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Background: This study updates the American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) for renal trauma using evidence-based criteria for bleeding control intervention., Methods: This was a secondary analysis of a multicenter retrospective study including patients with high-grade renal trauma from seven level 1 trauma centers from 2013 to 2018. All eligible patients were assigned new renal trauma grades based on revised criteria. The primary outcome used to measure injury severity was intervention for renal bleeding. Secondary outcomes included intervention for urinary extravasation, units of packed red blood cells transfused within 24 hours, and mortality. To test the revised grading system, we performed mixed-effect logistic regression adjusted for multiple baseline demographic and trauma covariates. We determined the area under the curve (AUC) to assess accuracy of predicting bleeding interventions from the revised grading system and compared this to 2018 AAST OIS., Results: Based on the 2018 OIS grading system, we included 549 patients with AAST grades III to V injuries and computed tomography scans (III, 52% [n = 284]; IV, 45% [n = 249]; and V, 3% [n = 16]). Among these patients, 89% experienced blunt injury (n = 491), and 12% (n = 64) underwent intervention for bleeding. After applying the revised grading criteria, 60% (n = 329) of patients were downgraded, and 4% (n = 23) were upgraded; 2.8% (n = 7) downgraded from grade V to IV, and 69.5% (n = 173) downgraded from grade IV to III. The revised renal trauma grading system demonstrated improved predictive ability for bleeding interventions (2018 AUC, 0.805; revised AUC, 0.883; p = 0.001) and number of units of packed red blood cells transfused. When we removed urinary injury from the revised system, there was no difference in its predictive ability for renal hemorrhage intervention., Conclusion: A revised renal trauma grading system better delineates the need for hemostatic interventions than the current AAST OIS renal trauma grading system., Level of Evidence: Diagnostic Test/Criteria; Level III., (Copyright © 2024 American Association for the Surgery of Trauma.)

Background: Risk of venous thromboembolism (VTE) in many trauma patients extends beyond hospitalization, but there is a paucity of evidence to guide the use of post-discharge prophylaxis (PDP)., Methods: A retrospective cohort study of trauma patients deemed moderate-to-high risk for VTE (risk assessment profile score [RAP] ≥5) who were prescribed PDP based on an internal clinical guideline assessing injury pattern and mobility status. PDP patients were compared with those that did not receive post-discharge prophylaxis (NPDP)., Results: 1512 patients were included. PDP group had higher mean RAP score (7.3 vs. 6.4, p ​< ​0.001), more likely to have a complex orthopedic fracture and underwent a longer median hospital (4.7 vs. 2.9 days, p ​< ​0.001). No difference between groups in 90-day VTE (11 [1.5 ​%] (PDP) vs. 8 [1.0 ​%] (NPDP), p ​= ​0.50), clinically relevant bleeding (p ​= ​0.58), or readmission (p ​= ​0.46)., Conclusions: VTE incidence, clinically relevant bleeding, and readmission 90-days after hospital discharge were low and similar between PDP and NPDP groups. PDP prescribed in a presumably higher VTE risk trauma population may mitigate the long-term risk of VTE., Competing Interests: Declaration of competing interest We declare no competing interests., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Management of below-knee DVT (BKDVT) in trauma patients is uncertain. We hypothesized that BKDVT can be managed with observation only., Methods: Secondary analysis on trauma inpatients March 2017-September 2019 with risk assessment profile ≥5. Management of BKDVT included observation with ultrasound. BKDVT was compared to above-knee DVT (AKDVT), and BKDVT with progression to AKDVT/PE compared to no progression., Results: Of 1988 patients, 136 (6.8%) BKDVT and 23 (1.2%) AKDVT. 7 (6.9%) BKDVT progressed to AKDVT/PE. 6.9% had BKDVT progression, associated with higher ISS (36.7 vs 21.6, p ​= ​0.005), longer prophylaxis delay (121 vs 45 ​h, p ​= ​0.02) and longer hospital LOS (25.6 vs 7.8, p ​= ​0.01). None experienced post-thrombotic syndrome., Conclusion: Majority of BKDVT in hospitalized trauma patients did not progress to AKDVT. Observation for progression, rather than treatment, was not associated with increased PE risk or thrombotic sequelae. Observation with serial ultrasound may serve as a practical alternative to anticoagulation in trauma patients with BKDVT., Competing Interests: Declaration of competing interest None of the authors have anything to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: The modified Brain Injury Guidelines (mBIG) support a subset of low-risk patients to be managed without repeat head computed tomography (RHCT), neurosurgical consult (NSC), or hospital transfer/admission. This pilot aimed to assess mBIG implementation at a single facility to inform future systemwide implementation., Methods: Single cohort pilot trial at a level I trauma center, December 2021-August 2022. Adult patients included if tICH meeting BIG 1 or 2 criteria. BIG 3 patients excluded., Results: No patients required neurosurgical intervention. 72 RHCT and 83 NSC were prevented. 21 isolated BIG 1 were safely discharged home from the ED. No hospital readmissions for tICH. Protocol adherence rate was 92%., Conclusion: Implementation of the mBIG at a single trauma center is feasible and optimizes resource utilization. This pilot study will inform an implementation trial of the mBIG across a 24-hospital integrated health system., Competing Interests: Declaration of competing interest None of the authors have anything to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To study the prevalence and management of shattered kidney and to evaluate if the new description of "loss of identifiable renal anatomy" in the 2018 American Association for the Surgery of Trauma (AAST) organ injury scale (OIS) would improve the ability to predict bleeding control interventions., Methods: We used high-grade renal trauma data from 21 Level-1 trauma centers from 2013 to 2018. Initial CT scans were reviewed to identify shattered kidneys, defined as a kidney having ≥3 parenchymal fragments displaced by blood or fluid on cross-sectional imaging. We further categorized patients with shattered kidney in two models based on loss of identifiable renal parenchymal anatomy and presence or absence of vascular contrast extravasation (VCE). Bleeding interventions were compared between the groups., Results: From 861 high-grade renal trauma patients, 41 (4.8%) had shattered kidney injury. 