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Background: Current guidelines recommend 24-hour telemetry monitoring for isolated sternal fractures (ISFs) with electrocardiogram (ECG) abnormalities or troponin elevation. However, a single-center study suggested ISF patients with minor ECG abnormalities (sinus tachycardia/bradycardia, nonspecific arrhythmia/ST-changes, and bundle branch block) may not require 24-hour telemetry monitoring. This study sought to corroborate this, hypothesizing ISF patients would not develop blunt cardiac injury (BCI)., Materials & Methods: A retrospective study was performed at 8 trauma centers (1/2018-8/2020). Patients with ISF (abbreviated injury scale <2 for the head/neck/face/abdomen/extremities) and minor ECG abnormalities or troponin elevations were included. Patients with multiple rib fractures or hemothorax/pneumothorax were excluded. The primary outcome was an echocardiogram confirmed BCI. The secondary outcome was significant BCI defined as cardiogenic shock, dysrhythmia requiring treatment, post-traumatic cardiac structural defects, unexplained hypotension, or cardiac-related procedures. Descriptive statistics were performed., Results: Of 124 ISF patients with minor ECG abnormalities or troponin elevation, 90% were admitted with a mean stay of 35 hours. Echocardiogram was performed for 31.5% of patients, 10 (25.6%) of which had abnormalities. However, no patient had BCI diagnosed on echocardiography. In total, 2 patients (1.6%) had a significant BCI (atrial fibrillation and supraventricular tachycardia at 10 and 82 hours after injury). No patient died., Conclusions: Following ISF with minor ECG changes or troponin elevation, <2% suffered significant BCI, and none had an echocardiogram diagnosed BCI, despite >30% receiving echocardiogram. These findings challenge the dogma of mandatory observation periods following ISF with associated ECG abnormalities and support the lack of utility for routine echocardiography in these patients., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Whole blood (WB) transfusion has been shown to improve mortality in trauma resuscitation. The optimal ratio of packed red blood cells (pRBC) to WB in emergent transfusion has not been determined. We hypothesized that a low pRBC/WB transfusion ratio is associated with improved survival in trauma patients., Methods: We analyzed the 2021 Trauma Quality Improvement Program (TQIP) database to identify patients who underwent emergent surgery for hemorrhage control and were transfused within 4 hours of hospital arrival, excluding transfers or deaths in the emergency department. We stratified patients based on pRBC/WB ratios. The primary outcome was mortality at 24 hours. Logistic regression was performed to estimate odds of mortality among ratio groups compared with WB alone, adjusting for injury severity, time to intervention, and demographics., Results: Our cohort included 17,562 patients; of those, 13,678 patients had only pRBC transfused and were excluded. Fresh frozen plasma/pRBC ratio was balanced in all groups. Among those who received WB (n = 3,884), there was a significant increase in 24-hour mortality with higher pRBC/WB ratios (WB alone 5.2%, 1:1 10.9%, 2:1 11.8%, 3:1 14.9%, 4:1 20.9%, 5:1 34.1%, p = 0.0001). Using empirical cutpoint estimation, we identified a 3:1 ratio or less as an optimal cutoff point. Adjusted odds ratios of 24-hour mortality for 4:1 and 5:1 groups were 2.85 (95% confidence interval [CI], 1.19-6.81) and 2.89 (95% CI, 1.29-6.49), respectively. Adjusted hazard ratios of 24-hour mortality were 2.83 (95% CI, 1.18-6.77) for 3:1 ratio, 3.67 (95% CI, 1.57-8.57) for 4:1 ratio, and 1.97 (95% CI, 0.91-4.23) for 5:1 ratio., Conclusion: Our analysis shows that higher pRBC/WB ratios at 4 hours diminished survival benefits of WB in trauma resuscitation. Further efforts should emphasize this relationship to optimize trauma resuscitation protocols., Level of Evidence: Therapeutic/Care Management; Level III., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Recent evidence suggests that routine intubation upon arrival for adults with isolated head trauma and a depressed Glasgow Coma Scale (GCS) score is associated with increased risk of morbidity and mortality. Whether these outcomes are similar within an adolescent trauma population has not been previously investigated. We hypothesized intubation upon arrival for adolescent trauma patients with isolated head trauma to be associated with a higher risk of death and prolonged length of stay (LOS)., Methods: The 2017-2019 TQIP was queried for adolescents (age 12-16) presenting after isolated blunt head trauma (abbreviated injury scale [AIS] < 1 spine/chest/abdomen/upper-extremity/lower-extremity) and GCS 6-8 on arrival. Transferred patients, dead-on-arrival, and those undergoing emergent operation from the emergency department were excluded. Patients intubated within one-hour were compared to patients not intubated within one-hour. A multivariable logistic regression analysis was performed adjusting for age, sex, GCS, and AIS-grade for the head., Results: From 141 patients, 73 (51.8%) were intubated upon arrival. Intubated patients had a low complication rate (5.6%). Intubated and non-intubated patients had a similar rate and mortality risk (6.8% vs 1.5%, P = .11) (OR 1.84, CI .08-43.69, P = .71) and median length of stay (LOS) (2 days vs 2 days, P = .13)., Discussion: Unlike adult patients, adolescents with isolated head trauma and a depressed GCS have similar outcomes if they are intubated upon arrival. Utilizing initial GCS score to determine which adolescent trauma patients with isolated head trauma should be intubated appears to be a safe practice., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Nearly 10% of pregnant women suffer traumatic injury. Clinical outcomes for pregnant trauma patients (PTPs) with severe injuries have not been well studied. We sought to describe outcomes for PTPs presenting with severe injuries, hypothesizing that PTPs with severe injuries will have higher rates of complications and mortality compared to less injured PTPs. A post-hoc analysis of a multi-institutional retrospective study at 12 Level-I/II trauma centers was performed. Patients were stratified into severely injured (injury severity score [ISS] > 15) and not severely injured (ISS < 15) and compared with bivariate analyses. From 950 patients, 32 (3.4%) had severe injuries. Compared to non-severely injured PTPs, severely injured PTPs were of similar maternal age but had younger gestational age (21 vs 26 weeks, p = 0.009). Penetrating trauma was more common in the severely injured cohort (15.6% vs 1.4%, p < 0.001). The severely injured cohort more often underwent an operation (68.8% vs 3.8%, p < 0.001), including a hysterectomy (6.3% vs 0.3%, p < 0.001). The severely injured group had higher rates of complications (34.4% vs 0.9%, p < 0.001), mortality (15.6% vs 0.1%, p < 0.001), a higher rate of fetal delivery (37.5% vs. 6.0%, p < 0.001) and resuscitative hysterotomy (9.4% vs. 0%, p < 0.001). Only approximately 3% of PTPs were severely injured. However, severely injured PTPs had a nearly 40% rate of fetal delivery as well as increased complications and mortality. This included a resuscitative hysterotomy rate of nearly 10%. Significant vigilance must remain when caring for this population., (© 2024. The Author(s).)

