Level-one Trauma Center Research Articles

Comparison of Elective Implant Removal and Complication Rates between Mini and Small Fragment Implants for Lateral Malleolar Fixation

IntroductionImplant removal after open reduction and internal fixation (ORIF) of ankle fractures is common. Mini-fragment implants have gained popularity for their smaller size, with studies showing similar load to failure to small-fragment implants. We hypothesized mini-fragment implant use for ORIF of the distal fibula is associated with a lower implant removal rate and without an increase in implant failure. MethodsIn this retrospective review study at two level-one trauma centers, adult patients (>18 years) with a lateral malleolar or bimalleolar fracture were included. Chart review was performed to determine if patients received ORIF of the distal fibula with mini-fragment implants or small-fragment implants. The primary outcome was elective implant removal of the fibular plate. Secondary outcomes included complications requiring reoperation. ResultsFive-hundred and five patients were included with a mean age of 50.6 ± 17.8 years old with a mean follow-up of was 75.7 ± 61.0 weeks. Sixty patients (11.9%) received mini-fragment fixation. The rate of elective distal fibula implant removal for the mini-fragment group was 8.3% (5 of 60) compared to 10.8% (48 of 445) in the small-fragment group (p= .66). The complication rate was 6.7% (4 of 60) for the mini fragment group versus 6.5% (29 of 445) for the small fragment group (p=1.00). Logistic regression demonstrated that each additional week of follow-up increased the implant removal rate with the observed odd ratio (OR) of 1.007 (95% CI 1.002-1.012). ConclusionElective implant removal rates and complications requiring reoperation were similar between mini-fragment and small-fragment fixation of distal fibula fractures. The hypothetical benefit of low-profile mini-fragment implants should be balanced with the higher implant cost.

Do all traumatic hemothorax require a tube thoracostomy: A retrospective review

Abstract Background: Blunt thoracic trauma accounts for a majority of trauma-related admissions. The Eastern Association for the Surgery of Trauma guidelines recommend placement of a tube thoracostomy for all patients with a hemothorax. Our study was conducted to look at those managed without an intercostal drain (ICD) and the factors that could predict a failure in conservative management. Materials and Methods: A retrospective study was conducted from January 2020 to June 2022 at a level-one trauma center in South India to account for patients who required a tube thoracostomy after planned expectant management for hemothorax. All adult patients above 16 years, with traumatic hemothorax were included. Those who had ICD inserted in the emergency department before computed tomography (CT) and those who did not have a CT Thorax were excluded. A retrospective review of patient records was conducted and analyzed using Stata (ver. 16). Results: Eighty-eight patients were included in the study, of whom 11 patients required a tube thoracostomy after an initial trial of conservative/expectant management (i.e., not inserting an ICD). The most common reason for failure was an increase in the size of the hemothorax. Among all the predictors we looked at, only a systolic blood pressure of <90 mm Hg on presentation was statistically significant for predicting failure of expectant management. Conclusion: Our study suggests not all patients with a traumatic hemothorax require a tube thoracostomy and can be managed expectantly provided close monitoring is possible. An increase in the size of the hemothorax was the main indication for a tube thoracostomy.

Augmented cement shelf acetabuloplasty to improve hip stability in elderly patients with recurrent hemiarthroplasty dislocations

Background The treatment of dislocated hip hemiarthroplasty in low-demand elderly patients is controversial due to poor results with closed reduction, and significant complications with exchange arthroplasty. This case series demonstrates the use of a novel, simple surgical technique for hip hemiarthroplasty containment without resorting to exchange arthroplasty. Methods Eleven patients where screw-augmented cement shelf acetabuloplasty procedures were performed were retrospectively identified. All surgeries were performed by a single attending surgeon, at a level-one trauma center, from 2015 to 2022. Previous dislocations, interventions, co-morbidities, mobility level, and posterior wall deficiency were recorded from the patient's charts. The following outcome measures were recorded: operative time, blood loss, perioperative complications, early and late infections, shelf loosening, subsequent dislocations, and the need for additional procedures. Results The median duration between hip hemiarthroplasty and shelf procedure was 56 days. The mean duration of the surgical procedure was only 63 min, and the mean blood loss was only 250 mL. There was only one instance of loosening of the cement shelf. Two patients had surgical site infections leading to sepsis and death. In two patients, the femoral head was exchanged to improve stability. All patients were allowed immediate weight bearing after the procedure. Conclusions Shelf acetabuloplasty is a simple, inexpensive, and safe procedure to salvage recurrent hip hemiarthroplasty dislocation in low-demand patients. Shorter surgical duration, relatively lower blood loss, and immediate weight bearing render this an attractive procedure for this fragile population.

