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The use of blood transfusion to treat hemorrhagic shock is a relatively new treatment with its origins in World War I. Due to the severity and nature of injuries seen, World War I provided the stimulus to propel medicine forward and accept whole blood transfusion for the trauma patient., (© The Association of Military Surgeons of the United States 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: U.S. military women were at risk of combat exposure and injury from asymmetric warfare during the conflicts in Iraq and Afghanistan. Previous research has yielded mixed results when examining sex differences in PTSD following operational deployment. To date, no study has explored sex differences in PTSD after combat injury., Materials and Methods: This retrospective study included U.S. military service men and women who experienced a combat injury in Iraq or Afghanistan (March 2003 to March 2013) and completed a Post-Deployment Health Assessment (PDHA) within 1 year of injury. The PDHA is administered at the end of deployment and includes the 4-item Primary Care PTSD Screen. The prevalence of screening positive for PTSD was evaluated by sex using a chi-square test. Multivariable logistic regression was used to assess the association between sex and PTSD while adjusting for covariates., Results: The study sample included 16,215 injured military personnel (666 women and 15,549 men). The average time between injury and PDHA was 132 days (SD = 91.0). Overall, women had a higher prevalence of screening positive for PTSD than men (48.3% vs. 40.9%, P < .001). In multivariable regression, women had higher odds than men of screening positive for PTSD (odds ratio, 1.34; 95% confidence interval, 1.14-1.57). Psychiatric history was the strongest predictor of screening positive for PTSD regardless of sex (odds ratio, 1.59; 95% confidence interval, 1.45-1.74)., Conclusions: In this novel study of military service members, women were more likely to screen positive for PTSD than men after combat injury. Strategies to mitigate PTSD, enhance resiliency, and incorporate psychological care into injury rehabilitation programs for women may be needed for future U.S. military conflicts where they will play a larger role in combat operations., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: Hemorrhage control and resuscitative concepts have evolved in recent years, leading to aggressive use of blood products in trauma patients. There is subsequently a potential risk for overtransfusion, adverse effects, and waste associated with unnecessary transfusion. Methods for conserving blood products are of particular importance in future large-scale combat operations where supply chains are likely to be strained. This study examined the association of emergency department (ED) arrival hemoglobin (HGB) with overtransfusion among survivors at 24 hours after major trauma at a military trauma center., Materials and Methods: We performed a retrospective cohort study of patients who had a "major trauma" activation and received any red blood cells. Overtransfusion was defined as a HGB level ≥11.0 g/dL at 24 hours (outcome variable). Multivariable logistic regression statistics were used to compare groups and adjust for confounders (injury severity score, arrival modified shock index, injury type, age, and gender). A receiver operating characteristic was constructed with overtransfusion at 24 hours as the outcome (binary) and arrival HGB (continuous) as the independent variable., Results: A total of 382 patients met inclusion criteria. Overtransfusion occurred in 30.4% (n = 116) of patients, with mean ED HGB levels of 13.2 g/dL (12.9 to 13.6) versus 11.6 g/dL (11.3 to 11.8, P < .001). Receiver operating characteristic analysis showed that ED HGB was highly sensitive (0.931) for predicting 24-hour overtransfusion. In our multivariable logistic regression analysis, when adjusting for injury severity score, arrival modified shock index, injury type, age, and gender, we found that the ED HGB value had a per-unit odds ratio of 1.60 (95% CI, 1.38 to 1.86) for 24-hour overtransfusion. Hospital and intensive care unit length of stay, mechanical ventilator days, and mortality did not increase., Conclusion: We found that the arrival HGB value was associated with overtransfusion among 24-hour survivors in a civilian trauma setting. Our findings will inform future prospective studies that investigate blood sparing clinical practice guidelines., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Earthquakes cause devastating effects, resulting in the deaths of thousands of people each year. Understanding the full range of impacts, including fatalities, and the pathophysiological mechanisms underlying these effects is crucial for mitigating the aftermath of earthquakes. Therefore, this review aims to: delineate the critical golden time periods following earthquakes and identify the most effective responses and resilience factors during these periods; accurately define the terminology for injuries sustained post-earthquake; elucidate the basic pathophysiology of CRUSH injury-induced myopathy, one of the most significant pathologies in post-earthquake patient management; explore the role of nitric oxide (NO) mechanisms in crush injuries, which are believed to be fundamental to the "smiling death phenomenon" and represent the unseen part of the iceberg; and highlight the importance of the 3 main phenomena responsible for mortality-acidosis, coagulopathy, and hypothermia-during disasters. This comprehensive review, based on the latest literature, encompasses search and rescue, pre-hospital processes, emergency department procedures, and subsequent internal and surgical management algorithms.

Background: Civilian acute trauma care has advanced in recent decades; however, traumatic injury remains the leading cause of death in individuals aged 15 to 29 years in the United States and worldwide. Uncontrolled hemorrhage is the leading preventable cause of death in trauma patients, with up to half of these deaths occurring before reaching a medical facility. The timely application of hemorrhage control measures is critical to enhance the survivability of trauma patients and is one of the major challenges faced by medical providers in austere environments. The purpose of this review is to explore if early resuscitation with cold-stored whole blood therapy reduces the need for component therapy in the first 24 hours postinjury in the civilian population., Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a systematic literature search in Medline, EMBASE, and Transfusion Evidence Library for studies reporting data on 24-hour blood product usage in trauma patients in hemorrhagic shock receiving initial therapy with whole blood. Two reviewers independently performed the selection of eligible studies., Results: Of a total of 2,150 identified studies, 11 studies (n = 4,792) met the inclusion criteria. There was heterogeneity in the study design, interventions, and outcomes. Seven studies reported a statistically significant decrease in 24-hour transfusion requirements in the whole blood intervention group in comparison with the control component therapy group. Three studies reported no significant difference between the two groups. One of the studies reported an increase in 24-hour transfusion requirements in the whole blood group., Conclusion: Overall, there appears to be a decrease in component therapy use following initial resuscitation with whole blood in trauma patients with hemorrhagic shock. However, further research is needed to address this important practical question (PROSPERO registration no. CRD42023422173)., Level of Evidence: Systematic Review; Level IV., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Trauma complications increase the burden of disease and hospitalization costs for patients. More research evidence is needed on how to more effectively prevent these complications and reduce hospitalization costs based on the characteristics of trauma patients. Therefore, this study will systematically analyze the characteristics of trauma complications and their specific impact on hospitalization costs., Methods: This is a multi-center retrospective study of trauma hospitalizations from 2018 to 2023. Associations between population characteristics, trauma features, and each complication occurrence were investigated using multiple correspondence analysis. Logistic regression analysis assessed factors influencing trauma complications. Additionally, a generalized linear model analyzed the relative increase in hospital costs for each complication., Results: A total of 48,032 trauma patients were included, with 22.0% experiencing at least one complication. Thrombosis is more prevalent among elderly women (aged ≥65) with pelvic and extremity trauma. In men aged 18-44 years, respiratory insufficiency and post-traumatic anemia primarily occurred in cases of head injuries and multiple injuries. Chest and multiple injuries predispose people aged 45-64 to pneumonia and electrolyte disorders. Body surface injuries are prone to surgical site infections. Complications resulted in an average relative increase in overall hospitalization costs of 1.32-fold, with thrombosis (1.58-fold), respiratory insufficiency (1.11-fold), post-traumatic anemia (0.58-fold), surgical site infection (0.48-fold), pneumonia (0.53-fold), electrolyte disorders (0.47-fold)., Conclusions: This study systematically analyzed the occurrence characteristics of trauma complications and the burden trends of hospitalization costs due to complications, providing a reference for the formulation of trauma classification and management strategies., Competing Interests: Declaration of competing interest The authors have no conflicts of interests or disclosures to report., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Prediction models for survival in trauma rely on arrival vital signs to generate survival probabilities. Hospitals are benchmarked on expected and observed outcomes. Prehospital blood (PB) transfusion has been shown to improve mortality, which may affect survival prediction modeling. We hypothesize that the use of PB increases the predicted survival derived from probability models compared with non-blood-based resuscitation., Methods: All adult trauma patients presenting to a level 1 trauma center requiring emergency release blood transfusion from January 2017 to December 2021 were reviewed. Patients were grouped into those receiving PB or those who did not (no PB). Prehospital Trauma and Injury Severity Score (TRISS) and shock index were compared with those at presentation to hospital. Univariate and multivariate regressions were performed to identify factors associated with changes in survival probability at presentation., Results: In total, 2117 patients were reviewed (PB, 1,011; no PB, 1,106). Patients receiving PB were younger (35 vs. 40 years, p < 0.001), more likely to have blunt mechanism (71% vs. 65%, p = 0.002), and more severely injured (Injury Severity Score, 27 vs. 25; p < 0.001) and had higher rates of prehospital hypotension (44% vs. 19%, p < 0.001) and shock index (1.10 vs. 0.87, p < 0.001). Upon arrival, PB patients had lower rates of ED hypotension (34% vs. 39%, p = 0.01), and significant improvements in arrival TRISS scores (+0.09 vs. -0.02, p < 0.001) and shock index (+0.10 vs. -0.07, p < 0.001) compared with prehospital. On multivariate analysis, PB was associated with a threefold increase in unexpected survivors (odds ratio, 3.28; 95% confidence interval, 2.23-4.60)., Conclusion: The use of PB was associated with improved probability of survival and an increase in unexpected survivors. Applying TRISS and shock index at hospital arrival does not account for en route hemostatic resuscitation, causing patients to arrive with improved vitals despite severity of injury. Caution should be used when implementing survival probability calculations using arrival vitals in centers with prehospital transfusion capability., Level of Evidence: Therapeutic/Care Management; Level IV., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Trauma hemorrhage induces a coagulopathy with a high associated mortality rate. The Implementing Treatment Algorithms for the Correction of Trauma Induced Coagulopathy (ITACTIC) randomized trial tested two goal-directed treatment algorithms for coagulation management: one guided by conventional coagulation tests and one by viscoelastic hemostatic assays (viscoelastic). The lack of a difference in 28-day mortality led the authors to hypothesize that coagulopathic patients received insufficient treatment to correct coagulopathy., Methods: During ITACTIC, two sites were coenrolling patients into an ongoing prospective observational study, which included serial blood sampling at the same intervals as in ITACTIC. The subgroup in both studies had conventional and viscoelastic test results for each patient available for analysis. A goal-directed treatment was defined as one triggered by an ITACTIC algorithm. Coagulopathy was defined as rotational thromboelastometry EXTEM A5 less than 40 mm. The primary outcome was correction of coagulopathy by the 12th unit of erythrocyte transfusion during resuscitation., Results: Full viscoelastic and conventional coagulation test results were available for 133 patients. Of these patients, 71% were coagulopathic on admission, and 16% developed a coagulopathy during resuscitation. ITACTIC viscoelastic hemostatic assay group patients were more likely to receive goal-directed treatment than the standard group (76% vs. 47%; odds ratio, 3.73; 95% CI, 1.64 to 8.49; P = 0.002). However, only 54% of patients received goal-directed treatment, and only 20% corrected their coagulopathy (vs. 0% with empiric treatment alone; not significant). Median time to first goal-directed treatment was 68 (53 to 88) min for viscoelastic and 110 (77 to 123) min for standard (P = 0.005)., Conclusions: In ITACTIC, many bleeding trauma patients did not receive an indicated goal-directed treatment. Interventions arrived late during resuscitation and were only partially effective at correcting coagulopathy., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc., on behalf of the American Society of Anesthesiologists.)