Introduction: The impact of obesity on the incidence of blunt pelvic fractures in adults is unclear, and adolescents may have an increased risk of fracture due to variable bone mineral density and leptin levels. Increased subcutaneous adipose tissue may provide protection, though the association between obesity and pelvic fractures in adolescents has not been studied. This study hypothesized that obese adolescents (OAs) presenting after motor vehicle collision (MVC) have a higher rate of pelvic fractures, and OAs with such fractures have a higher associated risk of complications and mortality compared to non-OAs., Methods: The 2017-2019 Trauma Quality Improvement Program database was queried for adolescents (12-16 y old) presenting after MVC. The primary outcome was a pelvic fracture. Adolescents with a body mass index ≥30 (OA) were compared to adolescents with a body mass index <30 (non-OA). Subgroup analyses for high-risk and low-risk MVCs were performed. Multivariable logistic regression analyses were also performed adjusting for age and sex., Results: From 22,610 MVCs, 3325 (14.7%) included OAs. The observed rate of pelvic fracture was similar between all OA and non-OA MVCs (10.2% versus 9.4%, P = 0.16), as well as subanalyses of minor or high-risk MVC (both P > 0.05). OAs presenting with a pelvic fracture after high-risk MVC had a similar risk of complications, pelvic surgery, and mortality compared to non-OAs (all P > 0.05). However, OAs with a pelvic fracture after minor MVC had a higher associated risk of complications (OR 2.27, CI 1.10-4.69, P = 0.03), but a similar risk of requiring pelvic surgery, and mortality (all P > 0.05)., Conclusions: This national analysis found a similar observed incidence of pelvic fractures for OAs versus non-OAs involved in an MVC, including subanalyses of minor and high-risk MVC. Furthermore, there was no difference in the associated risk of morbidity and mortality except for OAs involved in a minor MVC had a higher risk of complication., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Introduction: The analysis of surgical research using bibliometric measures has become increasingly prevalent. Absolute citation counts (CC) or indices are commonly used markers of research quality but may not adequately capture the most impactful research. A novel scoring system, the disruptive score (DS) has been found to identity academic work that either changes paradigms (disruptive (DIS) work) or entrenches ideas (developmental (DEV) work). We sought to analyze the most DIS and DEV versus most cited research in civilian trauma., Methods: The top papers by DS and by CC from trauma and surgery journals were identified via a professional literature search. The identified publications were then linked to the National Institutes of Health iCite tool to quantify total CC and related metrics. The top 100 DIS and DEV publications by DS were analyzed based on the area of focus, citation, and perceived clinical impact, and compared with the top 100 papers by CC., Results: 32 293 articles published between 1954 and 2014 were identified. The most common publication location of selected articles was published in Journal of Trauma (31%). Retrospective reviews (73%) were common in DIS (73%) and top CC (67%) papers, while DEV papers were frequently case reports (49%). Only 1 publication was identified in the top 100 DIS and top 100 CC lists. There was no significant correlation between CC and DS among the top 100 DIS papers (r=0.02; p=0.85), and only a weak correlation between CC and DS score (r=0.21; p<0.05) among the top 100 DEV papers., Conclusion: The disruption score identifies a unique subset of trauma academia. The most DIS trauma literature is highly distinct and has little overlap with top trauma publications identified by standard CC metrics, with no significant correlation between the CC and DS., Level of Evidence: Level IV., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Following motor vehicle collisions (MVCs), patients often undergo extensive computed tomography (CT) imaging. However, pregnant trauma patients (PTPs) represent a unique population where the risk of fetal radiation may supersede the benefits of liberal CT imaging. This study sought to evaluate imaging practices for PTPs, hypothesizing variability in CT imaging among trauma centers. If demonstrated, this might suggest the need to develop specific guidelines to standardize practice., Methods: A multicenter retrospective study (2016-2021) was performed at 12 Level-I/II trauma centers. Adult (≥18 years old) PTPs involved in MVCs were included, with no patients excluded. The primary outcome was the frequency of CT. Chi-square tests were used to compare categorical variables, and ANOVA was used to compare the means of normally distributed continuous variables., Results: A total of 729 PTPs sustained MVCs (73% at high speed of ≥ 25 miles per hour). Most patients were mildly injured but a small variation of injury severity score (range 1.1-4.6, p < 0.001) among centers was observed. There was a variation of imaging rates for CT head (range 11.8-62.5%, p < 0.001), cervical spine (11.8-75%, p < 0.001), chest (4.4-50.2%, p < 0.001), and abdomen/pelvis (0-57.3%, p < 0.001). In high-speed MVCs, there was variation for CT head (12.5-64.3%, p < 0.001), cervical spine (16.7-75%, p < 0.001), chest (5.9-83.3%, p < 0.001), and abdomen/pelvis (0-60%, p < 0.001). There was no difference in mortality (0-2.9%, p =0.19)., Conclusion: Significant variability of CT imaging in PTPs after MVCs was demonstrated across 12 trauma centers, supporting the need for standardization of CT imaging for PTPs to reduce unnecessary radiation exposure while ensuring optimal injury identification is achieved., (© 2023. The Author(s).)

