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Neal Lynch,1 Kristin Salottolo,1–4 Krislyn Foster,2 Alessandro Orlando,1–4 Catherine Koola,1–4 Victor Portillo,3 Allen Tanner II,1 Charles W Mains,4,5 David Bar-Or1–41Trauma Services Department, Penrose-St. Francis Health Services, Colorado Springs, CO, USA; 2Swedish Medical Center, Trauma Research Department, Englewood, CO, USA; 3Medical City Plano, Trauma Research Department, Plano, TX, USA; 4St. Anthony Hospital, Trauma Research Department, Lakewood, CO, USA; 5Centura Health, Trauma Services Department, Englewood, CO, USABackground: Catheter-based regional analgesia has been proposed as an alternative to systemic analgesia for patients with multiple rib fractures (MRF). This study sought to compare the efficacy of regional techniques for decreasing pain and improving clinical outcomes.Study design: This was a multi-institutional, retrospective cohort study of adult (≥18 years) patients admitted to four nonacademic trauma centers over two years (from 07/1/2014 to 06/30/2016). Study inclusion was MRF (≥3 fractures) with no other severe injuries. Two primary regional analgesia techniques were utilized and compared: continuous intercostal nerve blocks (CINB) and epidural (EPI) analgesia. The primary outcome, average pain scores on treatment, was examined using a repeated measures, linear regression mixed model. Secondary outcomes included hospital LOS, ICU LOS, ICU admission and hospital readmission, pulmonary complications, and incentive spirometry volumes during treatment, and were examined with univariate statistics.Results: There were 339 patients with isolated MRF; 85 (25%) required regional analgesia (CINB, n=41; EPI, n=44) and the remaining 75% received systemic analgesia only (IV, n=195; PO, n=59). There were demographic and clinical differences between regional analgesia and systemic analgesia groups; on the contrary, there were no demographic or clinical differences between the CINB and EPI groups. Adjusted pain scores were similar for the EPI and CINB groups (4.0 vs 4.4, p=0.49). Secondary outcomes were worse in the EPI group compared to the CINB group: less improvement in incentive spirometry volume (p=0.004), longer ICU LOS (p=0.03), longer hospital LOS (p

Abstract Background In critical injury, the occurrence of increased oxidative stress or a reduced antioxidant status has been observed. The purpose of this study was to correlate the degree of oxidative stress, by measuring the oxidation-reduction potential (ORP) of plasma in the critically injured, with injury severity and serum amyloid A (SAA) levels. Methods A total of 140 subjects were included in this retrospective study comprising 3 groups: healthy volunteers (N = 21), mild to moderate trauma (ISS < 16, N = 41), and severe trauma (ISS ≥ 16, N = 78). For the trauma groups, plasma was collected on an almost daily basis during the course of hospitalization. ORP analysis was performed using a microelectrode, and ORP maxima were recorded for the trauma groups. SAA, a sensitive marker of inflammation in critical injury, was measured by liquid chromatography/mass spectrometry. Results ORP maxima were reached on day 3 (± 0.4 SEM) and day 5 (± 0.5 SEM) for the ISS < 16 and ISS ≥ 16 groups, respectively. ORP maxima were significantly higher in the ISS < 16 (-14.5 mV ± 2.5 SEM) and ISS ≥ 16 groups (-1.1 mV ± 2.3 SEM) compared to controls (-34.2 mV ± 2.6 SEM). Also, ORP maxima were significantly different between the trauma groups. SAA was significantly elevated in the ISS ≥ 16 group on the ORP maxima day compared to controls and the ISS < 16 group. Conclusion The results suggest the presence of an oxidative environment in the plasma of the critically injured as measured by ORP. More importantly, ORP can differentiate the degree of oxidative stress based on the severity of the trauma and degree of inflammation.

The aging US population has altered the epidemiology of traumatic injury, but there are few studies examining changing patterns of traumatic intracranial hemorrhage (tICH). We examined temporal changes in incidence, demographics, severity, management, and outcomes of tICH among trauma admissions at six US Level I trauma centers over 6 years (July 1, 2016-June 30, 2022). Patients with tICH (subdural, epidural, subarachnoid, and intracerebral hemorrhage) were identified by 10th revision of the International Statistical Classification of Diseases diagnosis codes. Temporal trends were examined over 12 six-month intervals using joinpoint regression and reported as biannual percent change (BPC); models without joinpoints are described as linear trends over time. There were 67,514 trauma admissions over 6 years and 11,935 (17.7%) patients had a tICH. The proportion of tICH injuries significantly increased 2.6% biannually from July 2016 to July 2019 (BPC = 2.6, p = 0.04), then leveled off through June 2022 (BPC = -0.9, p = 0.19). Similarly, the proportion of geriatric patients (≥65 years old) increased 2.4% biannually from July 2016 to July 2019 (BPC = 2.4, p = 0.001) as did injuries due to falls (BPC = 2.2, p = 0.01). Three of the four most prevalent comorbidities significantly increased: hypertension linearly increased 2.1% biannually, functional dependence increased 25.5% biannually through June 2019, and chronic anticoagulant use increased 19.0% biannually through June 2019 and then 3.1% thereafter. There were no trends in the rates of neurosurgical intervention (BPC = -0.89, p = 0.40), ED Glasgow coma score 3-8 (BPC = -0.4, p = 0.77), or presence of severe extracranial injuries (BPC = -0.7, p = 0.45). In-hospital mortality linearly declined 2.6% biannually (BPC = 2.6, p = 0.05); however, there was a 10.3% biannual linear increase in discharge to hospice care (BPC = 10.3, p < 0.001). These results demonstrate the incidence of tICH admissions is temporally increasing, and the population is growing older with more comorbidities and injuries from falls. Yet, traumatic brain injury severity and neurosurgical management are unchanged. The shift from in-patient death to hospice care suggests an increased need for palliative care services., (© The Author(s) 2024. Published by Mary Ann Liebert, Inc.)

Background: There is an epidemic of firearm injuries in the United States since the mid-2000s. Thus, we sought to examine whether hospitalization from firearm injuries have increased over time, and to examine temporal changes in patient demographics, firearm injury intent, and injury severity., Methods: This was a multicenter, retrospective, observational cohort study of patients hospitalized with a traumatic injury to six US level I trauma centers between 1/1/2016 and 6/30/2022. ICD-10-CM cause codes were used to identify and describe firearm injuries. Temporal trends were compared for demographics (age, sex, race, insured status), intent (assault, unintentional, self-harm, legal intervention, and undetermined), and severity (death, ICU admission, severe injury (injury severity score ≥ 16), receipt of blood transfusion, mechanical ventilation, and hospital and ICU LOS (days). Temporal trends were examined over 13 six-month intervals (H1, January-June; H2, July-December) using joinpoint regression and reported as semi-annual percent change (SPC); significance was p < 0.05., Results: Firearm injuries accounted for 2.6% (1908 of 72,474) of trauma hospitalizations. The rate of firearm injuries initially declined from 2016-H1 to 2018-H2 (SPC = - 4.0%, p = 0.002), followed by increased rates from 2018-H2 to 2020-H1 (SPC = 9.0%, p = 0.005), before stabilizing from 2020-H1 to 2022-H1 (0.5%, p = 0.73). NH black patients had the greatest hospitalization rate from firearm injuries (14.0%) and were the only group to demonstrate a temporal increase (SPC = 6.3%, p < 0.001). The proportion of uninsured patients increased (SPC = 2.3%, p = 0.02) but there were no temporal changes by age or sex. ICU admission rates declined (SPC = - 2.2%, p < 0.001), but ICU LOS increased (SPC = 2.8%, p = 0.04). There were no significant changes over time in rates of death (SPC = 0.3%), severe injury (SPC = 1.6%), blood transfusion (SPC = 0.6%), and mechanical ventilation (SPC = 0.6%). When examined by intent, self-harm injuries declined over time (SPC = - 4.1%, p < 0.001), assaults declined through 2019-H2 (SPC = - 5.6%, p = 0.01) before increasing through 2022-H1 (SPC = 6.5%, p = 0.01), while undetermined injuries increased through 2019-H1 (SPC = 24.1%, p = 0.01) then stabilized (SPC = - 4.5%, p = 0.39); there were no temporal changes in unintentional injuries or legal intervention., Conclusions: Hospitalizations from firearm injuries are increasing following a period of declines, driven by increases among NH Black patients. Trauma systems need to consider these changing trends to best address the needs of the injured population., (© 2024. The Author(s).)

