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Background: Motor vehicle crashes (MVCs) are a leading cause of preventable trauma death in the United States. Access to trauma center care is highly variable nationwide. The objective of this study was to measure the association between geospatial access to trauma center care and MVC mortality., Methods: This was a population-based study of MVC-related deaths that occurred in 3,141 US counties (2017-2020). American College of Surgeons and state-verified Level I to III trauma centers were mapped. Geospatial network analysis estimated the ground transport time to the nearest trauma center from the population-weighted centroid for each county. In this way, the exposure was the predicted access time to trauma center care for each county population. Hierarchical negative binomial regression measured the risk-adjusted association between predicted access time and MVC mortality, adjusting for population demographics, rurality, access to trauma resources, and state traffic safety laws., Results: We identified 92,398 crash fatalities over the 4-year study period. Trauma centers mapped included 217 Level I, 343 Level II, and 495 Level III trauma centers. The median county predicted access time was 47 minutes (interquartile range, 26-71 minutes). Median county MVC mortality was 12.5 deaths/100,000 person-years (interquartile range, 7.4-20.3 deaths/100,000 person-years). After risk-adjustment, longer predicted access times were significantly associated with higher rates of MVC mortality (>60 minutes vs. <15 minutes; mortality rate ratio 1.36; 95% confidence interval, 1.31-1.40). This relationship was significantly more pronounced in urban/suburban vs. rural/wilderness counties ( p for interaction, <0.001). County access to trauma center care explained 16% of observed state-level variation in MVC mortality., Conclusion: Geospatial access to trauma center care is significantly associated with MVC mortality and contributes meaningfully to between-state differences in road traffic deaths. Efforts to improve trauma system organization should prioritize access to trauma center care to minimize crash fatalities., Level of Evidence: Prognostic and Epidemiological, Level III., (Copyright © 2023 American Association for the Surgery of Trauma.)

Aim: The number of geriatric trauma patients is rising; yet, there is no established best team to care for them. This study analyzed a geriatric trauma service (GTS) that is integrated into the trauma surgery workflow rather than a separate consultation service. We hypothesize this team will lead to decreased mortality, shorter length of stay and increased favorable discharges for geriatric trauma patients., Methods: In July 2017, we established a GTS consisting of geriatric nurse practitioners who were part of the hospital's geriatrics service, trauma surgeons and surgery residents on the acute care surgery service. The geriatric nurse practitioners were integrated into the trauma surgery workflow and functioned as independent members. The GTS responded to traumas and consultations for patients aged ≥65 years. Trauma surgeons carried out intensive care and operative management, while the geriatric nurse practitioners managed medical issues, family communication and end-of-life planning. We carried out a 2 year retrospective analysis of trauma patients aged ≥65 years seen at Dell Seton Medical Center at the University of Texas, Austin, Texas, USA, comparing patient outcomes before and after the GTS. The primary outcome was mortality, whereas secondary outcomes included hospital days, intensive care unit days, and discharge disposition., Results: We found no difference in mortality, intensive care unit days or hospital days with the GTS. However, post-GTS patients were more often discharged to home, rehabilitation, or hospice, and less often to nursing homes., Conclusion: An integrated geriatric and trauma team is feasible, and significant changes in disposition can be made by utilizing geriatric nurse practitioners. Geriatr Gerontol Int 2020; 20: 817-821., (© 2020 Japan Geriatrics Society.)

Background: The use of Tranexamic Acid (TXA) in trauma patients remains controversial. The CRASH II trial, while randomized and prospective, did not include patients suffering from major bleeding. We wanted to examine our population of patients who underwent a massive transfusion protocol (MTP) (greater than 10 Units of packed red blood cells in the first 24 h of admission) to see if those who were undergoing massive transfusion and received TXA had any benefit in mortality. Our hypothesis was that massively transfused patients who received TXA and those that did not had no difference in mortality., Methods: We performed a single institution retrospective review of our Trauma Registry for all patients who received a massive transfusion between 2010 and 2017. Patients were separated into two cohorts, those who received TXA within the first 24 h of admission and those who did not. The primary outcome of the study was mortality. Secondary outcomes included total blood products transfused, Deep Venous Thrombosis (DVT), Pulmonary Embolus (PE), Myocardial Infarction (MI), and cardiac arrest., Results: 283 patients received MTP between 2010 and 2017. 179 (63%) did not receive TXA and 104 (37%) were treated with TXA. The groups were then propensity matched and yielded 62 patients in each group (124 total) (ISS 36 ± 12 no TXA vs. 37 ± 13 TXA; p = 0.59). There was no significant difference observed in mortality (50% no TXA vs. 39% TXA; p = 0.21), total PRBC's transfused (20 ± 11 no TXA vs. 23 ± 18 TXA; p = 0.45), DVT (8% no TXA vs. 6% TXA; p = 0.99), PE (2% no TXA vs. 3% TXA; p = 0.99), MI (3% no TXA vs. 0% TXA; p = 0.50), or cardiac arrest (26% no TXA vs. 18% TXA; p = 0.28)., Conclusion: There does not appear to be any benefit to TXA administration in Trauma Patients in our institution. This is a single-center retrospective review. More data from other similar centers in the region or the United States is warranted., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Intoxication often prevents clinical clearance of the cervical spine (Csp) after trauma leading to prolonged immobilization even with a normal computed tomography (CT) scan. We evaluated the accuracy of CT at detecting clinically significant Csp injury, and surveyed participants on related opinions and practice., Methods: A prospective multicenter study (2013-2015) at 17 centers. All adult blunt trauma patients underwent structured clinical examination and imaging including a Csp CT, with follow-up thru discharge. alcohol- and drug-intoxicated patients (TOX+) were identified by serum and/or urine testing. Primary outcomes included the incidence and type of Csp injuries, the accuracy of CT scan, and the impact of TOX+ on the time to Csp clearance. A 36-item survey querying local protocols, practices, and opinions in the TOX+ population was administered., Results: Ten thousand one hundred ninety-one patients were prospectively enrolled and underwent CT Csp during the initial trauma evaluation. The majority were men (67%), had vehicular trauma or falls (83%), with mean age of 48 years, and mean Injury Severity Score (ISS) of 11. The overall incidence of Csp injury was 10.6%. TOX+ comprised 30% of the cohort (19% EtOH only, 6% drug only, and 5% both). TOX+ were significantly younger (41 years vs. 51 years; p < 0.01) but with similar mean Injury Severity Score (11) and Glasgow Coma Scale score (13). The TOX+ cohort had a lower incidence of Csp injury versus nonintoxicated (8.4% vs. 11.5%; p < 0.01). In the TOX+ group, CT had a sensitivity of 94%, specificity of 99.5%, and negative predictive value (NPV) of 99.5% for all Csp injuries. For clinically significant injuries, the NPV was 99.9%, and there were no unstable Csp injuries missed by CT (NPV, 100%). When CT Csp was negative, TOX+ led to longer immobilization versus sober patients (mean, 8 hours vs. 2 hours; p < 0.01), and prolonged immobilization (>12 hrs) in 25%. The survey showed marked variations in protocols, definitions, and Csp clearance practices among participating centers, although 100% indicated willingness to change practice based on these data., Conclusion: For intoxicated patients undergoing Csp imaging, CT scan was highly accurate and reliable for identifying clinically significant spine injuries, and had a 100% NPV for identifying unstable injuries. CT-based clearance in TOX+ patients appears safe and may avoid unnecessary prolonged immobilization. There was wide disparity in practices, definitions, and opinions among the participating centers., Level of Evidence: Diagnostic tests or criteria, level II.

