Higher ISS Research Articles

Poor Outcomes of Patients From Delayed Care After Ground Level Falls.

Ground level falls are a common cause of morbidity and mortality in trauma patients. Delayed presentation in many conditions has been proven to lead to worsened outcomes. Currently, there are limited data on outcomes of those who have a delayed presentation after a ground level fall. This study was a retrospective analysis of the Trauma Registry at our center. Any adult patient who presented after a ground level fall was grouped based on their time to presentation post-injury: less than or greater than 24h. Age, gender, hospital length of stay (LOS), intensive care unit (ICU) LOS, mechanical ventilation days, Injury Severity Score, and mortality were patient characteristics gathered. A Student's t-test and Chi-squared testing were utilized to determine the presence of significant differences between the groups. Significance was set at P < .05. Two hundred of 4018 patients had delayed presentation. Those with delayed presentation were more likely to be male (P = .028), younger in age (71 vs 74years old, P < .01), had greater hospital LOS (6 vs. 5, P < .01), ICU LOS (5 vs. 3, P < .01), and mechanical ventilation days (13 vs. 5days, P < .01). They also had higher ISS (8 vs. 7, P < .01), and mortality was significantly higher in those who presented after 24h (P = .034). Patients with delayed presentation after a ground level fall have worsened Injury Severity Scores and outcomes to include hospital and ICU LOS, ventilator days, and overall mortality.

Obstetrical Trauma: Reducing the Burden of Trauma Transfer to Tertiary Care Centers.

In rural state trauma systems, management of the obstetrical trauma patient often defaults to transfer to level I trauma centers. We evaluate the necessity of transferring obstetrical trauma patients without severe maternal injury. A retrospective 5-year review of obstetrical trauma patients admitted to a rural state-level I trauma center was conducted. Injury severity measures such as abdominal AIS, ISS, and GCS were correlated with outcomes. Furthermore, the impact of maternal and gestational age on uterine compromise, uterine irritability, and the need for cesarean section intervention are presented. Twenty-one percent of patients were transferred from outside facilities with a median age of 29 years, average ISS of 3.9 ± 5.6, GCS of 13.8 ± 3.6, and abdominal AIS of 1.6 ± .8. Outcomes included maternal fatality of 2%, fetal demise of 4%, 6% experienced premature rupture of membranes, 9% experienced fetal placental compromise, 15% had uterine contractions, 15% of cesarean deliveries, and fetal decelerations occurred in 4%. Predictors of fetal compromise are strongly associated with high maternal ISS and low GCS. The frequency of traumatic injury in this unique population of patients is fortunately limited. The best predictor for fetal demise and uterine irritability is maternal injury severity, measured by ISS and GCS. Therefore, without severe maternal trauma, obstetrical trauma patients with minor injuries can safely be managed at non-tertiary care facilities with obstetrical capabilities.

Tracheostomy in traumatic cervical spinal cord injury: Early versus late tracheostomy

ObjectiveThe purpose of this study was to characterize the relationship between predictors and the time of tracheostomy after traumatic cervical spinal cord injury (TCSCI). MethodsFive hundred twenty-six patients with TCSCI treated between January,2012 and December, 2021 were retrospectively reviewed. Patients were subdivided into two groups: early tracheostomy (≤7 days from initiation of endotracheal intubation) and late tracheostomy. Comparisons between early tracheostomy and late tracheostomy were statistically analyzed. Logistic regression analysis was applied to identify independent predictors of tracheostomy and calculate probability for different grades of combining predictors to predict tracheostomy. Spearman’s correlation coefficient was used to evaluate the association between the grade of combining predictors and the time to tracheostomy. ResultsAmong 526 eligible patients, 63(12.0%) had a tracheostomy performed. Compared with late tracheostomy group, patients in early tracheostomy group had higher ISS, more severe neurological status while fewer In-hospital LOS days and ICU LOS days. By Logistic regression analysis, severe American Spinal Injury Association Impairment Scale (AIS A), the neurological level of injury (NLI>C5), higher Injury Severity Score (ISS>16) and advanced age (over 50 years old) were identified as independent predictors for tracheostomy. Depending on the likelihood of tracheostomy, the combining predictors were graded into five categories. As the value of probability was higher than 50%, Grade I-III made optimistic predictions about tracheostomy. According to Spearman’s correlation analysis, early tracheostomy had a strong association with Grade I, while late tracheostomy was closely correlated with Grade III. ConclusionsFactors related to the decision of tracheostomy were ASIA impairment scale, neurological level of injury, injury severity score and age. The grades of combining predictors could support indication for predicting the time of tracheostomy.

