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1.
Clin Otolaryngol ; 47(1): 44-51, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-34323008

RESUMO

OBJECTIVES: To report the experience of civilian penetrating neck trauma (PNT) at a UK level I trauma centre, propose an initial management algorithm and assess the degree of correlation between clinical signs of injury, operative findings and radiological reports. DESIGN: Retrospective case note review. SETTING: UK level I trauma centre April 2012-November 2017. PARTICIPANTS: Three hundred ten cases of PNT were drawn from electronic patient records. Data were extracted on hard and soft signs of vascular or aerodigestive tract injury, clinical management, radiological imaging and patient outcomes. MAIN OUTCOME MEASURES: Patient demographics, mechanism of injury, morbidity and mortality. The correlation between clinical signs, and radiological reports to internal injury on surgical exploration. RESULTS: Two hundred seventy-one (87.4%) male and 39 (13.6%) female patients with a mean age of 36 years (16-87) were identified. The most common causes of injury were assault 171 (55.2%) and deliberate self-harm 118 (38%). A knife was the most common instrument 240 (77.4%). Past psychiatric history was noted in 119 (38.4%), and 60 (19.4%) were intoxicated. 50% were definitively managed in theatre with a negative exploration rate of 38%, and 50% were managed in ED. Pre-operative radiological reports correlated with operative reports in 62% of cases with venous injury the most common positive and negative finding. Multivariate correlation was r = 0.89, p = 0.045, between hard signs plus positive radiology findings and internal injury on neck exploration. CONCLUSIONS: Management of PNT by clinical and radiological signs is safe and effective, and can be streamlined by a decision-making algorithm as proposed here.


Assuntos
Lesões do Pescoço/diagnóstico por imagem , Lesões do Pescoço/cirurgia , Centros de Traumatologia , Ferimentos Penetrantes/diagnóstico por imagem , Ferimentos Penetrantes/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Lesões do Pescoço/mortalidade , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Reino Unido , Ferimentos Penetrantes/mortalidade , Adulto Jovem
2.
Ann Vasc Surg ; 80: 158-169, 2022 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-34752854

RESUMO

BACKGROUND: The inferior vena cava is the most frequently injured vascular structure in penetrating abdominal trauma. We aimed to review inferior vena cava injury cases treated at a limited resources facility and to discuss the surgical management for such injures. METHODS: This was a retrospective study of patients with inferior vena cava injuries who were treated at a single center between January 2011 and January 2020. Data pertaining to the following were assessed: demographic parameters, hypovolemic shock at admission, the distance that the patient had to be transported to reach the hospital, affected anatomical segment, treatment, concomitant injuries, complications, and mortality. Non-parametric data were analyzed using Fisher's exact, Chi-square, Mann-Whitney, or Kruskal-Wallis test, as applicable. The Student's t-test was used to assess parametric data. Moreover, multiple logistic regression analyses (including data of possible death-related variables) were performed. Statistical significance was set at P <0.05. RESULTS: Among 114 patients with inferior vena cava injuries, 90.4% were male, and the majority were aged 20-29 years. Penetrating injuries accounted for 98.2% of the injuries, and the infrarenal segment was affected in 52.7% of the patients. Suturing was perfomed in 69.5% and cava ligation in 29.5% of the patients, and 1 patient with retrohepatic vena cava injury was managed non-operatively. The overall mortality was 52.6% with no case of compartment syndrome in the limbs. A total of 7.9% of the patients died during surgery. CONCLUSION: The inferior vena cava is often injured by penetrating mechanisms, and the most frequently affected segment was the infrarenal segment. A higher probability of death was not associated with injury to a specific anatomical segment. Additionally, cava ligation was not related to an increased probability of compartment syndrome in the leg; therefore, prophylactic fasciotomy was not supported.


Assuntos
Traumatismos Abdominais/cirurgia , Lesões do Sistema Vascular/cirurgia , Veia Cava Inferior/lesões , Ferimentos Penetrantes/cirurgia , Traumatismos Abdominais/mortalidade , Adolescente , Adulto , Brasil , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Retrospectivos , Lesões do Sistema Vascular/mortalidade , Ferimentos Penetrantes/mortalidade
3.
Am Surg ; 88(3): 455-462, 2022 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-34797198

RESUMO

BACKGROUND: Trauma patients are at high risk for venous thromboembolism (VTE). Opportunity for chemical VTE prophylaxis improvement was identified and practice was altered to start chemoprophylaxis on admission in most patients. The purpose of this study was to determine if early VTE prophylaxis is safe and reduces VTE. METHODS: The trauma registry was queried over a 12-month period for patients admitted greater than 1 day for traumatic injury. The study spanned 6 months on either side of instituting aggressive chemoprophylaxis. Patients were risk adjusted on demographics, Injury Severity Score, transfusions, procedure type, length of stay, and mortality. Pre-intervention patients were then compared to patients in the aggressive cohort with the primary outcome of VTE. Secondary outcomes included transfusions, mortality, and length of stay (LOS). RESULTS: 1597 patients were identified over the study period with 754 (47%) patients in the aggressive period. There were no differences in age, sex, Injury Severity Score, transfusions, procedures, or LOS between cohorts. Pre-algorithm patients were more likely to have penetrating mechanism (9.3% vs 6.6%; P = .009) and longer time to VTE prophylaxis (23.3 vs 13.9 hours; P < .001). No differences were noted in anticoagulant, VTE rate (2.0% vs 1.2%; P = .195), or mortality. Linear regression analysis identified time to chemical prophylaxis as significant predictor of VTE (ß = 43.9, P < .001). CONCLUSIONS: Early aggressive chemical VTE prophylaxis is safe without increasing transfusions. Venous thromboembolism rates were decreased, but did not reach statistical significance.


