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Although guidelines for the performance of an emergency department thoracotomy (EDT) are available, high level evidence remains scarce potentially leading to variation in decisions and practices among trauma surgeons. The National Trauma Databank was queried for all subjects who died in the emergency department (ED) between 2007 and 2011. Trauma centers were divided into four quartiles based on the rate of EDT among ED deaths. A total of 31,623 subjects admitted to 729 trauma centers met inclusion criteria. Most of of these centers (n = 328, 53%) never performed an EDT during the study period. Very few outlier centers (1.1%) performed this procedure in 50.0 per cent or more of all patients who died in the ED. Trauma centers in the highest quartiles in performing EDT were more likely to intervene with both surgical and nonsurgical procedures in patients who died in the ED, independent of the performance of an EDT. There are significant variations among trauma centers in the management of trauma patients who expire in the ED. Further research at a national level toward standardizing the management of the trauma patient in extremis and the decision to perform an EDT is necessary, given the extremely low survival associated with this procedure. [ABSTRACT FROM AUTHOR]

Introduction: As bicycling has become more popular, admissions after bicycle trauma are on the rise. The impact of alcohol use on bicycle trauma has not been well studied. The aim of this study was to examine the effect of alcohol intoxication on injury burden following bicycle-related crashes.Methods: A retrospective review of trauma patients presenting to a Level I trauma center after bicycle-related crashes from January 2002 to December 2011 was conducted. Demographics, injury data, alcohol intoxication, helmet use, and clinical outcomes were reviewed. Blood alcohol level (BAL) was considered positive if >0.01 g/dL. Variables were compared between patients based on BAL: negative, 0.01-0.16 g/dL, and >0.16 g/dL.Results: During the 10 year study period, 563 patients met study criteria; mean age was 33.5 ± 16.5 years, 87% were male, and mortality was 1%. On average, bicycle crashes increased over the study period by 4.4 collisions per year. BAL was tested in 211 (38%) patients. Mean BAL was 0.24 g/dL, with 37% of these patients being intoxicated (BAL ≥ 0.010 g/dL). Intoxicated patients were significantly less likely to wear a helmet (4.7% vs. 22.2%, p = 0.002) and to be involved in motor vehicle crash (59.0% vs. 81.2%, p < 0.001). There was no difference noted in the injury burden including ISS ≥ 16 (14.3% vs. 19.5%, p = 0.335) and AIS Head ≥ 3 (17.9% vs. 21.8%, p = 0.502). When comparing patients according to their BAL, there was a decreasing risk of motor vehicle collision with increasing BAL (81.2% for undetected, 76.5% for BAL ≤ 0.16 g/dL and 54.1% for BAL >0.16 g/dL, p < 0.001). The risk for a severe head injury (AIS Head ≥ 3) was significantly lower in helmeted patients (8.4% vs. 15.8%, p = 0.035).Conclusions: The incidence of bicycle-related crashes is increasing and more than a third of patients tested for alcohol after bicycle-related crashes are found to be intoxicated. The injury burden in intoxicated patients, including head trauma, was not different compared to non-intoxicated patients. In addition, the risk for a collision with a motor vehicle was significantly lower. Nonetheless, these patients rarely utilize a helmet. The findings from this study can be used for the development and implementation of preventive strategies to minimize the injury burden associated with bicycle crashes and intoxicated cyclists. [ABSTRACT FROM AUTHOR]

Rapid transfer of trauma patients to a trauma center for definitive management is essential to increase survival. The utilization of helicopter transportation for this purpose remains heavily debated. The purpose of this study was to characterize the trends in helicopter transportations of trauma patients in the United States over the last decade. Subjects with a primary mode of either ground or helicopter transportation were selected from the National Trauma Data Bank datasets 2007 to 2015. Over this period, the proportion of patients transported by a helicopter decreased significantly in a linear fashion from 17 per cent in 2007 to 10.2 per cent in 2015 (P < 0.001). The overall mortality of this population was 7.6 per cent and remained unchanged over the study period (P = 0.545). Almost 3 of 10 subjects (29.4%) transported by a helicopter had an Injury Severity Score <9. The proportion of elderly (>65 years) patients requiring helicopter transportation increased by 69.1 per cent, whereas their associated mortality decreased by 21.5 per cent. The use of a helicopter for the transportation of trauma patients has significantly decreased over the last decade without any significant change in mortality, possibly indicating more effective utilization of available resources. Overtriage of patients with minor injuries remained relatively unchanged. [ABSTRACT FROM AUTHOR]

