Time and Risk Factors of Trauma-Related Mortality: A 5-Year Retrospective Analysis From a National Level I Trauma Center.

Background: We aimed to analyze in-hospital timing and risk factors for mortality in a level 1 trauma center. Methods: This is a retrospective analysis of all trauma-related mortality between 2013 and 2018. Patients were divided and analyzed based on the time of mortality (early (≤48 h) vs late (>48 h)), and within different age groups. Multivariate regression analysis was performed to predict in-hospital mortality. Results: 8624 trauma admissions and 677 trauma-related deaths occurred (47.7% at the scene and 52.3% in-hospital). Among in-hospital mortality, the majority were males, with a mean age of 35.8 ± 17.2 years. Most deaths occurred within 3-7 days (35%), followed by 33% after 1 week, 20% on the first day, and 12% on the second day of admission. Patients with early mortality were more likely to have a lower Glasgow coma scale, a higher shock index, a higher chest and abdominal abbreviated injury score, and frequently required exploratory laparotomy and massive blood transfusion (P < .005). The injury severity scores and proportions of head injuries were higher in the late mortality group than in the early group. The severity of injuries, blood transfusion, in-hospital complications, and length of intensive care unit stay were comparable among the age groups, whereas mortality was higher in the age group of 19 to 44. The higher proportions of early and late in-hospital deaths were evident in the age group of 24 to 29. In multivariate analysis, the shock index (OR 2.26; 95%CI 1.04-4.925; P = .04) was an independent predictor of early death, whereas head injury was a predictor of late death (OR 4.54; 95%CI 1.92-11.11; P = .001). Conclusion: One-third of trauma-related mortalities occur early after injury. The initial shock index appears to be a reliable hemodynamic indicator for predicting early mortality. Therefore, timely hemostatic resuscitation and appropriate interventions for bleeding control may prevent early mortality.

Patterns and Effects of Admission Hyperglycemia and Inflammatory Response in Trauma Patients: A Prospective Clinical Study.

BACKGROUND: The constellation of the initial hyperglycemia, proinflammatory cytokines and severity of injury among trauma patients is understudied. We aimed to evaluate the patterns and effects of on-admission hyperglycemia and inflammatory response in a level 1 trauma center. We hypothesized that higher initial readings of blood glucose and cytokines are associated with severe injuries and worse in-hospital outcomes in trauma patients. METHODS: A prospective, observational study was conducted for adult trauma patients who were admitted and tested for on-admission blood glucose, hemoglobin A1c, interleukin (IL)-6, IL-18 and hs-CRP. Patients were categorized into four groups [non-diabetic normoglycemic, diabetic normoglycemic, diabetic hyperglycemic (DH) and stress-induced hyperglycemic (SIH)]. The inflammatory markers were measured on three time points (admission, 24 h and 48 h). Generalized estimating equations (GEE) were used to account for the correlation for the inflammatory markers. Pearson's correlation test and logistic regression analysis were also performed. RESULTS: During the study period, 250 adult trauma patients were enrolled. Almost 13% of patients presented with hyperglycemia (50% had SIH and 50% had DH). Patients with SIH were younger, had significantly higher Injury Severity Score (ISS), higher IL-6 readings, prolonged hospital length of stay and higher mortality. The SIH group had lower Revised Trauma Score (p = 0.005), lower Trauma Injury Severity Score (p = 0.01) and lower GCS (p = 0.001). Patients with hyperglycemia had higher in-hospital mortality than the normoglycemia group (12.5% vs 3.7%; p = 0.02). A significant correlation was identified between the initial blood glucose level and serum lactate, IL-6, ISS and hospital length of stay. Overall rate of change in slope 88.54 (95% CI:-143.39-33.68) points was found more in hyperglycemia than normoglycemia group (p = 0.002) for IL-6 values, whereas there was no statistical significant change in slopes of age, gender and their interaction. The initial IL-6 levels correlated with ISS (r = 0.40, p = 0.001). On-admission hyperglycemia had an adjusted odds ratio 2.42 (95% CI: 1.076-5.447, p = 0.03) for severe injury (ISS > 12) after adjusting for age, shock index and blood transfusion. CONCLUSIONS: In trauma patients, on-admission hyperglycemia correlates well with the initial serum IL-6 level and is associated with more severe injuries. Therefore, it could be a simple marker of injury severity and useful tool for patient triage and risk assessment. TRIAL REGISTRATION: This study was registered at the ClinicalTrials.gov (Identifier: NCT02999386), retrospectively Registered on December 21, 2016. https://clinicaltrials.gov/ct2/show/NCT02999386 .

