The Importance of Circulation in Airway Management: Preventing Post-Intubation Hypotension in The Trauma Bay.

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.

Less is More: Dissecting Trauma Centers by Procedural Volume.

OBJECTIVE: This study aims to examine the relationship between procedural volume and annual trauma volume (ATV) of ACS Level I trauma centers (TC). SUMMARY BACKGROUND DATA: Although ATV is a hard criterion for TC verification, importance of procedural interventions as a potential quality indicator is understudied. METHODS: Patients managed at ACS level I TCs were identified from ACS-TQIP 2017-2021. TCs were identified using facility keys and stratified into quartiles based on ATV into low, low-medium, medium-high, and high volume. TCs were also stratified into tertiles (low [LV], medium [MV], high [HV]) based on procedural volume by assessing annual number of laparotomies, thoracotomies, craniotomies/craniectomies, angioembolizations, vascular repairs, and long bone fixations performed at each center. Cohen's κ statistic was used to assess concordance between ATV and procedural volume. RESULTS: 182 Level I TCs were identified: 76 low, 47 low-medium, 35 high-medium, and 24 high volume. Long bone fixation, laparotomy, and craniotomy/craniectomy were the most performed procedures with a median of 65, 59, and 46 cases/center/year respectively. 31% of HV laparotomy centers, 31% of HV thoracotomy centers, 22% of HV craniotomy/craniectomy centers, 22% of HV vascular repair centers, 32% of HV long bone fixation centers, and 33% of HV angioembolization centers contributed to the overall number of low-medium and low volume TCs. Cohen's κ statistic demonstrated poor concordance between ATV and procedural volumes for all procedures (Overall procedural volume-κ=0.378, laparotomy-κ=0.270, thoracotomy-κ=0.202, craniotomy/craniectomy- κ=0.394, vascular repair-κ=0.298, long bone fixation-κ=0.277, angioembolization-κ=0.286). CONCLUSION: ATV does not reflect the procedural interventions performed. Combination of procedural and ATV may provide a more accurate picture of the clinical experience at any given TC. LEVEL OF EVIDENCE: Level III.

The role of number of affected vessels on radiologic and clinical outcomes of patients with blunt cerebrovascular injury.

OBJECTIVE: There is a lack of data on the role of characteristics of injured vessels on the outcomes of patients with blunt cerebrovascular injuries (BCVIs). The aim of this study was to assess the effect of the number (single vs multiple) of injured vessels on outcomes. METHODS: This is a retrospective study at two American College of Surgeons Level I trauma centers (2017-2021). Adult (>16 years) trauma patients with BCVIs are included. Injuries were graded by the Denver Scale based on the initial computed tomography angiography (CTA). Early repeat CTA was performed 7 to 10 days after diagnosis. Patients were stratified by the number (single vs multiple) of the involved vessels. Outcomes included progression of BCVIs on repeat CTA, stroke, and in-hospital mortality attributable to BCVIs. Multivariable regression analyses were performed to identify the association between the number of injured vessels and outcomes. RESULTS: A total of 491 patients with 591 injured vessels (285 carotid and 306 vertebral arteries) were identified. Sixty percent were male, the mean age was 44 years, and the median Injury Severity Score was 18 (interquartile range, 11-25). Overall, 18% had multiple-vessel injuries, 16% had bilateral vessel injuries, and 3% had multiple injuries on the same side. The overall rates of progression to higher-grade injuries, stroke, and mortality were 23%, 7.7%, and 8.8%, respectively. On uni- and multivariable analyses, multiple BCVIs were associated with progression to higher-grade injuries on repeat imaging, stroke, and mortality compared with single-vessel injuries. CONCLUSIONS: BCVIs with multiple injured vessels are more likely to progress to higher grades on repeat CTA, with multiple injuries independently associated with worse clinical outcomes, compared with those with single injuries. These findings highlight the importance of incorporating the number of injured vessels in clinical decision-making and in defining protocols for repeat imaging.

