Level-1 Trauma Center Research Articles

Experiences and attitudes towards agitated behaviours in TBI ICU patients (EXSTATIC): understanding various management practices through qualitative interviews with nurses

ABSTRACT Introduction & objectives Agitation is a common complication after an acute TBI in ICU patients. Professionals have a range of strategies to address agitation. Yet the absence of evidence-based guidelines and how these strategies are implemented complicates the management and safety may often be compromised for both ICU professionals and patients. This project explores experiences and attitudes of ICU-nurses to better understand the management of agitated behaviors in acute TBI-patients. Methods Semi-structured interviews were conducted with 12 ICU-nurses from two Level-1 trauma centers in Canada. The interviews explored experiences and perceptions of managing agitation in critically ill TBI-patients. Interviews were analyzed using thematic analysis, facilitating the examination of how management practices interface with contextual variables and clinical strategies. Results Five themes were identified: (1) a variety of symptoms differing according to patient profile and time since awakening, (2) different agitation management approaches stem from different concerns, (3) strategies used by nurses to manage agitation, (4) contextual factors influence management, and (5) potential opportunities to improve integrated care model. Conclusions This research describes nurses’ perceptions and helps understand management of agitation, by considering underlying contexts and factors affecting TBI-agitated patients management, how ICU itself contributes to agitation and potential areas for improvement.

Hardware Removal After Lisfranc Open Reduction and Internal Fixation Results in Improved Physical Function.

The purpose of this study was to investigate whether hardware removal (HWR) after Lisfranc open reduction and internal fixation (ORIF) resulted in significant impact through PROMIS physical function (PF) and pain intensity (PI) scores. Retrospective cohort. Level-1 trauma center. Adult patients with isolated Lisfranc injuries who were treated through ORIF between 2002 and 2023 who 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 before HWR. A subanalysis 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 versus 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) years versus the HWR group that was 38.7 (18.3-74.1) years ( P = 0.053). Nineteen (63.3%) were women in the no HWR group compared with 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 (39.7-45.9, P < 0.001) at their standard 6 weeks (1.5 months) postoperative visit. HWR patients had a nonsignificant decrease in average PI scores (56.5-53.9, P = 0.24). Compared with 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 with patients with retained hardware, they also experienced significant improvement in PROMIS PF and PI scores. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Short-term clinical outcomes of subway-related amputations.

In city hospitals, subway-related traumatic amputations are a frequent pattern of injury, however there is a paucity of literature on this specific injury pattern. The purpose of this study was to describe the epidemiology of subway-related traumatic amputations, as well as compare them to non-subway traumatic amputations. Retrospective review was performed at a single Level-1 trauma center in a metropolitan area. All patients who sustained a traumatic lower-extremity amputation over a seven-year period were included. Demographics, injury, treatment-related information, and complications were collected. Subway and non-subway traumatic amputations were statistically compared. Cohorts were further subdivided into above-knee amputations (AKAs) and below-knee amputations (BKAs) for statistical comparison. Fifty-seven patients sustained 72 traumatic lower-extremity amputations, including 64 subway-related amputations. Fifteen patients with bilateral lower-extremity amputations all had subway-related injuries. Patients with subway-related injuries were more likely to have a history of alcohol use disorder (58.1 % vs. 0 %; P = 0.002), and experienced longer stays in the intensive care unit (ICU) (8.9 vs. 3.6 days; P = 0.006). Twenty-four amputations (33.3 %) were complicated by wound infection during the initial hospitalization, with wound cultures growing a variety of organisms, most frequently Enterococcus species and Enterobacter cloacae. When subway injuries were separated by AKAs and BKAs, patients with AKAs underwent more irrigation and debridement procedures on average (10.3 vs. 5.8; P = 0.006), had a higher rate of wound infections (58.8 % vs. 25.0 %; P = 0.018), and had longer hospital stays (50.4 vs. 32.2 days; P = 0.047). Subway-related amputations are associated with longer ICU stays and a history of alcohol use disorder compared to non-subway traumatic amputations. Approximately 1/3 of these patients are expected to develop a wound infection, with Enterococcus and Enterobacter species being the most commonly identified organisms. Further research into high-energy, traumatic amputations, including subway injuries, may help improve prognostication of patient outcomes, identify potential in-hospital complications, and proactively direct differences in care compared to the standard for non-subway-related amputations. Prognostic Level III.

Perioperative complications in spinal trauma patients: does timing matter?