The long-term risks of venous thromboembolism among non-operatively managed spinal fracture patients: A nationwide analysis

IntroductionLong-term readmission data for venous thromboembolism (VTE) after spinal fractures is limited. We aimed to evaluate the 1-month and 6-month VTE readmission rates in non-operatively managed traumatic spinal fractures. MethodsAnalysis of the 2017 NRD. Adults (≥18 years) with a primary diagnosis of spinal fracture who were managed non-operatively were included. Patients that died on index admission, were on pre-injury anticoagulants, and those with spinal cord injuries were excluded. Outcomes were rates of DVT, PE, and VTE during index admission, and at 1-month and 6-months after discharge. Multivariate regression analysis was performed to identify independent predictors of 6-month readmission with VTE. Results41,337 patients were identified. Mean age was 61 ± 22 years, and the median ISS was 17[9–22]. Vertebral fractures were: 11% sacrococcygeal; 29% lumbar; 19% thoracic; 20% cervical; and 21% multiple levels. During the index admission, 392(0.9%) patients developed DVT, 281(0.7%) developed PE, and 601(1.5%) VTE. Within 1-month of discharge, 177(0.4%) patients were readmitted with DVT, 142(0.3%) with PE, and 268(0.6%) with VTE. Within 6-months of discharge, 352(0.9%) patients were readmitted with DVT, 250(0.6%) with PE, and 513(1.2%) with VTE. Among those who were readmitted within 6-months with VTE, mortality was 6.7%. On multivariate analysis, older age(OR = 1.01,p < 0.01), higher ISS(OR = 1.03,p < 0.001), thoracic level of spinal fracture(OR = 1.37,p = 0.04), and discharge to skilled nursing facility, rehabilitation center, or care facility(OR = 1.73,p < 0.001) were independently associated with 6-month readmission due to VTE. ConclusionsVTE risk and associated mortality remains high for 6-months after non-operatively managed traumatic spinal fracture. Further studies regarding optimal duration and choice of thromboprophylactic agents are warranted.

Tailored Surgical Stabilization of Rib Fractures Matters More Than the Number of Fractured Ribs

Patients sustaining multiple rib fractures have a significant risk of developing morbidity and mortality. More evidence is emerging that the indication of surgical stabilization of rib fractures (SSRF) should expand beyond flail chest. Nevertheless, little is known about factors associated with poor outcomes after surgical fixation. We reviewed patients with rib fractures to further explore the role of SSRF; we matched two groups by propensity score (PS). A comparison of patients with blunt thoracic trauma treated with SSRF between 2010 and 2020 was compared with those who received conservative treatment for rib fractures. Risk factors for poor outcomes were analyzed by multivariate regression analysis. After tailored SSRF, the number of fractured ribs was not associated with longer ventilator days (p = 0.617), ICU stay (p = 0.478), hospital stay (p = 0.706), and increased nonprocedure-related pulmonary complications (NPRCs) (p = 0.226) despite having experienced much more severe trauma. In the multivariate regression models, lower GCS, delayed surgery, thoracotomy, and flail chest requiring mechanical ventilation were factors associated with prolonged ventilator days. Lower GCS, higher ISS, delayed surgery, and flail chest requiring mechanical ventilation were factors associated with longer ICU stays. Lower GCS and older age were factors associated with increased NPRCs. In the PS model, NPRCs risk was reduced by SSRF. The risk of NPRCs was reduced once ribs were surgically fixed through an algorithmic approach, and poor consciousness and aging were independent risk factors for NPRCs.

