Search

Few studies have investigated risk factors for recurrence of blunt traumatic abdominal wall hernias (TAWH).Twenty trauma centers identified repaired TAWH from January 2012 to December 2018. Logistic regression was used to investigate risk factors for recurrence.TAWH were repaired in 175 patients with 21 (12.0%) known recurrences. No difference was found in location, defect size, or median time to repair between the recurrence and non-recurrence groups. Mesh use was not protective of recurrence. Female sex, injury severity score (ISS), emergency laparotomy (EL), and bowel resection were associated with hernia recurrence. Bowel resection remained significant in a multivariable model.Female sex, ISS, EL, and bowel resection were identified as risk factors for hernia recurrence. Mesh use and time to repair were not associated with recurrence. Surgeons should be mindful of these risk factors but could attempt acute repair in the setting of appropriate physiologic parameters.

Introduction. Abdominal vascular injuries are rare and are associated with significant morbidity and mortality. Treatment options include nonoperative management, open repair, and endovascular procedures. This study aimed to characterize patients and detail treatment modalities among those who sustained a traumatic abdominal vascular injury. Methods. A 6-year descriptive retrospective study was conducted at an American College of Surgeons-verified level 1 trauma center and included all adult patients who sustained an abdominal vascular injury. Results. Most vascular injuries were to the iliac artery (27.9%), abdominal aorta (25.6%), and inferior vena cava (25.6%). Twenty-seven percent of patients sustained an injury to more than one vascular structure. Thirty-four percent of patients died before treatment of the abdominal vascular injury. Among the 28 patients (65.1%) treated for their vascular injuries, 46.4% were treated with open surgery, 32.1% were treated nonoperatively and 21.4% with coil embolization. The most common vascular injuries treated were lacerations (56%) and transections (21%). Sixty-four percent of the patients who survived to discharge presented for follow-up care with a mean follow-up period of 3 ± 4.1 months. There were no vascular reinterventions after discharge for patients who followed up with our hospital. Conclusions. Study findings suggests that appropriately selected cases of traumatic vascular injuries may be safely managed nonoperatively, as there were no mortalities, complications, or reinterventions among these patients.

Introduction. There is little data addressing rodeo injury outcomes, though injury incidence is well described. The purpose of this study was to describe rodeo-related injury patterns and outcomes. Methods. A 10-year retrospective case series was performed of patients injured in rodeo events and who were treated at an ACS-verified Level I trauma center. Data regarding demographics, injury characteristics and outcomes were summarized. Results. Seventy patients were identified. Half were injured by direct contact with rodeo stock, 34 by falls. Head injuries were most common, occurring in 38 (54.3%). Twenty injuries (28.6%) required surgery. Sixty-nine patients (98.6%) were discharged to home. There was 1 death. Conclusions. Head injuries were the most common injury among this cohort. With the exception of one fatality, immediate outcomes after injury were good, with 98.6% of patients dismissed home. Improved data collection at the time of admission may help to evaluate the success of current safety equipment use.

Introduction. New recommendations for emergency medical services spinal precautions limit long spinal board use to extrication purposes only and are to be removed immediately. Outcomes for spinal motion restriction versus spinal immobilization were studied. Methods. A retrospective chart review of trauma patients was conducted over a 6-month period at a level I trauma center. Injury severity details and neurologic assessments were collected on 277 patients. Results. Upon arrival, 25 (9.0%) patients had a spine board in place. Patients placed on spine boards were more likely to be moderately or severely injured (ISS>15: 36.0% vs. 9.9%, p = 0.001) and more likely to have neurological deficits documented by EMS (30.4% vs. 8.8%, p = 0.01) and the trauma team (29.2% vs. 10.9%, p = 0.02). Conclusions. This study suggests that the long spine board is being properly used for more critically injured patients. Further research is needed to compare neurological outcomes using a larger sample size and more consistent documentation.

BACKGROUND Trauma teams are often faced with patients on antithrombotic drugs, which is challenging when bleeding occurs. We sought to compare the effects of different antithrombotic medications on head injury severity and hypothesized that antithrombotic reversal would not improve mortality in severe TBI patients. METHODS An EAST-sponsored prospective, multi-centered, observational study of 15 trauma centers was performed. Patient demographics, injury burden, comorbidities, antithrombotic agents, and reversal attempts were collected. Outcomes of interest were head injury severity and in-hospital mortality. RESULTS Analysis was performed on 2793 patients. The majority of patients were on aspirin (ASA, 46.1%). Patients on a platelet chemoreceptor blocker (P2Y12) had the highest mean injury severity score (ISS, 9.1 ± 8.1). Patients taking P2Y12 inhibitors ± ASA, and ASA + warfarin had the highest head AIS mean (1.2 ± 1.6). On risk adjusted analysis, warfarin + ASA was associated with a higher head AIS (OR 2.43; 95% CI: 1.34-4.42) after controlling for injury severity score (ISS), Charlson Comorbidity Index (CCI), initial Glasgow Coma Score (I-GCS) and initial systolic blood pressure (I-SBP). Among patients with severe TBI (head AIS > 3) on antiplatelet therapy, reversal with desmopressin (DDAVP) and/or platelet transfusion did not improve survival (82.9% reversal vs 90.4% none, p = 0.30). In severe TBI patients taking Xa inhibitors who received prothrombin complex concentrate (PCC), survival was not improved (84.6% reversal vs 84.6% none, p = 0.68). With risk adjustment as described previously, mortality was not improved with reversal attempts (antiplatelet agents OR 0.83. 85% CI: 0.12-5.9, p = 0.85, Xa inhibitors OR 0.76, 95% CI: 0.12-4.64, p = 0.77). CONCLUSIONS Reversal attempts appear to confer no mortality benefit in severe TBI patients on antiplatelet agents or Xa inhibitors. Combination therapy was associated with severity of head injury among patients taking preinjury antithrombotic therapy, with ASA + warfarin possessing the greatest risk. LEVEL OF EVIDENCE Level II; prognostic. STUDY TYPE prospective observation.

BACKGROUND Despite the widespread institution of modern massive transfusion protocols with balanced blood product ratios, survival for patients with traumatic hemorrhage receiving ultramassive transfusion (UMT) (defined as ≥20 U of packed red blood cells [RBCs]) in 24 hours) remains low and resource consumption remains high. Therefore, we aimed to identify factors associated with mortality in trauma patients receiving UMT in the modern resuscitation era. METHODS An Eastern Association for the Surgery of Trauma multicenter retrospective study of 461 trauma patients from 17 trauma centers who received ≥20 U of RBCs in 24 hours was performed (2014-2019). Multivariable logistic regression and Classification and Regression Tree analysis were used to identify clinical characteristics associated with mortality. RESULTS The 461 patients were young (median age, 35 years), male (82%), severely injured (median Injury Severity Score, 33), in shock (median shock index, 1.2; base excess, -9), and transfused a median of 29 U of RBCs, 22 U of fresh frozen plasma (FFP), and 24 U of platelets (PLT). Mortality was 46% at 24 hours and 65% at discharge. Transfusion of RBC/FFP ≥1.5:1 or RBC/PLT ≥1.5:1 was significantly associated with mortality, most pronounced for the 18% of patients who received both RBC/PLT and RBC/FFP ≥1.5:1 (odds ratios, 3.11 and 2.81 for mortality at 24 hours and discharge; both p < 0.01). Classification and Regression Tree identified that age older than 50 years, low initial Glasgow Coma Scale, thrombocytopenia, and resuscitative thoracotomy were associated with low likelihood of survival (14-26%), while absence of these factors was associated with the highest survival (71%). CONCLUSION Despite modern massive transfusion protocols, one half of trauma patients receiving UMT are transfused with either RBC/FFP or RBC/PLT in unbalanced ratios ≥1.5:1, with increased associated mortality. Maintaining focus on balanced ratios during UMT is critical, and consideration of advanced age, poor initial mental status, thrombocytopenia, and resuscitative thoracotomy can aid in prognostication. LEVEL OF EVIDENCE Prognostic, level III.

