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Background: All-terrain vehicle (ATV) crashes result in severe morbidity in trauma. Limited data on these injury patterns come from large urban academic centers, but studies show increased use of ATVs in small rural communities with fewer resources, where these injuries are more likely to be treated. This study uses injury patterns to determine impact on community trauma systems based on length of stay. Methods: The trauma registry of a level II trauma center was reviewed for ATV crash patients from January 2015 to December 2020. Injury type and frequency were grouped by proportion and 95% confidence interval based on ‘score’ method, and co-incidences were first screened with Fisher’s exact test, with significant p-value18) and 65 pediatric patients. Injuries to skin/soft tissue and extremities were most common in both adult (68% and 42%, p

Background Intracranial pressure (ICP) monitoring has been recommended as a guiding tool for ICP treatment; however, data suggests invasive ICP monitoring had no better outcomes than those patients without it. We hypothesized that there is no difference in short term outcomes in patients with severe traumatic brain injury (TBI) who received invasive ICP monitoring compared to those who did not.Methods The trauma registry of a community Level II trauma center was queried from January 2015 to June 2020. Patients with severe TBI identified as Glasgow Coma Scale (GCS) ≤8 upon admission with an abnormal computed tomography (CT) scan, and those meeting Brain Injury Guideline (BIG) 3 (severe) were included. The data was analyzed in a logistic regression model to predict mortality, and a linear model to predict (log-transformed) hospital and ICU length of stay (LOS). Analyses were done in Rv4.0.2software.Results A total of 7,787 trauma patients were admitted during the study period, 592 were found to have GCS≤8 and of those, 118 met inclusion criteria. Forty-seven percent (n=55) received invasive ICP monitoring and 53 percent (n=63) did not. The majority (n=78, 66%) of patients were male. Median age was 35 for the ICP monitored group and 54 for the group with no ICP monitoring. The median GCS was 3 (IQR= 3,6) and the median ISS was 25 (IQR=17,26 or 27) for both groups. The ICU LOS was 5.3 days and hospital LOS 6.2 days longer for patients with ICP monitor compared to those without ICP monitor (p=0.001). The mortality rate of patients who received an ICP monitor was 19 in 55 (35%) compared to 27 of 63 (42%) for those who did not (p=0.84).Conclusions Patients with severe traumatic brain injury who received invasive ICP monitors had an increased ICU and hospital length of stay and no mortality difference when compared to those who did not. The use of an ICP monitor did not improve outcomes in this population of severe TBI patients, particularly for those who did not require neurosurgery.Level of Evidence: Level IV

Background:Odontoid fractures are common and projected to increase. Comorbidities compound risk of surgery and balancing the risk of non-operative management is controversial. Stable fractures are managed based on patient comorbidity with suspected clinical prognosis. Type I and III fractures are typically managed safely with cervical orthoses. Management decisions of type II fractures however, come under frequent debate. This paper evaluates overall morbidity and mortality, and outcomes of operative and non-operative management. Methods:We performed national database review of C2 fractures from January 2014 to December 2019. Patients were divided into categories based on Glasgow Coma Scale (GCS) and Injury Severity Score (ISS). Outcomes data considered hospital admission, Intensive Care Unit (ICU) admission, hospital length of stay (LOS), ICU LOS, and mortality. Logistic regression was used for mortality, hospital admission, and ICU admission. Odds ratios (OR) and 95% confidence intervals (CI) were calculated from the logistic regression models. The Kruskal-Wallis test was used to compare the hospital and ICU LOS based on surgery overall, and by GCS and ISS.Results:42,003 patients were identified, 9,187 had surgery with overall mortality rate of 0.7%. There was a younger operative median age (67) and interquartile range (IQR: 47, 78) than non-operative group (73, IQR: 56, 83). Both had the same median ISS score (10). Surgery was associated with lower rates of mortality, from 0.1% to 0.9% mortality for non-operative. Mild or moderate GCS mortality improved operative (0.07%) to non-operative (0.23%). Severe GCS patients with surgery had significantly improved mortality rates patients without (0.29% vs 7.69%, respectively). Surgery increased ICU admissions for every ISS category. Severe GCS had higher chances of ICU admission, but no interaction with surgery. Operative patients had longer hospital and ICU stays. For all GCS and ISS categories, hospital and ICU LOS was longer for operative patients.Conclusions:This review demonstrates significant improvement in mortality with operative management. Standard non-operative management of type I and III C2 fractures is appropriate. Surgeons should consider operating on type II odontoid fractures unless patient cannot undertake the surgical risks of induction with general anesthesia.Level of evidence: Level IV

Background:Firearm related mortality in the USA surpassed all other developed countries. This study hypothesizes that injury patterns, weapon type, and mortality differ between suicide groups as opposed to homicide. Methods:The American College of Surgeons National Trauma Database was queried from January 2017 to December 2019. All firearm related injuries were included, and weapon type was abstracted. Differences between homicide and suicide groups by sex, age, race, and injury severity were compared using a Mann-Whitney test for numerical data and Fisher’s exact test for categorical data. The association between weapon type and mortality relative to suicide as opposed to homicide was assessed in Fisher’s exact tests. Significance was defined as p < 0.05.Results:There were 100,031 homicide and 11,714 suicide subjects that met inclusion criteria. Homicides were mostly assault victims (97.6%), male (88%), African-American (62%), had less severe injury (mean ISS 12.07) and a median age of 20 years old (IQR: 14, 30, p < 0.01). Suicides were mostly male (83%), white (79%), had more severe injury (mean ISS 20.73), and a median age of 36 years old (IQR: 19, 54, p < 0.01). Suicide group had higher odds of head/neck (OR=13.6) or face (OR=5.7) injuries, with lower odds of injury to chest (OR=0.55), abdominal or pelvic contents (OR=0.25), extremities or pelvic girdle (OR=0.15), or superficial soft tissue (OR=0.32). Mortality rate was higher for suicide group (44.8%; 95% confidence interval (CI): 43.9%, 45.7%) compared to the homicide group (11.5%; 95% CI: 11.3%, 11.7%). Conclusions:Suicide had higher mortality, more severe injuries, and more head/neck/facial injuries than homicide. Majority of suicides were with handguns. Level of Evidence: Level IV

In the state of Hawai‘i, nearly all pediatric surgical care is delivered on the main island of O‘ahu at the state’s primary tertiary children’s hospital. Outpatient clinic visits require patients and families to travel to O‘ahu. The direct and opportunity costs of this can be significant. The objective of this study was to characterize potential telehealth candidates to estimate the opportunity for telehealth delivery of outpatient pediatric surgical care. A retrospective chart review including all patients transported from neighbor islands for outpatient consultation with a pediatric surgeon on O‘ahu over a 4-year period was performed. Each patient visit was examined to determine if the visit was eligible for telehealth services using stringent criteria. Direct, insurance-based costs of the travel necessary were then determined. Demographic data was used to characterize the patients potentially affected. A total of 1081 neighbor island patients were seen in the pediatric surgery clinic over 4 years. Thirty-one percent of these patients met criteria as candidates for telehealth visits. The majority of patients came from Hawai‘i and Maui. Most patients were identified as Native Hawaiian or Asian. The average cost per trip was $112.53 per person, leading to a potential direct cost savings of $37,697 over 4 years. Over 30% of outpatient pediatric surgical encounters met stringent criteria as candidates for telehealth delivery of care. Given the significant number of patients that met our criteria, we believe there is an opportunity for direct, travel-based cost savings with the implementation of telehealth delivery of outpatient pediatric surgical care in Hawai‘i.