Assuntos
Anticoagulantes/uso terapêutico , Tempo para o Tratamento , Tromboembolia Venosa/prevenção & controle , Ferimentos e Lesões/complicações , Adulto , Idoso , Algoritmos , Anticoagulantes/administração & dosagem , Transfusão de Sangue , Colorado/epidemiologia , Enoxaparina/administração & dosagem , Enoxaparina/uso terapêutico , Feminino , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Análise de Regressão , Estudos Retrospectivos , Tromboembolia Venosa/mortalidade , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/mortalidade , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/epidemiologia , Ferimentos não Penetrantes/mortalidade , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/epidemiologia , Ferimentos Penetrantes/mortalidade
4.
P R Health Sci J ; 40(3): 120-126, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34792925

RESUMO

OBJECTIVE: Although the lack of health insurance has been linked to poor health outcomes in several diseases, this relationship is still understudied in trauma. There exist differences between the Puerto Rico health care system and that of the United States. We therefore aimed to assess mortality disparities related to insurance coverage at the Puerto Rico Trauma Hospital (PRTH). METHODS: A retrospective cohort study of patients who sustained penetrating injuries (presenting at the PRTH from 2000 to 2014) was performed. Individuals were classified by their insurance status. Study variables comprised demographics, clinical characteristics and outcomes. A logistic regression analysis was performed to identify the association between health insurance status and risk of dying. RESULTS: Patients with public health insurance experienced more complications than did individuals who had private health insurance (PrHI) or who were uninsured. This group had longer durations of mechanical ventilation and spent more time in the hospital than did patients who had PrHI or who were uninsured. However, uninsured patients with gunshot wounds were 54% (adjusted odds ratio = 1.54; 95% CI: 1.01, 2.36) more likely to die than were their counterparts who had PrHI. CONCLUSION: Our study suggests that having health insurance could reduce a given patient mortality risk in trauma settings. More studies with larger samples are warranted to confirm these findings. If these findings hold true, then providing equitable access to health services for the entire population could prevent patients suffering trauma from having premature, preventable deaths.


Assuntos
Disparidades em Assistência à Saúde , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Qualidade da Assistência à Saúde , Ferimentos Penetrantes/etnologia , Ferimentos Penetrantes/mortalidade , Cuidados Críticos/economia , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Porto Rico/epidemiologia , Estudos Retrospectivos , Ferimentos por Arma de Fogo/mortalidade , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/terapia
5.
J Trauma Acute Care Surg ; 91(4): 621-626, 2021 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-34225345

RESUMO

BACKGROUND: Injury Severity Score (ISS) is a widely used metric for trauma research and center verification; however, it does not account for age-related physiologic parameters. We hypothesized that a novel age-based injury severity metric would better predict mortality. METHODS: Adult patients (≥18 years) sustaining blunt trauma (BT) or penetrating trauma (PT) were abstracted from the 2010 to 2016 National Trauma Data Bank. Admission vitals, Glasgow Coma Scale, ISS, mechanism, and outcomes were analyzed. Patients with incomplete/non-physiologic vital signs were excluded. For each age: (1) a cut point analysis was used to determine the ISS with the highest specificity and sensitivity for predicting mortality and (2) a linear discriminant analysis was performed using ISS, ISS greater than 16, Trauma and Injury Severity Score, and Revised Trauma Scale to compare each scoring system's mortality prediction. A novel injury severity metric, the trauma component score (TCS), was developed for each age using significant (p < 0.05) variables selected from Abbreviated Injury Scale scores, Glasgow Coma Scale, vital signs, and gender. Receiver operator curves were developed and the areas under the curve were compared between the TCS and other systems. RESULTS: There 777,794 patients studied (BT, 91.1%; PT, 8.9%). Blunt trauma patients were older (53.6 ± 21.3 years vs. 34.4 ± 13.8 years), had higher ISS scores (11.1 ± 8.5 vs. 8.5 ± 8.9), and lower mortality (2.9% vs. 3.4%) than PT patients (p < 0.05). When assessing the entire PT and BT cohort the optimal ISS cut point was 16. The optimal ISS was between 20 and 25 for BT younger than 70 years. For those older than 70 years, the optimal BT ISS steadily declined as age increased PT's cut point was 16 or less for all ages assessed. When the injury metrics were compared by area under the curve, our novel TCS more accurately predicted mortality across all ages in both BT and PT (p < 0.001). CONCLUSION: Injury Severity Score is a poor mortality predictor in older patients and those sustaining penetrating trauma. The age-based TCS is a superior metric for mortality prediction across all ages. LEVEL OF EVIDENCE: Clinical outcomes, Level IV.


Assuntos
Escala de Coma de Glasgow , Escala de Gravidade do Ferimento , Ferimentos não Penetrantes/mortalidade , Ferimentos Penetrantes/mortalidade , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Medição de Risco/métodos , Medição de Risco/estatística & dados numéricos , Fatores Sexuais , Centros de Traumatologia/estatística & dados numéricos , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/terapia , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/terapia , Adulto Jovem
6.
J Trauma Acute Care Surg ; 91(2S Suppl 2): S186-S193, 2021 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-34324473

RESUMO

BACKGROUND: Quantification of medical interventions administered during prolonged field care (PFC) is necessary to inform training and planning. MATERIALS AND METHODS: Retrospective cohort study of Department of Defense Trauma Registry casualties with maximum Abbreviated Injury Scale (MAIS) score of 2 or greater and prehospital records during combat operations 2007 to 2015; US military nonsurvivors were linked to Armed Forces Medical Examiner System data. Medical interventions administered to survivors of 4 hours to 72 hours of PFC and nonsurvivors who died prehospital were compared by frequency-matching on mechanism (explosive, firearm, other), injury type (penetrating, blunt) and injured body regions with MAIS score of 3 or greater. Covariates for adjustment included age, sex, military Service, shock, Glasgow Coma Scale, transport team, MAIS and Injury Severity Score (ISS). Sensitivity analysis focused on US military subgroup with AIS/ISS assigned to nonsurvivors after autopsy. RESULTS: The total inception cohort included 16,202 casualties (5,269 US military, 10,809 non-US military), 64% Afghanistan, 36% Iraq. Of US military, 734 deaths occurred within 30 days, nearly 90% occurred within 4 hours of injury. There were 3,222 casualties (1,111 US military, 2,111 non-US military) documented for prehospital care and died prehospital (691) or survived 4 hours to 72 hours of PFC (2,531). Twenty-five percent (815/3,222) received advanced airway, 18% (583) ventilatory support, 9% (281) tourniquet. Twenty-three percent (725) received blood transfusions within 24 hours. Of the matched cohort (1,233 survivors, 490 nonsurvivors), differences were observed in care (survivors received more warming, intravenous fluids, sedation, mechanical ventilation, narcotics, antibiotics; nonsurvivors received more intubations, tourniquets, intraosseous fluids, cardiopulmonary resuscitation). Sensitivity analysis focused on US military (732 survivors, 379 nonsurvivors) showed no significant differences in prehospital interventions. Without autopsy information, the ISS of nonsurvivors significantly underestimated injury severity. CONCLUSION: Tourniquets, blood transfusion, airway, and ventilatory support are frequently required interventions for the seriously injured. Prolonged field care should direct resources, technology, and training to field technology for sustained resuscitation, airway, and breathing support in the austere environment. LEVEL OF EVIDENCE: Prognostic, Level III.


