Feasibility and diagnostic accuracy of fast whole-body MRI in slightly to moderately injured trauma patients.

OBJECTIVES: To determine the feasibility and diagnostic accuracy of fast whole-body magnetic resonance imaging (WB-MRI) compared to whole-body computed tomography (WB-CT) in detecting injuries of slightly to moderately injured trauma patients. MATERIALS AND METHODS: In a prospective single-center approach, trauma patients from convenience sampling with an expected Abbreviated Injury Scale (AIS) score ≤ 3 at admission, received an indicated contrast-enhanced WB-CT (reference standard) and a plain WB-MRI (index test) voluntarily up to five days after trauma. Two radiologists, blinded to the WB-CT findings, evaluated the absence or presence of injuries with WB-MRI in four body regions: head, torso, axial skeleton, and upper extremity. Diagnostic accuracy was determined using sensitivity, specificity, positive predictive value, and negative predictive value by body region. RESULTS: Between June 2019 and July 2021, 40 patients were assessed for eligibility of whom 35 (median age (interquartile range): 50 (32.5) years; 26 men) received WB-MRI. Of 140 body regions (35 patients × 4 regions), 31 true positive, 6 false positive, 94 true negative, and 9 false negative findings were documented with WB-MRI. Thus, plain WB-MRI achieved a total sensitivity of 77.5% (95%-confidence interval (CI): (61.6-89.2%)), specificity of 94% (95%-CI: (87.4-97.8%)), and diagnostic accuracy of 89.3% (95%-CI: (82.9-93.9%)). Across the four regions sensitivity and specificity varied: head (66.7%/93.1%), torso (62.5%/96.3%), axial skeleton (91.3%/75%), upper extremity (33.3%/100%). Both radiologists showed substantial agreement on the WB-MRI reading (Cohen's Kappa: 0.66, 95%-CI: (0.51-0.81)). CONCLUSION: Regarding injury detection, WB-MRI is feasible in slightly to moderately injured trauma patients, especially in the axial skeleton. CLINICAL RELEVANCE STATEMENT: Besides offering a radiation-free approach, whole-body MRI detects injuries almost identically to whole-body CT in slightly to moderately injured trauma patients, who comprise a relevant share of all trauma patients. KEY POINTS: Whole-body MRI could offer radiation-free injury detection in slightly to moderately injured trauma patients. Whole-body MRI detected injuries almost identically compared to whole-body CT in this population. Whole-body MRI could be a radiation-free approach for slightly to moderately injured young trauma patients.

Pooled Analysis of Trauma Centers Better Predicts Risk Factors for Firearm Violence Reinjury.

INTRODUCTION: Many trauma centers use the first firearm injury admission as a reachable moment to mitigate reinjury. Understanding repeat firearm violence can be difficult in metropolitan areas with multiple trauma centers and laws that prohibit sharing private health information across health systems. We hypothesized that risk factors for repeat firearm violence could be better understood using pooled data from two major metropolitan trauma centers. METHODS: Two level I trauma center registries were queried (2007-2017) for firearm injury admissions using International Classification of Diseases, Ninth and Tenth Revision (ICD9/10) Ecodes. A pseudo encryption tool allowed sharing of deidentified firearm injury and repeat firearm injury data without disclosing private health information. Factors associated with firearm reinjury admissions including, age, sex, race, payor, injury severity, intent, and discharge, were assessed by multivariable logistic regression. RESULTS: We identified 2145 patients with firearm injury admissions, 89 of whom had a subsequent repeat firearm injury admission. Majority of repeat firearm admissions were assaulted (91%), male (97.8%), and non-Hispanic Black (86.5%). 31.5% of repeat firearm injury admissions were admitted to a different trauma center from their initial admission. Independent predictors of repeat firearm injuries were age (adjusted odds ratio [aOR] 0.94, P < 0.001), male sex (aOR 6.18, P = 0.013), non-Hispanic Black race (aOR 5.14, P = 0.007), or discharge against medical advice (aOR 6.64, P=<0.001). CONCLUSIONS: Nearly a third of repeat firearm injury admissions would have been missed in the current study without pooled metropolitan trauma center data. The incidence of repeat firearm violence is increasing and those at the highest risk for reinjury need to be targeted for mitigating interventions.

Follow-up after major traumatic injury: a survey of services in Australian and New Zealand public hospitals.