Social support in relation to posttraumatic stress disorder symptoms among patients with violent versus nonviolent injury.

Violent injuries have become increasingly more common in the United States. Individuals experiencing violent injury are at increased risk for the development of posttraumatic stress disorder (PTSD) as compared to those experiencing nonviolent injury. Social support is touted as a protective factor against various psychiatric symptoms (i.e., PTSD), though little is known about the relation between PTSD symptoms and social support in traumatic injury populations. The aims of the present paper were twofold: (1) examine the prevalence of PTSD as a function of injury type (2) explore differences in levels of social support as a function of injury type and (3) explore the association between injury type and later PTSD symptoms as moderated by baseline social support. Participants were 553 adults from a level-one trauma center in the Southeast United States who experienced a violent injury or nonviolent injury and completed measures of social support at baseline as well as PTSD symptoms at the 30-day follow-up timepoint. The study utilized data from both the baseline timepoint (i.e., upon admission to the trauma surgery unit), as well as a 30-day follow-up timepoint. Results demonstrated that those endorsing nonviolent injury reported lower levels of social support and PTSD symptoms. Social support predicted later PTSD symptoms until injury type was included as a covariate in the model. Social support did not moderate the relationship between injury type and later PTSD symptoms. Findings highlight the interrelatedness of key risk variables (i.e., injury type) with protective factors in influencing the trajectory of psychopathology postinjury. Violence intervention and interruption programs may have the capacity to fill patient needs when social support networks are insufficient. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The Hidden Pandemic: Impact of the COVID-19 Pandemic on Trauma Cases Due to Domestic Violence Admitted to the Biggest Level-One Trauma Center in Austria.

An alarming increase in domestic violence was reported during the COVID-19 pandemic worldwide. The aim of this study is to investigate changes in the frequency and the nature of domestic violence at the largest level-one trauma center in Austria. All patients admitted to our institution with domestic violence injuries 15 months before and after the beginning of the COVID-19 pandemic were included. For our analysis, we investigated the frequency of trauma patients after domestic violence in relation to all other trauma patients. Furthermore, age, sex, citizenship, injury pattern, injured body regions, injury mechanism, offender-victim relationship, and hospitalization rate were also analyzed. Among all trauma patients admitted, the ratio of patients who reported domestic violence injuries increased from 0.465% to 0.548% since the start of the pandemic. In addition, out of the total count of domestic violence victims, the percentage of Austrian citizens increased significantly from 51.2% to 60.6% (p = 0.016). All other parameters showed no significant changes pre and post-pandemic. The COVID-19 pandemic contributed to a relative increase in patients with domestic violence injuries at the largest trauma unit in Austria, along with a significant increase among Austrian citizens. The remaining study parameters did not differ significantly, indicating that the frequency changed during the pandemic but not the underlying pattern of domestic violence.

Cortical bone thickness on preoperative CT scans as predictor of bone quality in distal femur fractures: a retrospective study in Caucasians.

