Adult Blunt Trauma Patients Research Articles

Trends in utilization of whole-body computed tomography in blunt trauma after MVC: Analysis of the Trauma Quality Improvement Program database.

The use of whole-body computed tomography (WBCT) in awake, clinically stable injured patients is controversial. It is associated with unnecessary radiation exposure and increased cost. We evaluate use of computed tomography (CT) imaging during the initial evaluation of injured patients at American College of Surgeons Levels I and II trauma centers (TCs) after blunt trauma. We identified adult blunt trauma patients after motor vehicle crash (MVC) from the American College of Surgeons Trauma Quality Improvement Program (TQIP) database between 2007 and 2016 at Level I or II TCs. We defined awake clinically stable patients as those with systolic blood pressure of 100 mm Hg or higher with a Glasgow Coma Scale score of 15. Computed tomography imaging had to have been performed within 2 hours of arrival. Whole-body computed tomography was defined as simultaneous CT of the head, chest and abdomen, and selective CT if only one to two aforementioned regions were imaged. Patients were stratified by Injury Severity Score (ISS). There were 217,870 records for analysis; 131,434 (60.3%) had selective CT, and 86,436 (39.7%) had WBCT. Overall, there was an increasing trend in WBCT utilization over the study period (p < 0.001). In patients with ISS less than 10, WBCT was utilized more commonly at Level II versus Level I TCs in patients discharged from the emergency department (26.9% vs. 18.3%, p < 0.001), which had no surgical procedure(s) (81.4% vs. 80.3%, p < 0.001) and no injury of the head (53.7% vs. 52.4%, p = 0.008) or abdomen (83.8% vs. 82.1%, p = 0.001). The risk-adjusted odds of WBCT was two times higher at Level II TC vs. Level I (odds ratio, 1.88; 95% confidence interval 1.82-1.94; p < 0.001). Whole-body computed tomography utilization is increasing relative to selective CT. This increasing utilization is highest at Level II TCs in patients with low ISSs, and in patients without associated head or abdominal injury. The findings have implications for quality improvement and cost reduction. Care management, Level IV.

RISC II is superior to TRISS in predicting 30-day mortality in blunt major trauma patients in Hong Kong

Hong Kong (HK) trauma registries have been using the Trauma and Injury Severity Score (TRISS) for audit and benchmarking since their introduction in 2000. We compare the mortality prediction model using TRISS and Revised Injury Severity Classification, version II (RISC II) for trauma centre patients in HK. This was a retrospective cohort study with all five trauma centres in HK. Adult trauma patients with Injury Severity Score (ISS) > 15 suffering from blunt injuries from January 2013 to December 2015 were included. TRISS models using the US and local coefficients were compared with the RISC II model. The primary outcome was 30-day mortality and the area under the receiver operating characteristic curve (AUC) for tested models. 1840 patients were included, of whom 1236/1840 (67%) were male. Median age was 59years and median ISS was 25. Low falls were the most common mechanism of injury. The 30-day mortality was 23%. RISC II yielded a superior AUC of 0.896, compared with the TRISS models (MTOS: 0.848; PATOS: 0.839; HK: 0.858). Prespecified subgroup analyses showed that all the models performed worse for age ≥ 70, ASA ≥ III, and low falls. RISC II had a higher AUC compared with the TRISS models in all subgroups, although not statistically significant. RISC II was superior to TRISS in predicting the 30-day mortality for Hong Kong adult blunt major trauma patients. RISC II may be useful when performing future audit or benchmarking exercises for trauma in Hong Kong.

Above the Clavicle: A Simplified Screening Method for Asymptomatic Blunt Cerebral Vascular Injury.