Effect of Resident Involvement on Trauma Patient Outcomes: A Single-Institution Review

The purpose of this study was to examine the mortality difference and other outcome measures amongst trauma patients with residents involved in the initial management versus those that were managed by attending physicians only without resident involvement. Retrospective review. Chi-square, Fisher's tests were used to analyze the outcomes, diagnostics, and interventions using the presence of residents in the initial care of patients as an independent variable. Linear and logistic regression were used to estimate adjusted outcomes. Riverside Community Hospital, Riverside California (State-designated level I trauma center) PARTICIPANTS: Data on all trauma patients ≥18 years old that were admitted between July 1, 2018 and June 30, 2020 was collected retrospectively (total 2644 trauma patients). Trauma patients that were transferred from outside facilities were excluded from the study. There was no significant difference in mortality associated with resident involvement in both unadjusted and adjusted analysis. Patients treated by residents, however, had more comorbidities (higher CCI) and were more severely injured (higher ISS). On adjusted analysis, higher ISS was independently associated with resident presence. There was also a statistically significant increase in the use of diagnostic studies and therapeutic interventions in the resident-present group. Involvement of residents in the initial management of our trauma patient population was associated with no difference in overall mortality or morbidity, despite higher injury severity in the resident treated patient group.

Effect of COVID 19 pandemic on time to care, use of ambulance, admission characteristics, demography, injury characteristics, management and outcome of Paediatric Orthopaedic trauma patients admitted to the trauma centre

Background: Lockdown imposed to limit the spread of COVID 19 may have had a significant effect on the time to care, demography, injury causation, injury characteristics, volume and nature of admission, management and outcome of paediatric orthopaedic trauma patients. Objective: To document the effect of lockdown on the time to care at KGMU, use of ambulance, volume and type of admissions, demography, injury causation, injury characteristics, management and outcome of paediatric orthopaedic trauma patients. Methods:. This record review compared age, sex, type of admission, mechanism of injury, injury characteristics, type of treatment, vehicle used for transport, and outcome among patients admitted in pre-lockdown, lockdown and post lockdown. Results: Lockdown was associated with decrease in the number of cases (p&lt;0.01), increase in the time since injury to reception (p&lt;0.040), a rise in the share of referred admission (p&lt;0.040), time since reception at KGMU, time to definitive care (p&lt;0.001), high energy falls (p&lt;0.001), injuries at home (p&lt;0.001), higher ISS (p&lt;0.001), non operative treatment (p=0.038) and greater use of ambulance (p=0.003). Conclusion: Lockdown resulted in a significant change in the causation and management of injury, significant delays in timeliness of care, reduction in the volume of admissions, an increase in injury severity and share of referral admissions.

Does altitude increase the risk of traumatic aortic injuries? A retrospective cohort study among six level I trauma centers in the United States

BackgroundTraumatic aortic injuries (TAIs) are rare but are associated with a high mortality. Prior studies have shown skiers and pilots, whose injuries occur at high altitudes, are at an increased risk for a TAI. The purpose of this study was to examine the effect of altitude on the incidence of TAIs across all causes of injury.MethodsThis retrospective cohort study at six Level I trauma centers (8/1/2016–1/1/2020) included adult blunt trauma patients with a chest or abdomen injury. High altitude injuries (> 5000 ft.) were compared to low altitude injuries (≤ 5000 ft.). The primary outcome was incidence of TAI.ResultsThere were 8562 patients, 37% were at high altitude and 63% at low altitude. High altitude patients were older (p < 0.01), more often Caucasian (p < 0.01) and had a higher ISS (p < 0.01). There was a significantly greater incidence of TAI at high altitude than low altitude (1.5% vs. 1.1%, p = 0.01). The median altitude was significantly higher for patients with a TAI than for patients without a TAI (5100 ft. vs. 1400 ft., p = 0.01). After adjustment, high altitude patients had 2-fold [OR: 2.4 (1.6, 3.7)] greater odds of having a TAI than low altitude patients.ConclusionTAIs were more prevalent among high altitude injuries. Providers should be aware of the increased incidence of TAIs at high altitudes particularly when there is a delay in diagnosis and transfer to a trauma center with appropriate resources to manage these critical injuries. TAI screening at high altitude trauma centers may improve survival rates.

