repair technique, and predictors of stroke and mortality in penetrating carotid artery injuries.

OBJECTIVE: Penetrating carotid artery injuries (PCAI) are significantly morbid and deadly, often presenting in extremis with associated injuries and central nervous system deficit. Repair may be challenging with arterial reconstruction vs ligation role poorly defined. This study evaluated contemporary outcomes and management of PCAI. METHODS: PCAI patients in the National Trauma Data Bank from 2007 to 2018 were analyzed. Outcomes were compared between repair and ligation groups after additionally excluding external carotid injuries, concomitant jugular vein injuries, and head/spine Abbreviated Injury Severity score of ≥3. Primary end points were in-hospital mortality and stroke. Secondary end points were associated injury frequency and operative management. RESULTS: There were 4723 PCAI (55.7% gunshot wounds, 44.1% stab wounds). Gunshot wounds more frequently had associated brain (73.8% vs 19.7%; P < .001) and spinal cord (7.6% vs 1.2%; P < .001) injuries; stab wounds more frequently had jugular vein injuries (19.7% vs 29.3%; P < .001). The overall in-hospital mortality was 21.9% and the stroke rate was 6.2%. After exclusion criteria, 239 patients underwent ligation and 483 surgical repair. Ligation patients had lower presenting Glasgow Coma Scale (GCS) than repair patients (13 vs 15; P = .010). Stroke rates were equivalent (10.9% vs 9.3%; P = .507); however, in-hospital mortality was higher after ligation (19.7% vs 8.7%; P < .001). In-hospital mortality was higher in ligated common carotid artery injuries (21.3% vs 11.6%; P = .028) and internal carotid artery injuries (24.5% vs 7.3%; P = .005) compared with repair. On multivariable analysis, ligation was associated with in-hospital mortality, but not with stroke. A history of neurological deficit before injury lower GCS, and higher Injury Severity Score (ISS) were associated with stroke; ligation, hypotension, higher ISS, lower GCS, and cardiac arrest were associated with in-hospital mortality. CONCLUSIONS: PCAI are associated with a 22% rate of in-hospital mortality and a 6% rate of stroke. In this study, carotid repair was not associated with a decreased stroke rate, but did have improved mortality outcomes compared with ligation. The only factors associated with postoperative stroke were low GCS, high ISS, and a history of neurological deficit before injury. Beside ligation, low GCS, high ISS, and postoperative cardiac arrest were associated with in-hospital mortality.

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.

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.

Pseudoaneurysm after High-Grade Penetrating Solid Organ Injury and Utility of Delayed CT Angiography.

BACKGROUND: Leaving an injured solid organ in situ allows preservation of structure function but invites complications from the damaged parenchyma, including pseudoaneurysms (PSAs). Empiric PSA screening after solid organ injury is not yet established, particularly following penetrating trauma. The study objective was definition of delayed CT angiography (dCTA) yield in triggering intervention for PSA after penetrating solid organ injury. METHODS: Penetrating trauma patients at our American College of Surgeons-verified level 1 center with American Association for the Surgery of Trauma grade ≥3 abdominal solid organ injury (liver, spleen, kidney) were retrospectively screened (January 2017 to October 2021). Exclusions were age <18 y, transfers, death within <48 h, and nephrectomy/splenectomy within <4 h. Primary outcome was intervention triggered by dCTA. Statistical testing with ANOVA/chi-square compared outcomes between screened vs unscreened patients. RESULTS: A total of 136 penetrating trauma patients met study criteria: 57 patients (42%) screened for PSA with dCTA and 79 (58%) unscreened. Liver injuries were most common (n = 41, 64% vs n = 55, 66%), followed by kidney (n = 21, 33% vs n = 23, 27%) and spleen (n = 2, 3% vs n = 6, 7%) (p = 0.48). Median American Association for the Surgery of Trauma grade of solid organ injury was 3 (3 to 4) across groups (p = 0.75). dCTA diagnosed 10 PSAs (18%) at a median of hospital day 5 (3 to 9). Among screened patients, dCTA triggered intervention in 17% of liver patients, 29% of kidney patients, and 0% of spleen-injured patients, for an overall yield of 23%. CONCLUSIONS: Half of eligible penetrating high-grade solid organ injuries were screened for PSA with dCTA. dCTA identified a significant number of PSAs and triggered intervention in 23% of screened patients. dCTA did not diagnose any PSAs after splenic injury, although sample size hinders interpretation. To avoid missing PSAs and incurring their risk of rupture, universal screening of high-grade penetrating solid organ injuries may be prudent.

Pseudoaneurysms after high-grade blunt solid organ injury and the utility of delayed computed tomography angiography.