Background Firearm-related suicides comprise over two-thirds of gun-related violence in the United States, and gun laws and policies remain under scrutiny, with many advocating for revision of the regulatory map for lawful gun ownership, aiming at restricting access and distribution of these weapons. However, the quantitative relationship between how strict gun laws are and the incidence of firearm violence with their associated mortality is largely unknown. We therefore, sought to explore the impact of firearm law patterns among states on the incidence and outcomes of firearm-related suicide attempts, utilizing established objective criteria. Methods The National Inpatient Sample for the years 1998-2011 was queried for all firearm-related suicides. Discharge facilities were stratified into five categories (A, B, C, D, and F, with A representing states with the most strict and F representing states with the least strict laws) based on the Brady Campaign to prevent Gun Violence that assigns scorecards for every state. The primary outcomes were suicide attempts and in-hospital mortality per 100,000 populations by Brady state grade. Results During the 14-year study period, 34,994 subjects met inclusion criteria. The mean age was 42.0 years and 80.1% were male. A handgun was utilized by 51.8% of patients. The overall mortality was 33.3%. Overall, 22.0% had reported psychoses and 19.3% reported depression. After adjusting for confounding factors and using group A as reference, there were higher adjusted odds for suicide attempts for patients admitted in group C, D, and F category states (1.73, 2.09, and 1.65, respectively, all P < 0.001). Conclusions Firearm-related suicide attempt injuries are more common in states with less strict gun laws, and these injuries tend to be associated with a higher mortality. Efforts aimed at nationwide standardization of firearm state laws are warranted, particularly for young adults and suicide-prone populations. Level of evidence III. Study type Trauma Outcomes study. [ABSTRACT FROM AUTHOR]

Introduction: Selective nonoperative management of neck injuries from penetrating mechanism has become an acceptable management strategy. We herein characterize current management strategies of cervical pharyngoesophageal injuries implemented by trauma surgeons in the United States. Methods: The National Trauma Data Bank datasets 2007-2011 were queried for penetrating pharyngeal and/or cervical esophageal injuries. Subjects surviving 24 hours or more were analyzed based on whether a surgical exploration was pursued and by gunshot versus stabbing mechanism. Results: In all, 1,256 patients were identified, representing 6% of all penetrating neck injuries during the study period. The majority (84%) were male, with a median age of 27 years. Injury severity was high (median score of 14). Compared to stabbing victims, gunshot patients were more likely to have associated cervical spine (24% vs. 1%, p  < .01) and carotid artery injury (14% vs. 9%, p  < .01). Neck exploration was performed in 49% of patients who survived at least 24 hours, with 90% occurring within the first day of admission. Of patients who underwent a delayed neck exploration, 35% required a tracheostomy and 41% required a feeding tube placement. The overall mortality was 4%. Nonoperative management was not associated with increased odds for death (adjusted odds ratio (AOR) 0.55, p  = .17). Conclusions: Nonoperative management of penetrating pharyngoesophageal injuries is commonly utilized with no effect on mortality.

Background: Increasing evidence supports the limited use of magnetic resonance imaging (MRI) for cervical spine (C-spine) clearance following blunt trauma. We sought to characterize the utilization of MRI of the C-spine at a Level I trauma center., Methods: All blunt trauma patients undergoing a computed tomography (CT) of the C-spine between January 2009 and December 2018 were reviewed. The CT and MRI results, demographics, clinical presentation, subspecialty consultations, and interventions were recorded. The MRI results were considered clinically significant if they resulted in cervical thoracic orthosis/halo placement or surgical intervention. Linear regression models were utilized to identify trends., Results: There were 9,101 patients that underwent a CT of the C-spine, with 513 (5.6%) being positive for an acute injury. MRI was obtained for 375 (4.1%) of patients. A linear increase in the proportion of patients undergoing an MRI was noted, from 0.9% in 2009 to 5.6% in 2018 (p < 0.01). Of the 513 patients with a positive CT, 290 (56.5%) had an MRI. In 40 (13.8%) of them, the CT demonstrated a minor injury. Clinically significant MRI findings were noted only in two (5.0%) of the 40 patients, and both had a neurologic deficit on initial examination. Of the 8,588 patients with a negative CT, 85 (1.0%) underwent an MRI. Of those, 9 (10.6%) had a clinically significant MRI with all but one presenting with a neurological deficit., Conclusion: MRI is increasingly utilized for C-spine clearance following blunt trauma. MRI was exceedingly unlikely to demonstrate a clinically significant finding in the absence of a neurological deficit, when the CT was negative or included minor injuries. Trauma centers are encouraged to constantly evaluate their own practices and intervene with education and collaboration to limit the excessive use of unnecessary resources., Level of Evidence: Therapeutic/Care Management Study, Level III or IV. Diagnostic test, level IV.