25 (61%) underwent a bleeding control intervention including 18 (43.9%) nephrectomies and 11 (26.8%) angioembolizations. 18 (41%) had shattered kidney with "loss of identifiable parenchymal renal anatomy" per 2018 AAST OIS (model-1). 28 (68.3%) had concurrent VCE (model-2). Model-2 had a statistically significant improvement in area under the curve over model-1 in predicting bleeding interventions (0.75 vs 0.72; P = .01)., Conclusion: Shattered kidney is associated with high rates of active bleeding, urinary extravasation, and interventions including nephrectomy. The definition of shattered kidney is vague and subjective and our definition might be simpler and more reproducible. Loss of identifiable renal anatomy per the 2018 AAST OIS did not provide better distinction for bleeding control interventions over presence of VCE., Competing Interests: Declaration of Competing Interest None of the authors have any conflicts of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: To investigate management trends for American Association for the Surgery of Trauma (AAST) grade V renal trauma with focus on non-operative management., Methods: We used prospectively collected data as part of the Multi-institutional Genito-Urinary Trauma Study (MiGUTS). We included patients with grade V renal trauma according to the AAST Injury Scoring Scale 2018 update. All cases submitted by participating centers with radiology images available were independently reviewed to confirm renal trauma grade. Management was classified as expectant, conservative (minimally invasive, endoscopic or percutaneous procedures), or operative (renal-related surgery)., Results: Eighty patients were included, 25 of whom had complete imaging and had independent confirmation of AAST grade V renal trauma. Median age was 35 years (Interquartile range (IQR) 25-50) and 23 (92%) had blunt trauma. Ten patients (40%) were managed operatively with nephrectomy. Conservative management was used in nine patients (36%) of which six received angioembolization and three had a stent or drainage tube placed. Expectant management was followed in six (24%) patients. Transfusion requirements were progressively higher with groups requiring more aggressive treatment, and injury characteristics differed significantly across management groups in terms of hematoma size and laceration size. Vascular contrast extravasation was more likely in operatively managed patients though a statistically significant association was not found., Conclusion: Successful use of nonoperative management for grade V injuries is used for a substantial subset of patients. Lower transfusion requirement and less severe injury radiologic phenotype appear to be important characteristics delineating this group., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Assessment for risks associated with acute stable COVID-19 is important to optimize clinical trial enrollment and target patients for scarce therapeutics. To assess whether healthcare system engagement location is an independent predictor of outcomes we performed a secondary analysis of the ACTIV-4B Outpatient Thrombosis Prevention trial., Methods: A secondary analysis of the ACTIV-4B trial that was conducted at 52 US sites between September 2020 and August 2021. Participants were enrolled through acute unscheduled episodic care (AUEC) enrollment location (emergency department, or urgent care clinic visit) compared to minimal contact (MC) enrollment (electronic contact from test center lists of positive patients).We report the primary composite outcome of cardiopulmonary hospitalizations, symptomatic venous thromboembolism, myocardial infarction, stroke, transient ischemic attack, systemic arterial thromboembolism, or death among stable outpatients stratified by enrollment setting, AUEC versus MC. A propensity score for AUEC enrollment was created, and Cox proportional hazards regression with inverse probability weighting (IPW) was used to compare the primary outcome by enrollment location., Results: Among the 657 ACTIV-4B patients randomized, 533 (81.1%) with known enrollment setting data were included in this analysis, 227 from AUEC settings and 306 from MC settings. In a multivariate logistic regression model, time from COVID test, age, Black race, Hispanic ethnicity, and body mass index were associated with AUEC enrollment. Irrespective of trial treatment allocation, patients enrolled at an AUEC setting were 10-times more likely to suffer from the adjudicated primary outcome, 7.9% vs. 0.7%; p < 0.001, compared with patients enrolled at a MC setting. Upon Cox regression analysis adjustment patients enrolled at an AUEC setting remained at significant risk of the primary composite outcome, HR 3.40 (95% CI 1.46, 7.94)., Conclusions: Patients with clinically stable COVID-19 presenting to an AUEC enrollment setting represent a population at increased risk of arterial and venous thrombosis complications, hospitalization for cardiopulmonary events, or death, when adjusted for other risk factors, compared with patients enrolled at a MC setting. Future outpatient therapeutic trials and clinical therapeutic delivery programs of clinically stable COVID-19 patients may focus on inclusion of higher-risk patient populations from AUEC engagement locations., Trial Registration: ClinicalTrials.gov Identifier: NCT04498273., (© 2023. The Author(s).)