Objective: The perioperative management of patients on antiplatelet drugs is a rising challenge in orthopedic trauma because antiplatelet drugs are frequently encountered and carry an increased risk of hemorrhagic consequences. The study objective was to examine the effect of aspirin on bleeding outcomes for patients with lower extremity fractures., Methods: This retrospective study included patients requiring surgical fixation of traumatic hip, femur, and tibia fractures from January 1, 2018, to March 1, 2020. Patients were excluded if they had a significant head injury, were on chronic anticoagulant therapy, or they did not receive venous thromboembolism chemoprophylaxis. Comparisons between aspirin users (patients on aspirin therapy preinjury) and non-aspirin users were examined using χ 2 tests, Cochran-Mantel-Haenszel tests, and multivariate logistic regression. The primary outcome was an overt, actionable bleed (eg, blood transfusion for surgical site hemorrhage) within 24 hours postoperative., Results: There were 864 patients with lower extremity long bone fractures and 24% were aspirin users. The incidence of postoperative bleeding was 8.8% and significantly differed for patients taking aspirin versus not (13.6% vs 7.3%, p=0.01). However, biological sex at birth (M/F) was a significant effect modifier (interaction p=0.04). Among women, there were significantly more postoperative bleeds for aspirin users (17.8% aspirin vs 7.4% no aspirin, adjusted OR (AOR): 2.48 (1.28-4.81), p=0.01). Among men, there were similar postoperative bleeding events by aspirin use (5.6% aspirin vs 7.2% no aspirin, AOR: 0.50 (0.14-1.82), p=0.30). Postoperative hemoglobin values <8 g/dL were more frequent among female aspirin users (21.5% aspirin vs 12.5% no aspirin, p=0.01), but this association was not observed in men (p=0.43)., Conclusion: Women taking aspirin who suffer lower extremity fractures have greater than twofold greater odds of a postoperative bleeding event. These findings suggest adequate perioperative planning to ensure blood availability, and increased awareness to monitor closely for hemorrhage in the 24-hour postoperative window for women taking aspirin preinjury., Level of Evidence: IV., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: There are no studies to date that examine the association between anti-factor-Xa (AFXa)-based heparin monitoring and clinical outcomes in the setting of cerebral venous thrombosis (CVT)., Methods: This pilot study included adults aged ≥18 admitted with CVT between 1 January 2018 and 1 January 2021, who were treated with unfractionated heparin (UFH) and were monitored via AFXa-based nomogram within 24 h of arrival. Comparisons were made between patients with AFXa levels within the target therapeutic range (0.25-0.5 IU/mL) and patients whose levels were not within the therapeutic range within 24 h of arrival; the time (hours) from arrival to reach the therapeutic range was also examined. Outcomes were length of stay (LOS) in the hospital, major (actionable) bleeding events, and discharge home (vs. higher acuity location). Continuous data are reported in the form of the median (interquartile range)., Results: Among 45 patients, treatment with UFH was initiated 2 (1-11) h after arrival, and the majority (84%) of UFH infusions did not need dose adjustment. AFXa assays were conducted every 6 (5.5-7) h. Thirty patients (67%) fell within the therapeutic range. Outcomes were similar for patients with levels within the therapeutic range vs. not: major bleeding events, 10% vs. 0% ( p  = 0.54); discharge home, 77% vs. 80% ( p  = 1.0); LOS, 5 days in each group ( p  = 0.95). There was also no association between outcomes and time to reach the therapeutic range., Conclusion: Our findings demonstrate the practicability of monitoring UFH based on AFXa values in this population of patients with CVT, but reaching target AFXa levels within 24 h of arrival may not necessarily be prognostic., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Pirahanchi, Salottolo, Burrell, Tang, Bar-Or and Bartt.)

Background: Reversal of direct oral anticoagulants (DOACs) is currently recommended prior to emergent surgery, such as surgical intervention for traumatic geriatric hip fractures. However, reversal methods are expensive and timely, often delaying surgical intervention, which is a predictor of outcomes. The study objective was to examine the effect of DOAC reversal on blood loss and transfusions among geriatric patients with hip fractures., Methods: This retrospective propensity-matched study across six level I trauma centers included geriatric patients on DOACs with isolated fragility hip fractures requiring surgical intervention (2014-2017). Outcomes included: intraoperative blood loss, intraoperative pRBCs, and hospital length of stay (HLOS)., Results: After matching there were 62 patients (31 reversed, 31 not reversed), 29 patients were not matched. The only reversal method utilized was passive reversal (waiting ≥ 24 hours for elimination). Passively reversed patients had a longer time to surgery (mean, 43 vs. 18 hours, p < 0.01). Most patients (92%) had blood loss (90% passively reversed, 94% not reversed); the median volume of blood loss was 100 mL for both those groups, p = 0.97. Thirteen percent had pRBCs transfused (13% passively reversed and 13% not reversed); the median volume of pRBCs transfused was 525 mL for those passively reversed and 314 mL for those not reversed, p = 0.52. The mean HLOS was significantly longer for those passively reversed (7 vs. 5 days, p = 0.001)., Conclusions: Passive DOAC reversal for geriatric patients with isolated hip fracture requiring surgery may be contributing to delayed surgery and an increased HLOS without having a significant effect on blood loss or transfusions. These data suggest that passive DOAC reversal may not be necessary prior to surgical repair of isolated hip fracture., (© 2023. The Author(s).)

Objective: Operative management of axis fractures (C2) usually depend on the stability and location of the break and individual patient characteristics. We sought to describe the epidemiology of C2 fractures and hypothesized that determinants for surgery would differ by fracture diagnosis., Methods: Patients with C2 fractures were identified from the US National Trauma Data Bank from January 1, 2017, to January 1, 2020. Patients were classified by C2 fracture diagnosis: odontoid type II, odontoid types I and III, and non-odontoid fracture (hangman's fracture or fractures through base of the axis). The primary comparison was C2 fracture surgery versus non-operative management. Multivariate logistic regression was used to identify independent associations with surgery. Decision tree-based models were developed to identify determinants for surgery., Results: There were 38 080 patients; 42.7% had an odontoid type II fracture; 16.5% had an odontoid type I/III fracture; and 40.8% had a non-odontoid fracture. All examined patient demographics, clinical characteristics, outcomes, and interventions differed by C2 fracture diagnosis. Overall, 5292 (13.9%) were surgically managed (17.5% odontoid type II, 11.0% odontoid type I/III, and 11.2% non-odontoid; p<0.001). The following covariates increased odds of surgery for all three fracture diagnoses: younger age, treatment at a level I trauma center, fracture displacement, cervical ligament sprain, and cervical subluxation. Determinants of surgery differed by fracture diagnosis: for odontoid type II, age ≤80 years, a displaced fracture, and cervical ligament sprain were determinants; for odontoid type I/III, age ≤85 years, a displaced fracture, and cervical subluxation were determinants; for non-odontoid fractures, cervical subluxation and cervical ligament sprain were the strongest determinants for surgery, by hierarchy., Conclusions: This is the largest published study of C2 fractures and current surgical management in the USA. Odontoid fractures, regardless of type, had age and fracture displacement as the strongest determinants for surgical management, whereas associated injuries were determinants of surgery for non-odontoid fractures., Level of Evidence: III., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Collateral circulation is important for cerebral perfusion in acute ischemic strokes. Monitoring the oxidation-reduction potential (ORP) may be useful to assess collateral status or treatment efficacy. The objectives of the present study were to determine if the ORP was associated with collateral circulation status in middle cerebral artery (MCA) occlusions and to identify patterns in the ORP and the collateral circulation status among patients treated with intraarterial therapy (IAT) over time. The present pilot study was nested within a prospective cohort study measuring the ORP of the peripheral venous plasma of stroke patients. The population included in the present study were patients with MCA (M1/M2) occlusions. Two ORP parameters were examined: Static ORP (sORP; mV), indicating oxidative stress, and capacity ORP (cORP; µC), indicating antioxidant reserves. Collateral status was retrospectively graded using Miteff's system as good (grade 1) or reduced (grade 2/3). Comparisons were made between collateral status groups (reduced vs. good collaterals) in all patients, within a subset including only patients who received IAT, and between thrombolysis in cerebral infraction scale score (TICI) groups (0-2a vs. 2b/3). The Fisher's exact test, Student's t-test and Wilcoxon tests were used (α<0.20). The 19 patients were categorized based on their collaterals: Good collaterals (53%) and reduced collaterals (47%). The baseline characteristics were similar with the exception that the patients with good collaterals had a lower international normalized ratio (P=0.12) and were more likely to have a stroke on the left side (P=0.18) or to have a mismatch (P=0.05). The admission sORP values were comparable (169.5 vs. 164.2 mV; P=0.65), as was admission cORP (P=0.73). When considering only the patients who received IAT (n=12), admission sORP (P=0.69) and cORP (P=0.90) were also statistically similar. On day 2, after IAT, both groups experienced a worsening in ORP measures; however, the patients with good collaterals had a significantly lower sORP (169.4 vs. 203.5 mV; P=0.02) and a higher cORP (0.2 vs. 0.1 µC; P=0.002) compared with the patients with reduced collaterals. Neither sORP nor cORP were significantly different between TICI score groups on admission or on day 2. Upon discharge, patients with a TICI of 2b-3 had a significantly better sORP (P=0.03) and cORP (P=0.12) compared with those with a TICI of 0-2a. In conclusion, upon patient admission, the ORP parameters were not significantly different between the collateral circulation status groups for MCA occlusions. The ORP parameters worsened after IAT regardless of the collateral circulation status; however, after IAT, on day 2, patients with good collaterals experienced less oxidative stress (sORP) and had higher antioxidant reserves (cORP) than patients with reduced collaterals., Competing Interests: The authors declare that they have no competing interests., (Copyright: © Atchie et al.)

Objectives: Outcomes after traumatic hip fracture have shown to be significantly improved with timely surgical management. This study determined whether there were differences in efficacy of fascia iliaca compartment block (FICB) on pain outcomes in patients with hip fracture, once stratified by time to surgery., Methods: Trauma patients (55-90 years) admitted to five Level I/II trauma centers within 12 hours of hip fracture were included. Patients with coagulopathy, significant multi-trauma (injury severity score >16), bilateral hip fractures, and postoperative FICBs were excluded. The primary exposure was analgesia modality: adjunctive FICB or systemic analgesics (no FICB). Study endpoints were incidence of delirium through 48 hours postoperatively (%), preoperative and postoperative oral morphine equivalents (OMEs), and preoperative and postoperative pain (0-10 scale). Adjusted regression models were used to examine the effect of FICB on outcomes; all models were stratified by time from arrival to surgery, ≤24 hours (earlier surgery; n=413) and >24 hours (later surgery; n=143)., Results: FICB use was similar with earlier and later surgery (70.2% vs 76.2%), and there were no demographic differences by utilization of FICB, by time to surgery. In the earlier surgery group, preoperative pain was lower for patients with FICB versus no FICB (3.6 vs 4.5, p<0.001), with no difference by FICB for delirium (OR 1.00, p>0.99) or OMEs (p=0.75 preoperative, p=0.91 postoperative). In the later surgery group, there was a nearly twofold reduction in preoperative OMEs with FICB than no FICB (25.5 mg vs 45.2 mg, p=0.04), with no differences for delirium (OR 4.21, p=0.18), pain scores (p=0.25 preoperative, p=0.27 postoperative), and postoperative OMEs (p=0.34)., Conclusions: Compared with systemic analgesia, FICB resulted in improved pain scores at the preoperative assessment among patients with earlier surgery, whereas FICB reduced opioid consumption over the preoperative period only when surgery was later than 24 hours from arrival., Level of Evidence: II, prospective, therapeutic., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Traumatic aortic injuries (TAIs) are rare but are associated with a high mortality. Prior studies have shown skiers and pilots, whose injuries occur at high altitudes, are at an increased risk for a TAI. The purpose of this study was to examine the effect of altitude on the incidence of TAIs across all causes of injury., Methods: This retrospective cohort study at six Level I trauma centers (8/1/2016-1/1/2020) included adult blunt trauma patients with a chest or abdomen injury. High altitude injuries (> 5000 ft.) were compared to low altitude injuries (≤ 5000 ft.). The primary outcome was incidence of TAI., Results: There were 8562 patients, 37% were at high altitude and 63% at low altitude. High altitude patients were older (p < 0.01), more often Caucasian (p < 0.01) and had a higher ISS (p < 0.01). There was a significantly greater incidence of TAI at high altitude than low altitude (1.5% vs. 1.1%, p = 0.01). The median altitude was significantly higher for patients with a TAI than for patients without a TAI (5100 ft. vs. 1400 ft., p = 0.01). After adjustment, high altitude patients had 2-fold [OR: 2.4 (1.6, 3.7)] greater odds of having a TAI than low altitude patients., Conclusion: TAIs were more prevalent among high altitude injuries. Providers should be aware of the increased incidence of TAIs at high altitudes particularly when there is a delay in diagnosis and transfer to a trauma center with appropriate resources to manage these critical injuries. TAI screening at high altitude trauma centers may improve survival rates., (© 2022. The Author(s).)