BACKGROUND: Increased survival from traumatic injury has led to a higher demand for follow-up care when patients are discharged from hospital. It is currently unclear how follow-up care following major trauma is provided to patients, and how, when, and to whom follow-up services are delivered. The aim of this study was to describe the current follow-up care provided to patients and their families who have experienced major traumatic injury in Australia and New Zealand (ANZ). METHODS: Informed by Donabedian's 'Evaluating the Quality of Medical Care' model and the Institute of Medicine's Six Domains of Healthcare Quality, a cross-sectional online survey was developed in conjunction with trauma experts. Their responses informed the final survey which was distributed to key personnel in 71 hospitals in Australia and New Zealand that (i) delivered trauma care to patients, (ii) provided data to the Australasian Trauma Registry, or (iii) were a Trauma Centre. RESULTS: Data were received from 38/71 (53.5%) hospitals. Most were Level 1 trauma centres (n = 23, 60.5%); 76% (n = 16) follow-up services were permanently funded. Follow-up services were led by a range of health professionals with over 60% (n = 19) identifying as trauma specialists. Patient inclusion criteria varied; only one service allowed self-referral (3.3%). Follow-up was within two weeks of acute care discharge in 53% (n = 16) of services. Care activities focused on physical health; psychosocial assessments were the least common. Most services provided care for adults and paediatric trauma (60.5%, n = 23); no service incorporated follow-up for family members. Evaluation of follow-up care was largely as part of a health service initiative; only three sites stated evaluation was specific to trauma follow-up. CONCLUSION: Follow-up care is provided by trauma specialists and predominantly focuses on the physical health of the patients affected by major traumatic injury. Variations exist in terms of patient selection, reason for follow-up and care activities delivered with gaps in the provision of psychosocial and family health services identified. Currently, evaluation of trauma follow-up care is limited, indicating a need for further development to ensure that the care delivered is safe, effective and beneficial to patients, families and healthcare organisations.

Identifying the key characteristics, trends, and seasonality of pedestrian traffic injury at a major trauma center in Saudi Arabia: a registry-based retrospective cohort study, 2017-2022.

BACKGROUND: Pedestrian traffic injuries are a rising public health concern worldwide. In rapidly urbanizing countries like Saudi Arabia, these injuries account for a considerable proportion of trauma cases and represent a challenge for healthcare systems. The study aims to analyze the key characteristics, seasonality, and outcomes of pedestrian traffic injuries in Riyadh, Saudi Arabia. METHODS: This study was a retrospective cohort analysis of all pedestrian traffic injuries presented to King Saud Medical City, Riyadh, and included in the Saudi Trauma Registry (STAR) database between August 1, 2017, and December 31, 2022. The analysis of metric and nominal variables was reported as mean (standard deviation, SD) or median (interquartile range, IQR) and frequencies (%), respectively. A logistic regression analysis was performed to examine the influence of patients' pre-hospital vitals and key characteristics on arrival at the ED on the need for mechanical ventilation and in-hospital mortality. RESULTS: During the study period, 1062 pedestrian-injured patients were included in the analysis, mostly males (89.45%) with a mean (SD) age of 33.44 (17.92) years. One-third (35.88%) of the patients were Saudi nationals. Two-thirds (67.04%) of the injuries occurred from 6 p.m. until 6 a.m. Compared to other years, a smaller % of injury events (13.28%) were noticed during the COVID-19 pandemic (2020). Half (50.19%) of the patients were transported to the emergency department by the Red Crescent ambulance, and 19.68% required intubation and mechanical ventilation. Most of the patients (87.85%) were discharged home after completion of treatment, and our cohort had a 4.89% overall mortality. The logistic regression analysis showed the influence of patients' pre-hospital vitals and key characteristics on arrival at the ED on the need for mechanical ventilation (Chi2 = 161.95, p < 0.001) and in-hospital mortality (Chi2 = 63.78, p < 0.001) as a whole significant. CONCLUSION: This study details the demographic, temporal, and clinical trends of pedestrian traffic injuries at a major Saudi trauma center. Identifying high-risk individuals and injury timing is crucial for resource allocation, targeting road safety interventions like public awareness campaigns and regulatory reforms, and improving prehospital care and patient outcomes.

The State of the Union: Trauma System Development in the United States.