Background: Whole blood (WB) resuscitation is increasingly used at trauma centers. Prior studies investigating outcomes in WB versus component-only (CO) resuscitation have been limited by small cohorts, low volumes of WB resuscitation, and unbalanced CO resuscitation. This study aimed to address these limitations using data from a high-volume Level I trauma center, which adopted a WB-first resuscitation paradigm in 2018. We hypothesized that the resuscitation method, WB or balanced CO, would have no impact on patient mortality., Methods: A single-center, retrospective cohort study of adults presenting as a trauma activation from July 2016 through July 2021 was performed. Receipt of three or more units of WB or packed red blood cells (RBC) within the first hour of resuscitation was required for inclusion. Patients were grouped into WB versus CO resuscitation and important clinical outcomes were compared. Mortality was evaluated with Kaplan-Meier analysis, log-rank testing, and multivariable Cox proportional hazards modeling., Results: There were 180 patients in the WB group and 170 patients in the CO group. Of the 180 WB patients, 110 (61%) received only WB during the first 24 hours. The WB group received a median of 5.0 units (interquartile range, 4.0-8.0) of WB and CO group received a median of 6.0 units (interquartile range, 4.0-11.8) of RBCs during the first 24 hours of resuscitation. In the CO group, median RBC/plasma and RBC/platelet ratios approximated 1:1:1. Groups were similar in clinicopathologic characteristics including age, Injury Severity Score, mechanism of injury, and requirement for hemorrhage control interventions (WB 55% vs. CO 59%, p = 0.60). Unadjusted survival was equivalent at 24 hours ( p = 0.52) and 30 days ( p = 0.70) between both groups on Kaplan-Meier analysis with log-rank testing. On multivariable Cox regression, WB resuscitation was not independently associated with improved survival after accounting for age, Injury Severity Score, mechanism of injury, and receipt of hemorrhage control procedure (hazard ratio, 0.85; 95% confidence interval, 0.61-1.19, p = 0.34)., Conclusion: Balanced CO resuscitation is associated with similar mortality outcomes to that of WB based resuscitation., Level of Evidence: Therapeutic/Care Management; Level IV., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: Airway evaluation and management are generally the first priority for treatment of trauma patients from the prehospital setting throughout their hospital stay. Delay in recognition of an airway problem, or inability to oxygenate or ventilate because of an inadequate airway, will lead to rapid death. Therefore, all clinicians involved in the care of trauma patients should have adequate knowledge of current best practices for airway evaluation and management. In addition, trauma providers should develop and maintain the skills needed to perform various airway maneuvers to establish and maintain an adequate airway. While elective airway management has the luxury of time for thorough airway evaluation, the airway management in the trauma setting does not allow this same opportunity. For this reason, all trauma airways should be presumed to be a difficult airway, and teams should prepare accordingly. This review will summarize the best practices for airway evaluation and management for trauma patients from the prehospital setting through the emergency department., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Recent randomized clinical trials have demonstrated that prehospital tranexamic acid (TXA) administration following injury is safe and improves survival. However, the effect of prehospital TXA on adverse events, transfusion requirements, and any dose-response relationships require further elucidation., Methods: A secondary analysis was performed using harmonized data from two large, double-blinded, randomized prehospital TXA trials. Outcomes, including 28-day mortality, pertinent adverse events, and 24-hour red cell transfusion requirements, were compared between TXA and placebo groups. Regression analyses were used to determine the independent associations of TXA after adjusting for study enrollment, injury characteristics, and shock severity across a broad spectrum of injured patients. Dose-response relationships were similarly characterized based upon grams of prehospital TXA administered., Results: A total of 1,744 patients had data available for secondary analysis and were included in the current harmonized secondary analysis. The study cohort had an overall mortality of 11.2% and a median Injury Severity Score of 16 (interquartile range, 5-26). Tranexamic acid was independently associated with a lower risk of 28-day mortality (hazard ratio, 0.72; 95% confidence interval [CI], 0.54-0.96; p = 0.03). Prehospital TXA also demonstrated an independent 22% lower risk of mortality for every gram of prehospital TXA administered (hazard ratio, 0.78; 95% CI, 0.63-0.96; p = 0.02). Multivariable linear regression verified that patients who received TXA were independently associated with lower 24-hour red cell transfusion requirements ( β= - 0.31; 95% CI, -0.61 to -0.01; p = 0.04) with a dose-response relationship ( β= - 0.24; 95% CI, -0.45 to -0.02; p = 0.03). There was no independent association of prehospital TXA administration on thromboembolism, seizure, or stroke., Conclusion: In this secondary analysis of harmonized data from two large randomized interventional trials, prehospital TXA administration across a broad spectrum of injured patients is safe. Prehospital TXA is associated with a significant 28-day survival benefit and lower red cell transfusion requirements at 24 hours and demonstrates a dose-response relationship., Level of Evidence: Therapeutic/Care Management; Level III., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.)

Objective:  We evaluated if venous thromboembolism (VTE) prophylaxis in the inpatient antepartum period was associated with wound hematomas, VTE occurrence, and other adverse outcomes., Study Design:  This study is a secondary analysis of a retrospective cohort of patients who delivered at University of Alabama at Birmingham (UAB). Patients receiving outpatient anticoagulation (AC) were excluded. We grouped patients into those who received inpatient antepartum prophylactic AC and those who did not. The primary outcome was wound hematomas from delivery to 6 weeks postpartum (PP). Secondary outcomes included VTE occurrence and select adverse outcomes, including other wound complications, unplanned procedures, mode of anesthesia, and intensive care unit (ICU) admission. Analyses were performed with no AC group as the reference. A sensitivity analysis excluding those who received inpatient PP AC was performed., Results:  Of 1,035 included patients, only 169 patients received inpatient prophylactic AC. They were older, had higher body mass indices, and more comorbidities. Patients receiving inpatient antepartum AC had higher wound hematomas (adjusted odds ratio [aOR] 23.81; 95% confidence interval [CI] 7.04-80.47). They had similar risk for developing VTE as the control group (aOR 2.68; 95% CI 0.19-37.49) but were more likely to have wound complications (aOR 2.36; 95% CI 1.24-4.47), maternal deaths ( p  < 0.05), and require PP ICU admission (aOR 13.38; 95% CI 4.79-37.35). When excluding those receiving any PP AC, there was no difference in bleeding complications between the two groups and VTE rates remained unchanged. Rates of maternal deaths and PP ICU admissions remained higher in those who received inpatient antepartum AC prophylaxis., Conclusion:  In this small cohort study, increased wound hematomas were found in those who received inpatient antepartum AC prophylaxis with no difference in VTE occurrence. While adverse events were increased in the inpatient AC group, this was mostly associated with PP AC prophylaxis. Larger studies should be conducted to describe the true benefits and risks of antepartum AC prophylaxis and determine efficacy of this widely used practice., Key Points: · Peripartum chemoprophylaxis is associated with increased wound hematomas.. · VTE is rare, despite its association with significant peripartum morbidity/mortality.. · Large studies are needed to guide practices that optimize the risk/benefit ratio of chemoprophylaxis.., Competing Interests: G.S. is an editor of the American Journal of Perinatology., (Thieme. All rights reserved.)