Background: The decision-making for admission versus emergent transfer of patients with blunt splenic injuries presenting to remote trauma centers with limited resources remains a challenge. Although splenectomy is standard for hemodynamically unstable patients, the specific criterion for non-operative management continues to be debated. Often, lower-level trauma centers do not have interventional radiology capabilities for splenic artery embolization, leading to transfer to a higher level of a care. Thus, the aim of this study was to identify specific characteristics of patients with blunt splenic injuries used for admittance or transfer at a remote trauma center., Methods: A retrospective observational study was performed to examine the management of splenic injuries at a mountainous and remote Level III trauma center. Trauma patients ≥ 18 years who had a blunt splenic injury and initially received care at a Level III trauma center prior to admittance or transfer were included. Data were collected over 4.5 years (January 1, 2016 - June 1, 2020). Patients who were transferred out in > 24 h were excluded. Patient demographics, injury severity, spleen radiology findings, and clinical characteristics were compared by decision to admit or transfer to a higher level of care ≤ 24 h of injury. Results were analyzed using chi-square, Fisher's exact, or Wilcoxon tests. Multivariable logistic models were used to identify predictors of transfer., Results: Of the 73 patients included with a blunt splenic injury, 48% were admitted and 52% were transferred to a Level I facility. Most patients were male (n = 58), were a median age of 26 (21-42) years old, most (n = 62) had no comorbidities, and 47 had been injured from a ski/snowboarding accident. Compared to admitted patients, transferred patients were significantly more likely to be female (13/38 vs. 3/36, p = 0.007), to have an abbreviated injury scale score ≥ 3 of the chest (31/38 vs. 7/35, p = 0.002), have a higher injury severity score (16 (16-22) vs. 13 (9-16), p = 0.008), and a splenic injury grade ≥ 3 (32/38 vs. 12/35, p < 0.001). After adjustment, splenic injury grade ≥ 3 was the only predictor of transfer (OR: 12.1, 95% CI: 3.9-37.3, p < 0.001). Of the 32 transfers with grades 3-5, 16 were observed, and 16 had an intervention. Compared to patients who were observed after transfer, significantly more who received an intervention had a blush on CT (1/16 vs. 7/16, p = 0.02) and a higher median spleen grade of 4 (3-5) vs. 3 (3-3.5), p = 0.01)., Conclusions: Our data suggest that most patients transferred from a remote facility had a splenic injury grade ≥ 3, with concomitant injuries but were hemodynamically stable and were successfully managed non-operatively. Stratifying by spleen grade may assist remote trauma centers with refining transfer criteria for solid organ injuries., (© 2022. The Author(s).)

Background: The relationship between drug use and traumatic injury is well documented, yet only a small proportion of patients are biochemically tested for cannabis and other substances. The study objective was to determine whether patient self-report can be used as a proxy for biochemical drug testing following traumatic injury., Methods: This study was a secondary analysis that included 320 patients admitted to four level I trauma centers in Colorado and Texas, primarily involved in motor vehicle crash (89%). If performed, biochemical testing was collected via urine toxicology screen ("tox screen") for cannabis, amphetamines, barbiturates, cocaine, opiates, PCP, and benzodiazepines. All patients were screened for self-reported current drug use, which was evaluated for any drug and specifically for cannabis use. Analyses used to compare results of self-reported drug use and tox screen included sensitivity, specificity, positive, and negative predictive values, and percent agreement., Results: Among 320 patients, 23% (n = 75) self-reported drug use; cannabis was the most frequently reported drug (n = 63). A tox screen was performed in 59% of patients (n = 190); the proportion of patients who had a tox screen was similar for those self-reporting drug use (60.0%) to those who denied using drugs (59.2%), p = 0.90. Among patients who had a tox screen performed, 18% (n = 35) tested positive for any drug, 12% (n = 22) tested positive for THC, and 7% (n = 13) tested positive for opiates. The percent agreement was 80% for any drug and 81% for cannabis. The specificity was 84-85%, indicating a high likelihood that a patient will not have a positive tox screen if they do not report using drugs. Negative predictive values were 90-95%, indicating a negative self-report correctly identified nearly all patients testing negative on tox screen. Sensitivity was only 60% and positive predictive values were 30-47% for cannabis and drugs, respectively., Conclusion: These findings may negate the need for biochemical drug testing in this population, particularly as a "rule out" based on self-reporting. Future studies are needed to confirm these findings and should address risk of selection bias., (© 2022. The Author(s).)

Introduction: Cigarette smoking is a risk factor for hip fractures, while risk factors for developing delirium include older age and preexisting cognitive impairment. We sought to determine whether smoking status is independently associated with delirium and pain outcomes., Methods: This was a prospective, observational cohort study of 442 older adults (65 to 90 years) admitted for traumatic hip fracture at five trauma centers. The primary exposure was smoking status (n = 43, 10%). Additional risk factors included demographics, injury characteristics, and medical interventions. Delirium (primary) and analgesia-related complications were examined with multivariable logistic regression, while analysis of covariance models were used to examine preoperative and postoperative pain scores and opioid consumption (oral morphine equivalents)., Results: Smokers had significantly worse outcomes compared with nonsmokers: delirium incidence was 16.3% versus 5.0% (adjusted odds ratio, 4.23; P = 0.005), analgesia complications developed in 30.2% versus 14.8% (adjusted odds ratio, 2.63; P = 0.01), and postoperative opioid consumption was greater (53 mg versus 33 mg, adjusted P = 0.04). Adjusted pain scores were not different between groups., Discussion: Smoking status is associated with markedly worse outcomes in older adults with traumatic hip fracture. Smoking status should be considered in pain management protocols and for early screening and delirium prevention methods., Data Availability: On reasonable request., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Objectives: Until recently, systemic opioids have been standard care for acute pain management of geriatric hip fracture; however, opioids increase risk for delirium. Fascia Iliaca compartment blocks (FICB) may be favored to systemic analgesia for reducing delirium, but this has not been well demonstrated. We evaluated the efficacy of adjunctive FICB versus systemic analgesia on delirium incidence, opioid consumption, and pain scores., Methods: This prospective, observational cohort study was performed in patients (55-90 years) with traumatic hip fracture admitted to five trauma centers within 12 hours of injury, enrolled between January 2019 and November 2020. The primary end point was development of delirium, defined by the Confusion Assessment Method tool, from arrival through 48 hours postoperatively, and analyzed with multivariate Firth logistic regression. Secondary end points were analyzed with analysis of covariance models and included preoperative and postoperative oral morphine equivalents and pain numeric rating scale scores., Results: There were 517 patients enrolled, 381 (74%) received FICB and 136 (26%) did not. Delirium incidence was 5.4% (n=28) and was similar for patients receiving FICB versus no FICB (FICB, 5.8% and no FICB, 4.4%; adjusted OR: 1.2 (95% CI 0.5 to 3.0), p=0.65). Opioid requirements were similar for patients receiving FICB and no FICB, preoperatively (p=0.75) and postoperatively (p=0.51). Pain scores were significantly lower with FICB than no FICB, preoperatively (4.2 vs 5.1, p=0.002) and postoperatively (2.9 vs 3.5, p=0.04)., Conclusions: FICB demonstrated significant benefit on self-reported pain but without a concomitant reduction in opioid consumption. Regarding delirium incidence, these findings suggest clinical equipoise and the need for a randomized trial., Level of Evidence: II-prospective, therapeutic., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Inhaled therapeutics may act to directly target and attenuate lung inflammation due to COVID-19. An inhalation form of a novel biologic drug, AMP5A, is being developed as an immunomodulatory agent to treat dysregulated immune responses and is being studied in hospitalized patients to treat respiratory complications due to COVID-19., Methods: A randomized, controlled, phase I trial was conducted to evaluate hospitalized adults with respiratory distress secondary to COVID-19. Patients received the standard care (SOC) for COVID-19, including respiratory therapy, corticosteroids, and antiviral therapies such as remdesivir. Patients were randomized 1:1 to inhalation treatment with AMP5A as an adjunct to SOC or to SOC alone (control). AMP5A was administered via inhalation daily for 5 days via hand-held nebulizer, non-invasive ventilator, or mechanical ventilation. Safety and clinical efficacy endpoints were evaluated., Results: Forty subjects were enrolled and randomized (n = 19 AMP5A, n = 21 control). Remdesivir was used in fewer AMP5A subjects (26%) than control (52%), and dexamethasone was administered for most subjects (84% AMP5A, 71% control). The study met its primary endpoint with no AMP5A treatment-related adverse events (AEs), and the incidence and severity of AEs were comparable between groups: 18 AEs for control (8 mild, 1 moderate, 9 severe) and 19 AEs for AMP5A (7 mild, 7 moderate, 5 severe). Notably, subjects treated with AMP5A had fewer deaths (5% vs. 24%), shorter hospital stay (8 days vs. 12 days), fewer ICU admissions (21% vs. 33%), and a greater proportion with improved clinical outcomes than control., Conclusion: The phase I clinical results indicate inhaled AMP5A is safe, is well tolerated, and could lead to fewer patients experiencing deterioration or death. Based on the treatment effect (i.e., reduced mortality), a phase II trial has been initiated., Trial Registration: Clinicaltrials.gov identifier: NCT04606784., (© 2021. The Author(s).)

