Prehospital tourniquet placement in extremity trauma.

BACKGROUND: Extremity tourniquets (ET) use has increased in trauma systems to manage traumatic hemorrhage. This study aims to evaluate prehospital ET placement. METHODS: This is a retrospective review of a prospectively collected cohort of 211 adult patients who underwent prehospital ET placement over 3 ½ years. Data regarding ET placement was analyzed regarding ET applier, reported indications, extremity appearance at arrival and outcomes. RESULTS: A total of 211 patients had completed data sheets. Of these patients, 63.2% had no other intervention prior to ET placement. On arrival, nearly 1/3 of the patients had palpable pulses with ET in place and less than ½ had arterial bleeding upon ET release. DISCUSSION/CONCLUSIONS: This study shows that ET are frequently used as the initial intervention in the field. It is of paramount importance that we adapt our first responders training to teach wound assessment and appropriate steps in management of extremity hemorrhagic trauma.

Enhancing utility of interfacility triage guidelines using machine learning: Development of the Geriatric Interfacility Trauma Triage score.

BACKGROUND: Undertriage of injured older adults to tertiary trauma centers (TTCs) has been demonstrated by many studies. In predominantly rural regions, a majority of trauma patients are initially transported to nontertiary trauma centers (NTCs). Current interfacility triage guidelines do not highlight the hierarchical importance of risk factors nor do they allow for individual risk prediction. We sought to develop a transfer risk score that may simplify secondary triage of injured older adults to TTCs. METHODS: This was a retrospective prognostic study of injured adults 55 years or older initially transported to an NTC from the scene of injury. The study used data reported to the Oklahoma State Trauma Registry between 2009 and 2019. The outcome of interest was either mortality or serious injury (Injury Severity Score, ≥16) requiring an interventional procedure at the receiving facility. In developing the model, machine-learning techniques including random forests were used to reduce the number of candidate variables recorded at the initial facility. RESULTS: Of the 5,913 injured older adults initially transported to an NTC before subsequent transfer to a TTC, 32.7% (1,696) had the outcome of interest at the TTC. The final prognostic model (area under the curve, 75.4%; 95% confidence interval, 74-76%) included the following top four predictors and weighted scores: airway intervention (10), traffic-related femur fracture (6), spinal cord injury (5), emergency department Glasgow Coma Scale score of ≤13 (5), and hemodynamic support (4). Bias-corrected and sample validation areas under the curve were 74% and 72%, respectively. A risk score of 7 yields a sensitivity of 78% and specificity of 56%. CONCLUSION: Secondary triage of injured older adults to TTCs could be enhanced by use of a risk score. Our study is the first to develop a risk stratification tool for injured older adults requiring transfer to a higher level of care. LEVEL OF EVIDENCE: Prognostic and Epidemiolgical; Level III.

Clinical diagnosis of cholecystitis in emergency department patients with cholelithiasis is indication for urgent cholecystectomy: A comparison of clinical, ultrasound, and pathologic diagnosis.

BACKGROUND: Biliary pathology is a common reason for emergency department visits with discharge and outpatient follow up if sonographic evaluation does not reveal evidence of cholecystitis. This retrospective review was conducted to assess the sensitivity of clinical versus sonographic evaluation for indication of urgent cholecystectomy. METHODS: Retrospective chart review of 308 patients who presented to the emergency department (ED) with right upper quadrant (RUQ) pain and cholelithiasis whom underwent cholecystectomy. The history and physical exam, laboratory values, ultrasound (US), and final surgical pathology were compared for accuracy of clinical to pathologic diagnosis. RESULTS: 95.5% of our patients that presented to the ED secondary to RUQ pain with cholelithiasis had pathologic cholecystitis. Sensitivity of clinical diagnosis was superior to US findings as compared to pathologic diagnosis of cholecystitis at 96% vs 44% and 87% vs 18% for acute (AC) and chronic cholecystitis (CC) respectively. CONCLUSION: RUQ pain with known cholelithiasis lasting longer than 4 hours is sensitive for pathologic cholecystitis. This finding, even with the absence of sonographic evidence of cholecystitis, is indication for index encounter urgent cholecystectomy.

