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BACKGROUND Little is known about patient characteristics predicting postdischarge pleural space complications (PDPSCs) after thoracic trauma. We sought to analyze the patient population who required unplanned hospital readmission for PDPSC. METHODS Retrospective review of adult patients admitted to a Level I Trauma Center with a chest Abbreviated Injury Scale (AIS) score of 2 or greater between January 2015 and August 2020. Those readmitted within 30 days of index hospitalization discharge for PDPSC were compared with those not readmitted. Demographics, injury characteristics, surgical procedures, imaging, and readmission data were retrieved. RESULTS Out of 17,192 trauma evaluations, 3,412 (19.8%) suffered a chest AIS score of 2 or greater injury and 155 experienced an unplanned 30-day hospital readmission. Of those, 49 (1.4%) were readmitted for the management of PDPSC (readmit PDPSC) and were compared with patients who were not readmitted (no readmit, n = 3,257). The readmit PDPSC group was significantly older age, heavier, comprised of fewer men, and suffered a higher mean chest AIS score. The readmit PDPSC group had a significantly higher incidence of rib fractures, flail chest, pneumothorax, hemothorax, scapula fractures, and a higher rate of tube thoracostomy placement during index admission. The discharge chest X-ray in the readmit PDPSC group demonstrated a pleural space abnormality in 36 (73%) of patients. Mean time to readmission was 10.2 (7.2) days, and hospital length of stay on readmission was 5.8 (3.7) days. Pleural effusion was the most common readmission diagnosis (44 [90%]), and 42 (86%) required tube thoracostomy. CONCLUSION We describe the subset of chest wall injury patients who require hospital readmission for PDPSC. Characteristics from index hospitalization associated with PDPSC include older age, female sex, heavier weight, presence of rib fractures, pleural space abnormality, scapular fracture, and chest tube placement. Further studies are needed to characterize this at-risk chest wall injury population, and to determine what interventions can facilitate outpatient management of postdischarge pleural space complications and mitigate readmission risk. LEVEL OF EVIDENCE Prognostic and epidemiologic, Level IV; Care management, Level V.

BACKGROUND Prospective studies of surgical stabilization of rib fractures (SSRF) have excluded elderly patients, and no study has exclusively addressed the ≥80-year-old subgroup. We hypothesized that SSRF is associated with decreased mortality in trauma patients 80 years or older. METHODS Multicenter retrospective cohort study involving eight centers. Patients who underwent SSRF from 2015 to 2020 were matched to controls by study center, age, injury severity score, and presence of intracranial hemorrhage. Patients with chest Abbreviated Injury Scale score less than 3, head Abbreviated Injury Scale score greater than 2, death within 24 hours, and desire for no escalation of care were excluded. A subgroup analysis compared early (0-2 days postinjury) to late (3-7 days postinjury) SSRF. Poisson regression accounting for clustered data by center calculated the relative risk (RR) of the primary outcome of mortality for SSRF versus nonoperative management. RESULTS Of 360 patients, 133 (36.9%) underwent SSRF. Compared with nonoperative patients, SSRF patients were more severely injured and more likely to receive locoregional analgesia. There were 31 hospital deaths among the entire sample (8.6%). Multivariable regression demonstrated a decreased risk of mortality for the SSRF group, as compared with the nonoperative group (RR, 0.41; 95% confidence interval, 0.24-0.69; p < 0.01). However, SSRF patients were more likely to develop pneumonia, and had an increased duration of both mechanical ventilation and intensive care unit stay. There were no differences in discharge destination, although the SSRF group was less likely to be discharged on narcotics (RR, 0.66; 95% confidence interval, 0.48-0.90; p = 0.01). There was no difference in adjusted mortality between the early and late SSRF subgroups. CONCLUSION Patients selected for SSRF were substantially more injured versus those managed nonoperatively. Despite this, SSRF was independently associated with decreased mortality. With careful patient selection, SSRF may be considered a viable treatment option in octogenarian/nonagenarians. LEVEL OF EVIDENCE Therapeutic, Level IV.