BACKGROUND Blunt traumatic abdominal wall hernias (TAWH) occur in approximately 15,000 patients per year. Limited data are available to guide the timing of surgical intervention or the feasibility of nonoperative management. METHODS A retrospective study of patients presenting with blunt TAWH from January 2012 through December 2018 was conducted. Patient demographic, surgical, and outcomes data were collected from 20 institutions through the Western Trauma Association Multicenter Trials Committee. RESULTS Two hundred and eighty-one patients with TAWH were identified. One hundred and seventy-six (62.6%) patients underwent operative hernia repair, and 105 (37.4%) patients underwent nonoperative management. Of those undergoing surgical intervention, 157 (89.3%) were repaired during the index hospitalization, and 19 (10.7%) underwent delayed repair. Bowel injury was identified in 95 (33.8%) patients with the majority occurring with rectus and flank hernias (82.1%) as compared with lumbar hernias (15.8%). Overall hernia recurrence rate was 12.0% (n = 21). Nonoperative patients had a higher Injury Severity Score (24.4 vs. 19.4, p = 0.010), head Abbreviated Injury Scale score (1.1 vs. 0.6, p = 0.006), and mortality rate (11.4% vs. 4.0%, p = 0.031). Patients who underwent late repair had lower rates of primary fascial repair (46.4% vs. 77.1%, p = 0.012) and higher rates of mesh use (78.9% vs. 32.5%, p < 0.001). Recurrence rate was not statistically different between the late and early repair groups (15.8% vs. 11.5%, p = 0.869). CONCLUSION This report is the largest series and first multicenter study to investigate TAWHs. Bowel injury was identified in over 30% of TAWH cases indicating a significant need for immediate laparotomy. In other cases, operative management may be deferred in specific patients with other life-threatening injuries, or in stable patients with concern for bowel injury. Hernia recurrence was not different between the late and early repair groups. LEVEL OF EVIDENCE Therapeutic/care management, Level IV.

Introduction: Traumatic injuries are preventable and understanding determinants of injury, such as socio-economic and environmental factors, is vital. This study evaluated traumatic injuries and identified areas of high trauma incidence. Methods: A retrospective review was conducted of all patients 14 years or older who were admitted with a traumatic injury to a Level I trauma center between 2016 and 2017. Descriptive analyses were presented and maps of high injury areas were generated. Results: The most frequent mechanisms of injury were falls (58.3%), motor vehicle crashes (22.3%), and motorcycle crashes (5.7%). Fall patients were more likely to be female (59.6%) and were the oldest age group (72.1 ± 17.2) compared to motor vehicle and motorcycle crash patients. Severe head (22.1%, P = 0.007) and extremity (35.7%, P = 0.001) injuries were most frequent among fall patients, however more motorcycle crash patients required mechanical ventilation (16.1%, P < 0.001) and experienced the longest intensive care unit length of stay (5.3 ± 6.8, P < 0.001) and mechanical ventilation days (6.6 ± 8.5, P < 0.036). Motorcycle crash patients also had the most number of deaths (7.5%, P < 0.001). The generated maps of all traumatic suggest that most injuries occur near our hospital and are located in several of the most population-dense zip codes. Conclusions: Falls, motor vehicle crashes, and motorcycle crashes were the most common mechanisms of injury. The use of Geographic Information System aided in the identification of high injury incidence location.

The purpose of this study was to evaluate trends in agricultural mortality before and after implementation of safety initiatives. Retrospective review of Kansas mortality data from agriculture-related injuries from 1979 to 2018. The 39-year period was stratified into four periods to compare mechanisms of injury and fatality rates between study periods. There were 780 agricultural-related deaths. Mean age significantly increased between study Period I to Period IV from 46.4 to 55.3 years (

Introduction. Drowning is a major public health hazard worldwide, but associated traumatic injuries are rare. This study examined injuries and interventions performed on this population to assess the need for the trauma team activation. Methods. A 12-year retrospective review was conducted on all fatal and non-fatal drowning patients who underwent a trauma work-up. Data collection included demographics, injury characteristics, interventions, and outcomes. Results. Forty-three patients met inclusion criteria. Median patient age was six years (interquartile range 2 - 20) with 27.9% of patients under the age of 2 years. Most patients were white (62.8%) and male (69.8%), with median GCS score of 3 (60.5% had initial GCS = 3 with 25.6% with GCS = 15). Only two patients suffered traumatic injuries. Only two patients required operations, neither of which suffered traumatic injury. Eleven patients suffered anoxic brain injury (25.6%). Overall mortality was 48.8% (n = 21). Conclusion. Patients who present with drowning and no traumatic mechanism have a very low rate of traumatic injuries. Work-up and treatment would be appropriate for emergency physicians without the need for a trauma activation.

BACKGROUND The natural history of traumatic hemothorax (HTX) remains unclear. We aimed to describe outcomes of HTX following tube thoracostomy drainage and to delineate factors that predict progression to a retained hemothorax (RH). We hypothesized that initial large-volume HTX predicts the development of an RH. METHODS We conducted a prospective, observational, multi-institutional study of adult trauma patients diagnosed with an HTX identified on computed tomography (CT) scan with volumes calculated at time of diagnosis. All patients were managed with tube thoracostomy drainage within 24 hours of presentation. Retained hemothorax was defined as blood-density fluid identified on follow-up CT scan or need for additional intervention after initial tube thoracostomy placement for HTX. RESULTS A total of 369 patients who presented with an HTX initially managed with tube thoracostomy drainage were enrolled from 17 trauma centers. Retained hemothorax was identified in 106 patients (28.7%). Patients with RH had a larger median (interquartile range) HTX volume on initial CT compared with no RH (191 [48-431] mL vs. 88 [35-245] mL, p = 0.013) and were more likely to be older with a higher burden of thoracic injury. After controlling for significant differences between groups, RH was independently associated with a larger HTX on presentation, with a 15% increase in risk of RH for each additional 100 mL of HTX on initial CT imaging (odds ratio, 1.15; 95% confidence interval, 1.08-1.21; p < 0.001). Patients with an RH also had higher rates of pneumonia and longer hospital length of stay than those with successful initial management. Retained hemothorax was also associated with worse functional outcomes at discharge and first outpatient follow-up. CONCLUSION Larger initial HTX volumes are independently associated with RH, and unsuccessful initial management with tube thoracostomy is associated with worse patient outcomes. Future studies should use this experience to assess a range of options for reducing the risk of unsuccessful initial management. LEVEL OF EVIDENCE Therapeutic/care management study, level III.

Introduction. The purpose of this study was to identify additional injuries commonly seen with proximal humerus fractures experienced by patients 65 years or older and to evaluate discrepancies in the management of these patients with regard to provider type. Methods. A retrospective review was conducted of all patients 65 years or older who sustained a proximal humerus fracture. Patient data collected included demographics, injury details, hospital course, and discharge destination. Results. Patients with a concomitant fracture (45.5%, n = 65) had a slightly higher Injury Severity Score (ISS; 8.3 ± 3.0 vs. 6.4 ± 3.0, p < 0.001) and experienced one additional death than those with an isolated fracture (54.5%, n = 78). Slightly more patients were managed by a trauma provider (51.7%, n = 74) than by a non-trauma provider (48.3%, n = 69). Those managed by a trauma provider sustained the most pelvic fractures (12.2% vs. 2.9%, p = 0.038), were more likely to be injured in a motor vehicle collision (8.1% vs. 0%, p = 0.005), had a higher ISS (8.0 ± 3.3 vs. 6.4 ± 2.8, p = 0.003), and had more imaging performed than those treated by a non-trauma provider. There was, however, no difference in operative rates, concomitant injuries, length of stay or discharge disposition regarding provider type. Conclusions. It is important to recognize proximal humerus fractures as a sign of fragility and to optimize hospital management of these patients.