Introduction: Formula One returned to the United States on November 16-18, 2012, with the inaugural United States Grand Prix in Austin, Texas. Medical preparedness for motorsports events represents a unique challenge due to the potential for a high number of spectators seeking medical attention, and the possibility for a mass-casualty situation. Adequate preparation requires close collaboration across public safety agencies and hospital networks to minimize impact on Emergency Medical Services (EMS) resources., Hypothesis/problem: To report the details of preparation for an inaugural mass-gathering motorsports event, and to describe the details of the medical care rendered during the 3-day event., Methods: A retrospective analysis was completed utilizing postevent summaries, provided by the medical planning committee, by the Federation Internationale de L'Automobile (FIA), and Austin Travis County Emergency Medical Services (ATCEMS). Patient data were collected from standardized patient care records for descriptive analysis. Medical usage rates (MURs) are reported as a rate of patients per 10,000 (PPTT) participants., Results: A total of 566 patients received medical care over the 3-day period with the on-site care rate of 95%. Overall, MUR was 21.3 PPTT attendees. Most patients had minor problems, and there were no driver injuries or deaths., Conclusion: This mass-gathering motorsport event had a moderate number of patients requiring medical attention. The preparedness plan was implemented successfully with minimal impact on EMS resources and local medical facilities. This medical preparedness plan may serve as a model to other cities preparing for an inaugural motorsports event.

Objective: Determine the efficacy of 3 brief intervention strategies that address heavy drinking among injured patients., Background: The content or structure of brief interventions most effective at reducing alcohol misuse after traumatic injury is not known., Methods: Injured patients from 3 trauma centers were screened for heavy drinking and randomly assigned to brief advice (n = 200), brief motivational intervention (BMI) (n = 203), or BMI plus a telephone booster using personalized feedback or BMI + B (n = 193). Among those randomly assigned, 57% met criteria for moderate to severe alcohol problems. The primary drinking outcomes were assessed at 3, 6, and 12 months., Results: Compared with brief advice and BMI, BMI + B showed significant reductions in the number of standard drinks consumed per week at 3 (Δ adjusted means: -1.22, 95% confidence interval [CI]: -0.99, approximately -1.49, P = 0.01) and 6 months (Δ adjusted means: -1.42, 95% CI: -1.14, approximately -1.76, P = 0.02), percent days of heavy drinking at 6 months (Δ adjusted means: -5.90, 95% CI: -11.40, approximately -0.40, P = 0.04), maximum number of standard drinks consumed in 1 day at 3 (Δ adjusted means: -1.38, 95% CI: -1.18, approximately -1.62, P = 0.003) and 12 months (Δ adjusted means: -1.71, 95% CI: -1.47, approximately -1.99, P = 0.02), and number of standard drinks consumed per drinking day at 3 (Δ adjusted means: -1.49, 95% CI: -1.35, approximately -1.65, P = 0.002) and 6 months (Δ adjusted means: -1.28, 95% CI: -1.17, approximately -1.40, P = 0.01)., Conclusions: Brief interventions based on motivational interviewing with a telephone booster using personalized feedback were most effective at achieving reductions in alcohol intake across the 3 trauma centers.

Background: Nonmedical use of prescription opioids (NM-POs) has reached epidemic proportions in the United States. Unintentional overdose deaths involving prescription opioids have quadrupled since 1999. Herein, we examine NM-POs and their associated risk factors among two cohorts of trauma patients with at-risk drinking., Methods: This secondary analysis examines NM-PO from two separate randomized trials that delivered brief alcohol interventions to patients in urban Level I trauma centers. In the first study, data were collected from 1,493 injured patients at a single trauma center, and in the second study, data were collected from 596 injured patients at two trauma centers. All participants were considered at-risk drinkers because they were admitted for an alcohol related injury as indicated by a positive blood alcohol concentration and/or self-reported heavy drinking., Results: In Study 1, NM-PO nearly doubled from 5.2% before admission to 9.8% at 6 months after discharge. At 12 months after discharge, those who reported NM-PO (odds ratio [OR], 2.31; 95% confidence interval [CI], 1.28-4.15) and drug use (OR, 2.62, 95% CI, 1.70-4.04) before admission had the highest odds for postdischarge NM-PO. In Study 2, NM-PO increased from 5.2% before admission to 6.8% at 12 months after discharge. At 12 months after discharge, those who reported NM-PO (OR, 2.71; 95% CI, 1.10-6.66) or drug use (OR, 4.05; 95% CI, 2.00-8.21) before admission had the highest odds for postdischarge NM-PO., Conclusion: The results suggest that there is an increased risk of postdischarge NM-PO among injured patients with at-risk drinking, particularly among those with a recent history of drug use or NM-PO. Cautious, evidence-based opioid prescribing may reduce exposure to prescription opioids in high-risk patients, risk of subsequent misuse, and possible diversion., Level of Evidence: Prognostic/epidemiologic study, level II.

Inpatient falls lead to an injury in 30 per cent of cases and serious injury in 5 per cent. Increasing staffing and implementing fall prevention programs can be expensive and require a significant use of resources. We hypothesized that trauma patients have unique risk factors to sustain a fall while hospitalized. This is a retrospective cohort study from 2005 to 2010 of all trauma patients admitted to an urban Level I trauma center. Patients who fell while hospitalized were compared with patients who did not fall to identify risk factors for sustaining an inpatient fall. There were 16,540 trauma patients admitted during the study period and 128 (0.8%) fell while hospitalized. Independent risk factors for a trauma patient to fall while hospitalized included older age (odds ratio [OR], 1.02 [1.01 to 1.03], P < 0.001), male gender (OR, 1.6 [1.0 to 2.4], P = 0.03), blunt mechanism (OR, 5.1 [1.6 to 16.3], P = 0.006), Glasgow Coma Score at admission (OR, 0.59 [0.35 to 0.97], P = 0.04), intensive care unit admission (OR, 2.3 [1.4 to 3.7], P = 0.001), and need for mechanical ventilation (OR, 2.2 [1.2 to 3.9], P = 0.01). Trauma patients who fell while hospitalized sustained an injury in 17 per cent of cases and a serious injury in 5 per cent. Inpatient falls in hospitalized trauma patients are uncommon. Risk factors include older age, male gender, blunt mechanism, lower Glasgow Coma Score, and the need for intensive care unit admission or mechanical ventilation. Trauma patients with these risk factors may require higher staffing ratios and should be enrolled in a formal fall prevention program.