Background: The optimal time to initiate venous thromboembolism (VTE) chemoprophylaxis (VTEp) after blunt solid organ injury remains controversial, as VTE mitigation must be balanced against bleeding promulgation. Evidence from primarily small, retrospective, single-center work suggests that VTEp ≤48 hours is safe and effective. This study was undertaken to validate this clinical practice., Methods: Blunt trauma patients presenting to 19 participating trauma centers in North America were screened over a 1-year study period beginning between August 1 and October 1, 2021. Inclusions were age older than 15 years; ≥1 liver, spleen, or kidney injury; and initial nonoperative management. Exclusions were transfers, emergency department death, pregnancy, and concomitant bleeding disorder/anticoagulation/antiplatelet medication. A priori power calculation stipulated the need for 1,158 patients. Time of VTEp initiation defined study groups: Early (≤48 hours of admission) versus Late (>48 hours). Bivariate and multivariable analyses compared outcomes., Results: In total, 1,173 patients satisfied the study criteria with 571 liver (49%), 557 spleen (47%), and 277 kidney injuries (24%). The median patient age was 34 years (interquartile range, 25-49 years), and 67% (n = 780) were male. The median Injury Severity Score was 22 (interquartile range, 14-29) with Abbreviated Injury Scale Abdomen score of 3 (interquartile range, 2-3), and the median American Association for the Surgery of Trauma grade of solid organ injury was 2 (interquartile range, 2-3). Early VTEp patients (n = 838 [74%]) had significantly lower rates of VTE (n = 28 [3%] vs. n = 21 [7%], p = 0.008), comparable rates of nonoperative management failure (n = 21 [3%] vs. n = 12 [4%], p = 0.228), and lower rates of post-VTEp blood transfusion (n = 145 [17%] vs. n = 71 [23%], p = 0.024) when compared with Late VTEp patients (n = 301 [26%]). Late VTEp was independently associated with VTE (odd ratio, 2.251; p = 0.046)., Conclusion: Early initiation of VTEp was associated with significantly reduced rates of VTE with no increase in bleeding complications. Venous thromboembolism chemoprophylaxis initiation ≤48 hours is therefore safe and effective and should be the standard of care for patients with blunt solid organ injury., Level of Evidence: Therapeutic and Care Management; Level III., (Copyright © 2023 American Association for the Surgery of Trauma.)

Background: Pregnant trauma patients (PTPs) undergo observation and fetal monitoring following trauma due to possible fetal delivery (FD) or adverse outcome. There is a paucity of data on PTP outcomes, especially related to risk factors for FD. We aimed to identify predictors of posttraumatic FD in potentially viable pregnancies., Methods: All PTPs (≥18 years) with ≥24-weeks gestational age were included in this multicenter retrospective study at 12 Level-I and II trauma centers between 2016 and 2021. Pregnant trauma patients who underwent FD ((+) FD) were compared to those who did not deliver ((-) FD) during the index hospitalization. Univariate analyses and multivariable logistic regression were performed to identify predictors of FD., Results: Of 591 PTPs, 63 (10.7%) underwent FD, with 4 (6.3%) maternal deaths. The (+) FD group was similar in maternal age (27 vs. 28 years, p = 0.310) but had older gestational age (37 vs. 30 weeks, p < 0.001) and higher mean injury severity score (7.0 vs. 1.5, p < 0.001) compared with the (-) FD group. The (+) FD group had higher rates of vaginal bleeding (6.3% vs. 1.1%, p = 0.002), uterine contractions (46% vs. 23.5%, p < 0.001), and abnormal fetal heart tracing (54.7% vs. 14.6%, p < 0.001). On multivariate analysis, independent predictors for (+) FD included abdominal injury (odds ratio [OR], 4.07; confidence interval [CI], 1.11-15.02; p = 0.035), gestational age (OR, 1.68 per week ≥24 weeks; CI, 1.44-1.95; p < 0.001), abnormal FHT (OR, 12.72; CI, 5.19-31.17; p < 0.001), and premature rupture of membranes (OR, 35.97; CI, 7.28-177.74; p < 0.001)., Conclusion: The FD rate was approximately 10% for PTPs with viable fetal gestational age. Independent risk factors for (+) FD included maternal and fetal factors, many of which are available on initial trauma bay evaluation. These risk factors may help predict FD in the trauma setting and shape future guidelines regarding the recommended observation of PTPs., Level of Evidence: Therapeutic/Care Management; Level III., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Effects of advanced maternal age (AMA) pregnancies (defined as ≥35 years) on pregnant trauma patients (PTPs) are unknown. This study compared AMA versus younger PTPs, hypothesizing AMA PTPs have increased risk of fetal delivery (FD)., Methods: A retrospective (2016-2021) multicenter study included all PTPs. Multivariable logistic regression was used to evaluate risk of FD after trauma., Results: A total of 950 PTPs were included. Both cohorts had similar gestational age and injury severity scores. The AMA group had increased injuries to the pancreas, bladder, and stomach (p < 0.05). There was no difference in rate or associated risk of FD between cohorts (5.3% vs. 11.4%; OR 0.59, CI 0.19-1.88, p > 0.05)., Conclusion: Compared to their younger counterparts, some intra-abdominal injuries (pancreas, bladder, and stomach) were more common among AMA PTPs. However, there was no difference in rate or associated risk of FD in AMA PTPs, thus they do not require increased observation., Competing Interests: Declaration of competing interest The authors declare that there is no conflict of interest., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Hockey is a high-impact sport that carries a risk of injury. No national-level studies defining the burden of injury in this sport have yet been performed. This study sought to analyze patient demographics, injury types and severity, and outcomes after trauma sustained while playing hockey., Methods: Retrospective analysis of hockey-related injuries was performed using the National Trauma Data Bank (NTDB) (2007-2018). Patients were identified based on ICD-9 and -10 codes without exclusions. Demographics, clinical/injury data, and outcomes were examined using univariate analysis. Subgroup analysis was performed by patient sex., Results: Hockey injuries (n = 306) comprised <1% of the NTDB. Median age was 15 years [IQR 13-25] (range 5-71). Most patients (n = 279, 91%) were male. Lower extremities were the most frequently injured body region (n = 88, 29%). Head injuries occurred in 19% (n = 57). Facial injuries occurred in 6% (n = 17). Tooth loss was infrequent (n = 2, 1%). One (<1%) death occurred after a hockey-related brain injury. Clinical/injury data between male and female hockey players were comparable apart from a significantly higher rate of upper extremity fractures among the female cohort (22% vs 4%, P < .001)., Conclusion: Perceptions that hockey players may frequently sustain head, face, and tooth injuries from collisions, fighting, or stick/puck impacts were not supported by this national-level study, in which lower extremity fractures were the most common injury. While hockey injury prevention equipment has primarily focused on head/face protection (eg, helmets and mouthguards), this analysis suggests increased focus on extremity protective measures is warranted., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Marijuana use among adolescents may have increased after its legalization in the United States. An association between violence and marijuana use in adults has been demonstrated in previous reports. We hypothesized that adolescent trauma patients presenting with a positive marijuana screen (pMS) are more likely to have been injured by gunfire or knives and will have