Background: Acute substance intoxication is associated with traumatic injury and worse hospital outcomes. The objective of this study was to evaluate the association between simultaneous opioids and benzodiazepines (OB) use and hospital outcomes in elderly trauma patients., Methods: We performed a retrospective analysis using the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) 2017 database. We included trauma patients (age ≥ 65 years) examined by urine toxicology within 24 hours of presentation. The primary outcome was in-hospital mortality. Secondary outcomes included hospital and ICU lengths of stay (HLOS AND ICULOS), in-hospital complications (eg, ventilator-associated pneumonia), unplanned intubation, and duration of mechanical ventilation. Patients were stratified being both positive for opioids and benzodiazepines (OB+) or not (OB-) based on having positive or negative drug screen for both drugs, respectively. A 1:1 propensity score matching was performed controlling for demographics (eg, age and sex), comorbidities (eg, alcoholism), and injury characteristics., Results: Of 77,311 tested patients, 849 OB+ were matched to OB- patients. Compared to OB- group, OB+ patients were more likely to have unplanned intubation (26 [3.1%] vs 8 [0.9%], P = 0.002) and had prolonged HLOS (≥2 days: 683 [84.0%] vs 625 [77.8%], P = 0.002). There were no differences in all other outcomes ( P > 0.05)., Conclusions: The OB intake is associated with higher incidence of unplanned intubation and longer HLOS in elderly trauma patients. Early identification of elderly trauma patient with OB+ can help provide necessary pharmacologic and behavioral interventions to treat their substance use and potentially improve outcomes., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Abstract: Background : Trauma and blood loss are frequently associated with organ failure, immune dysfunction, and a high risk of secondary bacterial lung infections. We aim to test if plasma metabolomic flux and monocyte bioenergetics are altered in association with trauma and related secondary infections. Methods : Plasma samples were collected from trauma patients at three time points: days 0, 3, and 7 postadmission. Metabolites (140) were measured in plasma from trauma survivors ( n = 24) and healthy control individuals (HC, n = 10). Further analysis within the trauma cohort included subsets of trauma/infection-negative (TIneg, n = 12) and trauma/infection-positive patients (TIpos, n = 12). The bioenergetic profile in monocytes was determined using mitochondrial and glycolytic stress tests. Results : In the trauma cohort, significant alterations were observed in 29 metabolites directly affecting 11 major metabolic pathways, while 34 metabolite alterations affected 8 pathways in 9, versus TIneg patients. The most altered metabolic pathways included protein synthesis, the urea cycle/arginine metabolism, phenylalanine, tyrosine, tryptophan biosynthesis, and carnitine compound family. In monocytes from trauma patients, reduced mitochondrial indices and loss of glycolytic plasticity were consistent with an altered profile of plasma metabolites in the tricarboxylic acid cycle and glycolysis. Conclusions : Our study highlights that the metabolic profile is significantly and persistently affected by trauma and related infections. Among trauma survivors, metabolic alterations in plasma were associated with reduced monocyte bioenergetics. These exploratory findings establish a groundwork for future clinical studies aimed at enhancing our understanding of the interplay between metabolic/bioenergetic alterations associated with trauma and secondary bacterial infections., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by the Shock Society.)

Introduction: The American College of Surgeons (ACS) recommends that special considerations be made during triage of trauma patients aged ≥55 due to an observed increase in morbidity and mortality in this population. The geriatric population aged ≥65 represents 30% of all trauma patients. Our objective was to assess which pre-existing conditions (PECs) are associated with worse outcomes in trauma patients aged ≥55. Methods: Study population was selected from the local trauma registry (2020-22). Bi-variate analysis compared PEC status with outcomes controlling for each Injury Severity Score (ISS) category. Injury Severity Score was defined as mild (1-8), moderate (9-15), severe (16-24), and critical (≥25). Results: A total of 5,168 patients were identified (54.9% female, 56.7% age ≥75, 49.1% mild injury). Patients who had chronic renal failure (CRF) were at increased odds of mortality after adjusting for mild (adjusted odds ratio [aOR]: 2.63), moderate (aOR: 2.97), severe (aOR: 2.84), and critical (aOR: 2.62) injuries. Patients who had cirrhosis or congestive heart failure (CHF) were at increased odds of mortality after adjusting for mild (aOR: 3.03, 1.61), moderate (aOR: 3.63, 2.14), and severe (aOR: 3.46, 1.93) injuries, respectively. In addition, there was a relationship between having chronic obstructive pulmonary disease (COPD), dementia, anticoagulant therapy, or diabetes with unplanned intensive care unit (ICU) admission and development of acute kidney injury (AKI). Discussion: There is an association between certain pre-exiting conditions and worse outcomes. Early identification of these factors could provide a foundation for better interdisciplinary management, prevention of complications and associated mortality., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Patients with type O blood may have an increased risk of hemorrhagic complications because of lower baseline levels of von Willebrand factor and factor VIII, but the transition to a mortality difference in trauma is less clear. We hypothesized that type O trauma patients will have differential proteomic and metabolomic signatures in response to trauma beyond von Willebrand factor and factor VIII alone., Methods: Patients meeting the highest level of trauma activation criteria were prospectively enrolled. Blood samples were collected upon arrival to the emergency department. Proteomic and metabolomic (multiomics) analyses of these samples were performed using liquid chromatography-mass spectrometry. Demographic, clinical, and multiomics data were compared between patients with type O blood versus all other patients., Results: There were 288 patients with multiomics data; 146 (51%) had type O blood. Demographics, injury patterns, and initial vital signs and laboratory measurements were not different between groups. Type O patients had increased lengths of stay (7 vs. 6 days, p = 0.041) and a trend toward decreased mortality secondary to traumatic brain injury compared with other causes (traumatic brain injury, 44.4% vs. 87.5%; p = 0.055). Type O patients had decreased levels of mannose-binding lectin and mannose-binding lectin-associated serine proteases 1 and 2, which are required for the initiation of the lectin pathway of complement activation. Type O patients also had metabolite differences signifying energy metabolism and mitochondrial dysfunction., Conclusion: Blood type O patients have a unique multiomics signature, including decreased levels of proteins required to activate the lectin complement pathway. This may lead to overall decreased levels of complement activation and decreased systemic inflammation in the acute phase, possibly leading to a survival advantage, especially in traumatic brain injury. However, this may later impair healing. Future work will need to confirm these associations, and animal studies are needed to test therapeutic targets., Level of Evidence: Prognostic and Epidemiological; Level IV., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Patients admitted to the intensive care unit (ICU) following trauma often have multiple injuries, which can lead to disordered swallowing, dysphagia. The prevalence of dysphagia in trauma populations ranges between 4.2% and 86%; however, clinical and associated longitudinal health outcomes and patient-reported quality of life are unknown., Objectives: The objective of this study was to compare hospital and clinical outcomes for older critically ill trauma patients diagnosed with and without dysphagia up to 12 months after hospital admission. Secondary outcomes include characteristics of dysphagia assessment and recovery during indexed hospital admission., Methods: Post hoc analysis of an observational study. All patients were recruited from a tertiary ICU trauma unit, all were aged above 50 years, with an expected ICU length of stay of >24 h. Criteria of dysphagia diagnosis were determined via presence of International Classification of Diseases (ICD-10) code (R13). Hospital, clinical, and health-reported quality-of-life data were collected., Results: Ninety-eight patients were included with 79 (81%) being male, overall median injury severity scale: 21.5 (interquartile range: 14-29); 38 (38.8%) with spinal injury, 37 (37.8%) with multitrauma excluding head injury, and 23 (23.5%) with multitrauma including head injury. Prevalence of dysphagia was 29%, with patients diagnosed with dysphagia more likely to have required invasive mechanical ventilation (odds ratio [OR]: 4.0, 95% confidence interval [CI]: 1.25-12.78), for an increased duration (OR: 2.6, 95% CI: 0.27-4.92) and required longer ICU admission (OR: 2.98, 95% CI: 0.28-5.69). Recovery of swallow function was protracted beyond the indexed hospital admission, with only 18% of those diagnosed with dysphagia returning to a normal, unrestricted, oral diet by hospital discharge. At 6 and 12 months, functional disabilities were reported across the cohort with no significant differences between groups., Conclusions: In older critically ill trauma patients, dysphagia is common. Use and duration of invasive mechanical ventilation and increased ICU length of stay for survivors were significantly increased for those with dysphagia. Management of swallowing is required across the continuum of care commencing in and beyond ICU to optimise recovery and outcomes., (Copyright © 2023 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Introduction: Patients living with substance use disorder (SUD) have complex pain management needs, which may be mismanaged during hospital admission. Ineffectively managed pain following orthopaedic trauma, influenced by clinician biases related to race or SUD diagnosis, may subject patients to worse pain outcomes and subsequent emergency department (ED) encounters. This study examined ED encounters and opioid prescribing for pain-related complaints following orthopaedic trauma, among patients with SUD who identify as Black or African American relative to White patients., Methods: This retrospective analysis included 1089 patients with a SUD diagnosis discharged from a Level I trauma center, following hospitalization for orthopaedic injuries, between 2016 and 2021. Multivariable regressions assessed the associations among race, opioid prescribing, and ED encounters within 90 days for pain-related care., Results: Among the 1089 patients included in the sample, the proportion of individuals with an ED encounter within 90 days for pain-related care was 12.4 % and 4.5 % for Black and White patients, respectively (odds ratio [OR] = 3.0, p < .001). When adjusting for injury severity and demographics, the difference in ED encounters between Black and White patients remained significant (OR = 2.8, p = .002). Opioid prescription doses did not statistically differ by race., Conclusions: The difference in ED encounters between Black and White patients with SUDs following orthopaedic trauma may indicate a need to optimize pain management prior to initial discharge and improve post-injury care., Competing Interests: Declaration of competing interest Nothing to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: This study aims to evaluate the temporal trends of mortality among frail versus non-frail older adult trauma patients during index hospitalization., Methods: We performed a 3-year (2017-2019) analysis of ACS-TQIP. We included all older adult (age ≥65 years) trauma patients. Patients were stratified into two groups (Frail vs. Non-Frail). Outcomes were acute (<24 ​h), early (24-72 ​h), intermediate (72 hours-1 week), and late (>1 week) mortality., Results: A total of 1,022,925 older adult trauma patients were identified, of which 19.7 ​% were frail. The mean(SD) age was 77(8) years and 57.4 ​% were female. Median[IQR] ISS was 9[4-10] and both groups had comparable injury severity (p ​= ​0.362). On multivariable analysis, frailty was not associated with acute (aOR 1.034; p ​= ​0.518) and early (aOR 1.190; p ​= ​0.392) mortality, while frail patients had independently higher odds of intermediate (aOR 1.269; p ​= ​0.042) and late (aOR 1.835; p ​< ​0.001) mortality. On sub-analysis, our results remained consistent in mild, moderate, and severely injured patients., Conclusion: Frailty is an independent predictor of mortality in older adult trauma patients who survive the initial 3 days of admission, regardless of injury severity., Competing Interests: Declaration of competing interest There are no identifiable conflicts of interest to report. Bellal Joseph reports honoraria for travel and lecture from CSL Behring. All other authors have no financial or proprietary interest in the subject matter or materials discussed in the manuscript., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in trauma patients, despite chemoprophylaxis. Statins have been shown capable of acting upon the endothelium. We hypothesized that statin therapy in the pre- or in-hospital settings leads to a decreased incidence of VTE., Methods: We conducted a retrospective cohort study of injured patients who received statin therapy pre- or in-hospital. Adult, highest-level trauma activation patients admitted from January 2018 to June 2022 were included. Patients on prehospital anticoagulants, had history of inherited bleeding disorder, and who died within the first 24 hours were excluded. Statin users were matched to nonusers by statin use indications including age, current heart and cardiovascular conditions and history, hyperlipidemia, injury severity, and body mass index. Time to in-hospital statin initiation and occurrence of VTE and other complications within 60 days were collected. Differences between groups were determined by univariate, multivariable logistic regression, and Cox proportional hazard analyses., Results: Of 3,062 eligible patients, 79 were statin users, who were matched to 79 nonusers. There were no differences in admission demographics, vital signs, injury pattern, transfusion volumes, lengths of stay, or mortality between groups. The overall VTE incidence was 10.8% (17 of 158). Incidence of VTE in statin users was significantly lower (3%) than nonusers (19%; p = 0.003). Differences between statin users and nonusers were observed for rates of deep vein thrombosis (0% vs. 9%), pulmonary embolism (3% vs. 15%), and sepsis (0% vs. 5%). Exposure to statins was associated with an 82% decreased risk of developing VTE (hazard ratio, 0.18; 95% confidence interval, 0.04-0.86; p = 0.033)., Conclusion: Statin exposure was associated with decline in VTE and lower individual rates of deep vein thrombosis, pulmonary embolism, and sepsis. Our findings indicate that statins should be evaluated further as a possible adjunctive therapy for VTE chemoprophylaxis after traumatic injury., Level of Evidence: Therapeutic/Care Management; Level IV., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Approximately 20% to 50% of patients develop persistent pain after traumatic orthopaedic injuries. Psychosocial factors are an important predictor of persistent pain; however, there are no evidence-based, mind-body interventions to prevent persistent pain for this patient population., Questions/purposes: (1) Does the Toolkit for Optimal Recovery after Injury (TOR) achieve a priori feasibility benchmarks in a multisite randomized control trial (RCT)? (2) Does TOR demonstrate a preliminary effect in improving pain, as well as physical and emotional function?, Methods: This pilot RCT of TOR versus a minimally enhanced usual care comparison group (MEUC) was conducted among 195 adults with an acute orthopaedic traumatic injury at risk for persistent pain at four geographically diverse Level 1 trauma centers between October 2021 to August 2023. Fifty percent (97 of 195) of participants were randomized to TOR (mean age 43 ± 17 years; 67% [65 of 97] women) and 50% (98) to MEUC (mean age 45 ± 16 years; 67% [66 of 98] women). In TOR, 24% (23 of 97) of patients were lost to follow-up, whereas in the MEUC, 17% (17 of 98) were lost. At 4 weeks, 78% (76 of 97) of patients in TOR and 95% (93 of 98) in the MEUC completed the assessments; by 12 weeks, 76% (74 of 97) of patients in TOR and 83% (81 of 98) in the MEUC completed the assessments (all participants were still included in the analysis consistent with an intention-to-treat approach). The TOR has four weekly video-administered sessions that teach pain coping skills. The MEUC is an educational pamphlet. Both were delivered in addition to usual care. Primary outcomes were feasibility of recruitment (the percentage of patients who met study criteria and enrolled) and data collection, appropriateness of treatment (the percent of participants in TOR who score above the midpoint on the Credibility and Expectancy Scale), acceptability (the percentage of patients in TOR who attend at least three of four sessions), and treatment satisfaction (the percent of participants in TOR who score above the midpoint on the Client Satisfaction Scale). Secondary outcomes included additional feasibility (including collecting data on narcotics and rescue medications and adverse events), fidelity (whether the intervention was delivered as planned) and acceptability metrics (patients and staff), pain (numeric rating scale), physical function (Short Musculoskeletal Function Assessment questionnaire [SMFA], PROMIS), emotional function (PTSD [PTSD Checklist], depression [Center for Epidemiologic Study of Depression]), and intervention targets (pain catastrophizing, pain anxiety, coping, and mindfulness). Assessments occurred at baseline, 4 and 12 weeks., Results: Several outcomes exceeded a priori benchmarks: feasibility of recruitment (89% [210 of 235] of eligible participants consented), appropriateness (TOR: 73% [66 of 90] scored > midpoint on the Credibility and Expectancy Scale), data collection (79% [154 of 195] completed all surveys), satisfaction (TOR: 99% [75 of 76] > midpoint on the Client Satisfaction Scale), and acceptability (TOR: 73% [71 of 97] attended all four sessions). Participation in TOR, compared with the MEUC, was associated with improvement from baseline to postintervention and from baseline to follow-up in physical function (SMFA, baseline to post: -7 [95% CI -11 to -4]; p < 0.001; baseline to follow-up: -6 [95% CI -11 to -1]; p = 0.02), PROMIS (PROMIS-PF, baseline to follow-up: 2 [95% CI 0 to 4]; p = 0.045), pain at rest (baseline to post: -1.2 [95% CI -1.7 to -0.6]; p < 0.001; baseline to follow-up: -1 [95% CI -1.7 to -0.3]; p = 0.003), activity (baseline to post: -0.7 [95% CI -1.3 to -0.1]; p = 0.03; baseline to follow-up: -0.8 [95% CI -1.6 to -0.1]; p = 0.04), depressive symptoms (baseline to post: -6 [95% CI -9 to -3]; p < 0.001; baseline to follow-up: -5 [95% CI -9 to -2]; p < 0.002), and posttraumatic symptoms (baseline to post: -4 [95% CI -7 to 0]; p = 0.03; baseline to follow-up: -5 [95% CI -9 to -1]; p = 0.01). Improvements were generally clinically important and sustained or continued through the 3 months of follow-up (that is, above the minimum clinically important different [MCID] of 7 for the SMFA, the MCID of 3.6 for PROMIS, the MCID of 2 for pain at rest and pain during activity, the MCID of more than 10% change in depressive symptoms, and the MCID of 10 for posttraumatic symptoms). There were treatment-dependent improvements in pain catastrophizing, pain anxiety, coping, and mindfulness., Conclusion: TOR was feasible and potentially efficacious in preventing persistent pain among patients with an acute orthopaedic traumatic injury. Using TOR in clinical practice may prevent persistent pain after orthopaedic traumatic injury., Level of Evidence: Level I, therapeutic study., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2024 by the Association of Bone and Joint Surgeons.)