RCTs showed benefits in Lap repair of perforated peptic ulcer (PPU). The SWSC Multi-Center Trials Group sought to evaluate whether Lap omental patch repairs compared to Open improved outcomes in PPU in general practice. Data was collected from 9 SWSC Trial Group centers. Demographics, operative time, 30-day complications, length of stay and mortality were included. 461 PATIENTS: Open in 311(67%) patients, Lap in 132(28%) with 20(5%) patients converted from Lap to Open. Groups were similar at baseline. Significant variability was found between centers in their utilization of Lap (0-67%). Complications at 30 days were lower in Lap (18.5% vs. 27.5%, p < 0.05) as was unplanned re-operation (4.7% vs 14%, p < 0.05). Lap reduced LOS (6 vs 8 days, p < 0.001). Ileus was more in Lap (42% vs 18 p < 0.001) operative time was 14 min higher in Lap(p < 0.01) and admission to OR time was 4 h higher in Lap(<0.05). No significant difference readmission or mortality. Our results suggest Lap should be considered a first-line option in suitable PPU patients requiring omental patch repair in centers that have the capacity and resources 24/7., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: The Department of Homeland Security launched the Stop the Bleed initiative, a campaign intended to teach bystanders hemorrhage control strategies. Despite the program's popularity, little is known about actions taken by participants afterwards. We sought to determine how often participants acquired the equipment that is necessary in applying the skills taught., Design: A standardized survey instrument was distributed to all American College of Surgeons Bleeding Control Basic (B-Con) class participants from 05/2017 to 01/2018. The instrument queried about the likelihood of applying skills and obtaining materials. A web-based survey was administered one month later inquiring whether materials were obtained and barriers that would prohibit acquisition., Setting: Academic, urban, Level I trauma center., Participants: Healthcare and nonhealthcare personnel., Results: There were 336 and 183 participants who completed the initial and subsequent web-based survey, respectively. Participants indicated a high likelihood of applying a tourniquet (95.5%), applying pressure (97.9%), and packing a wound (96.4%), if required. Additionally, 74.7% and 76.2% reported a high likelihood of obtaining a tourniquet and packing material, respectively. However, only 21.3% and 50.8% obtained a tourniquet and packing material, respectively, 1 month later. Cost, time, and accessibility of items during a time of need were cited to be common reasons for not obtaining these materials., Conclusions: Despite reporting a high likelihood of utilizing hemorrhage control skills upon completion of the B-Con class, few went on to acquire the materials needed to apply these skills among those who responded. These results may be impacted by loss of follow up and response bias. Developing strategies that allow for easy access to materials is imperative and may lead to both better implementation of the purposes of the program and improved dissemination of its principles within the community., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Beta blockers, a class of medications that inhibit endogenous catecholamines interaction with beta adrenergic receptors, are often administered to patients hospitalized after traumatic brain injury (TBI). We tested the hypothesis that beta blocker use after TBI is associated with lower mortality, and secondarily compared propranolol to other beta blockers., Methods: The American Association for the Surgery of Trauma Clinical Trial Group conducted a multi-institutional, prospective, observational trial in which adult TBI patients who required intensive care unit admission were compared based on beta blocker administration., Results: From January 2015 to January 2017, 2,252 patients were analyzed from 15 trauma centers in the United States and Canada with 49.7% receiving beta blockers. Most patients (56.3%) received the first beta blocker dose by hospital day 1. Those patients who received beta blockers were older (56.7 years vs. 48.6 years, p < 0.001) and had higher head Abbreviated Injury Scale scores (3.6 vs. 3.4, p < 0.001). Similarities were noted when comparing sex, admission hypotension, mean Injury Severity Score, and mean Glasgow Coma Scale. Unadjusted mortality was lower for patients receiving beta blockers (13.8% vs. 17.7%, p = 0.013). Multivariable regression determined that beta blockers were associated with lower mortality (adjusted odds ratio, 0.35; p < 0.001), and propranolol was superior to other beta blockers (adjusted odds ratio, 0.51, p = 0.010). A Cox-regression model using a time-dependent variable demonstrated a survival benefit for patients receiving beta blockers (adjusted hazard ratio, 0.42, p < 0.001) and propranolol was superior to other beta blockers (adjusted hazard ratio, 0.50, p = 0.003)., Conclusion: Administration of beta blockers after TBI was associated with improved survival, before and after adjusting for the more severe injuries observed in the treatment cohort. This study provides a robust evaluation of the effects of beta blockers on TBI outcomes that supports the initiation of a multi-institutional randomized control trial., Level of Evidence: Therapeutic/care management, level III.