Background Retained rectal foreign bodies are a common but incompletely studied problem. This study defined the epidemiology, injury severity, and outcomes after rectal injuries following foreign body insertion. Methods Twenty-two level I trauma centers retrospectively identified all patients sustaining a rectal injury in this AAST multi-institutional trial (2005-2014). Only patients injured by foreign body insertion were included in this secondary analysis. Exclusion criteria were death before rectal injury management or ≤48 h of admission. Demographics, clinical data, and outcomes were collected. Study groups were defined as partial thickness (AAST grade I) versus full thickness (AAST grades II-V) injuries. Subgroup analysis was performed by management strategy (nonoperative versus operative). Results After exclusions, 33 patients were identified. Mean age was 41 y (range 18-57), and 85% (n = 28) were male. Eleven (33%) had full thickness injuries and 22 (67%) had partial thickness injuries, of which 14 (64%) were managed nonoperatively and 8 (36%) operatively (proximal diversion alone [n = 3, 14%]; direct repair with proximal diversion [n = 2, 9%]; laparotomy without rectal intervention [n = 2, 9%]; and direct repair alone [n = 1, 5%]). Subgroup analysis of outcomes after partial thickness injury demonstrated significantly shorter hospital length of stay (2 ± 1; 2 [1-5] versus 5 ± 2; 4 [2-8] d, P = 0.0001) after nonoperative versus operative management. Conclusions Although partial thickness rectal injuries do not require intervention, difficulty excluding full thickness injuries led some surgeons in this series to manage partial thickness injuries operatively. This was associated with significantly longer hospital length of stay. Therefore, we recommend nonoperative management after a retained rectal foreign body unless full thickness injury is conclusively identified.

Introduction. The practice of repeat head CT imaging in infants as a distinct population is poorly studied. The purpose of this study was to evaluate the incidence and utility of repeat head CT in the infant population. Methods. A 10-year retrospective review was conducted of infants with blunt traumatic head injuries (N = 50) that presented to a trauma center. Information from the hospital trauma registry and patient medical records were extracted regarding the size and type of injury, number and results of computed tomography (CT) imaging, changes in neurological exams, and any interventions that were required. Results. Most patients (68%) had at least one repeat CT, with 26% showing progression of hemorrhage. Decreased GCS was associated with having repeat CT scans. Nearly one in four infants had a change in management associated with repeat imaging. Repeat CT scans resulted in operative interventions in 11.8% of cases and longer ICU stays in 8.8% of cases. Repeat CT scans were associated with increased hospital length of stay, but not with increased ventilator days, ICU length of stay, or mortality. Worsening bleeds were associated with mortality, but not with other hospital outcomes. Conclusions. Changes in management following repeat CT appear to be more common in this population than in older children or adults. Findings from this study support repeat CT imaging in infants, however, further research is needed to validate results of this study.

Background This study aimed to describe patients admitted for attempted or completed suicide during the COVID-19 pandemic. Methods A 1-year retrospective review was performed of adult patients admitted for attempted or completed suicide. Results Of the 30 patients included, most injuries involved firearms (37%) and cutting/piercing (30%). Sixty-three percent of patients presented with an Injury Severity Score ≥16, and 37% of injuries involved the head. Upon admission, an alcohol test was completed for 83% of patients, 56% of whom tested positive. Thirty percent of patients died from their injuries, with all but one involving a firearm. Most of those who survived to discharge (62%) were discharged to an inpatient behavioral health facility. Discussion The current study indicated a large proportion of suicides during the COVID-19 pandemic involved firearms and alcohol use. These findings point to the need for interventions aimed at preventing suicide and substance abuse during pandemic situations.

Police transport (PT) of penetrating trauma patients in urban locations has become routine in certain metropolitan areas; however, whether it results in improved outcomes over prehospital Advanced life support (ALS) transport has not been determined in a multicenter study. We hypothesized that PT would not result in improved outcomes.This was a multicenter, prospective, observational study of adults (18+ years) with penetrating trauma to the torso and/or proximal extremity presenting at 25 urban trauma centers. Police transport and ALS patients were allocated via nearest neighbor, propensity matching. Transport mode also examined by Cox regression.Of 1,618 total patients, 294 (18.2%) had PT and 1,324 (81.8%) were by ALS. After matching, 588 (294/cohort) remained. The patients were primarily Black (n = 497, 84.5%), males (n = 525, 89.3%, injured by gunshot wound (n = 494, 84.0%) with 34.5% (n = 203) having Injury Severity Score of 16 or higher. Overall mortality by propensity matching was not different between cohorts (15.6% ALS vs. 15.0% PT, p = 0.82). In severely injured patients (Injury Severity Score ≥16), mortality did not differ between PT and ALS transport (38.8% vs. 36.0%, respectively; p = 0.68). Cox regression analysis controlled for relevant factors revealed no association with a mortality benefit in patients transported by ALS.Police transport of penetrating trauma patients in urban locations results in similar outcomes compared with ALS. Immediate transport to definitive trauma care should be emphasized in this patient population.Prognostic and Epidemiologic; Level III.

Tertiary surveys can help identify missed injuries, but how and when to conduct them remains uncertain. This study aimed to evaluate the outcomes of a policy requiring tertiary survey completion within 24 h post-admission.A retrospective review was performed with a pre-intervention time-period of 8/1/2019-1/31/2020, where tertiary surveys were performed prior to discharge (n = 762). During the post-intervention time-period of 8/1/2020-1/31/21 tertiary surveys were performed within 24 h of admission (n = 651).Missed injury (1.6% [n = 12] vs. 1.5% [n = 10]; p = 0.953) and mortality rates (3.1% vs. 3.7%, p = 0.579) were similar between the pre- and post-intervention groups. Tertiary survey completion rates were higher (86.8% vs. 80.2%; p = 0.001) and exams performed earlier (1[1-1] vs. 1 [1-2] day, p 0.001) in the post-intervention group. For those with missed injuries, time to injury identification and number of injuries identified on tertiary survey was unchanged.Requiring tertiary surveys within 24 h of admission can help identify and correct missed injuries, but standardization of the tertiary survey process and documentation may be as important as the timing.

Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a method of management of noncompressible torso hemorrhage in trauma patients. Increased utilization has shown increased vascular complications and mortality. This study aimed to evaluate complications of REBOA placement in a community trauma setting. Methods A 3-year retrospective review was performed of all trauma patients that underwent REBOA placement. Data collection included demographics, injury characteristics, complications, and mortality. Results Twenty-three patients were included, and the overall mortality was 65.2%. Most patients suffered blunt trauma (73.9%), and median ISS and TRISS (survival probability) were 24 and 42.2%, respectively. The median time to REBOA placement was 22 minutes, and hemorrhagic control was achieved in all patients. The most common complication was acute kidney injury at 34.8%. There was one complication associated with placement that required vascular intervention but did not lead to limb amputation. Conclusion Resuscitative endovascular balloon occlusion of the aorta was shown to have higher rates of acute kidney injury, similar rates of vascular injury, and lower rate of limb complications compared to published literature. Resuscitative endovascular balloon occlusion of the aorta remains a useful tool for trauma resuscitation without the fear of increased complications.

OBJECTIVE: Risk factors for mortality in patients with subdural hematoma (SDH) include poor Glasgow Coma Scale (GCS), pupil non-reactivity, and hemodynamic instability on presentation. Little is published regarding prognosticators of SDH in the elderly. This study aims to examine risk factors for hospital mortality and withdrawal of life-sustaining measures in an octogenarian population presenting with SDH. METHODS: A prospectively collected multi-center database of 3,279 TBI admissions to 45 different U.S. trauma centers between 2017–2019 was queried to identify patients >79 years old presenting with SDH. Factors collected included baseline demographic data, past medical history, antiplatelet/anticoagulant use, and clinical presentation (GCS, pupil reactivity, injury severity scale [ISS]). Primary outcome data included hospital mortality/discharge to hospice care and withdrawal of life-sustaining measures. Multivariate logistic regression analyses were used to identify factors independently associated with primary outcome variables. RESULTS: A total of 695 patients were isolated for analysis. Of the total cohort, the rate of hospital mortality or discharge to hospice care was 22% (n=150) and the rate of withdrawal of life-sustaining measures was 10% (n=66). A multivariate logistic regression model identified GCS 80 years with SDH. Pre-existing CHF may further predict withdrawal of life-sustaining measures.