Assuntos
Serviços Médicos de Emergência/estatística & dados numéricos , Lesões Relacionadas à Guerra/mortalidade , Escala Resumida de Ferimentos , Adulto , Fatores Etários , Traumatismos por Explosões/mortalidade , Traumatismos por Explosões/terapia , Estudos de Casos e Controles , Serviços Médicos de Emergência/métodos , Feminino , Escala de Coma de Glasgow , Humanos , Masculino , Sistema de Registros , Estudos Retrospectivos , Fatores Sexuais , Análise de Sobrevida , Estados Unidos , Lesões Relacionadas à Guerra/terapia , Ferimentos por Arma de Fogo/mortalidade , Ferimentos por Arma de Fogo/terapia , Ferimentos não Penetrantes/mortalidade , Ferimentos não Penetrantes/terapia , Ferimentos Penetrantes/mortalidade , Ferimentos Penetrantes/terapia , Adulto Jovem
7.
Ann Vasc Surg ; 76: 193-201, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34153491

RESUMO

BACKGROUND: Penetrating injuries to the inferior vena cava and/or iliac veins are a source of hemorrhage but may also predispose patients to venous thromboembolism (VTE). We sought to determine the relationship between iliocaval injury, VTE and mortality. METHODS: The National Trauma Data Bank was queried for penetrating abdominal trauma from 2015-2017. Univariate analyses compared baseline characteristics and outcomes based on presence of iliocaval injury. Multivariable analyses determined the effect of iliocaval injury on VTE and mortality. RESULTS: Of 9,974 patients with penetrating abdominal trauma, 329 had iliocaval injury (3.3%). Iliocaval injury patients were more likely to have a firearm mechanism (83% vs. 43%, P < 0.001), concurrent head (P = 0.036), spinal cord (P < 0.001), and pelvic injuries (P < 0.001), and higher total injury severity score (median 20 vs. 8.0, P < 0.001). They were more likely to undergo 24-hr hemorrhage control surgery (69% vs. 17%, P < 0.001), but less likely to receive VTE chemoprophylaxis during admission (64% vs. 68%, P = 0.04). Of patients undergoing iliocaval surgery, 64% underwent repair, 26% ligation, and 10% unknown. Iliocaval injury patients had higher rates of VTE (12% vs. 2%), 24-hr mortality (23% vs. 2.0%) and in-hospital mortality (33% vs. 3.4%) (P < 0.001 for all). VTE rates were similar following repair (14%) and ligation (17%). Iliocaval injury patients also had higher rates of cardiac complications (10.3% vs. 1.4%), acute kidney injury (8.2% vs. 1.3%), extremity compartment syndrome (4.0 vs. 0.2%), and unplanned return to OR (7.9% vs. 2.5%) (P < 0.001 for all). In multivariable analyses, iliocaval injury was independently associated with risk of VTE (OR 2.12; 95% CI, 1.29-3.48; P = 0.003), and in-hospital mortality (OR = 9.61; 95% CI, 4.96-18.64; P < 0.001). CONCLUSION: Iliocaval injuries occur in <5% of penetrating abdominal trauma but are associated with more severe injury patterns and high mortality rates. Regardless of repair type, survivors should be considered high risk for developing VTE.


Assuntos
Traumatismos Abdominais/epidemiologia , Veia Ilíaca/lesões , Lesões do Sistema Vascular/epidemiologia , Veia Cava Inferior/lesões , Tromboembolia Venosa/epidemiologia , Ferimentos Penetrantes/epidemiologia , Traumatismos Abdominais/diagnóstico , Traumatismos Abdominais/mortalidade , Traumatismos Abdominais/cirurgia , Adulto , Bases de Dados Factuais , Feminino , Humanos , Veia Ilíaca/cirurgia , Ligadura , Masculino , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Procedimentos Cirúrgicos Vasculares , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/mortalidade , Lesões do Sistema Vascular/cirurgia , Veia Cava Inferior/cirurgia , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/mortalidade , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/mortalidade , Ferimentos Penetrantes/cirurgia , Adulto Jovem
8.
Am Surg ; 87(10): 1594-1599, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34128407

RESUMO

INTRODUCTION: It remains unclear whether an increased mortality risk in uninsured patients exists across Injury Severity Score (ISS) classifications. We hypothesized that penetrating trauma self-pay patients would have a similarly increased mortality risk across all ISS categories. METHODS: The National Trauma Data Bank (2013-2015) was queried for patients presenting with penetrating firearm, explosive, or stab wound injuries. 115 651 patients were identified and a stratified multivariable logistic regression model was used. RESULTS: In the >15 ISS group, self-pay patients had a lower median total hospital Length of Stay (LOS) (3 vs 8, P < .001), lower median Intensive Care Unit LOS (1 vs 3, P < .001), and lower median ventilator days (0 vs 1, P < .001). Self-pay patients had an increased risk for mortality compared to patients with private insurance in both the ≤15 ISS group (OR 2.68, P < .001) and >15 ISS group (OR 1.56, P < .001). CONCLUSION: Uninsured patients have an increased mortality risk in both low and high ISS groups. A higher mortality risk among uninsured patients in the high ISS group can be explained by decreased resource availability and lower ICU days and ventilator time. However, more studies are needed to determine why there is an even greater mortality risk among uninsured patients with mild ISS.