Background: Acute care surgery encompasses trauma, surgical critical care, and emergency general surgery (EGS). While the first two components are well defined, the scope of EGS practice remains unclear. This article describes the work of the American Association for the Surgery of Trauma to define EGS., Methods: A total of 621 unique International Classification of Diseases-9th Rev. (ICD-9) diagnosis codes were identified using billing data (calendar year 2011) from seven large academic medical centers that practice EGS. A modified Delphi methodology was used by the American Association for the Surgery of Trauma Committee on Severity Assessment and Patient Outcomes to review these codes and achieve consensus on the definition of primary EGS diagnosis codes. National Inpatient Sample data from 2009 were used to develop a national estimate of EGS burden of disease., Results: Several unique ICD-9 codes were identified as primary EGS diagnoses. These encompass a wide spectrum of general surgery practice, including upper and lower gastrointestinal tract, hepatobiliary and pancreatic disease, soft tissue infections, and hernias. National Inpatient Sample estimates revealed over 4 million inpatient encounters nationally in 2009 for EGS diseases., Conclusion: This article provides the first list of ICD-9 diagnoses codes that define the scope of EGS based on current clinical practices. These findings have wide implications for EGS workforce training, access to care, and research.

Timely correction of coagulopathy in patients with traumatic brain injury (TBI) improves mortality. Recombinant, activated factor VII (VIIa) has been identified as an effective method to correct coagulopathy in patients with TBI. We performed a retrospective study (January 1, 2008-December 31, 2009) of all patients with TBI and coagulopathy (international normalized ratio (INR) > 1.5) transferred to our Level I trauma center. Twenty-three patients with coagulopathy and TBI were transferred to our trauma center, 100 per cent sustained a fall, and 100 per cent were taking warfarin at the time of injury. Ten patients received VIIa to correct coagulopathy before transfer, whereas 13 did not. The purpose of this study was to compare outcomes in patients who received VIIa with those who did not. When comparing the VIIa group with the no-VIIa group there was no difference in age, gender, Glasgow Coma Scale score, injury severity score, transfer time, or INR at outlying facility. Both groups received one unit of plasma before arrival at our trauma center; patients in the VIIa group received a single 1.2 mg dose of VIIa at the outlying facility. Upon arrival to our trauma center the VIIa group had a lower INR (1.0 vs 3.0, P = 0.02) and lower mortality (0% vs 39%, P = 0.03). In coagulopathic patients with TBI presenting to outlying institutions with limited resources to quickly provide plasma, VIIa efficiently corrects coagulopathy before transfer to definitive care at the regional trauma center. More rapid correction of coagulopathy with VIIa in this patient population may improve mortality.

Background: Brief alcohol interventions for patients in trauma settings have demonstrated significant reductions in drinking behaviors, injury related risk behaviors, and subsequent arrests for driving while intoxicated. However, although a number of surveys have examined the knowledge and attitudes of trauma center personnel regarding alcohol problems, the knowledge and attitudes toward alcohol misuse, screening, and intervention services among various trauma care personnel within an individual trauma center have not been investigated. The purpose of this study was to examine provider knowledge and attitudes related to screening and brief intervention for alcohol problems in a single Level-I trauma center., Methods: A cross-sectional online survey was administered to employees of a Level-I trauma center with a screening and brief intervention program. Surveys were solicited from hospital staff responsible for the care of trauma patients. Topics covered in the survey included alcoholism, brief interventions in trauma centers, and motivational interviewing., Results: Most trauma care staff members surveyed were white and held BS/BA degrees or Associates' degrees in nursing. The average years of professional practice were 8.6 years. Staff's attitudes regarding those who misuse alcohol was somewhat neutral, showing a weak understanding of the etiology of alcoholism and the effectiveness of brief intervention and referral for treatment. Staff members also struggled to correctly identify the components of brief interventions., Conclusions: This limited knowledge and the neutral attitudes regarding alcohol problems may indirectly influence metrics of program success. Trauma care staff will benefit from additional training regarding alcohol problems and brief interventions.

Background: The purpose of this study is to characterize traumatic suicide attempts (TSA) by age, gender, race, and mechanism of injury., Methods: This is a retrospective review of TSA patients (identified by E-codes) admitted to our urban, level I trauma center from 1992 through 2005. Mechanisms of TSA included jump from height, firearm (gunshot wound [GSW]), cutting or piercing instrument (stab wound [SW]), and motor vehicle (MV)-related. Patients were categorized in groups by age in years (< 18, 18-35, 36-54, 55-69, ≥ 70)., Results: A total of 876 TSA patients were identified; 83% were male, with a mean age of 35 years and a mean Injury Severity Score of 10. The most common mechanism was SW (39%), followed by jump (26%), GSW (21%), and MV-related (13%). Primary mechanism of TSA varied by age (p < 0.0001), with GSW most common in those patients aged < 18 years (64%) and ≥ 70 years (44%), and SW most common in all other age groups. Overall, 16% of TSAs were successful. The adjusted odds ratio (AOR) for mortality for age 70+ vs. age 36-54 was 12.4 (95% confidence interval [CI] 2.3-78, p = 0.005), and the AOR for mortality from GSW vs. SW was 9.8 (95% CI 2.6-44, p = 0.001)., Conclusions: The most common mechanism for TSA was SW, although GSW was the most effective. The mechanism of choice for TSA depends on age, with the extremes of age more commonly choosing a firearm. Age and method of TSA are significant contributing factors to success of suicide attempts., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Background: The "July Phenomenon" refers to the propensity for increased errors to occur with new housestaff, as they assume new responsibilities at the beginning of the academic year. The purpose of this study was to examine the impact of the new residents presenting in July at a high volume Level I Academic Trauma Center., Methods: The trauma registry at the Los Angeles County + University of Southern California Medical center was retrospectively reviewed to identify all injured patients admitted over a 5-year period ending in December 2006. All Morbidity and Mortality reports for the study period were reviewed to extract deaths and any complications classified as preventable or potentially preventable. Patients admitted in the first 2 months (July to August) of the academic year were compared with those treated at the end of the academic year (May to June). Baseline clinical and demographic characteristics were compared, and the rates of preventable and potentially preventable deaths and complications were determined for each of these groups., Results: During the 5-year study period, 24,302 injured patients were admitted. Of those, 8,151 were admitted during the period from May to August with 4,030 (49.4%) at the beginning of the academic year (July to August) and 4,121 (50.6%) at the end of the academic year (May to June). Overall, the average age was 35.1 +/- 17.7 years, 77% were men with an Injury Severity Score of 8.4 +/- 9.7 and 24.2% penetrating injury rate. When examining mortality, after adjustment for differences between the two groups, there was no difference between patients admitted at the beginning or at the end of the academic year (adjusted odds ratio [95% confidence interval]: 1.1 [0.8, 1.5], p = 0.52). However, when compared with the patients treated for their injuries in May to June, those treated at the beginning of the academic year had a significantly higher rate of preventable and potentially preventable complications (adjusted odds ratio [95% confidence interval]: 1.9 [1.1, 3.2], p = 0.013)., Conclusions: At an academic Level I trauma center, admission at the beginning of the academic year was associated with an increased risk of errors resulting in preventable and potentially preventable complications; however, these errors did not impact mortality. Specific errors associated with this increased rate of preventable complications warrant further investigation.