BackgroundEarly surgery in traumatic spinal fracture treatment may facilitate prompt mobilization, encountering affiliated complications. However, the safety and the benefits of early surgery are being questioned in spinal trauma patients. Therefore, the objective of this retrospective study is to investigate the effect of surgical timing on perioperative complications in these patients.MethodsSpinal trauma patients who underwent surgery between 2010 and 2020 in two Dutch Level-I trauma centers were included retrospectively and divided into an early (< 24 h), late (between 24 and 72 h) and delayed (> 72 h) surgical cohort. The primary outcome was the occurrence of peri-operative complications. Besides surgical timing, trauma and patient-specific factors were also analyzed as potential risk factors for the occurrence of complications.ResultsA total of 394 patients were included, of whom 149 received early, 159 late and 86 delayed surgical treatment. The occurrence of perioperative complications was significantly associated with age, body mass index, comorbidities, ASA grade 3 and 4, spinal cord injury (SCI), AO Spine type C injury, additional chest injury, and surgical delay. A multivariable analysis showed that age, ASA category, AO Spine classification and SCI were significantly associated with perioperative complications. Moreover, a subsequent analysis in non-SCI patients demonstrated an association between perioperative complications and delayed surgery.ConclusionsIn this study, delayed surgical treatment is potentially associated with more perioperative complications compared to early surgery in non-SCI patients. Other possible risk factors for the occurrence of perioperative complications may be older age, ASA 3 and 4, AO spine C injury and SCI.

Prevalence, incidence, and complications of malnutrition in severely injured patients

BackgroundSeverely injured patients may suffer from acute disease-related or injury-related malnutrition involving a marked inflammatory response. This study investigated the prevalence and incidence of malnutrition and its relation with complications in severely injured patients admitted to the intensive care unit (ICU).MethodsThis observational prospective cohort study included severely injured patients (Injury Severity Score ≥ 16), admitted to the ICU of five level-1 trauma centers in the Netherlands and United States. Malnutrition was defined as a Subjective Global Assessment score ≤ 5. Complications included systemic-, surgery-, and fracture-related complications, pneumonia, urinary tract infection, deep venous thrombosis, and pulmonary embolism. In-ICU and in-hospital mortality were recorded separately. The complication rate was compared between patients who had or developed malnutrition and patients who remained well-nourished, using multivariable logistic regression analysis.ResultsOf 100 included patients, twelve (12%) were malnourished at admission. Of the 88 well-nourished patients, 44 developed malnutrition during ICU admission, (ICU incidence 50%, 95% confidence interval [CI] 40–60%). Another 18 patients developed malnutrition at the ward (overall in-hospital incidence 70%, 95% CI 61–80%). The 62 patients who developed malnutrition and 12 patients who were malnourished upon admission had more complications than the 26 patients who remained well-nourished (58% vs. 50% vs. 27% respectively; p = 0.03; Odds Ratio 3.4, 95% CI 1.2–9.6).Conclusions50% of severely injured patients developed malnutrition during ICU admission, increasing to 70% during hospital admission. Malnutrition was related to an increased risk of complications. Recognition of sub-optimally nourished severely injured patients and assessment of nutritional needs could be valuable in optimizing their clinical outcomes.Level of evidenceLevel III, Prognostic/Epidemiological.

Increasing prehospital tourniquet use attributed to non-indicated use: an 11-year retrospective study

PurposeThe use of prehospital tourniquets (PHTQ) for haemorrhage control in the civilian trauma population has increased over the past decade with some reports documenting the overuse of the device. The aim of this study was to identify the proportion of PHTQ use that is non-indicated and determine how this proportion is changing over time.MethodsAn 11-year retrospective study was performed at a Level-1 Trauma Centre on all trauma patients admitted with a PHTQ. Local PHTQ guidelines were used to define non-indicated use. Collected variables included patient demographics, injury characteristics, tourniquet application characteristics, prehospital data, emergency department data, and clinical outcomes. The primary outcome was non-indicated PHTQ use. The secondary outcome was complications attributed to PHTQ use.ResultsThere were 88 PHTQ applications to 88 extremity injuries in 86 patients (n = 86, median (IQR) age 43 (28–57) years, 85% male). PHTQ use was deemed non-indicated in 68 cases (68/88, 77% [95%CI 67-86%]). The proportion of non-indicated PHTQ use increased over the period of the study period (p = 0.03). At least one complication potentially from PHTQ use was seen in 33 patients (33/86, 38%). In patients with prolonged tourniquet time (n = 13), at least one complication from PHTQ use was seen in 11 patients (11/13, 85%).ConclusionOver this 11-year period, we identified that the increase in PHTQ use in civilian trauma is from increasing non-indicated use. Given that complications are associated with unnecessary PHTQ use, the adherence to the guidelines needs to be urgently reinforced.

