Level-1 Trauma Center Research Articles

Abstract Su908: Unfavorable prognostic features and temporal trends in Out-of-Hospital Cardiac Arrests (OHCA) presenting to an Academic Center at the Border in El Paso

Introduction: Early recognition of cardiac arrest with bystander cardiopulmonary resuscitation (CPR), and early defibrillation when appropriate, can improve outcomes after Out of Hospital Cardiac Arrest (OHCA). Data from the national registries indicate there are both regional as well racial and ethnic differences in rates of bystander CPR in witnessed OHCA cases with significantly lower rates of bystander CPR in non-white persons. However, Hispanic as well border populations are underrepresented in these studies. University Medical Center (UMC) El Paso, Texas is an academic medical center located 1 mile from the US- Mexico border which is also the only not for profit safety net hospital with a Level1 trauma center. Research Question: Outcomes after OHCA are strongly affected by peri-arrest circumstances including bystander CPR and certain features portend poor outcomes. We performed a descriptive observational study of OHCA cases presenting to UMC to analyze temporal trends in these factors in our community as local data from El Paso is currently not reported in any registries. Methods: We collaborated with the El Paso Fire Department (EPFD) to obtain resuscitation data on patients who suffered OHCA and were brought to the University Medical Center (UMC)Emergency Department (ED) and created a registry of patients who suffered OHCA in El Paso FROM 2017 to Nov 2021. Results: Initial analysis identified around 698 predominantly Hispanic patients who suffered OHCA. Of these 115 were due to non-cardiac causes such as trauma, and 583 were possible cardiac etiology. OHCA cases peaked in 2020 coinciding with COVID 19 surge. Less than one third (31.5%) had bystander CPR with only 11.9% having a shockable rhythm. 64% did not achieve Return of spontaneous circulation in the field. 39% expired in the ED or in the field. We also performed a temporal analysis of these features and bystander CPR rates peaked in 2019 (38.1%to 24.8% in 2021). Conclusion: In our Hispanic underserved population in El Paso, we identified poor outcomes after OHCA, with non-shockable rhythm being the most common adverse feature and decreased rates of bystander CPR (31.5%) with further decrease after 2019. Local community level data which is critical for appropriate local resource allocation to improve OHCA outcomes is missing from underserved populations and additional resources are required improve outcomes.

Blood and Bone-Derived DNA Methylation Ages Predict Mortality After Geriatric Hip Fracture: A Pilot Study.

The purpose of this study was to (1) perform the first analysis of bone-derived DNA methylation, (2) compare DNA methylation clocks derived from bone with those derived from whole blood, and (3) establish a relationship between DNA methylation age and 1-year mortality within the geriatric hip fracture population. Patients ≥65 years old who presented to a Level-I trauma center with a hip fracture were prospectively enrolled from 2020 to 2021. Preoperative whole blood and intraoperative bone samples were collected. Following DNA extraction, RRBS (reduced representation bisulfite sequencing) libraries for methylation clock analysis were prepared. Sequencing data were analyzed using computational algorithms previously described by Horvath et al. to build a regression model of methylation (biological) age for each tissue type. Student t tests were used to analyze differences (Δ) in methylation age versus chronological age. Correlation between blood and bone methylation ages was expressed using the Pearson R coefficient. Blood and bone samples were collected from 47 patients. DNA extraction, sequencing, and methylation analysis were performed on 24 specimens from 12 subjects. Mean age at presentation was 85.4 ± 8.65 years. There was no difference in DNA extraction yield between the blood and bone samples (p = 0.935). The mean follow-up duration was 12.4 ± 4.3 months. The mortality cohort (4 patients, 33%) showed a mean ΔAgeBone of 18.33 ± 6.47 years and mean ΔAgeBlood of 16.93 ± 4.02 years. In comparison, the survival cohort showed a significantly lower mean ΔAgeBone and ΔAgeBlood (7.86 ± 6.7 and 7.31 ± 7.71 years; p = 0.026 and 0.039, respectively). Bone-derived methylation age was strongly correlated with blood-derived methylation age (R = 0.81; p = 0.0016). Bone-derived DNA methylation clocks were found to be both feasible and strongly correlated with those derived from whole blood within a geriatric hip fracture population. Mortality was independently associated with the DNA methylation age, and that age was approximately 17 years greater than chronological age in the mortality cohort. The results of the present study suggest that prevention of advanced DNA methylation may play a key role in decreasing mortality following hip fracture. Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Radiographic Outcomes of Flexible and Rigid Fixation Techniques of Syndesmotic Injuries Across Various Body Mass Indices: A Retrospective Analysis

