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The aim of this study was to identify a mortality benefit with the use of whole blood (WB) as part of the resuscitation of bleeding trauma patients.Blood component therapy (BCT) is the current standard for resuscitating trauma patients, with WB emerging as the blood product of choice. We hypothesized that the use of WB versus BCT alone would result in decreased mortality.We performed a 14-center, prospective observational study of trauma patients who received WB versus BCT during their resuscitation. We applied a generalized linear mixed-effects model with a random effect and controlled for age, sex, mechanism of injury (MOI), and injury severity score. All patients who received blood as part of their initial resuscitation were included. Primary outcome was mortality and secondary outcomes included acute kidney injury, deep vein thrombosis/pulmonary embolism, pulmonary complications, and bleeding complications.A total of 1623 [WB: 1180 (74%), BCT: 443(27%)] patients who sustained penetrating (53%) or blunt (47%) injury were included. Patients who received WB had a higher shock index (0.98 vs 0.83), more comorbidities, and more blunt MOI (all P0.05). After controlling for center, age, sex, MOI, and injury severity score, we found no differences in the rates of acute kidney injury, deep vein thrombosis/pulmonary embolism or pulmonary complications. WB patients were 9% less likely to experience bleeding complications and were 48% less likely to die than BCT patients ( P0.0001).Compared with BCT, the use of WB was associated with a 48% reduction in mortality in trauma patients. Our study supports the use of WB use in the resuscitation of trauma patients.

Hemodynamically normal pediatric trauma patients with solid organ injury receive nonoperative management. Prior research supports that pediatric patients have higher rates of nonoperative management at pediatric trauma centers (PTCs). We sought to evaluate differences in outcomes of pediatric trauma patients with liver injuries. We hypothesized that the type of trauma center (PTC versus adult trauma center [ATC]) would not be associated with any difference in mortality.The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003 to 2018 for all patients (15 y) with liver injuries by International Classification of Disease 9 and 10 codes. Patients were categorized based on admission to the PTC or ATC. The primary endpoint was mortality with secondary endpoints being operative intervention and length of stay. Multivariate logistic regressions assessed the adjusted impact on mortality and surgical intervention.Of the 1600 patients with liver trauma, 607 met inclusion criteria. A total of 78.4% were treated at PTCs. Patients underwent hepatobiliary surgery more frequently at ATCs (11.5% [n = 15] versus 2.74% [n = 13], P 0.001). Adjusted analysis showed lower odds of surgical intervention for hepatobiliary injuries at PTCs (adjusted odds ratio: 0.17, P = 0.001). There was a decrease in mortality at PTCs versus ATCs (adjusted odds ratio: 0.38, P = 0.032).Our statewide analysis showed that pediatric trauma patients with liver injuries treated at ATCs were associated with having higher odds of mortality and higher incidence of operative management for hepatobiliary injuries than those treated at PTCs. In addition, between centers, patients had similar functional status at discharge.

Frail, geriatric patients with pelvic fractures can present differently than non-frail patients. Using the Clinical Frailty Scale(CFS), a retrospective analysis was conducted to determine the relationship between patients’ CFS and outcomes after pelvic fractures. We hypothesized that frail, geriatric trauma patients defined as a CFS>4 with pelvic fractures have worse outcomes than non-frail patients with a CFS≤4 despite similar injuries. All geriatric patients with pelvic fractures and documented CFS were included. Seventy patients were included, with 59% (n = 41) frail. The groups were compared with no difference in mortality. The frail group was older and were most likely discharged to a skilled nursing facility (65.8%). Non-frail were most likely discharged to acute rehab (52%). Frail had lower functional status at discharge (median: 14.5v.16, P = .015). Frail patients had worse overall outcomes in this analysis of geriatric pelvic fracture patients. Special attention should focus on this vulnerable population to ensure optimal treatment and outcomes.