more severe injuries overall, compared to patients with a negative marijuana screen (nMS)., Methods: The 2017 Trauma Quality Improvement Program database was queried for adolescent (13-17 years old) pMS patients and compared to adolescents who tested negative for all substance/alcohol. Patients with positive polysubstance/alcohol were excluded., Results: From 8257 adolescent trauma patients, 2060 (24.9%) had a pMS with a higher rate of males in the pMS group (76.3% vs 64.3%, P < .001). The pMS group presented more frequently after gun (20.3% vs 7.9%, P < .001) or knife trauma (5.7% vs 3.0%, P < .001) and less frequently after falls (8.9% vs 15.6%, P < .001) and bicycle collisions (3.3% vs 4.8%, P = .002). The rate of serious thoracic injury (AIS ≥3) was higher for pMS patients (16.7% vs 12.0%, P < .001), and more pMS patients required emergent operation (14.9% vs 10.6%, P < .001)., Discussion: In our adolescent patient population, one quarter tested positive for marijuana. These patients are more likely to be injured by guns and/or knives suffering serious injuries, and often require immediate operative intervention. A marijuana cessation program for adolescents can help improve outcomes in this high-risk patient group., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: High grade solid organ injuries carry risk of complications, including pseudoaneurysms (PSA). The optimal approach to PSA screening among pediatric patients is unknown and may include delayed Computed Tomography Angiography (dCTA) and/or contrast-enhanced ultrasound (CEUS). This study endeavored to define dCTA/CEUS yield in PSA diagnosis after pediatric high grade solid organ injury., Methods: Patients <18y presenting to our ACS-verified Level 1 trauma center with ≥1 AAST grade ≥3 abdominal solid organ injury (kidney, liver, and spleen) were included (01/2017-10/2021). Transfers in, death <48h, and immediate nephrectomy/splenectomy were exclusions. PSA screening was pursued selectively based on attending discretion. Demographics, clinical/injury data, and outcomes were collected. Primary outcome was performance of dCTA or CEUS., Results: Forty-two patients satisfied criteria, with median age 12.5y and ISS 22. Liver injuries were most frequent (48%), followed by spleen (33%) and kidney (19%). Initial management strategy was most commonly nonoperative (liver 60%, spleen 64%, kidney 75%). Overall, 26% underwent PSA screening at a median of hospital day 4, with dCTA (21%) or CEUS (5%). CEUS was only used among liver injuries (10%), with no PSA identified. One PSA was diagnosed on dCTA after splenic injury and was managed with observation., Conclusion: PSA screening occurs infrequently after pediatric high grade solid organ injury, potentially due to concerns about radiation exposure from dCTA which would be mitigated with CEUS. Further delineation of PSA incidence and yield of screening investigations are needed to avoid missing this important diagnosis and to determine the diagnostic accuracy of dCTA and CEUS., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Early initiation of venous thromboembolism chemoprophylaxis (VTEp) decreases VTE risk in trauma patients in the Surgical Intensive Care Unit (SICU). The frequency and variation of VTEp interruption by different surgical subspecialties in the SICU is incompletely described in the literature. The objective of this study was to examine VTEp compliance in the SICU in terms of uninterrupted VTEp following initiation, both by surgical service and time of year, to identify opportunities for improvement., Methods: This single-center quality improvement (QI) study examined all SICU patients, which are almost exclusively trauma patients, at our institution (1/2021-04/2022). Exclusions were therapeutic anticoagulation. Type of VTEp, calendar month of SICU stay, perceived indications for interruption, and primary service were collected., Results: Of 5 434 patient days (PD), VTEp was not administered in 1879 (35%). Common reasons for VTEp interruption were ongoing bleeding (n = 964 PD, 51%) and periprocedural status (n = 651 PD, 35%). Periprocedural interruption was highest in July. Acute Care Surgery (ACS) (n = 208 PD, 32%) and Orthopedics (n = 188 PD, 29%) interrupted VTEp most often. ACS most commonly withheld VTEp for second look laparotomies while Orthopedics withheld VTEp for intramedullary nailing or external fixator application., Conclusion: Missed VTEp doses occurred most frequently at the beginning of the residency year, with a high percentage held for periprocedural status. Because the necessity of periprocedural VTEp holds is unclear, the appropriateness of these holds and any impact on VTE rates will be assessed as the next steps. In the interim, our findings provide targets for multidisciplinary QI endeavors., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Leaving an injured solid organ in situ allows preservation of structure function but invites complications from the damaged parenchyma, including pseudoaneurysms (PSAs). Empiric PSA screening after solid organ injury is not yet established, particularly following penetrating trauma. The study objective was definition of delayed CT angiography (dCTA) yield in triggering intervention for PSA after penetrating solid organ injury., Methods: Penetrating trauma patients at our American College of Surgeons-verified level 1 center with American Association for the Surgery of Trauma grade ≥3 abdominal solid organ injury (liver, spleen, kidney) were retrospectively screened (January 2017 to October 2021). Exclusions were age <18 y, transfers, death within <48 h, and nephrectomy/splenectomy within <4 h. Primary outcome was intervention triggered by dCTA. Statistical testing with ANOVA/chi-square compared outcomes between screened vs unscreened patients., Results: A total of 136 penetrating trauma patients met study criteria: 57 patients (42%) screened for PSA with dCTA and 79 (58%) unscreened. Liver injuries were most common (n = 41, 64% vs n = 55, 66%), followed by kidney (n = 21, 33% vs n = 23, 27%) and spleen (n = 2, 3% vs n = 6, 7%) (p = 0.48). Median American Association for the Surgery of Trauma grade of solid organ injury was 3 (3 to 4) across groups (p = 0.75). dCTA diagnosed 10 PSAs (18%) at a median of hospital day 5 (3 to 9). Among screened patients, dCTA triggered intervention in 17% of liver patients, 29% of kidney patients, and 0% of spleen-injured patients, for an overall yield of 23%., Conclusions: Half of eligible penetrating high-grade solid organ injuries were screened for PSA with dCTA. dCTA identified a significant number of PSAs and triggered intervention in 23% of screened patients. dCTA did not diagnose any PSAs after splenic injury, although sample size hinders interpretation. To avoid missing PSAs and incurring their risk of rupture, universal screening of high-grade penetrating solid organ injuries may be prudent., (Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Stress on the healthcare system requires careful allocation of resources such as renal replacement therapy (RRT). The COVID-19 pandemic generated difficulty securing access to RRT for trauma patients. We sought to develop a renal replacement after trauma (RAT) scoring tool to help identify trauma patients who may require RRT during their hospitalization., Study Design: The 2017 to 2020 TQIP database was divided into a derivation (2017 to 2018 data) and validation (2019 to 2020 data) set. A 3-step methodology was used. Adult trauma patients admitted from the emergency department to the operating room or ICU were included. Patients with chronic kidney disease, transfers from another hospital, and emergency department death were excluded. Multiple logistic regression models were created to determine the