Objective: To analyze the preventable and potentially preventable complications occurring at a mature level I trauma center., Design: Retrospective review., Setting: Academic level I trauma center., Patients: The study included 35 311 trauma registry patients., Main Outcome Measures: The cause, effect on outcome, preventability (preventable, potentially preventable, or nonpreventable), and loop closure recommendations for all preventable and potentially preventable complications, and clinical data related to each complication retrieved from the trauma registry and individual medical records., Results: Over the 8-year study, 35 311 trauma registry patients experienced 2560 complications. Three hundred fifty-one patients (0.99% of all patients) had 403 preventable or potentially preventable complications. The most common preventable or potentially preventable complications were unintended extubation (63 patients [17% of complications]), surgical technical failures (61 patients [15% of complications]), missed injuries (58 patients [14% of complications]), and intravascular catheter-related complications (48 patients [12% of complications]). These complications were clinically relevant; 258 (64% of complications) resulted in a change in management, including 61 laparotomies, 52 reintubations, 41 chest tube insertions, and 19 vascular interventions., Conclusions: The incidence of preventable or potentially preventable complications at an academic level I trauma center is low. These complications often require a change in management and cluster in 4 major categories (ie, unintended extubation, surgical technical failures, missed injuries, and intravascular catheter-related complications) that must be recognized as critical areas for quality improvement initiatives.

Objective: The objective of this study was to analyze the preventable and potentially preventable deaths occurring at a mature Level I trauma center., Methods: All trauma patients that died during their initial hospital admission during an 8-year period (January, 1998 to December, 2005) were analyzed. The deaths were initially reviewed at a weekly Morbidity and Mortality (M&M) conference followed by a multidisciplinary (Trauma Surgery, Critical Care, Emergency Medicine, Neurosurgery, Nursing, and Coroner) Combined Trauma Death Review Committee, and were classified into nonpreventable, potentially preventable, and preventable deaths. All preventable and potentially preventable deaths were identified for the purpose of the study. Quality improvement death forms included data on epidemiology, vital signs, injury severity, type of injury, probability of survival with Trauma and Injury Severity Score methodology, preventability (nonpreventable, potentially preventable, and preventable deaths), errors in the evaluation and management of the patient, and classification of errors (system, judgment, knowledge). Additional injury details, clinical course, circumstances leading to the death and autopsy findings were abstracted from the trauma registry and individual chart review., Results: During the study period, 35,311 patients meeting trauma registry criteria were admitted and a total of 2,081 (5.9%) deaths occurred. Fifty-one deaths were classified as preventable or potentially preventable deaths (0.1% of admissions, 2.5% of deaths). Eleven of them (0.53% of deaths) were classified as preventable and 40 (1.92% of deaths) as potentially preventable deaths. Mean age was 40 years, 66.7% were men, mean Injury Severity Score was 27, 74.5% were blunt. The most common cause of death was bleeding (20, 39.2%) followed by multiple organ dysfunction syndrome (14, 27.5%) and cardiorespiratory arrest (8, 15.6%). This was caused by a delay in treatment (27, 52.9%), clinical judgment error (11, 21.6%), missed diagnosis (6, 11.8%), technical error (4, 7.8%), and other (3, 5.9%). The deaths peaked at two time periods: 26 (51.1%) during the first 24 hours and 16 (31.4%) after 7 days. Only one patient (2.0%) died in the first hour. The most common location of death was the intensive care unit (28, 54.9%), operating room (13, 25.5%), and emergency room (5, 9.8%)., Conclusion: Preventable or potentially preventable deaths are rare but do occur at an academic Level I trauma center. Delay in treatment and error in judgment are the leading causes of preventable and potentially preventable deaths.

Hypothesis: The 80-hour workweek limitation for surgical residents is associated with an increase in mortality and complication rates among adult trauma surgical patients., Design: Retrospective cohort study., Setting: Academic level I trauma center., Patients: Trauma patients admitted before and after the 80-hour workweek limitation., Methods: We compared death and complication rates for adult trauma patients admitted during a 24-month period before (2001-2003) and a 24-month period after (2004-2006) implementation of the 80-hour workweek at our institution. Relative risk and its 95% confidence intervals were examined., Main Outcome Measures: Patient care outcomes included preventable and nonpreventable complications and deaths., Results: The patient populations from the 2 time periods were clinically similar. No significant differences were found in the total and the preventable death rates. The time period after the 80-hour workweek mandate had a significantly higher total complication rate (5.64% vs 7.28%; relative risk, 1.29; 95% confidence interval, 1.15-1.45; P < .001), preventable complication rate (0.89% vs 1.28%; relative risk, 1.43; 95% confidence interval, 1.06-1.91; P = .02), and nonpreventable complication rate (4.75% vs 5.81%; relative risk, 1.22; 95% confidence interval, 1.08-1.39; P = .002)., Conclusion: Although there was no difference in deaths between the 2 time periods, there was a significant increase in total, preventable, and nonpreventable complications. This increase in complication rate may be due, in part, to the new 80-hour workweek policy.

Hypothesis: The diagnosis of acute respiratory distress syndrome (ARDS) carries significant additional morbidity and mortality among critically injured patients., Design: Retrospective case-control study using a prospectively maintained ARDS database., Setting: Surgical intensive care unit (ICU) in an academic county hospital., Patients: All trauma patients admitted to the ICU from January 1, 2000, to December 31, 2003, who developed ARDS as defined by (1) acute onset, (2) a partial pressure of arterial oxygen-fraction of inspired oxygen ratio of 200 or less, (3) bilateral pulmonary infiltrates on chest radiographs, and (4) absence of left-sided heart failure. Each patient with ARDS was matched with 2 control patients without ARDS on the basis of sex, age (+/-5 years), mechanism of injury (blunt or penetrating), Injury Severity Score (+/-3), and chest Abbreviated Injury Score (+/-1)., Main Outcome Measures: Mortality, hospital charges, hospital and ICU lengths of stay, and complications (defined as pneumonia, deep venous thrombosis, pulmonary embolism, acute renal failure, and disseminated intravascular coagulopathy)., Results: Of 2042 trauma ICU admissions, 216 patients (10.6%) met criteria for ARDS. We identified 432 similarly injured control patients. Compared with controls, trauma patients with ARDS had more complications (43.1% vs 9.5%), longer hospital (32.2 vs 17.9 days) and ICU (22.1 vs 8.4 days) lengths of stay, and higher hospital charges (267,037 dollars vs 136,680 dollars) (P < .01 for all), but mortality was similar (27.8% vs 25.0%, P = .48)., Conclusion: Although ARDS is associated with increased morbidity, hospital and ICU length of stay, and costs, it does not increase overall mortality among critically ill trauma patients.

Background: We studied the association of the American College of Surgeons (ACS) trauma center designation and mortality in adult patients with severe trauma (Injury Severity Score > 15). ACS designation of trauma centers into different levels requires substantial financial and human resources commitments. There is very little work published on the association of ACS trauma center designation and outcomes in severe trauma., Study Design: National Trauma Data Bank study including all adult trauma admissions (older than 14 years of age) with Injury Severity Score (ISS) > 15. The relationship between ACS level of trauma designation and survival outcomes was evaluated after adjusting for age, mechanism of injury, ISS, hypotension on admission, severe liver trauma, aortic, vena cava, iliac vascular, and penetrating cardiac injuries., Results: A total of 130,154 patients from 256 trauma centers met the inclusion criteria. Adjusted mortality in ACS-designated Level II centers and undesignated centers was notably higher than in Level I centers (adjusted odds ratio, 1.14; 95% CI, 1.09-120; p < 0.0001 and adjusted odds ratio, 1.09; CI, 1.05-1.13; p < 0.0001, respectively)., Conclusions: Severely injured patients with ISS > 15 treated in ACS Level I trauma centers have considerably better survival outcomes than those treated in ACS Level II centers.