Trauma transfers discharged from the emergency department-Is there a role for telemedicine?

BACKGROUND: As the only Level I trauma center in the state, our hospital has seen an increase in the number of traumas requiring transfer for a higher level of care, placing strain on an already strained health care system. Traumas that are transferred to our facility and subsequently discharged back home indicate a subset of patients who may not be appropriate to transfer. The aim of this study is to identify commonalities between patients who were transferred for a higher level of care but do not require inpatient status and to assess patients who may benefit from a telemedicine evaluation. METHODS: A 2-year retrospective review of a prospective collected database of patients who were discharged from the ED following transfer to a Level I trauma center was conducted. Data included demographics, injuries, transferring facility, method of transport, activation criteria and level, additional imaging, consulting services, procedures, and disposition. RESULTS: A total of 2,350 patients were transferred. Of those, 27% (632/2,350) were discharged home directly from the trauma bay. Of those patients, 36% (230/632) required complex bedside intervention or subspecialty consultation prior to discharge including complex laceration repairs 53%, ophthalmology examination 24%, splinting 18%, and joint reduction 5%. Sixty-four percent (402/632) of patients did not require complex bedside procedures prior to discharge. One hundred twenty hospitals transferred patients to our center during this period. The top 10 transferring facilities accounted for 40% (948/2,350) of our transfer volume. CONCLUSION: Our study demonstrates that patients who are transferred to our facility and subsequently discharged have a common pattern of injuries; typically, isolated hand and face/ophthalmology. This is likely attributed to the lack of resources in rural facilities to evaluate and develop treatment plans for these injuries; however, only 36% of discharged patients required a bedside procedure. Excluding Level I traumas, head and spine injuries, and patients requiring complex bedside procedures, there was a 13% inappropriate rate of transfer (310/2,350). Development and implementation of a telemedicine system could potentially reduce the transfer and ED discharge rate, thereby improving efficiency and allowing for reallocation of resources as appropriate. LEVEL OF EVIDENCE: Prognostic and Epidemiologic, Level III.

Management of blunt traumatic abdominal wall hernias: A Western Trauma Association multicenter study.

BACKGROUND: Blunt traumatic abdominal wall hernias (TAWH) occur in approximately 15,000 patients per year. Limited data are available to guide the timing of surgical intervention or the feasibility of nonoperative management. METHODS: A retrospective study of patients presenting with blunt TAWH from January 2012 through December 2018 was conducted. Patient demographic, surgical, and outcomes data were collected from 20 institutions through the Western Trauma Association Multicenter Trials Committee. RESULTS: Two hundred and eighty-one patients with TAWH were identified. One hundred and seventy-six (62.6%) patients underwent operative hernia repair, and 105 (37.4%) patients underwent nonoperative management. Of those undergoing surgical intervention, 157 (89.3%) were repaired during the index hospitalization, and 19 (10.7%) underwent delayed repair. Bowel injury was identified in 95 (33.8%) patients with the majority occurring with rectus and flank hernias (82.1%) as compared with lumbar hernias (15.8%). Overall hernia recurrence rate was 12.0% (n = 21). Nonoperative patients had a higher Injury Severity Score (24.4 vs. 19.4, p = 0.010), head Abbreviated Injury Scale score (1.1 vs. 0.6, p = 0.006), and mortality rate (11.4% vs. 4.0%, p = 0.031). Patients who underwent late repair had lower rates of primary fascial repair (46.4% vs. 77.1%, p = 0.012) and higher rates of mesh use (78.9% vs. 32.5%, p < 0.001). Recurrence rate was not statistically different between the late and early repair groups (15.8% vs. 11.5%, p = 0.869). CONCLUSION: This report is the largest series and first multicenter study to investigate TAWHs. Bowel injury was identified in over 30% of TAWH cases indicating a significant need for immediate laparotomy. In other cases, operative management may be deferred in specific patients with other life-threatening injuries, or in stable patients with concern for bowel injury. Hernia recurrence was not different between the late and early repair groups. LEVEL OF EVIDENCE: Therapeutic/care management, Level IV.

