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Introduction: An increasing proportion of the population identifies as non-binary. This marginalized group may be at differential risk for trauma compared to those who identify as male or female, but physical trauma among non-binary patients has not yet been examined at a national level., Methods: All patients aged ≥ 16 years in the National Trauma Data Bank were included (2021-2022). Demographics, injury characteristics, and outcomes after trauma among non-binary patients were compared to males and females. The goal was to delineate differences between groups to inform the care and future study of non-binary trauma patients., Results: In total, 1,012,348 patients were included: 283 (<1%) non-binary, 610,904 (60%) male, and 403,161 (40%) female patients. Non-binary patients were younger than males or females (median age 44 vs 49 vs 67 years, P < .001) and less likely to be White race/ethnicity (58% vs 60% vs 74%, P < .001). Despite non-binary patients having a lower median Injury Severity Score (5 vs 9 vs 9, P < .001), mortality was highest among non-binary and male patients than females (5% vs 5% vs 3%, P < .001)., Discussion: In this study, non-binary trauma patients were younger and more likely minority races/ethnicities than males or females. Despite having a lower injury severity, non-binary patient mortality rates were comparable to those of males and greater than for females. These disparities identify non-binary trauma patients as doubly marginalized, by gender and race/ethnicity, who experience worse outcomes after trauma than expected based on injury severity. This vulnerable patient population deserves further study to identify areas for improved trauma delivery care., 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.

Purpose: Trauma patients are rapidly transported to the hospital for definitive care. Nonetheless, some are alive upon Emergency Medical Services (EMS) arrival but arrest on-scene or during transport. The study objective was to examine EMS-witnessed traumatic arrests to define patients who survived hospital discharge., Methods: Patients sustaining EMS-witnessed traumatic arrest and entered into the National Trauma Data Bank were included (2007-2018). Mortality defined groups: survival to hospital discharge vs. in-hospital death vs. death in ED/declared dead on arrival (DOA). ANOVA/Chi-square compared cohorts. Multivariable analysis established factors associated with survival out of ED and to hospital discharge., Results: After exclusions, 14,177 patients met the criteria: 10% survived, 22% died in hospital, and 68% died in ED/DOA. Survivors tended to be female (33% vs. 23% vs. 23%, p < 0.001), blunt traumas (71% vs. 56% vs. 60%, p < 0.001), have higher scene GCS (15 [7-15] vs. 3 [3-11] vs. 3 [3-7], p < 0.001), and lower injury severity (ISS 13 [7-26] vs. 27 [18-41] vs. 25 [10-30], p < 0.001), particularly of the head (AIS 0 [0-2] vs. 0 [0-4] vs. 1 [0-4], p < 0.001). Survival to hospital discharge was independently associated with higher field GCS (OR 1.252, p < 0.001) and SBP (OR 1.006, p < 0.001), and Head AIS scores (OR 1.073, p < 0.001). Increasing age (OR 0.984, p < 0.001), higher ISS (OR 0.975, p < 0.001), male sex (OR 0.695, p < 0.001), and penetrating mechanism of injury (OR 0.537, p < 0.001) were associated with reduced survival to discharge., Conclusion: After EMS-witnessed traumatic cardiac arrest, survivors were more likely to be young, female, injured by blunt trauma, and less hypotensive/comatose on-scene. These findings may have implications for ED resuscitation or declaration of care futility and should be further investigated with a prospective multicenter study., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Purpose: Fat embolism syndrome (FES) is a serious complication after orthopedic trauma. The aim of this study was to identify risk factors for FES in isolated lower extremity long bone fractures., Methods: The National Trauma Data Bank "NTDB" study included patients with isolated femoral and tibial fractures. A total of 344 patients with FES were propensity score matched with 981 patients without FES. Multivariate logistical regression was used to identify independent risk factors for FES., Results: FES was diagnosed in 344 (0.03%) out of the 1,251,143 patients in the study populations. In the two matched groups, the mortality was 7% in the FES group and 1% in the No FES group (p < 0.001). FES was associated with an increased risk of ARDS, VTE, pneumonia, AKI, and stroke. Younger age, femur fractures, obesity, and diabetes mellitus were independent predictors of FES. Early operative fixation (≤ 48 h) was protective against FES., Conclusion: FES increases mortality by seven times. Young age, obesity, and diabetes mellitus are significant independent risk factors for FES. Early fixation is independently associated with a reduced risk of FES., Level of Evidence: Level III., Study Type: Prognostic study., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

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: Prone position is an option for rescue therapy for acute respiratory distress syndrome. However, there are limited relevant data among trauma and surgical patients, who may be at increased risk for complications following position changes. This study aimed to identify the benefits and risks of proning in this patient subgroup., Methods: Follow the PRISMA 2020, MEDLINE and EMBASE database searches were conducted. Additional search of relevant primary literature and review articles was also performed. A random effects model was used to estimate the PF ratio, mortality rate, mechanical ventilator days, and intensive care unit length of stay using Review Manager 5.4.1 software., Results: Of 1,128 studies, 15 articles were included in this meta-analysis. The prone position significantly improved the PF ratio compared with the supine position (mean difference, 79.26; 95% CI, 53.38 to 105.13). The prone position group had a statistically significant mortality benefit (risk ratio [RR], 0.48; 95% CI, 0.35 to 0.67). Although there was no significant difference in the intensive care unit length of stay, the prone position significantly decreased mechanical ventilator days (-2.59; 95% CI, -4.21 to -0.97). On systematic review, minor complications were frequent, especially facial edema. There were no differences in local wound complications., Conclusions: The prone position has comparable complications to the supine position. With its benefits of increased oxygenation and decreased mortality, the prone position can be considered for trauma and surgical patients. A prospective multicenter study is warranted., (© 2023. The Author(s).)

Background: California issued stay-at-home (SAH) orders to mitigate COVID-19 spread. Previous studies demonstrated a shift in mechanisms of injuries (MOIs) and decreased length of stay (LOS) for the general trauma population after SAH orders. This study aimed to evaluate the effects of SAH orders on geriatric trauma patients (GTPs), hypothesizing decreased motor vehicle collisions (MVCs) and LOS., Methods: A post-hoc analysis of GTPs (≥65 years old) from 11 level-I/II trauma centers was performed, stratifying patients into 3 groups: before SAH (1/1/2020-3/18/2020) (PRE), after SAH (3/19/2020-6/30/2020) (POST), and a historical control (3/19/2019-6/30/2019) (CONTROL). Bivariate comparisons were performed., Results: 5486 GTPs were included (PRE-1756; POST-1706; CONTROL-2024). POST had a decreased rate of MVCs (7.6% vs 10.6%, P = .001; vs 11.9%, P < .001) and pedestrian struck (3.4% vs 5.8%, P = .001; vs 5.2%, P = .006) compared with PRE and CONTROL. Other mechanisms of injury, LOS, mortality, and operations performed were similar between cohorts. However, POST had a lower rate of discharge to skilled nursing facility (SNF) (20% vs 24.5%, P = .001; and 20% vs 24.4%, P = .001)., Conclusion: This retrospective multicenter study demonstrated lower rates of MVCs and pedestrian struck for GTPs, which may be explained by decreased population movement as a result of SAH orders. Contrary to previous studies on the generalized adult population, no differences in other MOIs and LOS were observed after SAH orders. However, there was a lower rate of discharge to SNF, which may be related to a lack of resources due to the COVID-19 pandemic, and thus potentially negatively impacted recovery of GTPs.Keywords., 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: 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.