Wound infection and excessive blood loss are the two major challenges associated with trauma injuries that account for 10% of annual deaths in the United States. Nitric oxide (NO) is a gasotransmitter cell signaling molecule that plays a crucial role in the natural wound healing process due to its antibacterial, anti-inflammatory, cell proliferation, and tissue remodeling abilities. Tranexamic acid (TXA), a prothrombotic agent, has been used topically and systemically to control blood loss in reported cases of epistaxis and combat-related trauma injuries. Its properties could be incorporated in wound dressings to induce immediate clot formation, which is a key factor in controlling excessive blood loss. This study introduces a novel, instant clot-forming NO-releasing dressing, and fabricated using a strategic bi-layer configuration. The layer adjacent to the wound was designed with TXA suspended on a resinous bed of propolis, which is a natural bioadhesive possessing antibacterial and anti-inflammatory properties. The base layer, located furthest away from the wound, has an NO donor, S-nitroso-N-acetylpenicillamine (SNAP), embedded in a polymeric bed of Carbosil®, a copolymer of polycarbonate urethane and silicone. Propolis was integrated with a uniform layer of TXA in variable concentrations: 2.5, 5.0, and 7.5 vol % of propolis. This design of the TXA-SNAP-propolis (T-SP) wound dressing allows TXA to form a more stable clot by preventing the lysis of fibrin. The lactate dehydrogenase-based platelet adhesion assay showed an increase in fibrin activation with 7.5% T-SP as compared with control within the first 15 min of its application. A scanning electron microscope (SEM) confirmed the presence of a dense fibrin network stabilizing the clot for fabricated dressing. The antibacterial activity of NO and propolis resulted in a 98.9 ± 1% and 99.4 ± 1% reduction in the colony-forming unit of Staphylococcus aureus and multidrug-resistant Acinetobacter baumannii, respectively, which puts forward the fabricated dressing as an emergency first aid for traumatic injuries, preventing excessive blood loss and soil-borne infections., (© 2024 Wiley Periodicals LLC.)