We sought to determine the secondary overtriage rate of pediatric trauma patients admitted to pediatric trauma centers. We hypothesized that pediatric secondary overtriage (POT) would constitute a large percentage of admissions to PTC.The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003 to 2017 for pediatric (age ≤ 18 y) trauma patients transferred to accredited pediatric trauma centers in Pennsylvania (n = 6). Patients were stratified based on discharge within (early) and beyond (late) 24 h following admission. POT was defined as patients transferred to a PTC with an early discharge. Multilevel mixed-effects logistic regression model controlling for demographic and injury severity covariates were utilized to determine the adjusted impact of injury patterns on early discharge.A total of 37,653 patients met inclusion criteria. For transfers, POT compromised 18,752 (49.8%) patients. Compared to POT, non-POT were more severely injured (ISS: 10 versus 6;P0.001) and spent less time in the ED (Min: 181 versus 207;P0.001). In adjusted analysis, concussion, closed skull vault fractures, supracondylar humerus fractures, and consults to neurosurgery were associated with increased odds of POT. Overall, femur fracture, child abuse evaluation, and consults to plastic surgery, orthopedics, and ophthalmology were all associated with a decreased risk of being POT.POT comprises 49.8% of PTC transfer admissions in Pennsylvania's trauma system. Improving community resources for management of pediatric concussion and mild TBI could result in decreased rates of POT to PTCs. Developing better inter-facility transfer guidelines and increased education of adult TC and nontrauma center hospitals is needed to decrease POT.Epidemiologic study, level III.

OBJECTIVES Pediatric trauma patients are injured during crucial developmental years and require subsequent absence from school and activities. The impact of these changes on pediatric trauma patients is not well studied. We sought to assess the functional and emotional impact of pediatric trauma. In addition, the inpatient experience was evaluated for performance improvement purposes. METHODS A prospective survey was conducted at our trauma center (February 2019 to May 2019) of admitted trauma patients (

Social determinants (SD) refer to a variety of environmental factors that can influence certain clinical outcomes. SD that affect clinical outcomes in trauma patients are largely understudied. We hypothesized that patients with an “at risk” (AR) classification for any SD will have a greater frequency of negative outcomes when compared to their “not at risk” (NAR) counterparts. A retrospective review was performed (1/2021-2/2022) of all trauma patients that met the inclusion criteria. 2225 patients were included. SD included (based on collection rates) for analysis were: tobacco use, stress, and intimate partner violence. Tobacco usage was the only SD that was significantly associated with a higher 30-day mortality. This study demonstrated a paucity of data in the medical record regarding SD. In an effort to provide more inclusive care and address health disparities in our patient population, there is a need for more complete data collection upon admission/duration of hospital stay.

There is little consensus in the literature regarding the effect of ethanol intoxication on trauma outcomes. Data on its effect in the elderly are even sparser. Our aim was to better define the impact of alcohol use in the geriatric trauma population.We conducted a retrospective review at a level I trauma center looking at admissions from January 2015 through December 2018. Patients were grouped by age: 15-64 y old (YOUNG) versus ≥ 65 y old (OLD). Blood alcohol content (BAC) ≤0.10 g/dL was ETOH (-), and BAC0.10 g/dL was ETOH (+). These were then propensity matched by injury severity score and mechanism of injury. Fisher's exact test and linear regression were applied as appropriate. Significance was defined as P 0.05.There were 8754 patients admitted during the study time frame. A total of 6106 patients were YOUNG and 2647 were OLD. A total of 146 (5.5%) OLD patients were ETOH (+), whereas 1488 (24.4%) YOUNG patients were ETOH (+) (P 0.0001). To assess the impact of alcohol between the two age groups, 285 OLD patients were propensity matched with 285 YOUNG patients. Mortality was significantly higher in the OLD (11.9%) group than that in the YOUNG (3.5%) group (P 0.001). Morbidity was also higher in OLD versus YOUNG patients overall (P 0.05). The presence of ethanol did not significantly impact morbidity or mortality in YOUNG or OLD patients.Higher mortality and morbidity is unsurprising in geriatric trauma patients; however, alcohol does not appear to play a significant role in these outcomes.