Trauma teams are often faced with patients on antithrombotic (AT) drugs, which is challenging when bleeding occurs. We sought to compare the effects of different AT medications on head injury severity and hypothesized that AT reversal would not improve mortality in severe traumatic brain injury (TBI) patients.An Eastern Association for the Surgery of Trauma-sponsored prospective, multicentered, observational study of 15 trauma centers was performed. Patient demographics, injury burden, comorbidities, AT agents, and reversal attempts were collected. Outcomes of interest were head injury severity and in-hospital mortality.Analysis was performed on 2,793 patients. The majority of patients were on aspirin (acetylsalicylic acid [ASA], 46.1%). Patients on a platelet chemoreceptor blocker (P2Y12) had the highest mean Injury Severity Score (9.1 ± 8.1). Patients taking P2Y12 inhibitors ± ASA, and ASA-warfarin had the highest head Abbreviated Injury Scale (AIS) mean (1.2 ± 1.6). On risk-adjusted analysis, warfarin-ASA was associated with a higher head AIS (odds ratio [OR], 2.43; 95% confidence interval [CI], 1.34-4.42) after controlling for Injury Severity Score, Charlson Comorbidity Index, initial Glasgow Coma Scale score, and initial systolic blood pressure. Among patients with severe TBI (head AIS score, ≥3) on antiplatelet therapy, reversal with desmopressin (DDAVP) and/or platelet transfusion did not improve survival (82.9% reversal vs. 90.4% none, p = 0.30). In severe TBI patients taking Xa inhibitors who received prothrombin complex concentrate, survival was not improved (84.6% reversal vs. 84.6% none, p = 0.68). With risk adjustment as described previously, mortality was not improved with reversal attempts (antiplatelet agents: OR 0.83; 85% CI, 0.12-5.9 [p = 0.85]; Xa inhibitors: OR, 0.76; 95% CI, 0.12-4.64; p = 0.77).Reversal attempts appear to confer no mortality benefit in severe TBI patients on antiplatelet agents or Xa inhibitors. Combination therapy was associated with severity of head injury among patients taking preinjury AT therapy, with ASA-warfarin possessing the greatest risk.Prognostic, level II.

Introduction. This study examined the incidence of gunshot wounds before and after enacting a conceal carry (CC) law in a predominately rural state. Methods. A retrospective review was conducted of all patients who were admitted with a gunshot injury to a Level I trauma center. Patient data collected included demographics, injury details, hospital course, and discharge destination. Results. Among the 238 patients included, 44.6% (n = 107) were admitted during the pre-CC period and 55.4% (n = 131) in the post-CC period. No demographic differences were noted between the two periods except for an increase in uninsured patients from 43.0% vs 61.1% (p = 0.020). Compared to pre-CC patients, post-CC patients experienced a trend toward increased abdominal injury (11.2% vs 20.6%, p = 0.051) and increased vascular injuries (11.2% vs 22.1%, p = 0.026) while lower extremity injuries decreased significantly (38.3% vs 26.0%, p = 0.041). Positive focused assessment with sonography in trauma (FAST) exams (2.2% vs 16.8, p < 0.001), intensive care unit admission (26.2% vs 42.0%, p = 0.011) and need for ventilator support (11.2% vs 22.1%, p = 0.026) all increased during the post-CC period. In-hospital mortality more than doubled (8.4% vs 18.3%, p = 0.028) across the pre- and post-CC time periods. Conclusion. Implementation of a CC law was not associated with a decrease in the overall number of penetrating injuries or a decrease in mortality.

The purpose of this study was to determine if thromboelastography (TEG) is associated with reduced blood product utilization for trauma patients undergoing massive transfusion protocol (MTP) compared to traditional coagulation tests.A retrospective review was conducted on an intent-to-treat basis of trauma patients undergoing MTP (Pre-TEG = Period I vs. Post-TEG = Period II). Traditional coagulation tests guided transfusion during Period I (n = 20) and the intent was that TEG guided transfusions during Period II (n = 47). Blood product administration and outcomes were compared.Intent-to-treat analysis demonstrated a significant reduction in red blood cell transfusions (11 vs. 6 units, P = 0.001), number of patients receiving fresh frozen plasma (85.0 vs. 17.0%, P 0.001), and platelets (75.0 vs. 38.3%, P = 0.006) in Period II. No difference was seen between Periods I and II in ICU days (7.0 vs. 11.0 days, P = 0.073), hospital length of stay (10.5 vs. 14.0 days, P = 0.618), or mortality (55.0 vs. 31.9%, P = 0.076).Use of TEG-guided transfusion in the critically-ill trauma patient conserved blood product utilization and appears to offer similar outcomes when compared to traditional coagulation tests.

Introduction Laparotomy, embolization, and observation are described for blunt splenic injury management. This study evaluated outcomes of blunt splenic injury management based on baseline factors, splenic injury severity, and associated injuries. Methods A nine-year retrospective review was conducted of adult patients with blunt splenic injury. Collected data included demographics, injury characteristics, treatment modality, complications, and outcomes (mechanical ventilation, days on mechanical ventilation, intensive care unit [ICU] admission and length of stay, hospital length of stay, and in-hospital mortality). Categorical and continuous variables were analyzed using χ2 analysis and one-way analysis of variance for normally distributed variables and a non-parametric test of medians for variables that did not meet the assumption of normality, respectively. Results Splenic injury grade was similar between operative and embolization groups, but severe hemoperitoneum was more common in the operative group. Complications and mortality were highest in the operative group (50.7% and 26.3%, respectively) and lowest in the embolization group (5.3% and 2.6%, respectively). Operative patients required more advanced interventions (ICU admission, mechanical ventilation). There were no differences between those treated with proximal versus distal embolization. Observation carried a failure rate of 11.2%, with no failures of embolization. Conclusions Embolization patients had the lowest rates of complications and mortality, with comparable splenic injury grades to those treated operatively. Further prospective research is warranted to identify patients that may benefit from early embolization and avoidance of major abdominal surgery.

Survivors of near-hangings suffer anoxic brain injuries, but it remains uncertain whether the incidence of associated injuries warrants extensive workup or trauma activation. An 11-year retrospective review was conducted on adult patients with a hanging mechanism who underwent trauma workup and management. The majority of patients (n = 98) were white (88.8%) males (75.5%) with an average age of 30 ± 12.3 years. Two-hundred fifty-four CTand magnetic resonance scans were performed and eight injuries were uncovered: three thyroid cartilage/hyoid fractures; three vertebral injuries; and two cervical vascular injuries. Anoxic brain injury was diagnosed clinically in 35 patients (35.7%) and was present in all 19 patients (19.4%) who died. Only one patient had intra-abdominal injury requiring surgical intervention. Injuries were more likely in patients with abnormal Glasgow Coma Scale (GCS) versus normal GCS (55% vs 10.5%, respectively). Patients who present after near-hanging have a low incidence of associated injuries. Workup can be restricted to patients with abnormal GCS scores and for specific signs and symptoms or high-risk energy mechanisms. The trauma team can be activated for signs of trauma.

Background Critical access hospitals (CAH) serve a key role in providing medical care to rural patients. The purpose of this study was to assess effectiveness of CAHs in initial care of trauma patients. Methods A 5-year retrospective review was conducted of all adult trauma patients who were transported directly to a level I trauma facility or were transported to a CAH then transferred to a level I trauma facility after initial resuscitation. Results Of 1478 patients studied, 1084 were transferred from a CAH with 394 transported directly to the level I facility. Patients transported directly to the level I hospital were younger and more severely injured. After controlling for injury severity score, age, GCS, and shock, the odds of mortality did not differ between CAH transfer patients and patients transported directly to a level I facility (OR 0.70, P = 0.20). Transfer from CAH was associated with decreased ICU and hospital days, but not associated with increased ventilator days. Conclusion This study demonstrates that use of a CAH for initial trauma care in rural areas is effective.