Introduction: Withdrawal of life sustaining treatment (WLST) occurs when medical intervention no longer benefits a patient's acute goals for care. The incidence of WLST in the trauma patient population is not well understood. The purpose of this study was to examine the incidence and independent risk factors associated with WLST., Methods: The Trauma Quality Improvement Program (2017-2018) was utilized. Patients arrived without signs of life or without mortality or WLST data were excluded. Demographics, injury data, and outcomes were analyzed. Categorical variables are presented as number (percentage) and continuous variables as median [interquartile range]. WLST and non-WLST patients were compared. Early (<24 h) WLST patients were compared to all other WLST patients., Results: Of 749,754 patients, 35,464 (4.7 %) died. Of these, 19,424 (2.6 %) died after WLST, constituting 54.8 % of all deaths. Median age was 67 [50-79], 67.6 % male, 17,557 (90.4 %) blunt injuries, 11,334 (58.4 %) GCS < 9. Median ISS 26 [17-30]. Median head AIS 4 (3-5). The WLST group had a much higher incidence of elderly (60+) patients (65.1% vs 41.0 %), blunt mechanism of injury (90.4% vs 76.9 %) and hypertension (43.5% vs 26.5 %). Black patients (8.2% vs 19.5 %) and Hispanic patients (7.9% vs 12.2 %) were less likely to undergo WLST. On multivariate analysis, patients 80+ years old (OR 12.939, p < 0.001), GCS < 9 (OR 15.621, p < 0.001), and head AIS = 5, head AIS = 6 (OR 3.886, p < 0.001 and OR 5.283, p < 0.001) were independently associated with WLST. GCS < 9 (OR 4.006, p < 0.001) and penetrating injury (OR 2.825, p < 0.001) were independently associated with early WLST within 24 h., Conclusions: More than half who die from trauma undergo withdrawal of life sustaining treatment. Elderly patients and those with severe TBI and low GCS scores are at high risk of experiencing withdrawal of life sustaining treatment. Further prospective evaluation is warranted., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest or disclosures of funding to declare., (Copyright © 2023. Published by Elsevier Ltd.)

Background: Combat-related gunshot wounds (GSW) may differ from those found in civilian trauma centers. Missile velocity, resources, logistics, and body armor may affect injury patterns and management strategies. This study compares injury patterns, management, and outcomes in isolated abdominal GSW between military (MIL) and civilian (CIV) populations., Methods: The Department of Defense Trauma Registry (DoDTR) and TQIP databases were queried for patients with isolated abdominal GSW from 2013 to 2016. MIL patients were propensity score matched 1:3 based on age, sex, and extraabdominal AIS. Injury patterns and in-hospital outcomes were compared. Initial operative management strategies, including selective nonoperative management (SNOM) for isolated solid organ injuries, were also compared., Results: Of the 6435 patients with isolated abdominal GSW, 183 (3%) MIL were identified and matched with 549 CIV patients. The MIL group had more hollow viscus injuries (84% vs. 66%) while the CIV group had more vascular injuries (10% vs. 21%) (p < .05 for both). Operative strategy differed, with more MIL patients undergoing exploratory laparotomy (95% vs. 82%) and colectomy (72% vs. 52%) (p < .05 for both). However, no difference in ostomy creation was appreciated. More SNOM for isolated solid organ injuries was performed in the CIV group (34.1% vs. 12.5%; p < 0.05). In-hospital outcomes, including mortality, were similar between groups., Conclusions: MIL abdominal GSW lead to higher rates of hollow viscus injuries compared to CIV GSW. MIL GSW are more frequently treated with resection but with similar ostomy creation compared to civilian GSW. SNOM of solid organ injuries is infrequently performed following MIL GSW., (© 2023. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Introduction: Chest compression with rescue breathing improves outcomes in cardiac arrest. However, the efficacy of rescue breathing through surgical masks has not been investigated., Objective: We aimed to compare the tidal volume generated by mouth-to-mouth ventilation (MMV) with that generated by surgical mask-to-mouth ventilation (SMV), mouth-to-surgical mask ventilation (MSV), and surgical mask-to-surgical mask ventilation (SSV) in a manikin., Methods: A crossover randomized controlled trial was conducted in 42 medical personnel volunteers randomly assigned to perform four ventilation techniques: MMV (no protective equipment), SMV (participant wearing a mask), MSV (manikin wearing a mask), and SSV, (both participant and manikin wearing a mask). The average tidal volume and the proportion of adequate ventilation, evaluated using a manikin, were compared across different ventilation methods., Results: The average tidal volume of MMV (828 ± 278 ml) was significantly higher than those of the MSV (648 ± 250 ml, P < 0.001) and SSV (466 ± 301 ml, P < 0.001), but not SMV (744 ± 288 ml, P = 0.054). Adequate ventilation was achieved in 144/168 (85.7%) cases in the MMV group, a proportion significantly higher than in the SMV (77.4%, P = 0.02), MSV (66.7%, P < 0.001) and SSV (39.3%, P < 0.001) groups. The willingness to perform SMV was higher than that to perform MMV., Conclusions: MMV resulted in a superior average tidal volume when compared to both MSV and SSV. However, SMV achieved a comparable average tidal volume to MMV., Competing Interests: Declaration of Competing Interest The authors declare no competing interests., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: The American College of Surgeons (ACS) delineates trauma team activation (TTA) criteria to identify seriously injured trauma patients in the field. Patients are deemed to be severely undertriaged (SU), placing them at risk for adverse outcomes, when they do not meet TTA criteria but nonetheless sustain significant injuries (Injury Severity Score [ISS] ≥25)., Objectives: Delineate patient demographics, injuries, and outcomes after SU., Participants: Trauma patients presenting to our ACS-verified Level 1 trauma center with ISS ≥25 were included (11/2015-03/2022). Transfers and private vehicle transports were excluded. Patients were dichotomized and compared by trauma arrival level: TTA (Appropriately Triaged, AT) vs routine consults (SU)., Results: Study criteria were satisfied by 1653 patients: 1375 (83%) AT and 278 (17%) SU. Severely undertriaged patients were older than AT patients (47 vs 36 years, P < .001). Severely undertriaged occurred almost exclusively following blunt trauma (96% vs 71%, P < .001). Injury Severity Score was lower following SU than AT (29 vs 32, P < .001). The most common severe injuries (Abbreviated Injury Scale score [AIS] ≥3) among the SU group were in the Chest (n = 179, 64%). Severely undertriaged patients necessitated emergent intubation (n = 34, 12%), surgery (n = 59, 21%), and angioembolization (n = 22, 8%) at high rates. Severely undertriaged mortality was n = 40, 14%., Conclusion: Severely undertriaged occurred among a substantial proportion of ISS ≥25 patients, predominately following blunt trauma. Severe chest injuries were most likely to evade capture. Rates of intubation, emergent intervention, and in-hospital mortality were high after SU. Efforts should be made to identify such patients in the field as they may benefit from TTA., 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.

Objective: Penetrating carotid artery injuries (PCAI) are significantly morbid and deadly, often presenting in extremis with associated injuries and central nervous system deficit. Repair may be challenging with arterial reconstruction vs ligation role poorly defined. This study evaluated contemporary outcomes and management of PCAI., Methods: PCAI patients in the National Trauma Data Bank from 2007 to 2018 were analyzed. Outcomes were compared between repair and ligation groups after additionally excluding external carotid injuries, concomitant jugular vein injuries, and head/spine Abbreviated Injury Severity score of ≥3. Primary end points were in-hospital mortality and stroke. Secondary end points were associated injury frequency and operative management., Results: There were 4723 PCAI (55.7% gunshot wounds, 44.1% stab wounds). Gunshot wounds more frequently had associated brain (73.8% vs 19.7%; P < .001) and spinal cord (7.6% vs 1.2%; P < .001) injuries; stab wounds more frequently had jugular vein injuries (19.7% vs 29.3%; P < .001). The overall in-hospital mortality was 21.9% and the stroke rate was 6.2%. After exclusion criteria, 239 patients underwent ligation and 483 surgical repair. Ligation patients had lower presenting Glasgow Coma Scale (GCS) than repair patients (13 vs 15; P = .010). Stroke rates were equivalent (10.9% vs 9.3%; P = .507); however, in-hospital mortality was higher after ligation (19.7% vs 8.7%; P < .001). In-hospital mortality was higher in ligated common carotid artery injuries (21.3% vs 11.6%; P = .028) and internal carotid artery injuries (24.5% vs 7.3%; P = .005) compared with repair. On multivariable analysis, ligation was associated with in-hospital mortality, but not with stroke. A history of neurological deficit before injury lower GCS, and higher Injury Severity Score (ISS) were associated with stroke; ligation, hypotension, higher ISS, lower GCS, and cardiac arrest were associated with in-hospital mortality., Conclusions: PCAI are associated with a 22% rate of in-hospital mortality and a 6% rate of stroke. In this study, carotid repair was not associated with a decreased stroke rate, but did have improved mortality outcomes compared with ligation. The only factors associated with postoperative stroke were low GCS, high ISS, and a history of neurological deficit before injury. Beside ligation, low GCS, high ISS, and postoperative cardiac arrest were associated with in-hospital mortality., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

