Reviewing Ethical Guidelines for the Care of Patients with Do-Not-Resuscitate Orders after 30 Years: Rethinking Our Approach at a Time of Transition.

The American Society of Anesthesiologists (ASA) opposes automatic reversal of do-not-resuscitate orders during the perioperative period, instead advocating for a goal-directed approach that aligns decision-making with patients' priorities and clinical circumstances. Implementation of ASA guidelines continues to face significant barriers including time constraints, lack of longitudinal relationships with patients, and difficulty translating goal-focused discussion into concrete clinical plans. These challenges mirror those of advance care planning more generally, suggesting a need for novel frameworks for serious illness communication and patient-centered decision-making. This review considers ASA guidelines in the context of ongoing transitions to serious illness communication and increasingly multidisciplinary perioperative care. It aims to provide practical guidance for the practicing anesthesiologist while also acknowledging the complexity of decision-making, considering limitations inherent to anesthesiologists' role, and outlining a need to conceptualize delivery of ethically informed care as a collaborative, multidisciplinary endeavor.

Blunt Adrenal Injury is Not Associated With Worse Outcomes in Adult Trauma Patients.

INTRODUCTION: Blunt adrenal injury is rare. Given production of hormones including catecholamines, adrenal injury may lead to worse outcomes. However, there is a paucity of literature on this topic. As such, we compared blunt trauma patients (BTPs) with and without adrenal injuries, hypothesizing similar mortality and complications between cohorts. METHODS: The 2017-2019 Trauma Quality Improvement Program database was queried for adult (≥18-year-old) BTPs. Patients with penetrating trauma, traumatic brain injury, severe thoracic injury, or who were transferred from another hospital were excluded. Patients with adrenal injury were compared to those without using a 1:2 propensity score model. Matched variables included patient age, comorbidities, vitals on admission and concomitant injuries (i.e., liver, spleen, kidney, pancreas, and hollow viscus). Univariable logistic regression was then performed for associated risk of mortality. RESULTS: 2287 (0.2%) BTPs had an adrenal injury, with 1470 patients with adrenal injury matched to 2940 without adrenal injury. The rate of all complications including sepsis (0.1% versus 0.0%) was similar between cohorts (all P > 0.05). Patients with adrenal injury had a lower rate of mortality (0.1% versus 0.6%, P = 0.035) but increased length of stay (4 [3-6] versus 3 [2-5] days, P = 0.002). However, there was no difference in associated risk of mortality for patients with and without adrenal injury (odds ratio = 0.234; confidence interval = 0.54-1.015; P = 0.052). CONCLUSIONS: Blunt adrenal injury occurred in <1% of patients. After propensity matching, there was a similar associated rate of complications but longer hospital length of stay for patients with adrenal injury. Adrenal injury was not associated with an increased risk of mortality.

Is Adolescent Obesity Associated With a Higher Risk for Pelvic Fractures in Motor Vehicle Collisions?

INTRODUCTION: The impact of obesity on the incidence of blunt pelvic fractures in adults is unclear, and adolescents may have an increased risk of fracture due to variable bone mineral density and leptin levels. Increased subcutaneous adipose tissue may provide protection, though the association between obesity and pelvic fractures in adolescents has not been studied. This study hypothesized that obese adolescents (OAs) presenting after motor vehicle collision (MVC) have a higher rate of pelvic fractures, and OAs with such fractures have a higher associated risk of complications and mortality compared to non-OAs. METHODS: The 2017-2019 Trauma Quality Improvement Program database was queried for adolescents (12-16 y old) presenting after MVC. The primary outcome was a pelvic fracture. Adolescents with a body mass index ≥30 (OA) were compared to adolescents with a body mass index <30 (non-OA). Subgroup analyses for high-risk and low-risk MVCs were performed. Multivariable logistic regression analyses were also performed adjusting for age and sex. RESULTS: From 22,610 MVCs, 3325 (14.7%) included OAs. The observed rate of pelvic fracture was similar between all OA and non-OA MVCs (10.2% versus 9.4%, P = 0.16), as well as subanalyses of minor or high-risk MVC (both P > 0.05). OAs presenting with a pelvic fracture after high-risk MVC had a similar risk of complications, pelvic surgery, and mortality compared to non-OAs (all P > 0.05). However, OAs with a pelvic fracture after minor MVC had a higher associated risk of complications (OR 2.27, CI 1.10-4.69, P = 0.03), but a similar risk of requiring pelvic surgery, and mortality (all P > 0.05). CONCLUSIONS: This national analysis found a similar observed incidence of pelvic fractures for OAs versus non-OAs involved in an MVC, including subanalyses of minor and high-risk MVC. Furthermore, there was no difference in the associated risk of morbidity and mortality except for OAs involved in a minor MVC had a higher risk of complication.