Introduction. Motor vehicle collision (MVC) is the second most common mechanism of injury among octogenarians and is on the rise. These “oldest old” trauma patients have much higher mortality rates than expected. This study examined potential factors influencing this increased mortality including comorbidities, medications, injury patterns, and hospital interventions. Methods. A 10-year retrospective review was conducted of patients aged 80 and over who were injured in a MVC. Data collected included patient demographics, comorbidities, medication use prior to injury, collision details, injury severity and patterns, hospitalization details, outcomes, and discharge disposition. Results. We identified 239 octogenarian patients involved in a MVC. Overall mortality was 18.8%. We recognized an increased mortality for specific injury patterns, patients injured in a rural setting, and those who were transfused, intubated, or admitted to the ICU. We found no correlation between mortality and medications or comorbidities. Conclusions. The high mortality rate for octogenarian patients involved in a MVC is related to injury severity, type of injury, and in-hospital complications, and not due to comorbidities and prior medications.

Author(s): Taghavi, Sharven; Maher, Zoe; Goldberg, Amy J; Chang, Grace; Mendiola, Michelle; Anderson, Christofer; Ninokawa, Scott; Tatebe, Leah C; Maluso, Patrick; Raza, Shariq; Keating, Jane J; Burruss, Sigrid; Reeves, Matthew; Coleman, Lauren E; Shatz, David V; Goldenberg-Sandau, Anna; Bhupathi, Apoorva; Spalding, M Chance; LaRiccia, Aimee; Bird, Emily; Noorbakhsh, Matthew R; Babowice, James; Nelson, Marsha C; Jacobson, Lewis E; Williams, Jamie; Vella, Michael; Dellonte, Kate; Hayward, Thomas Z; Holler, Emma; Lieser, Mark J; Berne, John D; Mederos, Dalier R; Askari, Reza; Okafor, Barbara U; Haut, Elliott R; Etchill, Eric W; Fang, Raymond; Roche, Samantha L; Whittenburg, Laura; Bernard, Andrew C; Haan, James M; Lightwine, Kelly L; Norwood, Scott H; Murry, Jason; Gamber, Mark A; Carrick, Matthew M; Bugaev, Nikolay; Tatar, Antony; Duchesne, Juan; Tatum, Danielle | Abstract: BackgroundPrehospital procedures (PHP) by emergency medical services (EMS) are performed regularly in penetrating trauma patients despite previous studies demonstrating no benefit. We sought to examine the influence of PHPs on outcomes in penetrating trauma patients in urban locations where transport to trauma center is not prolonged. We hypothesized that patients without PHPs would have better outcomes than those undergoing PHP.MethodsThis was an Eastern Association for the Surgery of Trauma-sponsored, multicenter, prospective, observational trial of adults (18+ years) with penetrating trauma to the torso and/or proximal extremity presenting at 25 urban trauma centers. The impact of PHPs and transport mechanism on in-hospital mortality were examined.ResultsOf 2,284 patients included, 1,386 (60.7%) underwent PHP. The patients were primarily Black (n = 1,527, 66.9%) males (n = 1,986, 87.5%) injured by gunshot wound (n = 1,510, 66.0%) with 34.1% (n = 726) having New Injury Severity Score of ≥16. A total of 1,427 patients (62.5%) were transported by Advanced Life Support EMS, 17.2% (n = 392) by private vehicle, 13.7% (n = 312) by police, and 6.7% (n = 153) by Basic Life Support EMS. Of the PHP patients, 69.1% received PHP on scene, 59.9% received PHP in route, and 29.0% received PHP both on scene and in route. Initial scene vitals differed between groups, but initial emergency department vitals did not. Receipt of ≥1 PHP increased mortality odds (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.01-1.83; p = 0.04). Logistic regression showed increased mortality with each PHP, whether on scene or during transport. Subset analysis of specific PHP revealed that intubation (OR, 10.76; 95% CI, 4.02-28.78; p l 0.001), C-spine immobilization (OR, 5.80; 95% CI, 1.85-18.26; p l 0.01), and pleural decompression (OR, 3.70; 95% CI, 1.33-10.28; p = 0.01) had the highest odds of mortality after adjusting for multiple variables.ConclusionPrehospital procedures in penetrating trauma patients impart no survival advantage and may be harmful in urban settings, even when performed during transport. Therefore, PHP should be forgone in lieu of immediate transport to improve patient outcomes.Level of evidencePrognostic, level III.

Introduction: Little is known surrounding the demographic and geospatial factors of firearm-related traumas in the Midwest Region. The purpose of this study was to describe the overall incidence of firearm-related traumas and examine any racial/ethnic disparities that may exist. Methods: A retrospective review was conducted of all patients 14 years or older who were admitted with a gunshot wound (GSW) to a Level I trauma center between 2016 and 2017. Results: Forty-nine percent of patients were Caucasian, 26.5% African American, and 19.6% Hispanic/Latino. Hispanic/Latino patients were the youngest (25.8 ± 8.8) and Caucasians were the oldest (34.3 ± 14.1, P = 0.002). Compared to Caucasian patients, African American (42.0%) and Hispanic/Latino (54.1%) patients were more likely to be admitted to the intensive care unit (ICU) (P = 0.034) and experienced longer ICU lengths of stay (2.5 ± 6.3 and 2.4 ± 4.7, P = 0.031, respectively). African American patients (96.0%) experienced more assaults while Caucasians were more likely to receive gunshot wounds accidentally (26.9%, P = 0.001). More African American (86.0%) and Hispanic/Latino (89.2%) patients were injured with a handgun and Caucasians sustained the highest number of shotgun/rifle related injuries (16.1%, P = 0.012). Most GSWs occurred in zip codes 67202, 67203, 67213, 67211, and 67214. Geographical maps indicated that GSWs were concentrated in low-income areas and areas with high minority populations. Conclusions: Racial differences were noted, however, unlike national trends, most of our patients were older Caucasian males.

Drug-specific agents for the reversal of direct oral anticoagulants (DOACs) were recently approved. We hypothesized that the approval of these reversal agents would lead improved outcomes for trauma patients taking DOACs.A multicenter, prospective (2015-2018), observational study of all adult trauma patients taking DOACs who were admitted to one of fifteen participating trauma centers was performed. The primary outcome was mortality.For 606 trauma patients on DOACs, those reversed were older (78 vs. 74, p = 0.007), more severely injured (ISS: 16 vs. 5, p 0.0001), had more severe head injuries (Head AIS: 2.9 vs. 1.3, p 0.0001), and higher mortality (11% vs. 3%, p = 0.001). Patients who received drug-specific agents (idarucizumab, andexanet alfa) had higher mortality (30% vs. 8%, p = 0.04) than those reversed with factor concentrates. However, the low usage of drug-specific reversal agents limits our ability to assess their efficacy and safety.DOAC reversal was not independently associated with mortality. At present, the overall usage of drug-specific reversal agents is too sparing to meaningfully assess outcomes in trauma.

Introduction. Computed tomography scans often are repeated ontrauma patient transfers, leading to increased radiation exposure,resource utilization, and costs. This study examined the incidenceof repeated computed tomography scans (RCT) in trauma patienttransfers before and after software upgrades, physician education,and encouragement to reduce RCT.Methods.xThe number of RCTs at an American College of SurgeonsCommittee on Trauma verified level 1 trauma center was measured.The trauma team was educated and encouraged to use the computedtomography scans received with transfer trauma patients as perstudy protocol. All available images were reviewed and reasons for aRCT when ordered were recorded and categorized. Impact of systemimprovements and education on subsequent RCT were evaluated.Results. A RCT was done on 47.2% (n = 76) of patients throughoutthe study period. Unacceptable image quality and possible misseddiagnoses were the most commonly reported reasons for a RCT. Preventablereasons for a RCT (attending refusal to read outside films,incompatible software, and physician preference) decreased from25.8 to 14.3% over the study periods.Conclusions. The volume of unnecessary RCT can be reduced primarilythrough software updates and physician education, therebydecreasing radiation exposure, patient cost, and inefficiencies in hospitalresource usage. Kans J Med 2019;12(1):7-10.