Injury is both a national and international epidemic that affects people of all age, race, religion, and socioeconomic class. Injury was the fourth leading cause of death in the United States (U.S.) in 2021 and results in an incalculable emotional and financial burden on our society. Despite this, when prevention fails, trauma centers allow communities to prepare to care for the traumatically injured patient. Using lessons learned from the military, trauma care has grown more sophisticated in the last 50 years. In 1966, the first civilian trauma center was established, bringing management of injury into the new age. Now, the American College of Surgeons recognizes 4 levels of trauma centers (I-IV), with select states recognizing Level V trauma centers. The introduction of trauma centers in the U.S. has been proven to reduce morbidity and mortality for the injured patient. However, despite the proven benefits of trauma centers, the U.S. lacks a single, unified, trauma system and instead operates within a "system of systems" creating vast disparities in the level of care that can be received, especially in rural and economically disadvantaged areas. In this review we present the history of trauma system development in the U.S, define the different levels of trauma centers, present evidence that trauma systems and trauma centers improve outcomes, outline the current state of trauma system development in the U.S, and briefly mention some of the current challenges and opportunities in trauma system development in the U.S. today.

Does the Probability of Survival Calculated by the Trauma and Injury Severity Score Method Accurately Reflect the Severity of Neurotrauma Patients Admitted to Regional Trauma Centers in Korea?

BACKGROUND: Assessing and improving the quality of trauma care is crucial in modern trauma systems and centers. In Korea, evaluations of regional trauma centers are conducted annually to assess and improve trauma management quality. This includes using the Trauma and Injury Severity Score (TRISS) method to calculate the W-score and mortality Observed-to-Expected ratio (O:E ratio), which are used to evaluate the quality of care. We analyzed the potential for overestimation of the probability of survival using TRISS method for patients with neurotrauma, as well as the potential for errors when evaluating and comparing regional trauma centers. METHODS: We included patients who visited the regional trauma center between 2019 and 2021 and compared their probability of survival of the TRISS method, W-score, mortality O:E ratio, and misclassification rates. The patient groups were further subdivided into smaller subgroups based on age, Glasgow Coma Scale (GCS), and Injury Severity Score, and comparisons were made between the neurotrauma and non-neurotrauma groups within each subgroup. RESULTS: A total of 4,045 patients were enrolled in the study, with 1,639 of them having neurotrauma. The neurotrauma patient group had a W-score of -0.68 and a mortality O:E ratio of 1.044. The misclassification rate was found to be 13.3%, and patients with a GCS of 8 or less had a higher misclassification rate of 37.4%. CONCLUSION: The limitations of using the TRISS method for predicting outcomes in patients with severe neurotrauma are exposed in this study. The TRISS methodology demonstrated a high misclassification rate of approximately 40% in subgroups of patients with GCS less than 9, indicating that it may be less reliable in predicting outcomes for severely injured patients with low GCS. Clinicians and researchers should be cautious when using the TRISS method and consider alternative methods to evaluate patient outcomes and compare the quality of care provided by different trauma centers.

Epidemiology and management of 10,486 pediatric fractures in Shenzhen: experience and lessons to be learnt.

PURPOSE: To explore and analyze the causes and related influencing factors of pediatric fractures, and provide theoretical basis for reducing the incidence and adverse effects of pediatric fractures. METHODS: This study retrospectively analyzed the epidemiological characteristics of fractures in pediatric aged ≤18 years old who were admitted to the our hospital between July 2015 and February 2020. RESULTS: A total of 10,486 pediatric patients were included in the study, of whom 6961 (66.38%) were boys, and 3525 (33.62%) were girls. For the fracture incidence, age group of the 3-6 years reached the peak. 5584 (60.76%) children were operated upon within 12 h after admission. The top three types of fractures were the distal humerus (3843 sites, 27.49%), distal ulna (1740 sites, 12.44%), and distal radius (1587 sites, 11.35%). The top three causes of injury were falls (7106 cases, 82.10%), car accidents (650 cases, 65.72%), and clipping (465 cases, 5.37%). Fractures predominantly occurred between July and November (4664 cases, 48.87%) and on Saturdays and Sundays (3172 cases, 33.24%). The highest number of hospital visits occurred between 20:00 and 00:00 (4339 cases, 45.46%). CONCLUSION: For pediatric fractures, we should take appropriate and effective preventive measures to reduce the incidence of children's fractures according to the distribution characteristics of age, gender, cause of injury, and fracture site.

