Search

Hospitalized burn patients are at increased risk for venous thromboembolism (VTE). Guidelines regarding thromboprophylaxis in burn patients are unclear. This study aims to compare the outcomes of early versus late thromboprophylaxis initiation in burn patients. In this 3-year analysis of 2017-2019 ACS-TQIP, adult(18-64years) burn patients were identified after applying inclusion/exclusion criteria and stratified based on timing of initiation of VTE prophylaxis: Early(<24 hours of admission); Late(>24 hours). Outcomes were deep venous thrombosis(DVT), pulmonary embolism(PE), unplanned return to operating room (OR), unplanned intensive care unit (ICU) admission, post-prophylaxis packed red blood cells (PRBC) transfusion, and mortality. Nine thousand two hundred and seventy-two patients were identified. Overall, median age was 41years, 71.5% were male, and median[IQR] injury severity score was 3[1-8]. 53% had second-degree burns, and 80% had less than 40% of total body surface area affected. Median time to thromboprophylaxis initiation was 11[6-20.6]hours. Overall VTE rate was 0.9% (DVT-0.7%, PE-0.2%). On univariable analysis, early prophylaxis group had lower rates of DVT(0.6% vs 1.1%, P = .025), and PE(0.1% vs 0.6%, P < .001). On multivariable regression, late prophylaxis was associated with 1.8 times higher odds of DVT (aOR = 1.8, 95% CI = 1.04-3.11, P = .03), 4.8 times higher odds of PE(aOR = 4.8, 95% CI = 1.9-11.9, P < .001), and 2 times higher odds of unplanned ICU admission(aOR = 2.1, 95% CI = 1.4-3.1, P < .001). Furthermore, early thromboprophylaxis was not associated with increased odds of post-prophylaxis PRBC transfusion(aOR = 1.1, 95% CI = 0.8-1.4, P = .4), and mortality(aOR = 0.68, 95% CI = 0.4-1.1, P = .13). Early VTE prophylaxis in burn patients is associated with decreased rates of DVT and PE, without increasing the risk of bleeding and mortality. VTE prophylaxis may be initiated within 24 hours of admission to reduce VTE in this high-risk patient population., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Elder abuse is a major cause of injury, morbidity, and death. We aimed to identify the factors associated with interventions against suspected physical abuse in older adults., Methods: Analysis of the 2017-2018 ACS TQIP. All trauma patients ≥60 years with an abuse report for suspected physical abuse were included. Patients with missing information on abuse interventions were excluded. Outcomes were rates of abuse investigation initiation following an abuse report and change of caregiver at discharge among survivors with an abuse investigation initiated. Multivariable regression analyses were performed., Results: Of 727,975 patients, 1405 (0.2%) had an abuse report. Patients with an abuse report were younger (mean, 72 vs 75, p < 0.001), and more likely to be females (57% vs 53%, p = 0.007), Hispanic (11% vs 6%, p < 0.001), Black (15% vs 7%, p < 0.001), suffer from dementia (18% vs 11%, p < 0.001), functional disability (19% vs 15%, p < 0.001), have a positive admission drug screen (9% vs 5%, p < 0.001) and had a higher ISS (median [IQR], 9 [4-16] vs 6 [3-10], p < 0.001). Perpetrators were members of the immediate/step/extended family in 91% of cases. Among patients with an abuse report, 1060 (75%) had abuse investigations initiated. Of these, 227 (23%) resulted in a change of caregiver at discharge. On multivariate analysis for abuse investigation initiation, male gender, private insurance, and management at non-level I trauma centers were associated with lower adjusted odds (p < 0.05), while Hispanic ethnicity, positive admission drug screen, and penetrating injury were associated with higher adjusted odds (p < 0.05). On multivariate analysis for change of caregiver, male gender, and private insurance were associated with lower adjusted odds (p < 0.05), while functional disability and dementia were associated with higher adjusted odds (p < 0.05)., Conclusions: Significant gender, ethnic, and socioeconomic disparities exist in the management of physical abuse of older adults. Further studies are warranted to expand on and address the contributing factors underlying these disparities., Level of Evidence: III., Study Type: Therapeutic/Care Management., (© 2023 The American Geriatrics Society.)

