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OBJECTIVE: To identify the modifiable and non-modifiable risk factors associated with post-intubation hypotension (PIH) among trauma patients who required endotracheal intubation (ETI) in the trauma bay. SUMMARY BACKGROUND DATA: ETI has been associated with hemodynamic instability, termed PIH, yet its risk factors in trauma patients remain under-investigated. METHODS: This is a prospective observational study at a level I trauma center over 4 years (2019-2022). All adult (≥18) trauma patients requiring ETI in the trauma bay were included. Blood pressure was monitored both pre- and post-intubation. Multivariable logistic regression analysis was performed to identify the modifiable and non-modifiable factors associated with PIH. RESULTS: 708 patients required ETI in the trauma bay, of which, 435 (61.4%) developed PIH. The mean (SD) age was 43 (21) and 71% were male. Median [IQR] arrival GCS was 7 [3-13]. Patients who developed PIH had a lower mean (SD) pre-intubation SBP (118 (46) vs. 138 (28), P<0.001) and higher median [IQR] ISS (27 [21-38] vs. 21 [9-26], P<0.001). Multivariable regression analysis identified BMI>25, increasing ISS, penetrating injury, spinal cord injury, Pre-intubation PRBC requirements, and diabetes mellitus as non-modifiable risk factors associated with increased odds of PIH. In contrast, pre-intubation administration of 3% hypertonic saline and vasopressors were identified as the modifiable factors significantly associated with reduced PIH. CONCLUSION: More than half of the patients requiring ETI in the trauma bay developed PIH. This study identified modifiable and non-modifiable risk factors that influence the development of PIH, which will help physicians when considering ETI upon patient arrival. LEVEL OF EVIDENCE: Level III, Prognostic Study.
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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.
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Ferimentos não Penetrantes , Ferimentos Penetrantes , Humanos , Masculino , Adulto , Pessoa de Meia-Idade , Idoso , Feminino , Laparotomia/efeitos adversos , Resultado do Tratamento , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/cirurgia , Cirrose Hepática/complicações , Cirrose Hepática/cirurgia , Ferimentos Penetrantes/cirurgia , Escala de Gravidade do Ferimento , Estudos Retrospectivos , Centros de TraumatologiaRESUMO
INTRODUCTION: Whole blood (WB) has recently gained increased popularity as an adjunct to the resuscitation of hemorrhaging civilian trauma patients. We aimed to assess the nationwide outcomes of using WB as an adjunct to component therapy (CT) versus CT alone in resuscitating geriatric trauma patients. METHODS: We performed a 5-y (2017-2021) retrospective analysis of the Trauma Quality Improvement Program. We included geriatric (age, ≥65 y) trauma patients presenting with hemorrhagic shock (shock index >1) and requiring at least 4 units of packed red blood cells in 4 h. Patients with severe head injuries (head Abbreviated Injury Scale ≥3) and transferred patients were excluded. Patients were stratified into WB-CT versus CT only. Primary outcomes were 6-h, 24-h, and in-hospital mortality. Secondary outcomes were major complications. Multivariable regression analysis was performed, adjusting for potential confounding factors. RESULTS: A total of 1194 patients were identified, of which 141 (12%) received WB. The mean ± standard deviation age was 74 ± 7 y, 67.5% were male, and 83.4% had penetrating injuries. The median [interquartile range] Injury Severity Score was 19 [13-29], with no difference among study groups (P = 0.059). Overall, 6-h, 24-h, and in-hospital mortality were 16%, 23.1%, and 43.6%, respectively. On multivariable regression analysis, WB was independently associated with reduced 24-h (odds ratio, 0.62 [0.41-0.94]; P = 0.024), and in-hospital mortality (odds ratio, 0.60 [0.40-0.90]; P = 0.013), but not with major complications (odds ratio, 0.78 [0.53-1.15]; P = 0.207). CONCLUSIONS: Transfusion of WB as an adjunct to CT is associated with improved early and overall mortality in geriatric trauma patients presenting with severe hemorrhage. The findings from this study are clinically important, as this is an essential first step in prioritizing the selection of WB resuscitation for geriatric trauma patients presenting with hemorrhagic shock.