BACKGROUND Although guidelines are established for the prevention and management of venous thromboembolism (VTE) in trauma, no consensus exists regarding protocols for the diagnostic approach. We hypothesized that at-risk trauma patients who undergo duplex ultrasound (DUS) surveillance for lower extremity deep venous thrombosis (DVT) will have a lower rate of symptomatic or fatal pulmonary embolism (PE) than those who do not undergo routine surveillance. METHODS Prospective, randomized trial between March 2017 and September 2019 of trauma patients admitted to a single, level 1 trauma center, with a risk assessment profile score of ≥5. Patients were randomized to receive either bilateral lower extremity DUS surveillance on days 1, 3, and 7 and weekly during hospitalization ultrasound group (US) or no surveillance no ultrasound group (NoUS). Rates of in-hospital and 90-day DVT and PE were reported as was DVT propagation and all-cause mortality. Standard care for the prevention and management of VTE per established institutional protocols was provided to all patients. RESULTS A total of 3,236 trauma service admissions were screened, and 1,989 moderate- and high-risk patients were randomized (US, 995; NoUS, 994). The mean ± SD age was 62 ± 20.1 years, Injury Severity Score was 14 ± 9.7, risk assessment profile was 7.1 ± 2.4, and 97% suffered blunt trauma. There was no difference in demographics or VTE risk factors between the groups. There were significantly fewer in-hospital PE in the US group than the NoUS group (1 [0.1%] vs. 9 [0.9%], p = 0.01). The US group experienced more in-hospital below-knee DVTs (124 [12.5%] vs. 8 [0.8%], p < 0.001) and above-knee DVTs (19 [1.9%] vs. 8 [0.8%], p = 0.05). There was no difference in 90-day PE or DVT, or overall mortality. CONCLUSION The implementation of a selective routine DUS protocol was associated with significantly fewer in-hospital PE. More DVTs were identified with routine screening; however, surveillance bias appears to exist primarily with distal DVT. Larger trials are needed to further characterize the relationship between routine DUS screening and VTE outcomes in the high-risk trauma population. LEVEL OF EVIDENCE Therapeutic/care management, level II.

PURPOSE:We studied the current management trends for extraperitoneal bladder injuries and evaluated the use of operative repair versus catheter drainage, and the associated complications with each approach. MATERIALS AND METHODS:We prospectively collected data on bladder trauma from 20 level 1 trauma centers across the United States from 2013 to 2018. We excluded patients with intraperitoneal bladder injury and those who died within 24 hours of hospital arrival. We separated patients with extraperitoneal bladder injuries into 2 groups (catheter drainage vs operative repair) based on their initial management within the first 4 days and compared the rates of bladder injury related complications among them. Regression analyses were used to identify potential predictors of complications. RESULTS:From 323 bladder injuries we included 157 patients with extraperitoneal bladder injuries. Concomitant injuries occurred in 139 (88%) patients with pelvic fracture seen in 79%. Sixty-seven patients (43%) initially underwent operative repair for their extraperitoneal bladder injuries. The 3 most common reasons for operative repair were severity of injury or bladder neck injury (40%), injury found during laparotomy (39%) and concern for pelvic hardware contamination (28%). Significant complications were identified in 23% and 19% of the catheter drainage and operative repair groups, respectively (p=0.55). The only statistically significant predictor for complications was bladder neck or urethral injury (RR 2.69, 95% 1.21-5.97, p=0.01). CONCLUSIONS:In this large multi-institutional cohort, 43% of patients underwent surgical repair for initial management of extraperitoneal bladder injuries. We found no significant difference in complications between the initial management strategies of catheter drainage and operative repair. The most significant predictor for complications was concomitant urethral or bladder neck injury.