In the setting of ankle trauma, surgical management of syndesmosis injury involves screw fixation and suture button technique. The efficacy of flexible (suture button) versus rigid (screw) fixation in the management of syndesmotic injury has been investigated extensively in current literature. There is sparse data comparing these two techniques across different body mass indices (BMI). In this study, two fellowship-trained foot and ankle surgeons at urban level-1 trauma centers reviewed blinded post-operative ankle radiographs of BMI-stratified patients undergoing syndesmotic fixation. A total of 79 patients were included for analysis based on inclusion and exclusion criteria. There were 42 patients in the screw fixation group and 37 patients in the suture button group. The average follow-up period was 5.5 months. No significant difference was found in the average radiographic measurements when comparing the two fixation types, regardless of BMI parameters. This was consistent when analyzing individual fixation types stratified by BMI, as well as when comparing BMI groups stratified by fixation type. Additionally, the distribution of body mass index was even across both fixation types. Our study demonstrates that both fixation groups achieved comparable anatomic ankle reduction regardless of body mass index. The authors suggest expanding the indication of suture button fixation to include the higher body mass index patients.

Platelet to erythrocyte ratio and mortality in massively transfused trauma patients.

BackgroundThe optimal transfusion ratio of platelets (PLT), plasma and red blood cells (RBC) in trauma patients with massive haemorrhage is still a subject of discussion. The objective of this study is to assess the effect of platelet transfusion on mortality in trauma patients who received massive transfusion. MethodsData were collected from four Dutch level-1 trauma centres. All trauma patients aged ≥ 16 years who received ≥ 6 RBC / 6 hours from the time of injury were included. Patients were divided based on PLT:RBC ratio (no platelets, low (<1:5) and high (≥1:5)). Primary outcome measure was 6-hour mortality and secondary outcomes included mortality at other time points and transfusion characteristics. ResultsA total of 292 patients were included. Patients in the high PLT ratio group had lower mortality rates at six and 12 hours as compared to the low PLT ratio and no PLT group. In the high PLT group mortality as a result of exsanguination (12%) was significantly lower as compared to the low PLT group (23%). High PLT ratio had lower probability for 6-hour mortality multivariable analysis. Higher plasma:RBC ratios were associated with lower mortality at all time points. ConclusionsAlthough the optimal patient specific transfusion strategy in patients with traumatic haemorrhage is still not resolved, these results show that higher PLT to RBC ratios are associated with lower early mortality.

Pilot deployment of a machine-learning enhanced prediction of need for hemorrhage resuscitation after trauma – the ShockMatrix pilot study

ImportanceDecision-making in trauma patients remains challenging and often results in deviation from guidelines. Machine-Learning (ML) enhanced decision-support could improve hemorrhage resuscitation.AimTo develop a ML enhanced decision support tool to predict Need for Hemorrhage Resuscitation (NHR) (part I) and test the collection of the predictor variables in real time in a smartphone app (part II).Design, setting, and participantsDevelopment of a ML model from a registry to predict NHR relying exclusively on prehospital predictors. Several models and imputation techniques were tested. Assess the feasibility to collect the predictors of the model in a customized smartphone app during prealert and generate a prediction in four level-1 trauma centers to compare the predictions to the gestalt of the trauma leader.Main outcomes and measuresPart 1: Model output was NHR defined by 1) at least one RBC transfusion in resuscitation, 2) transfusion ≥ 4 RBC within 6 h, 3) any hemorrhage control procedure within 6 h or 4) death from hemorrhage within 24 h. The performance metric was the F4-score and compared to reference scores (RED FLAG, ABC). In part 2, the model and clinician prediction were compared with Likelihood Ratios (LR).ResultsFrom 36,325 eligible patients in the registry (Nov 2010—May 2022), 28,614 were included in the model development (Part 1). Median age was 36 [25–52], median ISS 13 [5–22], 3249/28614 (11%) corresponded to the definition of NHR. A XGBoost model with nine prehospital variables generated the best predictive performance for NHR according to the F4-score with a score of 0.76 [0.73–0.78]. Over a 3-month period (Aug—Oct 2022), 139 of 391 eligible patients were included in part II (38.5%), 22/139 with NHR. Clinician satisfaction was high, no workflow disruption observed and LRs comparable between the model and the clinicians.Conclusions and relevanceThe ShockMatrix pilot study developed a simple ML-enhanced NHR prediction tool demonstrating a comparable performance to clinical reference scores and clinicians. Collecting the predictor variables in real-time on prealert was feasible and caused no workflow disruption.