risk for RRT in trauma patients. The weighted average and relative impact of each independent predictor was used to derive a RAT score, which was validated using area under receiver operating characteristic curve (AUROC)., Results: From 398,873 patients in the derivation and 409,037 patients in the validation set, 11 independent predictors of RRT were included in the RAT score derived with scores ranging from 0 to 11. The AUROC for the derivation set was 0.85. The rate of RRT increased to 1.1%, 3.3%, and 20% at scores of 6, 8, and 10, respectively. The validation set AUROC was 0.83., Conclusions: RAT is a novel and validated scoring tool to help predict the need for RRT in trauma patients. With future improvements including baseline renal function and other variables, the RAT tool may help prepare for the allocation of RRT machines/staff during times of limited resources., (Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Traumatic breast injuries that require surgical intervention are rare and incompletely studied. The study objective was to define the incidence, mechanism/burden of injury, interventions, and outcomes after breast injuries requiring surgery nationally., Methods: All patients with breast trauma necessitating surgery were identified from the National Trauma Data Bank (NTDB) (2006-2017) using ICD-9 and -10 codes, without exclusions. Demographics, injury mechanism/severity, procedures, and outcomes (mortality, hospital length of stay [LOS, days], ICU LOS, and AIS >1 in >1 body regions, defining multisystem trauma) were compared with ANOVA or Chi-squared tests, as appropriate., Results: In total, 899 patients (.01% of NTDB) met study criteria. Median age was 41 years and most patients were female (n = 802, 89%). Penetrating trauma was the most common injury mechanism (n = 395, 44%), followed by blunt trauma (n = 369, 41%) and burns (n = 135, 15%). Median ISS was higher after blunt trauma than penetrating trauma or burns (10 vs 5 vs 4, P < .001). Laceration repair/mastotomy was the most common procedure among penetrating (n = 354, 90%) and blunt (n = 265, 72%) trauma patients, while mastectomy was the most common after burns (n = 126, 93%). Breast procedures varied significantly by mechanism (P < .001)., Conclusion: Breast injuries requiring surgery are uncommon. Most occur following penetrating trauma, although injury severity is highest after blunt trauma and mortality is highest after burns. Procedure type, injury severity, and outcomes varied significantly by mechanism of injury, implying that breast trauma should be considered within the context of injury mechanism. These findings may assist with prognostication after breast trauma necessitating surgical intervention.

Purpose: Pseudoaneurysms (PSA) can occur following high-grade solid organ injury. PSA natural history is unclear but risk for spontaneous rupture and exsanguination exist. The yield of delayed CT Angiography (dCTA) for PSA diagnosis is not well delineated and optimal timing is undefined. The study objective was definition of dCTA utility in diagnosing and triggering intervention for PSA after high-grade blunt solid organ injury., Methods: All blunt trauma patients arriving to our ACS-verified Level 1 trauma center with AAST grade ≥ III liver, spleen, and/or kidney injury were included in this retrospective observational study (01/2017-10/2021). Exclusions were age < 18 year, transfers in, death < 48 h, and immediate nephrectomy/splenectomy. dCTA performance was not protocolized and pursued at attending surgeon discretion. Demographics, clinical/injury data, and outcomes were collected. Primary outcome was dCTA-triggered intervention. Statistical testing with ANOVA/Chi squared compared outcomes by type of solid organ., Results: 349 blunt trauma patients with 395 high-grade solid organ injuries met study criteria. Median AAST grade of solid organ injury was 3 [3-4]. dCTA for PSA screening was pursued in 175 patients (44%), typically on hospital day 4 [3-7]. dCTA identified vascular lesions in 16 spleen, 10 liver, and 6 kidney injuries. dCTA triggered intervention in 24% of spleen, 13% of kidney, and 9% of liver injured patients who were screened, for an overall yield of 14%. Intervention was typically AE (n = 23, 92%), although two splenic PSA necessitated splenectomy., Conclusion: Delayed CTA for PSA screening after high-grade blunt solid organ injury was performed in half of eligible patients. dCTA identified numerous vascular lesions requiring endovascular or surgical intervention, with highest yield for splenic injuries. We recommend consideration of universal screening of high-grade blunt solid organ injuries with delayed abdominal CTA to avoid missing PSA., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Purpose: Unlike adults, less is known of the etiology and risk factors for blunt cardiac injury (BCI) in children. Identifying risk factors for BCI in pediatric patients will allow for more specific screening practices following blunt trauma., Methods: A retrospective review was performed using the Trauma Quality Improvement Program (TQIP) database from 2017 to 2019. All patients ≤ 16 years injured following blunt trauma were included. Demographics, mechanism, associated injuries, injury severity, and outcomes were collected. Univariate and multivariate regression was used to determine specific risk factors for BCI., Results: Of 266,045 pediatric patients included in the analysis, the incidence of BCI was less than 0.2%. The all-cause mortality seen in patients with BCI was 26%. Motor-vehicle collisions (MVCs) were the most common mechanism, although no association with seatbelt use was seen in adolescents (p = 0.158). The strongest independent risk factors for BCI were pulmonary contusions (OR 15.4, p < 0.001) and hemothorax (OR 8.9, p < 0.001)., Conclusions: Following trauma, the presence of pulmonary contusions or hemothorax should trigger additional screening investigations specific for BCI in pediatric patients., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: There may be an association between violence and methamphetamine use. We hypothesized that trauma patients screening positive for methamphetamines are more likely to present after penetrating trauma and have increased mortality., Methods: The 2017-2019 TQIP was used to 1:2 match methamphetamine (meth + ) patients to patients testing negative for all drugs (meth - ). Patients with polysubstance/alcohol use were excluded. Bivariate and logistic regression analyses were performed., Results: The rate of methamphetamine use was 3.1 %. After matching, there was no difference in vitals, injury severity score, sex, and comorbidities between cohorts (all p  > 0.05). Compared to meth-, the meth+ group was more commonly sustained penetrating trauma (19.8 % vs. 9.2 %, p  < 0.001) with stab-wounds being the most common penetrating mechanism (10.5 % vs. 4.5 %, p  < 0.001). The meth + group more commonly underwent surgery immediately from the emergency department (ED) (20.3 % vs. 13.3 %, p < 0.001). The associated risk of death in the ED was higher for the meth + group (OR 2.77, CI 1.45-5.28, p  = 0.002), however, the risk was similar for patients that were admitted or received an operation ( p  = 0.065)., Conclusion: Trauma patients using methamphetamine more commonly presented after gun or knife violence and required immediate surgical intervention. They also have increased associated risk of death in the ED. Given these serious findings, a multidisciplinary approach in helping curtail the worsening epidemic of methamphetamine use appears warranted as it is related to penetrating trauma and outcomes., Level of Evidence: IV., Competing Interests: The authors report no conflicts of interest., (© 2023 The Authors.)