Background: Needle thoracostomy (NT) is the first-line intervention for tension pneumothorax in the prehospital setting. This study examined the effect of ATLS curriculum and EMS protocol changes on patient selection and successful performance of the procedure., Methods: This is a retrospective chart review of all patients presenting to a Level One Trauma Center from 2015 to 2020 after undergoing prehospital NT., Results: Lateral NT placement increased significantly from 5.1% to 38.9%. Proper patient selection, defined as presence decompensated shock, respiratory distress, and diminished breath sounds increased from 23.1% to 27.8%. There was no difference in radiographic confirmation of the catheter in the pleural space. Iatrogenic injury rates decreased slightly from 28.2% to 16.7%., Conclusions: Protocol and curriculum changes have fallen short in yielding improved NT success rates or patient selection. Continued development of EMS education on the performance of NT is indicated., Competing Interests: Declaration of competing interest None of the authors have anything to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: Adequate pain control is critical to the management and recovery of acutely injured patients. Opioids are associated with various adverse effects, and drug overdose is the leading cause of injury-related death in the United States. We hypothesized that a multimodal pain management protocol would reduce opioid use while still optimizing pain control., Methods: The study included the preanalysis (August 2017-September 2018) and postanalysis (October 2018-August 2019) of a multimodal pain management strategy implemented in hospitalized adult patients admitted to the trauma service at a single American College of Surgeons-verified level-1 trauma center. Patients less than 18 y of age, pregnant patients, or imprisoned patients were excluded. The primary endpoint was opioid prescription on discharge (morphine milligram equivalent [MME]). The secondary endpoints included inpatient MMEs, nonopioid adjunct use, and pain scores. Subgroup analysis evaluating opioid use based on Injury Severity Score groups (mild, moderate, or severe) and by the Abbreviated Injury Scale body region was performed., Results: There were 1755 patients in the PRE group and 1723 patients in the POST group. MMEs prescribed on discharge decreased from median 15 (interquartile range: 37.5) to 1.2 (interquartile range: 22.5) (P < 0.001). More patients in the POST group were discharged opioid-free (44% versus 37%, P < 0.001). There was a significant increase in the use of all nonopioid pain medications. Pain scores did not change. Subgroup analysis revealed a significant decrease in discharge MMEs in mild and moderate Injury Severity Score groups and in all injured body regions except the chest., Conclusions: The implementation of a multimodal pain management protocol in trauma patients targeting scheduled nonopioid medications and patient education is feasible and is associated with reduced opioid amount prescribed on discharge, without compromising pain control., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Little is known about patient characteristics predicting postdischarge pleural space complications (PDPSCs) after thoracic trauma. We sought to analyze the patient population who required unplanned hospital readmission for PDPSC., Methods: Retrospective review of adult patients admitted to a Level I Trauma Center with a chest Abbreviated Injury Scale (AIS) score of 2 or greater between January 2015 and August 2020. Those readmitted within 30 days of index hospitalization discharge for PDPSC were compared with those not readmitted. Demographics, injury characteristics, surgical procedures, imaging, and readmission data were retrieved., Results: Out of 17,192 trauma evaluations, 3,412 (19.8%) suffered a chest AIS score of 2 or greater injury and 155 experienced an unplanned 30-day hospital readmission. Of those, 49 (1.4%) were readmitted for the management of PDPSC (readmit PDPSC) and were compared with patients who were not readmitted (no readmit, n = 3,257). The readmit PDPSC group was significantly older age, heavier, comprised of fewer men, and suffered a higher mean chest AIS score. The readmit PDPSC group had a significantly higher incidence of rib fractures, flail chest, pneumothorax, hemothorax, scapula fractures, and a higher rate of tube thoracostomy placement during index admission. The discharge chest X-ray in the readmit PDPSC group demonstrated a pleural space abnormality in 36 (73%) of patients. Mean time to readmission was 10.2 (7.2) days, and hospital length of stay on readmission was 5.8 (3.7) days. Pleural effusion was the most common readmission diagnosis (44 [90%]), and 42 (86%) required tube thoracostomy., Conclusion: We describe the subset of chest wall injury patients who require hospital readmission for PDPSC. Characteristics from index hospitalization associated with PDPSC include older age, female sex, heavier weight, presence of rib fractures, pleural space abnormality, scapular fracture, and chest tube placement. Further studies are needed to characterize this at-risk chest wall injury population, and to determine what interventions can facilitate outpatient management of postdischarge pleural space complications and mitigate readmission risk., Level of Evidence: Prognostic and epidemiologic, Level IV; Care management, Level V., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Acutely ill inpatients with COVID-19 typically receive antithrombotic therapy, although the risks and benefits of this intervention among outpatients with COVID-19 have not been established., Objective: To assess whether anticoagulant or antiplatelet therapy can safely reduce major adverse cardiopulmonary outcomes among symptomatic but clinically stable outpatients with COVID-19., Design, Setting, and Participants: The ACTIV-4B Outpatient Thrombosis Prevention Trial was designed as a minimal-contact, adaptive, randomized, double-blind, placebo-controlled trial to compare anticoagulant and antiplatelet therapy among 7000 symptomatic but clinically stable outpatients with COVID-19. The trial was conducted at 52 US sites between September 2020 and June 2021; final follow-up was August 5, 2021. Prior to initiating treatment, participants were required to have platelet count greater than 100 000/mm3 and estimated glomerular filtration rate greater than 30 mL/min/1.73 m2., Interventions: Random allocation in a 1:1:1:1 ratio to aspirin (81 mg orally once daily; n = 164), prophylactic-dose apixaban (2.5 mg orally twice daily; n = 165), therapeutic-dose apixaban (5 mg orally twice daily; n = 164), or placebo (n = 164) for 45 days., Main Outcomes and Measures: The primary end point was a composite of all-cause mortality, symptomatic venous or arterial thromboembolism, myocardial infarction, stroke, or hospitalization for cardiovascular or pulmonary cause. The primary analyses for efficacy and bleeding events were limited to participants who took at least 1 dose of trial medication., Results: On June 18, 2021, the trial data and safety monitoring board recommended early termination because of lower than anticipated event rates; at that time, 657 symptomatic outpatients with COVID-19 had been randomized (median age, 54 years [IQR, 46-59]; 59% women). The median times from diagnosis to randomization and from randomization to initiation of study treatment were 7 days and 3 days, respectively. Twenty-two randomized participants (3.3%) were hospitalized for COVID-19 prior to initiating treatment. Among the 558 patients who initiated treatment, the adjudicated primary composite end point occurred in 1 patient (0.7%) in the aspirin group, 1 patient (0.7%) in the 2.5-mg apixaban group, 2 patients (1.4%) in the 5-mg apixaban group, and 1 patient (0.7%) in the placebo group. The risk differences compared with placebo for the primary end point were 0.0% (95% CI not calculable) in the aspirin group, 0.7% (95% CI, -2.1% to 4.1%) in the 2.5-mg apixaban group, and 1.4% (95% CI, -1.5% to 5.0%) in the 5-mg apixaban group. Risk differences compared with placebo for bleeding events were 2.0% (95% CI, -2.7% to 6.8%), 4.5% (95% CI, -0.7% to 10.2%), and 6.9% (95% CI, 1.4% to 12.9%) among participants who initiated therapy in the aspirin, prophylactic apixaban, and therapeutic apixaban groups, respectively, although none were major. Findings inclusive of all randomized patients were similar., Conclusions and Relevance: Among symptomatic clinically stable outpatients with COVID-19, treatment with aspirin or apixaban compared with placebo did not reduce the rate of a composite clinical outcome. However, the study was terminated after enrollment of 9% of participants because of an event rate lower than anticipated., Trial Registration: ClinicalTrials.gov Identifier: NCT04498273.