Mild and Severe Blood Alcohol Concentration Effects on Trauma and Traumatic Brain Injury Outcomes.

INTRODUCTION: Reported outcomes for trauma patients (TPs) with elevated blood alcohol concentration (BAC) have been mixed. Previous studies suggest that positive BAC might lead to lower venous thromboembolism (VTE) rates and mortality. This study expands upon these findings by examining the association of various levels of BAC, with additional emphasis on traumatic brain injury (TBI) patients. We hypothesize that both mild and severe-BAC levels in TPs are associated with decreased risk of VTE and mortality. METHODS: A retrospective review of the 2017 Trauma Quality Improvement Program was performed on adults (≥18 y old) screened for BAC on admission. Patients deceased on arrival and positive for drugs were excluded. We compared three groups: no-BAC, mild-BAC (0-70 mg/dL), and-severe BAC (>80 mg/dL) for associated risk of VTE and mortality. RESULTS: From 203,535 tested patients, 118,427 (58.2%) had no-BAC, 19,813 (9.7%) had mild-BAC, and 65,295 (32.1%) had severe-BAC. The associated risk of VTE was lower for mild-BAC (odds ratios [OR] 0.69, 0.58-0.82, P < 0.001) and severe-BAC (OR 0.80, 0.72-0.89, P < 0.001). This persisted in TBI patients, with mild-BAC (OR 0.67, 0.51-0.89, P = 0.006) and severe-BAC (OR 0.75, 0.64-0.89, P < 0.001) groups exhibiting lower associated VTE risk. However, the associated mortality risk was lower only in severe-BAC patients (OR 0.90, 0.83-0.97, P = 0.009). CONCLUSIONS: A positive BAC is linked to a reduced associated risk of VTE in TPs, including those with TBI. Notably, only the severe-BAC group demonstrated a lower associated risk of mortality. This merits future research including identification of basic science pathways that may be targeted to improve outcomes.

Firearm Violence Surrounding the COVID-19 Pandemic: A Reopening Phenomenon.

INTRODUCTION: Past research has demonstrated a "reopening phenomenon" of increased firearm violence associated with the initial lifting of coronavirus disease 2019 (COVID-19) pandemic-related restrictions after the first wave. Now, with widespread societal reemergence from stay-at-home measures, we hypothesize another spike in firearm violence in the United States (US). Thus, the purpose of this study was to evaluate the trends in firearm violence before and after extensive community reopenings during the COVID-19 pandemic. METHODS: The Gun Violence Archive was utilized to collect data on daily firearm violence incidents, injuries, and deaths as well as on types of firearm violence. Mann-Whitney U-tests were performed for trends and types of firearm violence "before" (12/14/20-4/9/21) versus "after" (4/10/21-7/31/21) widespread societal reopening in the US. Additional analyses also sought to compare the after reopening time-period to historical data (2017-2020) of similar calendar dates, to better control for possible annual/seasonal variation. RESULTS: Median daily firearm violence incidents (153 versus 176, P < 0.001), injuries (89 versus 121, P < 0.001) and deaths (54 versus 58, P < 0.001) increased from before versus after reopening. Compared to all historical years, in the after reopening time-period there were consistent increases in total as well as mass shooting incidents/injuries/deaths (all P < 0.05). CONCLUSIONS: Firearm violence incidents, injuries, and deaths increased after societal reemergence from the COVID-19 pandemic. In addition, there has been an increase in mass shootings despite a relative lull initially brought on by the pandemic. This suggests the "reopening phenomenon" has worsened an already substantial national firearm epidemic.

Narrative Review: Is There a Transfusion Cutoff Value After Which Nonsurvivability Is Inevitable in Trauma Patients Receiving Ultramassive Transfusion?