BACKGROUND The efficacy of surgical stabilization of rib fracture (SSRF) in patients without flail chest has not been studied specifically. We hypothesized that SSRF improves outcomes among patients with displaced rib fractures in the absence of flail chest. METHODS Multicenter, prospective, controlled, clinical trial (12 centers) comparing SSRF within 72 hours to medical management. Inclusion criteria were three or more ipsilateral, severely displaced rib fractures without flail chest. The trial involved both randomized and observational arms at patient discretion. The primary outcome was the numeric pain score (NPS) at 2-week follow-up. Narcotic consumption, spirometry, pulmonary function tests, pleural space complications (tube thoracostomy or surgery for retained hemothorax or empyema >24 hours from admission) and both overall and respiratory disability-related quality of life (RD-QoL) were also compared. RESULTS One hundred ten subjects were enrolled. There were no significant differences between subjects who selected randomization (n = 23) versus observation (n = 87); these groups were combined for all analyses. Of the 110 subjects, 51 (46.4%) underwent SSRF. There were no significant baseline differences between the operative and nonoperative groups. At 2-week follow-up, the NPS was significantly lower in the operative, as compared with the nonoperative group (2.9 vs. 4.5, p < 0.01), and RD-QoL was significantly improved (disability score, 21 vs. 25, p = 0.03). Narcotic consumption also trended toward being lower in the operative, as compared with the nonoperative group (0.5 vs. 1.2 narcotic equivalents, p = 0.05). During the index admission, pleural space complications were significantly lower in the operative, as compared with the nonoperative group (0% vs. 10.2%, p = 0.02). CONCLUSION In this clinical trial, SSRF performed within 72 hours improved the primary outcome of NPS at 2-week follow-up among patients with three or more displaced fractures in the absence of flail chest. These data support the role of SSRF in patients without flail chest. LEVEL OF EVIDENCE Therapeutic, level II.

OBJECTIVES Increasingly, patients admitted to an ICU survive to hospital discharge; many with ongoing medical needs. The full impact of an ICU admission on an individual's resource utilization and survivorship trajectory in the United States is not clear. We sought to compare healthcare utilization among ICU survivors in each year surrounding an ICU admission. DESIGN Retrospective cohort of patients admitted to an ICU during one calendar year (2012) in a multipayer healthcare system. We assessed mortality, hospital readmissions (categorized by ambulatory care sensitive conditions and emergency department), and outpatient visits. We compared the proportion of patients with visits during the pre-ICU year versus the post-ICU year. PATIENTS People admitted to an Intermountain healthcare ICU for greater than 48 hours in the year 2012 INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS Among 4,074 ICU survivors, 45% had increased resource utilization. Readmission rates at 30-day, 90-day, and 1-year were 15%, 26%, and 43%. The proportion of patients with a hospital admission increased significantly in the post-ICU period (43% vs 29%; p < 0.001). Of patients with a readmission in the post-ICU period, 24% were ambulatory care sensitive condition. Patients with increased utilization differed by socioeconomic status, insurance type, and severity of illness. Sixteen percent of patients had either an emergency department or inpatient admission, but no outpatient visits during the post-ICU period. CONCLUSIONS An ICU admission is associated with increased resource utilization including hospital readmissions, with many due to an ambulatory care sensitive condition. Lower socioeconomic status and higher severity of illness are associated with increased resource utilization. After an ICU visit patients seem to use hospital resources over outpatient resources. Interventions to improve and coordinate care after ICU discharge are needed.

Background Indications for intervention after high-grade renal trauma (HGRT) remain poorly defined. Certain radiographic findings can be used to guide the management of HGRT. We aimed to assess the associations between initial radiographic findings and interventions for hemorrhage after HGRT and to determine hematoma and laceration sizes predicting interventions. Methods The Genitourinary Trauma Study is a multicenter study including HGRT patients from 14 Level I trauma centers from 2014 to 2017. Admission computed tomography scans were categorized based on multiple variables, including vascular contrast extravasation (VCE), hematoma rim distance (HRD), and size of the deepest laceration. Renal bleeding interventions included angioembolization, surgical packing, renorrhaphy, partial nephrectomy, and nephrectomy. Mixed-effect Poisson regression was used to assess the associations. Receiver operating characteristic analysis was used to define optimal cutoffs for HRD and laceration size. Results In the 326 patients, injury mechanism was blunt in 81%. Forty-seven (14%) patients underwent 51 bleeding interventions, including 19 renal angioembolizations, 16 nephrectomies, and 16 other procedures. In univariable analysis, presence of VCE was associated with a 5.9-fold increase in risk of interventions, and each centimeter increase in HRD was associated with 30% increase in risk of bleeding interventions. An HRD of 3.5 cm or greater and renal laceration depth of 2.5 cm or greater were most predictive of interventions. In multivariable models, VCE and HRD were significantly associated with bleeding interventions. Conclusion Our findings support the importance of certain radiographic findings in prediction of bleeding interventions after HGRT. These factors can be used as adjuncts to renal injury grading to guide clinical decision making. Level of evidence Prognostic and Epidemiological Study, Level III and Therapeutic/Care Management, Level IV.