Objective: To test the hypothesis that undergoing nephrectomy after high-grade renal trauma is associated with higher mortality rates., Methods: We gathered data from 21 Level-1 trauma centers through the Multi-institutional Genito-Urinary Trauma Study. Patients with high-grade renal trauma were included. We assessed the association between nephrectomy and mortality in all patients and in subgroups of patients after excluding those who died within 24 hours of hospital arrival and those with GCS≤8. We controlled for age, injury severity score (ISS), shock (systolic blood pressure <90 mmHg), and Glasgow Coma Scale (GCS)., Results: A total of 1181 high-grade renal trauma patients were included. Median age was 31 and trauma mechanism was blunt in 78%. Injuries were graded as III, IV, and V in 55%, 34%, and 11%, respectively. There were 96 (8%) mortalities and 129 (11%) nephrectomies. Mortality was higher in the nephrectomy group (21.7% vs 6.5%, P <.001). Those who died were older, had higher ISS, lower GCS, and higher rates of shock. After adjusting for patient and injury characteristics nephrectomy was still associated with higher risk of death (RR: 2.12, 95% CI: 1.26-2.55)., Conclusion: Nephrectomy was associated with higher mortality in the acute trauma setting even when controlling for shock, overall injury severity, and head injury. These results may have implications in decision making in acute trauma management for patients not in extremis from renal hemorrhage., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Prospective studies of surgical stabilization of rib fractures (SSRF) have excluded elderly patients, and no study has exclusively addressed the ≥80-year-old subgroup. We hypothesized that SSRF is associated with decreased mortality in trauma patients 80 years or older., Methods: Multicenter retrospective cohort study involving eight centers. Patients who underwent SSRF from 2015 to 2020 were matched to controls by study center, age, injury severity score, and presence of intracranial hemorrhage. Patients with chest Abbreviated Injury Scale score less than 3, head Abbreviated Injury Scale score greater than 2, death within 24 hours, and desire for no escalation of care were excluded. A subgroup analysis compared early (0-2 days postinjury) to late (3-7 days postinjury) SSRF. Poisson regression accounting for clustered data by center calculated the relative risk (RR) of the primary outcome of mortality for SSRF versus nonoperative management., Results: Of 360 patients, 133 (36.9%) underwent SSRF. Compared with nonoperative patients, SSRF patients were more severely injured and more likely to receive locoregional analgesia. There were 31 hospital deaths among the entire sample (8.6%). Multivariable regression demonstrated a decreased risk of mortality for the SSRF group, as compared with the nonoperative group (RR, 0.41; 95% confidence interval, 0.24-0.69; p < 0.01). However, SSRF patients were more likely to develop pneumonia, and had an increased duration of both mechanical ventilation and intensive care unit stay. There were no differences in discharge destination, although the SSRF group was less likely to be discharged on narcotics (RR, 0.66; 95% confidence interval, 0.48-0.90; p = 0.01). There was no difference in adjusted mortality between the early and late SSRF subgroups., Conclusion: Patients selected for SSRF were substantially more injured versus those managed nonoperatively. Despite this, SSRF was independently associated with decreased mortality. With careful patient selection, SSRF may be considered a viable treatment option in octogenarian/nonagenarians., Level of Evidence: Therapeutic, Level IV., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Although guidelines are established for the prevention and management of venous thromboembolism (VTE) in trauma, no consensus exists regarding protocols for the diagnostic approach. We hypothesized that at-risk trauma patients who undergo duplex ultrasound (DUS) surveillance for lower extremity deep venous thrombosis (DVT) will have a lower rate of symptomatic or fatal pulmonary embolism (PE) than those who do not undergo routine surveillance., Methods: Prospective, randomized trial between March 2017 and September 2019 of trauma patients admitted to a single, level 1 trauma center, with a risk assessment profile score of ≥5. Patients were randomized to receive either bilateral lower extremity DUS surveillance on days 1, 3, and 7 and weekly during hospitalization ultrasound group (US) or no surveillance no ultrasound group (NoUS). Rates of in-hospital and 90-day DVT and PE were reported as was DVT propagation and all-cause mortality. Standard care for the prevention and management of VTE per established institutional protocols was provided to all patients., Results: A total of 3,236 trauma service admissions were screened, and 1,989 moderate- and high-risk patients were randomized (US, 995; NoUS, 994). The mean ± SD age was 62 ± 20.1 years, Injury Severity Score was 14 ± 9.7, risk assessment profile was 7.1 ± 2.4, and 97% suffered blunt trauma. There was no difference in demographics or VTE risk factors between the groups. There were significantly fewer in-hospital PE in the US group than the NoUS group (1 [0.1%] vs. 9 [0.9%], p = 0.01). The US group experienced more in-hospital below-knee DVTs (124 [12.5%] vs. 8 [0.8%], p < 0.001) and above-knee DVTs (19 [1.9%] vs. 8 [0.8%], p = 0.05). There was no difference in 90-day PE or DVT, or overall mortality., Conclusion: The implementation of a selective routine DUS protocol was associated with significantly fewer in-hospital PE. More DVTs were identified with routine screening; however, surveillance bias appears to exist primarily with distal DVT. Larger trials are needed to further characterize the relationship between routine DUS screening and VTE outcomes in the high-risk trauma population., Level of Evidence: Therapeutic/care management, level II., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Current decision algorithms involving surgical stabilization of rib fractures (SSRF) do not consider either specific fracture locations or other chest wall bony injuries. Our objective was to characterize the impact of scapula fractures on morbidity among patients who underwent fixation of sub-scapular rib fractures. We hypothesized that an ipsilateral scapula fracture was associated with poor acute and long-term outcomes., Methods: Retrospective review of two institutions' prospectively maintained SSRF databases (October 2010 to January 2019). Patients who underwent repair of ≥ 1 sub-scapular rib fracture were included. Patients were grouped by the presence of an ipsilateral scapula fracture. Outcomes were acute SSRF complications, long-term rib implant removal, and quality of life via phone survey., Results: A total of 144 patients were analyzed; 53 (36.8%) had an ipsilateral scapula fracture. Patients with a scapula fracture had a higher injury severity score (p = 0.02), degree of pulmonary contusion (p < 0.01), and RibScore (p < 0.01). The overall incidence of both acute re-operation (n = 4, 2.8%) and long-term implant removal (n = 5, 3.8%) following SSRF was low and did not vary by the presence of a scapula fracture. Only twenty-one patients completed phone questionnaires a median of 38 months after SSRF; both shoulder and rib outcomes were excellent and did not vary by the presence of a scapula fracture., Conclusion: Ipsilateral scapula fractures are common in patients who undergo surgical stabilization of sub-scapular rib fractures. Despite higher injury severity, patients with an ipsilateral scapula fracture did not incur worse outcomes.