Blunt cerebrovascular injury (BCVI) is an increasingly detected pattern in trauma with significant morbidity, putting patients at risk for subsequent stoke. Complex screening protocols exist to determine who should undergo CT angiography of the neck (CTAN) to evaluate for BCVI. Once identified, stroke incidence may be reduced with appropriate treatment across grades. We hypothesize that an expanded and simplified method for identifying patients with clinical suspicion for BCVI based upon injury above the clavicle (ATC) will illustrate a previously undiagnosed cohort of patients. A single-institution retrospective review of adult (age ≥18years) blunt trauma patients with BCVI from January 1, 2010 to December 31, 2019 was conducted at a tertiary academic medical center. Patients undergoing CTAN were divided into 2 groups based upon qualification by either the expanded Denver criteria or clinical evidence of any injury ATC. A total of 219 patients were diagnosed with BCVI (25566 blunt trauma admissions, .9% incidence). Seventeen patients (8%) who did not satisfy expanded Denver were diagnosed with BCVI by ATC, most commonly undergoing CTAN due to facial trauma (n = 8). There were no differences in distribution of carotid artery injuries (CAI) and vertebral artery injuries (VAI) in the expanded Denver criteria group compared to the ATC group. CTAN for blunt trauma with any injury ATC is an easy-to-use screening tool and may be seamlessly included with initial whole-body imaging.

CT as a first-line modality in elderly patients with stable blunt chest trauma

PurposeBlunt thoracic injuries are common among elderly patients and may be a common cause of morbidity and death from blunt trauma injuries. We aimed to examine the impact of chest CT on the diagnosis and change of management plan in elderly patients with stable blunt chest trauma. We hypothesized that chest CT may play an important role in providing optimal management to this subgroup of trauma patients. MethodsA retrospective analysis was performed on all the admitted adult blunt trauma patients between January 2014 and December 2018. Stable blunt chest trauma patients with abbreviated injury severity (AIS) < 3 for extra-thoracic injuries confirmed with chest X-ray (CXR) and chest CT on admission or during hospitalization were included in the study. The AIS is an international scale for grading the severity of anatomic injury following blunt trauma. Primary outcome variables were occult injuries, change in management, need for surgical procedures, missed injuries, readmission rate, intensive care unit (ICU) and length of hospital stay. ResultsThere are 473 patients with blunt chest trauma included in the study. The study patients were divided into two groups according to the age range: group 1: 289 patients were included and aged 18–64 years; group 2: 184 patients were included and aged 65–99 years . Elderly patients in group 2 more often required ICU admission (11.4% vs. 5.2%), had a longer length of ICU stay (days) (median 11 vs. 6, p = 0.01), and the length of hospital stay (days) (median 14 vs. 6, p = 0.04). Injuries identified on chest CT has led to a change of management in 4.4% of young patients in group 1 and in 10.9% of elderly patients in group 2 with initially normal CXR. Chest CT resulted in a change of management in 12.8% of young patients in group 1 and in 25.7% of elderly patients in group 2 with initially abnormal CXR. ConclusionChest CT led to a change of management in a substantial proportion of elderly patients. Therefore, we recommend chest CT as a first-line imaging modality in patients aged over 65 years with isolated blunt chest trauma.

Isolated traumatic brain injury: Routine intubation for Glasgow Coma Scale 7 or 8 may be harmful!

Despite strong recommendations, there is no direct evidence supporting routine intubation of trauma patients with Glasgow Coma Scale (GCS) score of 7 or 8. We hypothesized that routine intubation may not be beneficial in isolated blunt head injury. A retrospective Trauma Quality Improvement Program study, including adult blunt trauma patients with GCS score of 7 or 8 and isolated head injury, was performed. Epidemiological and clinical characteristics, neurosurgical procedures, timing of intubation, and outcome variables were collected. The study population was stratified by the intubation procedure: immediate intubation (≤1 hour of admission), delayed intubation (>1 hour of admission), and no intubation. Multivariable regression analysis was used to determine risk factors for mortality and complications, as well as factors predictive of the decision to intubate. Of 2,727 patients with GCS score of 7 or 8 and isolated blunt head trauma, 1,866 patients (68.4%) were intubated within 1 hour of admission (immediate intubation), 223 (8.2%) had an intubation >1 hour of admission (delayed intubation), and 638 patients (23.4%) were not intubated at all. After correcting for age, sex, overall comorbidities, tachycardia, GCS, alcohol, illegal drug use, and head injury severity, immediate intubation was independently associated with higher mortality (odds ratio, 1.79; 95% confidence interval, 1.31-2.44; p < 0.001) and more overall complications (odds ratio, 2.46; 95% confidence interval, 1.62-3.73; p < 0.001). Increasing head Abbreviated Injury Scale (AIS) score, GCS score of 7, and tachycardia were identified as independent clinical factors associated with the decision to intubate. A policy of intubating all isolated blunt head injury patients 45 years or younger with head AIS score of 5 and GCS score of 7 would have improved intubation management, with seven immediate instead of delayed intubations and only three potentially unnecessary intubations. In patients with GCS score of 7 or 8 and isolated head injury, immediate intubation was associated with higher mortality and more overall complications. Intubation management could have been improved by intubating all patients younger than 45 years with head AIS score of 5 and a GCS score of 7 on admission. Therapeutic, level III.