The worst-case scenario: Bridging repair with a biologic mesh in high-risk patients with very large abdominal wall hernias-a prospective multicenter study.

BACKGROUND: While modern techniques allow midline fascial closure for most abdominal hernias, a bridge repair with mesh may be the only alternative in very large defects. When the risk of infection is high, the use of prosthetic mesh is controversial. We aim to examine outcomes after bridge repair of very large abdominal hernias at high risk for postoperative infection with a second-generation biologic mesh. METHODS: Prospective, multicenter, single-arm study of patients with very large abdominal hernias who received bridge repair with a neonatal bovine dermis mesh. Primary outcome was hernia recurrence, as identified on computed tomography 1 year after the operation. Secondary outcomes included mesh laxity, surgical site occurrences, and any other mesh-related complications. Independent risk factors of the outcomes were determined by univariate and multivariable analyses. RESULTS: A total of 117 bridge repair patients were enrolled with a mean defect size of 442.5 ± 254.2 cm2. The patients were predominantly obese (mean body mass index 36.5 ± 10.5) and with multiple comorbidities (Charlson comorbidity index 3 ± 2.5). Hernia recurrence was identified in 24 (20.5%) patients. An infected mesh at the index operation was an independent predictor of hernia recurrence, whereas obesity was an independent predictor of the pooled endpoint of recurrence and mesh laxity. Surgical site occurrences were recorded in 36.8% of the patients, and no independent risk factors were identified. CONCLUSION: In patients with very large abdominal hernias and at high risk for postoperative infection, who cannot undergo midline fascial closure, a bridge repair with neonatal bovine dermis mesh offers an acceptable profile in terms of hernia recurrence and wound occurrences.

Association of Interfacility Helicopter versus Ground Ambulance Transport and in-Hospital Mortality among Trauma Patients.

BACKGROUND: Relatively few studies have compared outcomes between helicopter transport (HT) and ground transport (GT) for the inter-facility transfer of trauma patients to tertiary trauma centers (TTC). Mixed results have been reported from these studies ranging from a slight increase in odds of survival for the severely injured to no evident benefit for HT patients. We hypothesized there was no adjusted difference in mortality between patients transported interfacility by HT or GT taking into account distance from TTC. METHODS: Data from an inclusive statewide trauma registry was used to conduct a retrospective cohort study of adult (18+ years old) trauma patients who initially presented to a non-tertiary trauma center (NTC) before subsequent transfer by HT or GT to a TTC. Records from the NTC and TTC were linked (N = 9880). We used propensity adjusted, multivariable Cox proportional hazards models to assess the association of HT on mortality at 72-hour and within the first 2 weeks of arrival at a TTC; these multivariable analyses were stratified by distance (miles) between NTC and TTC: 21-90, and greater than 90. RESULTS: Mean distance between NTC and TTC was greater for HT patients, 96.7 miles versus 69.9 miles for GT. A higher proportion of patients among the HT group had an ISS of 16 or higher (24.6% vs 10.9%), an initial SBP < 90 mmHg (7.3% vs 2.8%), and GCS < 10 (12.5% vs 3.7%) than the GT group. HT was associated with significantly decreased 72-hour mortality (HR 0.65, 95%CI 0.48-0.90) for patients transferred from a NTC <90 miles from the TTC. No association was seen for patients transferred more than 90 miles to the TTC. No significant association of HT and 2-week mortality was seen at any distance from the TTC. CONCLUSIONS: Only for patients transferred from an NTC <90 miles from the receiving TTC was HT associated with a significantly decreased hazard of mortality in the first 72 hours. Many HT patients, especially from the most distant NTCs, had minor injuries and normal vital signs at both the NTC and TTC suggesting the decision to use HT for these patients was resource-driven rather than clinical.