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: Despite recent advances in the management of severe traumatic brain injury, the role of decompressive craniectomy remains unclear. The purpose of this study was to compare practice patterns and patient outcomes between 2 study periods over the past decade., Methods: This is a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Project database. We included patients (age ≥18 years) with isolated severe traumatic brain injury. The patients were divided into the early (2013-2014) and late (2017-2018) groups. The primary outcome was the rate of craniectomy, and secondary outcomes included in-hospital mortality and discharge disposition. A subgroup analysis of patients undergoing intracranial pressure monitoring was also performed. A multivariable logistic regression analysis assessed the association between the early/late period and study outcomes., Results: A total of 29,942 patients were included. In the logistic regression analysis, the late period was associated with decreased use of craniectomy (odds ratio: 0.58, P < .001). Although the late period was associated with higher in-hospital mortality (odds ratio: 1.10, P = .013), it was also associated with a higher likelihood of discharge to home/rehab (odds ratio: 1.61, P < .001). Similarly, the subgroup analysis of patients with intracranial pressure monitoring showed that the late period was associated with a lower craniectomy rate (odds ratio: 0.26, P < .001) and a higher likelihood of discharge to home/rehab (odds ratio:1.98, P < .001)., Conclusion: The use of craniectomy for severe traumatic brain injury has decreased over the study period. Although further studies are warranted, these trends may reflect recent changes in the management of patients with severe traumatic brain injury., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Colon and rectal injuries have been diverted at higher rates in military trauma compared with civilian injuries. However, in the last few years, there has been a shift to more liberal primary anastomosis in wartime injuries. The purpose of this study was to compare the management and outcomes in colorectal gunshot wounds (GSWs) between military and civilian settings., Methods: The study included Department of Defense Trauma Registry and Trauma Quality Improvement Program database patients who sustained colorectal GSWs, during the period 2013 to 2016. Department of Defense Trauma Registry patients were propensity score matched 1:3 based on age, sex, grade of colorectal injury, and extra-abdominal Abbreviated Injury Scale. Patients without signs of life, transfers from an outside hospital, and nonspecific colorectal Organ Injury Scale were excluded. Operative management and outcomes were compared between the two groups. Subanalysis was performed on the military cohort to identify any differences in the use primary repair, colectomy, or fecal diversion based upon military affiliation or North Atlantic Treaty Organization status., Results: Overall, there were 2,693 patients with colorectal GSWs; 60 patients in the military group were propensity score matched with 180 patients in the civilian group. Overall, colectomy was the most common procedure performed (72.1%) and was used more frequently in the military group (83.3% vs. 68.3%; p < 0.05). However, the rate of fecal diversion was similar in the two groups (23.3% vs. 27.8%; p = 0.500). Among those in the military group, no difference was seen in primary repair, colectomy, or fecal diversion based upon military affiliation or North Atlantic Treaty Organization status. The rates of in-hospital compilations and mortality were similar between the military and civilian groups., Conclusion: The severity of GSW colorectal injuries in military and civilian trauma was comparable. There was no significant difference in terms of fecal diversion, mortality, and complications between groups. Military personnel are treated similarly regardless of affiliation., Level of Evidence: Therapeutic/Care Management; Level III., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: The purpose of this study was to compare therapeutic strategies and outcomes, following isolated gunshot wounds of the head, between military and civilian populations., Background: Recent military conflicts introduced new concepts in trauma care, including aggressive surgical intervention in severe head trauma., Methods: This was a cohort-matched study, using the civilian Trauma Quality Improvement Program (TQIP) database of the American College of Surgeons (ACS) and the Department of Defense Trauma Registry (DoDTR), during the period 2013 to 2016. Included in the study were patients with isolated gunshots to the head. Exclusion criteria were dead on arrival, civilians transferred from other hospitals, and patients with major extracranial associated injuries (body area Abbreviated Injury Scale >3). Patients in the military database were propensity score-matched 1:3 with patients in the civilian database., Results: A total of 136 patients in the DoDTR database were matched for age, sex, year of injury, and head Abbreviated Injury Scale with 408 patients from TQIP. Utilization of blood products was significantly higher in the military population ( P <0.001). In the military group, patients were significantly more likely to have intracranial pressure monitoring (17% vs 6%, P <0.001) and more likely to undergo craniotomy or craniectomy (34% vs 13%, P <0.001) than in the civilian group. Mortality in the military population was significantly lower (27% vs 38%, P =0.013)., Conclusions: Military patients are more likely to receive blood products, have intracranial pressure monitoring and undergo craniectomy or craniotomy than their civilian counterparts after isolated head gunshot wounds. Mortality is significantly lower in the military population., Level of Evidence: Level III-therapeutic., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

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.)

Background: Classically, urgent breast consults are seen by Breast Surgery or Surgical Oncology (BS/SO). At our safety net hospital, Acute Care Surgery (ACS) performs all urgent surgical consultations, including initial assessment of breast consults with coordinated BS/SO follow-up. The objective was to determine safety of ACS initial assessment of acute breast pathology., Methods: All urgent breast-related consultations were included (2016-2019). Demographics, consult indications, and investigations/interventions were captured. Outcomes were compared between patients assessed by ACS versus both ACS and BS/SO at presentation., Results: 234 patients met study criteria, with median age 39 years. Patients were primarily Hispanic (82%) women (96%). Most were not seen by BS/SO at presentation (69%), although BS/SO assessment was more frequent among patients ultimately diagnosed with cancer (8% vs 1%, P = .012). No patient had delay >90 days to core biopsy from presentation. Outcomes including time to cancer diagnosis (14 vs 8 days, P = .143) and outpatient BS/SO assessment (16 vs 13 days, P = .528); loss to follow-up (25% vs 21%, P = .414); and ED recidivism (24% vs 18%, P = .274) were comparable between patients seen by ACS versus ACS/BS/SO at index presentation., Conclusion: Urgent breast consults at our safety net hospital typically underwent initial assessment by ACS with outpatient evaluation by BS/SO. Time to follow-up and cancer diagnosis, loss to follow-up, and ED recidivism were similar after index presentation assessment by ACS versus ACS and BS/SO. In a resource-limited environment, urgent breast consults can be safely managed in the acute setting by ACS with coordinated outpatient BS/SO follow-up.

Background: Prior institutional data have demonstrated trauma mortality to be highest between 06:00-07:59 at our center, which is also when providers change shifts (07:00-07:30). The objective was definition of patient, provider, and systems variables associated with trauma mortality at shift change among patients arriving as trauma team activations (TTA)., Methods: All TTA patients at our ACS-verified Level I trauma center were included (01/2008-07/2019), excluding those with undocumented arrival time. Study groups were defined by arrival time: shift change (SC) (06:00-07:59) vs. non-shift change (NSC) (all other times). Univariable/multivariable analyses compared key variables. Propensity score analysis compared outcomes after matching., Results: After exclusions, 6020 patients remained: 229 (4%) SC and 5791 (96%) NSC. SC mortality was 25% vs. 16% during NSC (p < 0.001). More SC patients arrived with SBP <90 (19% vs. 11%, p < 0.001) or GCS <9 (35% vs. 24%, p < 0.001). ISS was higher during SC (43[32-50] vs. 34[27-50], p < 0.001). Time to CT scan (36[23-66] vs. 38[23-61] minutes, p = 0.638) and emergent surgery (94[35-141] vs. 63[34-107] minutes, p = 0.071) were comparable. Older age (p < 0.001), SBP <90 (p < 0.001), GCS <9 (p < 0.001), need for emergent operative intervention (p = 0.044), and higher ISS (p < 0.001) were independently associated with mortality. After propensity score matching, mortality was no different between SC and NSC (p = 0.764)., Conclusions: Early morning is a low-volume, high-mortality time for TTAs. Increased mortality at shift change was independently associated with patient/injury factors but not provider/systems factors. Ensuring ample clinical resource allocation during this high acuity time may be prudent to streamline patient care at shift change., Competing Interests: Declaration of competing interest All authors have no conflict of interest to disclose., (Copyright © 2022 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. 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.)