Introduction: Penetrating thoracic aortic injuries (PTAI) represent a rare form of thoracic trauma. Unlike blunt thoracic aortic injuries (BTAI), only scarce data, included in small case series, are currently available for PTAI. The purpose of this study was to describe injury patterns, surgical management, and outcomes of patients with PTAI and compare to those with BTAI., Materials and Methods: A 9-y retrospective cohort study (2007-2015) was conducted using the National Trauma Data Bank. Patient demographics, injury profile, procedures performed, and patient outcomes were compared between the PTAI and BTAI group., Results: A total of 2714 patients with PTAI and 14,037 patients with BTAI were identified. Compared to BTAI, PTAI patients were younger (28 versus 42 y, P < 0.001), more often male (89.1% versus 71.7%, P < 0.001), and more likely to arrive without signs of life (27.6% versus 7.5%, P < 0.001). PTAI patients had less associated injuries, overall, compared to those with BTAI; however, were more likely to have injuries to the esophagus, diaphragm, and heart. Patients with PTAI were less likely to undergo endovascular (5.8% versus 30.5%, P < 0.001) or open surgical repair (3.0% versus 4.2%, P < 0.001) compared to BTAI. While the large majority of PTAI patients expired before their hospital arrival or in the emergency department, the in-hospital mortality rate among those who survivedemergency department stay was 43.1%., Conclusions: Most patients with PTAI present to the hospital without any signs of life, and their overall mortality rate is extremely high. Only a small portion of PTAI patients who survived the initial resuscitation period underwent surgical interventions for thoracic aortic injuries. Further studies are still warranted to clarify the indications and types of surgical interventions for PTAI., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: Prehospital trauma team activation (TTA) criteria allow for early identification of severely injured trauma patients. Although most TTA criteria are objective, one TTA criterion is subjective: emergency provider discretion. The study objective was to define the ability of emergency department physician and nurse discretion to accurately perform prehospital triage of high risk trauma patients., Methods: All highest level TTAs arriving to our American College of Surgeons (ACS)-verified Level 1 trauma center (06/2015-08/2020) were included. Exclusions were undocumented prehospital vitals or discharge disposition. At our institution, TTAs are triggered for standard ACS TTA criteria and age > 70 with traumatic mechanism other than ground level fall. Patients meeting ≥ 1 criterion apart from "Emergency Provider Discretion" were defined as Standard TTAs and patients meeting only "Emergency Provider Discretion" were defined as Discretion TTAs. Univariable/multivariable analyses compared injury data and outcomes., Results: 4540 patients met inclusion/exclusion criteria: 3330 (73%) Standard TTAs and 1210 (27%) Discretion TTAs. Discretion TTAs were younger (34 vs. 37 years, p < 0.001) and more frequently injured by penetrating trauma (38% vs. 33%, p = 0.008), particularly stab wounds (64% vs. 29%). Overtriage rates were comparable after Discretion vs. Standard TTAs (33% vs. 31%, p = 0.141). Blood transfusion < 4 h (31% vs. 32%, p = 0.503) and ICU admission ≥ 3 days (25% vs. 27%, p = 0.058) were comparable between groups. Discretion TTA was independently associated with increased need for emergent surgery (OR 1.316, p = 0.005)., Conclusions: Emergency provider discretion accurately identifies major trauma, with comparable rates of overtriage as standard TTA criteria. Discretion TTAs were as likely as Standard TTAs to require early blood transfusion and prolonged ICU stay. After controlling for confounders, Discretion TTAs were significantly more likely to require emergent surgical intervention. Emergency provider discretion should be recognized as a valid method of identifying major trauma patients at high risk of need for intervention., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background: Obesity is associated with adverse outcomes after major operations. The role of operative rib fixation (RF) in obese patients with flail chest is not clear. The presence of other associated injuries may complicate the interpretation of outcomes. This study compared outcomes after RF to nonoperative management (NOM) in obese patients with isolated flail chest injury., Methods: Adult obese patients (BMI > 29.9) with flail chest were identified from the Trauma Quality Improvement Program (TQIP) database (2016-2018). Hospital transfers, death within 72 h, and extrathoracic injuries were excluded. RF patients were propensity score matched (1:2) to similar NOM patients. Multivariate regression identified independent factors predicting adverse outcomes., Results: Overall, 367 patients with isolated flail chest who underwent RF were matched with 734 in the NOM group. After matching, the mortality rate was significantly lower in the RF group (1.4% vs. 3.7%; p < 0.05). RF had longer HLOS (15.7 days vs. 12.8 days; p < 0.05) and ICU LOS (10.1 days vs. 8.6 days; p < 0.05), shorter ventilator days (9.2 days vs. 11.5 days; p < 0.05), and a higher rate of venous thromboembolism (7.1% vs. 3.5%, p < 0.05). On multivariate analysis, RF was associated with decreased mortality (OR 0.27; p < 0.05). Early RF (≤ 72 h) was associated with shorter ICU stay and mechanical ventilation., Conclusion: RF for isolated flail chest in obese patients is associated with decreased mortality and fewer ventilator days. When performed early, fixation decreases the need for prolonged ventilator use and ICU stay. A more aggressive VTE prophylaxis should be considered in patients undergoing RF., (© 2022. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Background: Optimal management of bile leaks (BLs) after severe liver injury is unknown. Study objectives were to define current practices in diagnosis and management of BL to determine which patients may benefit from endoscopic retrograde cholangiopancreatography (ERCP)., Methods: American Association for the Surgery of Trauma grade ≥III liver injuries from 10 North American trauma centers were included in this retrospective study (February 2011 to January 2021). Groups were defined as patients who developed BL versus those who did not. Subgroup analysis of BL patients was performed by management strategy. Bivariate analysis compared demographics, clinical/injury data, and outcomes. Receiver operating characteristic curves were performed to investigate the relationship between bilious drain output and ERCP., Results: A total of 2,225 patients with severe liver injury met the study criteria, with 108 BLs (5%). Bile leak patients had higher American Association for the Surgery of Trauma grade of liver injury ( p < 0.001) and were more likely to have been managed operatively from the outset (69% vs. 25%, p < 0.001). Bile leak was typically diagnosed on hospital day 6 [4-10] via surgical drain output (n = 37 [39%]) and computed tomography scan (n = 34 [36%]). On the BL diagnosis day, drain output was 270 [125-555] mL. Endoscopic retrograde cholangiopancreatography was the most frequent management strategy (n = 59 [55%]), although 32 patients (30%) were managed with external drains alone. Bile leak patients who underwent ERCP, surgery, or percutaneous transhepatic biliary drain had higher drain output than BL patients who were managed with external drains alone (320 [180-720] vs. 138 [85-330] mL, p = 0.010). Receiver operating characteristic curve analysis of BL demonstrated moderate accuracy (area under the receiver operating characteristic curve, 0.636) for ERCP at a cutoff point of 390 mL of bilious output on the day of diagnosis., Conclusion: Patients with BL >300 to 400 mL were most likely to undergo ERCP, percutaneous transhepatic biliary drain, or surgical management. Once external drainage of BL has been established, we recommend ERCP be reserved for patients with BL >300 mL of daily output. Prospective multicenter examination will be required to validate these retrospective data., Level of Evidence: Therapeutic and Care Management; Level IV., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Laparoscopic colectomy following traumatic injury has been increasingly utilized, but open resection remains the standard of care. Therefore, identifying appropriate candidates for laparoscopy is critically important. This study's purpose was to identify predictors of clinical outcomes in patients undergoing laparoscopic colectomy following traumatic injury., Methods: The National Trauma Databank was queried for patients undergoing laparoscopic colectomy within 48 hours of admission between 2007 and 2015. Patient, injury, and management characteristics were abstracted. Multivariable regression analyses adjusted for baseline characteristics and identified significant predictors of clinical outcomes., Results: A total of 581 patients satisfied inclusion criteria. The median age was 31 years, 465 (80%) were male, and 321 (55%) sustained penetrating injuries. An ostomy was created in 143 (25%) cases. Multivariable logistic regression showed that significant predictors of mortality included a falling mechanism (odds ratio [OR] 104.917, P = .002), admission tachycardia (OR 5.823, P = .001), admission hypotension (OR 26.089, P < .001), and multi-system injuries like head (OR 1.587, P = .008) and thoracic (OR 1.627, P = .001) injuries. Significant predictors of unplanned reoperation included transverse (OR 7.657, P = .033) and left (OR 17.155, P = .014) colon resections, obesity (OR 24.407, P = .016), and chronic respiratory disease (OR 32.963, P = .018). Ostomy creation was significantly associated with neither mortality nor unplanned reoperation., Conclusion: These data suggest that readily identifiable preoperative characteristics are significantly associated with differences in clinical outcomes. Additional research is required to determine if varying treatment based on these qualities can improve outcomes.

Little is known of the possible injuries caused by a fall through an open manhole, with the last study published 40 years ago. The purpose of this study was to examine the injuries, surgical interventions, and outcomes in patients suffering from a fall through an open manhole or storm drain. All patients injured by falling through open manholes (ICD codes E883.2, W17.1) from 2007 to 2017 were queried from the National Trauma Data Bank® (NTDB). Transferred patients were excluded. Studied variables included patient demographics, comorbidities, emergency room physiology, toxicology, injury severity and pattern, surgical interventions, and outcomes. A total of 388 patients met study criteria. The number of patients injured from open manholes per year ranged from 20 (0.004%) to 49 (0.005%). Major trauma (ISS ≥16) occurred in 37 patients (10%). Severe injuries (AIS ≥ 3) most frequently occurred in the lower extremities (13%), chest (12%), and head (8%). Major surgery was performed in 18 patients (5%) and five (1%) died. Despite an increase in reporting in recent years, the number of patients who suffer severe injuries following a fall through an open manhole is low. Nonetheless, these injuries are easily preventable and mandate an increased focus on manhole safety.