Drugs, Delirium, and Trauma: Substance Use and Incidence of Delirium After Traumatic Brain Injury.

INTRODUCTION: There is a paucity of data on the effect of preinjury substance (alcohol, drugs) abuse on the risk of delirium in patients with traumatic brain injury (TBI). This study aimed to assess the incidence of delirium among patients with blunt TBI in association with different substances. METHODS: We analyzed the 2020 American College of Surgeons-Trauma Quality Improvement Program. We included all adult (≥18 y) patients with blunt TBI who had a recorded substance (drugs and alcohol) screening. Our primary outcome was the incidence of delirium. RESULTS: A total of 72,901 blunt TBI patients were identified. The mean (standard deviation) age was 56 (20) years and 68.0% were males. The median (interquartile range) injury severity score was 17 (10-25). Among the study population, 23.1% tested positive for drugs (Stimulants: 3.0%; Depressants: 2.9%, hallucinogens: 5.1%, Cannabinoids: 13.4%, TCAs: 0.1%), and 22.8% tested positive for Alcohol. Overall, 1856 (2.5%) experienced delirium. On univariate analysis, patients who developed delirium were more likely to have positive drug screening results. On multivariable regression analyses, positive screen tests for isolated stimulants (adjusted odds ratio [aOR]: 1.340, P = 0.018), tricyclic antidepressants (aOR: 3.107, P = 0.019), and cannabinoids (aOR: 1.326, P ≤ 0.001) were independently associated with higher odds of developing delirium. CONCLUSIONS: Nearly one-fourth of adult patients with blunt TBI had an initial positive substance screening test. Patients with positive results for isolated stimulants, tricyclic antidepressants, and cannabinoids were at a higher risk of developing delirium, whereas this association was not evident with other drugs and alcohol-positive tests. These findings emphasize the need for early drug screening in TBI patients and close monitoring of patients with positive screening tests.

Final Lifelines: The Implications and Outcomes of Thoracic Damage Control Surgeries.

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.

Predictors of Receiving Mental Health Services in Trauma Patients With Positive Drug Screen.

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.

The Role of Whole Blood Hemostatic Resuscitation in Bleeding Geriatric Trauma Patients.

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.

The Synergy Factor: Trauma and Cancer.

INTRODUCTION: Trauma and cancer are the leading causes of death in the US. There is a paucity of data describing the impact of cancer on trauma patients. We aimed to determine the influence of cancer on outcomes of trauma patients. METHODS: In this retrospective analysis of American College of Surgeons-Trauma Quality Improvement Program 2019-2021, we included all adult trauma patients (≥18 y) and excluded patients with severe head injuries and nonmelanomatous skin cancers. Patients were stratified into cancer (C), and no cancer (No-C). Propensity score matching (1:3) was performed. Outcomes were complications and mortality. RESULTS: A matched cohort of 3236 patients (C, 809; No-C, 2427) was analyzed. The mean age was 70 y, 50.5% were males, and the median injury severity score was 8 (4-10). There were no differences in terms of receiving thromboprophylaxis (C 51%: No-C 50%, P = 0.516). Compared to No-C group, the C group had higher rates of deep vein thrombosis (C 1.1% versus No-C 0.3%, P = 0.004), but there was no difference in terms of overall complications. Patients in the C group had higher mortality (C 7.5% versus No-C 2.7%, P < 0.001). CONCLUSIONS: Trauma patients with cancer have nearly 4 times higher odds of deep vein thrombosis and 3 times higher odds of mortality. Developing pathways specific to cancer patients might be necessary to improve the outcomes of trauma patients with cancer.

Endovascular Versus Open Repair in Adolescent Patients With Difficult-to-Access Vascular Injuries.