Distal femur fractures (DFF) are rare, but associated with high complication rates and mortality, particularly in patients with osteoporosis. To improve preoperative assessment, we analyzed if cortical bone thickness on CT and AP radiographs is associated with clinical parameters of bone quality. Retrospective single-center study of adult patients presenting at a level-one trauma center, with a DFF between 2011 and 2020. Clinical parameters for bone quality, such as age, sex, body mass index (BMI), energy impact level of trauma, and known history of osteoporosis, were assessed. Mean cortical bone thickness (CBTavg) on AP radiograph was determined using a previously published method. Cortical thickness on CT scan was measured at 8 and 14cm proximal to the articular surface of the lateral condyle. 71 patients (46 females) between 20 and 100years were included in the study. Cortical thickness determined by CT correlated significantly with CBTavg measurements on AP radiograph (Spearman r = 0.62 to 0.80; p < 0.001). Cortical thickness was inversely correlated with age (Spearman r = -0.341 to -0.466; p < 0.001) and significantly associated with trauma impact level and history of osteoporosis (p = < 0.001). The CT-based values showed a stronger correlation with the clinical parameters than those determined by AP X-ray. Our results showed that cortical thickness of the distal femur correlates with clinical parameters of bone quality and is therefore an excellent tool for assessing what surgical care should be provided. Interestingly, our findings indicate that cortical thickness on CT is more strongly correlated with clinical data than AP radiograph measurements.

Single-Use Reamer Shafts for Intramedullary Nail Fixation: An Addressable Source of Extraneous Cost and Medical Waste in Orthopaedic Surgery.

To analyze the impact of switching from single-use reamer shafts to reusable reamer shafts for intramedullary nail fixation (IMN) of femur and tibia fractures at a single level-one trauma center, in terms of cost, metal waste, and infection rates. Retrospective comparison study. Level one trauma centerPatients/Participants: Patients with operative femur and tibia fractures treated before and after adoption of a reusable reamer shaft. Reamed IMN fixation. Reductions in cost ($292 per shaft) and metal waste (0.44 pounds (lbs) per reamer shaft; reamer shaft failure (breakage and/or incarceration); superficial and deep infections. A single surgeon treated 125 and 135 fractures before and after adoption of a reusable reamer shaft. No reamer shaft failures were identified. The before and after groups did not differ in age, OTA/AO classification, or infection rates. By adopting reusable reamer shafts the surgeon avoided an estimated 54 single-use reamer shafts per year for an estimated cost and metal waste savings per year of $15,643 USD and 24 lbs. Over the same time period that the surgeon switched to using reusable reamer shafts, a total of 283 single-use reamer shafts were utilized by 12 surgeons in the same department. If the entire department had adopted reusable reamer shafts during that time period an estimated 164 reamer shafts per year would have been avoided for a total cost and metal waste savings per year of $47,763 USD and 72 lbs. Single-use reamer shafts represent an easily addressable source of extraneous cost and metal waste in orthopaedic surgery. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Impact of Sex on Completion of Life-Saving Interventions for Severely Injured Patients: A Retrospective Cohort Study

Sex disparities in access and quality of care are well known for some time-sensitive conditions. However, the impact of sex on early trauma care remains unknown. In this study, we compared delays of completion of life-saving interventions (LSIs) between females and males among severely injured patients. This is a retrospective cohort study of all patients who consulted or were transported by ambulance in the emergency department (ED) of a level-one trauma centre following injury between September 2017 and December 2019 and for whom at least one LSI was performed. The list of LSIs was established by an expert consensus and included trauma team leader (TTL) activation, endotracheal intubation, chest decompression, blood transfusion, massive transfusion protocol, neurosurgery, spinal surgery, intestinal surgery, and spleen, liver and/or kidney angiography. A total of 905 patients were included. No significant statistical differences in the LSI delays were found when comparing females and males brought directly to the ED and transferred from another health care setting. Results of this study suggest that delays before completion of LSIs are similar for severely injured patients at our major trauma centre regardless of their sex.

Incidence of Skin Sensitivity Following Dermabond Application in Pediatric Orthopedic Surgery.