The institution of massive transfusion protocols (MTPs) has improved the timely delivery of large quantities of blood products and improves patient outcomes. In recent years, the cost of blood products has increased, compounded by significant blood product shortages. There is practical need for identification of a transfusion volume in trauma patients that is associated with increased mortality, or a threshold after which additional transfusion is futile and associated with nonsurvivability. This transfusion threshold is often described in the setting of an ultramassive transfusion (UMT). There are few studies defining what constitutes amount or outcomes associated with such large volume transfusion. The purpose of this narrative review is to provide an analysis of existing literature examining the effects of UMT on outcomes including survival in adult trauma patients and to determine whether there is a threshold transfusion limit after which mortality is inevitable. Fourteen studies were included in this review. The data examining the utility of UMT in trauma are of poor quality, and with the variability inherent in trauma patients, and the surgeons caring for them, no universally accepted cutoff for transfusion exists. Not surprisingly, there is a trend toward increasing mortality with increasing transfusions. The decision to continue transfusing is multifactorial and must be individualized, taking into consideration patient characteristics, institution factors, blood bank supply, and most importantly, constant reevaluation of the need for ongoing transfusion rather than blind continuous transfusion until the heart stops.

A Prospective Multicenter Comparison of Trauma and Injury Severity Score, American Society of Anesthesiologists Physical Status, and National Surgical Quality Improvement Program Calculator's Ability to Predict Operative Trauma Outcomes.

BACKGROUND: Trauma outcome prediction models have traditionally relied upon patient injury and physiologic data (eg, Trauma and Injury Severity Score [TRISS]) without accounting for comorbidities. We sought to prospectively evaluate the role of the American Society of Anesthesiologists physical status (ASA-PS) score and the National Surgical Quality Improvement Program Surgical Risk-Calculator (NSQIP-SRC), which are measurements of comorbidities, in the prediction of trauma outcomes, hypothesizing that they will improve the predictive ability for mortality, hospital length of stay (LOS), and complications compared to TRISS alone in trauma patients undergoing surgery within 24 hours. METHODS: A prospective, observational multicenter study (9/2018-2/2020) of trauma patients ≥18 years undergoing operation within 24 hours of admission was performed. Multiple logistic regression was used to create models predicting mortality utilizing the variables within TRISS, ASA-PS, and NSQIP-SRC, respectively. Linear regression was used to create models predicting LOS and negative binomial regression to create models predicting complications. RESULTS: From 4 level I trauma centers, 1213 patients were included. The Brier Score for each model predicting mortality was found to improve accuracy in the following order: 0.0370 for ASA-PS, 0.0355 for NSQIP-SRC, 0.0301 for TRISS, 0.0291 for TRISS+ASA-PS, and 0.0234 for TRISS+NSQIP-SRC. However, when comparing TRISS alone to TRISS+ASA-PS (P = .082) and TRISS+NSQIP-SRC (P = .394), there was no significant improvement in mortality prediction. NSQIP-SRC more accurately predicted both LOS and complications compared to TRISS and ASA-PS. CONCLUSIONS: TRISS predicts mortality better than ASA-PS and NSQIP-SRC in trauma patients undergoing surgery within 24 hours. The TRISS mortality predictive ability is not improved when combined with ASA-PS or NSQIP-SRC. However, NSQIP-SRC was the most accurate predictor of LOS and complications.

A review of the utility of high-frequency oscillatory ventilation in burn and trauma ICU patients.

PURPOSE OF REVIEW: The purpose was to examine the utility of high-frequency oscillatory ventilation (HFOV) in trauma and burn ICU patients who require mechanical ventilation, and provide recommendations on its use. RECENT FINDINGS: HFOV may be beneficial in burn patients with smoke inhalation injury with or without acute lung injury/acute respiratory distress syndrome (ARDS), as it improves oxygenation and minimizes ventilator-induced lung injury. It also may have a role in improving oxygenation in trauma patients with blast lung injury, pulmonary contusions, pneumothorax with massive air leak, and ARDS; however, the mortality benefit is unknown. SUMMARY: Although some studies have shown promise and improved outcomes associated with HFOV, we recommend its use as a rescue modality for patients who have failed conventional ventilation.

Delirium in trauma ICUs: a review of incidence, risk factors, outcomes, and management.