Objective: To find clinical or radiographic factors that are associated with angioembolization failure after high-grade renal trauma., Material and Methods: Patients were selected from the Multi-institutional Genito-Urinary Trauma Study. Included were patients who initially received renal angioembolization after high-grade renal trauma (AAST grades III-V). This cohort was dichotomized into successful or failed angioembolization. Angioembolization was considered a failure if angioembolization was followed by repeat angiography and/or an exploratory laparotomy., Results: A total of 67 patients underwent management initially with angioembolization, with failure in 18 (27%) patients. Those with failed angioembolization had a larger proportion ofgrade IV (72% vs 53%) and grade V (22% vs 12%) renal injuries. A total of 53 patients underwent renal angioembolization and had initial radiographic data for review, with failure in 13 cases. The failed renal angioembolization group had larger perirenal hematoma sizes on the initial trauma scan., Conclusion: Angioembolization after high-grade renal trauma failed in 27% of patients. Failed angioembolization was associated with higher injury grade and a larger perirenal hematoma. Likely these characteristics are associated with high-grade renal trauma that may be less amenable to successful treatment after a single renal angioembolization., (Copyright © 2020 Elsevier Inc. All rights reserved.)

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

Objective: The aim of the study was to compare the relative predictive value of Marshall Classification System and Rotterdam scores on long-term rehabilitation outcomes. This study hypothesized that Rotterdam would outperform Marshall Classification System., Design: The study used an observational cohort design with a consecutive sample of 88 participants (25 females, mean age = 42.0 [SD = 21.3]) with moderate to severe traumatic brain injury who were admitted to trauma service with subsequent transfer to the rehabilitation unit between February 2009 and July 2011 and who had clearly readable computed tomography scans. Twenty-three participants did not return for the 9-mo postdischarge follow-up. Day-of-injury computed tomography images were scored using both Marshall Classification System and Rotterdam criteria by two independent raters, blind to outcomes. Functional outcomes were measured by length of stay in rehabilitation and the cognitive and motor subscales of the Functional Independence Measure at rehabilitation discharge and 9-mo postdischarge follow-up., Results: Neither Marshall Classification System nor Rotterdam scales as a whole significantly predicted Functional Independence Measure motor or cognitive outcomes at discharge or 9-mo follow-up. Both scales, however, predicted length of stay in rehabilitation. Specific Marshall scores (3 and 6) and Rotterdam scores (5 and 6) significantly predicted subacute outcomes such as Functional Independence Measure cognitive at discharge from rehabilitation and length of stay., Conclusions: Marshall Classification System and Rotterdam scales may have limited utility in predicting long-term functional outcome, but specific Marshall and Rotterdam scores, primarily linked to increased severity and intracranial pressure, may predict subacute outcomes.

Background: The Charlson and Elixhauser comorbidity indices are mortality predictors often used in clinical, administrative, and research applications. The Intermountain Mortality Risk Scores (IMRS) are validated mortality predictors that use all factors from the complete blood count and basic metabolic profile. How IMRS, Charlson, and Elixhauser relate to each other is unknown., Methods: All inpatient admissions except obstetric patients at Intermountain Healthcare's 21 adult care hospitals from 2010-2014 (N = 197,680) were examined in a observational cohort study. The most recent admission was a patient's index encounter. Follow-up to 2018 used hospital death records, Utah death certificates, and the Social Security death master file. Three Charlson versions, 8 Elixhauser versions, and 3 IMRS formulations were evaluated in Cox regression and the one of each that was most predictive was used in dual risk score mortality analyses (in-hospital, 30-day, 1-year, and 5-year mortality)., Results: Indices with the strongest mortality associations and selected for dual score study were the age-adjusted Charlson, the van Walraven version of the acute Elixhauser, and the 1-year IMRS. For in-hospital mortality, Charlson (c = 0.719; HR = 4.75, 95% CI = 4.45, 5.07), Elixhauser (c = 0.783; HR = 5.79, CI = 5.41, 6.19), and IMRS (c = 0.821; HR = 17.95, CI = 15.90, 20.26) were significant predictors (p<0.001) in univariate analyses. Dual score analysis of Charlson (HR = 1.79, CI = 1.66, 1.92) with IMRS (HR = 13.10, CI = 11.53, 14.87) and of Elixhauser (HR = 3.00, CI = 2.80, 3.21) with IMRS (HR = 11.42, CI = 10.09, 12.92) found significance for both scores in each model. Results were similar for 30-day, 1-year, and 5-year mortality., Conclusions: IMRS provided the strongest ability to predict mortality, adding to and attenuating the predictive ability of the Charlson and Elixhauser indices whose mortality associations remained statistically significant. IMRS uses common, standardized, objective laboratory data and should be further evaluated for integration into mortality risk evaluations., Competing Interests: BDH and JLA are inventors of IMRS and other clinical decision tools that are licensed to CareCentra and Alluceo. BDH is the PI of grants funded by Intermountain Healthcare’s Foundry innovation program, the Intermountain Research and Medical Foundation, CareCentra, GlaxoSmithKline, and AstraZeneca for the development and/or clinical implementation of clinical decision tools. No other potential conflicts of interest exist. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: In 2018, the American Association for the Surgery of Trauma (AAST) published revisions to the renal injury grading system to reflect the increased reliance on computed tomography scans and non-operative management of high-grade renal trauma (HGRT). We aimed to evaluate how these revisions will change the grading of HGRT and if it outperforms the original 1989 grading in predicting bleeding control interventions., Methods: Data on HGRT were collected from 14 Level-1 trauma centers from 2014 to 2017. Patients with initial computed tomography scans were included. Two radiologists reviewed the scans to regrade the injuries according to the 1989 and 2018 AAST grading systems. Descriptive statistics were used to assess grade reclassifications. Mixed-effect multivariable logistic regression was used to measure the predictive ability of each grading system. The areas under the curves were compared., Results: Of the 322 injuries included, 27.0% were upgraded, 3.4% were downgraded, and 69.5% remained unchanged. Of the injuries graded as III or lower using the 1989 AAST, 33.5% were upgraded to grade IV using the 2018 AAST. Of the grade V injuries, 58.8% were downgraded using the 2018 AAST. There was no statistically significant difference in the overall areas under the curves between the 2018 and 1989 AAST grading system for predicting bleeding interventions (0.72 vs. 0.68, p = 0.34)., Conclusion: About one third of the injuries previously classified as grade III will be upgraded to grade IV using the 2018 AAST, which adds to the heterogeneity of grade IV injuries. Although the 2018 AAST grading provides more anatomic details on injury patterns and includes important radiologic findings, it did not outperform the 1989 AAST grading in predicting bleeding interventions., Level of Evidence: Prognostic and Epidemiological Study, level III.