Purpose of Review: The relationship between trauma and the ongoing global coronavirus 2019 (COVID-19) pandemic is still largely unclear. This comprehensive review of recent studies examining overall trauma volumes, mechanisms of injury, and outcomes after trauma during the COVID-19 pandemic was performed to better understand the impact of the pandemic on trauma patients., Recent Findings: In the early stages of the pandemic, the overall volumes of patients seen in many major trauma centers had decreased; however, these rates largely returned to historical baselines after the cessation of stay-at-home orders. An increasing proportion of trauma patients were injured by penetrating mechanisms during the pandemic. Being a victim of interpersonal violence was an independent risk factor for COVID-19 infection. In two studies utilizing propensity score-matched analysis among trauma patients, COVID-19 infection was associated with a five- to sixfold increase in mortality risk as compared to uninfected patients., Summary: Consequences of the COVID-19 pandemic include increased financial stressors, job loss, mental illness, and illegal drug use, all of which are known risk factors for trauma. This is particularly true among vulnerable patient populations such as racial minority groups and low socioeconomic status patients. To lessen the impact of COVID-19 on trauma patients, increased awareness of the problem and heightened emphasis on injury prevention must be made., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Focused Assessment with Sonography for Trauma (FAST) has supplanted diagnostic peritoneal lavage (DPL) as the preferred bedside evaluation for traumatic hemoperitoneum. Diagnostic peritoneal aspiration (DPA) is a simpler, faster modification of DPL with an unclear role in contemporary practice. This study delineated modern roles for DPA and defined its diagnostic yield., Methods: All trauma patients presenting to our Level I center who underwent DPA were included (May 2015 to May 2020). Demographics, comorbidities, clinical/injury data, and outcomes were collected. The diagnostic yield and accuracy of DPA were calculated against the criterion standard of hemoperitoneum at exploratory laparotomy or computed tomography scan., Results: In total, 41 patients underwent DPA, typically after blunt trauma (n = 37, 90%). Patients were almost exclusively hypotensive (n = 20, 49%) or in arrest (n = 18, 44%). Most patients had an equivocal or negative FAST and hypotension or return of spontaneous circulation after resuscitative thoracotomy (n = 32, 78%); or had a positive FAST and known cirrhosis (n = 4, 10%). In two (5%) patients, one obese, the catheter failed to access the peritoneal cavity. Diagnostic peritoneal aspiration sensitivity, specificity, positive predictive value, and negative predictive value were 80%, 100%, 100%, and 90%, with an accuracy of 93%. One (2%) complication, a small bowel injury, occurred., Conclusion: Despite near ubiquitous FAST availability, DPA remains important in diagnosing or excluding hemoperitoneum with exceedingly low rates of failure and complications. Diagnostic peritoneal aspiration is most conclusive when positive, without false positives in this study. Diagnostic peritoneal aspiration was most used among blunt hypotensive or postarrest patients who had an equivocal or negative FAST, in whom the preliminary diagnosis of hemoperitoneum is a critically important decision making branch point., Level of Evidence: Diagnostic, level III., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Drug-specific agents for the reversal of direct oral anticoagulants (DOACs) were recently approved. We hypothesized that the approval of these reversal agents would lead improved outcomes for trauma patients taking DOACs., Methods: A multicenter, prospective (2015-2018), observational study of all adult trauma patients taking DOACs who were admitted to one of fifteen participating trauma centers was performed. The primary outcome was mortality., Results: For 606 trauma patients on DOACs, those reversed were older (78 vs. 74, p = 0.007), more severely injured (ISS: 16 vs. 5, p < 0.0001), had more severe head injuries (Head AIS: 2.9 vs. 1.3, p < 0.0001), and higher mortality (11% vs. 3%, p = 0.001). Patients who received drug-specific agents (idarucizumab, andexanet alfa) had higher mortality (30% vs. 8%, p = 0.04) than those reversed with factor concentrates. However, the low usage of drug-specific reversal agents limits our ability to assess their efficacy and safety., Conclusions: DOAC reversal was not independently associated with mortality. At present, the overall usage of drug-specific reversal agents is too sparing to meaningfully assess outcomes in trauma., Competing Interests: Declaration of competing interest There are no conflicts of interest to report., (Copyright © 2020. Published by Elsevier Inc.)

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: 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., (Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: There is a need for updated radiation dose estimates in pediatric fluoroscopy given the routine use of new dose-saving technologies and increased radiation safety awareness in pediatric imaging., Objective: To estimate effective doses for standardized pediatric upper gastrointestinal (UGI) examinations at our institute using direct dose measurement, as well as provide dose-area product (DAP) to effective dose conversion factors to be used for the estimation of UGI effective doses for boys and girls up to 10 years of age at other centers., Materials and Methods: Metal oxide semiconductor field-effect transistor (MOSFET) dosimeters were placed within four anthropomorphic phantoms representing children ≤10 years of age and exposed to mock UGI examinations using exposures much greater than used clinically to minimize measurement error. Measured effective dose was calculated using ICRP 103 weights and scaled to our institution's standardized clinical UGI (3.6-min fluoroscopy, four spot exposures and four examination beam projections) as determined from patient logs. Results were compared to Monte Carlo simulations and related to fluoroscope-displayed DAP., Results: Measured effective doses for standardized pediatric UGI examinations in our institute ranged from 0.35 to 0.79 mSv in girls and were 3-8% lower for boys. Simulation-derived and measured effective doses were in agreement (percentage differences <19%, T > 0.18). DAP-to-effective dose conversion factors ranged from 6.5 ×10(-4) mSv per Gy-cm(2) to 4.3 × 10(-3) mSv per Gy-cm(2) for girls and were similarly lower for boys., Conclusion: Using modern fluoroscopy equipment, the effective dose associated with the UGI examination in children ≤10 years at our institute is < 1 mSv. Estimations of effective dose associated with pediatric UGI examinations can be made for children up to the age of 10 using the DAP-normalized conversion factors provided in this study. These estimates can be further refined to reflect individual hospital examination protocols through the use of direct organ dose measurement using MOSFETs, which were shown to agree with Monte Carlo simulated doses.

When using ultrafast laser ablation in some orthopedic applications where precise cutting/drilling is required with minimal damage to collateral tissue, it is challenging to produce large-sized and deep holes using a tightly focused laser beam. The feasibility of producing deep, millimeter-size structures under different ablation strategies is investigated. X-ray computed microtomography was employed to analyze the morphology of these structures. Our results demonstrated the feasibility of producing holes with sizes required in clinical applications using concentric and helical ablation protocols.

Ultrashort pulsed lasers in bone ablation show promise for many orthopedic applications. To minimize collateral tissue damage and control the ablation process, the ablation threshold fluence must be well characterized. Using an amplified femtosecond laser (170 fs, 800 nm, 1 kHz), the ablation threshold on unaltered porcine cortical bone was measured using the D(2) method at multiple incident pulse numbers ranging from 25 to 1000 pulses per spot. The lowered threshold at greater pulse numbers indicated an incubation effect. Using a power law model, the incubation coefficient of unaltered porcine cortical bone was found to be 0.89 ± 0.03. Through extrapolation, the single-pulse ablation threshold was found to be 3.29 ± 0.14 J/cm(2).