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Transfusão de Sangue , Mortalidade Hospitalar , Ressuscitação , Choque Hemorrágico , Humanos , Feminino , Masculino , Idoso , Estudos Retrospectivos , Ressuscitação/métodos , Ressuscitação/estatística & dados numéricos , Idoso de 80 Anos ou mais , Choque Hemorrágico/terapia , Choque Hemorrágico/mortalidade , Choque Hemorrágico/etiologia , Choque Hemorrágico/diagnóstico , Transfusão de Sangue/estatística & dados numéricos , Transfusão de Sangue/métodos , Ferimentos e Lesões/complicações , Ferimentos e Lesões/mortalidade , Ferimentos e Lesões/terapia , Ferimentos e Lesões/diagnóstico , Escala de Gravidade do Ferimento , Técnicas Hemostáticas , Resultado do TratamentoRESUMO
INTRODUCTION: Initial interaction with health care system presents an important opportunity to provide substance use disorder (SUD) rehabilitation in the form of mental health services (MHSs). This study aims to identify predictors of receipt of MHSs among adult trauma patients with SUD and positive drug screen. METHODS: In this analysis of 2017-2021 American College of Surgeons-Trauma Quality Improvement Program (ACS TQIP), adult(≥18 y) patients with SUD and positive drug screen who survived the hospital admission were included. Outcomes measure was the receipt of MHS. Poisson regression analysis with clustering by facility was performed to identify independent predictors of receipt of MHS. RESULTS: 128,831 patients were identified of which 3.4% received MHS. Mean age was 41 y, 76% were male, 63% were White, 25% were Black, 12% were Hispanic, and 82% were insured. Median injury severity score was 9, and 54% were managed at an ACS level I trauma center. On regression analysis, female gender (aOR = 1.17, 95% CI = 1.09-1.25), age ≥65 y (aOR = 0.98, 95% CI = 0.97-0.99), White race (aOR = 1.37, 95% CI = 1.28-1.47), Hispanic ethnicity (aOR = 0.84, 95% CI = 0.76-0.93), insured status (aOR = 1.22, 95% CI = 1.13-1.33), and management at ACS level I trauma centers (aOR = 1.47, 95% CI = 1.38-1.57) were independent predictors of receipt of MHS. CONCLUSIONS: Race, ethnicity, and socioeconomic factors predict the receipt of MHS in trauma patients with SUD and positive drug screens. It is unknown if these disparities affect the long-term outcomes of these vulnerable patients. Further research is warranted to expand on the contributing factors leading to these disparities and possible strategies to address them.
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Serviços de Saúde Mental , Transtornos Relacionados ao Uso de Substâncias , Ferimentos e Lesões , Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/terapia , Ferimentos e Lesões/terapia , Serviços de Saúde Mental/estatística & dados numéricos , Idoso , Centros de Traumatologia/estatística & dados numéricos , Adulto Jovem , Estudos RetrospectivosRESUMO
INTRODUCTION: This study aimed to develop and validate Futility of Resuscitation Measure (FoRM) for predicting the futility of resuscitation among older adult trauma patients. METHODS: This is a retrospective analysis of the American College of Surgeons-Trauma Quality Improvement Program database (2017-2018) (derivation cohort) and American College of Surgeons level I trauma center database (2017-2022) (validation cohort). We included all severely injured (injury severity score >15) older adult (aged ≥60 y) trauma patients. Patients were stratified into decades of age. Injury characteristics (severe traumatic brain injury [Glasgow Coma Scale ≤ 8], traumatic brain injury midline shift), physiologic parameters (lowest in-hospital systolic blood pressure [≤1 h], prehospital cardiac arrest), and interventions employed (4-h packed red blood cell transfusions, emergency department resuscitative thoracotomy, resuscitative endovascular balloon occlusion of the aorta, emergency laparotomy [≤2 h], early vasopressor requirement [≤6 h], and craniectomy) were identified. Regression coefficient-based weighted scoring system was developed using the Schneeweiss method and subsequently validated using institutional database. RESULTS: A total of 5562 patients in derivation cohort and 873 in validation cohort were identified. Mortality was 31% in the derivation cohort and FoRM had excellent discriminative power to predict mortality (area under the receiver operator characteristic = 0.860; 95% confidence interval [0.847-0.872], P < 0.001). Patients with a FoRM score of >16 had a less than 10% chance of survival, while those with a FoRM score of >20 had a less than 5% chance of survival. In validation cohort, mortality rate was 17% and FoRM had good discriminative power (area under the receiver operator characteristic = 0.76; 95% confidence interval [0.71-0.80], P < 0.001). CONCLUSIONS: FoRM can reliably identify the risk of futile resuscitation among older adult patients admitted to our level I trauma center.
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INTRODUCTION: Interfacility transfer to higher levels of care is becoming increasingly common. This study aims to evaluate the association between transfer to higher levels of care and prolonged transfer times with outcomes of severely injured geriatric trauma patients compared to those who are managed definitively at lower-level trauma centers. METHODS: Severely injured (Injury Severity Score >15) geriatric (≥60 y) trauma patients in the 2017-2018 American College of Surgeons Trauma Quality Improvement Program database managing at an American College of Surgeons/State Level III trauma center or transferring to a level I or II trauma center were included. Outcome measures were 24-h and in-hospital mortality and major complications. RESULTS: Forty thousand seven hundred nineteen patients were identified. Mean age was 75 ± 8 y, 54% were male, 98% had a blunt mechanism of injury, and the median Injury Severity Score was 17 [16-21]. Median transfer time was 112 [79-154] min, and the most common transport mode was ground ambulance (82.3%). Transfer to higher levels of care within 90 min was associated with lower 24-h mortality (adjusted odds ratio [aOR]: 0.493, P < 0.001) and similar odds of in-hospital mortality as those managed at level III centers. However, every 30-min delay in transfer time beyond 90 min was progressively associated with increased odds of 24-h (aOR: 1.058, P < 0.001) and in-hospital (aOR: 1.114, P < 0.001) mortality and major complications (aOR: 1.127, P < 0.001). CONCLUSIONS: Every 30-min delay in interfacility transfer time beyond 90 min is associated with 6% and 11% higher risk-adjusted odds of 24-h and in-hospital mortality, respectively. Estimated interfacility transfer time should be considered while deciding about transferring severely injured geriatric trauma patients to a higher level of care.