The management of high-grade renal trauma (HGRT) and the indications for intervention are not well defined. The American Association for the Surgery of Trauma (AAST) renal grading does not incorporate some important clinical and radiologic variables associated with increased risk of interventions. We aimed to use data from a multi-institutional contemporary cohort to develop a nomogram predicting risk of interventions for bleeding after HGRT.From 2014 to 2017, data on adult HGRT (AAST grades III-V) were collected from 14 level 1 trauma centers. Patients with both clinical and radiologic data were included. Data were gathered on demographics, injury characteristics, management, and outcomes. Clinical and radiologic parameters, obtained after trauma evaluation, were used to predict renal bleeding interventions. We developed a prediction model by applying backward model selection to a logistic regression model and built a nomogram using the selected model.A total of 326 patients met the inclusion criteria. Mechanism of injury was blunt in 81%. Median age and injury severity score were 28 years and 22, respectively. Injuries were reported as AAST grades III (60%), IV (33%), and V (7%). Overall, 47 (14%) underwent interventions for bleeding control including 19 renal angioembolizations, 16 nephrectomies, and 12 other procedures. Of the variables included in the nomogram, a hematoma size of 12 cm contributed the most points, followed by penetrating trauma mechanism, vascular contrast extravasation, pararenal hematoma extension, concomitant injuries, and shock. The area under the receiver operating characteristic curve was 0.83 (95% confidence interval, 0.81-0.85).We developed a nomogram that integrates multiple clinical and radiologic factors readily available upon assessment of patients with HGRT and can provide predicted probability for bleeding interventions. This nomogram may help in guiding appropriate management of HGRT and decreasing unnecessary interventions.Prognostic and epidemiological study, level III.

The optimal timing of surgical stabilization of rib fractures (SSRF) remains debated. We hypothesized that (1) demographic, radiologic, and clinical variables are associated with time to surgery and (2) shorter time to SSRF improves acute outcomes.Prospectively collected SSRF databases from four trauma centers were merged and analyzed (2006-2016). The independent variable was days from hospital admission to SSRF (early [1 day], mid [1-2 days], and late [3-10 days]). Outcomes included length of operation, number of ribs repaired, prolonged (24 hours) mechanical ventilation, pneumonia, tracheostomy, length of stay, and mortality. Multivariable logistic regression was used to control for significant differences in covariates between groups.Five hundred fifty-one patients were analyzed. The median time to SSRF was 1 day (range, 0-10); 207 (37.6%) patients were in the early group, 168 (30.5%) in the midgroup, and 186 (31.9%) in the late group. There was a significant shift toward earlier SSRF over the study period. Time to SSRF was significantly associated with study center (p0.01), year of surgery (p0.01), age (p = 0.02), mechanism of injury (p = 0.04), and body mass index (p = 0.02). Injury severity was not associated with time to surgery. Despite repairing the same median number of ribs (4; range, 1-13), median length of surgery was 68 minutes longer for the late as compared to the early group (p0.01). After controlling for the aforementioned significant covariates, each additional hospital day before SSRF was independently associated with a 31% increased likelihood of pneumonia (p0.01), a 27% increased likelihood of prolonged mechanical ventilation (p0.01), and a 26% increased likelihood of tracheostomy (p0.01).Surgical stabilization of rib fractures within 1 day of admission is associated with certain demographic and physiologic variables. After controlling for confounding factors, early SSRF was accomplished using less operative time, and was associated with favorable outcomes. When indicated and feasible, SSRF should occur as early as possible.Therapy, level III.