Assuntos
Pessoas sem Cobertura de Seguro de Saúde , Ferimentos Penetrantes/mortalidade , Adulto , Idoso , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologia
9.
J Trauma Acute Care Surg ; 91(3): 501-506, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-34137746

RESUMO

BACKGROUND: The American College of Surgeons Committee on Trauma requires that all level I trauma centers have cardiopulmonary bypass (CPB) capabilities immediately available. Despite this mandate, there are limited data on the utilization and clinical outcomes among trauma patients requiring CPB in the management of injuries. The aim of this study was to evaluate the current use of CPB in the care of trauma patients. METHODS: This is a retrospective analysis of the National Trauma Data Bank from 2010 to 2015. Adult patients sustaining cardiothoracic injuries who underwent surgical repair within the first 24 hours of admission were included. Propensity score matching was used to compare outcomes (in-hospital mortality, hospital length of stay (LOS), intensive care unit LOS, and complications) between patients who underwent CPB within the first 24 hours of admission and those with similar injuries who did not receive CPB. RESULTS: A total of 28,481 patients who met the inclusion criteria were identified, of whom 319 underwent CPB. Three-hundred three CPB patients were matched to 895 comparison patients who did not undergo CPB. Overall in-hospital mortality was 35%. Patients who were not treated with CPB had a significantly higher in-hospital mortality compared with those treated with CBP (odds ratio, 1.57; 95% confidence interval, 1.16-2.12; p = 0.003); however, complications were significantly lower in those who did not receive CPB (odds ratio, 0.63; 95% confidence interval, 0.47-0.86; p = 0.003). Hospital LOS (non-CPB: mean, 13.4 ± 16.3 days; CPB: mean, 14.7 ± 15.1 days; p = 0.23) and intensive care unit LOS (non-CPB: mean, 9.9 ± 10.7 days; CPB: mean, 10.1 ± 9.7 days; p = 0.08) did not differ significantly between groups. CONCLUSION: The use of CPB in the initial management of select cardiothoracic injuries is associated with a survival benefit. Further investigation is required to delineate which specific injuries would benefit the most from the use of CPB. LEVEL OF EVIDENCE: Therapeutic, level IV.


Assuntos
Ponte Cardiopulmonar/estatística & dados numéricos , Traumatismos Torácicos/cirurgia , Lesões do Sistema Vascular/cirurgia , Adulto , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Estudos Retrospectivos , Taxa de Sobrevida , Traumatismos Torácicos/mortalidade , Resultado do Tratamento , Estados Unidos/epidemiologia , Lesões do Sistema Vascular/mortalidade , Ferimentos não Penetrantes/mortalidade , Ferimentos não Penetrantes/cirurgia , Ferimentos Penetrantes/mortalidade , Ferimentos Penetrantes/cirurgia , Adulto Jovem
10.
Scand J Trauma Resusc Emerg Med ; 29(1): 80, 2021 Jun 13.
Artigo em Inglês | MEDLINE | ID: mdl-34120631

RESUMO

BACKGROUND: The management of penetrating wounds is a rare challenge for trauma surgeons in Germany and Central Europe as a result of the low incidence of this type of trauma. In Germany, penetrating injuries are reported to occur in 4-5 % of the severely injured patients who are enrolled in the TraumaRegister DGU® (trauma registry of the German Trauma Society). They include gunshot injuries, knife stab injuries, which are far more common, and penetrating injuries of other origin, for example trauma caused by accidents. The objective of this study was to assess the epidemiology and outcome of penetrating injuries in Germany, with a particular focus on the level of care provided by the treating trauma centre to gain more understanding of this trauma mechanism and to anticipate the necessary steps in the initial treatment. MATERIALS AND METHODS: Since 2009, the TraumaRegister DGU® has been used to assess not only whether a trauma was penetrating but also whether it was caused by gunshot or stabbing. Data were taken from the standard documentation forms that participating German hospitals completed between 2009 and 2018. Excluded were patients with a maximum abbreviated injury scale (MAIS) score of 1 with a view to obtaining a realistic idea of this injury entity, which is rare in Germany. RESULTS: From 2009 to 2018, there were 1123 patients with gunshot wounds, corresponding to a prevalence rate of 0.5 %, and 4333 patients with stab wounds (1.8 %), which were frequently caused by violent crime. The high proportion of intentionally self-inflicted gunshot wounds to the head resulted in a cumulative mortality rate of 41 % for gunshot injuries. Stab wounds were associated with a lower mortality rate (6.8 %). Every fourth to fifth patient with a gunshot or stab wound presented with haemorrhagic shock, which is a problem that is seen during both the prehospital and the inhospital phase of patient management. Of the patients with penetrating injuries, 18.3 % required transfusions. This percentage was more than two times higher than that of the basic group of patients of the TraumaRegister DGU®, which consists of patients with a MAIS ≥ 3 and patients with a MAIS of 2 who died or were treated on the intensive care unit. CONCLUSIONS: In Germany, gunshot and stab wounds have a low incidence and are mostly caused by violent crime or attempted suicides. Depending on the site of injury, they have a high mortality and are often associated with major haemorrhage. As a result of the low incidence of these types of trauma, further data and analyses are required in order to provide the basis for evaluating the long-term quality of the management of patients with stab or gunshot wounds.


