Comparative Outcomes for Trauma Patients in Prison and the General Population.

BACKGROUND: Prisoners are a vulnerable population, and there are few contemporary studies that consider trauma patient outcomes within the prisoner population. Therefore, we sought to provide a descriptive analysis of prisoners involved in trauma and evaluate whether a healthcare disparity exists. We hypothesized that prisoners and non-prisoners have a similar risk of mortality and in-hospital complications after trauma. METHODS: The Trauma Quality Improvement Program (2015-2016) was queried for trauma patients based upon location inside or outside of prison at the time of injury. A multivariable logistic regression analysis was performed to compare these groups for risk of mortality-the primary outcome. RESULTS: From 593,818 trauma patients, 1115 were located in prison. Compared to non-prisoners, prisoner trauma patients had no significant difference in mortality (5.1 vs 6.0%, P = .204). However, after adjusting for covariates, prisoners had a shorter length of stay (LOS) (mean days, 6.3 vs 7.8, P < .001), shorter intensive care unit (ICU) LOS (mean days, 5.44 vs 5.89, P = .004), and fewer complications, including lower rates of drug/alcohol withdrawal (.4% vs 1.1%, P = .030), pneumonia (.5 vs 1.6%, P = .004), and urinary tract infections (.0 vs 1.1%, P < .001). Upon performing a multivariable logistic regression model, prisoner trauma patients had a similar associated risk of mortality compared to non-prisoners (OR 1.61, CI .52-4.94, P = .409). DISCUSSION: Our results suggest that prisoner trauma patients at least receive equivalent treatment in terms of mortality and may have better outcomes when considering some complications. Future prospective studies are needed to confirm these results and explore other factors, which impact prisoner patient outcomes.

Pancreatic Injuries in Abdominal Trauma in US Adults: Analysis of the National Trauma Data Bank on Management, Outcomes, and Predictors of Mortality.

BACKGROUND AND AIMS: Traumatic pancreatic injury is associated with high morbidity and mortality rates, and the management strategies associated with the best clinical outcomes are unknown. Our aims were to identify the incidence of traumatic pancreatic injury in adult patients in the United States using the National Trauma Data Bank, evaluate management strategies and clinical outcomes, and identify predictors of in-hospital mortality. MATERIALS AND METHODS: We retrospectively analyzed National Trauma Data Bank data from 2007 to 2011, and identified patients ⩾14 years old with pancreatic injuries either due to blunt or penetrating trauma. Patient characteristics, injury-associated factors, clinical outcomes, and in-hospital mortality rates were evaluated and compared between two groups stratified by injury type (blunt vs penetrating trauma). Statistical analyses used included Pearson's chi-square, Fisher's exact test, and analysis of variance. Factors independently associated with in-hospital mortality were identified using multivariable logistic regression. RESULTS: We identified 8386 (0.3%) patients with pancreatic injuries. Of these, 3244 (38.7%) had penetrating injuries and 5142 (61.3%) had blunt injuries. Penetrating traumas were more likely to undergo surgical management compared with blunt traumas. The overall in-hospital mortality rate was 21.2% (n = 1776), with penetrating traumas more likely to be associated with mortality (26.5% penetrating vs 17.8% blunt, p < 0.001). Unadjusted mortality rates varied by management strategy, from 6.7% for those treated with a drainage procedure to >15% in those treated with pancreatic repair or resection. Adjusted analysis identified drainage procedure as an independent factor associated with decreased mortality. Independent predictors of mortality included age ⩾70 years, injury severity score ⩾15, Glasgow Coma Scale motor <6, gunshot wound, and associated injuries. CONCLUSIONS: Traumatic pancreatic injuries are a rare but critical condition. The incidence of pancreatic injury was 0.3%. The overall morbidity and mortality rates were 53% and 21.2%, respectively. Patients undergoing less invasive procedures, such as drainage, were associated with improved outcomes.