Hybrid emergency room shows maximum effect on trauma resuscitation when used in patients with higher severity.

The hybrid emergency room (ER) system is a novel trauma workflow that uses angio-computed tomography equipment in a trauma resuscitation room. Although the hybrid ER system decreases time to start surgery and endovascular treatments and improves mortality, the optimal target benefitting from this system remained unclear. We aimed to identify a subset of trauma patients likely to receive the greatest benefits from the hybrid ER. This retrospective cohort study was conducted in a tertiary hospital in Japan from August 2007 to January 2020. We consecutively included severe adult blunt trauma patients (Injury Severity Score [ISS], ≥16) and divided them into two groups: conventional group (August 2007 to July 2011) and hybrid ER (August 2011 to January 2020) group. We evaluated the association between the hybrid ER group and 28-day mortality using multivariable logistic regression analysis. The 28-day mortality trend during the study period was evaluated with restricted cubic spline analysis. To evaluate heterogeneity of effects within various patient severities, we evaluated whether the patients' ISS modified the effect of the hybrid ER on survival. Among 1,050 trauma patients, the conventional group comprised 360 patients and the hybrid ER group comprised 690 patients. Injury Severity Score and probability of survival (Ps) were not significantly different between the groups. Twenty-eight-day mortality was significantly lower in the hybrid ER group (Ps-adjusted odds ratio, 0.48; 95% confidence interval, 0.32-0.71; p < 0.001). Restricted cubic spline analysis revealed that Ps-adjusted 28-day mortality sharply decreased approximately 200 days after installation of the hybrid ER. Increase of survival probabilities according to the increase of ISS was significantly improved in hybrid ER group (p = 0.014). Because ISS increased to >25, survival probabilities in the hybrid ER group were higher compared with those in the conventional group. The hybrid ER may improve posttraumatic mortality, especially in patients with higher baseline severity. Therapeutic/care management, level IV.

Universal screening for blunt cerebrovascular injury.

Blunt cerebrovascular injury (BCVI) can result in thromboembolic stroke. Many trauma centers selectively screen patients with cervical computed tomographic angiography (CTA) based on clinical criteria. In 2016, our institution adopted universal screening for BCVI for all blunt trauma patients. The aim of this study was to accurately determine the incidence of BCVI and to evaluate the diagnostic performance of the Denver criteria (DC), expanded Denver criteria (eDC), and Memphis criteria (MC) in selecting patients for screening. Retrospective cohort study of adult (≥16 years) blunt trauma patients who presented to the Level I trauma center at University of Alabama at Birmingham. We reviewed all CTA reports and selected CTA images to obtain the true incidence rate of BCVI. We then evaluated the diagnostic performance of the DC, eDC, and MC. A total of 6,800 patients who had suffered blunt trauma were evaluated, of whom 6,287 (92.5%) had a neck CTA. Of these, 480 (7.6%) patients had CTA evidence of BCVI. The eDC identified the most BCVI cases (sensitivity 74.7%) but had the lowest positive predictive value (14.6%). The DC and MC had slightly greater positive predictive values (19.6% and 20.6%, respectively) and had the highest diagnostic ability in terms of likelihood ratio (2.8 and 2.9) but had low sensitivity (57.5% and 47.3%). Consequently, if relying on the traditional screening criteria, the DC, eDC, and MC would have respectively resulted in 42.5%, 25.3%, and 52.7% of patients with BCVI identified by universal screening not receiving a neck CTA to screen for BCVI. Blunt cerebrovascular injury is even more common than previously thought. The diagnostic performance of selective clinical screening criteria is poor. Consideration should be given to the implementation of universal screening for BCVI using neck CTA in all blunt trauma patients. Diagnostic, level III.

Combined head and abdominal blunt trauma in the hemodynamically unstable patient: What takes priority?