Objective: The objective of this study was to investigate the effect of American College of Surgeons (ACS) trauma center designation and trauma volume on outcome in patients with specific severe injuries., Background: Trauma centers are designated by the ACS into different levels on the basis of resources, trauma volume, and educational and research commitment. The criteria for trauma center designation are arbitrary and have never been validated., Methods: The National Trauma Data Bank study, which included patients >14 years of age and had injury severity score (ISS) >15, were alive on admission and had at least one of the following severe injuries: aortic, vena cava, iliac vessels, cardiac, grade IV/V liver injuries, quadriplegia, or complex pelvic fractures. Outcomes (mortality, intensive care unit stay, and severe disability at discharge) were compared among level I and II trauma centers and between centers within the same level designation but different volumes of severe trauma (<240 vs > or =240 trauma admissions with ISS >15 per year). The outcomes were adjusted for age (<65 > or =65), gender, mechanism of injury, hypotension on admission, and ISS (< or =25 and >25)., Results: A total of 12,254 patients met the inclusion criteria. Overall, level I centers had significantly lower mortality (25.3% vs 29.3%; adjusted odds ratio [OR], 0.81; 95% confidence interval [CI], 0.71-0.94; P = 0.004) and significantly lower severe disability at discharge (20.3% vs 33.8%, adjusted OR, 0.55; 95% CI, 0.44-0.69; P < 0.001) than level II centers. Subgroup analysis showed that cardiovascular injuries (N = 2004) and grades IV-V liver injuries (N = 1415) had a significantly better survival in level I than level II trauma centers (adjusted P = 0.017 and 0.023, respectively). Overall, there was a significantly better functional outcome in level I centers (adjusted P < 0.001). Subgroup analysis showed level I centers had significantly better functional outcomes in complex pelvic fractures (P < 0.001) and a trend toward better outcomes in the rest of the subgroups. The volume of trauma admissions with ISS >15 (<240 vs > or =240 cases per year) had no effect on outcome in either level I or II centers., Conclusions: Level I trauma centers have better outcomes than lower-level centers in patients with specific injuries associated with high mortality and poor functional outcomes. The volume of major trauma admissions does not influence outcome in either level I or II centers. These findings may have significant implications in the planning of trauma systems and the billing of services according to level of accreditation.

Key Points: Question: Does adding sigh breaths to the usual care of trauma patients receiving mechanical ventilation increase ventilator-free days? Findings: In this randomized clinical trial among 524 trauma patients with risk factors for developing acute respiratory distress syndrome, the addition of sigh breaths did not significantly increase ventilator-free days compared with usual care alone (median ventilator-free days, 18.4 vs 16.1, respectively). Although not adjusted for multiple testing, sigh breaths were associated with improvement in secondary outcomes including all-cause mortality. There was no evidence of harm. Meaning: Sigh breaths added to usual care did not significantly increase ventilator-free days among trauma patients who received mechanical ventilation but may improve clinical outcomes. Importance: Among patients receiving mechanical ventilation, tidal volumes with each breath are often constant or similar. This may lead to ventilator-induced lung injury by altering or depleting surfactant. The role of sigh breaths in reducing ventilator-induced lung injury among trauma patients at risk of poor outcomes is unknown. Objective: To determine whether adding sigh breaths improves clinical outcomes. Design, Setting, and Participants: A pragmatic, randomized trial of sigh breaths plus usual care conducted from 2016 to 2022 with 28-day follow-up in 15 academic trauma centers in the US. Inclusion criteria were age older than 18 years, mechanical ventilation because of trauma for less than 24 hours, 1 or more of 5 risk factors for developing acute respiratory distress syndrome, expected duration of ventilation longer than 24 hours, and predicted survival longer than 48 hours. Interventions: Sigh volumes producing plateau pressures of 35 cm H2O (or 40 cm H2O for inpatients with body mass indexes >35) delivered once every 6 minutes. Usual care was defined as the patient's physician(s) treating the patient as they wished. Main Outcomes and Measures: The primary outcome was ventilator-free days. Prespecified secondary outcomes included all-cause 28-day mortality. Results: Of 5753 patients screened, 524 were enrolled (mean [SD] age, 43.9 [19.2] years; 394 [75.2%] were male). The median ventilator-free days was 18.4 (IQR, 7.0-25.2) in patients randomized to sighs and 16.1 (IQR, 1.1-24.4) in those receiving usual care alone (P =.08). The unadjusted mean difference in ventilator-free days between groups was 1.9 days (95% CI, 0.1 to 3.6) and the prespecified adjusted mean difference was 1.4 days (95% CI, −0.2 to 3.0). For the prespecified secondary outcome, patients randomized to sighs had 28-day mortality of 11.6% (30/259) vs 17.6% (46/261) in those receiving usual care (P =.05). No differences were observed in nonfatal adverse events comparing patients with sighs (80/259 [30.9%]) vs those without (80/261 [30.7%]). Conclusions and Relevance: In a pragmatic, randomized trial among trauma patients receiving mechanical ventilation with risk factors for developing acute respiratory distress syndrome, the addition of sigh breaths did not significantly increase ventilator-free days. Prespecified secondary outcome data suggest that sighs are well-tolerated and may improve clinical outcomes. Trial Registration: ClinicalTrials.gov Identifier: NCT02582957 This randomized clinical trial compares the efficacy of sighs in addition to usual care vs usual care alone in improving clinical outcomes among trauma patients receiving mechanical ventilation and are at risk for developing acute respiratory distress syndrome. [ABSTRACT FROM AUTHOR]

Purpose: As blunt thoracic aortic injury (BTAI) treatment has shifted from open to thoracic endovascular aortic repair (TEVAR), logistical challenges exist in creating and maintaining inventories of appropriately sized stent-grafts, including storage demands, shelf-life management and cost. We hypothesized that most injured aortas can be successfully repaired with a narrow range of stent-graft sizes and present a value-based anatomic approach to optimizing inventory. Methods: CT-scans of all patients with BTAI admitted to our Level I trauma center from Apr 2010-Dec 2018 were reviewed. Patients with anatomy incompatible with TEVAR were excluded. For each patient, after aortic sizing a set of two stent-grafts most likely to be utilized was selected from a list of twenty commercially available GORE conformable TAG endografts based on manufacturer instructions. Stent-graft sizes were then ranked based on the number of cases they would be suitable for. MATLAB was utilized to determine the combinations of stent-grafts which would cover the most patients. Results: Twenty-eight patients with BTAI were identified and three were excluded based on iliac diameter. Most patients were male (68%), mean age 42.3 ± 20.2 years, mean ISS 37.0 ± 9.8. Overall mortality was 25%. Of the 20 available stent-graft options, a combination of four stent-grafts would successfully treat 100% of the patients in this series. Conclusions: Based on actual CT-scan aortic measurements, we demonstrated that an inventory of four sent-graft sizes was sufficient to treat 100% of patients with BTAI. These data can be utilized as a value-based anatomic approach to aortic stent-graft institutional inventory creation and maintenance. [ABSTRACT FROM AUTHOR]