Introduction Traumatic injuries are preventable and understanding determinants of injury, such as socio-economic and environmental factors, is vital. This study evaluated traumatic injuries and identified areas of high trauma incidence. Methods A retrospective review was conducted of all patients 14 years or older who were admitted with a traumatic injury to a Level I trauma center between 2016 and 2017. Descriptive analyses were presented and maps of high injury areas were generated. Results The most frequent mechanisms of injury were falls (58.3%), motor vehicle crashes (22.3%), and motorcycle crashes (5.7%). Fall patients were more likely to be female (59.6%) and were the oldest age group (72.1 ± 17.2) compared to motor vehicle and motorcycle crash patients. Severe head (22.1%, p = 0.007) and extremity (35.7%, p = 0.001) injuries were most frequent among fall patients, however, more motorcycle crash patients required mechanical ventilation (16.1%, p < 0.001) and experienced the longest intensive care unit length of stay (5.3 ± 6.8 days, p < 0.001) and mechanical ventilation days (6.6 ± 8.5, p < 0.036). Motorcycle crash patients also had the greatest number of deaths (7.5%, p < 0.001). The generated maps of all traumas suggested that most injuries occur near our hospital and are located in several of the most population-dense zip codes. Conclusion Patient demographics, injury severity, and hospital outcomes varied by mechanisms of injury. Traumatic injuries occurred near our hospital and were located in several of the most populationdense zip codes. Injury prevention efforts should target high incident areas.

Introduction. Few data currently exist which are focused on typeand severity of onshore oil extraction-related injuries. The purposeof this study was to evaluate injury patterns among onshore oil fieldoperations. Methods. A retrospective review was conducted of all traumapatients aged 18 and older with an onshore oil field-related injuryadmitted to an American College of Surgeons-verified level 1 traumacenter between January 1, 2003 and June 30, 2012. Data collectedincluded demographics, injury severity and details, hospital outcomes,and disposition. Results. A total of 66 patients met inclusion criteria. All patientswere male, of which the majority were Caucasian (81.8%, n = 54)with an average age of 36.5 ± 11.8 years, injury severity score of 9.4 ±8.9, and Glasgow Coma Scale score of 13.8 ± 3.4. Extremity injurieswere the most common (43.9%, n = 29), and most were the resultof being struck by an object (40.9%, n = 27). Approximately onethirdof patients (34.8%, n = 23) were admitted to the intensive careunit. Nine patients (13.6%) required mechanical ventilation while27 (40.9%) underwent operative treatment. The average hospitallength of stay was 5.8 ± 16.6 days, and most patients (78.8%, n = 52)were discharged home. Four patients suffered permanent disabilities,and there were two deaths. Conclusions. Increased domestic onshore oil production inevitablywill result in higher numbers of oil field-related traumas. By focusingon employees who are at the greatest risk for injuries and by targetingthe main causes of injuries, training programs can lead to a decreasein injury incidence. Kans J Med 2018;11(2):34-37.

Introduction. This study compared outcomes between patientsinjured at a motorbike track, which requires riders to follow safetyequipment guidelines, and those involved in recreational riding wheresafety equipment usage is voluntary. Methods. A retrospective review was conducted of all patients presentingwith motorbike-related injuries at an American College ofSurgeons verified level-I trauma center between January 1, 2009 andDecember 31, 2013. Data collected included demographics, injurydetails, safety equipment use, hospitalization details, and dischargedisposition. Comparisons were made regarding protective equipmentusage. Results. Among the 115 patients admitted, more than half (54.8%, n =63) were injured on a motorbike track, and 45.2% (n = 52) were injuredin a recreational setting. The majority of patients were male (93.9%),Caucasian (97.4%), and between the ages of 18 to 54 (64.4%). Helmetusage was higher among track riders (95.2%, n = 60) than recreationalriders (46.2%, n = 24, p < 0.0001). Comparisons of injury severity andoutcomes between those who wore protective equipment and thosewho did not were not significant. Conclusions. Even though track riders wore protective equipmentmore than recreational riders, there was no difference between thegroups regarding injury severity or hospital outcomes. These resultssuggested that motocross riders should not rely on protective equipmentas the only measure of injury prevention.Kans J Med 2018;11(2):44-47.

Introduction. Agriculture is an industry where family members oftenlive and work on the same premises. This study evaluated injury patternsand outcomes in children from farm-related accidents. Methods. A 10-year retrospective review of farm-accident relatedinjuries was conducted of patients 17 years and younger. Data collectedincluded demographics, injury mechanism, accident details, injuryseverity and patterns, treatments required, hospitalization details, anddischarge disposition. Results. Sixty-five patients were included; 58.5% were male and themean age was 9.7 years. Median Injury Severity Score and GlasgowComa Scale were 5 and 15, respectively. Accident mechanisms includedanimal-related (43.1%), fall (21.5%), and motor vehicle (21.5%).Soft tissue injuries, concussions and upper extremity fractures werethe most common injuries observed (58.5%, 29.2%, and 26.2%,respectively). Twenty-six patients (40%) required surgical intervention.Mean hospital length of stay was 3.4 ± 4.7 days. The majority ofpatients were discharged to home (n = 62, 95.4%) and two patientssuffered permanent disability. Conclusion. Overall, outcomes for this population were favorable,but additional measures to increase safety, such as fall prevention,animal handling, and driver safety training should be advocated.KS J Med 2017;10(4):92-95.

Introduction. Recent studies have provided guidelines on the use ofhead computed tomography (CT) scans in pediatric trauma patients.The purpose of this study was to identify the prevalence of theseguidelines among concussed pediatric patients. Methods. A retrospective review was conducted of patients fouryears or younger with a concussion from blunt trauma. Demographics,head injury characteristics, clinical indicators for head CT scan(severe mechanism, physical exam findings of basilar skull fracture,non-frontal scalp hematoma, Glasgow Coma Scale score, loss ofconsciousness, neurologic deficit, altered mental status, vomiting,headache, amnesia, irritability, behavioral changes, seizures, lethargy),CT results, and hospital course were collected. Results. One-hundred thirty-three patients (78.2%) received a headCT scan, 7 (5.3%) of which demonstrated fractures and/or bleeds. Allpatients with skull fractures and/or bleeds had at least one clinicalindicator present on arrival. Clinical indicators that were observedmore commonly in patients with positive CT findings than in thosewith negative CT findings included severe mechanism (100% vs.54.8%, respectively, p = 0.020) and signs of a basilar skull fracture(28.6% vs. 0.8%, respectively, p = 0.007). Severe mechanism alonewas found to be sensitive, but not specific, whereas signs of a basilarskull fracture, headache, behavioral changes, and vomiting were specific,but not sensitive. No neurosurgical procedures were necessary,and there were no deaths. Conclusions. Clinical indicators were present in patients with positiveand negative CT findings. However, severe mechanism of injuryand signs of basilar skull fracture were more common for patients withpositive CT findings. Kans J Med 2018;11(2):38-43.

Introduction. Currently, no national standard exists for educatingmedical students regarding radiography or formal research indicatingthe level of improvement regarding computed tomography(CT) interpretation of medical students during clinical rotations. Methods. Students were evaluated based on their response totwenty-two open-ended questions regarding diagnosis and treatmentof eleven de-identified CT images of life-threatening injuries.The number of incorrect answers was compared withcorrect or partially correct answers between students startingthird-year clinical rotations and those starting their fourth year. Results. Survey results were collected from 65 of 65 (100%) beginningthird-year students and 9 of 60 (15%) beginning fourthyearstudents. Students in their fourth-year had less incorrectanswers compared to third-year students, with five questionsreflecting a statistically significant reduction in incorrect responses.The image with the least incorrect for both groups wasepidural hemorrhage, 33.9% and 18.5% incorrect for third-yearstudents for diagnosis and treatment, respectively, and 11.1%and 0% incorrect for fourth-year students. Outside of this image,the range of incorrect answers for third-year students was75.4% to 100% and 44.4% to 100% for fourth-year students. Conclusion. Baseline CT knowledge of medical students,regardless of clinical experience, indicated a strong deficit,as more students were incorrect than correct for themajority of CT images. KS J Med 2017;10(3):55-58.