A retrospective review of patients who sustained traumatic brain injury in Ireland 2014–2019

IntroductionTraumatic brain injury (TBI) is the most significant cause of death and disability resulting from major trauma. The aim of this study is to describe the demographics of TBI patients, the current pathways of care and outcomes in the Republic of Ireland from 2014 to 2019. MethodsWe performed a retrospective review of all TBI patients meeting inclusion criteria in Ireland's Major Trauma Audit (MTA) from 2014 to 2019. Severe TBI was defined as an abbreviated injury scale (AIS) ≥3 and GCS ≤8. ResultsDuring the study period, 30,891 patients sustained major trauma meeting inclusion criteria for MTA, of which 7,393 (23.9%) patients met the inclusion criteria for TBI; 1,025 (13.9%) were classified as severe. The median age was 60.6 years (IQR 36.9–78.0), 54.3 years (32.8–73.4) for males and 71.7 years (50.0–83.0) for females (p<0.001). Of patients with severe TBI, 185 (18.0%) were brought direct to a neurosurgical centre, 389 (37.9%) were transferred to a neurosurgical centre and 321 (31.3%) had a neurosurgical intervention performed. In patients sustaining severe TBI, older patients (Adjusted OR, 0.96,95% CI 0.95–0.97) and patients requiring another surgery (OR 0.31, 95%CI 0.18–0.53) were less likely to be secondarily transferred to a neurosurgical centre. There were 47 (4.6%) patients with severe TBI discharged to rehabilitation. The 30-day mortality in Ireland was 11.6% in all TBI patients and 45.5% in severe TBI patients. Older patients and patients with higher ISS had a higher chance of death. Male patients, patients treated in neurosurgical centre, patients who had neurosurgery or non-neurosurgical surgery had a higher chance of survival. ConclusionThis population-based study bench marks the ‘as is’ for patients with TBI in Ireland. We found that presently in Ireland, the mortality rate from severe TBI appears to be higher than that reported in international literature, and only a minority of severe TBI patients are brought directly from the incident to a neurosurgical centre. The new major trauma system should focus on providing effective and efficient access to neurosurgical, neuro-critical and neuro-rehabilitative care for patients who sustain TBI.

Examine the Incidence and Predictors of Neonatal Surgical Mortality

Objective: Aim of current study is to determine the incidence and predictors of neonatal surgical mortality. Study Design: Observational/Prospective study Place and Duration: Children Hospital PIMS.Nov-2021-April 2022 Methods: There were 130 neonates were presented in this study. Included neonates had age 1-25 days admitted to hospital for thoracic and abdominal surgery. After getting informed written consent from the parents, detailed demographics of neonates delivery was recorded. Frequency of mortality and its predictors were assessed in this study. SPSS 23.0 was used to analyze all data. Results: Among 130 neonates, 80 (61.5%) were male neonates and 50 (38.5%) were females. Mean gestational age at delivery was 35.4 ±11.9 weeks and mean age at surgery was 11.8±4.52 days. Mean weight at birth was 2.10±1.27 kg. Frequency of abdominal surgery was found in 70 (53.8%) cases, followed by thoracic surgery in 35 (36.9%) cases and superficial surgery in 25 (19.2%) cases. Frequency of mortality was found in 41 (31.5%) neonates. Predictors of mortality was prolong duration of surgery, higher ISS &gt;10, gestation age &lt;36weeks, prolong ventilation, re-operations, high vasopressors and low birth weight with p value &lt;0.004. Conclusion: The incidence of NSM was found to be highly reliant on both preoperative stress and postoperative treatment. As the margin for error in neonatal surgery is so small, skilled professionals are required to ensure the best possible outcomes and the shortest possible operating times. Our findings encourage the development of a risk classification score for neonatal operations. Keywords: Surgical Neonates, Complications, Mortality, Predictors

Impact of Intracranial Hypertension on Outcome of Severe Traumatic Brain Injury Pediatric Patients: A 15-Year Single Center Experience.