Introduction: Alcohol is commonly detected in patients presenting to hospital after major trauma and is a key preventable risk factor for injury. While it has been suggested that alcohol intoxication at the time of injury results in worse acute patient outcomes, there is currently limited knowledge on the impact of alcohol on health outcomes following hospital discharge. The aim of this study was to examine the relationship between acute pre-injury alcohol exposure and the self-reported health outcomes of survivors of major trauma 12-months post-injury., Methods: Data from the Victorian State Trauma Registry (January 1, 2018 to December 31, 2020) were used to identify major trauma patients who: (1) were aged ≥18 years; (2) survived to 12-months post-injury; and (3) had blood alcohol data available in the registry. Logistic regression analyses were used to examine differences in self-reported health status (EQ-5D) and return to work at 12-months post-injury by blood alcohol concentration (BAC) at the time of presentation to hospital. Analyses were adjusted for potential confounders including a range of demographic, hospital and injury characteristics., Results: A total of 2957 patients met inclusion criteria, of which 857 (29.0 %) had a BAC >0 and 690 (23.3 %) had a BAC ≥0.05 g/100 mL. After adjusting for potential confounders, having any alcohol detected (i.e., BAC >0) was associated with lower odds of reporting problems on the EQ-5D mobility (aOR = 0.72, 95 %CI = 0.53 to 0.99) and usual activities dimensions (aOR = 0.79, 95 %CI = 0.63 to 0.99). Having a BAC ≥0.05 g/100 mL was only associated with lower adjusted odds of reporting problems on the usual activities dimension (aOR = 0.69, 95 %CI = 0.55 to 0.88) of the EQ-5D. Alcohol detection was not associated with the self-care, pain/discomfort or anxiety/depression dimensions of the EQ-5D, or with return to work in adjusted analyses., Conclusion: Acute pre-injury alcohol exposure was not associated with increased reporting of problems on the EQ-5D or with return to work at 12-months post-injury. Further research is needed to understand why patients with alcohol detections were sometimes associated with paradoxically better 12-month post-injury outcomes relative to patients without alcohol detections., Competing Interests: Declaration of competing interest The VSTR is a Department of Health and Human Services, State Government of Victoria and Transport Accident Commission funded project. GL was supported by a Monash University Postgraduate Publications Award. BJG was supported by National Health and Medical Research Council Investigator Grant (L2, ID 2009998). PMD was supported by a National Health and Medical Research Council Senior Research Fellowship (1136090). BB was supported by an Australian Research Council Discovery Future Fellowship (FT210100183)., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Platelets are well known for their roles in hemostasis, but they also play a key role in thromboinflammatory pathways by regulating endothelial health, stimulating angiogenesis, and mediating host defense through both contact dependent and independent signaling. When activated, platelets degranulate releasing multiple active substances. We hypothesized that the soluble environment formed by trauma platelet releasates (TPR) attenuates thromboinflammation via mitigation of trauma induced endothelial permeability and metabolomic reprogramming., Methods: Blood was collected from injured and healthy patients to generate platelet releasates and plasma in parallel. Permeability of endothelial cells when exposed to TPR and plasma (TP) was assessed via resistance measurement by electric cell-substrate impedance sensing (ECIS). Endothelial cells treated with TPR and TP were subjected to mass spectrometry-based metabolomics., Results: TP increased endothelial permeability, whereas TPR decreased endothelial permeability when compared with untreated cells. When TP and TPR were mixed ex vivo, TPR mitigated TP-induced permeability, with significant increase in AUC compared with TP alone. Metabolomics of TPR and TP demonstrated disrupted redox reactions and anti-inflammatory mechanisms., Conclusion: Trauma platelet releasates provide endothelial barrier protection against TP-induced endothelial permeability. Our findings highlight a potential beneficial action of activated platelets on the endothelium in injured patients through disrupted redox reactions and increased antioxidants. Our findings support that soluble signaling from platelet degranulation may mitigate the endotheliopathy of trauma. The clinical implications of this are that activated platelets may prove a promising therapeutic target in the complex integration of thrombosis, endotheliopathy, and inflammation in trauma., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Congenital heart disease (CHD) is one the most common congenital anomalies, with a prevalence of 8-10 cases per 1000 live births in the United States. Congenital heart disease has been recognized as a risk factor for poor perioperative and postoperative outcomes in non-cardiac surgery. We aimed to determine if documentation of CHD-related diagnosis codes was associated with similar risks for trauma surgery., Methods: Data were acquired from the 2010-2019 American College of Surgeons' Trauma Quality Programs Participant Use Files. This study included trauma patients of all ages with one or more surgical procedures and at least one documented non-trauma (comorbidity) International Classification of Diseases code. Patients were stratified based on presence of CHD-related comorbidity codes vs any other comorbidity. Outcomes included mortality, hospital length of stay (LOS), discharge disposition, and in-hospital complications., Results: Using 1:1 propensity score matching, we matched 215 cases with CHD-related comorbid diagnoses to non-CHD controls. Compared to patients with other comorbidities, patients with CHD-related comorbidites were less likely to be discharged home to self-care (odds ratio: 0.44, 95% confidence interval [CI]: 0.25, 078 P = .005) and tended to have prolonged hospital LOS (incidence rate ratio [IRR]: 1.06, 95% CI: 1.001, 1.13, P = .046)., Conclusions: We present the first quantitative multicenter analysis correlating documentation of comorbid CHD-related diagnoses with higher risk of adverse outcomes after trauma surgery. These results support the need to routinely acknowledge and document CHD as comorbidity in trauma admissions that could lead to surgical intervention and for trauma centers to prepare for patients with a possible CHD comorbidity., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: DT discloses salary support from the Kate B. Reynolds Charitable Trust and Lilly and Co., Inc., for unrelated research and quality improvement projects. LS discloses consulting fees from Nutricia.

Background: Alcohol use is a contributing factor in many cases of traumatic injury. There is conflicting evidence on the impact of alcohol use at the time of physical trauma on severity of injury and hospital course. Similarly, the significance of alcohol use disorder on outcomes in hospitalized trauma patients is unclear. This scoping review aims to provide a concise overview of the current literature surrounding peri-trauma alcohol use and alcohol use disorder on injury severity, in-hospital complications, patient outcomes, and long-term health impact of alcohol use in trauma. We will also explore the associated healthcare costs of this patient population., Methods: A systematic search of the following databases MEDLINE, EMBASE, and Cochrane Library will be completed to extract all studies that meet our inclusion criteria from January 2000 onwards. Case reports will be excluded. Two reviewers will screen all citations, abstracts, and full text articles. A third reviewer will act as tiebreaker at each stage of the screening process. A narrative synthesis without meta-analysis will be conducted and assessed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines., Discussion: This review will contribute to the literature by providing a concise overview of the current data on the impact of alcohol on outcomes following trauma. We will explore the overall themes in the literature, limitations, and future directions to focus forthcoming research in this patient population., Scoping Review Registration: This project is registered via the Open Science Framework. The public registration is uniquely identified with the following DOI: https://doi.org/10.17605/OSF.IO/Z84WK., Support: There were no funders or sponsors involved in the development of this protocol., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Garland et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The use of prehospital tranexamic acid (TXA) in patients with trauma has attracted considerable attention. This systematic review and meta-analysis aimed to provide the best evidence for clinicians., Methods: All related literature in PubMed, Embase, and the Cochrane Central Register of Controlled Trials (Central) databases were searched systematically from their establishment to July 1, 2023. The outcome measures included 24-hour and 28-30-day mortality and adverse events (multiple organ dysfunction syndrome, acute respiratory distress syndrome, thrombotic events, and infection events). The Revised Cochrane Risk of Bias Tool for Randomized Trials was used to evaluate the quality of the randomized controlled trials (RCTs). The Methodological Index for Nonrandomized Studies (MINORS) was used to evaluate the risk of bias in non-RCTs. The required information size was estimated using trial sequential analysis. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to evaluate the evidence quality., Results: Eleven studies (comprising 11,259 patients) were included; two of these were RCTs. The overall risks of bias were low in the RCTs. ROBINS-I risk of bias was Moderate in 3 studies, serious in 5 studies, and critical in 1 study. A significant reduction in 24-hour mortality was observed (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.71-0.94). A subgroup analysis that included only RCTs revealed that prehospital TXA was associated with reduced 28-30-day mortality (OR, 0.80; 95% CI, 0.66-0.97) and increased risks of thromboembolism (OR, 1.22; 95% CI, 1.03-1.44) and infection (OR, 1.13; 95% CI, 1.00-1.28) events. The blood products for transfusion decreased by 2.3 units on average (weighted mean difference [WMD], - 2.30; 95%CI, - 3.59 to - 1.01)., Conclusions: This updated systematic review showed that prehospital TXA reduced the 24-hour and 28-38-day mortality and blood transfusion but increased the risks of infection and thromboembolism in patients with trauma. Future RCTs with larger and more homogeneous samples will help verify our results., (© 2024. The Author(s).)