The management of hypotensive patients with severe combined head and abdominal trauma is challenging, regarding the need, timing, and sequence of craniotomy or laparotomy. The purpose of the present study was to determine whether rare situations requiring craniotomy prior to laparotomy can be identified on admission with simple clinical parameters. We hypothesized that hypotension is rarely associated with the need of a combined procedure, especially in patients with mildly depressed consciousness. National Trauma Data Bank study, including adult blunt trauma patients with combined severe head (Abbreviated Injury Scale score, ≥ 3) and abdominal injury (Abbreviated Injury Scale score, ≥ 3). Data collection included demographic and clinical characteristics, laparotomy, and craniotomy within 24 hours of admission, types of intracranial pathologies, survival, and hospital stay. Multivariate regression analysis was used to determine factors predictive for the need of both operative procedures. Of 25,585 patients with severe combined head and abdominal trauma, 8,744 (34.2%) needed only laparotomy, 534 (2.1%) only craniotomy, and 394 (1.5%) required both procedures within 24 hours of admission. In the subgroup of 4,667 hypotensive patients, 2,421 (51.9%) underwent only laparotomy, 54 (1.2%) only craniotomy, and 79 (1.7%) both procedures within 24 hours of admission. Only 5 (0.7%) of 711 hypotensive patients with Glasgow Coma Scale (GCS) score above 8 who required a laparotomy also needed a craniotomy. Among clinical parameters available on patient's arrival, GCS score of 7 to 8 was independently associated with the highest need for craniotomy in hypotensive patients requiring laparotomy (odds ratio, 7.94; p = 0.004). The need for craniotomy in patients with severe combined head and abdominal injury requiring exploratory laparotomy is very low. In hypotensive patients requiring laparotomy, GCS score of 7 to 8 was an independent predictor of the need for craniotomy. In hemodynamically unstable patients with a GCS score greater than 8, it may be safer to proceed with a laparotomy first and address the head with a computed tomography scan at a later stage. Therapeutic, Level IV.

Multi-Biomarker Prediction Models for Multiple Infection Episodes Following Blunt Trauma.

SummarySevere trauma predisposes patients to multiple independent infection episodes (MIIEs), leading to augmented morbidity and mortality. We developed a method to identify increased MIIE risk before clinical signs appear, which is fundamentally different from existing approaches entailing infections' detection after their establishment. Applying machine learning algorithms to genome-wide transcriptome data from 128 adult blunt trauma patients' (42 MIIE cases and 85 non-cases) leukocytes collected ≤48 hr of injury and ≥3 days before any infection, we constructed a 15-transcript and a 26-transcript multi-biomarker panel model with the least absolute shrinkage and selection operator (LASSO) and Elastic Net, respectively, which accurately predicted MIIE (Area Under Receiver Operating Characteristics Curve [AUROC] [95% confidence intervals, CI]: 0.90 [0.84–0.96] and 0.92 [0.86–0.96]) and significantly outperformed clinical models. Gene Ontology and network analyses found various pathways to be relevant. External validation found our model to be generalizable. Our unique precision medicine approach can be applied to a wide range of patient populations and outcomes.

Regionalization of trauma care by operative experience: Does the volume of emergent laparotomy matter?

The volume-outcome relationship led to the regionalization of trauma care. The relationship between trauma centers' injury-specific laparotomy volume and outcomes has not been explored. The aim of our study was to examine the relationship between a trauma center's injury-specific laparotomy volume and outcomes in blunt and penetrating trauma patients. We performed a (2017) analysis of the Trauma Quality Improvement Program database. We included adult (age, ≥18 years) blunt and penetrating trauma patients who required emergent laparotomies for hemorrhage control. Trauma centers were stratified based on their blunt and penetrating laparotomy volumes: high volume (HV), ≥25 cases per year; medium volume (MV), 13 to 24 cases per year; and low volume (LV), ≤12 cases per year. Multivariate regression analysis was performed to explore predictors of in-hospital mortality. A total of 8,588 patients underwent emergent laparotomy for either blunt (4,936; 57.5%) or penetrating injuries (3,652; 42.5%). Overall, mean ± SD age was 40 ± 17 years, abdomen Abbreviated Injury Scale was 3 (2-4), and Injury Severity Score was 26 (17-35). For American College of Surgeons (ACS) level I centers, 50% were HV; 29%, MV; and 21%, LV. For ACS level II centers, 7% were HV; 23%, MV; and 70%, LV. For ACS level III centers, 100% were LV. On multivariate regression analysis, admission of blunt and penetrating trauma patients to HV blunt and HV penetrating centers, respectively, was independently associated with improved in-hospital mortality. High-volume blunt centers had a significantly lower time to laparotomy (72 [41-144] minutes) versus MV (81 [49-145] minutes) and LV (94 [56-158] minutes) centers (p < 0.001). The same trend was observed for HV penetrating trauma centers (35 [24-52] minutes) versus MV (46 [33-63] minutes) and LV (51 [38-69] minutes) centers (p < 0.001). Blunt and penetrating injury patients requiring emergent laparotomy had higher survival when admitted to trauma centers with HV operative experience for their particular mechanism of injury. The regionalization of trauma care should be based on a thorough evaluation of trauma centers' injury-specific operative experience. Prognostic, Level III; Therapeutic/Care management, Level IV.