Predictors of prolonged hospital stay of pelvic ring and acetabular fractures - a retrospective analysis in a 10-year period of a level 1 trauma center.

Pelvic ring and acetabular fractures are among the most complicated and severe injury patterns in orthopaedic trauma surgery. Inpatient treatment is not only costly but also very time-consuming. The aim of this study is to identify predictors leading to a prolonged length of hospital stay. This study is a retrospective review of data of 211 patients admitted to a Level-1 trauma centre. In this cohort a surgical treatment of pelvic ring and acetabular fractures between 2010 and 2020 was performed. Preclinical data and clinical parameters were analysed. Injury severity was the most important factor for a prolonged stay. High-energy trauma resulted in significantly longer hospital stays. Multiple injury had a significant effect. Low haemoglobin levels measured on admission and an increased shock index, as indicators of the severe trauma, could be identified as good predictors of a longer intensive care period and a long total length of stay. Except for the number of surgical procedures to treat the pelvic fracture, surgical approach and technique showed no predictive value. Age and gender do not play a role. Increased patient age does not result in a longer hospital stay or longer intensive care times. Pelvic fractures demonstrate a prolonged hospital stay. It depends on the severity of the injury. There are good predictors of a long length of stay at admission. These include the presence of multiple injury, the complexity of the fractures, haemoglobin levels, and the shock index.

Type B ankle fractures with additional medium-sized posterior fragment: mid-term functional and radiological outcome after fixation versus no fixation of the posterior fragment.

Guidelines for treatment of medium-sized posterior fragments in trimalleolar fractures are scarce and show varying advice. Recent trials comparing fixation and no fixation of posterior fragments, show no difference in outcomes one year postoperatively. This study compares functional outcome and development of osteoarthritis in patients with fixation of a posterior malleolar fracture to patients without fixation of the posterior malleolus fracture. This retrospective cohort study included patients operated for type B ankle fractures with medium-sized (5-25% of joint surface) posterior malleolar fragments in a Dutch level-1 trauma center between 2014 and 2018. ORIF of posterior fragments (FIX) was compared to no fixation (NO-FIX). Choice of treatment was based on the surgeon's preference. Functional outcome was assessed using the AOFAS-score, OMAS-score and VAS-pain. Development of osteoarthritis was assessed on radiographs. A linear regression analysis was performed to identify risk factors for worse functional outcome and osteoarthritis. 27 patients were included in the FIX group and 58 patients in the NO-FIX group. After a median follow-up of 74 months (range 50-108), no difference was observed for functional outcome and pain (median AOFAS 90 vs. 95, OMAS 85 vs. 88, VAS-pain 1 vs. 1; all p > 0.05). Osteoarthritis rates were comparable (grade ≥ 2: 22% in FIX vs. 21% in NO-FIX, p = 0.87). Median fragment size was 15.7% versus 13.6% of the tibial articular surface after FIX and NO-FIX respectively. Median postoperative step-off on radiograph was 0.0mm after FIX and 0.8mm after NO-FIX (p = 0.20). Complication rates, including infection, secondary operation and hardware removal, were comparable. Postoperative step-off > 1mm increased the risk of osteoarthritis (odds ratio 3.9, 95% CI 1.2-12.7). The value of fixation of medium-sized posterior fragments in type B ankle fractures seems limited after mid-term follow-up, although functional impairment caused by osteoarthritis might develop in the long-term. Because postoperative step-off > 1mm increases the risk of osteoarthritis, restoration of the tibial plafond seems essential.

The differences in injury patterns and outcomes of thoracic trauma between rural and urban level two trauma centers in a single country.