PURPOSE: Pseudoaneurysms (PSA) can occur following high-grade solid organ injury. PSA natural history is unclear but risk for spontaneous rupture and exsanguination exist. The yield of delayed CT Angiography (dCTA) for PSA diagnosis is not well delineated and optimal timing is undefined. The study objective was definition of dCTA utility in diagnosing and triggering intervention for PSA after high-grade blunt solid organ injury. METHODS: All blunt trauma patients arriving to our ACS-verified Level 1 trauma center with AAST grade ≥ III liver, spleen, and/or kidney injury were included in this retrospective observational study (01/2017-10/2021). Exclusions were age < 18 year, transfers in, death < 48 h, and immediate nephrectomy/splenectomy. dCTA performance was not protocolized and pursued at attending surgeon discretion. Demographics, clinical/injury data, and outcomes were collected. Primary outcome was dCTA-triggered intervention. Statistical testing with ANOVA/Chi squared compared outcomes by type of solid organ. RESULTS: 349 blunt trauma patients with 395 high-grade solid organ injuries met study criteria. Median AAST grade of solid organ injury was 3 [3-4]. dCTA for PSA screening was pursued in 175 patients (44%), typically on hospital day 4 [3-7]. dCTA identified vascular lesions in 16 spleen, 10 liver, and 6 kidney injuries. dCTA triggered intervention in 24% of spleen, 13% of kidney, and 9% of liver injured patients who were screened, for an overall yield of 14%. Intervention was typically AE (n = 23, 92%), although two splenic PSA necessitated splenectomy. CONCLUSION: Delayed CTA for PSA screening after high-grade blunt solid organ injury was performed in half of eligible patients. dCTA identified numerous vascular lesions requiring endovascular or surgical intervention, with highest yield for splenic injuries. We recommend consideration of universal screening of high-grade blunt solid organ injuries with delayed abdominal CTA to avoid missing PSA.

Emergency physician and nurse discretion accurately triage high-risk trauma patients.

PURPOSE: Prehospital trauma team activation (TTA) criteria allow for early identification of severely injured trauma patients. Although most TTA criteria are objective, one TTA criterion is subjective: emergency provider discretion. The study objective was to define the ability of emergency department physician and nurse discretion to accurately perform prehospital triage of high risk trauma patients. METHODS: All highest level TTAs arriving to our American College of Surgeons (ACS)-verified Level 1 trauma center (06/2015-08/2020) were included. Exclusions were undocumented prehospital vitals or discharge disposition. At our institution, TTAs are triggered for standard ACS TTA criteria and age > 70 with traumatic mechanism other than ground level fall. Patients meeting ≥ 1 criterion apart from "Emergency Provider Discretion" were defined as Standard TTAs and patients meeting only "Emergency Provider Discretion" were defined as Discretion TTAs. Univariable/multivariable analyses compared injury data and outcomes. RESULTS: 4540 patients met inclusion/exclusion criteria: 3330 (73%) Standard TTAs and 1210 (27%) Discretion TTAs. Discretion TTAs were younger (34 vs. 37 years, p < 0.001) and more frequently injured by penetrating trauma (38% vs. 33%, p = 0.008), particularly stab wounds (64% vs. 29%). Overtriage rates were comparable after Discretion vs. Standard TTAs (33% vs. 31%, p = 0.141). Blood transfusion < 4 h (31% vs. 32%, p = 0.503) and ICU admission ≥ 3 days (25% vs. 27%, p = 0.058) were comparable between groups. Discretion TTA was independently associated with increased need for emergent surgery (OR 1.316, p = 0.005). CONCLUSIONS: Emergency provider discretion accurately identifies major trauma, with comparable rates of overtriage as standard TTA criteria. Discretion TTAs were as likely as Standard TTAs to require early blood transfusion and prolonged ICU stay. After controlling for confounders, Discretion TTAs were significantly more likely to require emergent surgical intervention. Emergency provider discretion should be recognized as a valid method of identifying major trauma patients at high risk of need for intervention.

Therapeutic Interventions and Outcomes in Civilian and Military Isolated Gunshot Wounds to the Head: A Department of Defense Trauma Registry and ACS TQIP-matched Study.