Dermabond (Dermabond; Ethicon, Sommerville, NJ), is a skin adhesive commonly utilized in pediatric orthopedic surgery for postoperative wound care. Few studies have examined outcomes of Dermabond exposure in children. The purpose of this study is to estimate the incidence of skin reactions following Dermabond exposure in pediatric orthopedic surgery and investigate potential risk factors associated with Dermabond sensitivity. This was a retrospective study of a level-one pediatric trauma center. All orthopaedic surgeries in 2019 were screened for Dermabond application. Three surgeons with the highest rates of Dermabond application defined our cohort. Out of 2990 surgeries in 2019, the 3 surgeons performed 234 surgeries with Dermabond. Postoperative reactions and repeat Dermabond exposures were collected for these 234 patients. Subjects with known allergies to Dermabond were excluded. Reactions were defined. as discoloration, irritation, and wound dehiscence. Significant differences between patients with repeat Dermabond exposures and those without were determined using χ 2 analysis. Associations between patient characteristics and sensitivity were determined using logistic regression analysis. P values less than 0.05 were considered significant. In all, 234 patients were included for analysis. The mean age at surgery was 12.5 years (SD 6.1), and 39% (92/234) of the cohort was male. Thirty-two patients (14%) experienced skin reactions during the study period (95% CI=7%-19%). Reactions most frequently included. erythema (10/32; 31%) and itchiness (10/32; 31%). Reactions were most frequently treated with oral antibiotics, Benadryl, or a dressing change. Of 144 patients with 1 Dermabond exposure, 17 (12%) experienced reactions (95% CI=7%-18%). Of 128 patients experiencing a repeat Dermabond exposure, 27 (21%) experienced reactions (95% CI=19%-34%, P =0.03). Age, surgical procedure, and surgical location were not, associated with a variable rate of sensitivity. Sensitivity to Dermabond after pediatric orthopedic surgery occurred at a higher rate than seen in adults, and patients with multiple Dermabond exposures experienced significantly higher sensitivity than patients with a single exposure. Increased awareness of this potential complication is needed to help inform decisions regarding Dermabond's application in pediatric orthopedics.

Impact of Treatment Modalities on Discharge Disposition in Blunt Splenic Injuries.

Management of blunt splenic trauma has evolved over several decades, trending towards nonoperative management and splenic artery embolization. Extensive research has been conducted regarding the management of blunt splenic injuries, but there is little data on the association of treatment modality with discharge disposition. This is an observational retrospective study conducted at a level-one trauma center with blunt splenic trauma patients of age ≥18 years between January 2010 and December 2021. The primary outcome of unfavorable discharge was defined as discharge to an acute care facility, intermediate care facility, long-term care facility, rehabilitation (inpatient) facility, or skilled nursing facility. Five hundred seventy-nine patients were included in the analysis, with 108 (18.7%) in the unfavorable group and 471 (81.3%) in the favorable group. Most patients were managed nonoperatively (69.3%), followed by splenectomy (25.0%) and embolization (5.7%). Due to the low number of embolizations performed during the study period, treatment modalities were grouped into two broad categories: intervention (embolization and splenectomies) and nonintervention. The treatment modality was found to have no significant impact on unfavorable discharge. Independent risk factors for unfavorable discharge included age >55 years, injury severity score (ISS) >15, hospital-acquired pneumonia, and in-hospital complications of sepsis. This study provides an understanding of specific demographic and clinical factors that may predispose blunt splenic injury trauma patients to an unfavorable discharge. Providers may apply these data to identify at-risk patients and subsequently adapt the care they provide in an effort to prevent the development of in-hospital pneumonia and sepsis.

Reduced rates of pneumonia after implementation of an electronic checklist for the management of patients with multiple rib fractures at a Level One Trauma Center

Traumatic rib fractures are associated with increased morbidity and mortality, with complications including pneumothorax, difficult to control pain, and pneumonia. Use of a bundled, multi-disciplinary approach to the care of patients with multiple rib fractures has been shown to reduce morbidity and mortality. In this study, we investigate the implementation of a checklist for the multidisciplinary management of patients with multiple rib fractures who present to an urban, level 1 trauma center and safety-net hospital. This was a single-institution, retrospective cohort study to assess changes in treatment characteristics and patient outcomes before and after implementation of a comprehensive checklist for the management of high-risk patients with three or more traumatic rib fractures at a level-one trauma center. The primary outcome was pneumonia rates with secondary outcomes of rate mechanical ventilation and mechanical ventilation days, ICU length of stay, mortality, and non-opioid and opioid consumption (morphine milligram equivalents). A total of 104 patients met study eligibility, including 51 patients who presented during the pre-protocol period and 53 patients who received care after implementation. We observed that the checklist was utilized and reviewed in 83% of patients during the post-protocol period. Pneumonia rates were significantly lower in the post-protocol group (35.3% vs 15.1%, p=0.017). There was no difference in the number of patients who required mechanical ventilation or the duration of mechanical ventilation. On unadjusted analysis, median overall length of stay (11.5 days vs 13 days, p=0.71), median ICU stay (4 days vs 5 days, p=0.18), and rate of in-hospital mortality (11.8% vs 7.6%, p=0.47) was not different between the two time periods. In patients with chest wall trauma and associated rib fractures, implementation of a standardized, multidisciplinary checklist to ensure utilization of multimodal analgesia and non-pharmacological interventions was associated with decreased pneumonia rates at our institution.