Prognostic significance of inferior vena cava volume defined by initial polytrauma CT-imaging: single-center experience of a level-1 trauma center

BackgroundThe significance of computed tomography (CT)-based volume measurement of the inferior vena cava (IVC) in the treatment and prognosis of trauma patients is not yet fully understood. The conflicting results that have been reported may be attributable to differences in injury severity and the use of different measurement methods, including IVC index and volumetry. The purpose of this study was to determine the relationship between IVC volume and red blood cell (RBC) transfusion and mortality in intubated trauma patients who were stable enough for initial CT imaging.MethodsA retrospective analysis was conducted on all consecutive trauma patients who underwent emergency tracheal intubation and mechanical ventilation before initial whole-body CT imaging at a level-1 trauma center over a 12-year period (2008–2019). The IVC volume was determined on initial trauma CT and included in multivariable models with demographic and diagnostic data. Associations of overall RBC transfusion, massive transfusion, 24-h mortality, and 30-day mortality were assessed using logistic regression analyses and Cox proportional hazard models.ResultsA total of 438 patients (75.3% male) with a median age of 50 years, and a median injury severity score (ISS) of 26 points were included in the analysis. Most of the patients (97.5%) had suffered from blunt trauma mechanisms. Median IVC volume was 36.25 cm3, and RBC transfusion and massive transfusion were performed in 197 and 90 patients, respectively. The 24-h and 30-day mortality rates were 7.3% and 23.3%, respectively. VCI volume was found to be independently associated with the necessity of RBC transfusion and 24-h mortality (OR 0.98, 95% CI 0.96–0.99, p = 0.01 and HR 0.96, 95% CI 0.93–0.99, p = 0.025, respectively), while associations with massive transfusion and 30-day mortality were not statistically significant in multivariable analyses.ConclusionInitial IVC volume may serve as a predictor of patients at risk for overall RBC transfusion requirements and 24-h mortality, suggesting the possibility of its diagnostic efficacy in short-term outcomes. Further studies are needed to confirm these findings.

Hardware Removal After Lisfranc ORIF Results in Improved Physical Function.

The purpose of this study was to investigate whether HWR after Lisfranc ORIF resulted in significant impact via PROMIS physical function (PF) and pain intensity (PI) scores. Design: Retrospective cohort. Level-1 trauma center. Adult patients with isolated Lisfranc injuries who were treated via ORIF between 2002-2023 that had PROMIS PF and PI scores through 6 months follow-up were included. Patients were excluded if they received index treatment other than ORIF or underwent secondary surgical intervention prior to HWR. A sub analysis was performed at 1 year follow- up. Primary outcomes were PROMIS PF and PI scores. The Wilcoxon signed-rank test compared differences between PROMIS scores within the HWR group. The Wilcoxon ranked-sum test compared differences between HWR vs no HWR. Distributive MCID was calculated using the 0.5 SD method. There were 482 patients (489 feet) identified with isolated Lisfranc injuries. Seventy-seven feet underwent ORIF followed by HWR. Thirty feet underwent ORIF without HWR. The average age of the no HWR group was 45.8 (18.0-81.3) versus the HWR group which was 38.7 (18.3-74.1) (p=0.053). Nineteen (63.3%) were female in the no HWR group compared to 33 (42.9%) in the HWR group (p=0.084). HWR occurred an average of 4.43 months after ORIF. Patients who underwent HWR had a statistically significant increase in average PF scores (39.7 to 45.9, p<0.001) at their standard 6 week (1.5 month) postoperative visit. HWR patients had a non-significant decrease in average PI scores (56.5 to 53.9, p=0.24). Compared to those with retained hardware, the HWR group demonstrated a statistically significant net improvement in PF and PI scores from surgery, with an average improvement of 5.6 and 1.7, respectively (P=0.002, 0.008). Patients experienced significant improvement in PROMIS PF scores for Lisfranc ORIF at 6 weeks after HWR. Compared to patients with retained hardware, they also experienced significant improvement in PROMIS PF and PI scores. III.

Traumatic Aortic Disruption Index is Associated with Mortality and Urgency of Stent Grafting in Blunt Thoracic Aortic (Grade 3) Injuries