National Follow-up Survey of Preventable Trauma Death Rate in Korea.

BACKGROUND: The preventable trauma death rate survey is a basic tool for the quality management of trauma treatment because it is a method that can intuitively evaluate the level of national trauma treatment. We conducted this study as a national biennial follow-up survey project and report the results of the review of the 2019 trauma death data in Korea. METHODS: From January 1, 2019 to December 31, 2019, of a total of 8,482 trauma deaths throughout the country, 1,692 were sampled from 279 emergency medical institutions in Korea. All cases were evaluated for preventability of death and opportunities for improvement using a multidisciplinary panel review approach. RESULTS: The preventable trauma death rate was estimated to be 15.7%. Of these, 3.1% were judged definitive preventable deaths, and 12.7% were potentially preventable deaths. The odds ratio for preventable traumatic death was 2.56 times higher in transferred patients compared to that of patients who visited the final hospital directly. The group that died 1 hour after the accident had a statistically significantly higher probability of preventable death than that of the group that died within 1 hour after the accident. CONCLUSION: The preventable trauma death rate for trauma deaths in 2019 was 15.7%, which was 4.2%p lower than that in 2017. To improve the quality of trauma treatment, the transfer of severe trauma patients to trauma centers should be more focused.

Association of Psychosocial Factors and Hospital Complications with Risk for Readmission After Trauma.

BACKGROUND: Unplanned hospital readmissions are associated with morbidity and high cost. Existing literature on readmission after trauma has focused on how injury characteristics are associated with readmission. We aimed to evaluate how psychosocial determinants of health and complications of hospitalization combined with injury characteristics affect risk of readmission after trauma. MATERIALS AND METHODS: We conducted a retrospective cohort study of adult trauma admissions from July 2015 to September 2017 to Harborview Medical Center in Seattle, Washington. We assessed patient, injury, and hospitalization characteristics and estimated associations between risk factors and unplanned 30-d readmission using multivariable generalized linear Poisson regression models. RESULTS: Of 8916 discharged trauma patients, 330 (3.7%) had an unplanned 30-d readmission. Patients were most commonly readmitted with infection (41.5%). Independent risk factors for readmission among postoperative patients included public insurance (adjusted Relative Risk (aRR) 1.34, 95% CI 1.02-1.76), mental illness (aRR 1.39, 1.04-1.85), and chronic renal failure (aRR 2.17, 1.39-3.39); undergoing abdominal, thoracic, or neurosurgical procedures; experiencing an index hospitalization surgical site infection (aRR 4.74, 3.00-7.50), pulmonary embolism (aRR 3.38, 2.04-5.60), or unplanned ICU readmission (aRR 1.74, 1.16-2.62); shorter hospital stay (aRR 0.98/d, 0.97-0.99), and discharge to jail (aRR 4.68, 2.63-8.35) or a shelter (aRR 4.32, 2.58-7.21). Risk factors varied by reason for readmission. Injury severity, trauma mechanism, and body region were not independently associated with readmission risk. CONCLUSIONS: Psychosocial factors and hospital complications were more strongly associated with readmission after trauma than injury characteristics. Improved social support and follow-up after discharge for high-risk patients may facilitate earlier identification of postdischarge complications.

Automatic Detection of Thyroid and Adrenal Incidentals Using Radiology Reports and Deep Learning.

BACKGROUND: Computed tomography (CT) is commonly performed when evaluating trauma patients with up to 55% showing incidental findings. Current workflows to identify and inform patients are time-consuming and prone to error. Our objective was to automatically identify thyroid and adrenal lesions in radiology reports using deep learning. MATERIALS AND METHODS: All trauma patients who presented to an accredited Level 1 Trauma Center between January 2008 and January 2019 were included. Radiology reports of CT scans that included either a thyroid or adrenal gland were obtained. Preprocessing included word tokenization, removal of stop words, removal of punctuation, and replacement of misspellings. A word2vec model was trained using 1.4 million radiology reports. Both training and testing reports were selected at random, manually reviewed, and were considered the gold standard. True positive cases were defined as any lesions in the thyroid or adrenal gland, respectively. Training data was used to create models that would identify reports that contained either thyroid or adrenal lesions. Our primary outcomes were sensitivity and specificity of the models using predetermined thresholds on a separate testing dataset. RESULTS: A total of 51,771 reports were identified on 35,859 trauma patients. A total of 1,789 reports were annotated for training and 500 for testing. The thyroid model predictions resulted in a 90.0% sensitivity and 95.3% specificity. The adrenal model predictions resulted in a 92.3% sensitivity and a 91.1% specificity. A total of 240 reports were confirmed to have thyroid incidentals (mean age 69.1 yrs ± 18.9, 35% M) and 214 reports with adrenal incidentals (mean age 68.7 yrs ± 16.9, 50.5% M). CONCLUSIONS: Both the thyroid and adrenal models have excellent performance with sensitivities and specificities in the 90s. Our deep learning model has the potential to reduce administrative costs and improve the process of informing patients.