Retained rectal foreign bodies are a common but incompletely studied problem. This study defined the epidemiology, injury severity, and outcomes after rectal injuries following foreign body insertion. Twenty-two level I trauma centers retrospectively identified all patients sustaining a rectal injury in this AAST multi-institutional trial (2005-2014). Only patients injured by foreign body insertion were included in this secondary analysis. Exclusion criteria were death before rectal injury management or ≤48 h of admission. Demographics, clinical data, and outcomes were collected. Study groups were defined as partial thickness (AAST grade I) versus full thickness (AAST grades II-V) injuries. Subgroup analysis was performed by management strategy (nonoperative versus operative). After exclusions, 33 patients were identified. Mean age was 41 y (range 18-57), and 85% (n = 28) were male. Eleven (33%) had full thickness injuries and 22 (67%) had partial thickness injuries, of which 14 (64%) were managed nonoperatively and 8 (36%) operatively (proximal diversion alone [ n = 3, 14%]; direct repair with proximal diversion [ n = 2, 9%]; laparotomy without rectal intervention [ n = 2, 9%]; and direct repair alone [ n = 1, 5%]). Subgroup analysis of outcomes after partial thickness injury demonstrated significantly shorter hospital length of stay (2 ± 1; 2 [1-5] versus 5 ± 2; 4 [2-8] d, P = 0.0001) after nonoperative versus operative management. Although partial thickness rectal injuries do not require intervention, difficulty excluding full thickness injuries led some surgeons in this series to manage partial thickness injuries operatively. This was associated with significantly longer hospital length of stay. Therefore, we recommend nonoperative management after a retained rectal foreign body unless full thickness injury is conclusively identified. [ABSTRACT FROM AUTHOR]

Purpose: To determine the mechanisms of injury associated with occupational injuries (OI) to genitourinary (GU) organs and compare GU OIs with GU non-OIs. Methods: A single institution, retrospective study was conducted at a level 1 trauma center between 2010 and 2016 of all patients with GU injuries. OI was defined as any traumatic event that occurred in the workplace requiring hospital admission. Types of occupations were recorded in addition to the location of injury, mechanisms of injury, concomitant injuries, operative interventions, total cost, and mortality. GU OI patients were then compared to GU non-OI patients. Results: 623 patients suffered a GU injury, of which 39 (6.3%) had a GU OI. Fall (43%) was the most common mechanism of injury; followed by motor vehicle collision/motorcycle crash (31%), crush injury (18%), and pedestrian struck (8%). The adrenal gland (38%) and kidney (38%) were the most commonly injured organs. There was no difference in mortality (13% GU OI vs. 15% GU non-OI, p = 0.70) or total direct cost ($21,192 ± 28,543 GU OI vs. $28,215 ± 32,332 GU non-OI, p = 0.45). Total costs were decreased with mortality from a GU injury (odds ratio (OR) 0.3, CI 0.26–0.59; p = < 0.001) and increased with higher injury severity scores (OR 1.1, CI 1.09–1.2; p = < 0.0001). Total costs were not affected by OI status. Conclusions: Occupational GU trauma presents with similar patterns of injury, hospital course, and direct cost as GU trauma that occurs in non-occupational settings. [ABSTRACT FROM AUTHOR]

The objective of this study was to describe the management of the Jehovah’s Witness (JW) in an intensely active level I trauma center and review the modern therapeutic options available for the trauma care of these patients. A retrospective review of injured JWs admitted to a busy trauma center over a 13-year period was conducted. Over the study period, 143 JWs were identified. Among these, 15.4% (22/143) overall and 32.3% (10/31) requiring surgical intensive care unit (SICU) admission accepted transfusion. Overall, 56.6% of JWs (81/143) required operation and 21.7% (31/143) were admitted to the SICU with a complication rate of 4.2% (6/143) and a mortality of 1.4% (2/143). One patient of the 31 patients that were admitted to the SICU received 10 ml of blood with subsequent discontinuation of the transfusion and was excluded from analysis. Of the 30 JWs admitted to the SICU, 20 (66.7%) did not receive transfusion and demonstrated mean admission and nadir hemoglobin (Hb) levels of 12.7 (±2.5) and 9.1 (±3.0) mg/dl, respectively. Ten patients accepted transfusion. This group had longer mean SICU stays (23.3 vs. 5.5 days) but similar mortality (10%, 1/10 vs. 5%, 1/20) compared to non-transfused counterparts. Only one complication (1/20, 5%) was observed in the JWs who were not transfused, compared to a 40% (4/10) complication rate in those accepting transfusion. Although our experience was limited, we found no significant difference in the mortality or morbidity between JW patients who received or abstained from transfusion following major trauma. We should keep in mind that the population was small, in order to extract safe conclusions regarding whether we should transfuse or not transfuse trauma patients. We can, however, see interesting insights on the value of trauma resuscitation. [ABSTRACT FROM AUTHOR]

Venous duplex scan (VDS) has been used for interim bedside diagnosis of pulmonary embolism (PE) in severely injured patients deemed to be at risk if transported out of the intensive care unit. In combination with the level of clinical suspicion for PE, VDS helps select patients for temporary treatment until definitive diagnosis is made. We evaluate the sensitivity and specificity of VDS in critically injured patients with a high level of clinical suspicion for PE. We performed a prospective observational cohort study at the surgical intensive care unit of an academic level 1 trauma center. Patients were 59 critically injured patients suspected to have PE over a 30-month period. The level of clinical suspicion for PE was classified as low or high according to preset criteria. Interventions were VDS and a PE outcome test (conventional or computed tomographic pulmonary angiography). The sensitivity and specificity of VDS to detect PE in all patients and in patients with high level of clinical suspicion was calculated against the results of the outcome test. PE was diagnosed in 21 patients (35.5%). The sensitivity and specificity of VDS was 33 per cent and 89 per cent, respectively. Among the 28 patients who had a high level of clinical suspicion for PE, the sensitivity of VDS was 23 per cent and the specificity 93 per cent. In this latter population, 1 of the 4 (25%) positive VDS was of a patient without PE and 10 of the 24 (42%) negative VDS were of patients who had PE. VDS does not accurately predict PE in severely injured patients, even in the presence of a high level of clinical suspicion. [ABSTRACT FROM AUTHOR]

Background Blunt carotid artery injury (BCI) remains a rare but potentially lethal condition. Recent studies recommend that aggressive screening based on broad criteria (hyperextension-hyperflexion mechanism of injury, basilar skull fracture, cervical spine injury, midface fracture, mandibular fracture, diffuse axonal brain injury, and neck seat-belt sign) increases the rate of diagnosis of BCI by 9-fold. If this recommendation becomes a standard of care, it will require a major consumption of resources and may give rise to liability claims. The benefits of aggressive screening are unclear because the natural history of asymptomatic BCI is unknown and the existing treatments are controversial. Hypothesis The lack of an aggressive angiographic screening protocol does not result in delayed BCI diagnosis or BCI-related neurologic deficits. Methods A 10-year medical record review of patients with BCI was undertaken in 2 level I academic trauma centers. In both centers, urgent screening for BCI was performed in patients with focal neurologic signs or neurologic symptoms unexplainable by results of computed tomography of the brain as well as in selected patients undergoing angiography for another reason. Results Of 35 212 blunt trauma admissions, 17 patients (0.05%) were diagnosed as having BCI. Six showed no evidence of BCI-related neurologic symptoms during hospitalization or prior to death as a result of associated injuries. Eleven sustained a BCI-related stroke, 9 of whom had it within 2 hours of injury. The remaining 2 had a delayed diagnosis (9 and 12 hours after injury) and received only anticoagulation because the lesions were surgically inaccessible. Just 1 of these 2 patients met the criteria for BCI screening and could have been offered earlier treatment, of uncertain benefit, if we had adopted an aggressive screening policy. Conclusions Of the few patients with BCI, most remain asymptomatic or develop neurologic deficits shortly after injury. Although a widely applied, resource-consuming screening program may increase the rate of early diagnosis of BCI, an improvement in outcome is uncertain. A cost-effectiveness analysis should be done before trauma surgeons accept an aggressive screening protocol as the standard of care. [ABSTRACT FROM AUTHOR]