ObjectiveDelayed stent grafting for blunt thoracic aortic injuries (BTAI) is current standard of care. However, given the heterogeneity of pseudoaneurysm presentations, it is currently unclear which severe BTAIs require more urgent intervention. We hypothesize that a Traumatic Aortic Disruption Index (TADI) calculation based on sagittal computed tomography angiography (CTA) imaging measurements would correlate with urgency of stent grafting. MethodsAll patients at a level-1 trauma center with BTAIs over a 12-year period were identified. A TADI score was then calculated using the length of pseudoaneurysm (L), maximum width of pseudoaneurysm (W), and normal adjacent aortic diameter (NA) (Figure1). Patient presentation, injury characteristics, timing of stent grafting, and outcomes were then evaluated. ResultsForty-two patients were diagnosed with BTAIs. Mean age was 37.6 years, with a median injury severity score (ISS) of 29. Overall mortality was 11.9%. TADI scores ranged from 3.6 to 158.6. Compared to patients with a TADI<28, patients with TADI>28 had similar median ISS scores (34 vs 29, p=0.16), and rates of both traumatic brain injury (33.3% vs 42.0%, p=0.53) and non-aortic hemorrhage control procedures (44.4% vs 33.3%, p=0.3). TADI>28 patients had a lower initial mean systolic BP (98.5 vs 121.9, p=.003), more severe hypotension (lowest systolic 77.0 vs 91.2, p=.034), lower initial GCS (6 vs 13, p=.039), higher mean admission lactate (4.6 vs 3.3, p=.036), and higher overall mortality (23.8% vs 0%, p=.048). Patients with TADI>28 received stent grafting at significantly shorter median time intervals from injury identification (median 4 hrs vs 14 hrs, p=.001). Overall causes of mortality were aortic hemorrhage related (n=3, 60%) and traumatic brain injury (n=2, 40%). ConclusionThis simple-to-calculate index is independently correlated with mortality and urgency of stent grafting in blunt trauma patients with similar ISS. Patients with TADI scores >28 were more likely to undergo urgent stent grafting, thereby suggesting a trend in practice patterns with higher scores representing injuries that should be considered for expedited operative management. The TADI score should be validated in a larger sample of blunt trauma patients as an injury prioritization tool in the multi-system injured patient.

Sociodemographic Characteristics and Outcomes of Surgically Managed Central Cord Syndrome Patients

IntroductionUndiagnosed cervical spine stenosis is a risk factor for central cord syndrome (CCS), especially in vulnerable individuals. Social determinants of health (SDOH) are correlated with health outcomes. The aim of this study was to characterize the sociodemographic characteristics and outcomes in surgically-treated central cord syndrome (CCS) patients, and explore potential associations between them. MethodsThis is a retrospective cohort study of surgically-treated CCS patients at a Level-1 trauma center between 2015-2021. Patient demographics, radiological findings, and clinical outcomes were collected. SDOH were estimated using the Social Deprivation Index (SDI) and Area Deprivation Index (ADI). Descriptive statistics and regression analyses assessed associations between SDI/ADI, demographics and clinical outcomes. ResultsOf 56 patients, 75% were insured by Medicare/Medicaid and 70% were discharged to care facilities. Mean SDI was 66.4±24.4, and mean ADI was 7.4±2.2. Three patients required reoperation for post-operative complications. Post-operative neurologic outcomes varied, with 60.7% stable, 30.4% improved, and 8.9% declined. While SDI/ADI did not correlate with outcomes, higher ADI quartiles were associated with decreased likelihood of home discharge (p=0.048). Decline in neurologic function was associated with Medicare/Medicaid or Military insurance (p=0.011). ConclusionsThe results of this study indicated that CCS patients typically come from lower socioeconomic backgrounds, as indicated by high SDI and ADI scores. Despite this, we did not find significant correlations between SDI or ADI with post-operative outcomes, and most patients had stable or improved neurological function post-surgery in our cohort. Future studies with larger sample sizes will provide a more comprehensive understanding of these findings.

Recovery of Comfort and Capability After Upper Extremity Fracture Is Predominantly Associated With Mindset: A Longitudinal Cohort From the United Kingdom

OBJECTIVES: To determine the relative influence of mindset and fracture severity on 9-month recovery trajectories of pain and capability after upper extremity fractures. METHODS: Design: Secondary use of longitudinal data. Setting: Single Level-1 trauma center in Oxford, United Kingdom. Patient selection: English-speaking adults with isolated proximal humerus, elbow, or distal radius fracture managed operatively or nonoperatively were included, and those with multiple fractures or cognitive deficit were excluded. Outcome measures and comparisons: Incapability (Quick-DASH) and pain intensity (11-point rating scale) were measured at baseline, 2–4 weeks, and 6–9 months after injury. Cluster analysis was used to identify statistical groupings of mindset (PROMIS Depression and Anxiety, Pain Catastrophizing Scale, and Tampa Scale for Kinesiophobia) and fracture severity (low/moderate/high based on OTA/AO classification). The recovery trajectories of incapability and pain intensity for each mindset grouping were assessed, accounting for various fracture-related aspects. RESULTS: Among 703 included patients (age 59 ± 21 years, 66% women, 16% high-energy injury), 4 statistical groupings with escalating levels of distress and unhelpful thoughts were identified (fracture severity was omitted considering it had no differentiating effect). Groups with less healthy mindset had a worse baseline incapability (group 2: β = 4.1, 3: β = 7.5, and 4: β = 17) and pain intensity (group 3: β = 0.70 and 4: β = 1.4) (P &lt; 0.01). Higher fracture severity (β = 4.5), high-energy injury (β = 4.0), and nerve palsy (β = 8.1) were associated with worse baseline incapability (P &lt; 0.01), and high-energy injury (β = 0.62) and nerve palsy (β = 0.76) with worse baseline pain intensity (P &lt; 0.01). Groups 3 and 4 had a prolonged rate of recovery of incapability (β = 1.3, β = 7.0) and pain intensity (β = 0.19, β = 1.1) (P &lt; 0.02). CONCLUSIONS: Patients with higher levels of unhelpful thinking and feelings of distress regarding symptoms experienced worse recovery of pain and incapability, with a higher effect size than fracture location, fracture severity, high-energy injury, and nerve palsy. These findings underline the importance of anticipating and addressing mental health concerns during recovery from injury. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Etiological and epidemiological analysis of patella fractures: evaluation of COVID-19 pandemic and lockdown era effects

