Disparities in Care Among Gunshot Victims: A Nationwide Analysis.

INTRODUCTION: Given the well-known healthcare disparities most pronounced in racial and ethnic minorities, trauma healthcare in underrepresented patients should be examined, as in-hospital bias may influence the care rendered to patients. This study seeks to examine racial differences in outcomes and resource utilization among victims of gunshot wounds in the United States. METHODS: This is a retrospective review of the National Trauma Data Bank (NTDB) conducted from 2007 to 2017. The NTDB was queried for patients who suffered a gunshot wound not related to accidental injury or suicide. Patients were stratified according to race. The primary outcome for this study was mortality. Secondary outcomes included racial differences in resource utilization including air transport and discharge to rehabilitation centers. Univariate and multivariate analyses were used to compare differences in outcomes between the groups. RESULTS: A total of 250,675 patients were included in the analysis. After regression analysis, Black patients were noted to have greater odds of death compared to White patients (odds ratio [OR] 1.14, confidence interval [CI] 1.037-1.244; P = 0.006) and decreased odds of admission to the intensive care unit (ICU) (OR 0.76, CI 0.732-0.794; P < 0.001). Hispanic patients were significantly less likely to be discharged to rehabilitation centers (Hispanic: 0.78, CI 0.715-0.856; P < 0.001). Black patients had the shortest time to death (median time in minutes: White 49 interquartile range [IQR] [9-437] versus Black 24 IQR [7-205] versus Hispanic 39 IQR [8-379] versus Asian 60 [9-753], P < 0.001). CONCLUSIONS: As society carefully examines major institutions for implicit bias, healthcare should not be exempt. Greater mortality among Black patients, along with differences in other important outcome measures, demonstrate disparities that encourage further analysis of causes and solutions to these issues.

Selective Computed Tomography (CT) Imaging is Superior to Liberal CT Imaging in the Hemodynamically Normal Pediatric Blunt Trauma Patient.

BACKGROUND: The optimal imaging strategy in hemodynamically stable pediatric blunt trauma remains to be defined. The purpose of this study was to determine the differences between selective and liberal computed tomography (CT) strategy in a pediatric trauma population with respect to radiation exposure and outcomes. METHODS: We performed a retrospective analysis of hemodynamically stable blunt pediatric trauma patients (≤16 y) who were admitted to a Level I trauma center between 2013-2016. Patients were stratified into selective and liberal imaging cohorts. Univariate and multivariate regression analyses were used to compare outcomes between the groups. Outcomes included radiation dose, hospital and ICU length of stay, complications and mortality. RESULTS: Of the 485 patients included, 176 underwent liberal and 309 selective CT imaging. The liberal cohort were more likely to be severely injured (ISS>15: 34.1 versus 8.4%, P< 0.001). The odds of exposure to a radiation dose of >15 mSv were higher with liberal scanning in patients with both ISS > 15 (OR 2.78, 95% CI 1.76-5.19, P< 0.001) and ISS ≤ 15 (OR 3.41, 95% CI 2.19-8.44, P < 0.001). Adjusted outcomes regarding mortality, ICU length of stay, and complications were similar between the cohorts. CONCLUSION: Selective CT imaging in hemodynamically stable blunt pediatric trauma patients was associated with reduced radiation exposure and similar outcomes when compared to a liberal CT strategy.

Increased Incidence of COVID-19 Infections Amongst Interpersonal Violence Patients.

OBJECTIVE: To investigate whether any specific acute care surgery patient populations are associated with a higher incidence of COVID-19 infection. BACKGROUND: Acute care providers may be exposed to an increased risk of contracting the COVID-19 infection since many patients present to the emergency department without complete screening measures. However, it is not known which patients present with the highest incidence. METHODS: All acute care surgery (ACS) patients who presented to our level I trauma center between March 19, 2020, and September 20, 2020 and were tested for COVID-19 were included in the study. The patients were divided into two cohorts: COVID positive (+) and COVID negative (-). Patient demographics, type of consultation (emergency general surgery consults [EGS], interpersonal violence trauma consults [IPV], and non-interpersonal violence trauma consults [NIPV]), clinical data and outcomes were analyzed. Univariate and multivariate analyses were used to compare differences between the groups. RESULTS: In total, 2177 patients met inclusion criteria. Of these, 116 were COVID+ (5.3%) and 2061 were COVID- (94.7%). COVID+ patients were more frequently Latinos (64.7% versus 61.7%, P = 0.043) and African Americans (18.1% versus 11.2%, P < 0.001) and less frequently Caucasian (6.0% versus 14.1%, P < 0.001). Asian/Filipino/Pacific Islander (7.8% versus 7.2%, P = 0.059) and Native American/Other/Unknown (3.4% versus 5.8%, P = 0.078) groups showed no statistical difference in COVID incidence. Mortality, hospital and ICU lengths of stay were similar between the groups and across patient populations stratified by the type of consultation. Logistic regression demonstrated higher odds of COVID+ infection amongst IPV patients (OR 2.33, 95% CI 1.62-7.56, P < 0.001) compared to other ACS consultation types. CONCLUSION: Our findings demonstrate that victims of interpersonal violence were more likely positive for COVID-19, while in hospital outcomes were similar between COVID-19 positive and negative patients.