Effect of Post-splenectomy Booster Vaccine Program on Vaccination Compliance in Trauma Patients.

OBJECTIVE: In 2012, the Centers for Disease Control and Prevention (CDC) Advisory Council on Immunization Practice recommended an additional post-splenectomy booster vaccine at 8 weeks following the initial vaccine. The objective of this study was to evaluate our vaccination compliance rate and what sociodemographic factors were associated with noncompliance following this recommendation. MATERIALS AND METHODS: A retrospective review of a performance improvement database of trauma patients eligible for post-splenectomy vaccination (PSV) at a level I trauma center was carried out between 2009 and 2018. Overall and institutional compliance with PSV was compared before and after the addition of booster vaccine recommendation. Factors associated with booster noncompliance were also identified. RESULTS: A total of 257 patients were identified. PSV compliance rate in the pre-booster was 98.4%, while overall and institutional post-booster compliance rate were significantly lower at 66.9% (P ≤ .001) and 50.0% (P ≤ .001), respectively. Compared to booster institutional compliers, institutional noncompliers lived farther from the trauma center (48 vs. 86 miles, P = .02), and though not statistically significant, these patients were generally older (34.9 vs. 40.5, P = .05). DISCUSSION: PSV booster compliance is low even with the current educational materials and recommendations. Additional approaches to improve compliance rates need to be implemented, such as sending letters to the patient and their primary care providers (PCPs), collaborating with rehab/long-term acute care centers, communicating with city and county health departments and city pharmacies, or mirroring other countries and creating a national database for asplenic patients to provide complete information.

Survival Benefit of Treatment at or Transfer to a Tertiary Trauma Center among Injured Older Adults.

Objective: It is well established that seriously injured older adults are under-triaged to tertiary trauma centers. However, the survival benefit of tertiary trauma centers (TC) compared to a non-tertiary trauma centers (Non-TCs) remains unclear for this patient population. Using improved methodology and a larger sample, we hypothesized that there was a difference in hospital mortality between injured older adults treated at TCs and those treated at Non-TCs. Methods: This was a retrospective cohort study of injured older adults (> =55 years) reported to the Oklahoma statewide trauma registry between 2005 and 2014. The outcome of interest was 30-day in-hospital mortality and the exposure variable of interest was level of definitive trauma care (TC vs Non-TC). Overall survival benefit of treatment at a TC as well as the survival benefit of transferring injured older adults to a TC were evaluated using multivariable survival analyses as well as propensity score-adjusted analyses. Results: Of the 25,288 patients eligible for analysis, 43% (10,927) were treated at TCs. Multivariable Cox regression analyses revealed effect modification by age group and time. After adjusting for potential confounders within the age strata, overall, patients treated at TCs were significantly less likely to die within 7 days of admission and this effect was stronger for patients aged 55-64 years (HR 0.41, 95% CI 0.31-0.52) compared to those > =65 years (HR 0.62, 95% CI 0.55-0.70). Overall survival benefit of TCs beyond 7 days was also observed (HR 0.68, 95% CI 0.56-0.83). Similarly, for the survival benefit of transferring injured older adults, after adjusting for the propensity to be transferred and other confounders, transfer to a TC was associated with lower 30-day mortality both for patients less than 65 years old (HR 0.36, 95% CI: 0.27-0.49) and those 65 years and older (HR 0.55, 95% CI: 0.48-0.64). Conclusions: Our results suggest a survival benefit for injured older adults treated at TCs. This benefit was also observed for patients transferred from non-tertiary trauma centers. Further research should focus on identifying specific subgroups of patients who would especially benefit from this level of care to minimize trauma triage inefficiencies.