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Mortalidade Hospitalar , Escala de Gravidade do Ferimento , Transferência de Pacientes , Centros de Traumatologia , Ferimentos e Lesões , Humanos , Masculino , Feminino , Idoso , Transferência de Pacientes/estatística & dados numéricos , Centros de Traumatologia/estatística & dados numéricos , Idoso de 80 Anos ou mais , Ferimentos e Lesões/mortalidade , Ferimentos e Lesões/terapia , Ferimentos e Lesões/diagnóstico , Estudos Retrospectivos , Pessoa de Meia-Idade , Fatores de TempoRESUMO
INTRODUCTION: There is a lack of data on the outcomes of thoracic damage control surgery (TDCS). This study aimed to describe the characteristics and outcomes of patients undergoing TDCS. METHODS: This is a retrospective analysis of the American College of Surgeons-Trauma Quality Improvement Program database (2017-2021). All trauma patients who underwent emergency thoracotomy and packing with temporary closure were included. Patients were stratified based on the age groups (pediatric [<18 y], adults [18-64 y], and older adults [≥65 y]). Our primary outcome measures included 6-h, 24-h, and in-hospital mortality. Secondary outcomes were major complications. RESULTS: We identified 14,192 thoracotomies, out of which 213 underwent TDCS (pediatric [n = 17], adults [n = 175], and older adults [n = 21]). The mean (SD) age was 37 (18), and 86% were male. The mean shock index was 1.1 (0.4) on presentation with a median [IQR] Glasgow Coma Scale of 4 [3-14], and 22.1% had a prehospital cardiac arrest. The study population was profoundly injured with a median injury severity scoreand chest-abbreviated injury scale of 26 [17-38] and 4 [3-5], respectively, with lung (76.5%) being the most injured intrathoracic organs. Overall, the rates of 6-h, 24-h, and in-hospital mortality were 22.5%, 33%, and 53%, respectively, and 51% developed major complications. There was no significant difference in terms of in-hospital mortality (P = 0.800) and major complications (0.416) among pediatrics, adults, and older adults. CONCLUSIONS: One in three patients undergoing TDCS die within the first 24 h, and more than half of them develop major complications and die in the hospital, with no difference among pediatric, adults, and older adults. Future efforts should be directed to improve the survival of these severely injured, metabolically depleted, challenging patients.
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INTRODUCTION: There is a paucity of large-scale data on the factors that suggest an impending or underlying extremity pediatric acute compartment syndrome (ACS). In addition, literature regarding the timing of operative fixation and the risk of ACS is mixed. We aimed to describe the factors associated with pediatric ACS. METHODS: Analysis of 2017-2019 Trauma Quality Improvement Program. We included patients aged <18 y diagnosed with upper extremity (UE) and lower extremity (LE) fractures. Burns and insect bites/stings were excluded. Multivariable regression analyses were performed to identify the predictors of ACS. RESULTS: 61,537 had LE fractures, of which 0.5% developed ACS. 76,216 had UE fractures, of which 0.16% developed ACS. Multivariable regression analyses identified increasing age, male gender, motorcycle collision, and pedestrian struck mechanisms of injury, comminuted and open fractures, tibial and concurrent tibial and fibular fractures, forearm fractures, and operative fixation as predictors of ACS (P value <0.05). Among LE fractures, 34% underwent open reduction internal fixation (time to operation = 14 [8-20] hours), and 2.1% underwent ExFix (time to operation = 9 [4-17] hours). Among UE fractures, 54% underwent open reduction internal fixation (time to operation = 11 [6-16] hours), and 1.9% underwent ExFix (time to operation = 9 [4-14] hours). Every hour delay in operative fixation of UE and LE fractures was associated with a 0.4% increase in the adjusted odds of ACS (P value <0.05). CONCLUSIONS: Our results may aid clinicians in recognizing children who are "at risk" for ACS. Future studies are warranted to explore the optimal timing for the operative fixation of long bone fractures to minimize the risk of pediatric ACS.