Benefit of screening focused assessment with sonography in trauma is in hemodynamically normal adult blunt trauma patients.

Benefit of screening focused assessment with sonography in trauma is in hemodynamically normal adult blunt trauma patients.

Non-operative management of blunt abdominal solid organ trauma in adult patients.

IntroductionDespite agreement in the literature that “stable” blunt trauma patients may be managed conservatively, in Egypt many such patients receive operative management. This paper presents the results of a pragmatic, prospective, observational study to evaluate outcomes of non-operative (NOP) versus operative (OP) management of blunt abdominal solid organ trauma in hemodynamically stable adults admitted to Tanta University Emergency Hospital (TUH) in Egypt.MethodsA prospective observational study enrolled adult blunt abdominal trauma patients with solid organ injury at TUH over a 3-year period (June 2014–June 2017). Inclusion criteria were age ≥18 yr, mean arterial pressure >65 mm Hg, heart rate <110 bpm, hematocrit ≥7 mg/dl, and abdominal organ injury diagnosed by ultrasound or computed tomography (CT). Excluded patients were those with pelvis and femur fractures; patients with penetrating abdominal trauma; predominate burn injuries, children and pregnant women. All patients were assigned to non-operative or operative management based on clinician preference. Outcomes of interest were 30-day mortality, blood transfusion volume, and length of stay. Descriptive statistics and χ2 were used to compare outcomes.ResultsDuring the study period, 4254 trauma patients presented to TUH. Of these, 790 had blunt abdominal trauma and 111 (14.1%) met inclusion criteria. Injury severity scores for each group were comparable (24 ± 10 – NOP vs. 28 ± 11 – OP, p = 0.126). NOP received less transfused blood (213.41 ± 360.3 ml [NOP] vs.1155.17 ± 380.4 ml [OP] (p < 0.0001)) but had a longer length of stay (8.29 ± 2.8 [NOP] vs. 6.45 ± 1.97 days [OP] (p = 0.012)). There was no difference in mortality between groups (p = 0.091).ConclusionOur study demonstrated that non-operative management in Egypt of blunt abdominal trauma was safe and resulted in fewer procedures, fewer units of blood transfused, and no increase in mortality. Longer length of stay for non-operative patients might reflect treating physician caution in their management.

Racial Disparities in Adult Blunt Trauma Patients With Acute Respiratory Distress Syndrome.

Study incidence and mortality for blunt trauma patients developing acute respiratory distress syndrome (ARDS) across race and insurance. The National Trauma Data Bank (2007-2015) was queried for blunt trauma patients age >16. Covariates (age >65, injury severity score [ISS] >25, traumatic brain injury, lung injury, pneumonia, severe sepsis, hypotension on admission, and blood transfusion) were included in a multivariable logistic regression analysis. Despite progress in the treatment for ARDS, it remains a significant concern. Racial differences in response to trauma and ARDS have been inconsistently demonstrated. Since these prior studies, ARDS has been redefined by the Berlin Criteria, advances in care have been made, and health-care accessibility has changed. Adult blunt trauma patients with ISS > 15 and length of stay ≥ 3 days to examine patients at high risk of ARDS. There were 28 727 patients with ARDS. Most were white (76.2%), followed by blacks (11.5%), Hispanics (11.3%), and Asians (1.8%). Overall mortality was 20.5%. Compared to whites, blacks (odds ratio [OR]: 1.15, confidence interval [CI]: 1.10-1.20, P < .001) had higher risk of ARDS, being Hispanic was protective (OR: 0.80, CI: 0.76-0.83, P < .001). Asians with ARDS were at greater risk of death (OR: 1.31, CI: 1.07-1.61, P < .05) while being black was not associated with risk of death. Patients with private insurance had less diagnosed ARDS and those with ARDS had lower mortality than other insurances (OR: 0.86, CI: 0.79-0.92, P < .001). Data from the National Trauma Data Bank (2007-2015) demonstrates racial and insurance disparities in the development of ARDS in blunt trauma patients. When compared to whites, blacks are at higher risk of developing ARDS while being Hispanic is protective. Likewise, Asians are at greatest risk of death and blacks have no difference in mortality when compared to whites. Patients with private insurance have lower risk of incidence and mortality.