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

Background: Platelet dysfunction associated with isolated traumatic brain injury (TBI) can be measured using thromboelastography-platelet mapping (TEG-PM). We hypothesized that platelet dysfunction can be detected after blunt TBI, and the degree of dysfunction is associated with increased TBI severity and in-hospital mortality., Methods: This was a retrospective review of adult trauma patients admitted to a single level 1 trauma center from August 2013 to March 2015 who suffered isolated severe blunt TBI. Subjects were included if they received a TEG-PM within 24 h from injury, and excluded if on preinjury antiplatelet medications., Results: 119 subjects were analyzed. Severe TBI subjects (AIS-head 5) had ADPi 18.4 points higher than moderate TBI subjects (AIS-head 3) (p = 0.001). Platelet dysfunction was not associated with TBI progression. ADPi significantly predicted mortality (OR 1.033; 95% CI 1.005-1.061, p = 0.02)., Conclusion: Platelet dysfunction occurs immediately after isolated blunt TBI, is more pronounced with increasing TBI severity, and is associated with higher odds of in-hospital mortality. Further investigation is needed to determine whether this is a marker of disease severity or a therapeutic target., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: The optimal time to initiate venous thromboembolism (VTE) chemoprophylaxis in blunt solid organ injury (BSOI) patients is debated. We hypothesize that 1) BSOI patients are hypercoagulable within 12 h of injury and 2) hypercoagulability dominates in patients who develop clot complications (CC)., Material and Methods: This is a prospective study of BSOI patients admitted to two Level-1 Trauma Centers' trauma intensive care units (ICU). Serial kaolin thrombelastography (TEG) and tissue plasminogen activator (tPA)-challenge TEGs were performed. CC included VTE and cerebrovascular accidents., Results: On ICU admission, all patients (n = 95) were hypercoagulable, 58% were in fibrinolysis shutdown, and 50% of patients were tPA-resistant. Twelve patients (13%) developed CC. Compared to those without CC, they demonstrated decreased fibrinolysis at 12 h and higher clot strength at 48 h CONCLUSIONS: BSOI patients are universally hypercoagulable upon ICU admission. VTE chemoprophylaxis should be started immediately in BSOI patients with hypercoagulability on TEG., (Copyright © 2019 Elsevier Inc. All rights reserved.)

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

Background: We aimed to describe elderly engagement in recreational activities, their injury patterns, preinjury risks and outcomes., Methods: A 16-year retrospective trauma registry review. All trauma patients ≥65 years admitted after injury sustained during sport were evaluated, and compared to a non-sport cohort of elderly trauma patients., Results: During the study period, 9697 admissions age ≥65 were identified. 526 (5%) were sport-related. Compared to the non-sport group, the sport cohort was younger, had fewer medical comorbidities, and was more severely injured. The common sport mechanisms were skiing, offroad vehicle use and bicycling, and common sport injuries involved lower extremity, chest, and head. Sport patients were more often discharged home than non-sport patients (73% vs 36%, p < 0.001). There was no difference in ICU or hospital LOS between groups. The hospital mortality rate was 3% in sport and 5% in non-sport patients (p = 0.06)., Conclusion: Over time, the number of elderly sport-related trauma patients increased. Our data suggest that being active may improve outcomes after trauma in older adults., (Copyright © 2018 Elsevier Inc. All rights reserved.)

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

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

Background: Excretory phase computed tomography (CT) scan is used for diagnosis of renal collecting system injuries and accurate grading of high-grade renal trauma. However, optimal timing of the excretory phase is not well established. We hypothesized that there is an association between excretory phase timing and diagnosis of urinary extravasation and aimed to identify the optimal excretory phase timing for diagnosis of urinary extravasation., Methods: The Genito-Urinary Trauma Study collected data on high-grade renal trauma (grades III-V) from 14 Level I trauma centers between 2014 and 2017. The time between portal venous and excretory phases at initial CT scans was recorded. Poisson regression was used to measure the association between excretory phase timing and diagnosis of urinary extravasation. Predictive receiver operating characteristic analysis was used to identify a cutoff point optimizing detection of urinary extravasation., Results: Overall, 326 patients were included; 245 (75%) had excretory phase CT scans for review either initially (n = 212) or only at their follow-up (n = 33). At initial CT with excretory phase, 46 (22%) of 212 patients were diagnosed with urinary extravasation. Median time between portal venous and excretory phases was 4 minutes (interquartile range, 4-7 minutes). Time of initial excretory phase was significantly greater in those diagnosed with urinary extravasation. Increased time to excretory phase was positively associated with finding urinary extravasation at the initial CT scan after controlling for multiple factors (risk ratio per minute, 1.15; 95% confidence interval, 1.09-1.22; p < 0.001). The optimal delay for detection of urinary extravasation was 9 minutes., Conclusion: Timing of the excretory phase is a significant factor in accurate diagnosis of renal collecting system injury. A 9-minute delay between the early and excretory phases optimized detection of urinary extravasation., Level of Evidence: Diagnostic tests/criteria study, level III.

Background: Venous thromboembolism is a cause of morbidity and mortality in trauma patients. Chemoprophylaxis with low-molecular-weight heparin at a standardized dose is recommended. Conventional chemoprophylaxis may be inadequate. We hypothesized that a weight-adjusted enoxaparin prophylaxis regimen would reduce the frequency of venous thromboembolism in hospitalized trauma patients and at 90-day follow-up., Methods: This prospective, randomized pilot study enrolled adult patients admitted to a level 1 trauma center between July 2013 and January 2015. Subjects were randomized to receive either standard (30 mg subcutaneously every 12 hours) or weight-based (0.5mg/kg subcutaneously every 12 hours) enoxaparin. Surveillance duplex ultrasound for lower extremity deep vein thrombosis was performed on hospital days 1, 3, and 7, and weekly thereafter. The primary outcome was deep vein thrombosis during hospitalization. Secondary outcomes included venous thromboembolism at 90 days and significant bleeding events., Results: Two hundred thirty-four (124 standard, 110 weight-based) subjects were enrolled. There was no difference between standard and weight-based regarding age, body mass index, percentage female gender, injury severity score, or percentage that had surgery. There was a trend toward less in-hospital deep vein thrombosis in weight-based (12 [9.7%] standard vs 4 [3.6%] weight-based, P = .075). At 90 days, there was no difference in venous thromboembolism (12 [9.7%] standard vs 6 [5.5%] weight-based, P =.34). There was 1 bleeding event, which occurred in a standard subject., Conclusion: Weight-based enoxaparin dosing for venous thromboembolism chemoprophylaxis in trauma patients may provide better protection against venous thromboembolism than standard. A definitive study is necessary to determine whether weight-based dosing is superior to standard., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The rarity of renal trauma limits its study and the strength of evidence-based guidelines. Although management of renal injuries has shifted toward a nonoperative approach, nephrectomy remains the most common intervention for high-grade renal trauma (HGRT). We aimed to describe the contemporary management of HGRT in the United States and also evaluate clinical factors associated with nephrectomy after HGRT., Methods: From 2014 to 2017, data on HGRT (American Association for the Surgery of Trauma grades III-V) were collected from 14 participating Level-1 trauma centers. Data were gathered on demographics, injury characteristics, management, and short-term outcomes. Management was classified into three groups-expectant, conservative/minimally invasive, and open operative. Descriptive statistics were used to report management of renal trauma. Univariate and multivariate logistic mixed effect models with clustering by facility were used to look at associations between proposed risk factors and nephrectomy., Results: A total of 431 adult HGRT were recorded; 79% were male, and mechanism of injury was blunt in 71%. Injuries were graded as III, IV, and V in 236 (55%), 142 (33%), and 53 (12%), respectively. Laparotomy was performed in 169 (39%) patients. Overall, 300 (70%) patients were managed expectantly and 47 (11%) underwent conservative/minimally invasive management. Eighty-four (19%) underwent renal-related open operative management with 55 (67%) of them undergoing nephrectomy. Nephrectomy rates were 15% and 62% for grades IV and V, respectively. Penetrating injuries had significantly higher American Association for the Surgery of Trauma grades and higher rates of nephrectomy. In multivariable analysis, only renal injury grade and penetrating mechanism of injury were significantly associated with undergoing nephrectomy., Conclusion: Expectant and conservative management is currently utilized in 80% of HGRT; however, the rate of nephrectomy remains high. Clinical factors, such as surrogates of hemodynamic instability and metabolic acidosis, are associated with nephrectomy for HGRT; however, higher renal injury grade and penetrating trauma remain the strongest associations., Level of Evidence: Prognostic/epidemiologic study, level III; Therapeutic study, level IV.