BACKGROUND Surgical stabilization of rib fractures (SSRF) has become pivotal in the management of severe chest injuries. Recent literature supports improved outcomes and mortality in severe fracture and flail chest patients who undergo SSRF compared with nonoperative management (NOM). A 2014 National Trauma Data Bank review provided a point prevalence of 0.7% SSRF in flail patients. We hypothesize that this prevalence is increasing and that temporal, regional, and American College of Surgeons (ACS) trauma designation vary in SSRF utilization. METHODS Retrospective National Trauma Data Bank data were extracted for years 2007 to 2014 for patients with rib fractures. Cases were divided into SSRF versus NOM. SSRF frequencies were analyzed across year, region, and ACS level. Patient demographics, injury severity score, number of fractured ribs, and hospital characteristics were identified for multivariable analysis. RESULTS Between 2007 and 2014, 687,137 rib fracture patients were identified; 29,981 (4.36%) underwent SSRF. SSRF increased by 76% nationally during the review period (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.50-1.67; p < 0.001). Compared with the north, SSRF was used more in the west (OR, 1.6; 95% CI, 1.57-1.71), south (OR, 1.48; 95% CI, 1.43-1.54), then midwest (OR, 1.4; 95% CI, 1.34-1.46; p < 0.001). Although likelihood of SSRF is higher at ACS Level I (LI) centers compared with Level II (LII) centers (OR, 0.67; 95% CI, 0.65-0.69) or Level III (LIII) (OR, 0.24; 95% CI, 0.22-0.26); p < 0.001), frequency of SSRF increased dramatically at lower-level centers from 2007 to 2014 (LI, 41.4%; LII, 53.6%; LIII, 60.0%).Overall SSRF mortality was 1.58% (NOM, 5.3%; p < 0.001), decreasing significantly between 2007 and 2014 (p < 0.0001). ACS LII had higher mortality than LI (OR, 1.82; 95% CI, 1.39-2.39; p < 0.0001), controlled by Injury Severity Score. CONCLUSION Utilization of SSRF has risen considerably nationwide. Prevalence varies by region and ACS level. Although greatest growth is occurring at LII hospitals, mortality is also the highest at these centers. Further research is needed to determine the need for regionalization of care and center of excellence designation. LEVEL OF EVIDENCE Epidemiological study, level III.

INTRODUCTION AND OBJECTIVES:Radiologic factors are important for predicting bleeding interventions after high-grade renal trauma (HGRT). We aimed to assess the associations between laceration size ...

INTRODUCTION AND OBJECTIVES:The American Association for the Surgery of Trauma (AAST) injury scale is the most widely used grading system for renal trauma. However, reproducibility of the AAST grad...

Recreational use of small-wheeled vehicles (SWVs), which include skateboards, longboards, nonmotorized scooters, ice skates, and roller skates or rollerblades, results in numerous injuries in the United States.To describe the nature and severity of traumatic brain injuries (TBIs) that result from the use of SWVs in Utah.Patients who were admitted to any Utah hospital after a SWV-related injury from 2001 through 2010 were identified from the Utah State Trauma Registry. Patients who sustained TBI were identified by International Classification of Diseases, Ninth Revision, codes.Of 907 patients admitted with SWV injury, 392 (43%) had a TBI (85% male). Their mean age was 19.8 ± 0.5 years, including 234 (60%) aged ≤18 and 119 (30%) aged 19 to 29. Most patients sustained TBI while using a skate- or longboard (87%). Mean Glasgow Coma Scale score in the emergency department was 12.8 ± 0.2. Thirty-nine percent were admitted to an intensive care unit, and 6% (23) underwent emergent neurosurgical intervention. Thirty-three (8.4%) patients had a concussion; the rest had nonoperative intracranial hemorrhage. Among patients for whom helmet use data were available, 8 out of 291 (2.7%) patients with TBI were wearing a helmet, whereas 24 out of 190 (12.6%) non-TBI patients were wearing helmets (P.001). Overall mortality was higher in TBI patients than in non-TBI patients (2.3% vs 0.2%, P = .003).Young people, especially males, who ride SWVs in Utah are at risk for serious TBI, admission to the intensive care unit, neurosurgical intervention, and death. Helmet use in these patients is likely rare, but may reduce the risk of TBI and death.ED, emergency departmentSWV, small-wheeled vehicleTBI, traumatic brain injury.