Purpose: Recent work suggests patients with moderately depressed Glasgow Coma Scale (GCS) score in the Emergency Department (ED) who do not undergo immediate head CT (CTH) have delayed neurosurgical intervention and longer ED stay. The present study objective was to determine the impact of time to first CTH on functional neurologic outcomes in this patient population., Methods: Blunt trauma patients presenting to our Level I trauma center (11/2015-10/2019) with first ED GCS 9-12 were retrospectively identified and included. Transfers and those with extracranial AIS ≥ 3 were excluded. The study population was stratified into Immediate (≤ 1 h) and Delayed (1-6 h) CTH groups based on time from ED arrival to first CTH. Outcomes included functional outcomes at hospital discharge based on the Modified Rankin Scale (mRS)., Results: After exclusions, 564 patients were included: 414 (73%) with Immediate CTH and 150 (27%) Delayed CTH. Both groups arrived with median GCS 11 and alcohol/drug intoxication did not differ (p > 0.05). AIS Head/Neck was comparable (3[3-4] vs. 3[3-3], p = 0.349). Time to ED disposition decision and ED exit were significantly shorter after Immediate CTH (2.8[1.5-5.3] vs. 5.2[3.6-7.5]h, p < 0.001 and 5.5[3.3-8.9] vs. 8.1[5.2-11.7]h, p < 0.001). Functional outcomes were slightly worse after Immediate CTH (mRS 2[1-4] vs. 2[1-3], p = 0.002). Subgroup analysis of patients requiring neurosurgical intervention demonstrated a greater proportion of moderately disabled patients with a lower proportion of severely disabled or dead patients after Immediate CTH as compared to Delayed CTH (51 vs. 20%, p = 0.063 and 35 vs. 60%, p = 0.122)., Conclusions: Immediate CTH shortened time to disposition decision out of the ED and ED exit. Patients requiring neurosurgical intervention after Immediate CTH had improved functional outcomes when compared to those undergoing Delayed CTH. These differences did not reach statistical significance in this single-center study and, therefore, a large, multicenter study is the next step in demonstrating the potential functional outcomes benefit of Immediate CTH after blunt head trauma., (© 2021. Springer-Verlag GmbH Germany, part of Springer Nature.)

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: The optimal observation time required to exclude hollow viscus injury in patients undergoing selective nonoperative management (SNOM) for abdominal stab wounds (SWs) remains unclear. The aim of this study was to determine the safe period of observation required before discharge., Methods: In this prospective observational study, all patients who sustained an abdominal SW were screened for study inclusion (July 2018 to May 2021). The primary study outcome was time to SNOM failure, defined as the need for surgical intervention after an initial period of observation., Results: During the study period, 256 consecutive patients with an abdominal SW met the study criteria. The mean age was 33 (26-46) years, and 89% were male. Of all patients, 77% had single SW, and 154 (60%) had an anterior abdominal SW (most common site right upper quadrant, 31%). Forty-six (18%) underwent immediate laparotomy because of evisceration (59%), hemodynamic instability (33%), or peritonitis (24%). The remaining 210 patients (82%) were taken for computed tomography scan (n = 208 [99%]) or underwent clinical observation only (n = 2 [<1%]). Of the patients undergoing computed tomography scan, 27 (13%) triggered operative intervention, and 9 (4%) triggered angioembolization. The remaining 174 patients (83%) underwent SNOM. Of these, three patients (2%) failed SNOM and underwent laparotomy: two developed peritonitis at 10 and 20 hours after arrival, respectively, and at laparotomy had small bowel and gastric injuries. The third patient developed increasing leukocytosis but had nontherapeutic laparotomy., Conclusion: Selective nonoperative management of stab wounds to the abdomen commonly avoids nontherapeutic operative intervention and its resultant complications. A small percentage of patients will fail SNOM, and therefore, close clinical observation of these patients in hospital is critical. All patients in this series who failed SNOM did so within 24 hours of presentation. Therefore, we recommend a period of 24 hours of close clinical monitoring to exclude a hollow viscus injury before discharge of patients with abdominal stab wounds who do not meet the criteria for immediate operative intervention., Level of Evidence: Prognostic/Epidemiological; Level III., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

COVID-19 stay-at-home (SAH) orders were impactful on adolescence, when social interactions affect development. This has the potential to change adolescent trauma. A post-hoc multicenter retrospective analysis of adolescent (13-17 years-old) trauma patients (ATPs) at 11 trauma centers was performed. Patients were divided into 3 groups based on injury date: historical control (CONTROL:3/19/2019-6/30/2019, before SAH (PRE:1/1/2020-3/18/2020), and after SAH (POST:3/19/2020-6/30/2020). The POST group was compared to both PRE and CONTROL groups in separate analyses . 726 ATPs were identified across the 3 time periods. POST had a similar penetrating trauma rate compared to both PRE (15.8% vs 13.8%, P = .56) and CONTROL (15.8% vs 14.5%, P = .69). POST also had a similar rate of suicide attempts compared to both PRE (1.2% vs 1.5%, P = .83) and CONTROL (1.2% vs 2.1%, P = .43). However, POST had a higher rate of drug positivity compared to CONTROL (28.6% vs 20.6%, P = .032), but was similar in all other comparisons of alcohol and drugs to PRE and POST periods (all P > .05). Hence ATPs were affected differently than adults and children, as they had a similar rate of penetrating trauma, suicide attempts, and alcohol positivity after SAH orders. However, they had increased drug positivity compared to the CONTROL, but not PRE group.

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.

Background: Temporary bilateral internal iliac artery ligation (TBIIAL) is an option for surgical control of pelvic hemorrhage after trauma. Concerns persist that complications, particularly gluteal necrosis, following TBIIAL should preclude its use, despite a lack of formal research on TBIIAL complications. This study aimed to define complications following TBIIAL for emergent control of traumatic pelvic bleeding. Study Design: Patients undergoing TBIIAL after blunt trauma (2008-2020) at our level 1 trauma center were included without exclusions. Demographics, clinical/injury data, and outcomes were collected. Descriptive statistics summarized study variables. Multivariable analysis of factors independently associated with mortality after TBIIAL was performed. Results: In total, 77 patients undergoing emergent TBIIAL after blunt trauma were identified. Median age was 46 [IQR 29-63] years. Most patients ( n = 70, 91%) were severely injured (ISS ≥16), with 43% undergoing resuscitative thoracotomy prior to TBIIAL. No local complications (gluteal necrosis, iatrogenic injury, fascial dehiscence, surgical site infection) after TBIIAL occurred over the 13-year study period. In the first 28 days after injury, median hospital-, ICU-, and ventilator-free days were 0. Mortality was 70% ( n = 54). On multivariable analysis, older age was the only variable independently associated with in-hospital mortality (OR 1.081, P = .028). Conclusion: Zero cases of gluteal necrosis, iatrogenic injury to surrounding structures, or surgical site infection/fascial dehiscence of the exploratory laparotomy occurred over the study period. High concern for gluteal necrosis after TBIIAL in severely injured trauma patients is unfounded and should not prevent a surgeon from obtaining prompt pelvic hemorrhage control with this technique among patients in extremis.