Background: Tourniquet use has been proven to reduce mortality on the battlefield. Although empirically transitioned to the civilian environment, data substantiating survival benefit attributable to civilian tourniquet use is lacking. We hypothesized that civilian prehospital tourniquet use is associated with reduced mortality in patients with peripheral vascular injuries.Study Design: We conducted a multicenter retrospective review of all patients sustaining peripheral vascular injuries admitted to 11 Level I trauma centers (January 2011 through December 2016). The study population was divided into 2 groups based on prehospital tourniquet use. Baseline characteristics were compared and factors associated with mortality identified. Logistic regression, adjusting for demographic, physiologic and injury-related parameters, was used to evaluate the association between prehospital tourniquet use and mortality. Delayed amputation was the secondary end point.Results: During 6 years, 1,026 patients with peripheral vascular injuries were admitted. Prehospital tourniquets were used in 181 (17.6%) patients. Tourniquet time averaged 77.3 ± 63.3 minutes (interquartile range 39.0 to 92.3 minutes). Traumatic amputations occurred in 98 patients (35.7% had a tourniquet). Mortality was 5.2% in the non-tourniquet group compared with 3.9% in the tourniquet group (odds ratio 1.36; 95% CI 0.60 to 1.65; p = 0.452). After multivariable analysis, the use of tourniquets was found to be independently associated with survival (adjusted odds ratio 5.86; 95% CI 1.41 to 24.47; adjusted p = 0.015). Delayed amputation rates were not significantly different between the 2 groups (1.1% vs 1.1%; adjusted odds ratio 1.82; 95% CI 0.36 to 9.99; adjusted p = 0.473).Conclusions: Although still underused, civilian prehospital tourniquet application was independently associated with a 6-fold mortality reduction in patients with peripheral vascular injuries. More aggressive prehospital application of extremity tourniquets in civilian trauma patients with extremity hemorrhage and traumatic amputation is warranted. [ABSTRACT FROM AUTHOR]

Failed extubation in critically ill patients is associated with poor outcomes. In critically ill trauma patients who have failed extubation, providers must decide whether to proceed with tracheostomy or attempt extubation again. The aim of this study was to describe the natural history of failed extubation in trauma patients and determine whether tracheostomy or a second attempt at extubation is more appropriate. Trauma patients admitted to our level I trauma center from 2013 to 2019 were identified. Patients who failed extubation, defined as an unplanned reintubation within 48 h of extubation, were included. Patients who immediately underwent tracheostomy were compared with those who had subsequent attempts at extubation. The primary outcome was mortality, and the secondary outcomes were intensive care unit (ICU) length of stay (LOS), ventilator days, and hospital LOS. The population included 93 patients who failed extubation and met inclusion criteria. A total of 53 patients were ultimately successfully extubated, whereas 40 patients underwent a tracheostomy. There was no statistically significant difference in demographics or injury patterns. Patients who underwent tracheostomy had a longer ICU LOS and more ventilator days. There was no difference in mortality or hospital LOS between the two groups. In trauma patients, those who underwent subsequent attempts at extubation did not experience higher rates of mortality than those who received a tracheostomy. Tracheostomy was associated with longer ICU LOS and ventilator days. In certain situations, it is appropriate to consider subsequent attempts at extubation in trauma patients who fail extubation rather than proceeding directly to tracheostomy. [ABSTRACT FROM AUTHOR]

The purpose of this study is to determine the incidence, risk factors, and outcomes after the development of an atrial arrhythmia (AA) in trauma patients admitted to the Intensive Care Unit (ICU). We performed a retrospective study of more than 7 years of trauma patients admitted to the ICU at an urban, academic Level I trauma center. Patients with AA, defined as atrial fibrillation, atrial flutter, or paroxysmal supraventricular tachycardia, were compared with patients without AA. Groups were compared by univariate and multivariate analysis. Three thousand, four hundred and ninety-nine trauma patients were admitted to the ICU during the study period and 210 (6%) developed an AA. AA patients were more likely to sustain blunt trauma, were older, more often female, more severely injured, and sustained more head injuries. The only independent risk factor for developing an AA was age > 55 years (odds ratio = 4.6, P < 0.01). Mortality was higher in the AA group (33% vs 14%, P < 0.01) and AA was an independent risk factor for mortality (odds ratio = 1.7, P = 0.01). Twenty-eight per cent (n = 59) of AA patients received beta-blockers in the postinjury period, and these patients had lower mortality (22% vs 37%, P = 0.04). AA occurs in 6 per cent of trauma patients admitted to the ICU. Developing an AA is an independent risk factor for mortality after trauma. Beta-blocker therapy was associated with decreased mortality in trauma patients with AA. [ABSTRACT FROM AUTHOR]

Background: Patients with traumatic brain injury (TBI) frequently develop leukocytosis, fever, and tachycardia that may lead to extensive medical investigations to rule out an infectious process. Cerebrospinal fluid (CSF) is often acquired during this workup, however, the utility of this practice has not been studied previously. We hypothesized that CSF cultures would unlikely yield positive results in patients with TBI. Patients and Methods: A retrospective review was conducted of all patients with TBI admitted to two level 1 trauma centers at urban, academic institutions from January 2009 to December 2016. Data collected included patient demographics, presenting Glasgow Coma Score (GCS), injury profile, injury severity scores (ISS), regional abbreviated injury scale (AIS), hospital and intensive care unit (ICU) length of stay (LOS), ventilator days, and culture results. For purposes of the analysis, CSF cultures with Staphylococcus epidermidis, Staphylococcus aureus, or Candida underwent a chart review and were considered contaminates if indicated. Results: There were 145 patients who had CSF cultures obtained with a median age of 39 years; 77.2% were male. The majority of patients presented after blunt trauma with median GCS of 6, head AIS of 4, and ISS of 25. These patients had prolonged median ICU and hospital stays at 13 and 22 days, respectively. Six (4.1%) CSF cultures demonstrated growth. Four (2.8%) were deemed contaminants, with two growing Staphylococcus epidermidis only, one with both Staphylococcus epidermidis and Staphylococcus aureus, and one with Candida. Two cultures (1.4%) were positive and grew Enterobacter cloacae. Of note, both patients had prior instrumentation with an external ventricular drain. Conclusion: Obtaining CSF cultures in patients with TBI is of low yield, especially in patients without prior external ventricular drain. Other sources of infectious etiologies should be considered in this patient population. [ABSTRACT FROM AUTHOR]