PURPOSE OF REVIEW: This article reviews the impact and importance of delirium on patients admitted to the ICU after trauma, including the latest work on prevention and treatment of this condition. As the population ages, the incidence of geriatric trauma will continue to increase with a concomitant rise in the patient and healthcare costs of delirium in this population. RECENT FINDINGS: Recent studies have further defined the risk factors for delirium in the trauma ICU patient population, as well as better demonstrated the poor outcomes associated with the diagnosis of delirium in these patients. Recent trials and meta-analysis offer some new evidence for the use of dexmedetomidine and quetiapine as preferred agents for prevention and treatment of delirium and add music interventions as a promising part of nonpharmacologic bundles. SUMMARY: Trauma patients requiring admission to the ICU are at significant risk of developing delirium, an acute neuropsychiatric disorder associated with increased healthcare costs and worse outcomes including increased mortality. Ideal methods for prevention and treatment of delirium are not well established, especially in this population, but recent research helps to clarify optimal prevention and treatment strategies.

Traumatic brain injury and RSI is rocuronium or succinylcholine preferred?

PURPOSE OF REVIEW: Traumatic brain injury is widespread and has significant morbidity and mortality. Patients with severe traumatic brain injury often necessitate intubation. The paralytic for rapid sequence induction and intubation for the patient with traumatic brain injury has not been standardized. RECENT FINDINGS: Rapid sequence induction is the standard of care for patients with traumatic brain injury. Historically, succinylcholine has been the agent of choice due to its fast onset and short duration of action, but it has numerous adverse effects such as increased intracranial pressure and hyperkalemia. Rocuronium, when dosed appropriately, provides neuromuscular blockade as quickly and effectively as succinylcholine but was previously avoided due to its prolonged duration of action which precluded neurologic examination. However, with the widespread availability of sugammadex, rocuronium is able to be reversed in a timely manner. SUMMARY: In patients with traumatic brain injury necessitating intubation, rocuronium appears to be safer than succinylcholine.

Predicting Unplanned Intensive Care Unit Admission for Trauma Patients: The CRASH Score.

INTRODUCTION: Unplanned transfer of trauma patients to the intensive care unit (ICU) carries an associated increase in mortality, hospital length of stay, and cost. Trauma teams need to determine which patients necessitate ICU admission on presentation rather than waiting to intervene on deteriorating patients. This study sought to develop a novel Clinical Risk of Acute ICU Status during Hospitalization (CRASH) score to predict the risk of unplanned ICU admission. METHODS: The 2017 Trauma Quality Improvement Program database was queried for patients admitted to nonICU locations. The group was randomly divided into two equal sets (derivation and validation). Multiple logistic regression models were created to determine the risk of unplanned ICU admission using patient demographics, comorbidities, and injuries. The weighted average and relative impact of each independent predictor were used to derive a CRASH score. The score was validated using area under the curve. RESULTS: A total of 624,786 trauma patients were admitted to nonICU locations. From 312,393 patients in the derivation-set, 3769 (1.2%) had an unplanned ICU admission. A total of 24 independent predictors of unplanned ICU admission were identified and the CRASH score was derived with scores ranging from 0 to 32. The unplanned ICU admission rate increased steadily from 0.1% to 3.9% then 12.9% at scores of 0, 6, and 14, respectively. The area under the curve for was 0.78. CONCLUSIONS: The CRASH score is a novel and validated tool to predict unplanned ICU admission for trauma patients. This tool may help providers admit patients to the appropriate level of care or identify patients at-risk for decompensation.

Alcohol is not associated with increased mortality in adolescent traumatic brain injury patients.

PURPOSE: Compared to adults, there is a paucity of data regarding the association of a positive alcohol screen (PAS) and outcomes in adolescent patients with traumatic brain injury (TBI). We hypothesize adolescent TBI patients with a PAS on admission to have increased mortality compared to patients with a negative alcohol screen. METHODS: The 2017 Trauma Quality Improvement Program database was queried for patients aged 13-17 years presenting with a TBI and serum alcohol screen. Patients with missing information regarding midline shift on imaging and Glasgow Coma Scale (GCS) score were excluded. A multivariable logistic regression analysis for mortality was performed. RESULTS: From 2553 adolescent TBI patients with an alcohol screen, 220 (8.6%) had a PAS. Median injury severity scores and rates of penetrating trauma (all p > 0.05) were similar between alcohol positive and negative patients. Patients with a PAS had a similar mortality rate (13.2% vs. 12.1%, p = 0.64) compared to patients with a negative screen. Multivariate logistic regression controlling for risk factors associated with mortality revealed a PAS to confer a similar risk of mortality compared to alcohol negative patients (p = 0.40). CONCLUSION: Adolescent TBI patients with a PAS had similar associated risk of mortality compared to patients with a negative alcohol screen.