Background: Patella fractures are relatively rare, but significant public health burden with consequences ranging from skin problems to extensor mechanism deficiencies and patellofemoral arthrosis due to their significant effects on pain, functionality, and quality of life. It was aimed to present basic etiological, and epidemiological information about patella fractures and to evaluate the impact of the COVID-19 Pandemic and lockdown era period. Methods: All patellar fractures admitted to a stage-1 trauma center between 2016 and 2022 were collected retrospectively. Patient's gender, age, side, fracture classification, trauma mechanism, treatment method, admission day and season, accompanying extremity, and non-musculoskeletal/visceral pathologies were recorded and analyzed. Results: A retrospective evaluation was conducted on 304 patients, with 181 (59.5%) males and 123 (40.5%) females, with an average age of 46±19 years. Most patients were between 30-65 (51.4%) and the most common cause was simple falls (74%). Fractures mostly occurred in the winter (35.2%) and on Sundays (19.7%). 9.9% of the patients were accompanied by extremity traumas and 6.9% by non-musculoskeletal injuries. Regarding the descriptive classification, transverse, distal pole, and proximal pole; and according to the AO/OTA classification, C1 was the most common. Conclusion: The incidence of patella fractures is increasing. Non-surgical treatment is a priority, and the complication rates of surgical treatment are considerable. The study, which presents etiological and epidemiological data of level-1 trauma center patients, is a suitable sample for Türkiye. The study is unique in showing the potential effects of COVID-19 on the patient profile and treatment management of patella fractures.

TBI related death has become the new epidemic in polytrauma: a 10-year prospective cohort analysis in severely injured patients.

Advances in trauma care have attributed to a decrease in mortality and change in cause of death. Consequently, exsanguination and traumatic brain injury (TBI) have become the most common causes of death. Exsanguination decreased by early hemorrhage control strategies, whereas TBI has become a global health problem. The aim of this study was to investigate trends in injury severity,physiology, treatment and mortality in the last decade. In 2014, a prospective cohort study was started including consecutive severely injured trauma patients > 15years admitted to a Level-1 Trauma Center ICU. Demographics,physiology,resuscitation, and outcome parameters were prospectively collected. Five hundred and seventy-eight severely injured patients with predominantly blunt injuries (94%) were included. Seventy-two percent were male with a median age of 46 (28-61) years, and ISS of 29 (22-38). Overall mortality rate was 18% (106/578) with TBI (66%, 70/106) being the largest cause of death. Less than 1% (5/578) died of exsanguination. Trend analysis of the 10-year period revealed similar mortality rates despite an ISS increase in the last 2years. No significant differences in demographics,and physiology in ED were noted. Resuscitation strategy changed to less crystalloids and more FFP. Risk factors for mortality were age,brain injury severity,base deficit,hypoxia,and crystalloid resuscitation. TBI was the single largest cause of death in severely injured patients in the last decade. With an aging population TBI will increase and become the next epidemic in trauma. Future research should focus on brain injury prevention and decreasing the inflammatory response in brain tissue causing secondary damage, as was previously done in other parts of the body.

Epidemiology of postinjury multiple organ failure: a prospective multicenter observational study.