Assuntos
Ferimentos por Arma de Fogo/epidemiologia , Ferimentos por Arma de Fogo/terapia , Ferimentos Perfurantes/epidemiologia , Ferimentos Perfurantes/terapia , Acidentes/estatística & dados numéricos , Adolescente , Adulto , Idoso , Transfusão de Sangue/métodos , Europa (Continente) , Feminino , Alemanha/epidemiologia , Hemorragia/epidemiologia , Humanos , Incidência , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Prospectivos , Sistema de Registros , Choque Hemorrágico/epidemiologia , Ferimentos por Arma de Fogo/mortalidade , Ferimentos Penetrantes/epidemiologia , Ferimentos Penetrantes/mortalidade , Ferimentos Penetrantes/terapia , Ferimentos Perfurantes/mortalidade , Adulto Jovem
11.
J Trauma Acute Care Surg ; 91(2S Suppl 2): S226-S232, 2021 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-34039922

RESUMO

INTRODUCTION: Penetrating cervical carotid artery injury is an uncommon but high-stake scenario associated with stroke and death. The objective of this study was to characterize and compare penetrating carotid injury in the military and civilian setting, as well as provide considerations for management. METHODS: Cohorts with penetrating cervical carotid artery injury from the Department of Defense Trauma Registry (2002-2015) and the American Association for the Surgery of Trauma Prospective Observation Vascular Injury Treatment Registry (2012-2018) were analyzed. A least absolute shrinkage and selection operator multivariate analysis using random forest-based imputation was performed to identify risk factors affecting stroke and mortality. RESULTS: There were a total of 157 patients included in the study, of which 56 (35.7%) were military and 101 (64.3%) were civilian. The military cohort was more likely to have been managed with open surgery (87.5% vs. 44.6%, p < 0.001) and to have had any procedure to restore or maintain flow to the brain (71.4% vs. 35.6%, p < 0.001), while the civilian cohort was more likely to undergo nonoperative management (45.5% vs. 12.5%, p < 0.001). Stroke rate was higher within the military cohort (41.1% vs. 13.9%, p < 0.001); however, mortality did not differ between the groups (12.5% vs. 17.8%, p = 0.52). On multivariate analysis, predictors for stroke were presence of a battle injury (log odds, 2.1; p < 0.001) and internal or common carotid artery ligation (log odds 1.5, p = 0.009). For mortality outcome, protective factors included a high Glasgow Coma Scale on admission (log odds, -0.21 per point; p < 0.001). Increased admission Injury Severity Score was a predictor of mortality (log odds, 0.05 per point; p = 0.005). CONCLUSION: The stroke rate was higher in the military cohort, possibly reflecting complexity of injury; however, there was no difference in mortality between military and civilian patients. For significant injuries, concerted efforts should be made at carotid reconstruction to reduce the occurrence of stroke. LEVEL OF EVIDENCE: Retrospective cohort analysis, level III.


Assuntos
Lesões das Artérias Carótidas/epidemiologia , Ferimentos Penetrantes/epidemiologia , Adulto , Lesões das Artérias Carótidas/complicações , Lesões das Artérias Carótidas/mortalidade , Lesões das Artérias Carótidas/cirurgia , Artéria Carótida Primitiva/cirurgia , Artéria Carótida Interna/cirurgia , Feminino , Escala de Coma de Glasgow , Humanos , Escala de Gravidade do Ferimento , Masculino , Militares/estatística & dados numéricos , Sistema de Registros , Estudos Retrospectivos , Acidente Vascular Cerebral/etiologia , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/mortalidade , Ferimentos Penetrantes/cirurgia
12.
J Trauma Acute Care Surg ; 91(4): 599-604, 2021 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-33871405

RESUMO

BACKGROUND: The equivalent Injury Severity Score (ISS) cutoffs for severe trauma vary between adult (ISS, >16) and pediatric (ISS, >25) trauma. We hypothesized that a novel injury severity prediction model incorporating age and mechanism of injury would outperform standard ISS cutoffs. METHODS: The 2010 to 2016 National Trauma Data Bank was queried for pediatric trauma patients. Cut point analysis was used to determine the optimal ISS for predicting mortality for age and mechanism of injury. Linear discriminant analysis was implemented to determine prediction accuracy, based on area under the curve (AUC), of ISS cutoff of 25 (ISS, 25), shock index pediatric adjusted (SIPA), an age-adjusted ISS/abbreviated Trauma Composite Score (aTCS), and our novel Trauma Composite Score (TCS) in blunt trauma. The TCS consisted of significant variables (Abbreviated Injury Scale, Glasgow Coma Scale, sex, and SIPA) selected a priori for each age. RESULTS: There were 109,459 blunt trauma and 9,292 penetrating trauma patients studied. There was a significant difference in ISS (blunt trauma, 9.3 ± 8.0 vs. penetrating trauma, 8.0 ± 8.6; p < 0.01) and mortality (blunt trauma, 0.7% vs. penetrating trauma, 2.7%; p < 0.01). Analysis of the entire cohort revealed an optimal ISS cut point of 25 (AUC, 0.95; sensitivity, 0.86; specificity, 0.95); however, the optimal ISS ranged from 18 to 25 when evaluated by age and mechanism. Linear discriminant analysis model AUCs varied significantly for each injury metric when assessed for blunt trauma and penetrating trauma (penetrating trauma-adjusted ISS, 0.94 ± 0.02 vs. ISS 25, 0.88 ± 0.02 vs. SIPA, 0.62 ± 0.03; p < 0.001; blunt trauma-adjusted ISS, 0.96 ± 0.01 vs. ISS 25, 0.89 ± 0.02 vs. SIPA, 0.70 ± 0.02; p < 0.001). When injury metrics were assessed across age groups in blunt trauma, TCS and aTCS performed the best. CONCLUSION: Current use of ISS in pediatric trauma may not accurately reflect injury severity. The TCS and aTCS incorporate both age and mechanism and outperform standard metrics in mortality prediction in blunt trauma. LEVEL OF EVIDENCE: Retrospective review, level IV.