The impact of SARS and COVID-19 on major trauma in Hong Kong.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has been enormously disruptive and harmful to people around the world, but its impact on other illnesses and injuries has been more variable. To evaluate the ramification of infectious disease outbreaks on major traumatic injuries, we compared changes in the incidence of major trauma cases during the 2003 Severe Acute Respiratory Syndrome (SARS) period with COVID-19 in 2020. METHODS: Data were analyzed from the trauma registry of a major, tertiary-care teaching hospital in Hong Kong. Patients presenting with major traumatic injuries during the first six months of 2001-03 and 2018-20 were retrieved for analysis. Patient characteristics, injury mechanism, admitting service, and emergency department (ED)/hospital lengths of stay (LOS) were recorded. Raw and adjusted survival rates (using the modified Trauma Injury Severity Score (TRISS)) were recorded. RESULTS: The number of trauma cases fell dramatically during 2003 and 2020 compared with previous years. In both 2003 and 2020, the number of trauma registry patients fell by 49% in April (compared to the preceding reference years of 2001/02 and 2018/19, respectively). Patient characteristics, treatments, and outcomes were also different during the outbreak years. Comparing 2003 to 2020 relative to their respective reference baselines, the percentages of injuries that happened at home, patients without co-morbidities, and patients' mean age all increased in 2003 but decreased in 2020. Work-place injuries drastically dropped in 2003, but not in 2020. Average ED LOS dropped in 2003 by 36.4 min (95% CI 12.5, 60.3) but declined by only 14.5 min (95% CI -2.9, 32.1) in 2020. Both observed and expected 30-day mortality declined in 2020 vs. 2003 (observed 4.5% vs. 11.7%, p = 0.001, OR 0.352, 95% CI 0.187, 0.661) (expected 4.5% vs 11.6%, p = 0.002, OR 0.358, 95% CI 0.188, 0.684). CONCLUSION: Major trauma cases dropped by half during both the peak of the 2003 SARS and 2020 COVID-19 pandemics in Hong Kong, suggesting a trend for future pandemic planning. If similar findings are seen at other trauma centers, proactive personnel and resource allocations away from trauma towards medical emergency systems may be more appropriate for future pandemics.

An Evaluation of the Effect of Performance Improvement and Patient Safety Program Implemented in a New Regional Trauma Center of Korea.

BACKGROUND: This study examined the impact of the performance improvement and patient safety (PIPS) program implemented in 2015 on outcomes for trauma patients in a regional trauma center established by a government-led project for a national trauma system in Korea. METHODS: The PIPS program was based on guidelines by the World Health Organization and American College of Surgeons. The corrective strategies were proceeded according to the loop closure principle: data-gathering and monitoring, identification of preventable trauma deaths (PTDs), evaluation of preventable factors, analysis of findings, and corrective action plans. We established guidelines and protocols for trauma care, conducted targeted education and peer review presentations for problematic cases, and enhanced resources for improvement accordingly. A comparative analysis was performed on trauma outcomes over a four-year period (2015-2018) since implementing the PIPS program, including the number of trauma team activation and admissions, time factors related to resuscitation, ventilator duration, and the rate of PTDs. RESULTS: Human resources in the center significantly increased during the period; attending surgeons responsible for trauma resuscitation from 6 to 11 and trauma nurses from 85 to 218. Trauma admissions (from 2,166 to 2,786), trauma team activations (from 373 to 1,688), and severe cases (from 22.6 to 33.8%) significantly increased (all P < 0.001). Time to initial resuscitation and transfusion significantly decreased from 120 to 36 minutes (P < 0.001) and from 39 to 16 minutes (P < 0.001). Time to surgery for hemorrhage control and decompressive craniotomy improved from 99 to 54 minutes (P < 0.001) and 181 to 135 minutes (P = 0.042). Ventilator duration and rate of PTDs significantly decreased from 6 to 4 days (P = 0.001) and 22.2% to 8.4% (P = 0.008). CONCLUSION: Implementation of the PIPS program resulted in improvements in outcomes at a regional trauma center that has just been opened in Korea. Further establishment of the PIPS program is required for optimal care of trauma patients.