Background: The COVID-19 pandemic overwhelmed hospitals, forcing adjustments including discharging patients earlier and limiting intensive care unit (ICU) utilization. This study aimed to evaluate ICU admissions and length of stay (LOS) for blunt trauma patients (BTPs)., Methods: A retrospective review of COVID (3/19/20-6/30/20) versus pre-COVID (3/19/19-6/30/19) BTPs at eleven trauma centers was performed. Multivariable analysis was used to identify risk factors for ICU admission., Results: 12,744 BTPs were included (6942 pre-COVID vs. 5802 COVID). The COVID cohort had decreased mean LOS (3.9 vs. 4.4 days, p = 0.029), ICU LOS (0.9 vs. 1.1 days, p < 0.001), and rate of ICU admission (22.3% vs. 24.9%, p = 0.001) with no increase in complications or mortality compared to the pre-COVID cohort (all p > 0.05). On multivariable analysis, the COVID period was associated with decreased risk of ICU admission (OR = 0.82, CI 0.75-0.90, p < 0.001)., Conclusions: BTPs had decreased LOS and associated risk of ICU admission during COVID, with no corresponding increase in complications or mortality., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The presence of severe associated injuries in flail chest complicates the interpretation of outcomes and the role of rib fixation. This study examined the impact of fixation in patients with isolated flail chest., Methods: All patients diagnosed with flail chest injuries were queried from the National Trauma Data Bank (2016-2017). Patients who died within 72 hours, transferred from an another hospital, or had associated thoracic aortic injuries or significant extrathoracic injuries were excluded. Patients with rib fixation were propensity score matched 1:3 with similar patients treated nonoperatively, and outcomes were evaluated. Multivariate analysis was used to identify independent predictors for mortality and prolonged mechanical ventilation., Results: Of 287,947 patients with rib fractures, there were 12,110 patients (4.2%) with flail chest. After exclusion, 5293 patients with isolated blunt flail chest injuries were included in the analysis. Rib fixation was performed in 575 (10.9%), and 4718 (89.1%) were managed nonoperatively. After matching, the mortality rate was significantly lower in the fixation group (2.0% vs 5.5%, P = .001). On multivariate analysis, rib fixation was associated with improved mortality (odds ratio, 0.355; P = .002). The timing of the operation was not a significant independent risk factor for mortality. However, early fixation (≤72 hours) was associated with a significantly lower need for prolonged ventilation (>7 days)., Conclusions: Operative fixation in patients with isolated flail chest is associated with improved survival and should be considered liberally. The timing of fixation did not affect mortality, but early fixation was associated with a reduced need for prolonged mechanical ventilation., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) achieves temporary hemorrhage control via aortic occlusion. Existing REBOA literature focuses on blunt trauma without a clearly defined role in penetrating trauma. This study compared clinical/injury data and outcomes after REBOA in penetrating vs blunt trauma., Study Design: All patients in the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) database, an observational American Association for the Surgery of Trauma dataset of trauma patients requiring aortic occlusion, who underwent REBOA were included (January 2014 through February 2021). Study groups were defined by mechanism: penetrating vs blunt. Subgroup analysis was performed of patients arriving with vital signs. Univariable/multivariable analyses compared injuries and outcomes., Results: Seven hundred fifty-nine patients underwent REBOA: 152 (20%) penetrating and 607 (80%) blunt. Patients undergoing penetrating REBOA were less severely injured (injury severity score 25 vs 34; p < 0.001). The most common hemorrhage source was abdominal in penetrating REBOA (79%) and pelvic in blunt REBOA (31%; p = 0.002). Penetrating REBOA was more likely to occur in the operating room (36% vs 17%) and less likely in the emergency department (63% vs 81%; p < 0.001). Penetrating REBOA used more zone I balloon deployment (76% vs 64%) and less zone III (19% vs 34%; p = 0.001). Improved or stabilized hemodynamics were less frequent after penetrating REBOA (41% vs 62%, p < 0.001; 23% vs 41%, p < 0.001). On subgroup analysis of patients arriving alive, improvement or stabilization in hemodynamics was similar between groups (87% vs 86%, p = 0.388; 77% vs 72%, p = 0.273). Penetrating REBOA was not independently associated with mortality (odds ratio 1.253; p = 0.776)., Conclusions: Despite lower injury severity, REBOA was significantly less likely to improve or stabilize hemodynamics after penetrating trauma. Among patients arriving alive, however, outcomes were comparable, suggesting that penetrating REBOA may be most beneficial among patients with vital signs. Because hemorrhage source, catheter insertion setting, and deployment zone varied significantly between groups, existing blunt REBOA data may not be appropriately extrapolated to penetrating trauma. Further study of REBOA as a means of aortic occlusion in penetrating trauma is needed., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Penetrating injuries to the vertebral artery are rare and incompletely studied. Operative, angioembolic, and nonoperative strategies are management options, although the association between management strategy and outcomes is unknown. This study endeavored to define the epidemiology, management strategy, and outcomes after penetrating injuries to the vertebral artery presenting to trauma centers nationwide., Methods: Patients with veterbral artery injuries were identified from the National Trauma Data Bank (NTDB) (2016-2017) using ICD-10-CM codes. Only those with penetrating mechanisms of injury were included in the study. Transferred patients were excluded. Study groups were defined by management strategy (Operative management, OM; angioembolization, AE; and nonoperative management, NOM). Patient demographics, injury characteristics, and outcomes were compared between groups using univariate analysis. Multivariate analysis with logistic regression was used to examine independent risk factors for mortality and stroke., Results: Penetrating injuries to the vertebral artery were rare (n = 476, < 1% of NTDB patient population). Median age was 28 [IQR 21-37] years and 81% (n = 385) of patients were male. Interpersonal violence was the most common injury intent (n = 374, 79%). Most patients were managed with NOM (n = 409, 86%), with AE and OM utilized less frequently (8% and 6%, respectively). Stab wounds were the most frequent mechanism of injury among patients managed with OM (62%), while gunshot wounds were most common among patients managed with NOM (84%) or AE (79%). Multivariate analysis of risk factors for stroke revealed only associated carotid artery injury (OR 4.236, 95% CI 1.284-13.970, p = 0.018) and AE (OR 6.342, 95% CI 1.417-28.399, p = 0.016) were independent predictors. Independent risk factors for mortality were advanced age (OR 1.026, 95% CI 1.001-1.052, p = 0.044); elevated ISS (OR 1.030, 95% CI 1.008-1.052, p = 0.006); and associated traumatic brain injury (OR 3.020, 95% CI 1.333-6.843, p = 0.008). Higher ED GCS was independently associated with reduced mortality (OR 0.788, 95% CI 0.731-0.849, p < 0.001)., Conclusions: Vertebral artery injuries after penetrating mechanisms are infrequent in the United States. Patients with these injuries tend to be young adult men who were injured by gunshot wounds as a result of interpersonal violence. The majority of these injuries were managed nonoperatively, with operative intervention required most commonly for patients injured by stab wounds. Risk factors for both stroke and mortality were principally due to patient factors and associated injuries. Increased risk of stroke among patients managed with angioembolization will need to be further investigated with future study to determine if this risk is imparted from the management strategy itself or from underlying injury characteristics., (© 2020. Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: The COVID-19 pandemic resulted in increased penetrating trauma and decreased length of stay (LOS) amongst the adult trauma population, findings important for resource allocation. Studies regarding the pediatric trauma population are sparse and mostly single-center. This multicenter study examined pediatric trauma patients, hypothesizing increased penetrating trauma and decreased LOS after the 3/19/2020 stay-at-home (SAH) orders., Methods: A multicenter retrospective analysis of trauma patients ≤ 17 years old presenting to 11 centers in California was performed. Demographic data, injury characteristics, and outcomes were collected. Patients were divided into three groups based on injury date: 3/19/2019-6/30/2019 (CONTROL), 1/1/2020-3/18/2020 (PRE), 3/19/2020-6/30/2020 (POST). POST was compared to PRE and CONTROL in separate analyses., Results: 1677 patients were identified across all time periods (CONTROL: 631, PRE: 479, POST: 567). POST penetrating trauma rates were not significantly different compared to both PRE (11.3 vs. 9.0%, p = 0.219) and CONTROL (11.3 vs. 8.2%, p = 0.075), respectively. POST had a shorter mean LOS compared to PRE (2.4 vs. 3.3 days, p = 0.002) and CONTROL (2.4 vs. 3.4 days, p = 0.002). POST was also not significantly different than either group regarding intensive care unit (ICU) LOS, ventilator days, and mortality (all p > 0.05)., Conclusions: This multicenter retrospective study demonstrated no difference in penetrating trauma rates among pediatric patients after SAH orders but did identify a shorter LOS., (© 2021. The Author(s).)

Background: In patients undergoing resuscitative thoracotomy (RT) for traumatic cardiac arrest, focused assessment with sonography for trauma (FAST) is often used to look for intraperitoneal fluid. These findings can help determine whether abdominal exploration is warranted once return of spontaneous circulation is achieved; however, the diagnostic accuracy of FAST in this clinical scenario has yet to be evaluated. The purpose of this study was to assess the performance of FAST in identifying intra-abdominal hemorrhage following RT., Methods: We performed a 3-year retrospective study at a high-volume level 1 trauma center from 2014 to 2016. We included patients who underwent RT in the Emergency Department. All FAST examinations were performed by non-radiologists. Operative findings, computed tomography reports, diagnostic peritoneal aspirate (DPA) results, and autopsy findings were used as reference standards to calculate the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of the FAST., Results: A total of 158 patients met our inclusion criteria. The median age was 35 years (interquartile range [IQR]: 23-53), 86.1% were male, and 60.1% sustained blunt trauma. Most patients suffered severe injuries with a median injury severity score of 27 (IQR: 18-38). The sensitivity, specificity, PPV, NPV, and accuracy of FAST for identifying intra-abdominal hemorrhage were 66.0%, 84.8%, 68.6%, 83.2%, and 78.5%, respectively. Among the 107 patients with a negative FAST, 22 (20.6%) underwent DPA, which was positive in 5 patients., Conclusions: FAST can be utilized in the diagnostic workup of trauma patients after RT. In patients with a positive FAST, exploratory laparotomy is warranted, whereas other diagnostic adjuncts such as DPA or mandatory abdominal exploration may be considered in patients with a negative FAST., (© 2021. Société Internationale de Chirurgie.)