Epidemiological and clinical characteristics of fall-related injuries: a retrospective study.

BACKGROUND: Fall-related injuries are important public health problem worldwide. We aimed to describe the epidemiological and clinical characteristics of fall-related injuries in a level 1 trauma center. METHOD: A retrospective analysis of Qatar Trauma Registry data was conducted on patients admitted for fall-related injuries between 2010 and 2017. Comparative analyses of data by gender, age-groups and height of falls were performed to describe the epidemiological and clinical characteristics of patients, and in-hospital outcomes. RESULTS: A total of 4040 patients with fall-related injuries were identified in the study duration which corresponds to the rate of 2.34 per 10,000 population. Although the rate of fall-related injuries decreased over the years, the average number of patients per year remained high accounting for 32% of the hospitalized patients with moderate to severe injuries. Most of the injuries affected the head (36%) followed by spines (29%) and chest (23%). Males were predominant (89%), more likely to fall at workplace, fall from a greater height and have polytrauma than females. The working age-group (20-59 years) constituted the majority of injured (73%) and were more likely to fall at workplace, and to fall from higher heights compared to the older adults who sustained more fall at home. Overall in-hospital mortality was 3%. Outcomes including longer hospital length of stay and mortality were generally correlated with the height of fall except for the fall at home. CONCLUSION: Fall-related injuries remain as significant burden even in a level 1 trauma center. Variations in the pattern of injuries by age, gender and height of fall provide important information for targeted preventive measures.

The impact of emergency department length of stay on the outcomes of trauma patients requiring hospitalization: a retrospective observational study.

BACKGROUND: We aimed to explore the impact of the emergency department length of stay (EDLOS) on the outcome of trauma patients. METHODS: A retrospective study was conducted on all trauma patients requiring hospitalization between 2015 and 2019. Patients were categorized into 4 groups based on the EDLOS (<4 h, 4-12 h,12-24 h, and >24 h). Data were analyzed using Chi-square test (categorical variables), Student's t-test (continuous variables), correlation coefficient, analysis of variance and multivariate logistic regression analysis for identifying predictors of short EDLOS and hospital mortality. RESULTS: The study involved 7,026 patients with a mean age of 32.1±15.6 years. One-fifth of patients had a short EDLOS (<4 h) and had higher level trauma team T1 activation (TTA-1), higher Injury Severity Score (ISS), higher shock index (SI), and more head injuries than the other groups (P=0.001). Patients with an EDLOS >24 h were older (P=0.001) and had more comorbidities (P=0.001) and fewer deaths (P=0.001). Multivariate regression analysis showed that the predictors of short EDLOS were female gender, GCS, SI, hemoglobin level, ISS, and blood transfusion. The predictors of mortality were TTA-1 (odds ratio [OR]=4.081, 95%CI: 2.364-7.045), head injury (OR=3.920, 95%CI: 2.413-6.368), blood transfusion (OR=2.773, 95%CI: 1.668-4.609), SI (OR=2.132, 95%CI: 1.364-3.332), ISS (OR=1.077, 95%CI: 1.057-1.096), and age (OR=1.040, 95%CI: 1.026-1.054). CONCLUSIONS: Patients with shorter EDLOS had different baseline characteristics and hospital outcomes compared with patients with longer EDLOS. Patients with prolonged EDLOS had better outcomes; however, the burden of prolonged boarding in the ED needs further elaboration.

Management of Traumatic Femur Fractures: A Focus on the Time to Intramedullary Nailing and Clinical Outcomes.