New ischemic lesions on brain magnetic resonance imaging in patients with blunt traumatic cerebrovascular injury.

Patients with blunt cerebrovascular injuries are at risk of thromboembolic stroke. Although primary prevention with antithrombotic therapy is widely used in this setting, its effectiveness is not well defined and requires further investigation. The aim of this study was to evaluate the utility of magnetic resonance imaging (MRI)-detected ischemic brain lesions as a possible future outcome for randomized clinical trials in this patient population. This prospective observational study included 20 adult blunt trauma patients admitted to a level I trauma center with a screening neck CTA showing extracranial carotid or vertebral artery injury. All subjects lacked initial evidence of an ischemic stroke and were managed with antithrombotic therapy and observation and then underwent brain MRI within 30 days of the injury to assess for ischemic lesions. The MRI scans included diffusion, susceptibility, and Fluid-attenuated Inversion Recovery (FLAIR) sequences, and were reviewed by two neuroradiologists blinded to the computed tomography angiography (CTA) findings. Eleven CTAs were done in the emergency department upon admission. There were 12 carotid artery dissections and 11 unilateral or bilateral vertebral artery injuries. Median interval between injury and MRI scan was 4 days (range, 0.1-14; interquartile range, 3-7 days). Diffusion-weighted imaging evidence of new ischemic lesions was present in 10 (43%) of 23 of the injured artery territories. In those injuries with ischemic lesions, the median number was 8 (range, 2-25; interquartile range, 5-8). None of the lesions were symptomatic. Blunt cerebrovascular injury was associated with a higher mean ischemic lesion count (mean count of 3.17 vs. 0.14, p < 0.0001), with the association remaining after adjusting for injury severity score (p < 0.0001). In asymptomatic blunt trauma patients with CTA evidence of extracranial cerebrovascular injury and treated with antithrombotic therapy, nearly half of arterial injuries are associated with ischemic lesions on MRI. Therapeutic/care management, level IV.

Abstract TP444: New Ischemic Lesions on Brain MRI in Patients With Blunt Traumatic Cerebrovascular Injury

Introduction: Patients admitted after high energy blunt trauma with extracranial cerebrovascular injuries on screening neck computed tomography angiography (CTA) represent a unique group of patients at risk of thromboembolic stroke. These arterial dissections account for &gt;1,000 ischemic strokes in the United States per year. Although stroke prophylaxis with antithrombotics is widely used in this setting, the risk of ischemic brain injury is unknown. Methods: This prospective observational study included 20 adult blunt trauma patients admitted with a screening CTA showing extracranial carotid or vertebral artery injury. All subjects had no initial clinical evidence of ischemic stroke, were managed with antiplatelets and observation and had brain magnetic resonance imaging (MRI) within 14 days of admission. The MRIs included diffusion, susceptibility, and FLAIR sequences to distinguish acute ischemic lesions from contusions and chronic infarctions and were read by two neuroradiologists blind to the findings of the neck CTA. A negative binomial regression adjusted for age and Injury Severity Score (ISS) was used to assess association between artery injury and lesion counts. Results: There were 12 carotid injuries and 11 unilateral or bilateral vertebral artery injuries. Mean interval between injury and MRI scan was 6.9 days. New ischemic lesions in the territory of the affected artery were present in 10 (43%) of the injured artery territories. The mean number of ischemic lesions was 7.8 (range 2-25), which was higher for territories with artery injury (mean=3.17) than those without injury (mean=0.14). None of the lesions were symptomatic. Adjusted for age and ISS, those with artery injury had a 23-fold higher average count of lesions (p=0.0004). In a sensitivity analysis excluding lesion counts &gt;1.5 standard deviation units, the association remained 11-fold higher count for artery injury (p=0.0107). Conclusions: In blunt trauma patients with CTA evidence of extracranial cerebrovascular injury and treated with antiplatelets, &gt;40% of arterial injuries are associated with ischemic lesions on MRI. Ischemic lesions on MRI may be a useful endpoint for future clinical trials of antithrombotic strategies in patients with blunt cerebrovascular injury.