Extracorporeal support for trauma: A trauma quality improvement project (TQIP) analysis in patients with acute respiratory distress syndrome.

INTRODUCTION: The use of extracorporeal membrane oxygenation (ECMO) in trauma patients with severe acute respiratory distress syndrome (ARDS) continues to evolve. The objective of this study was to perform a comparative analysis of trauma patients with ARDS who received ECMO to a propensity matched cohort of patients who underwent conventional management. METHODS: The Trauma Quality Improvement Program (TQIP) database was queried from 2013 to 2016 for all patients with ARDS and those who received ECMO. Demographics, as well as clinical, injury, intervention, and outcome data were collected and analyzed. Patients with ARDS were divided into two groups, those who received ECMO and those who did not. A propensity score analysis was performed using the following criteria: age, gender, vital signs (HR, SBP) and GCS on admission, Injury Severity Score (ISS), and Abbreviated Injury Scale (AIS) score in several body regions. Outcomes between the groups were subsequently compared using univariate as well as Cox regression analyses. Secondary outcomes such as hospitalization (HLOS), ICU length-of-stay (LOS) and ventilation days stratified for patient demographics, timing of ECMO and anticoagulation status were compared. RESULTS: Over the 3-year study period, 8990 patients with ARDS were identified from the TQIP registry. Following exclusion, 3680 were included in the final analysis, of which 97 (2.6%) received ECMO. On univariate analysis following matching, patients who underwent ECMO had lower overall hospital mortality (23 vs 50%, p < 0.001) with higher rates of complications (p < 0.005), including longer HLOS. In those undergoing ECMO, early initiation (<7 days) was associated with shorter HLOS, ICU LOS, and fewer ventilator days. No difference was observed between the two groups with regard to anticoagulation. CONCLUSION: Extracorporeal membrane oxygenation use in trauma patients with ARDS may be associated with improved survival, especially for young patients with thoracic injuries, early in the course of ARDS. Anticoagulation while on circuit was not associated with increased risk of hemorrhage or mortality, even in the setting of head injuries. The mortality benefit suggested with ECMO comes at the expense of a potential increase in complication rate and prolonged hospitalization.

Falls from ladders: Injury patterns and outcomes.

BACKGROUND: Our contemporary understanding of the impact of falls from ladders remains limited. The purpose of this study was to examine the injury patterns and outcomes of falls from ladders. Our hypothesis was that age affects both injury type and outcomes. METHODS: The National Trauma Data Bank was queried for all patients who fell from a ladder (January 2007 to December 2017). Participants were stratified into four groups according to age: 15 years or younger, 16 years to 50 years, 51 years to 65 years, and older than 65 years. Univariate and multivariate analyses were performed to compare the injury patterns and outcomes between the groups. RESULTS: A total of 168,227 patients were included for analysis. Median age was 56 years (interquartile range, 45-66 years), 86.1% were male, and median ISS was 9 (interquartile range, 4-13). Increasing age was associated with a higher risk of severe trauma (ISS > 15: 8.8% vs. 13.7% vs. 17.5% vs. 22.0%; p < 0.001). Head injuries followed a U-shaped distribution, with pediatric and elderly patients representing the most vulnerable groups. Overall, fractures were the most common type of injury, in the following order: lower extremity, 27.3%; spine, 24.9%; rib, 23.1%; upper extremity, 20.1%; and pelvis, 10.3%. The overall intensive care unit admission rate was 21.5%; however, it was significantly higher in the elderly (29.1%). In-hospital mortality was 1.8%. The risk of death progressively increased with age with a mortality rate of 0.3%, 0.9%, 1.5%, and 3.6%, respectively ( p < 0.001). Strong predictors of mortality were Glasgow Coma Scale score of 8 or lower on admission (odds ratio, 29.80; 95% confidence interval, 26.66-33.31; p < 0.001) and age >65 years (odds ratio 4.07; 95% confidence interval, 3.535-4.692; p < 0.001). Only 50.8% of the elderly patients were discharged home without health services, 16.5% were discharged to nursing homes, and 15.2% to rehabilitation centers. CONCLUSION: Falls from ladders are associated with considerable morbidity and mortality, especially in the elderly. Head injuries and fractures are common and often severe. An intensified approach to safe ladder use in the community is warranted. LEVEL OF EVIDENCE: Therapeutic/care management; Level III.