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Síndromes Compartimentais , Humanos , Masculino , Síndromes Compartimentais/etiologia , Síndromes Compartimentais/diagnóstico , Síndromes Compartimentais/epidemiologia , Síndromes Compartimentais/cirurgia , Feminino , Criança , Adolescente , Estudos Retrospectivos , Pré-Escolar , Fatores de Risco , Fraturas Ósseas/cirurgia , Fraturas Ósseas/complicações , Fraturas Ósseas/epidemiologia , Tempo para o Tratamento/estatística & dados numéricos , Lactente , Fixação Interna de Fraturas/efeitos adversos , Doença Aguda , Redução Aberta/efeitos adversos , Fraturas da Tíbia/cirurgia , Fraturas da Tíbia/complicaçõesRESUMO
OBJECTIVE: Compare EGS patient outcomes after index and nonindex hospital readmissions, and explore predictive factors for nonindex readmission. BACKGROUND: Readmission to a different hospital leads to fragmentation of care. The impact of nonindex readmission on patient outcomes after EGS is not well established. METHODS: The Nationwide Readmissions Database (2017) was queried for adult patients readmitted after an EGS procedure. Patients were stratified and propensity-matched according to readmission destination: index versus nonindex hospital. Outcomes were failure to rescue (FTR), mortality, number of subsequent readmissions, overall hospital length of stay, and total costs. Hierarchical logistic regression was performed to account for clustering effect within hospitals and adjusting for patient- and hospital-level potential confounding factors. RESULTS: A total of 471,570 EGS patients were identified, of which 79,127 (16.8%) were readmitted within 30 days: index hospital (61,472; 77.7%) versus nonindex hospital (17,655; 22.3%). After 1:1 propensity matching, patients with nonindex readmission had higher rates of FTR (5.6% vs 4.3%; P < 0.001), mortality (2.7% vs 2.1%; P < 0.001), and overall hospital costs [in $1000; 37 (27-64) vs 28 (21-48); P < 0.001]. Nonindex readmission was independently associated with higher odds of FTR [adjusted odds ratio 1.18 (1.03-1.36); P < 0.001]. Predictors of nonindex readmission included top quartile for zip code median household income [1.35 (1.08-1.69); P < 0.001], fringe county residence [1.08 (1.01-1.16); P = 0.049], discharge to a skilled nursing facility [1.28 (1.20-1.36); P < 0.001], and leaving against medical advice [2.32 (1.81-2.98); P < 0.001]. CONCLUSION: One in 5 readmissions after EGS occur at a different hospital. Nonindex readmission carries a heightened risk of FTR. LEVEL OF EVIDENCE: Level III Prognostic. STUDY TYPE: Prognostic.
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Hospitais , Readmissão do Paciente , Adulto , Humanos , Fatores de Risco , Alta do Paciente , Mortalidade Hospitalar , Estudos Retrospectivos , Complicações Pós-OperatóriasRESUMO
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.
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Traumatismos Cardíacos , Contusões Miocárdicas , Traumatismos Torácicos , Ferimentos não Penetrantes , Adulto , Masculino , Humanos , Estados Unidos/epidemiologia , Pessoa de Meia-Idade , Idoso , Feminino , Hemotórax , Traumatismos Torácicos/complicações , Traumatismos Torácicos/diagnóstico , Contusões Miocárdicas/complicações , Contusões Miocárdicas/epidemiologia , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/diagnóstico , Escala de Gravidade do Ferimento , Traumatismos Cardíacos/etiologia , Estudos RetrospectivosRESUMO
INTRODUCTION: Bladder and ureteral injuries are uncommon in trauma patients but are associated with increased morbidity and mortality. Patients presenting with such injuries may undergo either open surgical repair or laparoscopic repair. We aimed to compare outcomes of open surgical approach and laparoscopy in trauma patients with isolated bladder and ureteral injury. We hypothesized that laparoscopy is associated with improved outcomes. METHODS: We performed a 2017 review of American College of Surgeons Trauma Quality Improvement Program and identified trauma patients with bladder and ureteral injury who underwent open surgical repair or laparoscopy. A 1:1 propensity score matching was performed adjusting for demographics, emergency department vitals (systolic blood pressure, heart rate, Glasgow Coma Scale), mechanism of injury, Injury Severity Score, each body region Abbreviated Injury Scale score, and transfusion units. Outcomes were rates of in-hospital major complications and mortality. RESULTS: Of the 1,004,440 trauma patients, 384 patients (open: 192 and laparoscopy: 192) were matched and included. The mean age was 36 ± 15 y, Injury Severity Score was 27 [27-48], 77% were males, and 56% of patients had a blunt mechanism of injury, and 44% had penetrating injuries. Overall mortality was 7.3%. On univariate analysis, mortality was lower in the open group as compared to the laparoscopy group (10.4% versus 4.2%, P = 0.019) and survivor-only hospital length of stay was longer in the open group (8 [8-9] versus 7 [5-11], P = 0.008). There was no difference in overall major complications (23% versus 21%, P = 0.621). On multivariate analysis, open surgical repair was independently associated with lower odds of mortality (adjusted odds ratio: 0.405, 95% confidence interval: [0.17-0.95], P-value = 0.038) CONCLUSIONS: In our analysis open surgical repair of bladder and ureteral injuries was associated with lower mortality with other outcomes being similar when compared to laparoscopy. Laparoscopic surgical repair may not have an advantage over the open surgical repair for bladder and ureteral injuries. Further prospective studies are needed to delineate the ideal surgical approach for these injuries.