Background: Tracheostomy is a commonly performed procedure in surgical intensive care units. Although the indications and benefits of this procedure are well known, little has been studied in the adult surgical/trauma population about patient family satisfaction after tracheostomy placement.Materials and Methods: We performed a prospective study at our academic level I trauma center from 2015-2016 in patients who underwent elective tracheostomy. Family members were asked to complete an eight-point questionnaire using a forced Likert scale of graded responses. Questionnaires were administered prior to tracheostomy and again at 24-and 72-hour post-tracheostomy placement. Responses were compared using univariate analysis.Results: A total of 26 family members completed all 3 surveys. Family members believed loved ones appeared more comfortable, were more interactive, and were better progressing clinically. After 72 hours, family members felt less anxiety. There was no difference in perceptions of patient distress, ability to provide support, or their worry about scars, or comfort in visiting them.Discussion: Family members believed tracheostomies provided greater patient comfort, increased interactive abilities, better progress in their care, and experienced less anxiety after placement. Family satisfaction may therefore be an additional benefit in support of earlier tracheostomy. [ABSTRACT FROM AUTHOR]

Angioembolization (AE) is an adjunct to nonoperative management (NOM) of splenic injuries. We hypothesize that failure of AE is associated with blood transfusion, grade of injury, and technique of AE. We performed a retrospective (2010-2017) multicenter study (nine Level I trauma centers) of adult trauma patients with splenic injuries who underwent splenic AE. Variables included patient physiology, injury grade, transfusion requirement, and embolization technique. The primary outcome was NOM failure requiring splenectomy. Secondary outcomes were mortality, complications, and length of stay. A total of 409 patients met inclusion criteria; only 33 patients (8%) required delayed splenectomy. Patients who failed received more blood in the first 24 h (P = 0.009) and more often received massive transfusion (P = 0.01). There was no difference in failure rates for grade of injury, contrast blush on computed tomography, and branch embolized. After logistic regression, transfusion in the first 24 h was independently associated with failure of NOM (P = 0.02). Patients who failed NOM had more complications (P = 0.002) and spent more days in the intensive care unit (P < 0.0001), on the ventilator (P = 0.0001), and in the hospital (P < 0.0001). Patients who failed NOM had a higher mortality (15% versus 3%, P = 0.007), and delayed splenectomy was independently associated with mortality (odds ratio, 4.2; 95% confidence interval, 1.2-14.7; P = 0.03). AE for splenic injury leads to effective NOM in 92% of patients. Transfusion in the first 24 h is independently associated with failure of NOM. Patients who required a delayed splenectomy suffered more complications and had higher hospital length of stay. Failure of NOM is independently associated with a fourfold increase in mortality. • Splenic angioembolization in trauma is safe. • There is no difference in embolization failure rates for grade of splenic injury. • There is no difference in failure rate for patients with a contrast blush on CT. • Transfusion in the first 24 h is associated with splenic embolization failure. • Failure of splenic embolization is associated with five-fold increase in mortality. [ABSTRACT FROM AUTHOR]

To determine whether a restrictive strategy of red cell transfusion was safe in elderly trauma patients, we compared those treated with a restrictive transfusion strategy versus those who were liberally transfused. We performed a retrospective study of elderly (age ≥ 70 years) trauma patients admitted to our Level I trauma center from 2005 to 2013. Patients with a hemoglobin (Hg) < 10 g/dL after 48 hours were included. We excluded patients with an Injury Severity Score > 25 or active cardiac ischemia. Patients who were transfused for an Hg < 10 g/dL (liberal group) were compared to those who were transfused for an Hg< 7 g/dL (restrictive group). There were 382 patients included, 229 and 153 in the liberal and restrictive transfusion groups, respectively. All patients in the liberal group and 20 per cent of patients in the restrictive group received a transfusion (P < 0.0001). Patients in the liberal group had more overall complications (52 vs 32%, P = 0.0001). On multivariate analysis, receiving a transfusion was an independent risk factor to develop a complication [odds ratio = 2.3 (1.5-3.6), P < 0.0001]. For survivors, patients in the liberal group spent more days in the hospital (nine versus seven days, P = 0.007) and intensive care unit (two versus one day, P = 0.01). There was no difference in mortality (3 vs 4%, P = 0.82). In conclusion, restrictive transfusion appears to be safe in elderly trauma patients and may be associated with decreased complications and shortened length of stay. [ABSTRACT FROM AUTHOR]

The present study examines the current management, closure rate, and complications of open abdomens in trauma patients admitted to an Academic Level I trauma center between May 2004 and April 2007. Variables examined include mechanism, injuries, use of antibiotics and paralytics, type of abdominal closure, days to closure, complications, ICU and hospital length of stay, and mortality. Stepwise logistic regression was performed to identify independent predictors of failed abdominal closure. Of 900 laparotomies, 93 (10%) were left open. Eighty-five (91%) patients survived for closure opportunity. Definitive fascial closure was achieved in 72 (85%) at 3.9 &plumsn; 3.7 days (range 1-21 days). Of the remaining 13 patients, seven were closed with biologic material, five by skin grafting, and one had skin-only closure. Entero-atmospheric fistulas occurred in 14 (15%) patients. Two independent risk factors associated with failed abdominal closure were the presence of deep surgical site infection [odds ratio (OR) 17.4; 95% confidence interval (CI) 2.6- 115.8, P = 0.003] and intra-abdominal abscess (OR 7.4; 95% CI 1.1-51.0, P = 0.04). In conclusion, open abdomens are commonly necessary after trauma laparotomies. Definitive fascial closure can be achieved in 85 per cent of cases. In conjunction with biologics, closure can be achieved in 93 per cent of cases. Failure to primarily close the abdomen is associated with a significantly higher risk for entero-atmospheric fistula occurrence. [ABSTRACT FROM AUTHOR]

Background: Blunt renal artery injuries are rare and no single trauma center can accumulate substantial experience for meaningful conclusions about optimal therapeutic strategies. The purpose of this study was to assess the incidence of renal artery injuries after different types of blunt trauma, and evaluate the current therapeutic approaches practiced by American trauma surgeons and the effect of various therapeutic modalities on hospital outcomes. Study design: This was a National Trauma Data Bank study including all blunt trauma admissions with renal artery injuries. Demographics, mechanism of injury, Injury Severity Score, Abbreviated Injury Score for each body area (head, chest, abdomen, extremities) injuries, type of management (nephrectomy, arterial reconstruction, or observation), time from admission to definitive treatment, and hospital outcomes (mortality, ICU, and hospital stay) were analyzed. Multiple and logistic regression analyses were used to examine the relationship between type of management and hospital outcomes. Results: Of a total of 945,326 blunt trauma admissions, 517 patients (0.05%) had injuries to the renal artery. Of the 517 patients, the kidney was not explored in 376 (73%), 95 (18%) patients had immediate nephrectomy, and 45 (9%) patients underwent surgical revascularization. In 87 of 517 (17%) patients, renal artery injury was the only intraabdominal injury. Of the 87 patients with isolated renal artery injuries, 73 (84%) were observed, 7 (8%) underwent surgical revascularization, and 7 (8%) had early nephrectomy. Multiple regression analysis demonstrated that patients who had surgical revascularization had a considerably longer ICU and hospital stay than observed patients. Patients who had nephrectomy had a considerably longer hospital stay than observed patients. Conclusions: Blunt renal artery injury is rare. Nonoperative management should be considered as an acceptable therapeutic option. [Copyright &y& Elsevier]