[The interdisciplinary orthogeriatric ward round : Recommendations for the clinical routine]. / Die interdisziplinäre alterstraumatologische Visite : Empfehlungen für den Klinikalltag.

BACKGROUND: An orthogeriatric co-management can improve the quality of care for geriatric trauma patients. OBJECTIVE: The aim of this study was the establishment of treatment recommendations for the clinical routine in order to improve the quality of care for geriatric trauma patients. MATERIAL AND METHODS: Over a period of 7 months, 226 patients were discussed and visited once a week on 29 defined days, taking into account current laboratory results, vital signs, the medication as well as the clinical assessment by the nursing personnel. Besides physicians of different medical specialties (trauma surgery, geriatrics, clinical pharmacology, microbiology), members of the nursing staff and case managers took part in the ward rounds. RESULTS: On average, three treatment recommendations were made per patient visit (two pharmacological and one non-pharmacological recommendation [e.g. concerning fluid and delirium management]). The pharmacological and non-pharmacological recommendations were divided into several subcategories. The most frequent pharmacological recommendation was the discontinuation of a drug (30.4% of all pharmacological recommendations). CONCLUSION: The pharmacotherapy of geriatric patients requires careful consideration of contraindications, adverse drug reactions, duplicate medications, circadian aspects, and renal function. Regular re-evaluation of medical equipment can prevent catheter-associated infections. Identification and management of postoperative delirium is an integral component of the interdisciplinary orthogeriatric ward round. Evaluation of anti-infective treatment regimens with the expertise of a microbiologist/infectiologist proved to be very beneficial.

Application of trauma time axis management in the treatment of severe trauma patients.

PURPOSE: This study aimed at exploring the application of trauma time axis management in the treatment of severe trauma patients by using the Medicalsystem trauma system. METHODS: We performed a retrospective cohort study involving patients with severe trauma. Patients who were admitted before the application of the Medicalsystem trauma system were divided into before system group; patients who were admitted after the application of the system were divided into after system group. Comparison was made between the two groups. For normally distributed data, means were reported along with standard deviation, and comparisons were made using the independent samples t test. Categorical data were compared using the Chi-square test. The Mann-Whitney U test was used to compare nonparametric variables. RESULTS: There were 528 patients admitted to the study during the study period. There was no significant statistical difference in the time from the start of trauma team to arrive at the resuscitation room between the two groups. The time from arrival at hospital to endotracheal intubation, to ventilator therapy, to blood transfusion, to completion of CT scan, to completion of closed thoracic drainage, to the start of operation, as well as the length of stay in resuscitation room and hospital were significantly lower after the application of the Medicalsystem trauma system. The mortality was decreased by 8.6% in the after system group compared with that in the before system group, but there was no statistical difference. CONCLUSION: The Medicalsystem trauma system can optimize diagnosis and treatment process for trauma patients, and accordingly improve the treatment efficiency and shorten the treatment time. Therefore, the Medicalsystem trauma system deserves further popularization and promotion.

Current Management of Extraperitoneal Bladder Injuries: Results from the Multi-Institutional Genito-Urinary Trauma Study (MiGUTS).