Introduction: Bladder and ureteral injuries are uncommon in trauma patients but are associated with increased morbidity and mortality. Patients presenting with such injuries may undergo either open surgical repair or laparoscopic repair. We aimed to compare outcomes of open surgical approach and laparoscopy in trauma patients with isolated bladder and ureteral injury. We hypothesized that laparoscopy is associated with improved outcomes., Methods: We performed a 2017 review of American College of Surgeons Trauma Quality Improvement Program and identified trauma patients with bladder and ureteral injury who underwent open surgical repair or laparoscopy. A 1:1 propensity score matching was performed adjusting for demographics, emergency department vitals (systolic blood pressure, heart rate, Glasgow Coma Scale), mechanism of injury, Injury Severity Score, each body region Abbreviated Injury Scale score, and transfusion units. Outcomes were rates of in-hospital major complications and mortality., Results: Of the 1,004,440 trauma patients, 384 patients (open: 192 and laparoscopy: 192) were matched and included. The mean age was 36 ± 15 y, Injury Severity Score was 27 [27-48], 77% were males, and 56% of patients had a blunt mechanism of injury, and 44% had penetrating injuries. Overall mortality was 7.3%. On univariate analysis, mortality was lower in the open group as compared to the laparoscopy group (10.4% versus 4.2%, P = 0.019) and survivor-only hospital length of stay was longer in the open group (8 [8-9] versus 7 [5-11], P = 0.008). There was no difference in overall major complications (23% versus 21%, P = 0.621). On multivariate analysis, open surgical repair was independently associated with lower odds of mortality (adjusted odds ratio: 0.405, 95% confidence interval: [0.17-0.95], P-value = 0.038) CONCLUSIONS: In our analysis open surgical repair of bladder and ureteral injuries was associated with lower mortality with other outcomes being similar when compared to laparoscopy. Laparoscopic surgical repair may not have an advantage over the open surgical repair for bladder and ureteral injuries. Further prospective studies are needed to delineate the ideal surgical approach for these injuries., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Importance: Management of hemodynamically unstable pelvic fractures remains a challenge. Hemostatic interventions are used alone or in combination. There is a paucity of data on the association between the pattern of hemorrhage control interventions and outcomes after a severe pelvic fracture., Objective: To characterize clinical outcomes and study the patterns of hemorrhage control interventions in hemodynamically unstable pelvic fractures., Design, Setting, and Participants: In this cohort study, a retrospective review was performed of data from the 2017 American College of Surgeons Trauma Quality Improvement Program database, a national multi-institutional database of trauma patients in the United States. Adult patients (aged ≥18 years) with pelvic fractures who received early transfusions (≥4 units of packed red blood cells in 4 hours) and underwent intervention for pelvic hemorrhage control were identified. Use and order of preperitoneal pelvic packing (PP), pelvic angioembolization (AE), and resuscitative endovascular balloon occlusion of the aorta (REBOA) in zone 3 were examined and compared against the primary outcome of mortality. The associations between intervention patterns and mortality, complications, and 24-hour transfusions were further examined by backward stepwise regression analyses. Data analyses were performed in September 2021., Main Outcomes and Measures: Primary outcomes were rates of 24-hour, emergency department, and in-hospital mortality. Secondary outcomes were major in-hospital complications., Results: A total of 1396 patients were identified. Mean (SD) age was 47 (19) years, 975 (70%) were male, and the mean (SD) lowest systolic blood pressure was 71 (25) mm Hg. The median (IQR) Injury Severity Score was 24 (14-34), with a 24-hour mortality of 217 patients (15.5%), ED mortality of 10 patients (0.7%), in-hospital mortality of 501 patients (36%), and complication rate of 574 patients (41%). Pelvic AE was the most used intervention (774 [55%]), followed by preperitoneal PP (659 [47%]) and REBOA zone 3 (126 [9%]). Among the cohort, 1236 patients (89%) had 1 intervention, 157 (11%) had 2 interventions, and 3 (0.2%) had 3 interventions. On regression analyses, only pelvic AE was associated with a mortality reduction (odds ratio [OR], 0.62; 95% CI, 0.47 to 0.82; P < .001). Preperitoneal PP was associated with increased odds of complications (OR, 1.39; 95% CI, 1.07 to 1.80; P = .01). Increasing number of interventions was associated with increased 24-hour transfusions (β = +5.4; 95% CI, +3.5 to +7.5; P < .001) and mortality (OR, 1.57; 95% CI, 1.05 to 2.37; P = .03), but not with complications., Conclusions and Relevance: This study found that among patients with pelvic fracture who received early transfusions and at least 1 invasive pelvic hemorrhage control intervention, more than 1 in 3 died, despite the availability of advanced hemorrhage control interventions. Only pelvic AE was associated with a reduction in mortality.