Assuntos
Escala de Gravidade do Ferimento , Choque/diagnóstico , Ferimentos não Penetrantes/mortalidade , Ferimentos Penetrantes/mortalidade , Adolescente , Fatores Etários , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Tempo de Internação/estatística & dados numéricos , Masculino , Curva ROC , Sistema de Registros/estatística & dados numéricos , Reprodutibilidade dos Testes , Estudos Retrospectivos , Medição de Risco/métodos , Medição de Risco/estatística & dados numéricos , Choque/etiologia , Choque/mortalidade , Centros de Traumatologia/estatística & dados numéricos , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/diagnóstico , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/diagnóstico
13.
J Trauma Acute Care Surg ; 90(4): 738-743, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33740785

RESUMO

INTRODUCTION: As the prevalence of geriatric trauma patients has increased, protocols are being developed to address the unique requirements of this demographic. However, categorical definitions for geriatric patients vary, potentially creating confusion concerning which patients should be cared for according to geriatric-specific standards. The aim of this study was to identify data-driven cut points for mortality based on age to support implementation of age-driven guidelines. METHODS: Adults aged 18 to 100 years with blunt or penetrating injury were selected from 95 hospitals' trauma registries. Change point analysis techniques were used to detect inflection points in the proportion of deaths at each age. Based on these calculated points, patients were allocated into age groups, and their characteristics and outcomes were compared. Logistic regression was used to estimate risk-adjusted in-hospital mortality controlling for sex, race, Injury Severity Score, Glasgow Coma Scale, and number of comorbidities. RESULTS: A total of 255,099 patients were identified (female, 45.7%; mean age, 59.3 years; mean Injury Severity Score, 8.69; blunt injury, 92.6%). Statistically significant increases in mortality rate were noted at ages 55, 77, and 82 years. Compared with the referent group (age, <55 years), adjusted odds ratios (AORs) showed increases in mortality if age 55 to 76 years (AOR, 2.42), age 77 to 81 years (AOR, 4.70), or age 82 years or older (AOR, 6.43). National Trauma Data Standard-defined comorbidities significantly increased once age surpassed 55 years, as the rate more than doubled for each of the older age categories (p < 0.001). As age increased, each group was more likely to be female, have dementia, sustain a ground level fall, and be discharged to a skilled nursing facility (p < 0.001). CONCLUSION: This large multicenter analysis established a clinically and statistically significant increase in mortality at ages 55, 77, and 82 years. This research strongly suggests that trauma patients older than 55 years be considered for inclusion in geriatric trauma protocols. The other age inflection points identified (77 and 82 years) may also warrant additional specialized care considerations. LEVEL OF EVIDENCE: Epidemiological study, level III; Care management, level IV.


Assuntos
Ferimentos não Penetrantes/mortalidade , Ferimentos Penetrantes/mortalidade , Acidentes por Quedas/mortalidade , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Avaliação Geriátrica , Escala de Coma de Glasgow , Hospitalização , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Taxa de Sobrevida , Centros de Traumatologia , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/terapia , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/terapia , Adulto Jovem
14.
BMC Surg ; 21(1): 142, 2021 Mar 19.
Artigo em Inglês | MEDLINE | ID: mdl-33740945

RESUMO

BACKGROUND: We present here our experience with surgical management of traumatic diaphragmatic hernia, trying to find out the era impact of different periods on the outcome and risk factors of mortality. METHODS: A series of 63 patients with traumatic diaphragmatic hernia were referred to us and operated on during March, 1990-August, 2017. The patient records were reviewed and statistically analyzed to demonstrate injury characteristics and to find out optimal treatment strategy, risk factors of death as well as the difference between two periods (1990-2005, 2005-2017) divided by introduction of computed tomography at our institution. RESULTS: The overall mean age was 31.2 ± 16.3 years old with a female to male ratio of 11/52. The mechanism was penetrating trauma in 19 cases (30.2%), and blunt trauma in 44 cases (69.9%). Two thirds of the patients in the second group (2005-2017) yet none in the first group (1990-2005) underwent computed tomography. Ten patients (15.9%), of which 8 in the first and the other 2 in the second group (p = .042), had late diagnoses. The most commonly used incision was a thoracotomy (n = 43, 89.6%). There was no statistical difference in etiology or mortality between the two periods. Univariate analysis showed survivors were younger, and had lesser injury severity scores (ISS) and lower American Association for the Surgery of Trauma (AAST) grade than non-survivors. By multivariate logistic regression analysis, increased age (odds ratio, 1.275; p = .013) and greater ISS (OR, 1.174; p = .028) were risk factors of death in all patients. CONCLUSIONS: High-definition computed tomography has significantly improved the preoperative diagnosis rate. The transthoracic approach could be used in selected cases with traumatic diaphragmatic hernia with good outcomes. Patients with greater ISS and advanced ages are at a higher risk of death.


Assuntos
Hérnia Diafragmática Traumática , Ferimentos não Penetrantes , Ferimentos Penetrantes , Adolescente , Adulto , Feminino , Hérnia Diafragmática Traumática/mortalidade , Hérnia Diafragmática Traumática/cirurgia , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Resultado do Tratamento , Ferimentos não Penetrantes/mortalidade , Ferimentos não Penetrantes/cirurgia , Ferimentos Penetrantes/mortalidade , Ferimentos Penetrantes/cirurgia , Adulto Jovem
15.
J Trauma Acute Care Surg ; 91(1): 93-99, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-33755641

RESUMO

BACKGROUND: Classic risk assessment tools often treat patients' risk factors as linear and additive. Clinical reality suggests that the presence of certain risk factors can alter the impact of other factors; in other words, risk modeling is not linear. We aimed to use artificial intelligence (AI) technology to design and validate a nonlinear risk calculator for trauma patients. METHODS: A novel, interpretable AI technology called Optimal Classification Trees (OCTs) was used in an 80:20 derivation/validation split of the 2010 to 2016 American College of Surgeons Trauma Quality Improvement Program database. Demographics, emergency department vital signs, comorbidities, and injury characteristics (e.g., severity, mechanism) of all blunt and penetrating trauma patients 18 years or older were used to develop, train then validate OCT algorithms to predict in-hospital mortality and complications (e.g., acute kidney injury, acute respiratory distress syndrome, deep vein thrombosis, pulmonary embolism, sepsis). A smartphone application was created as the algorithm's interactive and user-friendly interface. Performance was measured using the c-statistic methodology. RESULTS: A total of 934,053 patients were included (747,249 derivation; 186,804 validation). The median age was 51 years, 37% were women, 90.5% had blunt trauma, and the median Injury Severity Score was 11. Comprehensive OCT algorithms were developed for blunt and penetrating trauma, and the interactive smartphone application, Trauma Outcome Predictor (TOP) was created, where the answer to one question unfolds the subsequent one. Trauma Outcome Predictor accurately predicted mortality in penetrating injury (c-statistics: 0.95 derivation, 0.94 validation) and blunt injury (c-statistics: 0.89 derivation, 0.88 validation). The validation c-statistics for predicting complications ranged between 0.69 and 0.84. CONCLUSION: We suggest TOP as an AI-based, interpretable, accurate, and nonlinear risk calculator for predicting outcome in trauma patients. Trauma Outcome Predictor can prove useful for bedside counseling of critically injured trauma patients and their families, and for benchmarking the quality of trauma care.