Background: The Abbreviated Injury Scale (AIS) score is used widely to quantify injury severity by body region. The maximal AIS score is 6, which defines a nonsurvivable injury. This study was undertaken to define mortality after AIS-6 injuries in order to determine if they are uniformly lethal and, if not, if differences between survivors and nonsurvivors exist which may aid in prognostication or refinement of the current AIS system., Methods: All patients in the National Trauma Data Bank (2007-2017) with ≥1 AIS-6 injury were included. Exclusions were age <16 years, AIS-6 coding in the face/extremities (i.e., coding errors, as there are no AIS-6 injuries in these regions), and missing data. In-hospital mortality defined study groups, i.e., survivors vs. nonsurvivors. Univariable analysis compared clinical/injury data and outcomes. Multivariable analysis examined independent factors associated with mortality., Results: 19,247 patients met inclusion/exclusion criteria. Of these, 25% (n=4,886) survived to hospital discharge and 75% (n=14,361) died. The most common discharge destination among survivors was home (n=2,187,45%) Nonsurvivors had significantly worse GCS in the field (3 vs. 14, p<0.001) and ED (3 vs. 15, p<0.001). Median AIS was higher among nonsurvivors in the Head (5 vs. 3, p<0.001), Abdomen (3 vs. 2, p<0.001), and External regions (1 vs. 1, p<0.001). Median time to death was 0.65h, with maximum time to death 8.76h. Multivariable analysis revealed External AIS-6 injuries were associated with greatest odds of mortality (OR 34.002, p<0.001) followed by Head AIS-6 (OR 10.501, p<0.001)., Conclusion: AIS-6 injuries are not uniformly fatal, with 25% of such patients surviving to hospital discharge. Therefore, AIS-6 injuries may not be as catastrophic as previously considered. External and Head AIS-6, i.e. extensive burns and severe traumatic brain injuries, were associated with greatest odds of mortality. When death occurs after AIS-6 injury, it occurs rapidly, with all mortalities in this series occurring <9h after arrival. We suggest that the AIS-6 verbiage be revised to remove 'nonsurvivable'., (Copyright © 2021. Published by Elsevier Inc.)

Background: Albeit low survival rates, resuscitative thoracotomy (RT) is considered standard for selected trauma patients. Because it has potential for rapid cardiopulmonary rescue, extracorporeal membrane oxygenation (ECMO) may augment RT. The aim of this study was to identify the impact of ECMO on trauma patients that recently underwent RT after injury., Study Design: All patients who underwent RT were identified from the National Trauma Data Bank (2007-2017). Patients were excluded if they died within 60 minutes, underwent delayed ECMO, and/or had missing data. Delayed ECMO group was defined as those patients undergoing ECMO after 1 hour following RT., Results: Out of 8 694 272 injured patients, 10 106 (.1%) underwent RT. Median age was 31 years [23-45], 86% male. Penetrating injury was the dominant mechanism (62%). Of these, .6% (23) underwent immediate ECMO. Extracorporeal membrane oxygenation patients were significantly younger (23[17-33] vs. 31[23-46], p .003) and had significantly higher chest abbreviated injury scale scores (5[4-5] vs. 3[3-4], P < .001). Extracorporeal membrane oxygenation patients achieved significantly higher rate of return of spontaneous circulation (96% vs. 70%, p .007) and had nonsignificant trend of improved mortality (52% vs. 63%, p .260)., Conclusion: Immediate ECMO may be a useful therapeutic modality after RT. It achieves higher ROSC rates with opportunity for improved survival. Future prospective study is warranted.

Background: Glycemic control is an important aspect of critical care because derangements are associated with morbidity and mortality. Patients at highest risk for hypoglycemia in the surgical intensive care unit (SICU) are incompletely described by existing literature. Our objective was to delineate this high-risk patient population in our SICU., Study Design: In this single-center, retrospective, observational study, SICU patients admitted from June 1, 2019 to July 31, 2020 with ≥1 episode of hypoglycemia (blood glucose <60 mg/dL) were included., Results: There were 41 hypoglycemic events in 27 patients, comprising an incidence of 1.5% among SICU patients. The most common admission diagnoses were cirrhosis (n = 13, 48%), polytrauma (n = 12, 44%), multisystem organ failure (n = 11, 41%), diabetes mellitus (n = 9, 33%), and soft tissue infection (n = 8, 30%). Four high-risk populations were identified: patients in multisystem organ failure (MSOF) (n = 11, 41%); those who were nil per os (NPO) (n = 10, 37%); patients receiving long acting subcutaneous insulin, for example, Lantus (n = 3, 11%); and those on continuous intravenous insulin infusions (n = 3, 11%). After multi-disciplinary peer review, most hypoglycemic events (n = 16, 59%) were deemed iatrogenic., Conclusions: Hypoglycemia is rare in surgical critical care. When it does occur, patients are typically in MSOF, NPO, on long acting subcutaneous insulin or continuous insulin infusions, have soft tissue infections, or have acute or chronic liver failure. Increased vigilance with frequent blood glucose monitoring in these high-risk patients may reduce the risk of hypoglycemia in the SICU.

Background: The pulse pressure (PP) is the difference between systolic and diastolic blood pressures. Narrow PP in the Emergency Department (ED) has recently been shown to predict hemorrhagic shock after trauma. This study examined the impact of prehospital narrow PP on outcomes after trauma., Methods: Patients presenting to our ACS-verified Level I trauma center (2008-2020) were retrospectively screened. Exclusions were unrecorded prehospital/ED vitals, age <16 or >60, transfers, on-scene cardiac arrest, and missing discharge disposition. Prehospital blood pressure defined study groups: Narrow PP (<30 mmHg) vs. Hypotensive (SBP<90 mmHg) vs. Others (herein referred to as Normotensive). Univariable/multivariable analyses compared outcomes and determined independent predictors of mortality; resuscitative thoracotomy; emergent intervention; and need for trauma intervention (NFTI), a contemporary measure of major trauma., Results: In total, 39,144 patients met inclusion/exclusion criteria: 5% (n=1,834) Narrow PP, 3% (n=1,062) Hypotensive, and 92% (n=36,248) Normotensive. Penetrating trauma was more frequent among Narrow PP and Hypotensive patients (23% vs. 32% vs. 14%, p<0.001). ISS was higher among Narrow PP and Hypotensive patients (5[1-14] vs. 10[2-21] vs. 4[1-9], p<0.001). Mortality was highest among the Hypotensive (n=130, 12%) followed by Narrow PP (n=92, 5%) and Normotensive patients (n=502, 1%) (p<0.001). On multivariable analysis, prehospital narrow PP was independently associated with resuscitative thoracotomy (OR 1.609, p=0.009), emergent intervention (OR 1.356, p=0.001), and NFTI (OR 1.237, p=0.009)., Conclusion: Prehospital narrow PP independently predicts severe trauma, resuscitative thoracotomy, and emergent intervention. Although prehospital narrow PP is not currently a TTA criterion, these patients have a mortality rate and ISS intermediate to those of hypotensive and normotensive patients. Prehospital narrow PP should be recognized as a proxy for major trauma in patients with heightened surgical and interventional needs so that appropriate in-hospital preparations may be made prior to patient arrival., (Copyright © 2021. Published by Elsevier Inc.)

Background: The impact of body mass index (BMI) on trauma severity after ground-level falls (GLF) is currently unclear. This study aimed to examine the associations between BMI, injuries, and outcomes after GLF., Study Design: All patients ≥16 years of age injured by GLF were queried from the TQIP database (2013-2017). Exclusions were transfers, emergency department death, AIS 6 in any region, and missing data. Body mass index defined study groups: Underweight (BMI<18.5), Normal (BMI 18.5-24.9), Overweight (25.0-29.9), and Obese (≥30)., Results: After exclusions, 131 570 patients remained for analysis. Most patients had a normal BMI (n = 58 503, 44%). Median ISS was 9 [IQR 9-10] in all groups. The Obese group had significantly lower rates of fractures than the Normal group, particularly femur fractures (53% vs. 64%, P < .001), but required orthopedic surgical intervention more frequently (45% vs. 41%, P < .001). On multivariate analysis, being overweight was protective against mortality (OR .881, P = .005), while obesity was not associated with mortality (OR 1.012, P = .821)., Conclusion: Increasing BMI may be protective against both fracture risk and mortality after GLF. However, obese patients require operative fixation more frequently. Particularly as fracture diagnosis may be more challenging in the obese, special care should be taken during their tertiary surveys after GLF to ensure injuries are not missed.