Background: Damage control laparotomy (DCL) is a life-saving procedure in patients with abdominal hemorrhage. After DCL, patients are sometimes left with an open abdomen (OA) so they may undergo multiple exploratory laparotomies (EXLAP), or re-explorations. Patients with OA are at increased risk of infectious complications (ICs). The association between number of re-explorations after DCL and the number of ICs is not clear. We hypothesized that each additional re-exploration increases the risk of developing IC., Methods: This 6-year retrospective cohort study included patients aged ≥16 years from the NTDB who had DCL defined as EXLAP within 2 hours of arrival (ICD-9: 54.11, 54.12, 54.19) with at least one re-exploration. The primary outcome was IC (ie, superficial surgical site infection (SSI), organ space SSI, deep SSI, sepsis, pneumonia, or catheter-related bloodstream infection), examined dichotomously (present/absent) and ordinally as the number of ICs. Multivariate Poisson regression was used to assess the association between number of re-explorations and number of ICs. Significance was assigned at p<0.01., Results: There were 7431 patients who underwent DCL; 2509 (34%) patients developed at least one IC. The rate of IC was lowest in patients who were closed during the first re-exploration (27%) and significantly increased with each re-exploration to 59% in patients who had five or more re-explorations (Cochran-Armitage trend p<0.001). After adjustment, there was 14% increased risk of an additional IC with each re-exploration (p<0.001)., Discussion: For patients requiring DCL, each re-exploration of the abdomen is associated with increased rate of ICs., Level of Evidence: III, retrospective epidemiological study., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The COVID-19 pandemic resulted in nationwide social distancing and shelter-in-place orders meant to curb transmission of the SARS-CoV-2 virus. The effect of the pandemic on injury patterns has not been well described in the USA. The study objective is to determine the effect of the COVID-19 pandemic on the distribution and determinants of traumatic injuries., Methods: This retrospective multi-institutional cohort study included all hospital admissions for acute traumatic injury at six community level I trauma centers. Descriptive statistics were used to compare injury causes, diagnoses and procedures over two similar time periods: prepandemic (March 11-June 30, 2019) and pandemic (March 11-June 30, 2020)., Results: There were 7308 trauma patients included: 3862 (53%) prepandemic and 3446 (47%) during the pandemic. Cause of injury significantly differed by period (p<0.001). During the pandemic, there were decreases in motor vehicle crashes (from 17.0% to 14.0%, p<0.001), worksite injuries (from 5.2% to 4.1%, p=0.02), pedestrian injuries (from 3.0% to 2.2%, p=0.02) and recreational injuries (from 3.0% to 1.7%, p<0.001), while there were significant increases in assaults (6.9% to 8.5%, p=0.01), bicycle crashes (2.8% to 4.2%, p=0.001) and off-road vehicle injuries (1.8% to 3.0%, p<0.001). There was no change by study period in falls, motorcycle injuries, crush/strikes, firearm and self-inflicted injuries, and injuries associated with home-improvement projects. Injury diagnoses differed between time periods; during the pandemic, there were more injury diagnoses to the head (23.0% to 27.3%, p<0.001) and the knee/leg (11.7% to 14.9%, p<0.001). There were also increases in medical/surgical procedures (57.5% to 61.9%, p<0.001), administration of therapeutics/blood products (31.4% to 34.2%, p=0.01) and monitoring (11.0% to 12.9%, p=0.01)., Discussion: Causes of traumatic injury, diagnoses, and procedures were significantly changed by the pandemic. Trauma centers must adjust to meet the changing demands associated with altered injury patterns, as they were associated with increased use of hospital resources., Level of Evidence: III (epidemiological)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Concerns of contracting the highly contagious disease COVID-19 have led to a reluctance in seeking medical attention, which may contribute to delayed hospital arrival among traumatic patients. The study objective was to describe differences in time from injury to arrival for patients with traumatic hip fractures admitted during the pandemic to pre-pandemic patients., Materials and Methods: This retrospective cohort study at six level I trauma centers included patients with traumatic hip fractures. Patients with a non-fall mechanism and those who were transferred in were excluded. Patients admitted 16 March 2019-30 June 2019 were in the "pre-pandemic" group, patients were admitted 16 March 2020-30 June 2020 were in the "pandemic" group. The primary outcome was time from injury to arrival. Secondary outcomes were time from arrival to surgical intervention, hospital length of stay (HLOS), and mortality., Results: There were 703 patients, 352 (50.1%) pre-pandemic and 351 (49.9%) during the pandemic. Overall, 66.5% were female and the median age was 82 years old. Patients were similar in age, race, gender, and injury severity score. The median time from injury to hospital arrival was statistically shorter for pre-pandemic patients when compared to pandemic patients, 79.5 (56, 194.5) min vs. 91 (59, 420), p = 0.04. The time from arrival to surgical intervention (p = 0.64) was statistically similar between groups. For both groups, the median HLOS was 5 days, p = 0.45. In-hospital mortality was significantly higher during the pandemic, 1.1% vs 3.4%, p = 0.04., Conclusions: While time from injury to hospital arrival was statistically longer during the pandemic, the difference may not be clinically important. Time from arrival to surgical intervention remained similar, despite changes made to prevent COVID-19 transmission.

Background: Since the national stay-at-home order for COVID-19 was implemented, clinicians and public health authorities worldwide have expressed growing concern about the potential repercussions of drug and alcohol use due to social restrictions. We explored the impact of the national stay-at-home orders on alcohol or drug use and screenings among trauma admissions., Methods: This was a retrospective cohort study at six Level I trauma centers across four states. Patients admitted during the period after the onset of the COVID-19 restrictions (defined as March 16, 2020-May 31, 2020) were compared with those admitted during the same time period in 2019. We compared 1) rate of urine drug screens and blood alcohol screens; 2) rate of positivity for drugs or alcohol (blood alcohol concentration ≥ 10 mg/dL); 3) characteristics of patients who were positive for drug or alcohol, by period using chi-squared tests or Fisher's exact tests, as appropriate. Two-tailed tests with an alpha of p < 0.05 was used on all tests., Results: There were 4762 trauma admissions across the study period; 2602 (55%) in 2019 and 2160 (45%) in 2020. From 2019 to 2020, there were statistically significant increases in alcohol screens (34% vs. 37%, p = 0.03) and drug screens (21% vs. 26%, p < 0.001). Overall, the rate of alcohol positive patients significantly increased from 2019 to 2020 (32% vs. 39%, p = 0.007), while the rate of drug positive patients was unchanged (57% vs. 52%, p = 0.13). Of the 1025 (22%) patients who were positive for alcohol or drugs, there were significant increases in a history of alcoholism (41% vs. 26%, p < 0.001), and substance abuse (11% vs. 23%, p < 0.001) in the 2020 period. No other statistically significant differences were identified among alcohol or drug positive patients during COVID-19 compared to the same period in 2019., Conclusions: Our first wave of COVID-19 data suggests that trauma centers were admitting significantly more patients who were alcohol positive, as well those with substance use disorders, potentially due to the impact of social restrictions and guidelines. Further longitudinal research is warranted to assess the alcohol and drug positive rates of trauma patients over the COVID-19 pandemic.

Background: Recent studies have reported changes in trauma volumes resulting from the COVID-19 pandemic and social distancing orders (SDOs) implemented by federal and state governments. However, literature is lacking on demographic, injury and outcome patterns., Methods: This retrospective, cross-sectional study included patients aged ≥18 years at six US level 1 trauma centers. Patients not discharged by the date of data acquisition were excluded. Demographic, injury and outcome variables were assessed across four time periods: period 1 (January 1, 2019-December 31, 2019); period 1b (March 16, 2019-June 30, 2019); period 2 (January 1, 2020-March 15, 2020); and period 3 (March 16, 2020-June 30, 2020). Patients admitted in period 3 were compared with patients presenting during all other periods. Categorical data were compared with χ 2 and Fisher's exact tests, and continuous data were assessed with Student's t-tests and Wilcoxon rank-sum tests., Results: We identified 18 567 patients: 12 797 patients in period 1 (including 3707 in period 1b), 2488 in period 2 and 3282 in period 3. Compared with period 1, period 3 had a statistically significant decrease in mean patient volume, increase in portion of penetrating injuries, increase in higher levels of trauma activation, change in emergency department discharge disposition locations, increase in in-hospital mortality and a shorter hospital length of stay. Comparison between period 1b and period 3 demonstrated a decrease in mean patient volume, increase in penetrating injuries, increase in high acuity trauma activations and increase in in-hospital mortality rate. From period 2 to period 3, the penetrating injuries rose from 6.7% to 9.4% (p=0.004), injury severity scale ≥25 increased from 5.9% to 7.7% (p=0.002), full trauma team activations increased from 13.7% to 16.4% (p<0.001), interhospital transfers decreased from 36.7% to 31.6% (p<0.001) and the in-hospital mortality rate increased from 3.3% to 4.2% (p=0.003)., Discussion: Beyond altering social interactions among people, the federal SDO is associated with changes in trauma volumes, demographics and injury patterns among patients seeking care at six level 1 hospitals during the pandemic., Level of Evidence: IV, prognostic and epidemiological., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The Glasgow Coma Scale (GCS) score has been adapted into categories of severity (mild, moderate, and severe) and are ubiquitous in the trauma setting. This study sought to revise the GCS categories to account for an interaction by age and to determine the discrimination of the revised categories compared with the standard GCS categories., Methods: The American College of Surgeons National Trauma Data Bank registry was used to identify patients with traumatic brain injury (TBI; ICD-9 codes 850-854.19) who were admitted to participating trauma centers from 2010 to 2015. The primary exposure variables were GCS score and age, categorized by decade (teens, 20s, 30s…, 80s). In-hospital mortality was the primary outcome for examining TBI severity/prognostication. Logistic regression was used to calculate the conditional probability of death by age decade and GCS in a development dataset (75% of patients). These probabilities were used to create a points-based revision of the GCS, categorized as low (mild), moderate, and high (severe). Performance of the revised versus standard GCS categories was compared in the validation dataset using area under the receiver operating characteristic (AUC) curves., Results: The final population included 539,032 patients with TBI. Age modified the performance of the GCS, resulting in a novel categorization schema for each age decile. For patients in their 50s, performance of the revised GCS categories mirrored the standard GCS categorization (3-8, 9-12, 13-15); all other revised GCS categories were heavily modified by age. Model validation demonstrated the revised GCS categories statistically significantly outperformed the standard GCS categories at predicting mortality (AUC: 0.800 vs 0.755, p<0.001). The revised GCS categorization also outperformed the standard GCS categories for mortality within pre-specified subpopulations: blunt mechanism, isolated TBI, falls, non-transferred patients., Discussion: We propose the revised age-adjusted GCS categories will improve severity assessment and provide a more uniform early prognostic indicator of mortality following traumatic brain injury., Level of Evidence: III epidemiologic/prognostic., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Warfarin reversal is typically sought prior to surgery for geriatric hip fractures; however, patients often proceed to surgery with partial warfarin reversal. The effect of partial reversal (defined as having an international normalized ratio [INR] > 1.5) remains unclear., Methods: This was a retrospective cohort study. Geriatric patients (≥65 y/o) admitted to six level I trauma centers from 01/2014-01/2018 with isolated hip fractures requiring surgery who were taking warfarin pre-injury were included. Warfarin reversal methods included: vitamin K, factor VIIa, (a)PCC, fresh frozen plasma (FFP), and the "wait and watch" method. An INR of ≤ 1.5 defined complete reversal. The primary outcome was the volume of blood loss during surgery; other outcomes included packed red blood cell (pRBC) and FFP transfusions, and time to surgery., Results: There were 135 patients, 44% partially reversed and 56% completely reversed. The median volume of blood loss was 100 mL for both those completely and partially reversed, p = 0.72. There was no difference in the proportion of patients with blood loss by study arm, 95% vs. 95%, p > 0.99. Twenty-five percent of those completely reversed and 39% of those partially reversed had pRBCs transfused, p = 0.08. Of those completely reversed 5% received an FFP transfusion compared to 14% of those partially reversed, p = 0.09. There were no statistically significant differences observed for the volume of pRBC or FFP transfused, or for time to surgery., Conclusions: Partial reversal may be safe for blood loss and blood product transfusions for geriatric patients with isolated hip fractures. Complete warfarin reversal may not be necessary prior to hip fracture surgery, especially for mildly elevated INRs., Competing Interests: None., (© 2020 Delhi Orthopedic Association. All rights reserved.)