INTRODUCTION: Management of subclavian artery injuries (SAI) and iliac artery injuries (IAI) in adolescent trauma patients poses a considerable challenge due to their complex anatomical locations. The aim of our study was to determine the association between the injury mechanism and type of repair with the outcomes of patients with traumatic SAI and IAI. METHODS: In this retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database2017-2020, adolescent (<18 y) patients with SAI and IAI undergoing either endovascular or open repair were included. Patients were stratified by mechanism (blunt versus penetrating) and type of repair (endovascular [E] versus open [O]) and compared. Outcomes measured were mortality and major complications. Multivariable logistic regression analyses were performed. RESULTS: Over 4 y, 170 pediatric patients were identified, of which 73 (43%) sustained an SAI and 97 (57%) had IAI. The mean age was 15 and 79% were male. Overall, 39% were managed endovascularly. Both groups had comparable median injury severity score (E: 23 versus O: 25, P = 0.278). For patients with blunt injury (n = 60), the type of repair was neither associated with major complications (E: 39% versus O: 33%, P = 0.694) nor mortality (E: 2.6% versus O: 4.8%, P = 0.651). For patients with penetrating injuries (n = 110), the endovascular repair had significantly lower morbidity (19% versus 41%, P = 0.034) and mortality (3.7% versus 21%, P = 0.041). On multivariable logistic regression, endovascular repair was identified as the only modifiable risk factor associated with reduced mortality (adjusted odds ratio: 0.201, 95% confidence interval [0.14-0.76], P = 0.038). CONCLUSIONS: Difficult-to-access vascular injuries result in significant morbidity and mortality. Endovascular repair was found to be the only modifiable factor associated with decreased mortality of patients with penetrating injury, whereas the type of repair was not associated with mortality in those with blunt injury.

Should We Keep or Transfer Our Severely Injured Geriatric Patients to Higher Levels of Care?

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.

Development and Validation of Futility of Resuscitation Measure in Older Adult Trauma Patients.

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.

Pediatric Acute Compartment Syndrome in Long Bone Fractures: Who is at Risk?

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.

Initial Hemorrhage Control Procedure for Splenic Injuries May Affect Risk of Venous Thromboembolism.

INTRODUCTION: Venous thromboembolism (VTE) continues to be a major cause of morbidity in trauma. It is unclear whether the type of hemorrhage control procedure (i.e., splenectomy versus angioembolization) is associated with an increased risk of VTE. We hypothesize that hemodynamically stable patients undergoing angioembolization for blunt high-grade splenic injuries have lower rates of VTE compared to those undergoing splenectomy. METHODS: The American College of Surgeons Trauma Quality Program dataset from 2017 to 2019 was queried to identify all patients with American Association for the Surgery of Trauma grade 3-5 blunt splenic injuries. Outcomes including VTE rates were compared between those who were managed with splenectomy versus angioembolization. Propensity score matching (1:1) was performed adjusting for age, sex, initial vital signs, Injury Severity Score, and splenic injury grade. RESULTS: The analysis included 4698 matched patients (splenectomy [n = 2349] and angioembolization [n = 2349]). The median (interquartile range) age was 41 (27-58) years and 69% were male. Patients were well matched between groups. Angioembolization was associated with significantly lower VTE than splenectomy (2.2% versus 3.4%, P = 0.010) despite less use of VTE chemoprophylaxis (70% versus 80%, P < 0.001), as well as a relative delay in initiation of chemoprophylaxis (44 h versus 33 h, P < 0.001). Hospital and intensive care unit length of stay and mortality were also significantly lower in the angioembolization group. CONCLUSIONS: Angioembolization is associated with a significantly lower incidence of VTE than splenectomy. Thus, angioembolization should be considered for initial management of hemodynamically stable patients with high-grade blunt splenic injuries in whom laparotomy is not otherwise indicated.

Predicting the time of mortality among older adult trauma patients: Is frailty the answer?