Equal level trauma centers in the same country might have significant differences regarding their demographics and types of trauma. Understanding geographic variations in injury patterns are essential for optimal care. Here we describe the differences in injury patterns and associated outcomes of thoracic trauma patients between rural and urban level-II trauma centers in a single country. A retrospective analysis of patients with thoracic trauma over a three-year period in a rural level-II and an urban level-II in Israel were compared. Demographics, mechanism of injury, prehospital care, transport, hospitalization course, discharge disposition, and outcomes were all analyzed. There were significant differences between the demography, mechanisms of injury, and sustained injuries. The urban population was older, with more pedestrians hit by motor vehicles, falls from standing or sitting, and penetrating injuries. The rural population suffered from more motor vehicle crashes and falls from heights, with injuries related to higher velocity mechanisms such as lung contusions, sternal fractures, and liver injuries. There was no significant difference in transportation time or injury severity scores. More advanced life support ambulances were utilized in the rural setting together with more transfers to a higher level of care, while more patients in the urban center were lost to follow-up. Understanding the differences between geographic locations is crucial towards optimizing trauma care. The complexities of thoracic trauma patients are an important example of the variations between rural and urban trauma centers. Respecting these differences will help to improve preparedness and treatment for trauma patients.

The treatment of acute traumatic aortic injuries with TEVAR: a retrospective analysis of 19 cases in a level-1 trauma center

IntroductionBlunt traumatic aortic injury (TAI) is a critical condition and a leading cause of mortality in trauma patients, often resulting from high-speed accidents. Thoracic endovascular aortic repair (TEVAR) has developed into the preferred therapeutic approach due to its minimally invasive nature and promising outcomes. This study evaluates the safety and efficacy of TEVAR for managing TAI over a 10-year period at a Level-1 trauma center.MethodsA retrospective analysis was conducted on 19 patients with acute TAI treated with TEVAR between 2012 and 2022 at the University Hospital Zurich. Data were collected from digital records and analyzed according to the Fillinger TEVAR reporting framework. Outcomes included technical success, perioperative complications, and long-term graft durability.ResultsThe cohort had a mean age of 39 years and included patients with severe polytrauma. Technical success was achieved in 95% of cases, with no intraoperative deaths or need for open surgical conversion. Perioperative complications were minimal, and the reintervention rate was 5.3%. This study evaluates 10 years of clinical experience managing TAI with TEVAR. Long-term follow-up, with a median duration of 29 months, revealed no graft-related complications or secondary interventions. Imaging confirmed sustained graft integrity, and clinical outcomes were favorable.ConclusionTEVAR is a reliable and effective treatment for traumatic aortic injuries, offering excellent technical success rates and minimal perioperative and long-term complications. This study highlights TEVAR’s advantages in managing polytrauma patients and its role as a minimally invasive alternative to open surgery. Additionally, the findings emphasize the need for comprehensive long-term follow-up protocols. Future research should aim to address challenges related to device durability and the integration of advanced imaging techniques to further enhance patient outcomes and broaden the applicability of TEVAR in trauma care.

Increased Lag-Screw Slide and All-Cause Revision in a New-Generation Cephalomedullary Nail after Treatment of Geriatric Intertrochanteric Femoral Fractures.

To compare lag-screw slide and revision surgery rate between two generations of the Stryker Gamma cephalomedullary nail (Stryker, Kalamazoo, MI). Design: Retrospective chart review. Single academic, Level-1 Trauma Center. All geriatric patients (65-years and older) who underwent fixation of an intertrochanteric femoral fracture (AO/OTA type 31A1/2/3) by a single surgeon with the Stryker Gamma System from 2020-2024 with at least 3-month follow-up. The Gamma3 system was utilized until the Gamma4 became available in September 2022. Patients were grouped based on the implant utilized for fixation: Gamma3 (G3) or Gamma4 (G4) and sub-grouped based on the centrum-collum-diaphyseal (CCD) angle of the implant (125° versus 130°). The main outcome was sliding of the lag screw. Slide distance was calculated from the difference between the screw position immediately post-operatively and at 6 and 12 weeks post-operatively. The secondary outcome variables were revision surgery for any reason, tip-apex distance (TAD), and reduction quality. Fifty-one patients (40 female) with a mean age of 83 years (range 65-99) were in the G3 group compared to 46 patients (31 female) with a mean age of 79 years (range 65-96) in the G4 group. The average BMI of the G3 group was 24 kg/m2 (15-35 kg/m2) compared to 27 kg/m2 in the G4 group (17-41 kg/m2) (p = 0.004). There were no significant differences when comparing diabetes, smoking status, or mechanism of injury between groups (p>0.05). There was no significant difference when comparing the average TAD between the G3 (10 mm) and G4 (9.5 mm) (p = 0.39). There was no significant difference in reduction quality between the G3 (46 good reductions) and the G4 (42 good reductions) groups (p = 0,85).At 6 weeks, the G4 (5 mm) had significantly greater lag screw slide compared to the G3 (3 mm) (p = 0.016). At 12 weeks, the G4 (7 mm) also had significantly greater lag screw slide when compared to the G3 (4 mm) (p = 0.004). There was no significant difference in lag screw slide for the 125° implant between the G3 and G4 groups at 6-weeks (3 mm versus 5 mm, p = 0.44) or 12 weeks (4mm versus 6 mm, p = 0.14). Regarding the 130° implant, the G4 had significantly greater slide compared to the G3 at both at 6-weeks (5 mm versus 3mm, p =0.03; 95% CI -6.07 to -0.41) and 12-weeks (8 mm versus 4 mm, p = 0.03; 95% CI -5.65 to -0.26). The G4 group had 7 revision procedures performed (3 lag screw exchanges for iliotibial band irritation and 4 revision arthroplasties for lag screw slide, fracture shortening, iliotibial band irritation, abductor malfunction, and leg length discrepancy) compared to 1 revision procedure (lag screw exchange for iliotibial band irritation) in the G3 group (p = 0.04). The 130° Gamma4 demonstrated increased lag screw slide and all-cause revision surgery when compared to the 130° Gamma3 when utilized in the treatment of geriatric IT femoral fractures. Given the high incidence of increased slide and the significantly higher revision surgery rate, this implant should undergo further investigation.