Audiologic Consequences of Gunshot Wounds to the Temporal Bone Show No Relation to Concomitant Neurologic or Vascular Injuries.

To evaluate audiologic consequences of gunshot wounds (GSWs) to the temporal bone (TB), and to correlate hearing outcomes with neurologic and vascular injuries adjacent to the temporal bone. Retrospective case series. University-based level-one trauma center. Retrospective review of 35 patients surviving TB ballistic injury, 2012 to 2021. Main outcomes were audiologic results. Demographics, concomitant injuries, CT, and interventions were reviewed. Mean age was 30.7 years; 80% male. Seventeen patients (48.6%) underwent audiologic testing. Mean pure tone average (PTA) was 75 ± 35 dB, bone line average 41 ± 26 dB, and speech discrimination score (SDS) 60 ± 43%. Nineteen (54.3%) demonstrated facial nerve injury (FNI), who were more likely to show SNHL especially anacusis, though their mean PTA and SDS were not statistically different from those without (P = .30 and .47, respectively). Radiographic review of those with sensorineural loss (SNHL, 6/17) revealed otic capsule-disrupting fracture (n = 2), pneumolabyrinth (n = 2), intracranial hemorrhage (n = 3). Those with mixed loss (6/17) showed otic capsule-sparing fracture (n = 6), EAC injury (n = 5), ossicular discontinuity (n = 2), and intracranial hemorrhage (n = 4). Two with mastoid tip fractures alone had normal audiograms. Audiometric outcomes were not predicted by concomitant CSF leak, spinal injuries, vascular injuries, cranial neuropathies, or traumatic brain injury. All patterns of hearing loss-conductive, sensorineural, mixed and normal-may be seen following TB ballistic injuries. Trauma severe enough to disrupt the facial nerve is more likely to cause anacusis. However, all should be formally evaluated, since ballistic injuries complicated by neurologic or vascular damage do not necessarily correlate with worse audiologic outcomes, while patients with minimal fractures may demonstrate losses.

Pre-Trauma Pain Is the Strongest Predictor of Persistent Enhanced Pain Patterns after Severe Trauma: Results of a Single-Centre Retrospective Study.

Background and Objectives: Traumatic injuries are a significant public health issue worldwide, with persistent enhanced pain being a common complication following severe trauma. Persistent and chronic pain can have a profound impact on patients' quality of life, affecting physical, emotional, and social functioning. This study aimed to investigate the pain patterns of trauma patients before and after severe trauma, and identify the predictors of persisting pain after injury. Materials and Methods: A total of 596 patients of a level-one trauma centre with severe trauma were included in this study. The Trauma Outcome Profile Scale was used to assess pain severity before and after trauma, and a logistic regression analysis was performed to determine the most significant predictors of relevant pain after severe trauma. Results: The mean age of the included patients was 48.2 years, and 72% were males. The most frequent cause of injury was traffic accidents, and the mean Injury Severity Score was 17.6. Nearly half of the patients experienced reduced pain-related quality of life after trauma, with persisting pain predominantly occurring in the neck, spine, shoulder, pelvis, hip, knee, and feet. Even minor injuries led to increased pain scores. Preexisting pain before injury (OR: 5.43; CI: 2.60-11.34), older age (OR: 2.09, CI: 1.22-3.27), female gender (OR: 1.08, CI: 0.73-1.59), and high injury severity (OR: 1.80, CI: 1.20-2.69) were identified as significant predictors of enhanced pain. Conclusions: These findings highlight the importance of considering pre-existing pain, body area, and injury severity in assessing the risk of persistent pain in trauma patients.