INTRODUCTION: This study aims to evaluate the temporal trends of mortality among frail versus non-frail older adult trauma patients during index hospitalization. METHODS: We performed a 3-year (2017-2019) analysis of ACS-TQIP. We included all older adult (age ≥65 years) trauma patients. Patients were stratified into two groups (Frail vs. Non-Frail). Outcomes were acute (<24 â€‹h), early (24-72 â€‹h), intermediate (72 hours-1 week), and late (>1 week) mortality. RESULTS: A total of 1,022,925 older adult trauma patients were identified, of which 19.7 â€‹% were frail. The mean(SD) age was 77(8) years and 57.4 â€‹% were female. Median[IQR] ISS was 9[4-10] and both groups had comparable injury severity (p â€‹= â€‹0.362). On multivariable analysis, frailty was not associated with acute (aOR 1.034; p â€‹= â€‹0.518) and early (aOR 1.190; p â€‹= â€‹0.392) mortality, while frail patients had independently higher odds of intermediate (aOR 1.269; p â€‹= â€‹0.042) and late (aOR 1.835; p â€‹< â€‹0.001) mortality. On sub-analysis, our results remained consistent in mild, moderate, and severely injured patients. CONCLUSION: Frailty is an independent predictor of mortality in older adult trauma patients who survive the initial 3 days of admission, regardless of injury severity.

Surgical stabilization of rib fractures: The impact of volume and the need for standardized indications.

INTRODUCTION: We aimed to examine impact of trauma center (TC) surgical stabilization of rib fracture (SSRF) volume on outcomes of patients undergoing SSRF. METHODS: Blunt rib fracture patients who underwent SSRF were included from ACS-TQIP2017-2021. TCs were stratified according to tertiles of SSRF volume:low (LV), middle, and high (HV). Outcomes were time to SSRF, respiratory complications, prolonged ventilator use, mortality. RESULTS: 16,872 patients were identified (LV:5470,HV:5836). Mean age was 56 years, 74% were male, median thorax-AIS was 3. HV centers had a lower proportion of patients with flail chest (HV41% vs LV50%), pulmonary contusion (HV44% vs LV52%) and had shorter time to SSRF(HV58 vs LV76 â€‹h), less respiratory complications (HV3.2% vs LV4.5%), prolonged ventilator use (HV15% vs LV26%), mortality (HV2% vs LV2.6%) (all p â€‹< â€‹0.05). On multivariable regression analysis, HV centers were independently associated with reduced time to SSRF(ߠ​= â€‹-18.77,95%CI â€‹= â€‹-21.30to-16.25), respiratory complications (OR â€‹= â€‹0.67,95%CI â€‹= â€‹0.49-0.94), prolonged ventilator use (OR â€‹= â€‹0.49,95%CI â€‹= â€‹0.41-0.59), but not mortality. CONCLUSIONS: HV SSRF centers have improved outcomes, however, there are variations in threshold for SSRF and indications must be standardized. LEVEL OF EVIDENCE: Level III. STUDY TYPE: Therapeutic/Care Management.

Effect of PCC on outcomes of severe traumatic brain injury patients on preinjury anticoagulation.

INTRODUCTION: This study aims to evaluate effect of 4-factor PCC on outcomes of severe TBI patients on preinjury anticoagulants undergoing craniotomy/craniectomy. METHODS: In this analysis of 2018-2020 ACS-TQIP, patients with isolated blunt severe TBI (Head-AIS≥3, nonhead-AIS<2) using preinjury anticoagulants who underwent craniotomy/craniectomy were identified and stratified into PCC and No-PCC groups. Outcomes were time to surgery and mortality. Multivariable binary logistic and linear regression analyses were performed. RESULTS: 1598 patients were identified (PCC-107[7 %], No-PCC-1491[93 %]). Mean age was 74(11) years, 65 % were male, median head AIS was 4. Median time to PCC administration was 109 â€‹min. On univariable analysis, PCC group had shorter time to surgery (PCC-341, No-PCC-620 â€‹min, p â€‹= â€‹0.002), but higher mortality (PCC35 %, No-PCC21 %,p â€‹= â€‹0.001). On regression analysis, PCC was independently associated with shorter time to surgery (ߠ​= â€‹-1934,95 %CI â€‹= â€‹-3339to-26), but not mortality (aOR â€‹= â€‹0.70,95 %CI â€‹= â€‹0.14-3.62). CONCLUSION: PCC may be a safe adjunct for urgent reversal of coagulopathy in TBI patients using preinjury anticoagulants.