What is the Surgical Burden of Treatment for High-Energy Lower Extremity Trauma? A Secondary Analysis of the OUTLET Study.

To describe and enumerate surgeries for patients who underwent reconstruction or amputation after severe distal tibia, ankle, and mid to hindfoot injuries. Design: Secondary analysis of a multicenter prospective observational study. 31 U.S. level-I trauma centers and 3 military treatment facilities. Participants aged 18 to 60 with Gustilo type-III pilon (OTA 43B or 43C), IIIB or C ankle fracture (OTA 44A, 44B, or 44C), type-III talar or calcaneal fracture (OTA 81B, 82B, or 82C), or open or closed crush or blast injuries to the hindfoot or midfoot who underwent limb reconstruction or amputation from 2012 to 2017. Number of temporizing, definitive, and complication surgeries were compared by treatment and injury. 574 participants with 221 ankle and pilon, 140 talus and calcaneal, and 213 other foot injuries were followed for 18 months. The mean age was 38 (range 8-64) and 33% were female. Participants underwent reconstruction (n=472), primary amputation (n=76), and failed reconstruction followed by amputation (n=26). 841 temporizing, 958 definitive, and 501 complication surgeries were performed. The number of surgeries was highest for those who underwent failed reconstruction (mean 5.8, 95% CI: 4.9-6.8, range 3-13) compared to reconstruction (mean 3.8, 95% CI: 3.5-4.0, range 1-21), and primary amputation (mean 4.9, 95% CI: 4.3-5.5, range 2-14) (p<0.01). Those with ankle and pilon injuries required more surgeries (4.7, 95% CI: 4.3-5.1, range 1-21) than hindfoot (3.4, 95% CI: 3.0-3.7, range 1-10), and other foot injuries (3.7, 95% CI: 3.4-4.0, range 1-14) (p<0.01). The average participant would complete definitive treatment 23 days after their injury, and those who required surgery for a complication spent 41 days in the complication phase of treatment. Patients with high-energy lower extremity trauma underwent nearly 4 surgeries over 3 weeks until completion of definitive treatment, regardless of whether they underwent limb reconstruction or amputation. Those with ankle or pilon injuries and failed reconstruction attempts experienced the most operations, and those with complications required over an additional month of surgical care. These data may inform a shared decision-making process around limb optimization. Therapeutic Level II.

Intubation Practices in Community Emergency Departments

This study analyzes emergency medicine airway management trends and outcomes among community emergency departments. A multicenter, retrospective chart review was conducted on 11,475 intubations from 15 different community emergency departments between January 1, 2015, and December 31, 2022. Data collected included patient's age, sex, rapid sequence intubation medications, use of cricoid pressure, method of intubation, number of attempts, admission diagnosis, and all-cause mortality rates. Active cardiopulmonary resuscitation occurred in 11.4% of intubations. When rapid sequence intubation was employed, the most frequently used induction agents were etomidate (91.6%), propofol (4.3%), and ketamine (4.1%). From 2015 to 2022, the use of rocuronium (versus succinylcholine) increased from 33.9% to 61.9%, a difference of 28% (95% confidence interval [CI] 21.1% to 34.9%). During the same period, video laryngoscopy (versus direct laryngoscopy) increased from 27.4% to 77.7%, a difference of 50.3% (95% CI 44.2% to 56.4%). Only 46% of intubations used cricoid pressure. Physicians had a first-pass success rate of 80.5% and a failure rate of 0.2%. The most common documented admission diagnoses among intubated patients were respiratory etiologies (27.8%), neurologic causes (21.4%), and sepsis (16.0%). All-cause mortality rates were high for intubated patients at 24 hours (19.7%), 7 days (29.4%), 30 days (38.4%), and 1 year (45.4%). Physicians intubating in community emergency departments have similar rates of first-pass success and failure seen in academic Level-1 trauma centers despite treating medically sick patients with high all-cause mortality rates. Dramatic shifts in choice of paralytic and method for intubation were seen.