Background Research has shown improvements in patient care and outcomes with addition of a rounding geriatrician. The purpose of this study was to determine if addition of a hospitalist consultation improved patient outcomes. Methods A retrospective review was conducted of all trauma patients, ≥65 years, before (n=481) and after (n=430) addition of a hospitalist consultant. Data included were demographics, comorbidities, injury severity, blood pressure, laboratory levels, pain control methods, ICU and ventilator requirements, complications, hospital length of stay, mortality, preexisting wishes, and 30-day readmission. Results Adding a hospitalist consultation did not improve blood glucose or blood pressure control. It decreased narcotics-only use (36.0% vs 73.8%) while increasing multimodal pain control use (51.8% vs 14.8%, PConclusions This article does not support use of routine hospitalist consultation in the geriatric trauma population. However, with study limitations, we continue to evaluate hospitalist utility and will adjust our daily rounds to more closely match prior studies.

Screening for blunt cerebrovascular injuries (BCVIs) in asymptomatic high-risk patients has become routine. To date, the length of this asymptomatic period has not been defined. Determining the time to stroke could impact therapy including earlier initiation of antithrombotics in multiply injured patients. The purpose of this study was to determine the time to stroke in patients with a BCVI-related stroke. We hypothesized that the majority of patients suffer stroke between 24 hours and 72 hours after injury.Patients with a BCVI-related stroke from January 2007 to January 2017 from 37 trauma centers were reviewed.During the 10-year study, 492 patients had a BCVI-related stroke; the majority were men (61%), with a median age of 39 years and ISS of 29. Stroke was present at admission in 182 patients (37%) and occurred during an Interventional Radiology procedure in six patients. In the remaining 304 patients, stroke was identified a median of 48 hours after admission: 53 hours in the 144 patients identified by neurologic symptoms and 42 hours in the 160 patients without a neurologic examination and an incidental stroke identified on imaging. Of those patients with neurologic symptoms, 88 (61%) had a stroke within 72 hours, whereas 56 had a stroke after 72 hours; there was a sequential decline in stroke occurrence over the first week. Of the 304 patients who had a stroke after admission, 64 patients (22%) were being treated with antithrombotics when the stroke occurred.The majority of patients suffer BCVI-related stroke in the first 72 hours after injury. Time to stroke can help inform clinicians about initiation of treatment in the multiply injured patient.Prognostic/Epidemiologic, level III.

Introduction. Exposure to radiologic images during clinical rotationsmay improve students’ skill levels. This study aimed to quantifythe improvement in radiographic interpretation of life-threateningtraumatic injuries gained during third year clinical clerkships (MS-3). Methods. We used a paired-sample prospective study design tocompare students’ accuracy in reading computed tomography (CT)images at the beginning of their third year clerkships (Phase I) andagain after completion of all of their third year clerkships (Phase II).Students were shown life-threatening injuries that included head,chest, abdomen, and pelvic injuries. Overall scores for Phase II werecompared with Phase I, as well as sub-scores for each anatomicalregion: head, chest, abdomen, and pelvis. Results. Only scores from students participating in both Phase Iand Phase II (N = 57) were used in the analysis. After completingtheir MS3 clerkship, students scored significantly better overall andin every anatomical region. Phase I and Phase II overall mean scoreswere 1.2 ± 1.1 vs. 4.6 ± 1.8 (p < 0.001). Students improved the mostwith respect to injuries of the head and chest and the area of leastimprovement was in interpreting CT scans of the abdomen. Althoughimprovements in reading radiographic images were noted after theclerkship year, students accurately diagnosed only 46% of life-threateningimages on CT scan in the trauma setting. Conclusions. These results indicated that enhanced education isneeded for medical students to interpret CT scans.Kans J Med 2018;11(4):91-94.

Agricultural work results in numerous injuries and deaths. Efficacy of farm equipment safety interventions remains unclear. This study evaluated agricultural mortality pre- and post-implementation of safety initiatives. A 31-year retrospective review of mortality data from agriculture-related injuries was conducted. Demographics and injury patterns were evaluated by mechanism of injury. There were 660 deaths (mean age 48.6 years). Female deaths increased from 5.2 to 11.7 per cent ( P = 0.032). Mortality associated with tractors decreased (75.6% vs 53.9%; P < 0.001) and with all-terrain vehicles increased (3.5% vs 22.0%; P < 0.001) from Period I to III. However, tractors remain the primary cause of mortality. For mechanical equipment–associated mortality, there was a decrease (83.3% vs 50.0%) in “caught in equipment,” and an increase (6.7% vs 38.9%) in those killed by “crush injury” from Period I to III. Application of safety devices to enclose and stabilize machinery has led to an overall decrease in mortality associated with tractors and “caught in equipment.” Expanded rural education, as well as further development and use of safety devices, is warranted to curtail farm-related injuries and deaths.

The effects of methamphetamines (MAs) on trauma patient outcomes have been evaluated, but with discordant results. The purpose of this study was to identify hospital outcomes associated with MA use after traumatic injury. Retrospective review of adult trauma patients admitted to an American College of Surgeons verified–Level I trauma center who received a urine drug screen (UDS) between January 1, 2004 and December 31, 2013. Logistic regression analysis was used to identify factors associated with mortality. Patients with a negative UDS were used as controls. Among the 2321 patients included, 75.1 per cent were male, 81.9 per cent were white, and the average age was 39. Patients were grouped by UDS results (negative, MA only, other drug plus MA, or other drug without MA). A positive drug screen result of other drug without MA demonstrated a significantly lower risk for mortality, but longer intensive care unit and hospital length of stay, as well as increased ventilator days than negative results. Results of MA only did not alter the risk of mortality. These findings suggest that patients who test positive for MAs are not at an increased risk of in-hospital mortality when compared with patients having a negative drug screen.

Most emergency medical service personnel rely on one of two techniques to extricate motor vehicle crash victims; the Rapid Extrication Maneuver (REM) or the Kendrick Extrication Device (KED). The purpose of this study was to compare pre- and postextrication neurological outcomes between these two techniques. A retrospective review was conducted of all adult patients with a vertebral column injury resulting from motor vehicle collision and admitted to a Level I trauma center between January 1, 2003 and December 31, 2010. Standardized pre- and postextrication neurological examinations were reviewed for all patients. More than half of patients (N = 81) were extricated using the KED (53.1%, n = 43) and 46.9 per cent (n = 38) were extricated with the REM. Except for the thoracic Abbreviated Injury Score, no differences between groups emerged related to the Glasgow Coma Scale score, Injury Severity Score or Abbreviated Injury Score. There were no pre- and postextrication changes for motor to all extremities and sensation to all extremities using either method. The results of this study suggest that the REM and the KED are equivalent in protecting the patient from neurologic injury after motor vehicle collision.

Introduction Rectal injuries have been historically treated with a combination of modalities including direct repair, resection, proximal diversion, presacral drainage, and distal rectal washout. We hypothesized that intraperitoneal rectal injuries may be selectively managed without diversion and the addition of distal rectal washout and presacral drainage in the management of extraperitoneal injuries are not beneficial. Methods This is an American Association for the Surgery of Trauma multi-institutional retrospective study from 2004 to 2015 of all patients who sustained a traumatic rectal injury and were admitted to one of the 22 participating centers. Demographics, mechanism, location and grade of injury, and management of rectal injury were collected. The primary outcome was abdominal complications (abdominal abscess, pelvic abscess, and fascial dehiscence). Results After exclusions, there were 785 patients in the cohort. Rectal injuries were intraperitoneal in 32%, extraperitoneal in 58%, both in 9%, and not documented in 1%. Rectal injury severity included the following grades I, 28%; II, 41%; III, 13%; IV, 12%; and V, 5%. Patients with intraperitoneal injury managed with a proximal diversion developed more abdominal complications (22% vs 10%, p = 0.003). Among patients with extraperitoneal injuries, there were more abdominal complications in patients who received proximal diversion (p = 0.0002), presacral drain (p = 0.004), or distal rectal washout (p = 0.002). After multivariate analysis, distal rectal washout [3.4 (1.4-8.5), p = 0.008] and presacral drain [2.6 (1.1-6.1), p = 0.02] were independent risk factors to develop abdominal complications. Conclusion Most patients with intraperitoneal injuries undergo direct repair or resection as well as diversion, although diversion is not associated with improved outcomes. While 20% of patients with extraperitoneal injuries still receive a presacral drain and/or distal rectal washout, these additional maneuvers are independently associated with a three-fold increase in abdominal complications and should not be included in the treatment of extraperitoneal rectal injuries. Level of evidence Therapeutic study, level III.