When Every Minute Counts: REBOA Before Surgery Is Independently Associated With a 15-Minute Delay in Time to Definitive Hemorrhage Control.

INTRODUCTION: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a temporizing hemorrhage control intervention, but its inevitable effect on time to operating room (OR) has not been assessed. The aim of our study is to assess the impact of undergoing REBOA before surgery (RBS) on time to definitive hemorrhage control surgery. METHODS: In this retrospective analysis of 2017-2021 ACS-TQIP database, all adult (≥18 years) patients who underwent emergency hemorrhage control laparotomy (≤4 hours of admission) and received early blood products (≤4 hours) were included, and patients with severe head injury (Head-abbreviated injury score > 2) were excluded. Patients were stratified into those who did (RBS) vs those who did not undergo REBOA before surgery (No-RBS). Primary outcome was time to laparotomy. Secondary outcomes were complications and mortality. Multivariable linear and binary logistic regression analyses were performed to identify the independent associations between RBS and outcomes. RESULTS: A total of 32,683 patients who underwent emergency laparotomy were identified (RBS: 342; No-RBS: 32,341). The mean age was 39 (16) years, 78% were male, mean SBP was 107 (34) mmHg, and the median injury severity score was 21 [14-29]. The median time to emergency hemorrhage control surgery was 50 [32-85] minutes. Overall complication rate was 16% and mortality was 19%. On univariate analysis, RBS group had longer time to surgery (RBS 56 [41-89] vs No-RBS 50 [32-85] minutes, P < 0.001). On multivariable analysis, RBS was independently associated with a longer time to hemorrhage control surgery (ß + 14.5 [95%CI 7.8-21.3], P < 0.001), higher odds of complications (aOR = 1.72, 95%CI = 1.27-2.34, P < 0.001), and mortality (aOR = 3.42, 95%CI = 2.57-4.55, P < 0.001). CONCLUSION: REBOA is independently associated with longer time to OR for hemorrhaging trauma patients with an average delay of 15 minutes. Further research evaluating center-specific REBOA volume and utilization practices, and other pertinent system factors, may help improve both time to REBOA as well as time to definitive hemorrhage control across US trauma centers. LEVEL OF EVIDENCE: III. STUDY TYPE: Epidemiologic.

Finding The Sweet Spot: The Association Between Whole Blood to Red Blood Cells Ratio and Outcomes of Hemorrhaging Civilian Trauma Patients.

PURPOSE: To evaluate the dose-dependent effect of Whole Blood (WB) on the outcomes of civilian trauma patients with hemorrhagic shock. METHODS: We performed a 2-year (2020-2021) retrospective analysis of the ACS-TQIP dataset. Adult (≥18) trauma patients with a shock index (SI) >1 who received at least 5 units of PRBC and one unit of WB within the first 4 hours of admission were included. Primary outcomes were 6-hr, 24-hr, and in-hospital mortality. Secondary outcomes were major complications and hospital and ICU length of stay (LOS). RESULTS: A total of 830 trauma patients with a mean (SD) age of 38 (16) were identified. The median [IQR] 4-hour WB and PRBC requirements were 2[2-4] U and 10[7-15] U, respectively, with a median WB:RBC ratio of 0.2 [0.1-0.3]. Every 0.1 increase in WB:RBC ratio was associated with decreased odds of 24-hour mortality (aOR:0.916, p = 0.035) and in-hospital mortality (aOR:0.878, p < 0.001). Youden's index identified 0.25 (1 U of WB for every 4 U of PRBC) as the optimal WB:PRBC ratio to reduce 24-hour mortality. High ratio (≥0.25) group had lower adjusted odds of 24-hour mortality (aOR:0.678, p = 0.021) and in-hospital mortality (aOR:0.618, p < 0.001) compared to the Low ratio group. CONCLUSIONS: A higher WB:PRBC ratio was associated with improved early and late mortality in trauma patients with hemorrhagic shock. Given the availability of WB in trauma centers across the United States, at least one unit of WB for every four units of PRBC may be administered to improve the survival of hemorrhaging civilian trauma patients.