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Traumatismos Abdominais , Laparoscopia , Doenças Urológicas , Masculino , Humanos , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Feminino , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Procedimentos Cirúrgicos Minimamente Invasivos , Escala de Gravidade do Ferimento , Pontuação de Propensão , Laparoscopia/efeitos adversos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
INTRODUCTION: Multiple shock indices (SIs), including prehospital, emergency department (ED), and delta (ED SI - Prehospital SI) have been developed to predict outcomes among trauma patients. This study aims to compare the predictive abilities of these SIs for outcomes of polytrauma patients on a national level. METHODS: This was a retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program (2017-2018). We included adult (≥18 y) trauma patients and excluded patients who were transferred, had missing vital signs, and those with severe head injuries (Head-Abbreviated Injury Scale>3). Outcome measures were 24-h and in-hospital mortality, 24-h packed red blood cells transfusions, and intensive care unit and hospital length of stay. Predictive performances of these SIs were evaluated by the Area Under the Receiver Operating Characteristics for the entire study cohort and across all injury severities. RESULTS: A total of 750,407 patients were identified. Meanstandard deviation age and lowest systolic blood pressure were 53 ± 21 y, and 81 ± 32 mmHg, respectively. Overall, 24-h and in-hospital mortality were 1.2% and 2.5%, respectively. On multivariable analysis, all three SIs were independently associated with higher rates of 24-h and in-hospital mortality, blood product requirements, intensive care unit and hospital length of stay (P < 0.001). ED SI was superior to prehospital and delta SIs (P < 0.001) for all outcomes. On subanalysis of patients with moderate injuries, severe injuries, and positive delta SI, the results remained the same. CONCLUSIONS: ED SI outperformed both prehospital and delta SIs across all injury severities. Trauma triage guidelines should prioritize ED SI in the risk stratification of trauma patients who may benefit from earlier and more intense trauma activations.
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Serviços Médicos de Emergência , Choque , Ferimentos e Lesões , Adulto , Humanos , Estudos Retrospectivos , Pressão Sanguínea/fisiologia , Frequência Cardíaca/fisiologia , Choque/diagnóstico , Choque/etiologia , Choque/terapia , Serviço Hospitalar de Emergência , Ferimentos e Lesões/complicações , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/terapia , Escala de Gravidade do Ferimento , Serviços Médicos de Emergência/métodos , Centros de TraumatologiaRESUMO
OBJECTIVE: Child abuse is a major cause of childhood injury, morbidity, and death. There is a paucity of data on the practice of abuse interventions among this vulnerable population. The aim of our study was to identify the factors associated with interventions for child abuse on a national scale. METHODS: Retrospective analysis of 2017 to 2018 American College of Surgeons (ACS) Pediatric Trauma Quality Improvement Program (TQIP). All children presenting with suspected/confirmed child abuse and an abuse report filed were included. Patients with missing information regarding abuse interventions were excluded. Outcomes were abuse investigations initiated among those with abuse reports, and change of caregiver at discharge among survivors with an investigation initiated. Multivariable regression analyses were performed. RESULTS: A total of 7774 child abuse victims with an abuse report were identified. The mean age was 5±5 years, 4221 (54%) patients were White, 2297 (30%) Black, 1543 (20%) Hispanic, and 5298 (68%) had government insurance. The most common mechanism was blunt (63%), followed by burns (10%) and penetrating (10%). The median Injury Severity Score was 5 (1-12). The most common form of abuse was physical (92%), followed by neglect (6%), sexual (3%), and psychological (0.1%). The most common perpetrator of abuse was a care provider/teacher (49.5%), followed by a member of the immediate family (30.5%), or a member of the extended/step/foster family (20.0%). Overall, 6377 (82%) abuse investigations were initiated for those with abuse reports. Of these, 1967 (33%) resulted in a change of caregiver. Black children were more likely to have abuse investigated, and Black and Hispanic children were more likely to experience change of caregiver after investigations, while privately insured children were less likely to experience both. CONCLUSIONS: Significant racial, ethnic, and socioeconomic disparities exist in the nationwide management of child abuse. Further studies are strongly warranted to understand contributing factors and possible strategies to address them. LEVEL OF EVIDENCE: Level III-therapeutic/care management.