BACKGROUND Current guidelines suggest that traumatic pneumothorax (tPTX) is a contraindication to commercial airline travel, and patients should wait at least 2 weeks after radiographic resolution of tPTX to fly. This recommendation is not based on prospective, physiologic study. We hypothesized that despite having a radiographic increase in pneumothorax size while at simulated altitude, patients with a recently treated tPTX would not exhibit any adverse physiologic changes and would not report any symptoms of cardiorespiratory compromise. METHODS This is a prospective, observational study of 20 patients (10 in Phase 1, 10 in Phase 2) with tPTX that has been treated by chest tube (CT) or high flow oxygen therapy. CT must have been removed within 48 hours of entering the study. Subjects were exposed to 2 hours of hypobaria (554 mm Hg in Phase 1, 471 mm Hg in Phase 2) in a chamber in Salt Lake City, Utah. Vital signs and subjective symptoms were recorded during the "flight." After 2 hours, while still at simulated altitude, a portable chest radiograph (CXR) was obtained. tPTX sizes on preflight, inflight, and postflight CXR were compared. RESULTS Sixteen subjects (80%) were male. Mean (SD) age and ISS were 49 (5) years and 10.5 (4.6), respectively. Fourteen (70%) had a CT to treat tPTX, which had been removed 19 hours (range, 4-43 hours) before the study. No subject complained of any cardiorespiratory symptoms while at altitude. Radiographic increase in tPTX size at altitude was 5.6 (0.61) mm from preflight CXR. No subject developed a tension tPTX. No subject required procedural intervention during the flight. Four hours after the study, all tPTX had returned to baseline size. CONCLUSION Patients with recently treated tPTX have a small increase in the size of tPTX when subjected to simulated altitude. This is clinically well tolerated. Current prohibitions regarding air travel following traumatic tPTX should be reconsidered and further studied. LEVEL OF EVIDENCE Therapeutic study, level IV.

Objective To examine the rate of urethral trauma and pubic symphysis diastasis in saddle horn injury, which occurs when horseback riders are bucked into the air and land with their perineum striking the rigid saddle horn, compared to pelvic fracture from other mechanisms. Methods A retrospective review was performed of male patients presenting to our level-1 trauma center with pelvic ring fractures between January 1, 2001 and December 30, 2016. Demographics, injury severity score, mechanism of injury (saddle horn vs other), pubic symphysis diastasis, and lower genitourinary (GU) injuries (bladder and urethra) were identified in the trauma registry. Chart review confirmed accuracy of lower GU trauma. Results A total of 1195 males presented with pelvic ring fractures, average age 43 years (SD 19 years). Of these, 87 of 1195 (7%) presented with lower GU injuries. Saddle horn injuries had a higher rate of lower GU injuries, 12/60 (20%) versus 75 of 1135 (7%) [P = .001]. In those with lower GU injuries, 47 of 87 (54%) had urethral injury. The rate of urethral injury was significantly higher in the saddle horn cohort, 10 of 12 (83%) versus 37 of 75 (49%) [P = .03]. Furthermore, rate of pubic symphysis diastasis was higher amongst saddle horn injuries, 12 of 12 (100%) versus other mechanisms 39 of 75 (52%) [P = .001]. Conclusion We found that urethral injury and pubic symphysis diastasis were higher in patients with saddle horn injury compared to other mechanisms of pelvic ring disruption. Clinicians should be aware of these associations when treating pelvic fracture following equestrian injuries.