Background: Intracranial hypertension (IC-HTN) is significantly associated with higher risk for an unfavorable outcome in pediatric trauma. Intracranial pressure (ICP) monitoring is widely becoming a standard of neurocritical care for children. Methods: The present study was designed to evaluate influences of IC-HTN on clinical outcomes of pediatric TBI patients. Demographic, injury severity, radiologic characteristics were used as possible predictors of IC-HTN or of functional outcome. Results: A total of 118 pediatric intensive care unit (PICU) patients with severe TBI (sTBI) were included. Among sTBI cases, patients with GCS < 5 had significantly higher risk for IC-HTN and for mortality. Moreover, there was a statistically significant positive correlation between IC-HTN and severity scoring systems. Kaplan–Meier analysis determined a significant difference for good recovery among patients who had no ICP elevations, compared to those who had at least one episode of IC-HTN (log-rank chi-square = 11.16, p = 0.001). A multivariable predictive logistic regression analysis distinguished the ICP-monitored patients at risk for developing IC-HTN. The model finally revealed that higher ISS and Helsinki CT score increased the odds for developing IC-HTN (p < 0.05). Conclusion: The present study highlights the importance of ICP-guided clinical practices, which may lead to increasing percentages of good recovery for children.

Daratumumab (DARA) + lenalidomide, bortezomib, and dexamethasone (RVd) in transplant-eligible newly diagnosed multiple myeloma (NDMM): A post hoc analysis of sustained minimal residual disease (MRD) negativity from GRIFFIN.

8011 Background: In the primary analysis of the phase 2 randomized GRIFFIN study, DARA + RVd (D-RVd) improved the stringent complete response (sCR) rate by end of consolidation for transplant-eligible NDMM (42.4% vs 32.0%; 1-sided P = 0.068). With longer follow-up (median, 38.6 mo), D-RVd vs RVd improved MRD-negativity (10–5) rates in clinically relevant subgroups (ISS stage III, 71% vs 36%; high cytogenetic risk, 44% vs 29% [del17p, t(4;14), or t(14;16)]; revised high cytogenetic risk, 55% vs 32% [del17p, t(4;14), t(14;16), t(14;20), or gain 1q]). Here we present a post hoc analysis of sustained MRD negativity (median follow-up, 38.6 mo) in the same subgroups and in patients (pts) with ≥CR. Methods: Transplant-eligible NDMM pts were randomized 1:1 to 4 D-RVd/RVd induction cycles, ASCT, 2 D-RVd/RVd consolidation cycles, and 2 years of maintenance therapy with lenalidomide (R) ± DARA. For induction/consolidation (21-day cycles), pts received R (25 mg PO Days [D] 1-14), V (1.3 mg/m2 SC D1, 4, 8, 11), and d (40 mg PO weekly) ± DARA (16 mg/kg IV D1, 8, 15 of Cycles 1-4 and D1 of Cycles 5-6). In maintenance (28-day cycles), pts received R (10 mg PO D1-21; if tolerated, 15 mg in Cycles 10+) ± DARA (16 mg/kg IV Q8W/Q4W or 1800 mg SC per protocol amendments). The primary endpoint was sCR rate by end of consolidation. Results: The following features were balanced among randomized pts (D-RVd, n = 104; RVd, n = 103): high cytogenetic risk (16; 14), revised high cytogenetic risk (42; 37), gain 1q (34; 28), and ISS stage III (14; 14). Sustained MRD-negativity rates at 10–5 lasting ≥6 and ≥12 months were higher for D-RVd vs RVd among all high-risk subgroups (Table). D-RVd was superior to RVd for rates of sustained MRD negativity lasting ≥12 months for pts with ≥CR (53.7% vs 20.3%) and sCR (59.1% vs 17.4%; Table). Among all pts with sustained MRD negativity, only 1 D-RVd pt subsequently had disease progression, and 1 RVd pt died. Additional data on MRD at 10–6 and PFS will be presented. Conclusions: MRD data in GRIFFIN show that the addition of DARA to RVd induction/consolidation and R maintenance may lead to durable MRD-negativity (10–5) rates in pts with transplant-eligible NDMM with high cytogenetic risk, ISS stage III, and those who achieve ≥CR or sCR, however larger studies are needed. Clinical trial information: NCT02874742. [Table: see text]

Admission hypocalcemia in pediatric major trauma patients-An uncommon phenomenon associated with an increased need for urgent blood transfusion.