Predicting mortality in elderly trauma patients: a review of the current literature.

PURPOSE OF REVIEW: Advances in medical care allow patients to live longer, translating into a larger geriatric patient population. Adverse outcomes increase with older age, regardless of injury severity. Age, comorbidities, and physiologic deterioration have been associated with the increased mortality seen in geriatric trauma patients. As such, outcome prediction models are critical to guide clinical decision making and goals of care discussions for this population. The purpose of this review was to evaluate the various outcome prediction models for geriatric trauma patients. RECENT FINDINGS: There are several prediction models used for predicting mortality in elderly trauma patients. The Geriatric Trauma Outcome Score (GTOS) is a validated and accurate predictor of mortality in geriatric trauma patients and performs equally if not better to traditional scores such as the Trauma and Injury Severity Score. However, studies recommend medical comorbidities be included in outcome prediction models for geriatric patients to further improve performance. SUMMARY: The ideal outcome prediction model for geriatric trauma patients has not been identified. The GTOS demonstrates accurate predictive ability in elderly trauma patients. The addition of medical comorbidities as a variable in outcome prediction tools may result in superior performance; however, additional research is warranted.

The efficacy of apneic oxygenation to prevent hypoxemia during rapid sequence intubation in trauma patients.

PURPOSE OF REVIEW: Rapid and effective airway management is priority for trauma patients. Trauma patients are often at an increased risk of experiencing hypoxia, and thus at increased risk of morbidity and mortality. Apneic oxygenation has been widely debated but has been reported to provide benefit in terms of increased peri-intubation oxygen saturation and decreased rates of desaturation. This review aims to evaluate the current literature on the efficacy of apneic oxygenation in the setting of rapid sequence intubation (RSI) in trauma patients. RECENT FINDINGS: Two prospective studies published this year, demonstrated that apneic oxygenation was effective in reducing hypoxic events and hypoxic duration during RSI. SUMMARY: The use of apneic oxygenation can play an important role in preventing hypoxic events in trauma patients undergoing RSI. The use of apneic oxygenation is cheap, and should be considered to reduce hypoxemic events. Additional studies are required to see the effects of apneic oxygenation on outcomes in trauma patients undergoing RSI, specifically desaturation and hypoxemic events and duration, and early onset mortality.

Adult Bicycle Collisions: Impact of Helmet Use on Head and Cervical Spine Injury.

BACKGROUND: No states currently require adult bicycle riders to wear helmets. Opponents of a universal helmet law argue that helmets may cause a greater torque on the neck during collisions, potentially increasing the risk of cervical spine fracture (CSF). This assumption has not been supported by data for motorcyclists. Therefore, we sought to evaluate the risk of CSF and cervical spinal cord injury (CSCI) in helmeted bicyclists (HBs) versus nonhelmeted bicyclists (NHBs) involved in collisions. We hypothesize that in adult HBs, there is an increased incidence of CSF and injury but lower rates of severe head injury and mortality than in NHBs. MATERIALS AND METHODS: The Trauma Quality Improvement Program (2010-2016) was queried for adult bicyclists involved in collisions, comparing HBs with NHBs. A multivariable logistic regression model was used for analysis. RESULTS: Of 25,047 bicyclists, 14,234 (56.8%) were NHBs. NHBs were more often black (13.3% versus 2.3%, P < 0.001) and screened positive for alcohol on admission (25.7% versus 4.6%, P < 0.001). NHBs had lower rates of CSF (17.7% versus 23.7%, P < 0.001) and CSCI (1.1% versus 1.9%, P < 0.001) but higher rates of mortality (4.9% versus 2.2%, P < 0.001) and a higher risk for severe head injury (odds ratio [OR]: 2.26, 2.13-2.40, P < 0.001). After adjusting for covariates, NHBs had a higher risk of mortality (OR: 2.38, 2.00-2.84, P < 0.001) but lower risk of CSF (OR: 0.66 0.62-0.71, P < 0.001) and CSCI (OR: 0.53, 0.42-0.68, P < 0.001). CONCLUSIONS: HBs involved in collisions have a higher risk of CSF and CSCI; however, NHBs have a higher risk of severe head injury and mortality. Consideration for a universal helmet law among bicyclists and ongoing research regarding helmet development is needed.

University Teaching Trauma Centers: Decreased Mortality but Increased Complications.