Assuntos
Inteligência Artificial , Técnicas de Apoio para a Decisão , Smartphone , Ferimentos não Penetrantes/mortalidade , Ferimentos Penetrantes/mortalidade , Adulto , Idoso , Bases de Dados Factuais , Emergências , Feminino , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Medição de Risco/métodos , Fatores de Risco , Estados Unidos/epidemiologia
16.
J Trauma Acute Care Surg ; 91(1): 130-140, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-33675330

RESUMO

BACKGROUND: Prehospital procedures (PHP) by emergency medical services (EMS) are performed regularly in penetrating trauma patients despite previous studies demonstrating no benefit. We sought to examine the influence of PHPs on outcomes in penetrating trauma patients in urban locations where transport to trauma center is not prolonged. We hypothesized that patients without PHPs would have better outcomes than those undergoing PHP. METHODS: This was an Eastern Association for the Surgery of Trauma-sponsored, multicenter, prospective, observational trial of adults (18+ years) with penetrating trauma to the torso and/or proximal extremity presenting at 25 urban trauma centers. The impact of PHPs and transport mechanism on in-hospital mortality were examined. RESULTS: Of 2,284 patients included, 1,386 (60.7%) underwent PHP. The patients were primarily Black (n = 1,527, 66.9%) males (n = 1,986, 87.5%) injured by gunshot wound (n = 1,510, 66.0%) with 34.1% (n = 726) having New Injury Severity Score of ≥16. A total of 1,427 patients (62.5%) were transported by Advanced Life Support EMS, 17.2% (n = 392) by private vehicle, 13.7% (n = 312) by police, and 6.7% (n = 153) by Basic Life Support EMS. Of the PHP patients, 69.1% received PHP on scene, 59.9% received PHP in route, and 29.0% received PHP both on scene and in route. Initial scene vitals differed between groups, but initial emergency department vitals did not. Receipt of ≥1 PHP increased mortality odds (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.01-1.83; p = 0.04). Logistic regression showed increased mortality with each PHP, whether on scene or during transport. Subset analysis of specific PHP revealed that intubation (OR, 10.76; 95% CI, 4.02-28.78; p < 0.001), C-spine immobilization (OR, 5.80; 95% CI, 1.85-18.26; p < 0.01), and pleural decompression (OR, 3.70; 95% CI, 1.33-10.28; p = 0.01) had the highest odds of mortality after adjusting for multiple variables. CONCLUSION: Prehospital procedures in penetrating trauma patients impart no survival advantage and may be harmful in urban settings, even when performed during transport. Therefore, PHP should be forgone in lieu of immediate transport to improve patient outcomes. LEVEL OF EVIDENCE: Prognostic, level III.


Assuntos
Serviços Médicos de Emergência/estatística & dados numéricos , Centros de Traumatologia/estatística & dados numéricos , Ferimentos por Arma de Fogo/mortalidade , Ferimentos Penetrantes/mortalidade , Adulto , Serviços Médicos de Emergência/métodos , Feminino , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estados Unidos/epidemiologia , Serviços Urbanos de Saúde , Ferimentos por Arma de Fogo/terapia , Ferimentos Penetrantes/terapia , Adulto Jovem
17.
J Surg Res ; 263: 57-62, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33639370

RESUMO

BACKGROUND: Studies in the adult population are conflicting regarding whether obesity is protective in penetrating trauma. In the pediatric population, data on obesity and penetrating trauma are limited. We sought to determine if there is a different rate of operation or of survival in pediatric and adolescent patients with obesity. METHODS: We queried the National Trauma Data Bank research data set from 2013 to 2016 for all patients aged 2-18 who sustained traumatic penetrating injuries to the thorax and abdomen. The cohort was divided into body mass index percentiles for gender and age using Center for Disease Control definitions. Outcomes included overall survival, whether or not an operative procedure was performed, and hospital and intensive care unit (ICU) length of stay. RESULTS: We analyzed 9611 patients with penetrating trauma, of which 4285 had an operative intervention. When adjusted for other variables (age, gender, race, ICU length of stay, hospital length of stay, and Injury Severity Score), children of every body mass index percentile had similar survival. Healthy weight patients were more likely to get an operation than patients in the obese category. Length of hospital stay was similar between groups, but the ICU length of stay was longer in the overweight and obese groups compared with healthy weight and underweight groups. CONCLUSIONS: Children and adolescents with obesity are less likely to undergo operation after penetrating thoracoabdominal trauma. Further study is needed to determine the reason for this difference.


Assuntos
Traumatismos Abdominais/cirurgia , Obesidade/epidemiologia , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Traumatismos Torácicos/cirurgia , Ferimentos Penetrantes/cirurgia , Traumatismos Abdominais/complicações , Traumatismos Abdominais/diagnóstico , Traumatismos Abdominais/mortalidade , Adolescente , Índice de Massa Corporal , Criança , Pré-Escolar , Feminino , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Obesidade/complicações , Obesidade/diagnóstico , Fatores de Proteção , Estudos Retrospectivos , Fatores de Risco , Traumatismos Torácicos/complicações , Traumatismos Torácicos/diagnóstico , Traumatismos Torácicos/mortalidade , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/mortalidade
18.
Saudi Med J ; 42(3): 280-283, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33632906

RESUMO

OBJECTIVES: To review the patterns and outcomes of pediatric thoracic penetrating injuries in a level one trauma center. METHODS: Retrospective chart review of pediatric patients who presented to the King Abdulaziz Medical City Emergency Department (KAMC-ED), Riyadh, Saudi Arabia with thoracic penetrating injury from 2001 to 2016. RESULTS: Eighty-nine patients had a penetrating injury to the thorax were identified. The mean age was 15.5 ± 3.6 years. The mean length of hospital stay was 3.87 ± 5 days. The most common cause was stabbing followed by gunshot. Isolated injury to the thorax was seen in 58 patients. The most common injuries sustained were pneumothorax and hemothorax. In the ED, tube thoracostomy was required in 65 patients, endotracheal intubation in 12, blood transfusion in 14, massive blood transfusion in one, pericardiocentesis in one, and ED thoracotomy in 2. Only 15 patients required surgical intervention. The overall mortality rate was 3.4%. Death was mainly caused by associated injuries to the heart, aorta and/or inferior vena cava. CONCLUSION: Thoracic injuries represent 25% of the overall penetrating traumas in pediatric age group. Most sustained injuries can be safely managed non-operatively, with a favorable outcome. Prompt resuscitation and intervention are required to identify and manage life-threatening injuries.