Postinjury multiple organ failure (MOF) is the sequela to the disease of polytrauma. We aimed to describe the contemporary population-based epidemiology of MOF within a mature trauma system, to analyse the time taken for MOF to develop, and to evaluate the temporal patterns and contributions of the individual constituent organ failures. Prospective observational study conducted across five Level-1 trauma centers in New South Wales, Australia. Trauma patients at-risk of MOF (Denver > 3 from 48h post-admission), aged > 16 years, ISS > 15, and who stayed in ICU for ≥ 48h were eligible for inclusion. From May 2018-February 2021, 600 at-risk polytrauma patients were prospectively enrolled (mean(SD)age = 49(21)years, males = 453/600(76%),median(IQR)ISS = 26(20,34)). MOF incidence was 136/600(23%) among at-risk patients, 142/6248(2%) among major trauma patients (ISS > 12 per Australian definition), and 0.8/100,000 in the general population. The mortality rate was 55/600(11%) in the overall study population, and 34/136(25%) in MOF patients. 82/136(60%) of MOF patients developed MOF on day-3. No patients developed MOF after day-13. Among MOF patients, 60/136(44%) had cardiac failures (mortality = 37%), 39/136(29%) had respiratory failures (mortality = 23%), 24/136(18%) had renal failures (mortality = 63%), and 12/136(9%) had hepatic failures (mortality = 50%). Although a rare syndrome in the general population, MOF occurred in 23% of the most severely injured polytrauma patients. When compared to previous risk-matched cohorts, MOF become more common, but not more lethal, despite a decade older cohort. The heart has superseded the lungs as the most common organ to fail. Cardiac and respiratory failures occurred earlier and were associated with lower mortality than renal and hepatic failures.

The neuronal biomarker NSE correlates with the volume of lung contusion in polytraumatized patients.

Severe injuries caused by accidents, like traumatic brain injury (TBI) or thoracic trauma (TT) continue to be the leading cause of death in younger people with relevant socio-economic impact. Fast and targeted diagnostics is essential for further therapy decisions and prognosis. The following study investigates NSE as a potential biomarker for lung injury after blunt TT. This is a retrospective analysis of prospectively collected data in a level-1 trauma center from 2014 to 2020. Serum levels of Neuron-specific Enolase (NSE) and Interleukins (IL-6, IL-10) in injured patients (n = 41) with isolated TT (AISthorax ≥ 3) compared to isolated TBI (AIShead ≥ 3) were assessed from day 0 to 5 after trauma. The extend of lung injury was quantified by Hounsfield scale in CT scans. 30 patients with TT (ISSmed = 20, age 50y ± 17, 83,3% male) and 11 patients with TBI (ISSmed = 25, age 54y ± 17,27,3% male) were included. After TT, NSE concentration increased initially after trauma with a peak value on the day of admission (8.51 ± 3.68 ng/ml) compared to healthy controls (4.51 ± 1.504 ng/ml, p < 0.001). Isolated thoracic trauma and TBI lead to equally strong NSE release ad the day of admission. There is a significant linear relationship (r = 0.636, p = 0.035) between serum NSE levels and severity of pulmonary contusion at the time of admission and after 24 hours. A significant NSE release after isolated thoracic trauma peaks on the day of admission. The extent of lung contusion volume (defined as alveolar parenchymal density) correlates with NSE serum concentration. Thus, NSE has predictive value for the extent of pulmonary contusion. However, according to these data, NSE seems to have no diagnostic value as a TBI biomarker in concomitant TT.

Firearm violence and associated factors among young adults presenting to emergency departments in three cities: Baseline results from Project SPARK

ObjectiveRecent shifts in U.S. violence dynamics call for updated violence epidemiology among general emergency department (ED) samples of young adults. Using baseline data from a multi-site longitudinal study of firearm violence prediction, we describe violence rates and associated factors. MethodsStaff approached age 18–24 entrants to Level-1 trauma centers in three cities (Flint, Seattle, Philadelphia; 7/2021–5/2023). Consenting participants completed a survey including validated measures of violence experience, firearm-related behaviors, substance use, mental health symptoms, peer/parental/familial behaviors, community violence, and attitudes/norms. We described the sample and examined factors associated with firearm assault (victimization/aggression, including threats). ResultsAcross sites, 1506 participants enrolled (41.7. % Black; 33.6 % White; 61.4. % female). Half of participants self-reported past-six-month violent victimization and/or aggression; non-partner violence, and violent victimization were most common. Over half of participants self-reported high-risk substance use, and over half screened positive for post-traumatic stress disorder, depression, and/or anxiety. About 14.4 % self-reported past-six-month firearm assault, and 5.9 % self-reported firearm violence (excluding threats). Adjusted analysis showed community violence exposure was most strongly associated with firearm assault; each one-point-increase corresponded to a 13.7 % (95 %CI: 10.4 %–16.9 %) absolute increase in firearm assault prevalence. Drug misuse, mental health symptoms, firearm carrying, retaliatory attitudes, prosocial attitudes, and family conflict were also associated with firearm assault. ConclusionsViolence, including firearm assault, is common among young adults entering urban EDs, and is associated with several psychosocial factors. High rates of substance use and mental health symptoms underscore this as a high-need population. Leveraging this information could help tailor interventions and optimize resource allocation.