OBJECTIVE: The purpose of this study was to compare therapeutic strategies and outcomes, following isolated gunshot wounds of the head, between military and civilian populations. BACKGROUND: Recent military conflicts introduced new concepts in trauma care, including aggressive surgical intervention in severe head trauma. METHODS: This was a cohort-matched study, using the civilian Trauma Quality Improvement Program (TQIP) database of the American College of Surgeons (ACS) and the Department of Defense Trauma Registry (DoDTR), during the period 2013 to 2016. Included in the study were patients with isolated gunshots to the head. Exclusion criteria were dead on arrival, civilians transferred from other hospitals, and patients with major extracranial associated injuries (body area Abbreviated Injury Scale >3). Patients in the military database were propensity score-matched 1:3 with patients in the civilian database. RESULTS: A total of 136 patients in the DoDTR database were matched for age, sex, year of injury, and head Abbreviated Injury Scale with 408 patients from TQIP. Utilization of blood products was significantly higher in the military population ( P <0.001). In the military group, patients were significantly more likely to have intracranial pressure monitoring (17% vs 6%, P <0.001) and more likely to undergo craniotomy or craniectomy (34% vs 13%, P <0.001) than in the civilian group. Mortality in the military population was significantly lower (27% vs 38%, P =0.013). CONCLUSIONS: Military patients are more likely to receive blood products, have intracranial pressure monitoring and undergo craniectomy or craniotomy than their civilian counterparts after isolated head gunshot wounds. Mortality is significantly lower in the military population. LEVEL OF EVIDENCE: Level III-therapeutic.

Urgent Breast-Related Consults Seen by Acute Care Surgery at a Safety Net Hospital.

BACKGROUND: Classically, urgent breast consults are seen by Breast Surgery or Surgical Oncology (BS/SO). At our safety net hospital, Acute Care Surgery (ACS) performs all urgent surgical consultations, including initial assessment of breast consults with coordinated BS/SO follow-up. The objective was to determine safety of ACS initial assessment of acute breast pathology. METHODS: All urgent breast-related consultations were included (2016-2019). Demographics, consult indications, and investigations/interventions were captured. Outcomes were compared between patients assessed by ACS versus both ACS and BS/SO at presentation. RESULTS: 234 patients met study criteria, with median age 39 years. Patients were primarily Hispanic (82%) women (96%). Most were not seen by BS/SO at presentation (69%), although BS/SO assessment was more frequent among patients ultimately diagnosed with cancer (8% vs 1%, P = .012). No patient had delay >90 days to core biopsy from presentation. Outcomes including time to cancer diagnosis (14 vs 8 days, P = .143) and outpatient BS/SO assessment (16 vs 13 days, P = .528); loss to follow-up (25% vs 21%, P = .414); and ED recidivism (24% vs 18%, P = .274) were comparable between patients seen by ACS versus ACS/BS/SO at index presentation. CONCLUSION: Urgent breast consults at our safety net hospital typically underwent initial assessment by ACS with outpatient evaluation by BS/SO. Time to follow-up and cancer diagnosis, loss to follow-up, and ED recidivism were similar after index presentation assessment by ACS versus ACS and BS/SO. In a resource-limited environment, urgent breast consults can be safely managed in the acute setting by ACS with coordinated outpatient BS/SO follow-up.

Does mortality after trauma team activation peak at shift change?

BACKGROUND: Prior institutional data have demonstrated trauma mortality to be highest between 06:00-07:59 at our center, which is also when providers change shifts (07:00-07:30). The objective was definition of patient, provider, and systems variables associated with trauma mortality at shift change among patients arriving as trauma team activations (TTA). METHODS: All TTA patients at our ACS-verified Level I trauma center were included (01/2008-07/2019), excluding those with undocumented arrival time. Study groups were defined by arrival time: shift change (SC) (06:00-07:59) vs. non-shift change (NSC) (all other times). Univariable/multivariable analyses compared key variables. Propensity score analysis compared outcomes after matching. RESULTS: After exclusions, 6020 patients remained: 229 (4%) SC and 5791 (96%) NSC. SC mortality was 25% vs. 16% during NSC (p < 0.001). More SC patients arrived with SBP <90 (19% vs. 11%, p < 0.001) or GCS <9 (35% vs. 24%, p < 0.001). ISS was higher during SC (43[32-50] vs. 34[27-50], p < 0.001). Time to CT scan (36[23-66] vs. 38[23-61] minutes, p = 0.638) and emergent surgery (94[35-141] vs. 63[34-107] minutes, p = 0.071) were comparable. Older age (p < 0.001), SBP <90 (p < 0.001), GCS <9 (p < 0.001), need for emergent operative intervention (p = 0.044), and higher ISS (p < 0.001) were independently associated with mortality. After propensity score matching, mortality was no different between SC and NSC (p = 0.764). CONCLUSIONS: Early morning is a low-volume, high-mortality time for TTAs. Increased mortality at shift change was independently associated with patient/injury factors but not provider/systems factors. Ensuring ample clinical resource allocation during this high acuity time may be prudent to streamline patient care at shift change.