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Maus-Tratos Infantis , Hispânico ou Latino , Criança , Pré-Escolar , Etnicidade , Humanos , Lactente , Recém-Nascido , Estudos Retrospectivos , Fatores SocioeconômicosRESUMO
BACKGROUND: Routine frailty assessment has emerged recently in the surgical literature and is an important prognostication and risk stratification tool. The aim of our study was to review our 7-y experience with two frailty assessment tools and changing trends in their use. METHODS: We performed a 7-y (2011-2017) analysis of our prospectively maintained frailty database. Frail patients were identified using the emergency general surgery and trauma specific frailty indices. Outcome measures were rates of compliance with frailty assessment, overall complications, discharge to skilled nursing facility (SNF)/rehab, and mortality over the study period. Multivariate logistic regression and Cochran-Armitage trend analyses were performed. RESULTS: We evaluated a total of 1045 geriatric patients (Trauma: 587, EGS: 458). Mean age was 74.5 ± 7.9 y, 74% were males, and 81% were white. Overall, 34% of the patients were frail. Compared to non-frail patients, frail patients had higher adjusted rates of complications (OR 2.4 [1.9-2.9]), mortality (OR 1.8 [1.4-2.3]), and rehab/SNF disposition (OR 3.7 [3.1-4.3]). The compliance rate of measuring frailty increased from 12% in 2011 to 78% in 2017, P < 0.001 (Figure). The complication rate decreased (33% versus 21%, P < 0.001), while the rate of discharge disposition to SNF/Rehab increased (41% versus 58%, P < 0.001). There was no difference in mortality (11% versus 9.8%, P = 0.48) over the study period. CONCLUSIONS: Adherence to frailty measurement increased over the study period. This was accompanied by a significant decline in overall in-hospital complications. Frailty indices can be utilized to identify high-risk patients and develop post-operative strategies to improve outcomes in acute care surgery.
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Fragilidade , Idoso , Idoso de 80 Anos ou mais , Feminino , Idoso Fragilizado , Fragilidade/complicações , Fragilidade/diagnóstico , Avaliação Geriátrica , Humanos , Masculino , Alta do Paciente , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Medição de Risco , Fatores de RiscoRESUMO
INTRODUCTION: Ground-level falls (GLF) are typically reported as a minor mechanism of injury; however, they represent a significant portion of hospitalized geriatric trauma patients as they can result in multisystem injury in this subset of the population. Our study aimed to analyze trends in geriatric trauma falls on the national level. METHODS: We performed a 5-y (2011-2015) analysis of the American College of Surgeons National Trauma Data Bank (ACS-NTDB) and included all geriatric trauma patients (age ≥ 65 y) who presented with GLF. GLF was identified using ICD-9 E CODES. Our outcome measures were national incidence of GLF, and overall discharge disposition and trauma center level discharge disposition following GLF. We used Cochran Armitage test and multivariate regression analysis. RESULTS: We analyzed a total of 1,017,326 geriatric trauma patients, of which 39% had had a fall as a mechanism of injury. Among those who fell, mean age was 78 ± 7, 63% were females, and 85% were whites. The incidence of falls significantly increased over the study period, and was noted to be proportional to age, with a plateau beyond age 85 y old. The rate of discharge to SNF and/or Rehab significantly increased over the study period; however, discharge to home and mortality rates trended downwards over the study period. Discharge to SNF and/or Rehab was significantly lower among level I trauma centers compared to other level trauma centers. Conversely, discharge to home was higher in level I trauma centers compared to other level trauma centers. CONCLUSION: Around one in three elderly trauma patients were admitted following a GLF with an overall increased incidence of falls over time. Although overall mortality rates decreased, there was an increase in adverse discharge disposition and loss of functional independence over the study period, mostly among those admitted to non-level I trauma centers.
Assuntos
Acidentes por Quedas/mortalidade , Alta do Paciente/tendências , Ferimentos e Lesões/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Humanos , Incidência , Masculino , Alta do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos/epidemiologia , Ferimentos e Lesões/etiologiaRESUMO
BACKGROUND: The femoral artery is commonly injured following lower extremity trauma. If not identified early and addressed properly, it can lead to compartment syndrome (CS) and limb amputation. The aim of this study is to examine traumatic femoral artery injuries and identify risk factors for the development of lower extremity CS. METHODS: Adult (≥18 years) patients who presented with traumatic femoral artery injuries were identified in the Trauma Quality Improvement Program 2017. Patients were stratified into two groups, those with evidence of lower extremity compartment syndrome (CS) and those without CS (NCS), for comparison. Multivariate regression analysis was performed. RESULTS: A total of 1,297 adult trauma patients with femoral artery injury were identified. Mean age was 36 ± 15 y, 86% were male, and 68% had penetrating injuries. Median extremity abbreviated injury scale (AIS) was 3 [3,4], and median injury severity score (ISS) was 27 [22-41]. 68 (5.2%) patients were diagnosed with CS of the lower extremity, 66 (97.1%) of those patients underwent fasciotomy and one (1.5%) patient eventually had an amputation. On multivariate regression analysis, concomitant femoral vein, femoral nerve, and popliteal artery injuries and early need for blood transfusions were independent risk factors for the development of CS (OR 3.1, 3.8, 4.3, and 2.5 respectively). CONCLUSIONS: CS following traumatic femoral artery injury is a relatively common finding. Physicians must maintain a high index of suspicion and should consider prophylactic fasciotomy in the setting of combined femoral vein and nerve injuries, combined popliteal artery injury, and multiple blood transfusions.