Not All Proximal Humerus Fractures Do Well Without Surgery: Anterior Translation Predicts the Need for Surgery.

To evaluate the effect of translation on a large series of low energy proximal humerus fractures initially treated nonoperatively. Retrospective multicenter analysis. 5 level-one trauma centers. 210 Patients (152F;58M) average age 64 with 112 left and 98 right sided low energy proximal humerus fractures (OTA/AO 11-A-C). All patients were initially treated nonoperatively and were followed for an average 231 days. Radiographic translation in the sagittal and coronal planes was measured. Patients with anterior translation were compared to those with posterior or no translation. Patients with ≥80% anterior humeral translation were compared to those with < 80% anterior translation, including those with no or posterior translation. The primary outcome was failure of nonoperative treatment resulting in surgery and the secondary outcome was symptomatic malunion. Nine patients (4%) had surgery, 8 for nonunion and 1 for malunion. All 9 patients (100%) had anterior translation. Anterior translation as compared with posterior or no sagittal plane translation was associated with failure of nonoperative management requiring surgery (p = 0.012). Additionally, of those with anterior translation, having ≥80% anterior translation as compared with < 80% was also associated with surgery (p = 0.001). Finally, 26 patients were diagnosed with symptomatic malunion, of whom translation was anterior in 24 and posterior in 2 (p = 0.0001). In a multicenter series of proximal humerus fractures anterior translation of >80% was associated with failure of nonoperative care resulting in non-union, symptomatic malunion, and potential surgery.

The impact of the SARS-CoV-2 pandemic-related lockdowns on orthopedic trauma emergencies at a level-one trauma center.

The SARS-CoV-2 pandemic and its associated lockdowns had a profound effect on orthopedic trauma emergencies. This study aimed to investigate the patient volume and injury patterns at a level-one trauma center during the SARS-CoV-2 pandemic and compare them to the pre-pandemic conditions. A retrospective chart review of all patients who presented to the orthopedic trauma emergency department of a level-one trauma center in Cologne, Germany within a 2year period from March 16th, 2019 to March 15th, 2020 (pre-pandemic control) and from March 16th, 2020 and March 15th, 2021 (pandemic) was performed. The pandemic year was separated into three periods: (1) first lockdown, (2) between lockdowns and (3) second lockdown. The absolute numbers of patient presentations, the Manchester triage score (MTS) and the relative proportion of patients with structural organ injuries, fractures and dislocations, of polytraumatized patients, of hospital admissions, of subsequent emergency or semi-elective surgeries and of work-related accidents were evaluated in comparison to the pre-pandemic control. A total of 21,642 patient presentations were included in this study. Significantly less weekly orthopedic trauma emergency patient presentations were recorded during the pandemic (p < 0.01). The MTS was significantly lower during the first lockdown and between lockdowns (p < 0.01). The proportional incidence of overall structural organ injuries, fractures and dislocations, of upper limb fractures/dislocations, of hospital admissions and of patients requiring surgery was significantly increased during the pandemic (p ≤ 0.03). The proportional incidence of work-related injuries was significantly decreased during the pandemic (p < 0.01). Orthopedic trauma emergency presentations were reduced during the SARS-CoV-2 pandemic. Due to the reluctancy of patients to visit the emergency department during the pandemic, the proportions of relevant injuries in general and of upper limb injuries in particular as well as of patients requiring hospital admission and trauma-related surgery were significantly increased.