Hemorrhage is a leading cause of death among children. Recent data from adult trauma suggests that early, transfusion-unrelated, hypocalcemia is common and that it is associated with an increased need for blood transfusion, mortality, and coagulopathy. The objectives of this study are to evaluate the prevalence of admission hypocalcemia in severely injured children and its correlation with urgent blood transfusion. This is a retrospective cohort study of all severely injured (Injury Severity Score [ISS] > 15) pediatric (<18 years) trauma patients admitted to Rambam Health Care Campus, Israel between 2012 and 2020. We excluded patients transferred from other facilities and those who received blood before determining calcium levels. Severe hypocalcemia was defined as ionized calcium (Ca++ ) < 1.0 mmol/L and mild hypocalcemia as 1.0 mmol/L ≤ Ca++ < 1.1 mmol/L. The primary outcome was urgent blood transfusion (transfusion in the emergency department [ED]). Six hundred seventy-three severely injured children were admitted from the field. Ca++ levels were determined before blood transfusion in 457 patients. Severe hypocalcemia was found in three patients (0.7%) and mild hypocalcemia in additional 21 patients (4.6%). Hypocalcemic patients required more urgent blood transfusion (29.2% vs. 6.5%, p< .001) and had higher ISS (29 [interquartile range, IQR: 22-35] vs. 25 [IQR: 19-34], p= .05). Multivariable logistic regression analysis identified Ca++ < 1.1 mmol/L as an independent predictor of the need for blood transfusion, odds ratio 5.44 (95% confidence interval 1.44-20.58), p= .01. Contrary to adults, admission hypocalcemia is uncommon in severely injured children. However, it may be associated with an increased risk of blood transfusion in the ED.

The Validity of Quantifying Pulmonary Contusion Extent by Lung Ultrasound Score for Predicting ARDS in Blunt Thoracic Trauma

Background Thoracic trauma comprises 20–25% of all traumas worldwide and constitutes the third most common cause of death after abdominal injury and head trauma in polytrauma patients. Pulmonary contusion (PC) is a common injury seen after blunt trauma that is associated with significant morbidity and mortality. The aim of this prospective study was to determine the value of PC extent measurements using lung ultrasound in predicting high risk patients for ARDS development. Methods In one year, 50 polytrauma patients with blunt chest trauma were admitted to the ICU at Damanhur Institute. Lung contusion extent was evaluated using a lung US score (LUS) and was compared to the CT contusion score. The ability of the LUS to predict ARDS was tested. The diagnostic accuracy of LUS was compared with chest radiography for lung contusion and pneumothorax with thoracic CT scan as a reference. Patients were restratified by LUS into two groups: severe and nonsevere contusion group. The two groups' data were compared with respect to difference in mortality and injury characteristics. Results Lung contusion assessed by LUS score was well correlated to thoracic CT scan measurements (r = 0.78). A LUS of 4 was defined as a cut-off value for predicting ARDS development within 72 hours of trauma with sensitivity and specificity (91.67% and 84.21%), respectively. Patients with severe lung contusions had a lower hypoxic index on admission, more ventilator days, a higher risk of ARDS development, more fractured ribs; higher rate of hemothorax and a higher ISS score than patients with nonsevere lung contusions. Conclusion LUS on admission can quantify lung contusion extent and the high risk of developing ARDS after blunt thoracic trauma.

Does mortality after trauma team activation peak at shift change?

BackgroundPrior 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). MethodsAll 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. ResultsAfter 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). ConclusionsEarly 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.

Under-triage of Elderly Trauma Patients With Comorbid Conditions.

This study aims at identifying the under-triage patients to improve the quality of care among those transferred into a level I trauma system. This is a single-center study of Trauma Registry data, inclusive years, from July 1, 2016 to January 31, 2021. Patients were grouped based upon under-triage, over-triage, and OK triage. The under-triage group was more likely to be older, partially activated, blunt, fall trauma patients with a higher GCS, higher ISS, and significant injuries found to the head/neck who experienced a longer length of stay at the referring facility and higher morbidity outcomes with diagnosed comorbidities of dementia and hypertension. There are distinct differences in under and over-triage groups within this trauma system, which gives insight into future education and outreach among interfacility transfers.