BACKGROUND: Teaching hospitals are often regarded as excellent institutions with significant resources and prominent academic faculty. However, the involvement of trainees may contribute to higher rates of complications. Conflicting reports exist regarding outcomes between teaching and nonteaching hospitals, and the difference among trauma centers is unknown. We hypothesized that university teaching trauma centers (UTTCs) and nonteaching trauma centers (NTTCs) would have a similar risk of complications and mortality. METHODS: We queried the Trauma Quality Improvement Program (2010-2016) for adults treated at UTTCs or NTTCs. A multivariable logistic regression analysis was performed to evaluate the risk of mortality and in-hospital complications, such as respiratory complications (RCs), venous thromboembolisms (VTEs), and infectious complications (ICs). RESULTS: From 895,896 patients, 765,802 (85%) were treated at UTTCs and 130,094 (15%) at NTTCs. After adjusting for covariates, UTTCs were associated with an increased risk of RCs (odds ratio (OR) 1.33, confidence interval (CI) 1.28-1.37, P < 0.001), VTEs (OR 1.17, CI 1.12-1.23, P < 0.001), and ICs (OR 1.56, CI 1.49-1.64, P < 0.001). However, UTTCs were associated with decreased mortality (OR 0.96, CI 0.93-0.99, P = 0.008) compared with NTTCs. CONCLUSIONS: Our study demonstrates increased associated risks of RCs, VTEs, and ICs, yet a decreased associated risk of in-hospital mortality for UTTCs when compared with NTTCs. Future studies are needed to identify the underlying causative factors behind these differences.

A Dual Pandemic: The Influence of Coronavirus Disease 2019 on Trends and Types of Firearm Violence in California, Ohio, and the United States.

BACKGROUND: This study sought to determine the impact of coronavirus disease 2019 stay-at-home (SAH) and reopening orders on trends and types of firearm violence in California, Ohio, and the United States, hypothesizing increased firearm violence after SAH. MATERIALS AND METHODS: Retrospective data (January 1, 2018, to July 31, 2020) on firearm incidents/injuries/deaths and types of firearm violence were obtained from the Gun Violence Archive. The periods for SAH and reopening for the US were based on dates for California. Ohio dates were based on Ohio's timeline. Mann-Whitney U analyses compared trends and types of daily firearm violence per 100,000 legal firearm owners across 2018-2020 periods. RESULTS: In California, SAH and reopening orders had no effect on firearm violence in 2020 compared with 2018 and 2019 periods, respectively. In Ohio, daily median firearm deaths increased during 2020 SAH compared with 2018 and 2019 and firearm incidents and injuries increased during 2020 reopening compared with 2018, 2019 and 2020 SAH. In the United States, during 2020, SAH firearm deaths increased compared with historical controls and firearm incidents, deaths and injuries increased during 2020 reopening compared with 2018, 2019 and 2020 SAH (all P < 0.05). Nationally, when compared with 2018 and 2019, 2020 SAH had increased accidental shootings deaths with a decrease in defensive use, home invasion, and drug-involved incidents. CONCLUSIONS: During 2020 SAH, the rates of firearm violence increased in Ohio and the United States but remained unchanged in California. Nationally, firearm incidents, deaths and injuries also increased during 2020 reopening versus historical and 2020 SAH data. This suggests a secondary "pandemic" as well as a "reopening phenomenon," with increased firearm violence not resulting from self-defense.

No Difference in Mortality Between Level I and II Trauma Centers for Combined Burn and Trauma.

BACKGROUND: Trauma patients with burn injuries have higher morbidity and mortality rates compared with patients who solely experience burn or trauma injuries. There is a paucity of data regarding burn-trauma (BT) patient outcomes at level I (LI) trauma centers compared with level II (LII) centers. We hypothesized that BT patients at LI trauma centers have lower mortality rates than those at LII trauma centers. METHODS: The Trauma Quality Improvement Program (2010-2016) was queried for patients aged ≥18 y who had BT injuries. Patients treated at an LI were compared with those at an LII center with a primary outcome of in-hospital mortality. Secondary outcomes included hospital length of stay (LOS) and intensive care unit (ICU) LOS. A multivariable logistic regression analysis was used to identify factors associated with all-cause mortality. RESULTS: From 1971 BT patients, 1540 (78%) were treated at an LI trauma center, and 431 (22%) at an LII center. Compared with LII centers, LI BT patients had a longer median LOS (10 versus 7 d; P < 0.001) and ICU LOS (5 versus 4 d; P < 0.001). Both LI and LII centers had similar mortality rates (8.5% versus 7.0%; P = 0.300). On multivariable analysis, receiving care at an LI trauma center was not associated with decreased mortality (odds ratio 0.79, 95% confidence interval 0.42-1.48; P = 0.456). CONCLUSIONS: We report that LI trauma center BT patients had an increased hospital and ICU LOS compared with those at LII centers. However, there was no significant difference in mortality between patients cared for at LI and LII trauma centers in risk-adjusted models.