Contemporary management of blunt colonic injuries – Experience from a level one trauma center in New Zealand

Blunt colonic injury (BCI) is relatively rare, and literature on the topic is sparse. This study reviews our contemporary experience in its management at a level-one trauma centre in New Zealand. This was a retrospective study (January 2012 to December 2020) that included all patients who sustained a BCI managed at Waikato Hospital, New Zealand. Of the total of 1181 patients with blunt abdominal trauma, 69 (6%) of them sustained a BCI (49% male, mean age: 36 years). 78 separate colonic injuries were identified in the 69 cases. The most commonly injured segment was the ascending colon 49% (38/78). Eighty percent (55/69) underwent a CT scan, with only 16 showing definite evidence of a colonic injury. AAST Grade 1 was the most common (81%). Fifteen patients underwent damage control surgery. All 11 grade 1 injuries were repaired primarily, whilst the other four grade 4 and 5 colonic injuries were resected, with 3 having a subsequent stoma formation and one delayed anastomosis. There were four mortalities. Patients who had negative or equivocal admission CT findings for colonic injury had delays to the operating theatre and had poorer outcomes. BCI is rare but is associated with a prolonged hospital stay. The treatment of BCI is similar to that of penetrating colonic injury. CT appeared inaccurate in many cases.

Predictors of hospital-acquired pressure injuries in patients with complete spinal cord injury: a retrospective case–control study

BackgroundDespite current best practices, pressure injuries (PI) remain a devastating and prevalent hospital-acquired complication for patients with acute traumatic spinal cord injuries (SCIs). This study examined associations between risk factors for PI development in patients with complete SCI, such as norepinephrine dose and duration, and other demographic factors or lesion characteristics.MethodsThis case–control study included adults with acute complete SCIs ASIA-A, who were admitted to a level-one trauma center between 2014–18. A retrospective review was implement using data on patient and injury characteristics, including age, gender, level of SCI (cervical vs. thoracic), Injury Severity Score (ISS), length of stay (LOS) and mortality; presence/absence of PI during their acute hospital stay; and treatment factors such as spinal surgery, mean arterial pressure (MAP) targets, and vasopressor treatment. Multivariable logistic regression evaluated associations with PI.ResultsEighty-two out of 103 eligible patients had complete data, and 30 (37%) developed PIs. Patient and injury characteristics, including age (Mean: 50.6; SD:21.3), location of SCI (48 cervical, 59%) and ISS (Mean 33.1; SD:11.8), did not differ between PI and non-PI groups. Logistic regression analysis revealed that male gender (OR:34.1; CI95:2.3–506.5, p = 0.010) and increased LOS (log-transformed; OR:20.5, CI95:2.8–149.9, p = 0.003) were associated with increased risk of PI. Having an order for a MAP > 80mmg (OR:0.05; CI95:0.01–0.30, p = 0.001) was associated with a reduced risk of PI. There were no significant associations between PI and duration of norepinephrine treatment.ConclusionsNorepinephrine treatment parameters were not associated with development of PI, suggesting that MAP targets should be a focus for future investigations for SCI management. Increasing LOS should highlight the need for high-risk PI prevention and vigilance.

Implementing the IMIST-AMBO tool for paramedic to trauma team handovers: a video review analysis

Patient handover betweenparamedics and the trauma team is vulnerable to communication errors that may adversely affect patient care. This study assesses the feasibility of a handover tool, IMIST-AMBO (acronym of categories), implementation in the trauma bay and evaluates the degree to which it improves handover metrics. This is a prospective observational cohort study conducted at Canada's largest level-one trauma center. Feasibility of the tool implementation and improvement in handover metrics were assessed. Strategies for implementation included distribution of an educational video and posters, and point-of-care reminders in the trauma bay. Two reviewers independently assessed video recordings of handovers to evaluate handover metrics. Findings were compared to data obtained during a knowledge gap analysis conducted prior to the initiation of this study at the same institution. Over 13weeks (August to November 2020), 140 videos were recorded, of which 80 used the IMIST-AMBO tool (compliance of 57%). Paramedic adherence to the handover structure occurred in 70.4% of cases, with greater adherence to the IMIST (82.2%) compared to the AMBO (47.1%) section. The mean (± standard deviation) handover duration was shorter (1min:58s ± 0:44s during implementation vs. 2min:47s ± 1:14s pre-implementation, [p < 0.001]). Frequency of parallel conversations and informal handovers improved (61% to 30% and 65% to 13%, [p < 0.001], respectively). Interruptions during the handover decreased from 3.05 (± 1.95) to 1.5 (± 1.7), p < 0.001. The tool was received favorably among study participants. The IMIST-AMBO tool reduced the frequency of interruptions, parallel conversations, and informal handovers during paramedic-trauma team handovers at our institution. The quality and amount of information communicated per handover improved, all with a decrease in handover duration. The IMIST-AMBO tool may be applied to other trauma centers across Canada, or more broadly on an international scale.