Firearm injuries during legal interventions Nationwide analysis.

INTRODUCTION: There is limited literature on firearm injuries during legal interventions. The purpose of this study was to examine the epidemiology, injury characteristics, and outcomes of both civilians and law enforcement officials (LEOs) who sustained firearm injuries over the course of legal action. METHODS: Retrospective observational study using data from the National Trauma Data Bank (2015-2017) was performed. All patients who were injured by firearms during legal interventions were identified using the International Classification of Disease, Tenth Revision, external cause of injury codes. The study groups were injured civilian suspects and police officers. Demographics, injury characteristics, and outcomes were analyzed and compared between the groups. Primary outcomes were the clinical and injury characteristics among the victims. RESULTS: A total of 1,411 patients were included in the study, of which 1,091 (77.3%) were civilians, 289 officers (20.5%), and 31 bystanders (2.2%). Overall, 95.2% of patients were male. Compared with LEOs, civilians were younger (31 vs. 34 years, p = 0.007) and more severely injured (median Injury Severity Score, 13 vs. 10 [p = 0.005]; Injury Severity Score >15, 44.4% vs. 37.1% [p = 0.025]). Civilians were more likely to sustain severe (Abbreviated Injury Scale, ≥3) intra-abdominal injuries (26.8% vs. 16.1%, p < 0.001) and spinal fractures (13.0% vs. 6.9%, p = 0.004). In-hospital mortality and overall complication rate were similar between the groups (mortality: civilians, 24.7% vs. LEOs, 27.3% [p = 0.360]; overall complications: civilians, 10.3% vs. LEOs, 8.4% [p = 0.338]). CONCLUSION: Firearm injuries during legal interventions are associated with significant injury burden and a higher mortality than the reported mortality in gunshot wounds among civilians. The mortality and overall complication rate were similar between civilian suspects and law enforcement officials. LEVEL OF EVIDENCE: Epidemiologic, level IV.

Diagnostic Peritoneal Aspiration Revisited: Its Diagnostic Accuracy for the Detection of Intraabdominal Hemorrhage.

BACKGROUND: The use of Focused Assessment with Sonography for Trauma (FAST) in combination with computed tomography (CT) has become the mainstay of diagnostic workup in patients with suspected intraabdominal hemorrhage (IAH). However, diagnostic peritoneal aspiration (DPA) can be an important adjunct in hemodynamically unstable patients. The aim of this study was to evaluate the utility and diagnostic accuracy of DPA in detecting IAH. METHODS: Retrospective analysis of all patients who presented to the LAC+USC Medical Center and underwent evaluation with DPA between January 2010 and December 2016. Intraoperative, CT, and autopsy findings were used as gold standards in determining the diagnostic accuracy of DPA for the detection of IAH. RESULTS: A total of 73 consecutive patients were included in the study. The median age was 42 years (interquartile range [IQR]: 25-56), median injury severity score was 29 (IQR: 21-41), and 82.2% sustained blunt trauma. The most common indications for DPA were hemodynamically unstable patients with suspected IAH and patients with return of spontaneous circulation following resuscitative thoracotomy. Overall, the positive and negative predictive values of DPA were 89.4% and 88.9%, respectively. In 14 cases (19.2%), DPA correctly identified false positive/negative FAST results. CONCLUSION: Our data suggest that DPA has high diagnostic yield for IAH. The use of DPA should be considered in unstable patients with inconclusive FAST results who cannot safely be evaluated with CT.