Assuntos
Traumatismos Torácicos/epidemiologia , Centros de Traumatologia/estatística & dados numéricos , Ferimentos Penetrantes/epidemiologia , Adolescente , Fatores Etários , Transfusão de Sangue/estatística & dados numéricos , Criança , Feminino , Humanos , Intubação Intratraqueal/estatística & dados numéricos , Tempo de Internação , Masculino , Estudos Retrospectivos , Arábia Saudita/epidemiologia , Traumatismos Torácicos/mortalidade , Traumatismos Torácicos/cirurgia , Toracostomia/estatística & dados numéricos , Ferimentos Penetrantes/mortalidade , Ferimentos Penetrantes/cirurgia
19.
JAMA Surg ; 156(5): 453-460, 2021 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-33595600

RESUMO

Importance: Although most massive transfusion protocols incorporate cryoprecipitate in the treatment of hemorrhaging injured patients, minimal data exist on its use in children, and whether its addition improves their survival is unclear. Objective: To determine whether cryoprecipitate use for injured children who receive massive transfusion is associated with lower mortality. Design, Setting, and Participants: This retrospective cohort study included injured patients examined between January 1, 2014, and December 31, 2017, at one of multiple centers across the US and Canada participating in the Pediatric Trauma Quality Improvement Program. Patients were aged 18 years or younger and had received massive transfusion, which was defined as at least 40 mL/kg of total blood products in the first 4 hours after emergency department arrival. Exclusion criteria included hospital transfer, arrival without signs of life, time of death or hospital discharge not recorded, and isolated head injuries. To adjust for potential confounding, a propensity score for treatment was created and inverse probability weighting was applied. The propensity score accounted for age, sex, race/ethnicity, injury type, payment type, Glasgow Coma Scale score, hypoxia, hypotension, assisted respirations, chest tube status, Injury Severity Score, total volume of blood products received, hemorrhage control procedure, hospital size, academic status, and trauma center designation. Data were analyzed from December 11, 2019, to August 31, 2020. Exposures: Cryoprecipitate use within the first 4 hours of emergency department arrival. Main Outcomes and Measures: In-hospital 24-hour and 7-day mortality. Results: Of the 2387 injured patients who received massive transfusion, 1948 patients were eligible for analysis. The median age was 16 years (interquartile range, 9-17 years), 1382 patients (70.9%) were male, and 807 (41.4%) were White. A total of 541 patients (27.8%) received cryoprecipitate. After propensity score weighting, patients who received cryoprecipitate had a significantly lower 24-hour mortality when compared with those who did not (adjusted difference, -6.9%; 95% CI, -10.6% to -3.2%). Moreover, cryoprecipitate use was associated with a significantly lower 7-day mortality but only in children with penetrating trauma (adjusted difference, -9.2%; 95% CI, -15.4% to -3.0%) and those transfused at least 100 mL/kg of total blood products (adjusted difference, -7.7%; 95% CI, -15.0% to -0.5%). Conclusions and Relevance: In this cohort study, early use of cryoprecipitate was associated with lower 24-hour mortality among injured children who required massive transfusion. The benefit of cryoprecipitate appeared to persist for 7 days only in those with penetrating trauma and in those who received extremely large-volume transfusion.


Assuntos
Transfusão de Sangue , Fator VIII/uso terapêutico , Fibrinogênio/uso terapêutico , Hemorragia/terapia , Ferimentos não Penetrantes/terapia , Ferimentos Penetrantes/terapia , Adolescente , Criança , Feminino , Hemorragia/etiologia , Humanos , Masculino , Pontuação de Propensão , Estudos Retrospectivos , Taxa de Sobrevida , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/mortalidade , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/mortalidade
20.
Perspect Health Inf Manag ; 18(Winter): 1c, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33633513

RESUMO

Background: Comparative morbidity after either sternotomy or non-resuscitative thoracotomy in penetrating cardiac injuries (PCI) is unknown. Methods: Retrospective review of adults with PCI who underwent either sternotomy or non-resuscitative thoracotomy using the National Trauma Data Bank 2007-2015. Since there is no unique International Classification of Diseases Procedure Coding System (ICD-PCS) codes assigned for resuscitative vs. non-resuscitative thoracotomy, and both procedures were coded as "thoracotomy", propensity score (PS) methods were applied to avoid inclusion of resuscitative thoracotomy. Results: Despite well PS matching on injury severity score the non-thoracotomy group compared to the sternotomy group had a significantly increased risk of mortality (30 percent vs 8 percent, p<0.0001). The morbidity differed as well-25 percent vs. 12 percent, p=0.0007. Conclusions: The differences in mortality in PCI patients who underwent non-resuscitative thoracotomy vs. sternotomy may be biased by unintentional inclusion of resuscitative thoracotomy. To accurately capture thoracotomy type, separate unique resuscitative and non-resuscitative thoracotomy procedure codes should be created in future revisions of the ICD PCS.


Assuntos
Traumatismos Cardíacos/cirurgia , Classificação Internacional de Doenças/normas , Esternotomia/mortalidade , Toracotomia/mortalidade , Ferimentos Penetrantes/cirurgia , Adulto , Feminino , Traumatismos Cardíacos/mortalidade , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Ferimentos Penetrantes/mortalidade
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