Background: Injuries sustained by civilians from interaction with police are a polarizing contemporary sociopolitical issue. Few comprehensive studies have been published using national hospital-based data. The aim of this study was to examine the epidemiology of these injuries to better understand this mechanism of injury., Methods: Patients entered into the National Trauma Data Bank (NTDB) (January 2007 to December 2012) with E-codes E970.0 to E976.0 (International Classification of Diseases, Ninth Revision, Clinical Modification), identifying injuries associated with law enforcement in the course of legal action, were enrolled. Patients' demographics, injury characteristics, procedures, and outcomes were collected and analyzed. Patients injured by other civilians (E960.0-E968.0) were used for comparison., Results: Of 4,146,428 patients in the NTDB, 7,203 (0.17%) were injured during interaction with police. The numbers of patients in consecutive study years were 858, 1,103, 1,148, 1,274, 1,316, and 1,504. The incidence of these injuries was stable over time (0.17-0.18%) (p = 0.129). Patients had a median age of 31 years (range, 0-108), and 94.3% were male. Median injury severity score was 9 (interquartile range [IQR], 4-17). The most common mechanism of injury was gunshot wound (44%).Patients were white, 43%; black, 30%; Hispanic, 17%; Asian, 1%; and Other, 9%. As a proportion of the total race-specific NTDB trauma population, there was an average of 1.13 white patients, 2.71 Hispanic patients, and 3.83 black patients per 1,000. Mechanism, injury severity score, and outcomes did not vary by race. Compared to patients injured by civilians, patients injured by police are more likely to be white (43% vs 25%, p < 0.001) and injured by gunshot wounds (44% vs 32%, p < 0.001)., Conclusions: Based on data from trauma centers across the United States, the rate of injuries sustained during interactions with police has been stable over time. Gunshot wounds are the most common mechanism of injury. Proportionally, black patients are the most frequently injured race. When compared to patients injured by civilians, however, patients injured by police are more likely to be white. This study provides a step toward a better understanding of police-associated injuries., Level of Evidence: Prognostic/epidemiologic study, level III.

Background: The purpose of this investigation was to delineate whether elderly patients with spinal injuries benefit from transfers to higher level trauma centers., Methods: Retrospective review of the National Trauma Data Bank 2007 to 2011, including patients > 65 (y) with any spinal fracture and/or spinal cord injury from a blunt mechanism. Patients who were transferred to level I and II centers from other facilities were compared to those admitted and received their definitive treatment at level III or other centers., Results: Of 3,313,117 eligible patients, 43,637 (1.3%) met inclusion criteria: 19,588 (44.9%) were transferred to level I-II centers, and 24,049 (55.1%) received definitive treatment at level III or other centers. Most of the patients (95.8%) had a spinal fracture without a spinal cord injury. Transferred patients were more likely to require an intensive care unit admission (48.5% versus 36.0%, P < 0.001) and ventilatory support (16.1% versus 13.3%, P < 0.001). Mortality for the entire cohort was 7.7% (8.6% versus 7.1%, P < 0.001) and significantly higher, at 21.7% for patients with a spinal cord injury (22.3% versus 21.0%, P < 0.001). After adjusting for all available covariates, there was no difference in the adjusted mortality between patients transferred to higher level centers and those treated at lower level centers (adjusted odds ratio [95% confidence interval]: 1.05 [0.95-1.17], P = 0.325)., Conclusions: Transfer of elderly patients with spinal injuries to higher level trauma centers is not associated with improved survival. Future studies should explore the justifications used for these transfers and focus on other outcome measures such as functional status to determine the potential benefit from such practices., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Importance: BRCA mutation carriers are at increased risk of developing breast cancer. However, the incidence of breast cancer after a diagnosis of epithelial ovarian cancer (EOC), one of the tubal/peritoneal cancers collectively referred to as pelvic serous carcinomas, is not well known. Optimal breast cancer surveillance and detection for these patients have also not been well characterized., Objectives: To determine the incidence of breast cancer after a diagnosis of EOC and to evaluate the need for breast cancer surveillance for these patients., Design, Setting, and Participants: A retrospective database review of 364 patients who underwent BRCA mutation testing for EOC (stages I-IV) between 1998 and 2012 at an academic medical center with gynecologic and breast cancer centers., Main Outcomes and Measures: Incidence of breast cancer and methods of surveillance., Results: Of 364 patients, 135 (37.1%) were found to carry a germline BRCA1 or BRCA2 mutation. The mean age of patients at diagnosis of EOC was 49.5 years (range, 28-89 years). Of the 135 patients, 12 (8.9%) developed breast cancer. The median time from diagnosis of EOC to diagnosis of breast cancer was 50.5 months. Annual mammography was performed for 80 patients (59.3%), with annual magnetic resonance imaging of the breasts performed for 60 patients (44.4%). Thirteen patients (9.6%) underwent a bilateral prophylactic mastectomy at a median of 23 months following EOC diagnosis. Breast cancer was most commonly diagnosed by mammography for 7 of the 12 patients (58.3%), 3 (25.0%) of whom had a palpable mass and 2 (16.7%) of whom had incidental breast cancer detected during a prophylactic mastectomy. Seven patients with breast cancer (58.3%) underwent a bilateral mastectomy. All patients had early-stage breast cancer (stages 0-II). Four patients (33.3%) received adjuvant chemotherapy. At a median follow-up of 6.3 years, 4 of the 12 patients (33.3%) died of recurrent EOC after a diagnosis of breast cancer. The overall 10-year survival rate for the entire cohort of 135 patients was 17.0%., Conclusions and Relevance: The risk of metachronous breast cancer is low in patients with known BRCA mutations and EOC. A majority of these cases of breast cancer at an early stage are detected by use of mammography. Despite the small number of patients in our study, these results suggest that optimal breast cancer surveillance for patients with BRCA-associated EOC needs to be reevaluated given the low incidence of breast cancer among these high-risk patients. Confirmation of our findings from larger studies seems to be indicated.