Early Tracheostomy for Severe Pediatric Traumatic Brain Injury is Associated with Reduced Intensive Care Unit Length of Stay and Total Ventilator Days.

OBJECTIVES: To determine whether, similar to adults, early tracheostomy in pediatric patients with severe traumatic brain injury (TBI) improves inhospital outcomes including ventilator days, intensive care unit (ICU) length of stay (LOS), and total hospital LOS when compared to late tracheostomy. DESIGN: Retrospective cohort analysis. SETTING: The Pediatric Trauma Quality Improvement Program (TQIP) database. PATIENTS: One hundred twenty-seven pediatric patients <16 years old with severe (>3) abbreviated injury scale TBI who underwent early (days 1-6) or late (day ≥7) tracheostomy between 2014 and 2016. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: The Pediatric TQIP database was queried for patients <16 years old with severe TBI, who underwent tracheostomy. Patient demographics and outcomes of early versus late tracheostomy were compared using Student t test, Mann-Whitney U test, and χ2 analysis. Sixteen patients underwent early tracheostomy while 111 underwent late tracheostomy. The groups had similar distributions of age, gender, mechanism of injury, and mean injury severity scores (P > .05). Early tracheostomy was associated with decreased ICU LOS (early: 17 vs late: 32 days, P < .05) and ventilator days (early: 9.7 vs late: 27.1 days, P < .05). There was no difference in total LOS (early: 26.7 vs late: 41.3 days, P = .06), the incidence of acute respiratory distress syndrome (early: 6.3% vs late: 2.7%, P = .45), pneumonia (early: 12.5% vs late: 29.7%, P = .15), or mortality (early: 0% vs late: 2%, P = .588) between the 2 groups. CONCLUSION: Similar to adults, early tracheostomy in pediatric patients with severe TBI is associated with decreased ICU LOS and ventilator days. Future prospective trials are needed to confirm these findings. ARTICLE TWEET: Early tracheostomy in pediatric patients with severe TBI is associated with decreased ICU LOS and ventilator days.

Predictors of discharge against medical advice in adult trauma patients.

BACKGROUND: Patients who leave against medical advice (AMA) have higher readmission rates and mortality. However, little is known about the characteristics of trauma patients that leave AMA. The purpose of this study was to identify predictors for leaving AMA in adult trauma patients. METHODS: The Trauma Quality Improvement Program database was queried between 2010 and 2016 for patients ≥18 years of age presenting after trauma. Two groups were compared: those who left AMA and those that did not. Bivariate analysis using Chi-squared and Mann-Whitney U tests was performed. A multivariable logistic regression analysis was performed to identify predictors for leaving AMA. RESULTS: Of 1,403,466 trauma patients identified, 10,659 (0.76%) left AMA. Patients that left AMA were younger (median age, 48 vs. 53 years-old, p < 0.001), more often male (82.1% vs. 62.8%, p < 0.001), more likely to be black (23.6% vs. 14.9%, p < 0.001), and more likely to be uninsured (27.0% vs. 12.3%, p < 0.001). Patients leaving AMA were more likely to test positive for alcohol (36.1% vs. 17.4%, p < 0.001) or drug use (36.0% vs. 17.2%, p < 0.001) at time of admission. On multivariable logistic regression, the strongest predictors for leaving AMA were: no insurance (OR 2.00, CI 1.88-2.14, p < 0.001), alcohol use (OR 1.85, CI 1.74-1.96, p < 0.001) or drug use (OR 1.83, CI 1.72-1.94, p < 0.001), male gender (OR 1.83, CI 1.71-1.97, p < 0.001), and stab mechanism of injury (OR 1.58, CI 1.43-1.73, p < 0.001). CONCLUSION: In adult trauma patients, male gender, stab mechanism of injury, being uninsured, and alcohol/drug use were strong predictors of leaving AMA. The risk factors identified may help in developing strategies aimed at preventing trauma patients from leaving AMA.