Background The specific contribution of dementia towards mortality in trauma patients is not well defined. The purpose of the study was to evaluate dementia as a predictor of mortality in trauma patients when compared to case-matched controls. Methods A 5-year retrospective review was conducted of adult trauma patients with a diagnosis of dementia at an American College of Surgeons-verified level I trauma center. Patients with dementia were matched with non-dementia patients and compared on mortality, ICU length of stay, and hospital length of stay. Results A total of 195 patients with dementia were matched to non-dementia controls. Comorbidities and complications (11.8% vs 12.4%) were comparable between both groups. Dementia patients spent fewer days on the ventilator (1 vs 4.5, P = 0.031). The length of ICU stay (2 days), hospital length of stay (3 days), and mortality (5.1%) were the same for both groups (P > 0.05). Conclusions Dementia does not appear to increase the risk of mortality in trauma patients. Further studies should examine post-discharge outcomes in dementia patients.

Subclavian and axillary artery injuries are uncommon. In addition to many open vascular repairs, endovascular techniques are used for definitive repair or vascular control of these anatomically challenging injuries. The aim of this study was to determine the relative roles of endovascular and open techniques in the management of subclavian and axillary artery injuries comparing hospital outcomes, and long-term limb viability.A multicenter, retrospective review of patients with subclavian or axillary artery injuries from January 1, 2004, to December 31, 2014, was completed at 11 participating Western Trauma Association institutions. Statistical analysis included χ, t-tests, and Cochran-Armitage trend tests. A p value less than 0.05 was significant.Two hundred twenty-three patients were included; mean age was 36 years, 84% were men. An increase in computed tomography angiography and decrease in conventional angiography was observed over time (p = 0.018). There were 120 subclavian and 119 axillary artery injuries. Procedure type was associated with injury grade (p0.001). Open operations were performed in 135 (61%) patients, including 93% of greater than 50% circumference lacerations and 83% of vessel transections. Endovascular repairs were performed in 38 (17%) patients; most frequently for pseudoaneurysms. Fourteen (6%) patients underwent a hybrid procedure. Use of endovascular versus open procedures did not increase over the duration of the study (p = 0.248). In-hospital mortality rate was 10%. Graft or stent thrombosis occurred in 7% and graft or stent infection occurred in 3% of patients. Mean follow-up was 1.6 ± 2.4 years (n = 150). Limb salvage was achieved in 216 (97%) patients.The management of subclavian and axillary artery injuries still requires a wide variety of open exposures and procedures, especially for the control of active hemorrhage from more than 50% vessel lacerations and transections. Endovascular repairs were used most often for pseudoaneurysms. Low early complication rates and limb salvage rates of 97% were observed after open and endovascular repairs.Prognostic/epidemiologic, level IV.

Background Recent literature suggests the majority of traumatic intracranial hemorrhage does not require intervention. One recently described clinical decision rule was sensitive in identifying patients requiring critical care interventions in an urban setting. We sought to validate its effectiveness in our predominately rural setting. Methods A retrospective study was conducted of adult patients with traumatic intracranial hemorrhage. The rule, based on age, initial Glasgow coma scale score, and presence of a non-isolated head injury, was applied to externally validate the previously reported findings. Results In our population, the rule displayed a sensitivity of 0.923, specificity of 0.251, positive predictive value of 0.393, and negative predictive value of 0.862. The area under curve was 0.587. While our population has a similar adjusted head injury severity score as that from which the rule was developed, significant differences in age and intracranial hemorrhage pattern were noted. Conclusions The rule displayed decreased performance in our population, most likely secondary to differences in age and intracranial hemorrhage patterns. Prospective evaluation and cost-savings analysis are appropriate subsequent steps for the rule.

Introduction This study examined the incidence of gunshot wounds before and after enacting a conceal carry (CC) law in a predominately rural state. Methods A retrospective review was conducted of all patients who were admitted with a gunshot injury to a Level I trauma center. Patient data collected included demographics, injury details, hospital course, and discharge destination. Results Among the 238 patients included, 44.6% (n = 107) were admitted during the pre-CC period and 55.4% (n = 131) in the post-CC period. No demographic differences were noted between the two periods except for an increase in uninsured patients from 43.0% vs 61.1% (p = 0.020). Compared to pre-CC patients, post-CC patients experienced a trend toward increased abdominal injury (11.2% vs 20.6%, p = 0.051) and increased vascular injuries (11.2% vs 22.1%, p = 0.026) while lower extremity injuries decreased significantly (38.3% vs 26.0%, p = 0.041). Positive focused assessment with sonography in trauma (FAST) exams (2.2% vs 16.8, p < 0.001), intensive care unit admission (26.2% vs 42.0%, p = 0.011) and need for ventilator support (11.2% vs 22.1%, p = 0.026) all increased during the post-CC period. In-hospital mortality more than doubled (8.4% vs 18.3%, p = 0.028) across the pre- and post-CC time periods. Conclusion Implementation of a CC law was not associated with a decrease in the overall number of penetrating injuries or a decrease in mortality.

Survivors of near-hangings suffer anoxic brain injuries, but it remains uncertain whether the incidence of associated injuries warrants extensive workup or trauma activation. An 11-year retrospective review was conducted on adult patients with a hanging mechanism who underwent trauma workup and management. The majority of patients (n = 98) were white (88.8%) males (75.5%) with an average age of 30 ± 12.3 years. Two-hundred fifty-four CT and magnetic resonance scans were performed and eight injuries were uncovered: three thyroid cartilage/hyoid fractures; three vertebral injuries; and two cervical vascular injuries. Anoxic brain injury was diagnosed clinically in 35 patients (35.7%) and was present in all 19 patients (19.4%) who died. Only one patient had intra-abdominal injury requiring surgical intervention. Injuries were more likely in patients with abnormal Glasgow Coma Scale (GCS)

BACKGROUND Historically, hemorrhage has been attributed as the leading cause (40%) of early death. However, a rigorous, real-time classification of the cause of death (COD) has not been performed. This study sought to prospectively adjudicate and classify COD to determine the epidemiology of trauma mortality. METHODS Eighteen trauma centers prospectively enrolled all adult trauma patients at the time of death during December 2015 to August 2017. Immediately following death, attending providers adjudicated the primary and contributing secondary COD using standardized definitions. Data were confirmed by autopsies, if performed. RESULTS One thousand five hundred thirty-six patients were enrolled with a median age of 55 years (interquartile range, 32-75 years), 74.5% were male. Penetrating mechanism (n = 412) patients were younger (32 vs. 64, p < 0.0001) and more likely to be male (86.7% vs. 69.9%, p < 0.0001). Falls were the most common mechanism of injury (26.6%), with gunshot wounds second (24.3%). The most common overall primary COD was traumatic brain injury (TBI) (45%), followed by exsanguination (23%). Traumatic brain injury was nonsurvivable in 82.2% of cases. Blunt patients were more likely to have TBI (47.8% vs. 37.4%, p < 0.0001) and penetrating patients exsanguination (51.7% vs. 12.5%, p < 0.0001) as the primary COD. Exsanguination was the predominant prehospital (44.7%) and early COD (39.1%) with TBI as the most common later. Penetrating mechanism patients died earlier with 80.1% on day 0 (vs. 38.5%, p < 0.0001). Most deaths were deemed disease-related (69.3%), rather than by limitation of further aggressive care (30.7%). Hemorrhage was a contributing cause to 38.8% of deaths that occurred due to withdrawal of care. CONCLUSION Exsanguination remains the predominant early primary COD with TBI accounting for most deaths at later time points. Timing and primary COD vary significantly by mechanism. Contemporaneous adjudication of COD is essential to elucidate the true understanding of patient outcome, center performance, and future research. LEVEL OF EVIDENCE Epidemiologic, level II.