Geriatric Trauma Intensive Care Unit Admission Guideline Is Associated With Reduction in Unplanned Intensive Care Unit Admissions

IntroductionGeriatric trauma patients experience disproportionate adverse outcomes compared to younger patients with similar injuries and represent an important target for quality improvement. Our institution created a Geriatric Trauma Intensive Care Unit (ICU) Admission Guideline to identify high-risk patients and elevate their initial level of care. The goal of implementation was reducing unplanned ICU admissions (UIAs), a recognized surrogate marker for adverse outcomes. MethodsThe Geriatric Trauma ICU Admission Guideline was implemented on July 1, 2020, at a large academic level-1 trauma center. Using trauma registry data, we retrospectively analyzed geriatric patients who met the criteria for ICU admission 2 y preimplementation and postimplementation. The main outcome was UIAs in the target geriatric population. Secondary outcomes included hospital length of stay, ICU length of stay, ventilator days, mortality, and 30-d readmissions. Characteristics between groups were compared with t-test, Mann-Whitney U test, or chi-square test. Risk-adjusted logistic and negative binomial regressions were used for the categorical and continuous outcomes, respectively. ResultsA total of 1075 patients were identified with 476 in the preimplementation and 599 in the postimplementation group. The groups were similar across most demographic and physiologic characteristics, with the exception of a higher incidence of hypertension in the preimplementation group (77.7% versus 71.6%, P = 0.02) and COVID in the postimplementation group (3.8% versus 0.4%, P < 0.001). While mechanism of injury was similar, there was a higher incidence of traumatic brain injury in the preimplementation group (35.1% versus 26.2%, P = 0.002). In the postimplementation group, there was a higher incidence ≥3 rib fractures (68% versus 61.3%, P = 0.02) and an expected increase in initial ICU level of care (69.5% versus 37.1%, P < 0.001). The odds of a UIA after guideline implementation were reduced by half (adjusted odds ratio 0.52, 95% confidence interval 0.3-0.92). There was not a significant difference in the secondary outcomes of mortality, 30-d readmission, hospital-free days, ICU-free days, or ventilator-free days. ConclusionsImplementation of the Geriatric Trauma ICU Admission Guideline was associated with a reduction in UIAs by half in the target population. There was not a significant change in hospital-free days, ICU-free days, ventilator-free days, mortality, 30-d readmission, or venous thromboembolism. Further research is needed to better refine admission guidelines, examine the association of preventative admission on delirium, and determination of criteria that would allow safe, earlier downgrade.

Predicting nosocomial pneumonia risk in level-1 trauma patients: An external validation study using the trauma quality improvement program

BackgroundEarly identification of patients at risk of nosocomial pneumonia enables the opportunity for preventative measures, which may improve survival and reduce costs. Therefore, this study aimed to externally validate an existing prediction model (issued by Croce et al.) to predict nosocomial pneumonia in patients admitted to US level-1 trauma centers. MethodsA retrospective cohort study including patients admitted to level-1 trauma centers and registered in the TQIP, a US nationwide trauma registry, admitted between 2013–2015 and 2017–2019. The main outcome was total nosocomial pneumonia for the first period and ventilator-associated pneumonia (VAP) for the second. Model discrimination and calibration were assessed before and after recalibration. ResultsThe study comprised 902,231 trauma patients (N2013–2015 ​= ​180,601; N2017–2019 ​= ​721,630), with a median age of 52 in both periods, 64–65 ​% male, and approximately 90 ​% sustaining blunt traumatic injury. The median Injury Severity Scores were 13 (2013–2015) versus 9 (2017–2019); median Glasgow Coma Scale scores were 15. Nosocomial pneumonia incidence was 4.4 ​%, VAP incidence was 0.7 ​%. The original model demonstrated good to excellent discrimination for both periods (c-statistic2013–2015 0.84, 95%CI 0.83–0.84; c-statistic2017–2019 0.92, 95%CI 0.91–0.92). After recalibration, discriminatory capacity and calibration for the lower predicted probabilities improved. ConclusionsThe Croce model can identify patients admitted to US level-1 trauma centers at risk of total nosocomial pneumonia and VAP. Implementing (modified) Croce models in route trauma clinical practice could guide judicious use of preventative measures and prescription of additional non-invasive preventative measures (e.g., increased monitoring, pulmonary physiotherapy) to decrease the occurrence of nosocomial pneumonia in at-risk patients.