Blunt cerebrovascular injuries and association with cervical spine injury

INTRODUCTION. Blunt cerebrovascular injuries (BCVI) associated with cervical spine injuries (CSI) carry a high risk of morbidity and mortality. This nationwide Danish study, covering the years 2017-2023, aimed to identify key BCVI predictors in patients with CSI to support improved early detection and management strategies. METHODS. The study analysed data from four level-1 trauma centres using the Abbreviated Injury Scale to classify BCVI cases. Factors assessed included age, sex, type of cervical injury and the Injury Severity Score (ISS). RESULTS. Age and sex were not significant predictors of BCVI (p = 0.12, p = 0.65). However, any form of CSI was a strong predictor (p &lt; 0.001; odds ratios (OR) = 26.3; confidence intervals (95% CI): 16.84-41.12), as were cervical spine ligamentous injuries (p = 0.0007; OR = 5.4; 95% CI: 2.3-12.89). An increase in ISS score significantly correlated with BCVI risk (p = 0.001; OR = 1.03 per unit increase; 95% CI: 1.01-1.05). Specific cervical fractures were not independent predictors of BCVI. CONCLUSIONS. From a Danish cohort of patients admitted to a level 1 trauma centre, we found a BCVI incidence of three per thousand. In case of verified injury to the cervical region, the incidence rose to 6.25%. Our findings underscore the need for increased vigilance and a standardised nationwide algorithm to prevent disability, loss of health-related quality of life, and mortality in CSI patients at risk of BCVI. FUNDING. The study was funded by Offerfonden, Dagmar Marshall Fonden, and Torben &amp; Alice Frimodt Fonden. TRIAL REGISTRATION. The data collection was approved by the local ethical committee and the Central Denmark Region Office for Research: 1-45-70-19-23.

Frailty index predicts adverse short- and long-term outcomes in older adults with rib fractures.

Older adults with rib fractures pose an increasing clinical and financial burden on healthcare. Identifying and addressing the increased risk of adverse outcomes has been a key objective in geriatric co-management of surgical patients. The Comprehensive Geriatric Assessment-based Frailty Index (FI-CGA) is a useful predictor of complications and mortality in older adults, but its value in rib fracture management remains unclear. This study investigates the association between FI-CGA and short- and long-term outcomes of older adults with rib fractures. Rib fracture patients ≥65 years, with a FI-CGA score available, were retrospectively identified from a single level-I trauma center between 2018 and 2022. FI-CGA scores were categorized as pre-frail (<0.20), mild frailty (0.20-0.29), moderate frailty (0.30-0.39), and severe frailty (≥0.40). Outcome measures included mortality up to two years, length of stay (LOS), complications, and 30-day readmission. 288 patients were included for analysis (57 pre-frail; 66 mildly frail; 61 moderately frail; 104 severely frail). Compared to the pre-frail group, only severely frail patients were at higher risk of 90-day (OR 5.71 [CI 1.29 - 52.67]) and 1-year mortality (OR 6.66 [CI 2.18 - 27.37]), while 2-year mortality was higher in mild (OR 3.77 [CI 1.30 - 12.57]), moderate (OR 4.28 [CI 1.46 - 14.51]) and severe (OR 6.42 [CI 2.43 - 20.11]) frailty groups. Hospital (p=0.183) and ICU LOS (p=0.131) was similar across groups. Severely frail patients were at risk of pneumonia (OR 3.50 [CI 0.95 - 19.48]) and delirium (OR 4.16 [CI 1.33 - 17.40]), while other complications were similar between groups (p=0.679). Adjusted proportional hazard ratios for mortality were significantly higher for moderate frailty (HR 1.99 [CI 1.02 - 3.89]) and severe frailty (HR 2.66 [CI 1.10 - 3.73]). FI-CGA was also a significant predictor if used per 0.01 point (HR 1.03 [CI 1.01 - 1.04)]) and per 0.1 point (HR 1.29 [CI 1.12 - 1.47]). FI-CGA can identify vulnerable rib fracture patients at risk of in-hospital complications, and short- and long-term mortality. Continuous FI-CGA scores provide a granular and individualized risk assessment. In severely frail patients with rib fractures, FI-CGA may assist in aligning treatment with individual patients' needs and goals of care.