Background: The optimal timing of surgical stabilization of rib fractures (SSRF) remains debated. We hypothesized that (1) demographic, radiologic, and clinical variables are associated with time to surgery and (2) shorter time to SSRF improves acute outcomes., Methods: Prospectively collected SSRF databases from four trauma centers were merged and analyzed (2006-2016). The independent variable was days from hospital admission to SSRF (early [<1 day], mid [1-2 days], and late [3-10 days]). Outcomes included length of operation, number of ribs repaired, prolonged (>24 hours) mechanical ventilation, pneumonia, tracheostomy, length of stay, and mortality. Multivariable logistic regression was used to control for significant differences in covariates between groups., Results: Five hundred fifty-one patients were analyzed. The median time to SSRF was 1 day (range, 0-10); 207 (37.6%) patients were in the early group, 168 (30.5%) in the midgroup, and 186 (31.9%) in the late group. There was a significant shift toward earlier SSRF over the study period. Time to SSRF was significantly associated with study center (p < 0.01), year of surgery (p < 0.01), age (p = 0.02), mechanism of injury (p = 0.04), and body mass index (p = 0.02). Injury severity was not associated with time to surgery. Despite repairing the same median number of ribs (4; range, 1-13), median length of surgery was 68 minutes longer for the late as compared to the early group (p < 0.01). After controlling for the aforementioned significant covariates, each additional hospital day before SSRF was independently associated with a 31% increased likelihood of pneumonia (p < 0.01), a 27% increased likelihood of prolonged mechanical ventilation (p < 0.01), and a 26% increased likelihood of tracheostomy (p < 0.01)., Conclusion: Surgical stabilization of rib fractures within 1 day of admission is associated with certain demographic and physiologic variables. After controlling for confounding factors, early SSRF was accomplished using less operative time, and was associated with favorable outcomes. When indicated and feasible, SSRF should occur as early as possible., Level of Evidence: Therapy, level III.

Background: Concussion (mild) and other moderate traumatic brain injury (TBI) and Alzheimer's disease (AD) share overlapping neuropathologies, including neuronal pre-programmed cell death (PPCD), and clinical impairments and disabilities. Multiple clinical trials targeting mechanisms based on the Amyloid Hypothesis of AD have so far failed, indicating that it is prudent for new drug developments to also pursue mechanisms independent of the Amyloid Hypothesis. To address these issues, we have proposed the use of an animal model of concussion/TBI as a supplement to AD transgenic mice to provide an indication of an AD drug candidate's potential for preventing PPCD and resulting progression towards dementia in AD., Methods: We searched PubMed/Medline and the references of identified articles for background on the neuropathological progression of AD and its implications for drug target identification, for AD clinical trial criteria used to assess disease modification outcomes, for plasma biomarkers associated with AD and concussion/TBI, neuropathologies and especially PPCD, and for methodological critiques of AD and other neuropsychiatric clinical trial methods., Results: We identified and address seven issues and highlight the Thal-Sano AD 'Time to Onset of Impairment' Design for possible applications in our clinical trials. Diverse and significant pathological cascades and indications of self-induced neuronal PPCD were found in concussion/TBI, anoxia, and AD animal models. To address the dearth of peripheral markers of AD and concussion/TBI brain pathologies and PPCD we evaluated Extracellular Vesicles (EVs) enriched for neuronal origin, including exosomes. In our concussion/TBI, anoxia and AD animal models we found evidence consistent with the presence of time-dependent PPCD and (-)-phenserine suppression of neuronal self-induced PPCD. We hence developed an extended controlled release formulation of (-)-phenserine to provide individualized dosing and stable therapeutic brain concentrations, to pharmacologically interrogate PPCD as a drug development target. To address the identified problems potentially putting any clinical trial at risk of failure, we developed exploratory AD and concussion/TBI clinical trial designs., Conclusions: Our findings inform the biomarker indication of progression of pathological targets in neurodegenerations and propose a novel approach to these conditions through neuronal protection against self-induced PPCD., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.)