Introduction: To summarize and compare the effectiveness of pharmacological thromboprophylaxis to pneumatic compression devices (PCD) for the prevention of venous thromboembolism in patients with acute intracerebral hemorrhage., Methods: MEDLINE, PUBMED, EMBASE, and CENTRAL were systematically searched to identify randomized and non-randomized studies that compared each intervention directly to each other or against a common control (hydration, anti-platelet agents, stockings) in adults with acute spontaneous intracerebral hemorrhage. Two investigators independently screened the studies, extracted data, and appraised risk of bias. Studies with a high risk of bias were excluded from our final analysis. The primary outcome was the occurrence of venous thromboembolism (proximal deep vein thrombosis or pulmonary embolism) in the first 30 days., Results: 8,739 articles were screened; four articles, all randomized control trials, met eligibility criteria. Bayesian network meta-analysis was performed to calculate risk estimates using both fixed and random effects analyses. 607 patients were included in the network analysis. PCD were associated with a significant decrease in venous thromboembolism compared to control (OR: 0.43, 95% Credible Limits [CrI]: 0.23-0.80). We did not find evidence of statistically significant differences between pharmacological thromboprophylaxis and control (OR: 0.93, 95% CrI: 0.19-4.37) or between PCD and pharmacological thromboprophylaxis (OR: 0.47, 95% CrI: 0.09-2.54)., Conclusion: PCDs are superior to control interventions, but meaningful comparisons with pharmacotherapy are not possible due to a lack of data. This requires further exploration via large pragmatic clinical trials., Trial Registration: PROSPERO: CRD42018090960., Competing Interests: The authors have declared that no competing interests exist.

Introduction: There is a lack of data on the use and effectiveness of pre-hospital pelvic circumferential compression devices (PCCD) as a temporary intervention for pelvic fracture management; they are thought to decrease pelvic volume and hemorrhage but are not without risks. The purpose of this study is to examine pre-hospital PCCD practices at US Level I trauma centers., Methods: This was a prospective cross-sectional survey of trauma medical directors at US Level I trauma centers. The aim of this study was to describe patterns of pre-hospital PCCD utilization for pelvic fractures. Responses were compared by region, length in time the center was designated Level I, trauma patient volume, pelvic management guideline followed and blood product guidelines. Data were compared using Fisher's exact and chi-squared tests., Results: Of the 158 Level I trauma centers invited, 25% responded. All Level I trauma centers use in-hospital PCCDs, whereas 71% of participant's paramedic agencies trained on pre-hospital PCCD application. Of those, 44% trained to apply pre-hospital PCCDs to all suspected pelvic fractures. A higher proportion of high-volume centers (77%) than low-volume centers (25%) trained on pre-hospital PCCD placement, p  = 0.06. PCCD practices were not dependent on the trauma center's region, trauma volume, length in time as a Level I trauma center, or pelvic fracture guideline followed., Conclusions: There is widespread application of in-hospital and pre-hospital PCCD at US Level I trauma centers, however pre-hospital PCCDs are not applied to all suspected pelvic fractures. Future studies should focus on efficacy, safety, and contraindications for pre-hospital PCCDs., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s) 2020.)

Delta-9-tetrahydrocannabinol (Δ 9 -THC) and other cannabinoids present in cannabis (marijuana) have been shown to affect the normal inhibitory pathways that influence nociception in humans. The potential benefits of cannabinoids as an analgesic are likely greatest in hyperalgesic and inflammatory states, suggesting a role as a therapeutic agent for treating acute pain following injury. Dronabinol is a licensed form of Δ 9 -THC. The primary objective of this single center randomized controlled trial is to evaluate the efficacy of adjunctive dronabinol versus control (systemic analgesics only, no dronabinol) for reducing opioid consumption in adults with traumatic injury. Study inclusion is based on high baseline utilization of opioids ≥50 morphine equivalents (mg) within 24 h of admission for adults aged 18-65 years with traumatic injury. There is a 48-hour screening period followed by a 48-hour treatment period after randomization. A total of 122 patients will be randomized 1:1 across 2 study arms: adjunctive dronabinol versus control (standard of care using systemic analgesics, no adjunctive dronabinol). Patients randomized to the dronabinol arm should receive their first dose within 12 h of randomization, with a dose range of 5 mg up to 30 mg daily in divided doses, in addition to systemic analgesics as needed for pain. The primary efficacy endpoint is a change in opioid consumption (morphine equivalents), assessed post-randomization (48 h after randomization) minus pre-randomization (24 h prior to randomization). This is the first randomized trial to investigate whether adjunctive dronabinol is effective in reducing opioid consumption in acute pain management of traumatic injury. Trial Registration: ClinicalTrials.gov Identifier: NCT03928015.

Background: In patients with hemodynamically stable blunt splenic injury (BSI), there is no consensus on whether quantity of hemoperitoneum (HP) is a predictor for intervention with splenic artery embolization (SAE) or failing nonoperative management (fNOM). We sought to analyze whether the quantity of HP was associated with need for intervention., Methods: This retrospective cohort study included adult trauma patients with hemodynamically stable BSI admitted to six trauma centers between 2014 and 2016. Quantity of HP was defined as small (perisplenic blood or blood in Morrison's pouch), moderate (blood in one or both pericolic gutters), or large (additional finding of free blood in the pelvis). Multivariate logistic regression was performed to identify predictors of intervention with SAE or fNOM versus successful observation., Results: There were 360 patients: hemoperitoneum was noted in 214 (59%) patients, of which the quantity was small in 92 (43%), moderate in 76 (35.5%), and large in 46 (21.5%). Definitive management was as follows: 272 (76%) were observed and 88 (24%) had intervention (83 SAE, 5 fNOM). The rate of intervention was univariately associated with quantity of HP, even after stratification by American Association for the Surgery of Trauma (AAST) grade. After adjustment, larger quantities of HP significantly increased odds of intervention (p=0.01). Compared with no HP, the odds of intervention were significantly increased for moderate HP (OR=3.51 (1.49 to 8.26)) and large HP (OR=2.89 (1.03 to 8.06)), with similar odds for small HP (OR=1.21 (0.46 to 2.76)). Other independent predictors of intervention were higher AAST grade, older age, and presence of splenic vascular injury., Conclusion: Greater quantity of HP was associated with increased odds of intervention, with no difference in risk for moderate versus large HP. These findings suggest quantity of HP should be incorporated in the management algorithm of BSI as a consideration for angiography and/or embolization to maximize splenic preservation and reduce the risk of splenic rupture., Level of Evidence: III, retrospective epidemiological study., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: To determine whether adjunctive dronabinol, a licensed form of delta-9-tetrahydrocannabinol, reduces opioid consumption when used off-label for managing acute pain following traumatic injury., Methods: This matched cohort study included patients who were admitted with a traumatic injury between 1 March 2017 and 30 October 2017. The hospital pharmacy database was used to identify patients who received dronabinol (cases), and they were matched 1:1 to patients who did not receive dronabinol (controls) using age, cause of injury and hospital length of stay. The primary outcome, change in opioid consumption, was calculated using morphine milligram equivalents (MME). The change in MME was calculated for cases as total MME over 48 hours with adjunctive dronabinol minus 48 hours prior to dronabinol, and for controls as total MME 48-96 hours from admission minus 0-48 hours from admission. Data are presented as mean and SE or median and IQR. Statistical analysis was performed using paired t-tests and McNemar's tests., Results: There were 66 patients included: 33 cases and 33 matched controls. Dronabinol was initiated 55 (28-107) hours from admission. Cases and controls were well matched. Cases had a significant reduction in opioid consumption with adjunctive dronabinol (-79 (20) MME, p<0.001), while opioid consumption was unchanged for controls (-9 (20) MME, p=0.63). This resulted in a ninefold greater reduction in opioid consumption for cases versus controls that was statistically different between pairs (p=0.02). Nineteen (58%) cases reported using marijuana; in this subset, opioid consumption was reduced with adjunctive dronabinol (-97 (24) MME, p<0.001) versus a non-significant increase in opioid consumption in matched controls (11 (29) MME, p=0.70); difference between groups, p=0.01., Conclusions: The results of this study suggest adjunctive dronabinol reduces opioid consumption following traumatic injury. The opioid-sparing effect of dronabinol may be greater in patients who are marijuana users., Level of Evidence: III., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Hospital length of stay (HLOS) is a commonly used measure of hospital quality and is influenced by clinical and non-clinical factors. To reduce HLOS, it is key to identify factors placing patients at increased risk of lengthy HLOS and discharge delays., Methods: This was a retrospective cohort study of patients age ≥ 18 admitted to four level 1 trauma centers between 1/1/2015 and 3/31/2018 with traumatic brain injury (TBI). The primary outcome was discharge delay, defined as discharge ≥24 h after case management notes indicated the patient was ready for discharge. The independent variables of interest were primary insurance provider and discharge destination. Chi-square, Fisher exact, and unadjusted and adjusted logistic regression analyses were used to assess associations between discharge delay and the two primary independent variables, as well as other patient demographic and clinical characteristics. Complications developing during the delay period were also examined., Results: A total of 1543 patients with TBI were included. The median age was 61 years, and the median HLOS was 5 days. Approximately half of patients were discharged home (54%). The most common insurance providers were Medicare (35%) and commercial/private (35%). Two-hundred ten (14%) patients experienced a discharge delay. The median delay period was 3 days, and the most common reasons for delay were insurance authorization (52%) and lack of accepting bed (41%). Compared to being discharged home, patients discharged to a skilled nursing facility (adjusted odds ratio (AOR) = 10.35) or intermediate care facility (AOR = 10.64) had the highest odds of discharge delay. Compared to Medicare patients, uninsured/self-pay patients (AOR = 2.98) and those with Medicaid (AOR = 2.83) or commercial/private insurance (AOR = 2.22) had higher odds of delay. Thirty-two patients (15% of those delayed) experienced at least one complication during the delay, some of which were clinically severe., Conclusions: A substantial portion of TBI patients in this study experienced discharge delays, and discharge destination and primary insurance provider were significant drivers of these delays. Evaluation of a facility's quality of care should consider the specific causes of these delays., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s). 2020.)