18F-FDG-PET/CT in relapsed multiple myeloma: Are prognostic thresholds different from first-line therapy?

PurposeWhile 18F-FDG PET/CT yields valuable prognostic information for patients in first-line therapy of multiple myeloma (MM), its prognostic relevance in relapse is not established. Available studies of relapsed MM describe prognostic thresholds for frequently used PET/CT parameters that are significantly higher than those identified in the first-line setting. The purpose of this study was to evaluate the prognostic role of PET/CT in relapsed MM, based on parameters used in the first-line setting.MethodsOur retrospective study included 36 patients with MM who had received autologous or allogeneic stem cell transplantation, suffered at least one relapse, and underwent FDG-PET/CT at relapse. Number of focal bone lesions (FL), maximal standardised uptake value (SUVmax), and presence of PET-positive extramedullary lesions (EMD) were analysed.ResultsFor the number of FLs, the prognostic value was demonstrated with a cut-off of > 3 (median OS 3.8 months vs. not reached, p = 0.003). Median OS of patients with SUVmax ≤ 4 was not reached, while it was 3.9 months in patients with SUVmax > 4 (p = 0.014). Presence of EMD was a significant prognostic parameter too, with median OS of 3.6 months versus not reached (p = 0.004). The above-mentioned parameters showed prognostic significance for PFS as well. Combination of higher ISS stage and PET/CT parameters identified patients with particularly short OS (3.7 months vs. not reached, p < 0.001) and PFS (3.6 vs. 11.7 months p < 0.001).ConclusionThe PET/CT parameters SUVmax > 4, nFL > 3, and presence of EMD identify patients with poor prognosis not only in the first-line setting but also in relapsed MM.

Maternal Outcomes After Trauma in Pregnancy: A National Database Study.

Trauma is an important non-obstetric cause of mortality in pregnant females. The National Trauma Databank (NTDB) was queried between 2017 and 2018. Pregnant women >20weeks gestation, who underwent trauma, were included. They were categorized into different age groups from 12-18, 18-35, and 36-50years of age. The primary outcome measure was 30-day mortality. 1,058 pregnant trauma patients were included. Mean age was 26.7 ± 6years. Of those 94.5% had blunt and 3.8% had penetrating injuries. Median GCS and ISS were 15 (15, 15) and 2 (1, 5), respectively. Penetrating trauma patients required more operative intervention (57.5%) than blunt trauma patients (24.6%). Univariate analysis comparing age groups 12-18, 19-35, and >36years revealed differences. (P < .05) in ED systolic blood pressure (110.9 ± 19.7 vs 117.3 ± 20.3 vs 129.1 ± 29.3 mmHg, P = .01) and diabetes mellitus (.0 vs 2.7% vs 6.6% P = .03). There was no difference in HLOS (P = .72), complications (P = .279), and mortality (P = .32). Multivariate logistic regression analysis revealed that compared to patients 12-18 years old, patients 19 to 35 (P = .27) or those >36 (P = 1.0) did not show a significant difference in mortality. Patients with high ISS had higher complication rates (OR 1.09; 95% CI 1.04-1.15) and prolonged HLOS (OR 1.00; 95% CI 1.07-1.15). On average pregnant women (>20weeks gestation) who presented to trauma centers had minor injuries and maternal age or mechanism of injury did not affect mortality. Despite a low ISS, a significant number of these patients required operative procedures.