Background: The epidemiology of vascular injuries in the geriatric patient population has not been described. The purpose of this study was to examine nationwide data on vascular injuries in the geriatric patients and to compare this with the nongeriatric adult patients with respect to the incidence, injury mechanisms, and outcomes., Methods: Geriatric patients aged 65 or older with at least one traumatic vascular injury were compared with an adult cohort aged 16 years to 64 years with a vascular injury using the National Trauma Databank version 7.0., Results: During the study period, 29,736 (1.6%) patients with a vascular injury were identified. Of those, geriatric patients accounted for 7.6% (2,268) and the nongeriatric adult patients accounted for 83.1% (n=24,703). Compared with the nongeriatric adult patients, the geriatric vascular patients had a significantly higher Injury Severity Score (26.6±17.0 vs. 21.3±16.7; p<0.001) and less frequently sustained penetrating injuries (16.1% vs. 54.1%; p<0.001). The most commonly injured vessels in the elderly were vessels of the chest (n=637, 40.2%), including the thoracic aorta and innominate and subclavian vessels. The overall incidence of thoracic aorta injuries was significantly higher in geriatric patients (33.0% vs. 13.9%; p<0.001) and increased linearly with progressing age. After adjusting for confounding factors, geriatric patients demonstrated a fourfold increase in mortality following vascular injuries (adjusted odds ratio, 3.9; 95% confidence interval, 3.32-4.58; p<0.001)., Conclusion: Vascular trauma is rare in the geriatric patient population. These injuries are predominantly blunt, with the thoracic aorta being the most commonly injured vessel. Although vascular injuries occur less frequently than in the nongeriatric cohort, in the geriatric patient, vascular injury is associated with a fourfold increase in adjusted mortality.

Work-related injuries impose a significant burden on society. The goal of this study was to delineate the epidemiology and the effect of age on type and mortality after occupational injuries. Patients 16 years of age or older sustaining work-related injuries were identified from the National Trauma Databank 12.0. The study population was stratified into four age groups: 16 to 35, 36 to 55, 56 to 65, and older than 65 years old. The demographic characteristics, type of injury, mechanism of injury, setting of injury, use of alcohol or other illicit drugs, and mortality were analyzed and related to age strata. Overall 67,658 patients were identified. There were 27,125 (40.1%) patients in the age group 16 to 35 years, 30,090 (44.5%) in the group 36 to 55 years, 6,618 (9.8%) in the group 56 to 65 years, and 3,825 (5.7%) older than 65 years. The injury severity increased significantly with age. Elderly patients were significantly more likely to sustain intracranial hemorrhages, spinal, and other skeletal injuries. The overall mortality was 2.9 per cent (1938) with the latter increasing significantly in a stepwise fashion with progressing age, becoming sixfold higher in patients older than 65 years (OR, 6.18; 95% CI, 4.78 to 7.80; P < 0.001). Our examination illustrates the associations between occupational injury and significant mortality that warrant intervention for mortality reduction. There is a stepwise-adjusted increase in mortality with progressing age.