PURPOSE: We studied the current management trends for extraperitoneal bladder injuries and evaluated the use of operative repair versus catheter drainage, and the associated complications with each approach. MATERIALS AND METHODS: We prospectively collected data on bladder trauma from 20 level 1 trauma centers across the United States from 2013 to 2018. We excluded patients with intraperitoneal bladder injury and those who died within 24 hours of hospital arrival. We separated patients with extraperitoneal bladder injuries into 2 groups (catheter drainage vs operative repair) based on their initial management within the first 4 days and compared the rates of bladder injury related complications among them. Regression analyses were used to identify potential predictors of complications. RESULTS: From 323 bladder injuries we included 157 patients with extraperitoneal bladder injuries. Concomitant injuries occurred in 139 (88%) patients with pelvic fracture seen in 79%. Sixty-seven patients (43%) initially underwent operative repair for their extraperitoneal bladder injuries. The 3 most common reasons for operative repair were severity of injury or bladder neck injury (40%), injury found during laparotomy (39%) and concern for pelvic hardware contamination (28%). Significant complications were identified in 23% and 19% of the catheter drainage and operative repair groups, respectively (p=0.55). The only statistically significant predictor for complications was bladder neck or urethral injury (RR 2.69, 95% 1.21-5.97, p=0.01). CONCLUSIONS: In this large multi-institutional cohort, 43% of patients underwent surgical repair for initial management of extraperitoneal bladder injuries. We found no significant difference in complications between the initial management strategies of catheter drainage and operative repair. The most significant predictor for complications was concomitant urethral or bladder neck injury.

Survival Benefit of Treatment at or Transfer to a Tertiary Trauma Center among Injured Older Adults.

Objective: It is well established that seriously injured older adults are under-triaged to tertiary trauma centers. However, the survival benefit of tertiary trauma centers (TC) compared to a non-tertiary trauma centers (Non-TCs) remains unclear for this patient population. Using improved methodology and a larger sample, we hypothesized that there was a difference in hospital mortality between injured older adults treated at TCs and those treated at Non-TCs. Methods: This was a retrospective cohort study of injured older adults (> =55 years) reported to the Oklahoma statewide trauma registry between 2005 and 2014. The outcome of interest was 30-day in-hospital mortality and the exposure variable of interest was level of definitive trauma care (TC vs Non-TC). Overall survival benefit of treatment at a TC as well as the survival benefit of transferring injured older adults to a TC were evaluated using multivariable survival analyses as well as propensity score-adjusted analyses. Results: Of the 25,288 patients eligible for analysis, 43% (10,927) were treated at TCs. Multivariable Cox regression analyses revealed effect modification by age group and time. After adjusting for potential confounders within the age strata, overall, patients treated at TCs were significantly less likely to die within 7 days of admission and this effect was stronger for patients aged 55-64 years (HR 0.41, 95% CI 0.31-0.52) compared to those > =65 years (HR 0.62, 95% CI 0.55-0.70). Overall survival benefit of TCs beyond 7 days was also observed (HR 0.68, 95% CI 0.56-0.83). Similarly, for the survival benefit of transferring injured older adults, after adjusting for the propensity to be transferred and other confounders, transfer to a TC was associated with lower 30-day mortality both for patients less than 65 years old (HR 0.36, 95% CI: 0.27-0.49) and those 65 years and older (HR 0.55, 95% CI: 0.48-0.64). Conclusions: Our results suggest a survival benefit for injured older adults treated at TCs. This benefit was also observed for patients transferred from non-tertiary trauma centers. Further research should focus on identifying specific subgroups of patients who would especially benefit from this level of care to minimize trauma triage inefficiencies.

A pragmatic evaluation of trauma care: an evidence from the province of Punjab, Pakistan.

Road Traffic Accident (RTA) injuries pose a public health challenge which significantly impacts the human capital development. The Punjab Economic Research Institute (PERI) conducted a study to assess the frequency, causes of trauma injuries, distribution and need and gap analysis of trauma centers in the province of Punjab. For gap/situational analysis, information was extracted through a structured questionnaire from randomly selected 8 District Head Quarters hospitals, 6 Teaching hospitals and 8 independent trauma centers. According to the data of Rescue 1122, 70% of RTA injuries involved the age group 11-40 years. In 295589(63.26%) of the RTA cases the vehicle involved was a motorbike. The major RTA injuries were leg fractures 71699 (16.44%) and head injuries 44738(10.26%). Over speeding 159977(44%) and careless driving 121545 (33.35%) were the major causes of RTAs. Noted was a shortage and mismatch between human resources and equipment in the trauma treatment facilities. Inequality was also found in distribution of trauma care units. Integrated and fully equipped trauma care system along with the establishment of trauma centers in places of high accidents' frequency is recommended. Strict implementation of road traffic safety laws is mandatory.

The Affordable Care Act: Long-Term Financial Impact on a Level I Trauma Center.