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

Background: Duplication of Computed Tomography (CT) scanning in trauma patients has been a source of quality waste in healthcare and potential harm for patients. Integrated and regional health systems have been shown to promote opportunities for efficiencies, cost savings and increased safety., Methods: This study evaluated traumatically injured patients who required transfer to a Level One Trauma Center (TC) from either within a vertically integrated healthcare system (IN) or from an out-of-network (OON) hospital., Results: We found the rate of repeat CT scanning, radiology costs and total costs for day one of hospitalization to be significantly lower for trauma patients transferred from an IN hospital as compared to those patients transferred from OON hospitals., Conclusion: The inefficiencies and waste often associated with transferred patients can be mitigated and strategies to do so are necessary to reduce costs in the current healthcare environment., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Chest wall trauma is common, and contributes significantly to morbidity and mortality of trauma patients. Early identification of major chest wall and concomitant intrathoracic injuries is critical. Generalized management of multiple rib fractures and flail chest consists of adequate pain control (including locoregional modalities); management of pulmonary dysfunction by invasive and noninvasive means; and, in some cases, surgical fixation. Multiple studies have shown that patients with flail chest have substantial benefit (decreased ventilator and intensive care unit days, improved pulmonary function, and improved long-term functional outcome) when they undergo surgery compared with nonoperative management., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Day-of-injury (DOI) brain lesion volumes in traumatic brain injury (TBI) patients are rarely used to predict long-term outcomes in the acute setting. The purpose of this study was to investigate the relationship between acute brain injury lesion volume and rehabilitation outcomes in patients with TBI at a level one trauma center., Methods: Patients with TBI who were admitted to our rehabilitation unit after the acute care trauma service from February 2009-July 2011 were eligible for the study. Demographic data and outcome variables including cognitive and motor Functional Independence Measure (FIM) scores, length of stay (LOS) in the rehabilitation unit, and ability to return to home were obtained. The DOI quantitative injury lesion volumes and degree of midline shift were obtained from DOI brain computed tomography scans. A multiple stepwise regression model including 13 independent variables was created. This model was used to predict postrehabilitation outcomes, including FIM scores and ability to return to home. A p value less than 0.05 was considered significant., Results: Ninety-six patients were enrolled in the study. Mean age was 43 ± 21 years, admission Glasgow Coma Score was 8.4 ± 4.8, Injury Severity Score was 24.7 ± 9.9, and head Abbreviated Injury Scale score was 3.73 ± 0.97. Acute hospital LOS was 12.3 ± 8.9 days, and rehabilitation LOS was 15.9 ± 9.3 days. Day-of-injury TBI lesion volumes were inversely associated with cognitive FIM scores at rehabilitation admission (p = 0.004) and discharge (p = 0.004) and inversely associated with ability to be discharged to home after rehabilitation (p = 0.006)., Conclusion: In a cohort of patients with moderate to severe TBI requiring a rehabilitation unit stay after the acute care hospital stay, DOI brain injury lesion volumes are associated with worse cognitive FIM scores at the time of rehabilitation admission and discharge. Smaller-injury volumes were associated with eventual discharge to home. Volumetric neuroimaging in the acute injury phase may improve surgeons' ultimate outcome predictions in TBI patients., Level of Evidence: Prognostic/epidemiologic study, level V.

The use of prophylactic anticonvulsants to prevent early post-traumatic seizures (PTSs) is recommended but inconsistently employed in patients with traumatic brain injury (TBI). The authors evaluated outcomes associated with prophylaxis administration in patients with TBI at a Level 1 trauma center. All patients admitted with TBI from October 2007 through May 2012 were included. Our primary outcome was the incidence of early PTSs. Secondary outcomes included mortality, length of hospital and intensive care unit (ICU) stays, and incidence of late seizures. Of the 2,111 patients with TBI, 557 (26.4%) received seizure prophylaxis and 1,554 (73.6%) did not. Two early PTSs occurred in the prophylaxis group (0.4%), whereas 21 occurred in the non-prophylaxis group (1.4%) (p = 0.05). The overall mortality rate was higher in patients who received prophylaxis (14.2% vs. 6.2%; p < 0.001), and the mean hospital length of stay (LOS) was longer (6.8 ± 6.9 vs. 3.8 ± 5 days; p < 0.001). In patients with severe and moderate TBI, the rate of prophylaxis administration was approximately half, whereas significantly fewer patients with mild TBI received prophylaxis than did not (20.2% vs 79.8%, p < 0.001). Lower Glasgow Coma Scale (GCS) score and longer hospital LOS were associated with early PTS (p = 0.008 for both comparisons), but sex and age were not. Brain hemorrhage was present in 78.3% of those patients who experienced early seizures. In our cohort, patients who received seizure prophylaxis had a lower GCS score, higher overall mortality rate, longer LOS, and more frequent ICU admissions, suggesting that patients who received prophylaxis were likely more severely injured., Competing Interests: The authors have declared that no competing interests exist.

Background: Prolonged systemic antibiotic prophylaxis for central nervous system (CNS) devices may be associated with increased risk of antimicrobial resistance. The primary objective of this study was to determine the impact of prolonged CNS device antibiotic prophylaxis on the growth of resistant microorganisms and Clostridium difficile., Methods: This retrospective, observational, cohort study included patients admitted to intensive care units with traumatic brain injury or other neurocritical illness. Patients who received a CNS device and antibiotic prophylaxis for at least 72 h were compared to patients with similar neurologic injuries who did not receive a CNS device., Results: Study (n = 116) and control (n = 557) patients had mean APACHE II scores of 17.7 ± 9.2 and 15.1 ± 10.6 (p = 0.004) with 53.4 and 24.6 % receiving craniotomies (p < 0.001), respectively. Mean CNS device duration was 9.9 days, and 73 % of patients received cefuroxime for prophylaxis. The study cohort had a higher absolute incidence of resistant organisms compared with the control cohort (15.5 vs 4.1 %; odds ratio 1.93, 95 % CI 0.93-4.03, p = 0.078), though the study was underpowered to show statistical significance in multivariate analysis. C. difficile incidence was similar between groups (2.6 vs 2.0 %; odds ratio 1.45, 95 % CI 0.35-6.12, p = 0.61)., Conclusion: We found a higher incidence of resistant organisms in patients receiving prolonged antibiotic prophylaxis with a CNS device, but similar incidence of C. difficile compared to controls. Lack of data supporting prolonged antibiotic prophylaxis for CNS devices and the risk of nosocomial infections with resistant organisms encourage limiting prophylactic antibiotics to a short periprocedural course.

Background: Retained hemothorax (RH) is relatively common after chest trauma and can lead to empyema. We hypothesized that patients who have surgical fixation of rib fractures (SSRF) have less RH and empyema than those who have medical management of rib fractures (MMRF)., Methods: Admitted rib fracture patients from January 2009 to June 2013 were identified. A 2:1 propensity score model identified MMRF patients who were similar to SSRF. RH, and empyema and readmissions, were recorded. Variables were compared using Fisher exact test and Wilcoxon rank-sum tests., Results: One hundred thirty-seven SSRF and 274 MMRF were analyzed; 31 (7.5%) had RH requiring 35 interventions; 3 (2.2%) SSRF patients had RH compared with 28 (10.2%) MMRF (P = .003). Four (14.3%) MMRF subjects with RH developed empyema versus zero in the SSRF group (P = .008); 6 (19.3%) RH patients required readmission versus 14 (3.7%) in the non-RH group (P = .002)., Conclusions: Patients with rib fractures who have SSRF have less RH compared with similar MMRF patients. Although not a singular reason to perform SSRF, this clinical benefit should not be overlooked., (Copyright © 2015 Elsevier Inc. All rights reserved.)

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