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Background: The objective of this study was to re-evaluate and simplify the Greenfield risk assessment profile (RAP) for venous thromboembolism (VTE) in trauma using information readily available at the bedside., Methods: Retrospective review of 1233 consecutive admissions to the trauma intensive care unit from August 2011-January 2015. Univariate analyses were performed to determine which RAP risk factors were significant contributors to VTE. Multivariable logistic regression was used to develop models for risk stratification. All results were considered statistically significant at P ≤ 0.05., Results: The study population was as follows: age 44 ± 19, 75% male, 72% blunt, injury severity score 21 ± 13, RAP score 9 ± 5, and 8% mortality. Groups were separated into +VTE (n = 104) and -VTE (n = 1129). They were similar in age, gender, mechanism, and mortality, but injury severity and RAP scores were higher in the +VTE group (all P < 0.0001). The +VTE group had more transfusions and longer time to prophylaxis (all P < 0.05). Receiving four or more transfusions in the first 24 h (odds ratio [OR], 2.60; 95% confidence interval [CI], 1.64-4.13), Glasgow coma score <8 for >4 h (OR, 2.13; 95% CI, 1.28-3.54), pelvic fracture (OR, 2.26; 95% CI, 1.44-3.57), age 40-59 y (OR, 1.70; 95% CI, 1.10-2.63), and >2-h operation (OR, 1.80; 95% CI, 1.14-2.85) predicted VTE with an area under the receiver operator curve of 0.729, which was comparable with 0.740 for the RAP score alone., Conclusions: VTE risk in trauma can be easily assessed using only five risk factors, which are all readily available at the bedside (transfusion, Glasgow coma scale, pelvic fracture, prolonged operation, and age). This simplified model provides similar predictive ability to the more complicated RAP score. Prospective validation of a simplified risk assessment score is warranted., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Stress-induced hyperglycemia is associated with worse outcomes after trauma; however, the effect of mechanism of injury has not been studied. To fill this gap, we tested the hypothesis that blunt and penetrating trauma evoke different glycemic responses which are associated with different outcomes., Materials and Methods: A retrospective cohort study comparing adults with blunt (n = 835) or penetrating trauma (n = 858) and admission glucose levels ≥ 106 mg/dL, ≥150 mg/dL, and ≥200 mg/dL at a level 1 trauma center from 02, 2011 to 08, 2013. Primary outcomes were mortality and infectious complications., Results: For all patients, mean Injury Severity Score was 14 ± 12, with 10% (n = 162) infections and 6% (n = 102) mortality. Median admission glucose was 122 mg/dL (102-154 mg/dL). Hyperglycemia was associated with infections, length of stay, and mortality (all P < 0.01). Ten percent had an admission glucose ≥200 mg/dL, which was associated with infections after blunt trauma (odds ratio [OR], 2.28; 95% CI, 1.16-4.47; P = 0.017) but not penetrating trauma. Hyperglycemia was not an independent predictor of mortality in blunt trauma. In contrast, glucose ≥150 mg/dL (OR, 2.58; 95% CI, 1.13-5.89; P = 0.025) and ≥200 mg/dL (OR, 2.98; 95% CI, 1.27-6.98; P = 0.012) both predicted mortality in penetrating trauma patients., Conclusions: This is the first study to show that hyperglycemia is associated with fundamentally different outcomes after blunt versus penetrating trauma. Patients who died were 4-8 times more likely to have hyperglycemia and penetrating, not blunt, trauma. Incorporation of hyperglycemia in injury scoring systems might improve outcome predictions after trauma., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: A massive transfusion protocol (MTP) presents a logistical challenge for most blood banks and trauma centers. We compare the ratio of packed red blood cells (PRBC) and plasma transfused over serial time points in those requiring MTP (10-30 U PRBC/24 h) to those requiring "super" MTP (S-MTP; >30 U PRBC/24 h) and test the hypothesis that changes in allocation of blood products with use of readily transfusable liquid plasma (LP) improves the ratio of PRBC and plasma during S-MTP., Materials and Methods: All transfused trauma patients (n = 1305) from January 01, 2009-April, 03, 2015 were reviewed. PRBC:plasma ratio was compared for MTP (n = 277) and S-MTP (n = 61) patients, before and after the availability of LP at our institution. Data are reported as mean ± standard deviation or median (interquartile range)., Results: Age was 41 ± 19 y, 52% blunt mechanism, injury severity score 32 ± 16, and 46.3% mortality. In 24 h, requirements were 17 (14) U PRBC and 10 (11) U plasma, with a PRBC:plasma of 1.6 (0.8). Within the first hour, PRBC:plasma for S-MTP versus MTP was 2.1:1 versus 1.7:1 (P = 0.017). With LP, S-MTP patients received significantly lower PRBC:plasma at the first hour (P < 0.001). Before institutional changes, PRBC:plasma positively correlated with PRBC transfused at hour 1 (r = 0.410, R(2) = 0.168, P < 0.001); after institutional changes and the advent of LP, there was no correlation (r = 0.177, R(2) = 0.031, P = 0.219)., Conclusions: Within the first hour of transfusion, units of PRBC transfused positively correlated with PRBC:plasma, and patients receiving S-MTP had higher PRBC:plasma than those receiving MTP. Changes in our institution's