Assuntos
Síndromes Compartimentais/epidemiologia , Artéria Femoral/lesões , Lesões do Sistema Vascular/complicações , Adulto , Síndromes Compartimentais/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Despite improvements in operative techniques, major abdominal complications (MACs) continue to occur after penetrating abdominal trauma (PAT). This study aimed to evaluate the burden of MAC after PAT. METHODS: The (2012-2015) National Readmission Database was queried for all adult (age ≥18 y) trauma patients with penetrating injuries who underwent exploratory laparotomy and were readmitted within 6 mo of index hospitalization discharge. Patients were stratified by firearm injuries (FIs) and stab injuries (SIs). Primary outcomes were rates of MAC: intra-abdominal abscesses (IAAs), superficial surgical site infection (SSI), and fascial dehiscence within 6 mo after discharge. Secondary outcomes were both nonabdominal complications and mortality, postdischarge, and 6-mo readmission. Regression analysis was performed. RESULTS: A total of 4473 patients (FI, 2326; SI, 2147) were included in the study; the mean age was 32 ± 14 y, the Injury Severity Score was 19 (15-25), and 23% underwent damage control laparotomy (DCL). The rate of MAC within 6 mo was 22% (IAA 19%, SSI 7%, and fascial dehiscence 4%). Patients with FIs had a higher rate of IAA (27% versus 10%; P < 0.01), SSI (11% versus 3%; P < 0.01), fascial dehiscence (5% versus 3%; P = 0.03), nonabdominal complications (54% versus 24%; P < 0.01), and postdischarge mortality (8% versus 6%; P < 0.01) compared with patients with SIs . On regression analysis, DCL (P < 0.01), large bowel perforation (P < 0.01), biliary-pancreatic injury (P < 0.01), hepatic injury (P < 0.01), and blood transfusion (P = 0.02) were predictors of MAC. CONCLUSIONS: MAC developed in one in five patients after PAT. FIs have a higher potential for hollow viscus injury and peritoneal contamination, and are more predictive of MAC and nonabdominal complications, especially after DCL. LEVEL OF EVIDENCE: Level III Prognostic.
Assuntos
Abdome/cirurgia , Traumatismos Abdominais/cirurgia , Laparotomia , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Ferimentos Penetrantes/cirurgia , Abscesso Abdominal/epidemiologia , Traumatismos Abdominais/complicações , Traumatismos Abdominais/mortalidade , Adolescente , Adulto , Feminino , Humanos , Escala de Gravidade do Ferimento , Laparotomia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Deiscência da Ferida Operatória/epidemiologia , Infecção da Ferida Cirúrgica/epidemiologia , Ferimentos por Arma de Fogo/complicações , Ferimentos por Arma de Fogo/cirurgia , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/mortalidade , Ferimentos Perfurantes/complicações , Ferimentos Perfurantes/cirurgia , Adulto JovemRESUMO
BACKGROUND: Blood pressure alterations in patients with traumatic brain injury (TBI) have been shown to be associated with increased mortality. However, there is paucity of data describing the optimal emergency department (ED) systolic blood pressure (SBP) target during the initial evaluation. The aim of our study was to assess the association between SBP on presentation and mortality in patients with TBI. METHODS: We performed a retrospective (2015-2016) review of the American College of Surgeons Trauma Quality Improvement Program database and included all adult (age ≥18y) trauma patients who had TBI on presentation. The outcome measure was in-hospital mortality at different ED-SBP values. A subanalysis by age and TBI severity in accordance with the Glasgow Coma Scale (GCS) was performed (mild (GCS ≥13), moderate (GCS 9-12), and severe (≤8)). Multivariate logistic regression analysis was performed. RESULTS: A total of 94,411 adult trauma patients with TBI were included. Mean age was 59 ± 21y, 62% were male, and median GCS was 15 [14-15]. Mean SBP was 147 ± 28 mmHg, and overall mortality was 8.6%. The lowest rate of mortality was noticed at ED SBP between 110 and 149 mmHg, whereas the highest mortality was at admission SBP <90 mmHg and SBP >190 mmHg. On regression analysis, SBP between 130 and 149 mmHg (odds ratio = 0.92; P = 0.68) was not associated with increased odds of mortality relative to SBP between 110 and 129 mmHg. On subanalysis based on severity of TBI (mild 80.9%, moderate 5.3%, and severe 13.8%), patients with SBP between 110 and 149 mmHg were less likely to die across all TBI groups. CONCLUSIONS: The optimal ED-SBP range for patients with TBI seems to be age and severity dependent. The optimum range might guide clinicians in developing resuscitation protocols for managing patients with TBI. LEVEL OF EVIDENCE: Level III Prognostic.