Acetabular fracture in India: An epidemiological study

IntroductionAcetabular fractures, resulting from high-energy trauma, present significant orthopaedic challenges. Despite their rarity, the incidence of these fractures is rising, necessitating a comprehensive understanding of their epidemiological characteristics, especially in diverse populations like India. MethodsThis retrospective study analyzed data from 3643 patients across four level-1 trauma centers in India (North 1, North 2, West, and South) from January 2001 to December 2019. Prior ethical approval was obtained from the respective institutions. Data were collected using the computerized patient record system (CPRS) and included patients with complete clinical and radiological records. Only patients with full radiological data were included, comprising standard anteroposterior radiograph, Judet views on radiographs, and computed tomography scan of the pelvis. The study evaluated the demographic characteristics, fracture patterns and surgical approaches. ResultsThe majority of patients were males (84.05 %) and the fractures were mostly seen in young individuals between 19 and 40 years’ age group (44.9 %), followed by 41–60 years (42.3 %). Associated bony or other system injuries were seen in 53.42 % of patients, with pelvic injuries being the most common (9.8 %). Posterior wall fractures were the most frequent (20.7 %), while anterior wall fractures were the least common (0.8 %). Operative management was employed in 82 % of cases, with the Kocher-Langenbeck approach being the most commonly employed (42.5 %). ConclusionHigh-velocity trauma remains the commonest cause of acetabular trauma in India, primarily affecting young male individuals. Pelvic fractures are the most commonly associated injuries. Posterior wall fractures are the commonest type of acetabular fracture, and the Kocher-Langenbeck approach is the commonly adopted surgical approach.

Is patient-reported outcome after treatment of unstable pelvic ring injuries related to pelvic symmetry? A prospective study.

To determine the relation between pelvic symmetry, as measured by the cross-measurement technique, and patient-reported outcome measures (PROMs) in terms of functional status and health-related quality of life. In this prospective cohort study, X and Y measurements were taken according to the cross-measurement technique on AP radiographs of patients who were treated for an unstable pelvic ring injury in a level-1 trauma center. Patients completed PROMs at the time of admission (recalled pre-injury score) and one year following their injury, reporting their functional status with the Short Musculoskeletal Function Assessment (SMFA-NL), specifically the lower extremity dysfunction (LED), problems with daily activities (PDA) and mental and emotional problems (MEP) subscales, and quality of life with EuroQol-5D (EQ-5D). Subgroup analyses were also performed. PROMs were used to analyze the relation between pelvic symmetry and patient-reported outcome, using Spearman's Rank correlation coefficients. A total of 130 patients (mean age 58 (SD18) years) with an unstable pelvic ring injury were included, of which 95 (73%) sustained type-B injuries and 35 (27%) type-C injuries. Sixty-three (49%) patients were treated operatively. The median pelvic symmetry ratio was 1.01 (IQR: 0.05). Weak or no correlations were found between the pelvic symmetry scores and the outcome measurements (Spearman's correlation coefficients: LED r = 0.09; PDA r = 0.11; MEP r=-0.02; and EQ-5D r=-0.08). Subgroup analyses revealed no correlations. No significant relation was found between pelvic symmetry, measured radiologically, and functional status and health-related quality of life, one year following an unstable pelvic ring injury.

Body composition parameters in initial CT imaging of mechanically ventilated trauma patients: Single-centre observational study.

Body composition parameters provide relevant prognostic significance in critical care cohorts and cancer populations. Published results regarding polytrauma patients are inconclusive to date. The goal of this study was to analyse the role of body composition parameters in severely injured trauma patients. All consecutive patients requiring emergency tracheal intubation and mechanical ventilation before initial computed tomography (CT) at a level-1 trauma centre over a 12-year period (2008-2019) were reanalysed. The analysis included CT-derived body composition parameters based upon whole-body trauma CT as prognostic variables for 30-day mortality, intensive care unit length of stay (ICU LOS) and mechanical ventilation duration. Four hundred seventy-two patients (75% male) with a median age of 49years, median injury severity score of 26 and 30-day mortality rate of 22% (104 patients) met the inclusion criteria and were analysed. Regarding body composition parameters, 231 patients (49%) had visceral obesity, 75 patients had sarcopenia (16%) and 35 patients had sarcopenic obesity (7.4%). After adjustment for statistically significant univariable predictors age, body mass index, sarcopenic obesity, visceral obesity, American Society of Anesthesiologists classification ≥3, injury severity score and Glasgow Coma Scale≤8 points, the Cox proportional hazard model identified sarcopenia as significant prognostic factor of 30-day mortality (hazard ratio 2.84; 95% confidence interval 1.38-5.85; P=0.004), which was confirmed in Kaplan-Meier survival analysis (log-rank P=0.006). In a subanalysis of 363 survivors, linear multivariable regression analysis revealed no significant associations of body composition parameters with ICU LOS and duration of mechanical ventilation. In a multivariable analysis of mechanically ventilated trauma patients, CT-defined sarcopenia was significantly associated with 30-day mortality whereas no associations of body composition parameters with ICU LOS and duration of mechanical ventilation were observed.