Identifying predictors of nosocomial pneumonia in trauma patients admitted to a level-1 trauma center.

Nosocomial pneumonia is common in trauma patients and associated with an adverse prognosis. We recently externally validated and recalibrated an existing formula to predict nosocomial pneumonia risk. Identifying more potential predictors could aid in a more accurate prediction of nosocomial pneumonia risk in level-1 trauma patients. This study aims to identify predictors of nosocomial pneumonia in level-1 trauma patients available in the emergency department or shortly after, and examine their added predictive value to an existing prediction model by Croce. This retrospective cohort study included all consecutive trauma patients (≥ 16 years) admitted for > 24 h to our level-1 trauma center in 2017. Excluded were patients with active infection upon admission, transfer from another hospital, or in-hospital mortality < 48 h. Multiple imputations were used for missing values. Multivariable logistic regression analysis and Ridge penalization were performed to assess the association of predictors with nosocomial pneumonia and evaluate predictor stability. The predictive performance in addition to the existing prediction model was evaluated as well. The study included 809 patients [median age 51 (IQR 32-68) years, 66.9% male, median ISS 10 (5-17), median GCS score 15 (14-15)]. Pneumonia incidence was 10.6% (n = 86). Age (OR 1.03 per year), ISS (OR 1.10 per point), GCS score (OR 0.91 per point), pulmonary contusion (OR 2.77), male sex (OR 1.36), hypertension (OR 1.86), diabetes (OR 1.20), number of rib fractures (OR 1.05 per fractured rib), and thoracic spine fracture (OR 1.51) were found to be predictors of nosocomial pneumonia. All variables showed added predictive value in addition to the existing model. Patient history, injury severity, thoracic trauma, and traumatic brain injury are essential components of nosocomial pneumonia prediction and add to the predictive value of an existing model. Our results further build a basis for more accurate prediction. Level III, prognostic/epidemiological.

Evaluation of prehospital care for neurotrauma in Iran.

Narrative review. Neurotrauma has a considerable impact on healthcare, the economy, and human resources worldwide. In Iran, young males are especially vulnerable, with road traffic accidents (RTAs) being the major cause. Evaluating prehospital care systems is critical for detecting shortcomings and implementing improvements. This study seeks to evaluate the prehospital neurotrauma care procedure in Iran, highlighting its strengths and flaws. We searched PubMed and Scopus databases for literature on the present condition of prehospital neurotrauma care in Iran. Consultations with an expert panel yielded additional material not previously available in the literature, particularly on Iran's emergency medical system. Our findings indicate that the emergency dispatch system in Iran is relatively well-managed, regardless of the lack of a single emergency contact number. However, major obstacles still exist, particularly in terms of human resources, training, and equipment availability. Emergency medical technicians (EMTs) have intermediate to poor levels of knowledge and skills in dealing with neurotrauma, which might be considerably improved by ongoing training programs. Furthermore, Iranian hospitals lack specific trauma center designations and levels, resulting in overcrowded emergency rooms and delayed care delivery. National neurotrauma guidelines have been adopted in recent years, although their compliance is not consistently monitored. Compared to developed healthcare systems, Iran's prehospital treatment system for individuals with neurotrauma has considerable limitations. Improving EMT education, recruiting more trained professionals, and simultaneous improvement of current medical facilities should be addressed as the first steps toward better care.

Does the treatment modality affect nosocomial pneumonia and other in-hospital outcomes in patients with combined injuries to the ribs and clavicle? A propensity score weighted analysis of a retrospective cohort.