Introduction: Although gunshot and stab wounds are a common cause of self-inflicted injury, very little is understood about this mechanism of injury. The aim of this study was to characterise the epidemiology and outcomes of patients who injured themselves with a gun or sharp object., Methods: After IRB approval, the LAC+USC Trauma Registry was utilised to identify all patients who sustained a self-inflicted injury caused by firearm (GSW) or stabbing (SW) from 1997 to 2007. Demographic data, injury characteristics, surgical interventions, and outcomes were abstracted and analysed., Results: During the 11-year study period, a total of 753 patients (1.6%) were admitted for a self-inflicted injury. Of these, 369 (49.0%) had a self-inflicted penetrating injury, with 72 (19.5%) having sustained a GSW and 297 (80.5%) having a SW. Overall, the mean age was 36.4+/-15.8 years, 83.5% were male, with a mean ISS of 7.4+/-11.0. The most commonly injured body region in GSW patients was the head (76.4%), followed by the chest (15.3%) and in SW patients the upper extremity (37.0%), followed by the abdomen (36.4%). When compared to SW, GSW were significantly more frequent in males (21.4% vs. 9.8%, p=0.04), and were most commonly to the head (21.4% vs. 8.2%, p=0.02). Patients sustaining a GSW were more likely to be older than 55 years (22.2% vs. 8.4%, p<0.001). Intoxication was noted at presentation in 38.3% of screened GSW patients and 39.9% of SW patients. SW patients required operative intervention more frequently (40.9% vs. 22.2%, p<0.01), with 12.8% of them requiring exploratory laparotomy. However, patients who shot themselves were much more likely to die (66.7%) than those presenting with SW (1.7%). For those presenting with a GSW to the head, the mortality rate was even higher, at 80%. Mortality did not differ between males and females in either group., Conclusion: Although a self-inflicted SW is far more common than a self-inflicted GSW, patients sustaining a GSW are more severely injured, and have a nearly 110-fold increased risk of death. Though less lethal, stab wounds still consume significant amounts of healthcare resources and incur large in-hospital costs. The average hospital charge incurred for treating these self-inflicted injuries was five times the amount spent per annum on American citizens. Self-inflicted penetrating injuries represent a golden opportunity for secondary prevention through psychiatric intervention. These interventions may not only preserve life but also improve resource utilisation., (2010 Elsevier Ltd. All rights reserved.)

Background: Trauma in the elderly (≥ 55 years) accounts for a significant proportion of admissions to trauma centers. Our understanding of the epidemiology and outcomes associated with penetrating injury in this age segment of the population, however, is severely limited. The aim of the present study therefore was to investigate the incidence and type of injuries sustained by elderly patients from firearms and the impact of age on outcomes., Methods: This was a 5-year National Trauma Databank (NTDB) study. Injury demographics, mortality rates, and lengths of stay in the Intensive Care Unit (ICU) and the hospital were analyzed. Elderly patients ≥ 55 years old were assigned to one of three categorical strata: 55-64 years old, 65-74 years old, and ≥ 75 years old., Results: During the study period, 98,242 patients were admitted for firearm-related injuries, and 3,190 (3.2%) of them were ≥ 55 years old. Within the elderly age segment of the population, 1,676 patients (52.5%) were 55-64 years of age, 727 (22.8%) were 65-74 years of age, and 787 (24.7%) were ≥ 75 years old. The incidence of severe trauma [Injury Severity Score (ISS) ≥ 16] in the elderly age strata was 43.3, 46.8, and 57.6%, respectively (p < 0.001). Patients ≥ 75 years old were significantly more likely than patients 55-74 years old to suffer self-inflicted injuries. The most commonly encountered injury in elderly patients was gunshot wounds to the head, which increased in a stepwise fashion with advancing age (25.8, 31.6, and 39.4% respectively; p < 0.001). The crude mortality rate in all patients sustaining gunshot wounds increased progressively with age. Within the elderly age segment, mortality ranged from 28.5% in the age stratum 55-64 years, to 55.4% in the stratum ≥ 75 years (adjusted p < 0.001). Intensive care unit and hospital length of stay increased with advancing age but peaked and remained stable among the elderly age groups. An admission Glasgow Coma Score (GCS) ≤ 8, an ISS ≥ 16, hypotension on admission, age, self-inflicted injury, and injury sustained by assault were factors independently associated with death in patients ≥ 55 years., Conclusions: Injury from firearms is not uncommon in the elderly patient population and is primarily a result of self-inflicted gunshot wounds to the head. These patients sustain a high burden of injury and a high rate of mortality, which increases with advancing age.