OBJECTIVES Isolated intraperitoneal free fluid (IIFF) is defined as intraperitoneal fluid seen on computed tomography (CT) without identifiable injury. In a hemodynamically stable patient, this finding creates a challenge for physicians regarding the next steps in management because the clinical significance of this fluid is not completely understood. We hypothesized that pediatric blunt trauma patients with a finding of simple IIFF on CT would not have clinically significant intraabdominal injury. METHODS A retrospective review (2009-2018) was conducted of all pediatric blunt trauma patients who underwent CT scan of the abdomen/pelvis at our institution. All patients with scans performed at our institution with the finding of IIFF were included. Scans were reviewed to measure the Hounsfield Units (HU) of the intraabdominal fluid. Groups were stratified into HU > 25 and HU ≤ 25, below accepted cutoffs for acute blood, and clinical outcomes were reviewed. RESULTS A total of 413 patients had free fluid on CT abdomen/pelvis with 279 (68%) having only the finding of IIFF. The HU was 25 or less in 236 (85%) patients. No patients in the HU ≤ 25 group required operative exploration or had examination findings to indicate they had intraabdominal injury. Four (9%) patients in the HU > 25 required laparotomy (P < 0.0001). No patients in the HU ≤ 25 group required further workup or hospital admission over concern for intraabdominal injury. CONCLUSIONS Pediatric blunt trauma patients with HU of 25 or less IIFF and a nonperitonitic physical examination did not require operative exploration or further workup for intraabdominal injury. In the absence of other injuries, it is safe to discharge these patients without further workup.

Hay-holes are openings on the second floor of barns used to drop feed to ground level. Hay-hole falls (HHFs) are a unique problem among Anabaptist communities, especially for children. To follow-up on our previous study that created the Anabaptist Youth Trauma Prevention Consortium with distribution of 231 hay-hole covers in South Central Pennsylvania, we compared a five-year period before cover distribution with the 5-year period after. Data were stratified by phase: Before Cover Implementation (BC): 1/2011-12/2016, After Cover Implementation (AC): 1/2017-12/2021. 49 patients met inclusion criteria. There was a 47% decrease in the number of HHF from the BC phase to the AC phase, suggesting that cover distribution has significantly impacted HHF incidence. Further investigation is needed to elucidate the long-term impact of cover distribution and to guide future interventions, such as another round of cover distribution or improvements in the design of these covers for long-term use.

Marijuana use has been reported to promote hypercoagulable states among trauma patients, particularly respecting venous thromboembolism (VTE), a major contributor to morbidity and mortality in patients sustaining traumatic injury. We sought to investigate this further through a retrospective, single institutional study performed from January 2018 through June 2021, utilizing data from patients presenting to a Level 1 Trauma Center as a trauma activation. We observed less frequent VTE development in the marijuana-positive group compared to the marijuana-negative group, with patient thromboelastography revealing a longer mean R-time in the marijuana-positive group. Overall occurrence of VTE was too low for definitive conclusions, but a trend toward reduction in VTE frequency among marijuana users compared to nonusers was noted. More studies with larger populations and more VTE occurrences are needed to confirm a potential correlation between marijuana use and VTE development

Introduction Whole blood (WB) resuscitation has been associated with a mortality benefit in trauma patients. Several small series report the safe use of WB in the pediatric trauma population. We performed a subgroup analysis of the pediatric patients from a large prospective multicenter trial comparing patients receiving WB or blood component therapy (BCT) during trauma resuscitation. We hypothesized that WB resuscitation would be safe compared to BCT resuscitation in pediatric trauma patients. Methods This study included pediatric trauma patients (0-17 y), from ten level-I trauma centers, who received any blood transfusion during initial resuscitation. Patients were included in the WB group if they received at least one unit of WB during their resuscitation, and the BCT group was composed of patients receiving traditional blood product resuscitation. The primary outcome was in-hospital mortality with secondary outcomes being complications. Multivariate logistic regression was performed to assess for mortality and complications in those treated with WB vs BCT. Results Ninety patients, with both penetrating and blunt mechanisms of injury (MOI), were enrolled in the study (WB: 62 (69%), BCT: 28 (21%)). Whole blood patients were more likely to be male. There were no differences in age, MOI, shock index, or injury severity score between groups. On logistic regression, there was no difference in complications. Mortality was not different between the groups ( P = .983). Conclusion Our data suggest WB resuscitation is safe when compared to BCT resuscitation in the care of critically injured pediatric trauma patients.