BACKGROUND: Prior studies of the impact of the Affordable Care Act on reimbursement for inpatient trauma care do not include disproportionate share hospital (DSH) funding. Because trauma centers and other safety-net hospitals are sensitive to any changes in financial support, it is essential to include DSH funding in evaluating overall reimbursement. This study analyzes the long-term financial trends, including DSH, of a level I trauma center in Ohio, a state that expanded Medicaid. METHODS: Charges, reimbursement, sources of insurance coverage, Injury Severity Scores, and DSH funding for the trauma patient population of an Ohio American College of Surgeons level 1 trauma center were studied from 2012 to 2017. Data were collected from Transition Systems, Inc. RESULTS: During 2012-2017, self-pay patient cases decreased from 15.0% to 4.1% and commercial insurance patients decreased from 34.2% to 27.6%. The percentage of Medicaid patients increased from 15.5% to 27.1%; however, Medicaid reimbursement average per case declined from $17,779 in 2012 to $10,115 in 2017 (a decline of 43.1%). Self-pay charges decreased from $22.0 million to $6.7 million. Total DSH funding, compensation given to hospitals that disproportionately treat underserved populations, decreased 17.4%. CONCLUSIONS: Self-pay charges and self-pay patients decreased dramatically; Medicaid patients and charges increased substantially in the years after the implementation of the Affordable Care Act at our trauma center. However, there was a decrease in commercial insurance, which had the highest reimbursement for our hospital, and a significant decline in DSH, a critical supplemental source of funding for safety-net hospitals.

Orbital roof fractures as an indicator for concomitant ocular injury.

BACKGROUND: Orbital roof fractures are a significant cause of morbidity in trauma and are associated with a spectrum of orbital and ocular injuries. This study aims to characterize orbital roof fracture patterns and quantify the rate of acute intervention as compared with non-roof involving orbital wall fractures. METHODS: This study is a retrospective analysis of 340 orbital wall fractures diagnosed by CT imaging from August 2015 to October 2016. Orbital wall fractures were categorized as roof involving (N = 50) and non-roof involving (N = 290). Comparisons were made between these two groups to indicate a statistically significant difference in mechanism of injury, subjective symptoms, CT and exam findings, and final plan of care to include acute ophthalmologic intervention at the time of consultation. RESULTS: Assault (40.7%) was the most common cause of non-roof-involving fractures while falls from height (20.0%) were associated with a higher rate of roof fractures. Roof-involving orbital wall fractures were associated with a higher prevalence of corneal abrasions (16.3%), lid lacerations (23.4%), and traumatic optic neuropathy (10.4%). A reliable subjective exam on initial ophthalmic consultation was not achieved in a larger proportion of roof fracture patients (30%). Despite this, the rate of acute intervention in this group (34%) was almost double, including lateral canthotomy and cantholysis. CONCLUSIONS: Concomitant ocular injury is common in roof-involving orbital wall fractures, and may require more urgent ophthalmologic evaluation and acute intervention. As subjective patient data is often less readily available, a high index of suspicion and thorough investigation is warranted in caring for patients with roof-involving orbital wall fractures.

Clinical characteristics and management of patients with fat embolism syndrome in level I Apex Trauma Centre.

PURPOSE: Fat embolism syndrome (FES) is systemic manifestation of fat emboli in the circulation seen mostly after long bone fractures. FES is considered a lethal complication of trauma. There are various case reports and series describing FES. Here we describe the clinical characteristics, management in ICU and outcome of these patients in level I trauma center in a span of 6 months. METHODS: In this prospective study, analysis of all the patients with FES admitted in our polytrauma intensive care unit (ICU) of level I trauma center over a period of 6 months (from August 2017 to January 2018) was done. Demographic data, clinical features, management in ICU and outcome were analyzed. RESULTS: We admitted 10 cases of FES. The mean age of patients was 31.2 years. The mean duration from time of injury to onset of symptoms was 56 h. All patients presented with hypoxemia and petechiae but central nervous system symptoms were present in 70% of patients. The mean duration of mechanical ventilation was 11.7 days and the mean length of ICU stay was 14.7 days. There was excellent recovery among patients with no neurological deficit. CONCLUSION: FES is considered a lethal complication of trauma but timely management can result in favorable outcome. FES can occur even after fixation of the fracture. Hypoxia is the most common and earliest feature of FES followed by CNS manifestations. Any patient presenting with such symptoms should raise the suspicion of FES and mandate early ICU referral.