Introduction: The measure of mortality following a major complication (failure to rescue [FTR]) provides a quantifiable assessment of the level of care provided by trauma centers. However, there is a lack of data on the effects of patient-related factors on FTR incidence. The aim of this study was to identify the role of frailty on FTR incidence among geriatric trauma patients with ground-level falls (GLFs)., Methods: This is a retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database (2017-2020). All geriatric (aged ≥ 65 ys) trauma patients with GLFs admitted to a level I trauma center were included. Transferred patients, those with severe head injuries (head abbreviated injury scale ≥ 3), and those who died within 24 h of admission or whose length of stay was ≤1 d were excluded. FTR was defined as death following a major complication (cardiac arrest, myocardial infarction, sepsis, acute respiratory distress syndrome, unplanned intubation, acute renal failure, cerebrovascular accident, ventilator-associated pneumonia, or pulmonary embolism). Patients were stratified into frail (F) and nonfrail (NF) based on the 11-Factor Modified Frailty Index. Multivariable regression analyses were performed to identify the independent effect of frailty on the incidence of FTR., Results: Over 4 ys, 34,100 geriatric patients with GLFs were identified, of whom 9140 (26.8%) were F. The mean (standard deviation) age was 78 (7) years and 65% were female. The median injury severity score was 9 (5-10) with no difference among F and NF groups (P = 0.266). Overall, F patients were more likely to develop major complications (F: 3.6% versus NF: 2%, P < 0.001) and experience FTR (F: 1.8%% versus NF: 0.6%, P < 0.001). Moreover, among patients with major complications, F patients were more likely to die (F: 47% versus NF: 27%, P < 0.001). On multivariable regression analysis, frailty was identified as an independent predictor of major complications (adjusted odds ratio: 1.98, 95% confidence interval [1.70-2.29], P < 0.001) and FTR (adjusted odds ratio: 2.26, 95% confidence interval [1.68-3.05], P < 0.001)., Conclusions: Among geriatric trauma patients with GLFs, frailty increases the risk-adjusted odds of FTR by more than two times. One in every two F patients with a major complication does not survive to discharge. Future efforts should concentrate on improving patient-related and hospital-related factors to decrease the risk of FTR among these vulnerable populations., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Abstract: Fat embolism syndrome refers to a systemic condition caused by the circulation of fat droplets in the bloodstream, reaching various target organs typically after major bone fractures or related surgical procedures. Although most cases resolve spontaneously, severe instances can lead to significant respiratory failure, neurological damage, and even mortality. Therefore, appropriate prevention, timely diagnosis, and management are crucial for trauma patients at risk. The objective of this review article is to explore the definition, epidemiology, risk factors, clinical presentation, and pathophysiology of fat embolism syndrome. Furthermore, it aims to examine current recommendations for the accurate diagnosis, prevention, and treatment of it, providing a comprehensive guide for the effective management of patients prone to this condition., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Context: Epileptic seizures and the unpredictable falls resulting from epileptic seizures predispose the people living with epilepsy (PLWE) to various physical injuries as well as postictal cognitive and behavioral changes., Aims: The aim of the study was to determine the frequency and patterns of seizure-related physical injuries, postictal cognitive impairments, and behavioral changes., Settings and Design: This was a cross-sectional descriptive study in a Southeast Nigeria local government area., Subjects and Methods: PLWE identified during a two-phase door-to-door survey and their caregivers were interviewed using a semi-structured questionnaire., Statistical Analysis Used: The Statistical Package for the Social Sciences version 22.0 was used., Results: There were 56 cases of active convulsive seizures comprising 33 (58.9%) males and 23 (41.1%) females, with a mean age of 32.9 ± 14.2. The lifetime prevalence of seizure-related physical injuries, postictal behavioral changes, and postictal cognitive impairments was 9.8 per 1000 (95% confidence interval [CI]: 9.1-10.0), 8.4 per 1000 (95% CI: 7.2-9.2), and 6.3 per 1000 (95% CI: 4.9-7.5), respectively. Skin/soft-tissue injuries and tongue laceration were the most frequent physical injuries found in 66.1% ( n = 37/56) and 60.7% ( n = 34/56) of cases, respectively. The frequency of soft-tissue injuries was significantly higher (χ 2 = 5.038; P = 0.0248) in the females 78.3% ( n = 18/23) than the males 48.5% ( n = 16/33). About a third of the females 39.1% had burn injuries compared to 18.1% of the males., Conclusions: Seizure-related injuries are common and have the tendency to increase the burden of epilepsy and epilepsy-related stigma from deformities and the chronic disfiguring scars resulting from such injuries., (Copyright © 2024 Copyright: © 2024 Annals of African Medicine.)

Background: This study reviews and meta-analysis factors affecting mortality in older adult trauma patients, addressing previously unidentified heterogeneity and risk burden., Methods: Databases (PubMed, Embase, Cochrane and Scopus) were searched for studies from January 1, 2000, to April 30, 2024. Inclusion criteria were patients aged ≥65 years with trauma, assessing survival or death outcomes. Two authors independently screened and extracted data using the PRISMA checklist; disagreements were resolved by a third author., Results: Eighteen retrospective studies were included (425,355 patients), showing an overall mortality rate of 9.6 ​%. Falls were the predominant cause of injury. Demographic mortality risk factors included advanced age, frailty, male sex, and comorbidities (blood/bleeding disorders, liver disease, cancer, kidney disease, and lung disease). Injury risk factors were identified as contributing to the outcome, including low systolic blood pressure, Glasgow Coma Scale, Injury Severity Score, Revised Trauma Score, and surgical intervention., Conclusion: Trauma significantly elevates the mortality rate in older adults, with advanced age, gender, comorbidities, injury severity, frailty, and surgical intervention being key factors., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Malnutrition is shown to be associated with worse outcomes among surgical patients, yet its postdischarge outcomes in trauma patients are not clear. This study aimed to evaluate both index admission and postdischarge outcomes of geriatric trauma patients who are at risk of poor nutritional status., Methods: This is a secondary analysis of the prospective observational American Association of Surgery for Trauma Frailty Multi-institutional Trial. Geriatric (≥65 years) patients presenting to 1 of the 17 Level I/II/III trauma centers (2019-2021) were included and stratified using the simplified Geriatric Nutritional Risk Index (albumin [g/dL] + body mass index [kg/m 2 ]/10) into severe (simplified Geriatric Nutritional Risk Index <5), moderate (5.5> simplified Geriatric Nutritional Risk Index ≥5), mild level of nutritional risk (6> simplified Geriatric Nutritional Risk Index ≥5.5), and good nutritional status (simplified Geriatric Nutritional Risk Index ≥6) and compared., Results: Of the 1,321 patients enrolled, 22% were at risk of poor nutritional status (mild: 13%, moderate: 7%, severe: 3%). The mean age was 77 ± 8 years, and the median [interquartile range] Injury Severity Score was 9 [5-13]. Patients at risk of poor nutritional status had greater rates of sepsis, pneumonia, discharge to the skilled nursing facility and rehabilitation center, index-admission mortality, and 3-month mortality (P < .05). On multivariable analyses, being at risk of severe level of nutritional risk was independently associated with sepsis (adjusted odds ratio 6.21, 95% confidence interval 1.68-22.90, P = .006), pneumonia (adjusted odds ratio 4.40, 95% confidence interval 1.21-16.1, P = .025), index-admission mortality (adjusted odds ratio 3.16, 95% confidence interval 1.03-9.68, P = .044), and 3-month mortality (adjusted odds ratio 8.89, 95% confidence interval 2.01-39.43, P = .004) compared with good nutrition state., Conclusion: Nearly one quarter of geriatric trauma patients were at risk of poor nutritional status, which was identified as an independent predictor of worse index admission and 3-month postdischarge outcomes. These findings underscore the need for nutritional screening at admission., Competing Interests: Conflicts of interest/Disclosure The authors have no related conflicts of interest to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Hemorrhage is a leading cause of preventable death in trauma. Accurately predicting a patient's blood transfusion requirement is essential but can be difficult. Machine learning (ML) is a field of artificial intelligence that is emerging within medicine for accurate prediction modeling. This systematic review aimed to identify and evaluate all ML models that predict blood transfusion in trauma., Methods: This systematic review was registered on the International Prospective register of Systematic Reviews (CRD4202237110). MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were systematically searched. Publications reporting an ML model that predicted blood transfusion in injured adult patients were included. Data extraction and risk of bias assessment were performed using validated frameworks. Data were synthesized narratively because of significant heterogeneity., Results: Twenty-five ML models for blood transfusion prediction in trauma were identified. Models incorporated diverse predictors and varied ML methodologies. Predictive performance was variable, but eight models achieved excellent discrimination (area under the receiver operating characteristic curve, >0.9) and nine models achieved good discrimination (area under the receiver operating characteristic curve, >0.8) in internal validation. Only two models reported measures of calibration. Four models have been externally validated in prospective cohorts: the Bleeding Risk Index, Compensatory Reserve Index, the Marsden model, and the Mina model. All studies were considered at high risk of bias often because of retrospective data sets, small sample size, and lack of external validation., Discussion: This review identified 25 ML models developed to predict blood transfusion requirement after injury. Seventeen ML models demonstrated good to excellent performance in silico, but only four models were externally validated. To date, ML models demonstrate the potential for early and individualized blood transfusion prediction, but further research is critically required to narrow the gap between ML model development and clinical application., Level of Evidence: Systematic Review Without Meta-analysis; Level IV., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Aim: This study aimed to explore the relationships between serum cortisol levels, personality traits, and the development of Post-Traumatic Stress Disorder (PTSD) over 2 years among individuals with physical injuries., Methods: Participants were consecutively recruited from a trauma center and followed prospectively for 2 years. At baseline, serum cortisol levels were measured, and personality traits were categorized into five dimensions (Extraversion, Agreeableness, Conscientiousness, Neuroticism, and Openness), using the Big Five Inventory-10. The diagnosis of PTSD during follow-up (at 3, 6, 12, and 24 months post-injury) was determined using the Clinician-Administered PTSD Scale for DSM-5. Binary and multinomial logistic regression analyses were conducted to examine the interactions between cortisol levels, personality traits, and PTSD development., Results: Among 923 patients analyzed, 112 (12.1%) were diagnosed with PTSD at some point during the study period, with prevalence rates decreasing from 8.8% at 3 months to 3.7% at 24 months post-injury. Direct associations between cortisol levels or personality traits and PTSD were not observed. However, a significant interaction between lower cortisol levels and higher Neuroticism in relation to PTSD risk was identified, especially during the early follow-up periods (3 to 6 months), but this association waned from the 12-month follow-up onward., Conclusion: Our findings reveal Neuroticism-dependent associations between serum cortisol levels and PTSD development, exhibiting temporal variations. These results suggest that PTSD development may be influenced by a complex, time-sensitive interplay of biological and psychosocial factors, underscoring the importance of considering individual differences in stress reactivity and personality in PTSD research and treatment., (© 2024 The Author(s). Psychiatry and Clinical Neurosciences © 2024 Japanese Society of Psychiatry and Neurology.)