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.)

Purpose: Trauma team activation (TTA) criteria trigger early mobilization of resources for the sickest trauma patients. Patients with moderately depressed GCS who do not trigger the highest level activation are at risk for adverse outcomes, potentially from delayed time to intervention. The study objective was to define the impact of time to first CT Head (CTH) on outcomes among blunt trauma patients with moderately depressed GCS., Methods: Patients from the Trauma Quality Improvement Program (TQIP) databank (2013-2016) with first ED GCS 9-12 were included. Transfers, penetrating mechanisms, death < 24 h, AIS = 6 in any body region, and patients with severe associated injuries were excluded. Study groups were defined by time to first CTH after ED arrival: immediate (≤ 1 h) vs. delayed (1-6 h). Primary outcomes were time to neurosurgical intervention and time to ED discharge., Results: After exclusions, 4997 patients were identified. Of these, 79% (n = 3,954) underwent immediate CTH and 21% (n = 1,043) had delayed CTH. Median GCS was 11 [10-12] in both groups and there was no difference in median Head AIS (4 [3-4] vs. 4 [3-4], p = 0.586). Time to craniotomy and ICP monitor insertion were longer in the delayed group (4.2 h [3.0-7.6] vs. 3.1 h [2.1-8.7], p = 0.001; and 5.7 h [3.8-13.0] vs. 4.4 h [2.6-12.0], p = 0.008), as was time in the ED (4.3 h [2.7-6.5] vs. 2.1 h [1.2-3.7], p < 0.001). There was no difference in need for craniotomy (11% vs. 10%, p = 0.287), need for ICP monitor (12% vs. 12%, p = 0.899), or mortality (11% vs. 9%, p = 0.160). On multivariate analysis, age > 65 (OR 2.813, p < 0.001), SBP < 90 mmHg (OR 2.934, p < 0.001), ED intubation (OR 1.486, p = 0.001), and Head AIS scores of 4 (OR 1.884, p < 0.001) and 5 (OR 6.729, p < 0.001) were independently associated with death., Conclusions: Immediate CTH for blunt trauma patients with moderately depressed GCS decreases time to intervention and reduces ED time. A protocol to shorten time to CTH may be beneficial for both patients and hospitals., (© 2020. Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: There is mounting evidence that surgical patients with COVID-19 have higher morbidity and mortality than patients without COVID-19. Infection is prevalent amongst the trauma population, but any effect of COVID-19 on trauma patients is unknown. We aimed to evaluate the effect of COVID-19 on a trauma population, hypothesizing increased mortality and pulmonary complications for COVID-19-positive (COVID) trauma patients compared to propensity-matched COVID-19-negative (non-COVID) patients., Methods: A retrospective analysis of trauma patients presenting to 11 Level-I and II trauma centers in California between 1/1/2019-6/30/2019 and 1/1/2020-6/30/2020 was performed. A 1:2 propensity score model was used to match COVID to non-COVID trauma patients using age, blunt/penetrating mechanism, injury severity score, Glasgow Coma Scale score, systolic blood pressure, respiratory rate, and heart rate. Outcomes were compared between the two groups., Results: A total of 20,448 trauma patients were identified during the study period. 53 COVID trauma patients were matched with 106 non-COVID trauma patients. COVID patients had higher rates of mortality (9.4% vs 1.9%, p = 0.029) and pneumonia (7.5% vs. 0.0%, p = 0.011), as well as a longer mean length of stay (LOS) (7.47 vs 3.28 days, p < 0.001) and intensive care unit LOS (1.40 vs 0.80 days, p = 0.008), compared to non-COVID patients., Conclusion: This multicenter retrospective study found increased rates of mortality and pneumonia, as well as a longer LOS, for COVID trauma patients compared to a propensity-matched cohort of non-COVID patients. Further studies are warranted to validate these findings and to elucidate the underlying pathways responsible for higher mortality in COVID trauma patients., (© 2021. The Author(s).)

Background : COVID-19 related stay-at-home (SAH) orders created many economic and social stressors, possibly increasing the risk of drug/alcohol abuse in the community and trauma population. Objectives : Describe changes in alcohol/drug use in traumatically injured patients after SAH orders in California and evaluate demographic or injury pattern changes in alcohol or drug-positive patients. Methods : A retrospective analysis of 11 trauma centers in Southern California (1/1/2020-6/30/2020) was performed. Blood alcohol concentration, urine toxicology results, demographics, and injury characteristics were collected. Patients were grouped based on injury date - before SAH (PRE-SAH), immediately after SAH (POST-SAH), and a historical comparison (3/19/2019-6/30/2019) (CONTROL) - and compared in separate analyses. Groups were compared using chi-square tests for categorical variables and Mann-Whitney U tests for continuous variables. Results : 20,448 trauma patients (13,634 male, 6,814 female) were identified across three time-periods. The POST-SAH group had higher rates of any drug (26.2% vs. 21.6% and 24.7%, OR = 1.26 and 1.08, p < .001 and p = .035), amphetamine (10.4% vs. 7.5% and 9.3%, OR = 1.43 and 1.14, p < .001 and p = .023), tetrahydrocannabinol (THC) (13.8% vs. 11.0% and 11.4%, OR = 1.30 and 1.25, p < .001 and p < .001), and 3,4-methylenedioxy methamphetamine (MDMA) (0.8% vs. 0.4% and 0.2%, OR = 2.02 and 4.97, p = .003 and p < .001) positivity compared to PRE-SAH and CONTROL groups. Alcohol concentration and positivity were similar between groups ( p > .05). Conclusion : This Southern California multicenter study demonstrated increased amphetamine, MDMA, and THC positivity in trauma patients after SAH, but no difference in alcohol positivity or blood concentration. Drug prevention strategies should continue to be adapted within and outside of hospitals during a pandemic.

Background: The rapid spread of coronavirus disease 2019 in the United States led to a variety of mandates intended to decrease population movement and "flatten the curve." However, there is evidence some are not able to stay-at-home due to certain disadvantages, thus remaining exposed to both coronavirus disease 2019 and trauma. We therefore sought to identify any unequal effects of the California stay-at-home orders between races and insurance statuses in a multicenter study utilizing trauma volume data., Methods: A posthoc multicenter retrospective analysis of trauma patients presenting to 11 centers in Southern California between the dates of January 1, 2020, and June 30, 2020, and January 1, 2019, and June 30, 2019, was performed. The number of trauma patients of each race/insurance status was tabulated per day. We then calculated the changes in trauma volume related to stay-at-home orders for each race/insurance status and compared the magnitude of these changes using statistical resampling., Results: Compared to baseline, there was a 40.1% drop in total trauma volume, which occurred 20 days after stay-at-home orders. During stay-at-home orders, the average daily trauma volume of patients with Medicaid increased by 13.7 ± 5.3%, whereas the volume of those with Medicare, private insurance, and no insurance decreased. The average daily trauma volume decreased for White, Black, Asian, and Latino patients with the volume of Black and Latino patients dropping to a similar degree compared to White patients., Conclusion: This retrospective multicenter study demonstrated that patients with Medicaid had a paradoxical increase in trauma volume during stay-at-home orders, suggesting that the most impoverished groups remain disproportionately exposed to trauma during a pandemic, further exacerbating existing health disparities., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Hangings are an infrequent wounding mechanism among patients arriving alive to hospital but are frequently encountered by the Coroner's Office. It is unclear if classically described hanging injuries, such as the Hangman's fracture, are common among contemporary hangings patients who typically do not suspend from height. This study was undertaken to define patient and injury characteristics after hangings causing death., Methods: All patients presenting to the Los Angeles County Medical Examiner/Coroner's Office (January 2016 - May 2020) who died by hanging were included. Demographics, psychiatric history, hanging details, autopsy type, and sustained injuries were collected. Data variables were summarized with descriptive statistics and the diagnostic yield of a ligature mark in the diagnosis/exclusion of cervical injuries was calculated., Results: Over the study, 1,401 patients died by hanging. Patients underwent external exam alone (n = 1,282, 92%), traditional neck autopsy (n = 114, 8%), or traditional neck autopsy plus postmortem computed tomography scan (n = 5, <1%). Home was the most frequent hanging setting (n = 1,028, 73%) followed by public spaces (n = 80, 6%) and jail (n = 28, 2%). The manner of death was almost exclusively suicide (n = 1,395, >99%) and psychiatric disease was common (n = 968, 69%). Of the patients undergoing traditional autopsy, most had a ligature mark (n = 109, 92%) and only 9 (8%) had a cervical injury (hyoid fractures, n = 6, 5%; thyroid cartilage fractures, n = 4, 3%). None had a vertebral fracture/dislocation. Sensitivity, specificity, positive predictive value, and negative predictive value of a ligature mark were 100%, 5%, 8%, and 100%., Conclusions: Hangings are a frequent cause of death in Los Angeles County. Patients typically have a psychiatric history and die almost exclusively from suicide. Hangings commonly occur at home, in public places, and in jail. Injuries were exceedingly rare and no patient sustained a Hangman's fracture, which may be related to the lack of significant suspension with modern hangings., (Copyright © 2021. Published by Elsevier Inc.)