What is the effect of surgical or conservative treatment on the in-hospital outcomes of patients with combined fractures of the clavicle and ribs? Retrospective cohort study. Two level-1 trauma centers and academic teaching hospitals in Boston, Massachusetts. All adult patients with a clavicle fracture and ≥3 rib fractures admitted from 2016 to 2021. None. Nosocomial pneumonia, hospital length-of-stay (HLOS), ICU length-of-stay (ILOS), days on mechanical ventilation (DMV). 252 patients were included (212 conservative, 40 surgical; median age 62 years, 67% male). The median ISS and GCS scores were 17 and 15, respectively. Thirty-seven patients developed nosocomial pneumonia. For clavicle fixation (n = 26), the OR for pneumonia was 0.3 (95% CI 0.0-2.2), ILOS had a ß-coefficient of -2.6 (95% CI -5.9-0.8), and DMV a ß-coefficient of -3.6 (95% CI -12.0-4.8). For rib plating (n = 10), the OR for pneumonia was 1.4 (95% CI 0.2-8.6), HLOS had a ß-coefficient of 4.9 (95% CI -1.6-11.5), and ILOS a ß-coefficient of 4.1 (95% CI -0.4-8.6). For both surgeries (n = 4), the CIs were wide. Clavicle fixation in patients with combined injuries of the clavicle and ribs did not improve nor worsen in-hospital outcomes; the orthopedic surgeon should make a patient-tailored treatment decision. Rib plating did not improve in-hospital outcomes in non-flail patients with a concomitant clavicle fracture. Guidelines on non-flail rib plating could profit from these findings in combination with previous and additional research. Level III, Therapeutic Study.

Predictors of healthy days at home: Benchmarking long-term outcomes in geriatric trauma.

Quality benchmarking has recently evolved from a historical focus on short-term morbidity and mortality as the key metrics to assessing long-term outcomes. Long-term quality metrics have been shown to provide a more complete assessment of geriatric trauma care. Among these metrics, patients' average number of healthy days at home (HDAH) proports to be a useful administrative claims-based marker of patient functional status. Our goal was to determine the predictors of HDAH among injured older adults. Medicare inpatient claims (2014-2015) were used to identify all geriatric trauma patients. Patients' number of HDAH was measured from the date of discharge and calculated as the total sum of patients' time during that period less any time spent in the hospital or emergency department, step-down/rehabilitation/nursing care, home health, or after death within a 365-period after index admission. Controlling for demographic, injury severity, and hospital-level characteristics, multivariable regression analyses were performed to identify the factors associated with increased HDAH. We included 772,109 geriatric trauma patients. The mean age was 82.15 years (SD, 8.49 years), 68.3% were female, and 91.6% were White. The median HDAH was 351 days (interquartile range, 351-355 days). After adjusted analysis, age, Black race, Charlson Comorbidity Index (CCI), and care at a level 3/nontrauma center were associated with fewer HDAH within 365 days after discharge. This study suggests that higher level trauma centers provide more HDAH after index admission for injured older adults. Future studies should focus on correlating HDAH with more granular but less readily accessible quality of life metrics. Prognostic and Epidemiological; III.

Traumatic pediatric cervical spine injury-a proposed clearance algorithm incorporating a 24-h time delay.

Pediatric cervical spine injury (pCSI) is rare. Physiological differences necessitate alternate management from adults. Yet, no standardized pediatric protocols exist. Previous investigations applying adult-validated clinical decision rules (CDRs)-NEXUS Criteria (NX) and Canadian C-spine Rules (CCR)-to children are mixed. We hypothesized a combined NX + CCR approach applied at a delayed 24-h time point would enhance screening efficacy in select patients. We conducted a retrospective review of a prospectively-collected database over 15months at a pediatric-capable Level-1 trauma center. Age and mechanism determined initial inclusion. NX and CCR criteria were collected and retroactively applied on arrival (T0) and 24h later (T1). Statistical analyses were performed in SPSS. A total of 306 patients met inclusion. Current practices compel computed tomography (CT) overuse for craniocervical evaluations: 298 (97.4%) underwent ≥ 1 CT. Of cervical spines imaged (n = 175), 161 (92.0%) underwent CT while 74 (42.3%) underwent magnetic resonance imaging with 14 (18.9%) completed after 72h. Of collars placed on arrival (n = 181), 136 (75.1%) were cleared before discharge with 86 (63.2%) CTs denoting preferred clearance modality; CT utilization was unchanged when stratified by age < 5years (p = 0.819). Notably, we found more patients met NX + CCR criteria at T1 versus T0 (p = 0.008) without missed pCSI resulting in imaging overutilization in 15 (8.6%) patients. We showed incorporating a 24-h time delay before a second CDR reapplication may enhance screening efficacy in pCSI. Our new algorithm combines these findings with other literature-based recommendations and may represent a standardizable option for evaluating pCSI in the acute trauma setting.