BACKGROUNDRed blood cell distribution width (RDW) is a component of the complete blood count (CBC) that is traditionally used to identify iron-deficiency anemia. RDW has been shown to predict mortality in patients with multiple different medical conditions and in general populations. It is unknown w

Objective: To examine the effect of surgeon specialization on patient outcomes, controlling for volume. Background: There is great interest in the degree to which surgical specialization affects outcomes, particularly considering drives to measure and reward quality in healthcare. Although surgical specialization has been previously analyzed with respect to outcomes, most studies have treated it as a dichotomous variable based on academic credentials. We treat it here as a continuous variable defined quantitatively by procedural diversity. Methods: We used 2002 to 2005 patient data from the National Surgical Quality Improvement Program for the Department of Surgery, Barnes Jewish Hospital, St. Louis, Missouri. To quantitate procedural specialization, Herfindahl-Hirschman indices for surgeons were calculated using billing codes. These indices were calculated according to 3 different levels of procedural aggregation. Using conditional logit models, we examined the relationship between these indices and 30-day postoperative mortality rates. Results: Surgeon specialization was inversely related to mortality rates after adjusting for case volume when indices were calculated using medium procedural aggregation (odds ratio for mortality = 0.580 per 0.1 unit Herfindahl increase; P = 0.025) or low aggregation (odds ratio for mortality = 0.510 per 0.1 unit Herfindahl increase; P = 0.015). No relationship was observed at the high level of aggregation. Conclusions: The procedural concentration component of surgical specialization is correlated with improved mortality rates independently of case volume. However, how broadly or narrowly "specialization" is defined has an impact on this relationship.

Odontoid fractures are the most common cervical spine fractures in elderly patients. Treatment options included operative fixation (OP) or nonoperative management with either a halo-vest (HV) or rigid cervical orthosis (CO). Our previous study suggested increased morbidity and mortality with the use of HV in the treatment of elderly patients with cervical spine fractures. We review a series of odontoid fractures in elderly patients and evaluate for predictors for in-hospital morbidity and mortality.There were 78 patients65 years of age who sustained a type II or III odontoid fracture from January 1997 to June 2004 identified from the Rhode Island Hospital Trauma registry. Demographic, mechanism, injury pattern, treatment, and outcome data were recorded. Patients were analyzed according to treatment method.The mean age was 80.7 +/- 0.9 years. There were 50 type II, 17 type III, and 11 combined fractures. There were 38 (49%) patients treated with HV: 34 with halo alone, and 4 after OP; 40 (51%) patients were treated without HV: 27 with CO, and 13 with OP. There was no difference in injury severity or baseline medical condition between HV and non-HV patients. There were 24 (31%) patients who died during their hospital stay. Of the HV patients, 42% died compared with 20% in the non-HV group (p = 0.03). Major complications occurred in 66% of HV patients compared with 36% of non-HV patients (p = 0.003).Odontoid fractures are associated with significant morbidity and mortality in elderly patients. Outcomes after treatment with HV appear inferior to those achieved with CO or OP.

Background: Cervical spine fractures (CSFs) in elderly patients are increasingly common as the population ages. In many centers, halo vest immobilization (HVI) is the treatment of choice. Our anecdotal experience suggested that elderly patients treated with HVI have frequent bad outcomes. The purpose of this study was to compare the outcomes of elderly and younger CSF patients as related to treatment (HVI, surgery, or hard collar). Methods: Registry data from our Level I trauma center were reviewed to identify patients admitted with CSFs during an 80-month period. We excluded those with Glasgow Coma Scale (GCS) score of 3 at admission or death within 24 hours of admission. Patients were grouped as OLD (aged ≥ 66 years) or YNG (aged 18-65 years). Data were compared using X 2 and Student's t test, with p < 0.05 considered statistically significant. Results: One hundred twenty-nine OLD (aged 79.7 ± 0.7 years) and 289 YNG (aged 383 ± 0.8 years) patients met study criteria. Injury Severity Score was higher in YNG (18.9 ± 0.8 vs. 14.8 ± 1.0, p < 0.05), and GCS score was the same (OLD, 13.7 ± 0.2; YNG, 13.0 ± 0.2; p = 0.06) in both, but mortality was higher in OLD patients (21% vs. 5%, p < 0.05). OLD HVI patients had higher mortality than YNG HVI (40% vs. 2%). Among OLD patients, age, Injury Severity Score, GCS, and number of comorbidities were the same for each treatment subgroup. Despite this, mortality for the HVI subgroup was higher than either the surgery or collar subgroup. Of the OLD HVI patients that died, 14 died with pneumonia and 10 had a cardiac or respiratory arrest that preceded death. Conclusion: OLD patients with CSFs have higher mortality than YNG. HVI in OLD patients is associated with the worst outcomes, irrespective of injury severity, and should be considered a last resort. Further study is warranted to determine the optimal treatment for CSF in OLD patients.