Patterns, management options and outcome of blunt thoracic aortic injuries: a 20-year experience from a Tertiary Care Hospital

BackgroundBlunt Thoracic aortic injury (BTAI) is the second leading cause of mortality after head injuries in blunt trauma patients. There is a paucity of information on the presentation, management and outcome of BTAIs from the Middle Eastern region. We explored the patterns, management options and outcomes of BTAIs in a level I trauma center.MethodsWe conducted a retrospective observational study on all adult patients who were admitted with BTAIs between 2000 and 2020. Patients were compared for the management option (conservative vs endovascular aortic repair (TEVAR) vs open surgery) and outcomes. Comparison between the respective groups was performed using one-way analysis of variance for continuous variables, and Pearson chi-square test for categorical variables. Kaplan–Meier curve and Cox regression analysis were performed for the outcome.ResultsEighty-seven patients had BTAI (82% male) with mean age 37.3 ± 14.5 years. The mean injury severity score was 30 ± 10 and the aortic injury grade was III (I–IV). Grade III (41.4%) and Grade IV (33.3%) injuries were more common followed by Grade II (13.8%) and Grade I (11.5%). Forty percent of cases were treated conservatively whereas aortic interventions were performed in 60% of cases (n = 52). The TEVAR was performed in 33 patients (63.5%), and 19 (36.5%) were treated with open surgery (14 with graft interposition and 5 with clamp and direct repair). The aortic injury grade was significantly higher in the intervention groups as compared to the conservative group (p = 0.001). Patients with Grade IV injuries were more likely to be treated by open repair whereas a higher frequency of patients with grade III was managed by TEVAR (p = 0.001). All the patients with Grade I–II were treated conservatively. The overall in-hospital mortality rate was 25.3% and it was significantly higher in the conservative group (40.0%) in comparison to the open repair (31.6%) and TEVAR (6.1%) group (P = 0.004). More of the non-survivors sustained head injuries (P = 0.004), had higher ISS (P = 0.001) and greater aortic injury grades (P = 0.002), and were treated non-operatively (P = 0.001).ConclusionsBTAI seems not common in trauma, however, one quarter of cases died in a level 1 trauma center, prehospital deaths were not analyzed, and postmortem examination was lacking. The associated head injury and aortic injury grade have an impact on the management option and hospital outcome. The conservative and TEVAR options were performed almost equally in 78% of cases. TEVAR and open surgery were performed only for aortic injury grade III or IV whereas the conservative treatment was offered for selected cases among the 4 injury grades. However, the mortality was higher in the conservative followed by the open surgery group and mostly due to the associated severe head injury. TEVAR should be considered for patients requiring intervention unless contraindicated due to technical difficulties. Appropriately selected patients with low-grade injuries may be managed conservatively. Long-term follow-up is needed in young adults for concerns of aortic remodeling and complications.

Outcomes in Blunt vs Penetrating Pelvic Vascular Injuries.

The purpose of this study is to determine if there is a difference in outcomes for patients with blunt and penetrating vascular injuries of the pelvis. Data were abstracted from the Trauma Quality Improvement Program database from 2011 to 2015. Patients >18 years with hypogastric, iliac, uterine, or ovarian arterial or venous injuries were included. Individuals with an AIS head or chest score >3 were excluded. Of the 2559 patients included, the mean age was 43 years (±19), 75.25% were male, and 32.6% had a comorbidity. 64.9% presented with blunt injury (mean ISS of 23 (±12)). 74.9% experienced a complication. The median hospital length of stay (LOS) and ICU LOS were 10days and 4 days, respectively. 6.7% had an adverse discharge. Mortality occurred in 8.3%. On bivariate analysis, patients who sustained blunt trauma were older (51 vs 31years), female (32.7% vs 10.1%), had a higher ISS (25.71 vs 17.65), and had a longer hospital LOS (16.65 vs 13.88). Patients with penetrating trauma had an increased chance of complications (78.4% vs 73.0%) and mortality (10.7% vs 7.0%). Multivariate analysis revealed in patients with blunt injuries have more complications (OR: 1.950 CI: 0.886-4.291 P = .097), a lower ISS (OR: 0.919, CI: 0.908-0.930, P < .001, were more likely to have an adverse discharge (OR: 2.05, CI: 1.62-2.60, P = .000), and had a higher risk of mortality (OR: 4.08 CI: 2.78-6.41 P < .000). Patients with blunt pelvic vessel injuries are at risk for an increased number of complications and have a higher risk of mortality. Those who survive are more likely to have an adverse discharge.