Cross-sectional imaging of the torso reveals occult injuries in asymptomatic blunt trauma patients

BackgroundHigh morbidity and mortality rates of trauma injuries make early detection and correct diagnosis crucial for increasing patient’s survival and quality of life after an injury. Improvements in technology have facilitated the rapid detection of injuries, especially with the use of computed tomography (CT). However, the increased use of CT imaging is not universally advocated for. Some advocate for the use of selective CT imaging, especially in cases where the severity of the injury is low. The purpose of this study is to review the CT indications, findings, and complications in patients with low Injury Severity Scores (ISS) to determine the utility of torso CT in this patient cohort.MethodsA retrospective review of non-intubated, adult blunt trauma patients with an initial GCS of 14 or 15 evaluated in an ACS verified level 1 trauma center from July 2012 to June 2015 was performed. Data was obtained from the hospital’s trauma registry and chart review, with the following data included: age, sex, injury type, ISS, physical exam findings, all injuries recorded, injuries detected by torso CT, missed injuries, and complications. The statistical tests conducted in the analysis of the collected data were chi-squared, Fischer exact test, and ANOVA analysis.ResultsThere were 2306 patients included in this study, with a mean ISS of 8. For patients with a normal chest exam that had a chest CT, 15% were found to have an occult chest injury. In patients with a negative chest exam and negative chest X-ray, 35% had occult injuries detected on chest CT. For patients with a negative abdominal exam and CT abdomen and pelvis, 16% were found to have an occult injury on CT. Lastly, 25% of patients with normal chest, abdomen, and pelvis exams with chest, abdomen, and pelvis CT scans demonstrated occult injuries. Asymptomatic patients with a negative CT had a length of stay 1 day less than patients without a corresponding CT. No incidents of contrast-induced complications were recorded.ConclusionsA negative physical exam combined with a normal chest X-ray does not rule out the presence of occult injuries and the need for torso imaging. In blunt trauma patients with normal sensorium, physical exam and chest X-ray, the practice of obtaining cross-sectional imaging appears beneficial by increasing the accuracy of total injury burden and decreasing the length of stay.

Optimizing Pelvic X-Ray indication in blunt trauma patients using clinical criteria.

to identify a subgroup of blunt trauma patients with very low chance of sustaining pelvic fractures based on clinical criteria. retrospective analysis of the trauma registry data, collected in a period of 24 months. We selected adult blunt trauma patients who had a PXR on admission. The frequency of pelvic fractures was calculated for the following groups: Normal neurological examination at admission (NNE), hemodynamical stability (HS), normal pelvic examination at admission (NPE), less than 60 years old (ID<60) and absence of distracting injuries (ADI). Logistic regression analysis was carried out in order to create a probability model of negative PXR. an abnormal PXR was identified in 101 (3.3%) out of the 3,055 patients who had undergone a PXR at admission. Out of these, 1,863 sustained a NNE, with 38 positive CXRs (2.0%) in this group. Considering only the 1,535 patients with NNE and HS, we found 28 positive PXRs (1.8%). Out of these, 1,506 have NPE, with 21 abnormal PXRs (1.4%). Of these, 1,202 were younger than 60 y, with 11 positive PXRs (0.9%). By adding all these criteria to the ADI, we found 2 abnormal PXRs in 502 (0.4%) cases. The probability model including all these variables had a 0,89 area under the ROC curve. by adding clinical criteria, it is possible to identify a group of trauma patients with very low chance of sustaining pelvic fractures. The necessity of PXR in these patients needs to be reassessed.