The purpose of this study was to review our experience with interfacility transfers to identify problems that could be addressed in the development of a statewide trauma system.The fundamental tenet of a trauma system is to get the right patient to the right hospital at the right time. This hinges on well-defined prehospital destination criteria, interfacility transfer protocols, and education of caregivers. Patients arriving at local community hospitals (LOCs) benefit from stabilization and transfer to trauma centers (TCs) for definitive care. However, in the absence of a formalized trauma system, patients may not reach the TC in a timely fashion and may not be appropriately treated or stabilized at LOCs prior to transfer.Our facility is a level I TC and regional referral center for a compact geographic area without a formal trauma system. The Trauma Registry was queried for adult patients admitted to the trauma service between January 1, 2001 and March 30, 2003. Patients were divided into 2 groups: those received directly from the scene (DIR) and those transferred from another institution (TRAN). Medical records were reviewed to elucidate details of the early care. Data are presented as mean +/- SEM. Continuous data were compared using Student t test, and categorical data using chi2. Transfer times were analyzed by one-way ANOVA.A total of 3507 patients were analyzed. The TRAN group had a higher Injury Severity Score (ISS) (17.5 versus 11.0, P0.05), lower Glasgow Coma Score (GCS) (13.3 versus 14.1, P0.05), lower initial systolic blood pressure (SBP) (130 versus 140, P0.05), and higher mortality (10% versus 79%, P0.05) than the DIR group. The average time spent at the LOC was 162 +/- 8 minutes. The subgroup of patients with hypotension spent an average of 134 minutes at the LOC, often receiving numerous diagnostic tests despite unavailability of surgeons to provide definitive care. Severe head injury (GCS = 3) triggered more prompt transfer, but high ISS was underappreciated and did not result in a prompt transfer in all but the most severely injured group (ISS40). Some therapeutic interventions were initiated at the LOCs, but many were required at the TC. A total of 23 (8%) TRAN patients required critical interventions within 15 minutes of arrival; mortality in this group was 52%. Mortality among those requiring laparotomy after transfer was 33%.All but the most severely injured patients spend prolonged periods of time in LOCs, and many require critical interventions upon arrival at the TC. It is unreasonable to expect immediate availability of surgeons or operating rooms in LOCs. Thus, trauma system planning efforts should focus on 1) prehospital destination protocols that allow direct transport to the TC; and 2) education of caregivers in LOCs to enhance intervention skill sets and expedite transfer to definitive care.

Background My colleagues and I compared trauma patient demographics and outcomes between two time periods in the last 10 years in our Level I trauma center to evaluate the impact of the marked evolution in trauma care and determine additional opportunities for improvement. Methods Our trauma registry was queried for adult trauma patients admitted from 1991 to 1993 (EARLY) and 1999 to 2001 (LATE). The EARLY period predated creation and maturation of a dedicated trauma service and Level I trauma center verification. Continuous data were compared using Student's t-test, and categorical data using chi-square. Results Increased transfers of severely injured patients from regional hospitals, combined with fewer admissions for "observation," resulted in fewer, but sicker, patients admitted in the LATE period. Patients were considerably older in the LATE period and mortality was higher. Despite higher acuity of patients, hospital and ICU lengths of stay were shorter in the LATE period. Nonoperative management of solid organ injuries was more common in the LATE period, but the overall operative volume was similar. Nonsurvivors in the LATE period had higher Injury Severity Scores and were older compared with the EARLY period. Mortality attributable to blunt CNS injury was higher, and that attributed to late sepsis and multiple organ failure was lower in the LATE period. Conclusions Over the past decade, more older, severely injured patients have been admitted to our Level I trauma center. Overall mortality among these higher acuity patients has increased, with a marked shift in attributable mortality to CNS injury and away from late sepsis and multiple organ failure. This highlights the need for continued efforts to identify optimal management strategies for severe brain injury. Additional areas for improvement include enhancement of our regional trauma network and injury prevention initiatives.