BACKGROUND: Femur shaft factures (FSF) are common injuries following high-energy mechanisms mainly involving motor vehicle crashes (MVC). We evaluated the timings of nailing management and analyzed the pattern of fracture union and outcome in a level 1 trauma center. METHODS: This was a retrospective observational study of all the admitted trauma patients who sustained femoral fractures between January 2016 and September 2020. Data were analyzed and compared based on time to Intramedullary Nailing (IMN) (<12 h, 12-24 h and >24 h) and outcomes of FSF (union, delayed union and nonunion). RESULTS: A total of 668 eligible patients were included in the study, of which the majority were males (90.9%) with a mean age of 34.5 ± 15.8, and 54% of the injuries were due to MVCs. The chest (35.8%) was the most commonly associated injured body region, followed by the pelvis (25.9%) and spine (25.4%). Most of femur fractures (93.3%) were unilateral, and 84.4% were closed fractures. The complete union of fractures was observed in 76.8% of cases, whereas only 4.2% and 3.3% cases had delayed union and nonunion, respectively, on the clinical follow-up. Patients in the delayed IMN (>24 h) were severely injured, had bilateral femur fracture (p = 0.001) and had higher rate of external fixation, blood transfusion, pulmonary complications and prolonged hospitalization. Non-union proportion was greater in those who had IMN <24 h, whereas a delayed union was greater in IMN done after 24 h (p = 0.5). Those with a nonunion femur fracture were more likely to have bilateral fracture (p = 0.003), frequently had retrograde nailing (p = 0.01), and high-grade femur fracture (AO type C; p = 0.04). CONCLUSION: This study showed that femur fracture is not uncommon (8.9%), which is manifested with the variety of clinical characteristics, depending on the mechanism, management and outcome in our center. Bilateral fracture, retrograde nailing and AO classification type C were the significant risk factors of non-union in patients with diaphyseal fractures. The timing of IMN has an impact on the fracture union; however, it is not a statistically significant difference. Therefore, the treating physicians should consider the potential risk factors for a better outcome by careful selection of treatment in sub-groups of patients.

Efficacy and safety of the second in-hospital dose of tranexamic acid after receiving the prehospital dose: double-blind randomized controlled clinical trial in a level 1 trauma center.

BACKGROUND: Prehospital administration of tranexamic acid (TXA) to injured patients is increasing worldwide. However, optimal TXA dose and need of a second infusion on hospital arrival remain undetermined. We investigated the efficacy and safety of the second in-hospital dose of TXA in injured patients receiving 1 g of TXA in the prehospital setting. We hypothesized that a second in-hospital dose of TXA improves survival of trauma patients. METHODS: A prospective, double-blind, placebo-controlled randomized, clinical trial included adult trauma patients receiving 1 g of TXA in the prehospital settings. Patients were then blindly randomized to Group I (second 1-g TXA) and Group II (placebo) on hospital arrival. The primary outcome was 24-h (early) and 28-day (late) mortality. Secondary outcomes were thromboembolic events, blood transfusions, hospital length of stay (HLOS) and organs failure (MOF). RESULTS: A total of 220 patients were enrolled, 110 in each group. The TXA and placebo groups had a similar early [OR 1.000 (0.062-16.192); p = 0.47] and late mortality [OR 0.476 (95% CI 0.157-1.442), p = 0.18].The cause of death (n = 15) was traumatic brain injury (TBI) in 12 patients and MOF in 3 patients. The need for blood transfusions in the first 24 h, number of transfused blood units, HLOS, thromboembolic events and multiorgan failure were comparable in the TXA and placebo groups. In seriously injured patients (injury severity score > 24), the MTP activation was higher in the placebo group (31.3% vs 11.10%, p = 0.13), whereas pulmonary embolism (6.9% vs 2.9%, p = 0.44) and late mortality (27.6% vs 14.3%, p = 0.17) were higher in the TXA group but did not reach statistical significance. CONCLUSION: The second TXA dose did not change the mortality rate, need for blood transfusion, thromboembolic complications, organ failure and HLOS compared to a single prehospital dose and thus its routine administration should be revisited in larger and multicenter studies. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03846973.

Patterns, Management, and Outcome of Traumatic Femur Fracture: Exploring the Experience of the Only Level 1 Trauma Center in Qatar.