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Pressão Sanguínea , Lesões Encefálicas Traumáticas/mortalidade , Sistema de Registros , Adulto , Idoso , Idoso de 80 Anos ou mais , Lesões Encefálicas Traumáticas/fisiopatologia , Serviço Hospitalar de Emergência/normas , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Melhoria de Qualidade , Estudos Retrospectivos , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Thromboprophylaxis in patients with spinal trauma is often delayed due to the risk of bleeding and expansion of the intraspinal hematoma (ISH). Our study aimed to assess the safety of early initiation of thromboprophylaxis in patients with operative spinal trauma (OST). METHODS: We performed a 2014-2017 retrospective analysis of our level I trauma registry and included all adult patients with isolated OST who received low-molecular-weight heparin (LMWH). Patients were stratified into early (≤48 h) and late (>48 h) initiation of LMWH groups. Outcomes were a decline in hemoglobin level, packed red blood cell transfusion, and progression of ISH. We performed multivariable logistic regression. RESULTS: We identified a total of 526 patients (early: 332, late: 194). Mean age was 46 ± 22y, and the median spine abbreviated injury scale was 3 [2-4]. After thromboprophylaxis, 1.5% (8) of the patients had progression of ISH and 1% (5) underwent surgical decompression of the spinal canal. There was no difference between the two groups regarding the rate of postprophylaxis ISH progression (1.5% versus 1.6%, P = 0.11) or surgical decompression (0.9% versus 1.1%, P = 0.19). Patients who received LMWH within 48 hrs had a lower incidence of clinically significant deep vein thrombosis (2.4% versus 6.8%, P = 0.02), but no difference in pulmonary embolism (0.6% versus 1.6%, P = 0.33) or mortality (1.2% versus 1.5%, P = 0.41). On regression analysis, there was no difference regarding decline in hemoglobin levels (ß = 0.079, [-0.253 to 1.025]; P = 0.23) or number of packed red blood cell units transfused (ß = -0.011, [-0.298 to 0.471]; P = 0.35). CONCLUSIONS: Thromboprophylaxis with LMWH within the first 48 h in patients with OST is safe and efficacious. Prospective studies are needed to further validate their risk-benefit ratio. LEVEL OF EVIDENCE: Level III therapeutic.
Assuntos
Anticoagulantes/administração & dosagem , Hemorragia/induzido quimicamente , Heparina de Baixo Peso Molecular/administração & dosagem , Traumatismos da Coluna Vertebral/complicações , Tromboembolia Venosa/prevenção & controle , Adulto , Idoso , Anticoagulantes/efeitos adversos , Feminino , Heparina de Baixo Peso Molecular/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Traumatismos da Coluna Vertebral/cirurgiaRESUMO
INTRODUCTION: Firearm-related injuries (FRI) are an important public health crisis in the US. There is relatively less city level data examining the injury-related trends in Tucson, Arizona. Our study aims to examine FRI, in Southern Arizona's only Level I trauma center. METHODS: We conducted a (2014-2019) review of our Level-I trauma center registry. We selected all patients who were evaluated for a FRI. We collected patient and center related variables. Our outcomes were the trends of FRI, injury-related characteristics, and mortality. Cochran-Armitage trend analysis was performed. RESULTS: A total of 1012 FRI patients were identified. The majority of patients were teenagers (32%) and young adults (30%), and 88% were male. Greater than 80% of patients belonged to the low/low-middle socioeconomic class, and 18.5% completed college. The most common firearm utilized was the handgun (45%). The prevalence of FRI increased significantly (2014:15%; 2019:21%; P< 0.01). The most common injury intention was assault (75%). The median ISS was 17(9-25) with most injuries sustained to the extremities (23%). Also, 25% required emergent operative intervention. There is a significant rise in the number of severely injured patients (ISS≥25) (2014:12.1%, 2019:20%; P< 0.01), self-inflicted injuries (2014:10%, 2019:17%; P < 0.01), unintentional injuries (2014:6%, 2019:12%; P< 0.01), and mortality (2014:11%; 2019:19%; P< 0.01). A high prevalence of substance abuse was noted (73% alcohol, 64% drugs). CONCLUSIONS: The prevalence of FRI at our center has been rising over the past decade with a shift towards more severe injuries and higher mortality rates. Addressing these alarming changes requires targeted interventions on multiple frontiers.