Introduction of a standardised protocol, including systematic use of tranexamic acid, for management of severe adult trauma patients in a low-resource setting: the MSF experience from Port-au-Prince, Haiti

BackgroundBleeding is an important cause of death in trauma victims. In 2010, the CRASH-2 study, a multicentre randomized control trial on the effect of tranexamic acid (TXA) administration to trauma patients with suspected significant bleeding, reported a decreased mortality in randomized patients compared to placebo. Currently, no evidence on the use of TXA in humanitarian, low-resource settings is available. We aimed to measure the hospital outcomes of adult patients with severe traumatic bleeding in the Médecins Sans Frontières Tabarre Trauma Centre in Port-au-Prince, Haiti, before and after the implementation of a Massive Haemorrhage protocol including systematic early administration of TXA.MethodsPatients admitted over comparable periods of four months (December2015- March2016 and December2016 - March2017) before and after the implementation of the Massive Haemorrhage protocol were investigated. Included patients had blunt or penetrating trauma, a South Africa Triage Score ≥ 7, were aged 18–65 years and were admitted within 3 h from the traumatic event. Measured outcomes were hospital mortality and early mortality rates, in-hospital time to discharge and time to discharge from intensive care unit.ResultsOne-hundred and sixteen patients met inclusion criteria. Patients treated after the introduction of the Massive Haemorrhage protocol had about 70% less chance of death during hospitalization compared to the group “before” (adjusted odds ratio 0.3, 95%confidence interval 0.1–0.8). They also had a significantly shorter hospital length of stay (p = 0.02).ConclusionsImplementing a Massive Haemorrhage protocol including early administration of TXA was associated with the reduced mortality and hospital stay of severe adult blunt and penetrating trauma patients in a context with poor resources and limited availability of blood products.

Predictors of Delayed Emergency Department Throughput Among Blunt Trauma Patients

BackgroundDelayed emergency department (ED) LOS has been associated with increased mortality and increased hospital length of stay (LOS) for various patient populations. Trauma patients often require significant effort in evaluation, workup, and disposition; however, patient and hospital characteristics associated with increased LOS in the ED for trauma patients remain unclear. MethodsThe Trauma Quality Improvement Project database (2014-2016) was queried for all adult blunt trauma patients. Patients discharged from the ED to the operating room were excluded. Univariate and multivariable linear regression analysis was conducted to identify independent predictors of ED LOS, controlling for patient characteristics (age, gender, race, insurance status), hospital characteristics (teaching status, ACS trauma verification level, geographic region), abbreviated injury scale and comorbid status. Results412,000 patients met inclusion criteria for analysis. When controlling for covariates, an increase in age by 1 y resulted in 0.63 increased minutes in the ED (P < 0.001). In multivariable linear regression controlling for injury severity and comorbid conditions, non-white race groups, university status, and northeast region were associated with increased ED LOS. Black and Hispanic patients spent on average 41 and 42 more minutes, respectively, in the ED room when compared with white patients (P < 0.001). Patients seen at University hospitals spent 52 more minutes in the ED when compared with community hospitals, whereas patients at nonteaching hospitals spent 31 fewer minutes (P < 0.001). Patients seen in the Midwest spent the least amount of time in the ED, with patients in the South, West, and Northeast spending 45, 36, and 89 more minutes, respectively (P < 0.001). Non-Medicaid patients at level 1 trauma centers and those requiring intensive care admission had significantly decreased ED LOS. Medicaid patients took the longest to move through the ED with Medicare, BlueCross, and Private insurance outpacing them by 17, 23, and 23 min, respectively (P < 0.001). ACS level 1 trauma centers moved patients through the ED fastest, whereas ACS level II trauma centers and level III trauma centers moved patients through 50 and 130 min slower when compared with ACS level 1 trauma centers (P < 0.001). ConclusionsED LOS varied significantly by patient and hospital characteristics. Medicaid patients and those patients at university hospitals were associated with significantly higher ED LOS, whereas ACS trauma verification level status had strong correlation with ED LOS. These results may allow targeted quality improvement programs to enhance ED LOS.

Can trauma surgeons keep up? A prospective cohort study comparing outcomes between patients with traumatic brain injury cared for in a trauma versus neuroscience intensive care unit

BackgroundAlthough many patients with traumatic brain injury (TBI) are admitted to trauma intensive care units (ICUs), some question whether outcomes would improve if their care was provided in neurocritical care...