Marijuana use and outcomes in adult and pediatric trauma patients after legalization in California.

BACKGROUND: Marijuana has become legal in eight states since 2012. We hypothesized the incidence of marijuana-positive trauma patients and rate of mortality has increased post-legalization. METHODS: A single level-I trauma center was used to identify patients screening positive for marijuana on urine-toxicology. Patients in the pre-legalization and post-legalization periods were compared. RESULTS: In the pre-legalization cohort 9.4% were marijuana-positive versus 11.0% in the post-legalization cohort (p = 0.001). Marijuana-positive patients post-legalization had higher rates of critical trauma activation (20.0% vs. 15.0%, p = 0.01) and mortality (2.6% vs. 1.2%, p = 0.03). In the pediatric (age 12-17) subgroup, the incidence of marijuana-positive patients did not change after legalization (pre: 39.3%, post: 46.4%, p = 0.24). CONCLUSION: The incidence of marijuana-positive trauma patients increased post-legalization. Adult marijuana-positive trauma patients post-legalization were more likely to meet criteria for critical trauma activation and have a higher mortality rate. A subgroup of pediatric patients had an alarmingly high rate of marijuana use. SUMMARY: The rate of marijuana use among trauma patients increased post-legalization in California. The rate of critical trauma activation also increased as well as the mortality rate.

Non-accidental trauma increases length of stay and mortality in pediatric trauma.

PURPOSE: More than half a million children experience non-accidental trauma (NAT) annually. Historically, NAT has been associated with an increased hospital length of stay (LOS). We hypothesized that in pediatric trauma patients, NAT is associated with longer hospital LOS, independent of injury severity, compared to accidental trauma (AT). METHODS: The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients aged 1-16 years. Patients were stratified into two groups: AT and NAT. The median LOS for the entire cohort was identified and used in a multivariable logistic regression analysis. RESULTS: From 93,089 pediatric trauma patients, 417 (< 0.1%) were involved in NAT. Patients with NAT had a lower median age (3 vs. 9 years, p < 0.001) and higher median injury severity score (10 vs. 5, p < 0.001), compared to patients with AT. After controlling for covariates, patients with NAT were associated with a longer hospital LOS (≥ 2 days), compared to those with AT (OR = 4.99 CI = 3.55-7.01, p < 0.001). In comparison to AT, NAT was also associated with a higher mortality rate (10.3% vs. 0.8%, p < 0.001). CONCLUSION: Pediatric patients presenting after NAT have a prolonged hospital and ICU LOS, even after adjusting for injury severity. Furthermore, pediatric victims of NAT had a higher mortality rate compared to those presenting after AT.

Measuring gastric residual volumes in critically ill burn patients - A systematic review.

PURPOSE: Measuring gastric residual volumes (GRV) is common in intensive care units (ICU) in patients receiving enteral nutrition (EN) and are a common source of feeding interruptions. Interruptions in EN yield adverse outcomes and are an area of improvement in burn care. The objectives of this study are to summarize the literature's ICU GRV practices and offer practical suggestions to GRV management in the burn patient. METHODS: PubMed, SCOPUS, and OvidSP Medline were systematically reviewed using the keywords: burns; thermal injury; gastric residual volume; enteral feeding; tube feeding; enteral nutrition; gastric intolerance; ICU; critical illness. Reviews, case reports, and consensus and opinion papers were excluded. RESULTS: 26 articles were identified. Six burn-specific studies were identified. GRV practices vary widely and are a common cause of EN interruption. Elevated GRVs do not equate to gastrointestinal intolerance and do not always reflect aspiration risk. CONCLUSIONS: We advocate a GRV threshold of 500mL should be used to optimize the benefits of EN in burn ICUs. A single incident of elevated GRVs should not mandate immediate EN rate reduction or cessation but should prompt a thoughtful examination of secondary causes of gastrointestinal intolerance. Randomized controlled trials are needed to define the ideal GRV threshold and re-evaluate its role in burn care.