Background: We sought to identify predictors of splenic artery embolization (SAE) over observation for hemodynamically stable patients with blunt splenic injury (BSI), by Organ Injury Scale (OIS) grade., Methods: This was a multi-institutional retrospective study of all adults (≥18) with BSI who were initially managed non-operatively between 2014 and 2016. Multivariate logistic regression analysis was used to identify predictors of SAE by OIS grade. Covariates included radiographic characteristics (presence/quantity of hemoperitoneum, blush, vascular injury), demographics (age, sex, cause), Injury Severity Score, vital signs, and hemoglobin values. We also examined outcomes of death, length of stay (LOS), intensive care unit (ICU) admission, blood products, and failed non-operative management (NOM)., Results: Among 422 patients with stable BSI, 93 (22%) had SAE and 329 (78%) were observed. The rate of SAE increased by grade (p<0.001). In grade I and II BSI, 7% had SAE; significant predictors of SAE were blush (OR: 5.9, p=0.02), moderate or large hemoperitoneum (OR: 3.0, p=0.01), and male sex (OR: 6.3, p=0.05). In grade III BSI, 26% had SAE; significant predictors included moderate or large hemoperitoneum (OR: 3.9, p=0.04), motor vehicle crash (OR: 6.1, p=0.005), and age (OR=1.4, 40% with each decade increase in age, p=0.02). The rate of SAE was 52% for grade IV and 85% for grade V BSI; there were no independent predictors of SAE in either grade. Clinical outcomes were comparable by NOM strategy and grade, except longer LOS with SAE in grades I-III (p<0.05) and longer ICU LOS with SAE in grades I-IV (p<0.05). Only 5 (1.2%) patients failed NOM (4 observation, 1 SAE)., Conclusion: These results strongly support SAE consideration for patients with stable grade IV and V BSI even if there are no other high-risk clinical or radiographic findings. For grades I-III, the identified predictors may help refine consideration for SAE., Level of Evidence: Level III, retrospective epidemiological study., Competing Interests: Competing interests: None declared.

Introduction: Plasma oxidized human serum albumin (OxHSA) is evidence of an active antioxidant mechanism as measured by oxidized species of HSA. CXCL-10 is a pro-inflammatory chemokine associated with ischemic conditions. Accordingly, we examined the relationship of admission OxHSA and CXCL-10 with discharge mRS in acute ischemic stroke (AIS). Methods: Plasma samples and clinical data were collected prospectively at a Comprehensive Stroke Center. Admission biomarkers of oxidative stress, CXCL-10 and %OxHSA, were measured. We examined if CXCL-10 or %OxHSA correlated with age, admission NIHSS score, and discharge mRS score using Spearman's Rank correlation. Logistic regression was performed to identify independent predictors of a favorable discharge mRS (≤2). Results: In 106 consecutive AIS patients, the median age was 73 (IQR 61-84), 47% were male, and the median admission NIHSS score was 11 (IQR 5-19). %OxHSA and CXCL-10 were significantly correlated ( r = 0.23, p = 0.02). Both biomarkers were significantly correlated with age: %OxHSA ( r = 0.44, p < 0.001) and CXCL-10 ( r = 0.32, p = 0.001). Neither biomarker was correlated with admission NIHSS. There was a borderline significant correlation with discharge mRS and %OxHSA ( r = -0.17, p = 0.08), where higher %OxHSA correlated with lower discharge mRS scores. For every 1% increase in %OxHSA, the odds of a favorable discharge mRS increased 11%. The odds of a favorable discharge mRS decreased 18% for every 1-point increase in the initial NIHSS. Conclusions: OxHSA, the result of an oxidative environment and evidence of the strong antioxidant buffering capacity of HSA, correlated with CXCL-10 and discharge mRS, implying that strong antioxidant activity of albumin may confer better outcomes.

Background: The medical legalization of marijuana has been shown to result in an increased risk of motor vehicle injuries. In Colorado, commercialization of recreational marijuana (initiation of retail sales) occurred on January 1, 2014, resulting in the rapid proliferation of its availability. The objective of this study was to determine whether the proportion of injured patients testing positive for marijuana and other drugs changed two years before and two years after commercialization of recreational marijuana in Colorado., Methods: This retrospective multi-institutional cohort study included all patients admitted with a traumatic injury to six trauma centers (three centers in Colorado and three centers in states without permissive marijuana laws) from 2012 to 2015. The primary outcome was the rate (%) of a positive urine drug screen (UDS) for marijuana. Generalized linear regression models were used to examine the rate of change over time in the pre-commercialization period relative to the post- commercialization period (via an interaction effect), separately for states with and without recreational marijuana legalization., Results: There were 40,591 trauma admissions. In Colorado, the rate of marijuana detected with UDS decreased over time pre-commercialization; this trend reversed post-commercialization, when marijuana detection rates increased significantly over time (interaction p = 0.004). At non-Colorado hospitals, the rate over time of marijuana detection was significantly reduced post-commercialization relative to the pre-commercialization period (p <  0.001)., Conclusion: There was an overall increased rate over time of marijuana detected among trauma patients at Colorado hospitals but not at non-Colorado hospitals, suggesting an increased use of marijuana or an increased risk of injury while using marijuana following the commercialization of recreational marijuana in Colorado.

