Trauma Laparotomy for the Cirrhotic Patient: An Outcome-Based Analysis.

INTRODUCTION: There is a lack of large-scale data on outcomes of cirrhotic patients undergoing trauma laparotomy. We aimed to compare outcomes of cirrhotic versus noncirrhotic trauma patients undergoing laparotomy. METHODS: We analyzed 2018 American College of Surgeons Trauma Quality Improvement Program. We included blunt trauma patients (≥18 y) who underwent a laparotomy. Patients who were transferred, dead on arrival, or had penetrating injuries were excluded. Patients were matched in a 1:2 ratio (cirrhotic and noncirrhotic). Outcomes included mortality, complications, failure to rescue, transfusion requirements, and hospital and intensive care unit (ICU) lengths of stay. Multivariable backward stepwise regression analysis was performed. RESULTS: Four hundred and seventy-one patients (cirrhotic, 157; noncirrhotic, 314) were matched. Mean age was 57 ± 15 y, 78% were male, and median injury severity score was 24. Cirrhotic patients had higher rates of mortality (60% versus 30%, P value <0.001), complications (49% versus 37%; P value = 0.01), failure to rescue (66% versus 36%, P value<0.001), and pRBC (units, median, 11 [7-18] versus 7 [4-11], P value <0.001) transfusion requirements. There were no significant differences in hospital and intensive care unit (ICU) lengths of stay (P value ≥0.05). On multivariate analysis, increasing age (adjusted odds ratio [aOR] 1.02, P value <0.001), Glasgow Coma Scale score ≤8 at presentation (aOR 3.3, P value <0.001), and total splenectomy (aOR 5.7, P value <0.001) were associated with higher odds of mortality. Platelet transfusion was associated with lower odds of mortality (aOR 0.84, P value = 0.044). CONCLUSIONS: On a national scale, mortality following trauma laparotomy is twice as high for cirrhotic patients compared to noncirrhotic patients with higher rates of major complications and failure to rescue. Our finding of a protective effect of platelet transfusion may be explained by the platelet dysfunction associated with cirrhosis. Liver cirrhosis among trauma patients warrants heightened surveillance.

Predictors of Mortality in Blunt Cardiac Injury: A Nationwide Analysis.

INTRODUCTION: Blunt thoracic injury (BTI) is one of the most common causes of trauma admission in the United States and is uncommonly associated with cardiac injuries. Blunt cardiac injury (BCI) after blunt thoracic trauma is infrequent but carries a substantial risk of morbidity and sudden mortality. Our study aims to identify predictors of concomitant cardiac contusion among BTI patients and the predictors of mortality among patients presenting with BCI on a national level. MATERIALS AND METHODS: We performed a 1-y (2017) analysis of the American College of Surgeons Trauma Quality Improvement Program. We included all adults (aged ≥ 18 y) with the diagnosis of BTI. We excluded patients who were transferred, had a penetrating mechanism of injury, and who were dead on arrival. Our primary outcomes were the independent predictors of concomitant cardiac contusions among BTI patients and the predictors of mortality among BCI patients. Our secondary outcome measures were in-hospital complications, differences in injury patterns, and injury severity between the survivors and nonsurvivors of BCI. RESULTS: A total of 125,696 patients with BTI were identified, of which 2368 patients had BCI. Mean age was 52 ± 20 y, 67% were male, and median injury severity score was 14 [9-21]. The most common type of cardiac injury was cardiac contusion (43%). Age ≥ 65 y, higher 4-h packed red blood cell requirements, motor vehicle collision mechanism of injury, and concomitant thoracic injuries (hemothorax, flail chest, lung contusion, sternal fracture, diaphragmatic injury, and thoracic aortic injuries) were independently associated with concomitant cardiac contusion among BTI patients (P value < 0.05). Age ≥ 65 y, thoracic aortic injury, diaphragmatic injury, hemothorax, and a history of congestive heart failure were independently associated with mortality in BCI patients (P value < 0.05). CONCLUSIONS: Predictors of concomitant cardiac contusion among BTI patients and mortality among BCI patients were identified. Guidelines on the management of BCI should incorporate these predictors for timely identification of high-risk patients.

Emergency readmissions following geriatric ground-level falls: How does frailty factor in?

BACKGROUND: Ground-level falls (GLFs) in older adults are increasing as life expectancy increases, and more patients are being discharged to skilled nursing facilities (SNFs) for continuity of care. However, GLF patients are not a homogenous cohort, and the role of frailty remains to be assessed. Thus, the aim of this study is to examine the impact of frailty on the in-hospital and 30-day outcomes of GLF patients. MATERIALS AND METHODS: This is a cohort analysis from the Nationwide Readmissions Database 2017. Geriatric (age ≥65 years) trauma patients presenting following GLFs were identified and grouped based on their frailty status. The associations between frailty and 30-day mortality and emergency readmission were examined by multivariate regression analyses adjusting for patient demographics and injury characteristics. RESULTS: A total of 100,850 geriatric GLF patients were identified (frail: 41% vs. non-frail: 59%). Frail GLF patients were younger (81[74-87] vs. 83[76-89] years; p<0.001) and less severely injured-Injury Severity Score [ISS] (4[1-9] vs. 5[2-9]; p<0.001). Frail patients had a higher index mortality (2.9% vs. 1.9%; p<0.001) and higher 30-day readmissions (14.0% vs. 9.8%; p<0.001). Readmission mortality was also higher in the frail group (15.2% vs. 10.9%; p<0.001), with 75.2% of those patients readmitted from an SNF. On multivariate analysis, frailty was associated with 30-day mortality (OR 1.75; p<0.001) and 30-day readmission (OR 1.49; p<0.001). CONCLUSION: Frail geriatric patients are at 75% higher odds of mortality and 49% higher odds of readmission following GLFs. Of those readmitted on an emergency basis, more than one in seven patients died, 75% of whom were readmitted from an SNF. This underscores the need for optimization plans that extend to the post-discharge period to reduce readmissions and subsequent high-impact consequences.