Posterior pelvic ring involvement detected with CT taken within a week of admission in acute fragility fractures of the pelvis (FFP) does not predict failure of conservative treatment: a retrospective cohort study

BackgroundAcute low energy pubic rami fractures in the elderly receive primarily conservative treatment. There is debate to what extent posterior ring involvement, which is detected superiorly by CT compared to X-ray, has an impact on outcome and may require modified treatment. We want to demonstrate if posterior ring involvement has an influence on different types of outcome in primarily conservatively treated acute FFP, questioning the usefulness of early CT. Additionally we analysed the early fracture pattern in cases where conservative treatment failed with need for secondary surgery.MethodsA retrospective cohort study of 155 consecutive patients, recruited between 2009 and 2016, aged over 65 years diagnosed with an acute LE-PFr on X-ray at the emergency department of a single, level-one trauma centre and receiving an early CT. A set of outcome parameters was compared between patients with an isolated pubic rami fracture (CTia) and patients who had a combined posterior pelvic ring fracture (CTcp).ResultsThere were 155 patients of whom 85.2% were female with a mean age of 83 years. 76.8% of patients living at home returned home and 15.5% moved to a nursing home. Mortality rate during hospitalisation was 6.4% and 14.8% at one year post-trauma. Secondary fracture displacement occurred in 22.6%. Secondary surgery was performed in 6 cases (3.9%). Median hospitalisation length of stay was 21 days (range 0 to 112 days). There was no significant association between the subgroups and change in residential status (p = 0.65), complications during hospitalisation (p = 0.75), mortality rate during admission (p = 0.75) and at 1 year (p = 0.88), readmission within 30 days (p = 0.46) and need for secondary surgery (p = 0.2). There was a significant increased median length of stay (p = 0.011) and rate of secondary displacement (p = 0.015) in subgroup CTcp. Secondary displacement had no impact on in-hospital complications (p = 0.7) nor mortality rate during admission (p = 0.79) or at 1 year (0.77). Early CT in patients who underwent secondary surgery showed stable B2.1 lesions in 4 of 6 cases.ConclusionsOur data suggest that early CT in patients with conservatively treated acute LE-PFr in order to detect posterior lesions, has limited value in predicting failure of conservative treatment.

Neurosurgical Outcomes in Severe Traumatic Brain Injuries Between Service Lines: Review of a Single Institution Database.

Severe traumatic injury (sTBI) continues to be a common source of morbidity and mortality. While there have been several advances in understanding the pathophysiology of this injury, the clinical outcome has remained grim. These trauma patients often require multidisciplinary care and are admitted to a surgical service line, depending on hospital policy. A retrospective chart review spanning 2019-2022 was completed using the electronic health record of the neurosurgery service. We identified 140 patients with a Glasgow Coma Scale (GCS) of eight or less, ages 18-99, who were admitted to a level-one trauma center in Southern California. Seventy patients were admitted under the neurosurgery service, while the other half were admitted to the surgical intensive care unit (SICU) service after initial assessment in the emergency department by both services to evaluate for multisystem injury. Between both groups, the injury severity scores that evaluated patients' overall injuries were not significantly different. The results demonstrate a significant difference in GCS change, modified Rankin Scale (mRS) change, and Glasgow Outcome Scale (GOS) change between the two groups. Furthermore, the mortality rate differed between neurosurgical care and other service care by 27% and 51%, respectively, despite similar Injury Severity Scores (ISS) (p=0.0026). Therefore, this data demonstrates that a well-trained neurosurgeon with critical care experience can safely manage a severe traumatic brain injury patient with an isolated head injury as a primary service while in the intensive care unit. Since injury severity scores did not differ between these two service lines, we further theorize that this is likely due to a deep understanding of the nuances of neurosurgical pathophysiology and Brain Trauma Foundation (BTF) guidelines.