Background: Isolated blunt renal artery injury (BRAI) is uncommon. Treatment options include observation, nephrectomy, surgical reconstruction and endovascular stenting. Over the last decade, there has been an increasing use of angiointervention techniques in vascular trauma. Previous studies reported underutilization of endovascular stenting in BRAI, in favor of observation. The aim of this study was to examine the epidemiology and assess changes in the management of isolated BRAI over the last decade., Methods: Patients with BRAI identified from the National Trauma Data Bank (2016-2017). Deaths in the emergency department, transferral from outside hospital, and those with associated high-grade kidney injuries were excluded. Demographics, type of renal artery injury, and renal artery management were analyzed. Multivariate analysis was used to identify independent factors associated with isolated BRAI., Results: During the study period, there were 1,708,076 patients with blunt trauma and 873 (0.05%) of them had BRAI. After exclusions, 563 patients with isolated BRAI who met the criteria for inclusion in the analysis. Auto versus pedestrian mechanism and male sex were associated with the highest risk for isolated BRAI. Comorbidities, such as hypertension or diabetes, were not associated with an increased risk of BRAI. Seatbelt use had a protective effect against BRAI. In the majority of patients (534, 95%), the renal artery injury was treated with observation, 23 (4%) with nephrectomy, 5 (0.9%) with endovascular stent and 1 (0.2%) with open renal artery repair. Among the 103 patients with isolated major renal artery laceration, 91.2% were treated with observation, 7.8% with nephrectomy and 1% with stenting., Conclusion: Isolated blunt renal artery trauma is rare. The vast majority of patients with BRAI is managed with observation with only a small number undergoing endovascular intervention. Endovascular stenting utilization has remained very low and has not changed in the last decade., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Motor vehicle crashes (MVCs) are a leading cause of death in pregnant women. Even after minor trauma, there is risk of fetal complications. The purpose of this study was to compare injuries and outcomes in pregnant with matched nonpregnant women after MVC and evaluate the incidence and type of pregnancy-related complications., Methods: Retrospective study at a Level I trauma center included pregnant MVC patients, admitted 2009 to 2019. Pregnant patients were matched for age, seatbelt use, and airbag deployment with nonpregnant women (1:3). Gestation-related complications included uterine contractions, vaginal bleeding, emergency delivery, and fetal loss., Results: During the study period, there were 6,930 MVC female admissions. One hundred forty-five (2%) were pregnant, matched with 387 nonpregnant. The seat belt use (71% in nonpregnant vs. 73% in pregnant, p = 0.495) and airbag deployment (10% vs. 6%, p = 0.098) were similar in both groups. Nonpregnant women had higher Injury Severity Score (4 vs. 1, p < 0.0001) and abdominal Abbreviated Injury Scale (2 vs. 1, p < 0.001), but a smaller proportion sustained abdominal injury (18% vs. 53%, p < 0.0001). Mortality (1% vs. 0.7%, p = 0.722), need for emergency operation (6% vs. 3%, p = 0.295) or angiointervention (0.3% vs. 0%, p = 0.540), ventilator days (3 vs. 8, p = 0.907), and intensive care unit (4 vs. 4, p = 0.502) and hospital length of stay (2 vs. 2, p = 0.122) were all similar. Overall, 13 (11.1%) patients developed gestation-related complications, most commonly uterine contractions (6.3%), need for emergency delivery (3.5%), and vaginal bleeding (1.4%)., Conclusion: Most pregnant patients hospitalized for MVC suffered minor injuries. Pregnant women had lower Injury Severity Score and abdominal Abbreviated Injury Scale than matched nonpregnant women. However, there was still a considerable incidence of gestation-related complications. It is imperative that pregnant patients be closely monitored even after minor trauma., Level of Evidence: Prognostic and epidemiological, level III., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The COVID-19 pandemic resulted in a statewide stay-at-home (SAH) order in California beginning March 19, 2020, forcing large-scale behavioral changes and taking an emotional and economic toll. The effects of SAH orders on the trauma population remain unknown. We hypothesized an increase in rates of penetrating trauma, gunshot wounds, suicide attempts, and domestic violence in the Southern California trauma population after the SAH order., Methods: A multicenter retrospective analysis of all trauma patients presenting to 11 American College of Surgeons levels I and II trauma centers spanning seven counties in California was performed. Demographic data, injury characteristics, clinical data, and outcomes were collected. Patients were divided into three groups based on injury date: before SAH from January 1, 2020, to March 18, 2020 (PRE), after SAH from March 19, 2020, to June 30, 2020 (POST), and a historical control from March 19, 2019, to June 30, 2019 (CONTROL). POST was compared with both PRE and CONTROL in two separate analyses., Results: Across all periods, 20,448 trauma patients were identified (CONTROL, 7,707; PRE, 6,022; POST, 6,719). POST had a significantly increased rate of penetrating trauma (13.0% vs. 10.3%, p < 0.001 and 13.0% vs. 9.9%, p < 0.001) and gunshot wounds (4.5% vs. 2.4%, p = 0.002 and 4.5% vs. 3.7%, p = 0.025) compared with PRE and CONTROL, respectively. POST had a suicide attempt rate of 1.9% and a domestic violence rate of 0.7%, which were similar to PRE (p = 0.478, p = 0.514) and CONTROL (p = 0.160, p = 0.618)., Conclusion: This multicenter Southern California study demonstrated an increased rate of penetrating trauma and gunshot wounds after the COVID-19 SAH orders but no difference in attempted suicide or domestic violence rates. These findings may provide useful information regarding resource utilization and a target for societal intervention during the current or future pandemic(s)., Level of Evidence: Epidemiological, level IV., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The impact of obesity, on outcomes after a gunshot wound, remains unclear. We hypothesized that patients with obesity have a higher burden of intraabdominal injuries after gunshot injury when compared with the nonobese population., Methods: The Trauma Quality Improvement Program database (2013-2017) was queried for all patients age ≥16 with abdominal gunshot injuries. Patients who died in the emergency department (ED), arrived without signs of life, had Abbreviated Injury Scale score ≥ 3 in any other region, or transferred from an outside hospital were excluded. The patient with obesity was defined by a body mass index ≥ 30. Demographics, injury data, and outcomes were abstracted and analyzed. Patients with obesity were compared to those with a body mass index < 30. Multivariate logistical regression was used to compare mortality between groups., Results: Of 34,138 patients with gunshot injuries, there were 2,616 (7.7%) with isolated abdominal injuries. Median age is 29 years (22-39 years), 86.7% men. Eight hundred twenty-seven (31.6%) were obese. The obese group was significantly older (32 [25-42] vs. 27 [22-37]; p < 0.001) with a higher incidence of hypertension (16.8% vs. 6.3%, p < 0.001) and diabetes mellitus (7.1% vs. 2.3%, p < 0.001). There was no difference in presenting vital signs, abdominal Abbreviated Injury Scale or Injury Severity Score between groups. The rate of superficial injuries and intraabdominal organ injuries were comparable between groups. Patients with obesity had significantly higher mortality (6.5% vs. 4.2%, p = 0.010), hospital length of stay (9 [7-16] vs. 9[6-14], p < 0.001), ventilator days (3 [2-5] vs. 3 [2-4], p = 0.015), and hospital-acquired pneumonia (3.5% vs. 1.7%, p = 0.005). On multivariate analysis, in addition to older age (odds ratio [OR], 1.050; p < 0.001), ED hypotension (OR, 3.192; p < 0.001), and ED tachycardia (OR, 3.714; p < 0.001), obesity was significantly associated with mortality (OR, 1.636; p = 0.021)., Conclusion: Patients with obesity are at a high risk of mortality after abdominal gunshot injury. Further prospective evaluation is warranted., Level of Evidence: Prognostic study, Level III., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)