Delayed splenic hemorrhage: Myth or mystery? A Western Trauma Association multicenter study.

BACKGROUND: Multi-detector computed tomography imaging is now the reference standard for identifying solid organ injuries, with a high sensitivity and specificity. However, delayed splenic hemorrhage (DSH), defined as no identified injury to the spleen on the index scan but delayed bleeding from a splenic injury, has been reported. We hypothesized that the occurrence of DSH would be minimized by utilization of modern imaging techniques. METHODS: Data was retrospectively collected from 2006 to 2016 in 12 adult Level I and II trauma centers. All patients had an initial CT scan demonstrating no splenic injury but subsequently were diagnosed with splenic bleeding. Demographic, injury characteristics, imaging parameters and results, interventions and outcomes were collected. RESULTS: Of 6867 patients with splenic injuries, 32 cases (0.4%) of blunt splenic hemorrage were identified. Patients were primarily male, had blunt trauma, severely injured (ISS 32 (9-57) and with associated injuries. Injuries of all grades were identified up to 16 days following admission. Overall, half of patients required splenectomy. All index images were obtained using multi-detector CT (16-320 slice). Secondary review of imaging by two trauma radiologists judged 72% (n = 23) of scans as suboptimal. This was due to poor scan quality primary from artifact(23), single phase contrast imaging (16), and/or poor contrast bolus timing or volume (6). Notably, only 28% of scans in patients with DSH were performed with optimal scanning techniques. CONCLUSION: This is the largest reported series of DSH in the era of modern imaging. Although the incidence of DSH is low, it still occurs despite the use of multi-detector imaging and when present, is associated with a high rate of splenectomy. Most cases of DSH can be attributed to missed diagnosis from suboptimal index imaging and ultimately be avoided.

Removal of retrievable inferior vena cava filters before discharge: Is it associated with increased incidence of pulmonary embolism?

BACKGROUND: Severely injured trauma patients are at high risk of developing deep venous thrombosis and pulmonary emboli (PE), and may have contraindications to prophylactic or therapeutic anticoagulation. Retrievable inferior vena cava filters (rIVCFs) are used to act as a mechanical obstruction to prevent PE in high risk populations and those with deep venous thrombosis who cannot be anticoagulated. The removal rate of rIVCFs is variable in trauma centers, including our previous published rate of 50% to 89%/year. Indwelling filters carry a risk of significant morbidity and the success of retrieval decreases as the dwell time increases. We hypothesized that once patients could receive appropriate prophylactic or therapeutic anticoagulation, rIVCF could be removed before hospital discharge without impact on occurrence or recurrence of PE. METHODS: All trauma patients with rIVCF placed and removed between January 2006 and August 2018 were reviewed. We collected data from record review from admission to 6 months postfilter removal, including demographics, filter indication, filter type, dwell time, placement and removal complications, antithrombosis medications, location of venous thromboembolism, complications, and discharge disposition. Exposure of interest was timing of filter removal: before (BEF) or after hospital discharge (AFT). The outcome of interest was whether the patient had a documented PE within 6 months of filter removal. RESULTS: A total of 281 rIVCFs were placed, 218 were eligible for removal, 72.4% (158/218) were retrieved with 63% (100/158) removed before discharge. Mean filter duration was 26 days and 103 days for the before and after groups, respectively. No differences (p > 0.05) were noted in the distribution of demographic and clinical factors except for filter indication (venous thromboembolism indication, 95% in AFT vs. 74% in BEF, p = 0.0043). Postremoval PE rates were 0% BEF and 1% AFT (Fisher's exact test, p = 1.000). CONCLUSION: Our results suggest that removal of rIVCFs before discharge once patients are appropriately anticoagulated is a safe strategy to improve retrieval rates. LEVEL OF EVIDENCE: Therapeutic, level V.

Equivalent outcomes with once versus thrice weekly dressing changes in midline laparotomy wounds treated with negative pressure wound therapy.