Introduction: Tranexamic acid (TXA) is an antifibrinolytic drug that is used in traumatic hemorrhage and traumatic brain injury. Although TXA is considered relatively safe and inexpensive and is widely available, data regarding its mechanisms, optimal dosing, and timing, as well as relative risks and benefits for different patient populations, are inconsistent. In this study, we aim to identify and summarize consensus research questions related to TXA across all National Trauma Research Action Plan (NTRAP) Delphi expert panels to identify priorities for future research on TXA in trauma., Methods: A secondary analysis was performed using consensus-based research priorities collected by 11 NTRAP topic panels using a Delphi methodology. The database of questions was queried for the keywords "tranexamic" and "TXA." The identified questions were sorted by subject matter and summarized., Results: Seven panels included a total of 73 TXA-related questions. Forty-six questions reached consensus. The most addressed topic was outcomes (discussed in 64% of questions) followed by indications (49%) and specific patient populations (38%). Because of overlap across panels, questions were summarized and sorted by topic resulting in 21 priority research questions., Conclusion: Seventy-three total questions and 46 questions reaching consensus were identified by NTRAP panelists. The key topics identified in these questions should be prioritized in future funded research on TXA in trauma., Level of Evidence: Prognostic and Epidemiological; Level V., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: The indications, safety, and efficacy of chemical venous thromboembolism prophylaxis (cVTE) in pediatric trauma patients remain unclear. A set of high-risk criteria to guide cVTE use was recently recommended; however, these criteria have not been evaluated prospectively., Objective: To examine high-risk criteria and cVTE use in a prospective multi-institutional study of pediatric trauma patients., Design, Setting, and Participants: This cohort study was completed between October 2019 and October 2022 in 8 free-standing pediatric hospitals designated as American College of Surgeons level I pediatric trauma centers. Participants were pediatric trauma patients younger than 18 years who met defined high-risk criteria on admission. It was hypothesized that cVTE would be safe and reduce the incidence of VTE., Exposures: Receipt and timing of chemical VTE prophylaxis., Main Outcomes and Measures: The primary outcome was overall VTE rate stratified by receipt and timing of cVTE. The secondary outcome was safety of cVTE as measured by bleeding or other complications from anticoagulation., Results: Among 460 high-risk pediatric trauma patients, the median (IQR) age was 14.5 years (10.4-16.2 years); 313 patients (68%) were male and 147 female (32%). The median (IQR) Injury Severity Score (ISS) was 23 (16-30), and median (IQR) number of high-risk factors was 3 (2-4). A total of 251 (54.5%) patients received cVTE; 62 (13.5%) received cVTE within 24 hours of admission. Patients who received cVTE after 24 hours had more high-risk factors and higher ISS. The most common reason for delayed cVTE was central nervous system bleed (120 patients; 30.2%). There were 28 VTE events among 25 patients (5.4%). VTE occurred in 1 of 62 patients (1.6%) receiving cVTE within 24 hours, 13 of 189 patients (6.9%) receiving cVTE after 24 hours, and 11 of 209 (5.3%) who had no cVTE (P = .31). Increasing time between admission and cVTE initiation was significantly associated with VTE (odds ratio, 1.01; 95% CI, 1.00-1.01; P = .01). No bleeding complications were observed while patients received cVTE., Conclusions and Relevance: In this prospective study, use of cVTE based on a set of high-risk criteria was safe and did not lead to bleeding complications. Delay to initiation of cVTE was significantly associated with development of VTE. Quality improvement in pediatric VTE prevention may center on timing of prophylaxis and barriers to implementation.

Background: Non-narcotic intravenous medications may be a beneficial adjunct to oral multimodal pain regimens (MMPRs) which reduce but do not eliminate opioid exposure and prescribing after trauma. We hypothesized that the addition of a subdissociative ketamine infusion (KI) to a standardized oral MMPR reduces inpatient opioid exposure., Methods: Eligible adult trauma patients admitted to the intermediate or intensive care unit were randomized upon admission to our institutional MMPR per usual care (UC) or UC plus subdissociative KI for 24 hours to 72 hours after arrival. The primary outcome was morphine milligram equivalents per day (MME/d) and secondary outcomes included total MME, discharge with an opioid prescription (OP%), and rates of ketamine side effects. Bayesian posterior probabilities (pp) were calculated using neutral priors., Results: A total of 300 patients were included in the final analysis with 144 randomized to KI and 156 to UC. Baseline characteristics were similar between groups. The Injury Severity Scores for KI were 19 [14, 29] versus UC 22 [14, 29]. The KI group had a lower rate of long-bone fracture (37% vs. 49%) and laparotomy (16% vs. 24%). Patients receiving KI had an absolute reduction of 7 MME/day, 96 total MME, and 5% in OP%. In addition, KI had a relative risk (RR) reduction of 19% in MME/day (RR, 0.81 [0.69-0.95], pp = 99%), 20% in total MME (RR, 0.80 [0.64-0.99], pp = 98%), and 8% in OP% (RR, 0.92 [0.76-1.11], pp = 81%). The KI group had a higher rate of delirium (11% vs. 6%); however, rates of other side effects such as arrythmias and unplanned intubations were similar between groups., Conclusion: Addition of a subdissociative ketamine infusion to an oral MMPR resulted in a decrease in opioid exposure in severely injured patients. Subdissociative ketamine infusions can be used as a safe adjunct to decrease opioid exposure in monitored settings., Level of Evidence: Therapeutic/Care Management; Level I., (Copyright © 2024 American Association for the Surgery of Trauma.)

Introduction: In the era of rising antimicrobial resistance and successful protocols for empiric and prophylactic antimicrobial therapy in elective surgical procedures, it is important to consider the specific needs of the trauma population based on injury location, severity, and environmental exposures. In this study, we aim to compare outcomes of high-activation trauma patients who received antibiotics during initial evaluation with those who did not., Methods: A retrospective chart review of patients focusing on antimicrobial administration who presented as the highest trauma activation criteria during the year 2021 was conducted at a single urban institution. Patient demographic, injury, and outcome data ere collected through manual data abstraction from our institutional trauma registry., Results: Nearly half of all trauma patients in our study received antibiotics after initial evaluation and age was found to be significantly associated with antibiotic administration within the first 1.5 h. Young men with penetrating injuries were more likely to receive antibiotic treatment. Seventy-eight percent of patients who received early antibiotics underwent a procedure, while 61% of those who did not receive early antibiotics did not (P < 0.001)., Conclusions: These findings emphasize the importance of individualizing antibiotic treatment based on the patient's age and specific injury pattern. They also underscore the need for trauma providers to prioritize antibiotic stewardship., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: A nomogram is a visualized clinical prediction models, which offer a scientific basis for clinical decision-making. There is a lack of reports on its use in predicting the risk of arrhythmias in trauma patients. This study aims to develop and validate a straightforward nomogram for predicting the risk of arrhythmias in trauma patients., Methods: We retrospectively collected clinical data from 1119 acute trauma patients who were admitted to the Advanced Trauma Center of the Affiliated Hospital of Zunyi Medical University between January 2016 and May 2022. Data recorded included intra-hospital arrhythmia, ICU stay, and total hospitalization duration. Patients were classified into arrhythmia and non-arrhythmia groups. Data was summarized according to the occurrence and prognosis of post-traumatic arrhythmias, and randomly allocated into a training and validation sets at a ratio of 7:3. The nomogram was developed according to independent risk factors identified in the training set. Finally, the predictive performance of the nomogram model was validated., Results: Arrhythmias were observed in 326 (29.1%) of the 1119 patients. Compared to the non-arrhythmia group, patients with arrhythmias had longer ICU and hospital stays and higher in-hospital mortality rates. Significant factors associated with post-traumatic arrhythmias included cardiovascular disease, catecholamine use, glasgow coma scale (GCS) score, abdominal abbreviated injury scale (AIS) score, injury severity score (ISS), blood glucose (GLU) levels, and international normalized ratio (INR). The area under the receiver operating characteristic curve (AUC) values for both the training and validation sets exceeded 0.7, indicating strong discriminatory power. The calibration curve showed good alignment between the predicted and actual probabilities of arrhythmias. Decision curve analysis (DCA) indicated a high net benefit for the model in predicting arrhythmias. The Hosmer-Lemeshow goodness-of-fit test confirmed the model's good fit., Conclusion: The nomogram developed in this study is a valuable tool for accurately predicting the risk of post-traumatic arrhythmias, offering a novel approach for physicians to tailor risk assessments to individual patients., Competing Interests: Declaration of competing interest All authors have seen and approved the final version of the manuscript being submitted. The authors declare that there were no conflicts of interest concerning the work contained herein., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Trauma and cancer are the leading causes of death in the US. There is a paucity of data describing the impact of cancer on trauma patients. We aimed to determine the influence of cancer on outcomes of trauma patients., Methods: In this retrospective analysis of American College of Surgeons-Trauma Quality Improvement Program 2019-2021, we included all adult trauma patients (≥18 y) and excluded patients with severe head injuries and nonmelanomatous skin cancers. Patients were stratified into cancer (C), and no cancer (No-C). Propensity score matching (1:3) was performed. Outcomes were complications and mortality., Results: A matched cohort of 3236 patients (C, 809; No-C, 2427) was analyzed. The mean age was 70 y, 50.5% were males, and the median injury severity score was 8 (4-10). There were no differences in terms of receiving thromboprophylaxis (C 51%: No-C 50%, P = 0.516). Compared to No-C group, the C group had higher rates of deep vein thrombosis (C 1.1% versus No-C 0.3%, P = 0.004), but there was no difference in terms of overall complications. Patients in the C group had higher mortality (C 7.5% versus No-C 2.7%, P < 0.001)., Conclusions: Trauma patients with cancer have nearly 4 times higher odds of deep vein thrombosis and 3 times higher odds of mortality. Developing pathways specific to cancer patients might be necessary to improve the outcomes of trauma patients with cancer., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background and Importance: Traumatic cardiac arrest is associated with poor prognosis, and timely evidence-based treatment is paramount for increasing survival rates. Physician-staffed helicopter emergency medical service use in major trauma has demonstrated improved outcomes. However, the sparsity of data highlights the necessity for a comprehensive understanding of the epidemiology of traumatic cardiac arrest., Objectives: The primary objective of the present study was to evaluate survival and return of spontaneous circulation (ROSC) and to investigate the characteristics of patients with traumatic cardiac arrest assessed by the Danish HEMS., Design: This was a population-based cohort study based on data from the Danish helicopter emergency medical service database., Settings and Participants: The study included all patients assessed by the Danish helicopter emergency medical services between 2016 and 2021., Outcome Measures and Analysis: Data were analysed using descriptive statistics, non-parametric testing and logistic regression analyses. Descriptive analysis of prehospital interventions included cardiopulmonary resuscitation, defibrillation, airway management, administration of blood products, and thoracic decompression. The primary outcome was 30-day survival, and the key secondary outcome was prehospital ROSC., Main Results: A total of 223 patients with TCA were included. The median age was 54 years (IQR 34-68), and the majority were males. Overall, 23% of patients achieved prehospital ROSC, and the 30-day survival rate was 4%. Factors associated with an increased likelihood of ROSC were an initial shockable cardiac rhythm, odds ratio (OR) of 3.78 (95% CI 1.33-11.00) and endotracheal intubation, OR 7.10 (95% CI 2.55-22.85)., Conclusion: This study highlights the low survival rates observed among patients with traumatic cardiac arrest assessed by helicopter emergency medical services. The findings support the positive impact of an initial shockable cardiac rhythm and endotracheal intubation in improving the likelihood of ROSC. The study contributes to the limited literature on traumatic cardiac arrests assessed by physician-staffed helicopter emergency services. Finally, the findings emphasise the need for further research to understand and improve outcomes in this subgroup of cardiac arrest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Study Objective: To evaluate if out-of-hospital administration of fentanyl and intranasal ketamine, compared to fentanyl alone, improves early pain control after injury., Methods: We conducted an out-of-hospital randomized, placebo-controlled, blinded, parallel group clinical trial from October 2017 to December 2021. Participants were male, aged 18 to 65 years, receiving fentanyl to treat acute traumatic pain prior to hospital arrival, treated by an urban fire-based emergency medical services agency, and transported to the region's only adult Level I trauma center. Participants randomly received 50 mg intranasal ketamine or placebo. The primary outcome was the proportion with a minimum 2-point reduction in self-described pain on the verbal numerical rating scale 30 minutes after study drug administration assessed by 95% confidence interval overlap. Secondary outcomes were side effects, pain ratings, and additional pain medications through the first 3 hours of care., Results: Among the 192 participants enrolled, 89 (46%) were White, (median age, 36 years; interquartile range, 27 to 53 years), with 103 receiving ketamine and 89 receiving placebo. There was no difference in the proportion experiencing improved pain 30 minutes after treatment (46/103 [44.7%] ketamine versus 32/89 [36.0%] placebo; difference in proportions, 8.7%; 95% confidence interval, -5.1% to 22.5%; P=.22) or at any time point through 3 hours. There was no difference in secondary outcomes or side effects., Conclusion: In our sample, we did not detect an analgesic benefit of adding 50 mg intranasal ketamine to fentanyl in out-of-hospital trauma patients., (Copyright © 2024 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background: The incidence of severe injury in the geriatric population is increasing. However, the impact of frailty on long-term outcomes after injury in this population remains understudied. Therefore, we aimed to understand the impact of frailty on long-term functional outcomes of severely injured geriatric patients., Methods: We conducted a retrospective cohort study, including patients ≥65 years old with an Injury Severity Score ≥15, who were admitted between December 2015 and April 2022 at one of 3 level 1 trauma centers in our region. Patients were contacted between 6 and 12 months postinjury and administered a trauma quality of life survey, which assessed for the presence of new functional limitations in their activities of daily living. We defined frailty using the mFI-5 validated frailty tool: patients with a score ≥2 out of 5 were considered frail. The impact of frailty on long-term functional outcomes was assessed using 1:1 propensity matching adjusting for patient characteristics, injury characteristics, and hospital site., Results: We included 580 patients, of whom 146 (25.2%) were frail. In a propensity-matched sample of 125 pairs, frail patients reported significantly higher functional limitations than nonfrail patients (69.6% vs 47.2%; P < .001). This difference was most prominent in the following activities: climbing stairs, walking on flat surfaces, going to the bathroom, bathing, and cooking meals. In a subgroup analysis, frail patients with traumatic brain injuries experienced significantly higher long-term functional limitations., Conclusion: Frail geriatric patients with severe injury are more likely to have new long-term functional outcomes and may benefit from screening and postdischarge monitoring and rehabilitation services., (Copyright © 2024. Published by Elsevier Inc.)