The purpose of this study was to examine the epidemiology and outcomes of posttraumatic upper (UEA) and lower extremity amputations (LEA). The National Trauma Databank version 5 was used to identify all posttraumatic amputations. From 2000 to 2004 there were 8910 amputated patients (1.0% of all trauma patients). Of these, 6855 (76.9%) had digit and 2055 (23.1%) had limb amputation. Of those with limb amputation, 92.7 per cent (1904/2055) had a single limb amputation. LEA were more frequent than UEA among patients in the single limb amputation group (58.9% vs 41.1%). The mechanism of injury was blunt in 83 per cent; most commonly after motor vehicle collisions (51.0%), followed by machinery accidents (19.4%). Motor vehicle collision occupants had more UEA (54.5% vs 45.5%, P < 0.001), whereas motorcyclists (86.2% vs 13.8%, P < 0.001) and pedestrians (91.9% vs 8.1%, P < 0.001) had more LEA. Patients with LEA were more likely to require discharge to a skilled nursing facility; whereas those with UEA were more likely to be discharged home. Traumatic limb amputation is not uncommon after trauma in the civilian population and is associated with significant morbidity. Although single limb amputation did not impact mortality, the need for multiple limb amputation was an independent risk factor for death.

Introduction: The purpose of this study was to examine nationwide data on vascular injuries in children and to compare pediatric and adult patients with respect to the incidence, injury mechanisms, and outcomes., Methods: This is a National Trauma Databank analysis based on dataset version 7.0 (spanning a 5-year period ending December 2006). Pediatric patients under the age of 16 with at least one reported diagnosis of a vascular injury were compared to the adult cohort aged 16 and greater with a vascular injury., Results: During the study period, of 251,787 injured patients younger than 16 years, 1138 (0.6%) had a vascular injury. The incidence in patients 16 years or older was significantly higher, at 1.6% (P < .01). Compared to the adult vascular patients, pediatric patients had a significantly lower Injury Severity Score (16.8 +/- 14.9 vs 26.3 +/- 16.7, P < .001) and encountered less frequently penetrating injuries (41.8% vs 51.2%, P < .001). The most commonly injured vessels in the pediatric population were vessels of the upper extremity (424 patients or 37.9%). The overall incidence of thoracic aortic injuries in children was seven-fold lower compared to the incidence in adults (0.03% vs 0.21%). After adjusting for confounding factors, pediatric patients demonstrated improved survival following vascular injuries (adjusted odds ratio, 0.60; 95% CI, 0.45-0.79; P < .001). No significant difference was identified in the rate of amputation between pediatric and adult patients who had sustained upper or lower extremity vascular injuries., Conclusion: Vascular trauma in the pediatric population is uncommon, occurring in only 0.6% of all pediatric trauma patients. Although less frequent than adults, a significant proportion was due to penetrating injury. Vessels of the upper extremity were the most commonly injured and were associated with low mortality. Injuries of the thoracic aorta are rare. Overall, pediatric patients had an improved adjusted mortality when compared to adults., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: Recent reports have demonstrated increasing lethality among young women after inflicted injuries (SII). The aim of this study was to examine sex differences in the methods and outcomes of childhood and adolescent SII., Methods: The National Trauma Databank (v 7.0) was used to identify all patients 18 years or younger who sustained a SII. Demographic data, clinical data, and outcomes were compared between male and female patients., Results: During the study period, a total of 1853 (61.1%) male and 1182 (38.9%) female patients sustained a SII. The most common SII mechanism in male patients was gunshot wound (32.1% vs 6.8%, P < .001); in female patients, poisoning (45.6% vs 9.6%, P < .001). For younger patients (<12 years) hanging was the most common method for both male and female patients (36.5% and 29.2%, respectively). The most lethal method in both male and female patients was gunshot wound (32.3% and 38.0%, respectively). This was followed by hanging which had a high rate of lethality particularly in male adolescents 14 years or younger (36.5% and 33.2% for males <12 years and 12-14 years, respectively)., Conclusion: Self-inflicted injuries in childhood and adolescence show distinct sex differences primarily with regard to mechanism. Males favor shooting; females, poisoning; younger ages, hanging. Gunshot wound and hanging were the 2 most lethal methods of self-inflicted injury., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: Cervical spine clearance in the very young child is challenging. Radiographic imaging to diagnose cervical spine injuries (CSI) even in the absence of clinical findings is common, raising concerns about radiation exposure and imaging-related complications. We examined whether simple clinical criteria can be used to safely rule out CSI in patients younger than 3 years., Methods: The trauma registries from 22 level I or II trauma centers were reviewed for the 10-year period (January 1995 to January 2005). Blunt trauma patients younger than 3 years were identified. The measured outcome was CSI. Independent predictors of CSI were identified by univariate and multivariate analysis. A weighted score was calculated by assigning 1, 2, or 3 points to each independent predictor according to its magnitude of effect. The score was established on two thirds of the population and validated using the remaining one third., Results: Of 12,537 patients younger than 3 years, CSI was identified in 83 patients (0.66%), eight had spinal cord injury. Four independent predictors of CSI were identified: Glasgow Coma Score <14, GCSEYE = 1, motor vehicle crash, and age 2 years or older. A score of <2 had a negative predictive value of 99.93% in ruling out CSI. A total of 8,707 patients (69.5% of all patients) had a score of <2 and were eligible for cervical spine clearance without imaging. There were no missed CSI in this study., Conclusions: CSI in patients younger than 3 years is uncommon. Four simple clinical predictors can be used in conjunction to the physical examination to substantially reduce the use of radiographic imaging in this patient population.