Background: Trauma-induced coagulopathy is frequently associated with hypofibrinogenemia. Cryoprecipitate (Cryo), and fibrinogen concentrate (FC) are both potential means of fibrinogen supplementation. The aim of this study was to compare the outcomes of traumatic hemorrhagic patients who received fibrinogen supplementation using FC versus Cryo., Methods: We performed a 2-year (2016-2017) retrospective cohort analysis of the American College of Surgeons Trauma Quality Improvement Program database. All adult trauma patients (≥18 years) who received FC or Cryo as an adjunct to resuscitation were included. Patients with bleeding disorders, chronic liver disease, and those on preinjury anticoagulants were excluded. Patients were stratified into those who received FC, and those who received Cryo. Propensity score matching (1:2) was performed. Outcome measures were transfusion requirements, major complications, hospital, and intensive care unit lengths of stay, and mortality., Results: A matched cohort of 255 patients who received fibrinogen supplementation (85 in FC, 170 in Cryo) was analyzed. Overall, the mean age was 41 ± 19 years, 74% were male, 74% were white and median Injury Severity Score was 26 (22-30). Compared with the Cryo group, the FC group required less units of packed red blood cells, fresh frozen plasma, and platelets, and had shorter in-hospital and intensive care unit length of stay. There were no significant differences between the two groups in terms of major in-hospital complications and mortality., Conclusion: Fibrinogen supplementation in the form of FC for the traumatic hemorrhagic patient is associated with improved outcomes and reduced transfusion requirements as compared with Cryo. Further studies are required to evaluate the optimal method of fibrinogen supplementation in the resuscitation of trauma patients., Level of Evidence: Therapeutic/Care Management; Level III., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Several advancements in hemorrhage control have been advocated for in the past decade, including balanced transfusions and earlier times to intervention. The aim of this study was to examine the effect of these advancements on outcomes of blunt trauma patients undergoing emergency laparotomy., Methods: This is a 5-year (2013-2017) analysis of the Trauma Quality Improvement Program. Adult (18 years or older) blunt trauma patients with early (≤4 hours) packed red blood cell (PRBC) and fresh frozen plasma (FFP) transfusions and an emergency (≤4 hours) laparotomy for hemorrhage control were identified. Time-trend analysis of 24-hour mortality, PRBC/FFP ratio, and time to laparotomy was performed over the study period. The association between mortality and PRBC/FFP ratio, patient demographics, injury characteristics, transfusion volumes, and American College of Surgeons verification level was examined by hierarchical regression analysis adjusting for interyear variability., Results: A total of 9,773 blunt trauma patients with emergency laparotomy were identified. The mean ± SD age was 44 ± 18 years, 67.5% were male, and median Injury Severity Score was 34 (range, 24-43). The mean ± SD systolic blood pressure at presentation was 73 ± 28 mm Hg, and the median transfusion requirements were PRBC 9 (range, 5-17) and FFP 6 (range, 3-12). During the 5-year analysis, time to laparotomy decreased from 1.87 hours to 1.37 hours ( p < 0.001), PRBC/FFP ratio at 4 hours decreased from 1.93 to 1.71 ( p < 0.001), and 24-hour mortality decreased from 23.0% to 19.3% ( p = 0.014). On multivariate analysis, decreased PRBC/FFP ratio was independently associated with decreased 24-hour mortality (odds ratio, 0.88; p < 0.001) and in-hospital mortality (odds ratio, 0.89; p < 0.001)., Conclusion: Resuscitation is becoming more balanced and time to emergency laparotomy shorter in blunt trauma patients, with a significant improvement in mortality. Future efforts should be directed toward incorporating transfusion practices and timely surgical interventions as markers of trauma center quality., Level of Evidence: Therapeutic/care management, level III., (Copyright © 2022 American Association for the Surgery of Trauma.)

Introduction: The Rib Injury Guidelines (RIG) were developed to guide triage of traumatic rib fracture patients to home, regular floor, or intensive care unit (ICU) and standardize care. The RIG score is based on patient history, physical examination, and imaging findings. The aim of this study was to evaluate triage effectiveness and health care resources utilization following RIG implementation., Methods: This is a prospective analysis at a level I trauma center from October 2017 to January 2020. Adult (18 years or older) blunt trauma patients with a diagnosis of at least one rib fracture on computed tomography imaging were included. Patients before (PRE) and after (POST) implementation of RIG were compared. In the POST group, patients were divided into RIG 1, RIG 2, and RIG 3 based on their RIG score. Outcomes were readmission for RIG 1 patients, unplanned ICU admission for RIG 2 patients, and overall ICU admission. Secondary outcomes were hospital length of stay (LOS) and mortality., Results: A total of 1,100 patients were identified (PRE, 754; POST, 346). Mean ± SD age was 56 ± 19 years, 788 (71.6%) were male, and median Injury Severity Score was 14 (range, 10-22). The most common mechanism of injury was motor vehicle collision (554 [50.3%]), 253 patients (22.9%) had ≥5 rib fractures, and 53 patients (4.8%) had a flail chest. In the POST group, 74 patients (21.1%) were RIG 1; 121 (35.2%), RIG 2; and 151 (43.7%), RIG 3. No patient in RIG 1 was readmitted following initial discharge, and two patients (1.6%) in RIG 2 had an unplanned ICU admission (both for alcohol withdrawal syndrome). Patients after implementation of RIG had shorter hospital LOS (3 [1-6] vs. 4 [1-7] days; p = 0.019) and no difference in mortality (5.8% vs. 7.7%; p = 0.252). On multivariate analysis, RIG implementation was associated with decreased ICU admission (adjusted odds ratio, 0.55 [0.36-0.82]; p = 0.004)., Conclusion: Rib Injury Guidelines are safe and effectively define triage of rib fracture patients with an overall reduction in ICU admissions, shorter hospital LOS, and no readmissions., Level of Evidence: Therapeutic/care management, level III., (Copyright © 2022 American Association for the Surgery of Trauma.)