BACKGROUND: While negative pressure wound therapy (NPWT) has been used for decades, there is a paucity of data regarding the appropriate length of time between dressing changes. METHODS: This was a prospective, randomized control trial examining time to wound closure in open midline laparotomy wounds treated with NPWT. The control group received the standard thrice weekly sponge changes (thrice) and the treatment group received once weekly sponge changes (once). RESULTS: 44 patients met study criteria over a 3-year period. There was no difference in NPWT duration between the two groups (37.1 vs 34.7 days, p = 0.7324), even after adjusting for potential confounders (p = 0.8091). No differences were found in initial wound size or reduction. The wound complication profile was similar for both groups. CONCLUSION: There is no difference in time to wound closure or complications with NPWT dressing changes once a week compared to the standard three times a week.

The paralyzing effect of insurance status on throughput of acute spinal cord patients.

OBJECTIVE: To determine whether lack of insurance is a predictor of poor outcomes and increased healthcare expenditure for SCI patients. METHODS: Retrospective cohort study of trauma patients admitted with an acute, severe (AIS ≥ 3) SCI and admission score of ASIA-A to a Level 1 trauma center (2012-2016). Patient characteristics and outcomes (LOS, complications) were compared between insured and uninsured patients. Multivariable adjustment was performed using linear regression. RESULTS: Of 76 patients who met eligibility, 44 had insurance and 32 were uninsured (NOINSUR). Despite having similar ventilator days (13 vs. 12.1) and ICU LOS (20.1 vs. 16.8), the NOINSUR group had more ventilator-free days (22.3 vs 6.6; p < 0.0001), longer Stepdown Unit length of stay (10.2 vs 2.3; p = 0.0036), and a longer hospital length of stay (35.3 vs 18.7; p = 0.0062). CONCLUSION: Uninsured SCI patients face longer hospital LOS due to their insurance status and lack of funding for timely rehabilitation placement. This utilizes valuable hospital resources and puts them at risk for hospital related complications and further increased healthcare expenditures.

Out-of-hospital and Inter-hospital Under-triage to Designated Tertiary Trauma Centers among Injured Older Adults: A 10-year Statewide Geospatial-Adjusted Analysis.

OBJECTIVE: While out-of-hospital under-triage of seriously injured older adults to tertiary trauma centers has long been acknowledged, no study has adjusted for place of injury or evaluated the extent of inter-facility under-triage. We sought to determine distance and confounder adjusted odds of treatment at a tertiary trauma center (TTC) for older adult trauma patients compared to younger trauma patients, for patients transported from the scene of injury and those transferred from a non-tertiary trauma (NTTC) center. METHODS: This was a retrospective cohort study utilizing data from a statewide trauma registry reported over a 10-year period (2005-14). The outcome of interest was treatment at an American College of Surgeons or state-designated Level I/II trauma center (TTC). The predictor variable of interest was age group (> = 55 years vs. < 55 years). Covariates of interest included patient demographics, clinical characteristics and various distance measures calculated based on the patient's injury location. RESULTS: 84 930 patients met study criteria. Of these 42% (35659) were 55 years and older with an average age of 74 years (SD, 11.6). Older adult patients were on average, injured slightly farther away from a TTC (median distance, 34 vs. 29 miles, p < 0.001). Among patients initially presenting to NTTCs, older adults were significantly more likely to be transferred to another NTTC (53% vs. 34%). After adjusting for confounders and distance measures, older adults were less likely to be treated at TTCs overall (OR = 0.54, 95% CI: 0.52-0.56), whether transported by EMS from the scene of injury (OR = 0.47, 95% CI: 0.44-0.50) or via inter-facility transfer (OR = 0.63, 95%CI: 0.59-0.68). CONCLUSIONS: Injured older adults face significant under-triage to TTCs whether by EMS from the scene of injury or via transfer from NTTCs. Adjusting for proximity of injury to a TTC does not alter these findings.