BACKGROUND: Femur is the most fractured long bone in the body that often necessitates surgical fixation; however, data on the impact of the mechanism of injury (MOI), age, and timing of intervention are lacking in our region of the Arab Middle East. We aimed to describe the patterns, management, and outcome of traumatic femoral shaft fractures. METHODS: A retrospective descriptive observational study was conducted for all trauma patients admitted with femoral shaft fractures between January 2012 and December 2015 at the only level 1 trauma center and tertiary hospital in the country. Data were analyzed and compared according to the time to intervention (intramedullary nailing; IMN), MOI, and age groups. Main outcomes included in-hospital complications and mortality. RESULTS: A total of 605 hospitalized cases with femur fractures were reviewed. The mean age was 30.7 ± 16.2 years. The majority of fractures were unilateral (96.7%) and 91% were closed fractures. Three-fourths of fractures were treated by reamed intramedullary nailing (rIMN), antegrade in 80%. The pyriform fossa nails were used in 71.6% while trochanteric entry nails were used in 28.4%. Forty-five (8.9%) fractures were treated with an external fixator, 37 (6.1%) had conservative management. Traffic-related injuries occurred more in patients aged 14-30 years, whereas fall-related injuries were significantly higher in patients aged 31-59. Thirty-one patients (7.8%) had rIMN in less than 6 h post-injury, 106 (25.5%) had rIMN after 6-12 h and 267 (66.8%) had rIMN after more than 12 h. The implant type, duration of surgery, DVT prophylaxis, in-hospital complications, and mortality were comparable among the three treatment groups. CONCLUSIONS: In our center, the frequency of femoral fracture was 11%, and it mainly affected severely injured young males due to traffic-related collisions or falls. Further multicenter studies are needed to set a consensus for an appropriate management of femur fracture based on the MOI, location, and timing of injury.

Traumatic injuries associated with suicide attempts: A retrospective study from single national level 1 trauma center.

BACKGROUND: Suicide is a complex phenomenon involving several risk factors. We aimed to describe the frequency, pattern, and outcomes of patients with traumatic injuries following suicide attempts admitted to a level 1 trauma center. METHODS: We conducted a retrospective analysis of data obtained from Qatar National Trauma Registry and mortuary database. The study included all patients with traumatic injuries following suicide attempts, admitted to the Hamad Trauma Center (HTC) from April 2008 to March 2018. RESULTS: During this 10-year period, 206 patients were admitted to the HTC for injuries associated with suicide attempts. The majority were males (76%), young age (mean age 31 years), and expatriates specifically from South Asia (55%). The most common injury was due to self-inflicted cutting and piercing (51%) followed by jumping from height (30%). Females chose jumping from high place more often as a method of suicide attempt (59% vs. 20%), while males chose self-stabbing or cutting their throat (59% vs. 25%) (P = 0.001). Most of the patients had head injuries (30%) that was severe in terms of abbreviated injury scale score (3.6 ± 0.9). More than half (54%) of the patients required psychiatric consultations. The in-hospital mortality was 8% which was comparable in both genders. CONCLUSIONS: The present study revealed that 1.8% of trauma admissions at HTC were related to suicidal attempts. Better understanding of risk factors is important in devising preventive strategies.

Delayed bile leak in a patient with grade IV blunt liver trauma: A case report and review of the literature.

INTRODUCTION: Delayed bile leak following blunt liver trauma is not common. PRESENTATION OF CASE: We presented a case report and literature review of delayed bile leak in a young male patient who presented with grade IV blunt liver injury following a motor vehicle collision; he was a restrained driver who hit a fixed object. Physical examination was unremarkable except for revelaed tachycardia, right upper quadrant abdominal tenderness, and open left knee fracture. A diagnosis of grade IV multiple liver lacerations with large hemo-peritoneum was made and urgent exploratory laparotomy was performed. The patient developed a biloma collection post- operatively. He underwent endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct stenting. His recovery was uneventful, and he was discharged home after 1 month. DISCUSSION: This is a rare case with no intra or extra hepatic biliary radicle injury seen on magnetic resonance cholangiopancreatography (MRCP) and no evidence of leak by ERCP. A review of the literature to highlight the incidence of delayed bile leak revealed only few reported cases. CONCLUSION: Our findings demonstrate the need for prompt diagnosis and treatment of delayed bile leak in blunt liver injuries. When these principles are followed, a successful outcome is possible.

Left internal mammary artery injury requiring resuscitative thoracotomy: a case presentation and review of the literature.

Background. Penetrating injuries to the chest and in particular to the heart that results in pericardial tamponade and cardiac arrest requires immediate resuscitative thoracotomy as the only lifesaving technique and should be performed without delay. Objective. To describe an external cardiac tamponade caused by massive tension hemothorax from penetrating injury of the left internal mammary artery (LIMA). Method. A case presentation treated at the Level I trauma center at Hamad General Hospital, in Doha, Qatar and review of the literature on LIMA injuries reported cases. Results. LIMA injury as a cause of hemothorax is not uncommon, but to our knowledge our case is the first massive tension hemothorax with witnessed cardiac arrest reported in the literature requiring emergency thoracotomy, performed in trauma room, with full recovery. Conclusion. Injury to the LIMA with massive tension hemothorax requires immediate resuscitative thoracotomy.