Objectives Pan scanning in trauma patients has become routine, resulting in increased identification of incidental findings (IF), findings unrelated to the reason for the scan. This has posed a conundrum of ensuring patients have appropriate follow-up for these findings. We sought to evaluate our compliance and follow-up for patients after implementation of an IF protocol at our level-I trauma center. Methods We performed a retrospective review from 9/2020 to 4/2021, to encompass before and after protocol implementation. Patients were separated into PRE and POST groups. Charts were reviewed evaluating several factors including three- and six-month follow-ups on IF. Data were analyzed comparing PRE and POST groups. Results A total of 1989 patients were identified, 31.22% (n = 621) with an IF. 612 patients were included in our study. Compared to PRE, POST showed a significant increase in PCP notification (35% vs 22%, P < .001) and patient notification (82% vs 65%, P < .001). As a result, patient follow-up regarding IF at six months was significantly higher in POST (44%) v. PRE (29%), ( P < .001). There was no difference in follow-up based on insurance carrier. There was no difference in patient age for PRE (63 y) and POST (66 y) overall, ( P = .089); nor in age of patients who followed up; 68.8 PRE vs 68.2 years POST ( P = .819). Conclusion Implementation of an IF protocol with patient and PCP notification was significantly improved in overall patient follow-up for category one and two IF. Utilizing the results of this study, the protocol will be further revised to improve patient follow-up.

Background Individuals presenting with traumatic injury in rural populations have significantly different injury patterns than those in urban environments. With an increasing Amish population, totaling over 33 000 in our catchment area, their unique way of life poses additional factors for injury. This study aims to evaluate differences in mechanism of injury, location of injury, and demographic patterns within the Amish population. We hypothesize that there will be an increased incidence of agriculture-related mechanisms of injury. Methods All Amish trauma patients presenting to our level I trauma center over 20 years (1/2000-4/2020) were retrospectively analyzed. Mechanism and geographic location of injury were collected. Demographic and clinical variables were compared between the age groups. Results There were 1740 patients included in the study with 36.4% (n = 634) ≤ 14 years. Only 10% (n = 174) were ≥ 65 years. The most common mechanism across all ages was falls. However, when separating out the pediatric population ( ≤ 14 years), 27.8% (n = 60) fell from a height on average > 8-10 feet. The most common geographic location of injury was at home in all age groups, except for the 15-24 year group, which was roadways. Discussion The Amish population poses a unique set of mechanisms of injury and thus injury patterns to rural trauma centers. We have found the most common injuries to be falls, buggy accidents, animal-related injuries, and farming accidents across all age groups. Future research and collaboration with other rural trauma centers treating large Amish populations would be beneficial to maximize injury prevention in this population. Level of Evidence Level 3a, epidemiological.

Introduction It is well known that trampolines can be a particular source of danger, especially in children. We sought to examine the profile of those patients with trampoline injuries. We hypothesized there would be certain injury patterns predicative of trampoline injuries. Methods All patients submitted to Pennsylvania Trauma Outcome Study database from 2016 to 2018 were analyzed. Trampoline injury was determined by ICD-10 activity code. Injury patterns in the form of abbreviated injury scale body regions were examined. Patient demographics and clinical variables were compared between those with trampoline injury vs those without. Results There were 107 patients with a trampoline injury. All of these patients were discharged alive and had a blunt mechanism of injury. The most common injury type was injury to the extremities (n=90,[84.1%]) with 54(50.5%) upper extremity injuries and 36(33.6%) lower extremity injuries. Ten (9.35%) patients had injury to the spine and five (4.67%) had head injury. Those with trampoline injuries were significantly younger (13y vs. 48.6y) and more likely to be white or of Hispanic ethnicity. Almost half of the patients injured (49.5%) were under 10 years. Patients with trampoline injuries had significantly lower Injury Severity Scores and significantly higher shock index. Discussion The majority of patients with trampoline injuries had injury to an extremity. These results help better understand the demographic, physiologic, and anatomic patterns surrounding trampoline injuries. Current government standards recommend that no child under age six should use a full-sized trampoline; however, based of this study, we advise that this age be increased to ten.