Background: Widespread legislative efforts to legalize marijuana have increased the prevalence of marijuana use and abuse. The effects of marijuana on pain tolerance and analgesic pain management in the acute pain setting have not been reported. Although marijuana has been shown to have antinociceptive effects and is approved for medical use to treat chronic pain, anecdotal evidence suggests marijuana users admitted with traumatic injuries experience poorer pain control than patients who do not use marijuana. We hypothesized that marijuana users would report higher pain scores and require more opioid analgesia following traumatic injury., Methods: This retrospective pilot study included all patients involved in motor vehicle crashes, consecutively admitted to four trauma centers from 1/1/2016-4/30/2016. Marijuana status was examined as non-use and use, and was further categorized as chronic and episodic use. We performed a repeated measures mixed model to examine the association between marijuana use and a) average daily opioid consumption and b) average daily pain scores (scale 0-10). Opioid analgesics were converted to be equianalgesic to 1 mg IV hydromorphone., Results: Marijuana use was reported in 21% (54/261), of which 30% reported chronic use (16/54). Marijuana use was reported more frequently in Colorado hospitals (23-29%) compared to the hospital in Texas (6%). Drug use with other prescription/street drugs was reported in 9% of patients. Other drug use was a significant effect modifier and results were presented after stratification by drug use. After adjustment, marijuana users who did not use other drugs consumed significantly more opioids (7.6 mg vs. 5.6 mg, p  <  0.001) and reported higher pain scores (4.9 vs. 4.2, p  <  0.001) than non-marijuana users. Conversely, in patients who used other drugs, there were no differences in opioid consumption (5.6 mg vs. 6.1 mg, p  = 0.70) or pain scores (5.3 vs. 6.0, p  = 0.07) with marijuana use compared to non-use, after adjustment. Chronic marijuana use was associated with significantly higher opioid consumption compared to episodic marijuana use in concomitant drug users (11.3 mg vs. 4.4 mg, p  = 0.008) but was similar in non-drug users ( p  = 0.41)., Conclusion: These preliminary data suggest that marijuana use, especially chronic use, may affect pain response to injury by requiring greater use of opioid analgesia. These results were less pronounced in patients who used other drugs., Competing Interests: The study was approved from the Institutional Review Boards at each respective facility; informed consent was waived. Reference numbers: Swedish Medical Center: 987891; St. Anthony Hospital: 973145; Penrose Hospital: 975740; Medical City Plano: 103099.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: There are limited efficacious treatment options for severe osteoarthritis of the knee (OAK). The Low Molecular Weight Fraction of 5% human serum Albumin (LMWF-5A) is in development to treat severe OAK. This study evaluated the safety and efficacy of LMWF-5A for the signs and symptoms of OAK., Methods: This 12-week randomized, double-blind, controlled clinical trial was conducted at thirteen sites across the United States. Patients with symptomatic, severe OAK (Kellgren-Lawrence grade 4 disease) who were fully ambulatory and had no other conditions interfering with the study knee were randomized to a single 4 ml intra-articular injection of LMWF-5A or saline, randomized 6:1. The primary endpoint was Outcome Measures in Rheumatology-Osteoarthritis Research Society International (OMERACT-OARSI) responder rate (%), examined with a one-sided exact binomial test compared to a clinically meaningful response rate of 30%. Efficacy of LMWF-5A was also evaluated as controlled responder (%), defined as 20% improvements in both pain and function, compared to historical saline control from three previous trials. Safety was examined as the incidence and severity of adverse events (AEs). This trial was registered (clinicaltrials.gov identifier: NCT03182686)., Results: In total, 168 patients were randomized; 144 subjects treated with LMWF-5A were analysed. Overall, 71% (95% CI: 63.4%-78.3%) of subjects treated with LMWF-5A met the OMERACT-OARSI responder criteria, exceeding the 30% threshold ( p  < 0.001). There were also significantly more responders at week 12 in the LMWF-5A arm than historical saline control (65% vs. 43%, p  < 0.001). There were no drug-related serious AEs reported and no deaths or withdrawals due to adverse events., Conclusion: LMWF-5A provides relief for the signs and symptoms of severe osteoarthritis, and may be an alternative therapeutic treatment option for patients with severe osteoarthritis of the knee., Competing Interests: The study was approved from the Schulman Institutional Review Board with documentation of informed consent. Dr. Bar-Or reports personal fees from Ampio Pharmaceuticals Inc., during the conduct of the study; In addition, Dr. Bar-Or has 120 issued patents and 80 pending. Dr. Bar-Or is an employee of Ampio Pharmaceuticals, Inc. and serves as the chief Scientific officer of Ampio Pharmaceuticals and own stocks and stock options in the company. Ampio is developing LMWF-5A for the treatment of OA of the knee. Mrs. Salottolo reports personal fees from Ampio Pharmaceuticals, Inc., and own stocks and stock options in the company. Dr. Cole reports conflicts outside the submitted work including: personal fees and other from Arthrex, other from Arthroscopy; other from Aesculap/B.Braun, other from American Journal of Orthopedics, other from American Orthopaedic Society for Sports Medicine, other from American Shoulder and Elbow Surgeons, personal fees and other from Arthrex, Inc., other from Arthroscopy Association of North America, other from Athletico, other from Carticept, other from Cytori, other from DJ Orthopaedics, other from Elsevier Publishing, other from International Cartilage Repair Society, other from Journal of Bone & Joint Surgery - American, other from Journal of Shoulder and Elbow Surgery, other from Journal of the American Academy of Orthopaedic Surgeons, other from Medipost, other from National Institutes of Health (NIAMS & NICHD), other from Ossur, personal fees and other from Regentis, other from Saunders/Mosby-Elsevier, other from Smith & Nephew, other from Tornier, personal fees and other from Zimmer, other from Arthroscopy.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: The disease modifying potential of osteoarthritis therapies are of increasing interest, including their effects on delaying total knee replacement (TKR). To date, there have been no studies to determine the effect of LMWF-5A, a novel anti-inflammatory compound derived from human serum albumin, on delaying TKR., Methods: We evaluated time to TKR three years after patients participated in a randomized trial of three intra-articular injections of LMWF-5A or saline. Patients were contacted via last known phone number and were asked to participate in a short nine item telephone questionnaire; verbal consent was obtained. The primary endpoint was incidence of TKR (%)., Results: In total, 39 of 45 patients responded (87% response rate). The overall incidence of TKR was 38.5% (15/39). TKR rates were higher in patients with more severe osteoarthritis defined by Kellgren-Lawrence grade 4, compared to patients with moderate osteoarthritis defined by Kellgren-Lawrence grade 3 (56% vs. 26%, p  = 0.06). Overall, there were no differences in TKR rates by treatment arm (39% LMWF-5A vs. 38% saline, p  = 0.92). In the severe osteoarthritis subset ( n  = 16), treatment with LMWF-5A resulted in a lower incidence of TKR compared to saline vehicle arm (40% vs. 83%, p  = 0.15). TKR rates were significantly lower with LMWF-5A in patients who responded to treatment (14% with LMWF-5A, vs. 100% with saline, p  = 0.03)., Conclusion: This study demonstrates significant delays in TKR for patients with severe osteoarthritis treated with LMWF-5A, suggesting that LMWF-5A has the potential to provide structure modifying/preserving therapy in this population., Competing Interests: The study was approved from the Integreview Institutional Review Board with waiver of documentation of informed consent (AP-007-B).Dr. Schwappach reports consulting fees paid to his institution. Mrs. Salottolo reports personal fees from Ampio Pharmaceuticals, Inc., and own stocks and stock options in the company. Dr. Bar-Or is an employee of Ampion Pharmaceuticals, Inc. and serves as the chief Scientific officer of Ampio Pharmaceuticals and own stocks and stock options in the company. In addition, Dr. Bar-Or has more than 120 issued patents and 80 pending. Mr. Schultz has no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Objective: Vasoactive substances, including marijuana, are known precipitating factors of reversible cerebral vasoconstriction syndrome (RCVS). Our objective was to describe the demographics, suspected etiology, and outcomes of RCVS patients, with specific interest in examining the subset of patients who used marijuana prior to the onset of RCVS., Methods: We identified and described consecutive RCVS cases treated at a regional, high-volume Comprehensive Stroke Center in Colorado (2012-2015). Univariate analyses were performed to examine the associations between the characteristics and outcomes (stroke and discharge disposition) of the RCVS patients by precipitating factors. We compared patients who used marijuana to those who did not and patients who used marijuana to patients who used vasoactive substances aside from marijuana., Results: Forty patients had RCVS. Sixteen (40%) cases were deemed idiopathic and 24 (60%) were secondary to a suspected trigger. Vasoactive substances were the most common suspected trigger ( n = 18/24, 75%), 6 (33%) of which were marijuana. Approximately 80% of patients experienced an intracranial hemorrhage, 20% had an ischemic stroke, and yet 78% were discharged home. Patients with RCVS secondary to marijuana were more often male ( p = 0.05) and younger ( p = 0.02) compared to those who did not use marijuana; no differences were observed in the outcomes. These findings were consistent when examining marijuana versus other vasoactive substances., Conclusion: This study suggests there are demographic differences between patients with RCVS triggered by marijuana compared to the typical RCVS patient. As more states legalize marijuana, medical conditions such as RCVS and their association with marijuana warrants further study and awareness.

The minimal clinically important improvement (MCII) is the smallest change that signifies an important improvement. Disease severity may complicate MCII. We developed an eight-question survey examining MCII in patients with severe knee osteoarthritis (Kellgren-Lawrence grade 4). Twenty-seven of 101 clinicians completed the survey. An MCII of 20% was selected most frequently for pain, function, and patient global assessment. Clinicians were divided on responder rate, selecting 20%, 30%, and 50% equally. These findings suggest a 20% MCII may be useful in patients with severe osteoarthritis, but that there is not enough evidence to support a responder rate in this population.

Objectives: In congestive heart failure (CHF), men are younger, more likely to have reduced ejection fraction (HF-rEF), and to be diabetic compared to women. Despite this, sex differences in oxidative stress have yet to be explored in CHF., Methods: Data from 67 males and 63 females hospitalized for CHF were collected. Static oxidation-reduction potential (sORP), a relative indicator of oxidative stress, and capacity ORP (icORP), a relative indicator of antioxidant capacity, were measured from plasma samples. We examined whether sex modified the relationship between ORP and hospital discharge disposition (poor outcome: death, hospice), along with other demographics, medications, and diagnostic parameters., Results: Males with poor outcomes had higher sORP and icORP values than females (P < 0.05). For those with a good outcome, there were no differences between the sexes (P > 0.05). Males were younger and more likely to have HF-rEF and diabetes. Controlling for these variables did not account for the sex differences in ORP measures. Regardless of sex, higher creatinine was related to higher sORP and icORP, while lower magnesium and potassium were related to higher sORP and icORP, respectively., Discussion: Increases in sORP during CHF are partially affected by sex and acute outcomes, but are also related to variables without sexual biases.

Background: Tibial plateau fractures (TPFs) are frequently associated with motor vehicle accidents, auto-pedestrian crashes and falls. However, hospitals near ski resorts commonly treat TPF resulting from skiing. The soft tissue envelope and original mechanism of injury are important determinants in the decision to proceed with immediate or delayed fixation of the fracture. Our objective was to assess whether immediate (≤24 hours) versus delayed (>24 hours) open reduction internal fixation (ORIF) affected in-hospital outcomes among snow sport participants., Methods: This was a retrospective study of patients with isolated TPF who were injured while skiing or snowboarding and treated at a Level III Trauma Center that serves four major ski resorts between 2010 and 2013. Clinical characteristics and in-hospital outcomes were obtained from an existing trauma database. Imaging was reviewed to classify the fracture as high (Schatzker IV-VI) or low (Schatzker I-III) energy. Differences in clinical characteristics and outcomes between immediate and delayed ORIF patients were analyzed with χ 2 and Wilcoxon two-sample tests. These analyses were also performed in the high-energy and low-energy fracture populations., Results: ORIF was performed on 119 snow sport patients, 93 (78%) immediately. Patients had a median age of 49 years (range 19-70) and were predominantly male (66%). Forty percent sustained a high-energy TPF. No differences were observed between the demographic characteristics, injury severity, Schatzker scores or time from injury to hospital arrival for patients treated immediately versus delayed treatment. Compared with delayed fixation, patients treated immediately had less compartment syndrome (3% vs 27%), needed fewer fasciotomies (6% vs 31%) and had a shorter length of stay (3 vs 6.5 days), p<0.05 for all. These results persisted in the stratified analysis of high-energy fracture patients., Discussion: Treating patients immediately led to more favorable in-hospital outcomes compared with delayed treatment, even among the patients with a high-energy fracture., Level of Evidence: Level IV, Therapeutic/Care Management., Competing Interests: Competing interests: None declared.