Background: Several authors have examined the relationship between outcomes following severe trauma and American College of Surgeons (ACS) trauma centre designation. Little is known, however, about the association between ACS level and outcomes following complications of trauma., Methods: The National Trauma Databank (NTDB, v. 5.0) was queried to identify adult (age > or =18) trauma patients developing post-traumatic ARDS, who were admitted to either ACS level 1 or level 2 trauma centres from 2000 to 2004. Patients transferred between institutions and injuries following burns were excluded. Univariate analysis was used to assess differences between those patients admitted to ACS level 1 and level 2 facilities. Adjusted mortality was derived using logistic regression analysis., Results: A total of 902 adult trauma patients with ARDS after 48 h of mechanical ventilation were identified from the NTDB. Five hundred and thirty six patients were admitted to a level 1 ACS verified centre and 366 to a level 2 facility. Univariate analysis revealed no statistical differences in clinical and demographic characteristics between the two groups. On univariate comparison, patients admitted to level 1 facilities had longer mean hospital and ICU length of stay and higher hospital related charges than level 2 counterparts. Patients admitted to a level 1 centre were, however, significantly more likely to achieve discharge to home. Using multivariate logistic regression, ACS level designation was shown to have no statistical effect on mortality. Hypotension on admission and age greater than 55 were the only independent predictors of mortality., Conclusion: ACS trauma centre designation level is not an independent predictor of mortality following post-traumatic ARDS.

Background: Empyema is a rare, but morbid complication of diaphragmatic injury. The purpose of this study was to use the National Trauma Databank of the American College of Surgeons to determine (1) the incidence of empyema after diaphragmatic injury, (2) risk factors for development of empyema after these injuries, and (3) the effect of empyema on mortality, hospital, and intensive care unit (ICU) length of stay (LOS) after diaphragm injury., Methods: The National Trauma Databank (v. 5.0) was used to identify adult patients sustaining diaphragmatic injury and surviving for greater than 48 hours. Demographics, injury characteristics, associated abdominal injuries, thoracic procedures, and outcomes data were abstracted for comparison of patients who did and did not develop empyema after these injuries. Stepwise logistic regression analysis was used to identify independent risk factors for the development of empyema. Subsequent adjusted analysis was used to determine the effect of empyema on outcomes (hospital LOS, ICU LOS, mortality)., Results: Among 4,153 patients with diaphragmatic injury who survived more than 48 hours from admission, 57 (1.4%) developed empyema. Demographics did not differ significantly between the two groups. Empyema was associated with longer adjusted mean hospital (35.9 vs. 16.1, p < 0.001) and ICU (18.1 vs. 8.5, p < 0.001) LOS, but was not associated with increased mortality. Patients with empyema more commonly had associated hollow viscus (63.2% vs. 35.6%, p < 0.001), gastric (40.4% vs. 18.8%, p < 0.001), and splenic injuries (49.1% vs. 33.3%, p = 0.01). After multivariable analysis, two independent risk factors for the development of empyema after diaphragmatic injury were identified: gastric injury (adjusted odds ratio = 2.90; 95% confidence interval: 1.69-5.00; p < 0.001) and Injury Severity Score > or = 20 (adjusted odds ratio = 2.99; 95% confidence interval: 1.61-5.59; p = 0.001). Concomitant colonic injury did not significantly increase the risk of empyema in the study population., Conclusions: Empyema is an uncommon sequela of diaphragm injury that contributes to the need for prolonged hospital and ICU LOSs. Associated gastric trauma and Injury Severity Score > or = 20 were independently associated with empyema development after diaphragmatic injury.