Introduction Nonoperative management of hemodynamically stable patients with blunt splenic and/or hepatic injury has been widely accepted in the pediatric population. However, variability exists in the utilization and timing of repeat imaging to assess for delayed complications during index hospitalization. Recent level-IV evidence suggests that repeat imaging in children should be performed based on a patient’s clinical status rather than on a routine basis. The aim of this study is to examine the rate of delayed complications and interventions in pediatric trauma patients with blunt splenic and/or hepatic injuries who undergo repeat imaging prompted either by a clinical change (CC) or non-clinical change (NCC). Methods A 9-year (2011-2019), retrospective, dual-institution study was performed of children (0-17 years) with blunt splenic and/or hepatic injuries. Patients were grouped based on reason for repeat imaging: CC or NCC. The rate of organ-specific delayed complications and interventions was examined by reason for scan. Results A total of 307 injuries were included in the study period (174 splenic, 113 hepatic, and 20 both). Of 194 splenic injuries, 30(15.5%) underwent repeat imaging (CC = 19; NCC = 11). Of 133 hepatic injuries, 27(20.3%) underwent repeat imaging (CC = 21; NCC = 6). There was no difference in the incidence of organ-specific delayed complications between the CC and NCC groups. Of the 4 patients with complications necessitating intervention, only one was identified based on NCC. Conclusions Our data suggest routine repeat imaging is unnecessary in children with blunt splenic and/or hepatic injuries; therefore, practitioners may rely on a patient’s clinical change.

Background There are no definitive recommendations guiding repeat imaging, or its timing, in patients with blunt splenic injury managed non-operatively. This study examines delayed complications and interventions in patients with blunt splenic injuries who undergo repeat imaging. Imaging was prompted either by a clinical change (CC) or non-clinical change (NCC) including institutional recommendations and individual physician practice patterns. Methods A 3-year, retrospective, dual-institution study was conducted of adult patients with blunt splenic injuries. Patients who underwent repeat imaging were grouped based on the reason for scan: CC or NCC. The incidence of delayed complications and interventions was examined. Results Of 235 patients, 105 (45%) underwent repeat imaging [CC n = 67 (64%), NCC n = 38 (36%)]. Median time to repeat imaging was shorter in the NCC group [CC = 96 (IQR 48–192) hours, NCC = 48 (IQR 36–68) hours, p = .0005]. Delayed complications were found in 28 (42%) CC patients versus 18 (47%) NCC patients ( p = .683). Interventions for complications were performed in 6 (21%) CC versus 10 (56%) NCC ( p = .027). Discussion Nearly half of patients reimaged because of NCC were found to have complications, with more than half undergoing intervention. Complications were identified and treated earlier in the NCC group than the CC group. This suggests patients with blunt splenic injuries should undergo routine repeat imaging to allow for prompt identification and treatment of delayed complications.

Objectives Intracranial pressure (ICP) monitoring in pediatric traumatic brain injury (TBI) patients remains controversial. This study aimed to characterize the association between ICP monitoring and mortality for pediatric severe TBI, hypothesizing that ICP monitoring would not be associated with improved survival. Methods Pediatric patients (≤14 years) presenting to Pennsylvania trauma centers from 2003 to 2018 who met severe brain injury criteria (Glasgow Coma Score Results A total of 802 pediatric patients met the inclusion criteria. Of those, 28.7% were in ICP+ group ( n = 230) and overall mortality was 33.9% ( n = 272). Despite a higher Injury Severity Score in ICP+ compared to ICP− (33 v. 27, p < 0.001), the mortality rate was lower (22% v. 39%, p < 0.001). The ICP+ group had lower functional statuses at discharge (8 v. 18, p < 0.001). The multivariate logistic regression revealed that presence of an ICP monitor significantly decreased odds of mortality (adjusted odds ratio:0.57, p = 0.027). Conclusion While ICP monitor placement remains controversial in pediatric trauma, there appears to be an association between ICP monitor placement and decreased mortality, despite the ICP monitor group having lower functional status at discharge.

OBJECTIVES Vascular injury in pediatric trauma patients is uncommon but associated with a reported mortality greater than 19% in some series. The purpose of this study was to characterize pediatric major vascular injuries (MVIs) and analyze mortality at a high-volume combined adult and pediatric trauma center. METHODS A retrospective review (January 2000 to May 2016) was conducted of all pediatric (