The implications of poor nutritional status on outcomes of geriatric trauma patients.

BACKGROUND: Malnutrition is shown to be associated with worse outcomes among surgical patients, yet its postdischarge outcomes in trauma patients are not clear. This study aimed to evaluate both index admission and postdischarge outcomes of geriatric trauma patients who are at risk of poor nutritional status. METHODS: This is a secondary analysis of the prospective observational American Association of Surgery for Trauma Frailty Multi-institutional Trial. Geriatric (≥65 years) patients presenting to 1 of the 17 Level I/II/III trauma centers (2019-2021) were included and stratified using the simplified Geriatric Nutritional Risk Index (albumin [g/dL] + body mass index [kg/m2]/10) into severe (simplified Geriatric Nutritional Risk Index <5), moderate (5.5> simplified Geriatric Nutritional Risk Index ≥5), mild level of nutritional risk (6> simplified Geriatric Nutritional Risk Index ≥5.5), and good nutritional status (simplified Geriatric Nutritional Risk Index ≥6) and compared. RESULTS: Of the 1,321 patients enrolled, 22% were at risk of poor nutritional status (mild: 13%, moderate: 7%, severe: 3%). The mean age was 77 ± 8 years, and the median [interquartile range] Injury Severity Score was 9 [5-13]. Patients at risk of poor nutritional status had greater rates of sepsis, pneumonia, discharge to the skilled nursing facility and rehabilitation center, index-admission mortality, and 3-month mortality (P < .05). On multivariable analyses, being at risk of severe level of nutritional risk was independently associated with sepsis (adjusted odds ratio 6.21, 95% confidence interval 1.68-22.90, P = .006), pneumonia (adjusted odds ratio 4.40, 95% confidence interval 1.21-16.1, P = .025), index-admission mortality (adjusted odds ratio 3.16, 95% confidence interval 1.03-9.68, P = .044), and 3-month mortality (adjusted odds ratio 8.89, 95% confidence interval 2.01-39.43, P = .004) compared with good nutrition state. CONCLUSION: Nearly one quarter of geriatric trauma patients were at risk of poor nutritional status, which was identified as an independent predictor of worse index admission and 3-month postdischarge outcomes. These findings underscore the need for nutritional screening at admission.

Role of endovascular management on outcomes in patients with traumatic inferior vena cava injuries.

INTRODUCTION: The aim of this study was to examine the association between the injury mechanism and repair type with outcomes in patients with traumatic inferior vena cava injuries. METHODS: This is a retrospective analysis of the ACS-TQIP database (2017-2020), including patients with traumatic IVC injuries. Patients were stratified by injury mechanism and type of repair and compared. RESULTS: Out of 1334 patients, 5 â€‹% underwent endovascular repair while 95 â€‹% had an open procedure. Overall, 74.7 â€‹% sustained a penetrating injury. On multivariable regression analysis, the type of repair was not associated with mortality and morbidity for patients with penetrating injuries. However, among patients with blunt injuries, endovascular repair was associated with lower odds of in-hospital mortality (aOR:0.35, p â€‹= â€‹0.020) and non-venous thromboembolism (VTE) morbidity (aOR:0.41, p â€‹= â€‹0.015), and higher odds of VTE complications (aOR:6.74, p â€‹< â€‹0.001). CONCLUSIONS: Although the type of repair did not impact morbidity and mortality in patients with penetrating injuries, endovascular repair was identified as the only modifiable predictor of reduced non-VTE morbidity and mortality in patients with blunt injuries.