Objective: Falls are a serious cause of morbidity and mortality among older people. One of the underlying causes of falls is dehydration. Therefore, ultrasonography has become an essential tool for evaluating volume status in the emergency department. However, the effect of volume status on falls in older people has not been evaluated before. The aim of this study was to determine the relationship between the inferior vena cava collapsibility index and the injury severity score in older patients who presented with fall-related injuries to the emergency department., Methods: A total of 66 patients were included in the study. The injury severity score was used as the trauma severity score, and the Edmonton Frail Scale was used as the frailty scale. Volume status was evaluated with inferior vena cava collapsibility index. The primary outcome measure was defined as the correlation between inferior vena cava collapsibility index and injury severity score. Secondary outcome measures were defined as the effect of inferior vena cava collapsibility index and injury severity score on hospitalization and mortality., Results: There was no significant correlation between injury severity score and inferior vena cava collapsibility index (p=0.342). Neither inferior vena cava collapsibility index nor injury severity score was an indicator of the mortality of these patients. However, injury severity score was an indicator of hospitalization. The mean Edmonton Frail Scale score was an indicator of mortality among older people who experienced falls (p=0.002)., Conclusion: Inferior vena cava collapsibility index cannot be used to predict trauma severity in older patients who have experienced falls admitted to the emergency department.

Background: Posttraumatic stress disorder (PTSD) is a common consequence of traumatic injury, yet certain biological factors contributing to PTSD are poorly understood. The gut microbiome may influence mental health outcomes, but its role in heterogeneous PTSD presentations requires elucidation., Methods: Bacterial composition was examined in adults 2-4 years post-trauma with probable PTSD (n = 24) versus trauma-exposed controls without probable PTSD (n = 24). 16S rRNA sequencing and bioinformatic tools assessed microbial diversity and abundance. Relationships between taxa and PTSD symptom clusters were evaluated., Results: No differences were found in overall microbial community structure between groups. The probable PTSD group exhibited significantly reduced Actinobacteriota and increased Verrucomicrobiota phylum abundance compared to controls. Specific taxa showed notable inverse associations with negative mood/cognition versus hyperarousal symptoms. Prevotella and Ruminococcaceae were negatively associated with negative mood but positively associated with hyperarousal., Conclusions: Results demonstrate microbial signatures of probable PTSD subtypes, highlighting the microbiome as a potential mediator of heterogeneous trauma psychopathology. Definition of PTSD microbial correlates provides a foundation for personalized psychobiotic interventions targeting predominant symptom profiles., Competing Interests: Declaration of competing interest This research was supported by a Medical College of Wisconsin Neuroscience Research Center Imagine More grant (PI: deRoon-Cassini). The authors have no other relevant financial or non-financial interests to disclose., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Importance: Acute respiratory distress syndrome (ARDS) is associated with high mortality and morbidity. Extracorporeal membrane oxygenation (ECMO) is one of the interventions that have been in practice for ARDS for decades., Objectives: The purpose of the study was to investigate the outcomes of ECMO in pediatric trauma patients who suffered from ARDS., Design: Observational cohort study., Setting and Participants: The Trauma Quality Improvement Program database for years 2017 to 2019 and 2021 through 2022 was accessed for the study. All children younger than 18 years old who were admitted to the hospital after trauma and suffered from ARDS were included in the study. Other variables included in the study were patients' demographics, clinical characteristics, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) score, comorbidities, and outcomes., Main Outcomes and Measures: ECMO is the exposure, and the outcomes are in-hospital mortality and hospital complications (acute kidney injury [AKI], pneumonia and deep vein thrombosis [DVT])., Results: Of 453 patients who qualified for the study, propensity score matching found 50 pairs of patients. There were no significant differences identified between the groups, ECMO+ vs. ECMO- on patients' age in years (16 yr; interquartile range [IQR], 13.25-17 yr vs. 16 yr [14.25-17 yr]), race (White; 62.0% vs. 66.0%), sex (male; 78% vs. 76%), ISS (23 [IQR, 9.25-34] vs. 22 [9.25-32]), and GCS (15 [IQR, 3-15] vs. 13.5 [3-15]), mechanism of injury; and comorbidities. There was no difference between the groups, ECMO+ vs. ECMO-, in-hospital mortality (10.0% vs. 20.0%; p = 0.302), hospital complications (AKI 12.0% vs. 2.0%; p = 0.131), pneumonia (10.0% vs. 20.0%; p = 0.182 > ), and DVT (16% vs. 6%; p = 0.228)., Conclusions and Relevance: No difference in mortality was observed in injured children who suffered from the ARDS and were placed on ECMO when compared with patients who were not placed on ECMO. Patients with trauma and ARDS who require ECMO have comparable outcomes to those who do not receive ECMO. A larger sample size study is needed to find the exact benefit of ECMO in this patients' cohort., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Deep vein thrombosis (DVT) is a leading cause of morbidity and mortality after trauma. Here, we integrate plasma metabolomics and proteomics to evaluate the metabolic alterations and their function in up to 680 individuals with and without DVT after trauma (pt-DVT). We identify 28 metabolites and 2 clinical parameter clusters associated with pt-DVT. Then, we develop a panel of 9 metabolites (hexadecanedioic acid, pyruvic acid, L-Carnitine, serotonin, PE(P-18:1(11Z)/18:2(9Z,12Z)), 3-Hydroxycapric acid, 5,6-DHET, 3-Methoxybenzenepropanoic acid and pentanenitrile) that can predict pt-DVT with high performance, which can be verified in an independent cohort. Furthermore, the integration analysis of metabolomics and proteomics data indicates that the upregulation of glycolysis/gluconeogenesis-TCA cycle may promote thrombosis by regulating ROS levels in red blood cells, suggesting that interfering with this process might be potential therapeutic strategies for pt-DVT. Together, our study comprehensively delineates the metabolic and hematological dysregulations for pt-DVT, and provides potential biomarkers for early detection., (© 2024. The Author(s).)