MTP protocol to include LP improved the early PRBC:plasma transfused in patients requiring S-MTP., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Obesity negatively affects outcomes after trauma and surgery; results after burns are more limited and controversial. The purpose of this study was to determine the effect of obesity on clinical and economic outcomes after thermal injury., Methods: The National Inpatient Sample was queried for adults from 2005-2009 with International Classification of Diseases-9 codes for burn injury. Demographics and clinical outcomes of obese and nonobese cohorts were compared. Univariate and multivariate analysis using logistic regression models were performed. Data are expressed as median (interquartile range) or mean ± standard deviation and compared at P < 0.05., Results: In 14,602 patients, 3.3% were obese (body mass index ≥30 kg/m(2)). The rate of obesity increased significantly by year (P < 0.001). Univariate analysis revealed significant differences between obese and nonobese patients in incidence of wound infection (7.2% versus 5.0%), urinary tract infection (7.2% versus 4.6%), deep vein thrombosis in total body surface area (TBSA) ≥10% (3.1% versus 1.1%), pulmonary embolism in TBSA ≥10% (2.3% versus 0.6%), length of stay [6 d (8) versus 5 d (9)], and hospital costs ($10,122.12 [$18,074.72] versus $7892.07 [$17,191.96]) (all P < 0.05). Death occurred less frequently in the obese group (1.9% versus 4%, P = 0.021). Significant predictors of grouped adverse events (urinary tract infection, wound infection, deep vein thrombosis, and pulmonary embolism) on multivariate analysis include obesity, TBSA ≥20%, age, and black race (all P ≤ 0.05)., Conclusions: Obesity is an independent predictor of adverse events after burn injury; however, obesity is associated with decreased mortality. Our findings highlight the potential clinical and economic impact of the obesity epidemic on burn patients nationwide., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Despite advances in prehospital emergency medical services (EMS), most advocate "scoop-and-run" over "stay-and-play." However, there are almost no studies in children. We hypothesize that the transportation of mortally injured children is delayed and that the performance of prehospital interventions (PHIs) themselves delay transportation and worsen outcomes in pediatric trauma patients., Materials and Methods: A total of 1884 admissions (≤17-y-old) transported via EMS to a level 1 trauma center from January 2000-December 2012 were reviewed. Propensity scores were assigned based on the need for a PHI (intubation and resuscitation). PHI and non-PHI cohorts were matched 1:1 to compare outcomes. Data are expressed as mean ± standard deviation or median (interquartile range)., Results: The population was 11 ± 6 y, 70% male, 50% black, 76% blunt injury, injury severity score 13 ± 12, length of stay 3 (7) d, and mortality 3.6%. Incident to EMS arrival was 38 (20) min, EMS on-scene time was 14 (12) min, and overall time of arrival to hospital was 27 (15) min. Patients that were mortally wounded, despite having significantly higher rates of PHI, still had similar transportation times to those who survived. Mostly every measure of injury severity was worse in those who required PHI. When these factors were corrected, EMS on-scene time was 18 (13) versus 14 (13) min (P = 0.551), EMS arrival at the hospital was 31 (16) versus 28 (12) min (P = 0.292), length of stay was 5 (15) versus 4 (12) d (P = 0.368), and mortality was 31.7% versus 28.3% (P = 0.842) for PHI and non-PHI matched cohorts., Conclusions: PHIs did not delay transportation times or worsen outcomes in pediatric trauma patients. Although mortally injured children more often required PHIs, this did not delay transportation to the trauma center., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Our purpose was to analyze modern major vascular injury (MVI) patterns in pediatric trauma, interventions performed, and outcomes at a level 1 trauma center., Materials and Methods: From January 2000-December 2012, all pediatric admissions (≤17 y) were reviewed., Results: Of 1928 pediatric admissions, 103 (5.3%) sustained MVI. This cohort was 85% male, age 15 ± 3 y, 55% black, 58% penetrating, injury severity score of 23 ± 15, with a length of stay of 8 (5) days. Firearm-related injury (47%) was the most common mechanism. Location of injuries included the extremities (50.5%), abdomen/pelvis (29.1%), and chest/neck (20.4%). Operative procedures included repair/bypass (71.4%), ligation (12.4%), amputation (10.5%), or temporary shunt (2.9%). Only three injuries (2.9%) were treated endovascularly. MVI patients had a mortality rate of 19.4%, higher than the overall pediatric trauma population of 3.5% (P < 0.001). After logistic regression, independent risk factors of mortality were vascular injury to the neck (odds ratio [OR]: 6.5; confidence interval (CI): 1.1-39.3), abdomen/pelvis (OR: 16.3; CI: 3.13-80.2), and chest (OR: 49.0; CI: 3.0-794.5)., Conclusions: MVI in children more commonly results from firearm-related injury. The mortality rate associated with MVI is profoundly higher than that of the overall pediatric trauma population. These findings underscore the major public health concern of firearm-related injury in children., (Copyright © 2015 Elsevier Inc. All rights reserved.)