Background: Cerebral venous thrombosis is a rare cause of stroke that poses diagnostic, therapeutic, and prognostic challenges. Mainstay treatment is systemic anticoagulation, but endovascular treatment is increasingly advocated. Our objectives were to describe the epidemiology, treatment, and prognosis of 152 patients with cerebral venous thrombosis., Methods and Results: This was a retrospective study of consecutive cerebral venous thrombosis cases from 2006 to 2013 at a comprehensive stroke center through hospital discharge. Predictors of full recovery (modified Rankin Scale scores 0-1) were analyzed with multiple logistic regression and presented as adjusted odds ratios (AORs) with 95% confidence intervals (CIs). The population was young (average age: 42 years), majority female (69%), and commonly presenting with cerebral edema (63%), and 72% were transferred in. All patients received systemic anticoagulation; 49% (n=73) required endovascular treatment. Reasons for requiring endovascular treatment included cerebral edema, herniation, or hemorrhagic infarct (n=38); neurologic decline (n=17); rethrombosis, persistent occlusion, or clot propagation (n=10); extensive clot burden (n=7); and persistent headache despite anticoagulation (n=1). There were 7 (10%) procedural complications. Recanalization was successful (61%), partial (30%), and unsuccessful (9%). Overall, 60% fully recovered. Positive predictors of full recovery included hormonal etiology, particularly for patients who were transferred in (AOR: 7.06 [95% CI, 2.27-21.96], interaction P =0.03) and who had migraine history (AOR: 4.87 [95% CI, 1.01-23.50], P =0.05), whereas negative predictors of full recovery were cerebral edema (AOR: 0.11 [95% CI, 0.04-0.34], P <0.001) and motor weakness (AOR: 0.28 [95% CI, 0.09-0.96], P =0.04)., Conclusions: As one of the largest cohort studies, our findings suggest that cerebral edema, history of migraine, and hormonal etiology were prognostic and that endovascular treatment might be a safe and effective treatment for cerebral venous thrombosis when conventional management is inadequate., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Objective: The modified early warning score (MEWS) is a 'track and trigger' score using routine physiological vital signs. The objective is to determine if the pretransfer MEWS can be used for predicting outcomes in trauma patients requiring interfacility transfer to higher levels of care., Design, Setting and Participants: Retrospective study of consecutively transferred trauma patients into a level-II trauma centre from 2013 to 2014., Interventions: None., Outcome Measures: Mortality, intensive care unit (ICU) admission, operative procedure, MEWS deterioration in-transit, air transport interfacility, secondary overtriage (low injury severity score (ISS) <10, LOS<1 day, discharged home) and severe injury (ISS ≥16). The association between the pretransfer MEWS and outcomes were analysed with Cochran-Armitage trend tests, receiver operator characteristic (ROC) curves and univariate logistic regression., Results: There were 587 transferred patients; outcomes were reported in 339 patients with complete data on all five vital signs used to calculate the MEWS. The MEWS ranged from 0 to 9 (median of 1). There was a significant linear relationship between MEWS and study outcomes, especially mortality, ICU admission, air medical transport and severe injury (p<0.001 for all). A threshold score ≥4 was identified by ROC analysis; 11.2% of patients had MEWS ≥4. Outcomes were significantly worse in patients with MEWS ≥4 versus <4: mortality (26.2% vs 3.0%, OR=11.59, p<0.001); ICU admission (73.7% vs 47.2%, OR=3.14, p=0.003); air transfer (42.1% vs 15.6%, OR=3.93, p<0.001) and severe injury (59.5% vs 27.2%, OR=3.9, p<0.001). The MEWS was not associated with surgery, in-transit MEWS deterioration or secondary overtriage., Conclusion: Pretransfer MEWS ≥4 may be used by the receiving facility for predicting injury severity, mortality, air transport and ICU resource use. In the interfacility transport setting, the MEWS may be useful for identifying patients with less obvious need for transfer or requiring more expeditious transfer., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Electrolyte imbalances are common among patients with traumatic brain injury (TBI). Cerebral salt wasting (CSW) is an electrolyte imbalance characterized by hyponatremia and hypovolemia. Differentiating the syndrome of inappropriate antidiuretic hormone and CSW remains difficult and the pathophysiological mechanisms underlying CSW are unclear. Our intent was to review the literature on CSW within the TBI population, in order to report the incidence and timing of CSW after TBI, examine outcomes, and summarize the biochemical changes in patients who developed CSW. We searched MEDLINE through 2014, hand-reviewed citations, and searched abstracts from the American Association for the Surgery of Trauma (2003-2014). Publications were included if they were conducted within a TBI population, presented original data, and diagnosed CSW. Publications were excluded if they were review articles, discussed hyponatremia but did not differentiate the etiology causing hyponatremia, or presented cases with chronic disease. Fifteen of the 47 publications reviewed met the selection criteria; nine (60%) were case reports, five (33%) were prospective and 1 (7%) was a retrospective study. Incidence of CSW varied between 0.8 - 34.6%. The populations studied were heterogeneous and the criteria used to define hyponatremia and CSW varied. Though believed to play a role in the development of CSW, increased levels of natriuretic peptides in patients diagnosed with CSW were not consistently reported. These findings reinforce the elusiveness of the CSW diagnosis and the need for strict and consistent diagnostic criteria.

Background: Do-Not-Resuscitate (DNR) orders in patients with traumatic injury are insufficiently described. The objective is to describe the epidemiology and outcomes of DNR orders in trauma patients., Methods: We included all adults with trauma to a community Level I Trauma Center over 6 years (2008-2013). We used chi-square, Wilcoxon rank-sum, and multivariate stepwise logistic regression tests to characterize DNR (established in-house vs. pre-existing), describe predictors of establishing an in-house DNR, timing of an in-house DNR (early [within 1 day] vs late), and outcomes (death, ICU stay, major complications)., Results: Included were 10,053 patients with trauma, of which 1523 had a DNR order in place (15%); 715 (7%) had a pre-existing DNR and 808 (8%) had a DNR established in-house. Increases were observed over time in both the proportions of patients with DNRs established in-house (p = 0.008) and age ≥65 (p < 0.001). Over 90% of patients with an in-house DNR were ≥65 years. The following covariates were independently associated with establishing a DNR in-house: age ≥65, severe neurologic deficit (GCS 3-8), fall mechanism of injury, ED tachycardia, female gender, and comorbidities (p < 0.05 for all). Age ≥65, female gender, non-surgical service admission and transfers-in were associated with a DNR established early (p < 0.05 for all). As expected, mortality was greater in patients with DNR than those without (22% vs. 1%), as was the development of a major complication (8% vs. 5%), while ICU admission was similar (19% vs. 17%). Poor outcomes were greatest in patients with DNR orders executed later in the hospital stay., Conclusions: Our analysis of a broad cohort of patients with traumatic injury establishes the relationship between DNR and patient characteristics and outcomes. At 15%, DNR orders are prevalent in our general trauma population, particularly in patients ≥65 years, and are placed early after arrival. Established prognostic factors, including age and physiologic severity, were determinants for in-house DNR orders. These data may improve physician predictions of outcomes with DNR and help inform patient preferences, particularly in an environment with increasing use of DNR and increasing age of patients with trauma.

Background: The abrupt discontinuation of statin therapy has been suggested as being deleterious to patient outcomes. Although pre-injury statin (PIS) therapy has been shown to have a protective effect in elderly trauma patients, no study has examined how this population is affected by its abrupt discontinuation. This study examined the effects of in-hospital statin discontinuation on patient outcomes in elderly traumatic brain injury (TBI) patients., Methods: This was a multicenter, retrospective cohort study on consecutively admitted elderly (≥ 55) PIS patients who were diagnosed with a blunt TBI and who had a hospital length of stay (LOS) ≥ 3 days. Patients who received an in-hospital statin within 48 hours of admission were considered continued, and patients who never received an in-hospital statin were considered discontinued. Differences in in-hospital mortality, having at least one complication, and LOS > 1 week were examined between those who continued and discontinued PIS., Results: Of 93 PIS patients, 46 continued and 15 discontinued statin therapy. The two groups were equivalent vis-a-vis demographic and clinical characteristics. Those who discontinued statin therapy had a 4-fold higher mortality rate than those who continued (n = 4, 27% vs. n = 3, 7%, P = 0.055). Statin discontinuation did not have a higher complication rate, compared to statin continuation (n = 3, 20% vs. n = 7, 15%, P = 0.70), and no difference was seen in the proportion with a hospital LOS > 1 week (P > 0.99)., Conclusions: Though our study is not definitive, it does suggest that the abrupt, unintended discontinuation of statin therapy is associated with increased mortality in the elderly TBI population. Continuing in-hospital statin therapy in PIS users may be an important factor in the prevention of in-hospital mortality in this elderly TBI population.

Background and Purpose: Patients with acute ischemic stroke require immediate medical treatment, and a CT to rule out hemorrhage is required before tPA. We adapted our protocol to include multimodal CT: unenhanced CT, CTA, and PCT. The purpose of this study was to determine whether multimodal CT imaging delays initiation of IV tPA beyond 60 minutes from hospital arrival., Materials and Methods: All patients admitted during 3 years through the ED with a stroke alert and time from symptom onset to hospital arrival <2.5 hours were included. We examined 2 subgroups (multimodal CT versus unenhanced CT) to determine whether multimodal CT delayed tPA administration. Logistic regression was used to identify variables that predicted tPA within 60 minutes., Results: There were 123 patients in the analysis, including 108 patients who were examined with multimodal CT. The median time from arrival to tPA was 56 minutes and was shorter for patients examined with multimodal CT (55 versus 78 minutes, P = .02). After adjustment, variables that were associated with tPA administration within 60 minutes included prehospital stroke alert (OR = 3.47, P = .03), time to CT (OR = 0.94, P = .01), and onset-to-arrival time (OR = 1.02, P = .04). There was no statistically significant difference in the odds of receiving timely tPA for multimodal versus unenhanced CT (OR = 3.99, P = .07)., Conclusions: In our single-center experience, the use of multimodal imaging in patients with acute stroke did not delay IV tPA beyond 60 minutes. Further study is needed to assess the feasibility of the routine use of multimodal imaging in the acute stroke setting.