Local Trauma Center Research Articles

Treatment of the wounded from the war in Ukraine in the trauma networks of the DGU-Requirement, reality and motivation over the course of 18months…

The war in Ukraine and the medical treatment of the wounded in hospitals in Germany has now represented achallenge for more than 15months. The majority of trauma patients were distributed via the general holding center (GMLZ) at the Federal Office of Civil Protection and Disaster Assistance (BBK) by the cloverleaf concept and the trauma networks. Initially, numerous offers of assistance were promoted with great solidarity. For documentation of the current motivation situation and also for identification of the potential for improvement, a2-stage survey of senior physicians in the organized and certified hospitals in the trauma networks was carried out. An online survey of senior physicians of the trauma network hospitals was carried out with asemistructured written questionnaire in December 2022 and afollow-up survey during the Trauma Network Meeting (TNT) Congress in September 2023 in Frankfurt. Of the questionnaires 113 could be evaluated in December 2022 and 70completed questionnaires in September 2023. The answers came from national trauma centers (ÜTZ), regional trauma centers (RTZ) and local trauma centers (LTZ) each with approximately one third. On average 2.7patients were treated in all participating hospitals up to December and up to September no more than 5in more than half of the hospitals overall. The main challenges for all participants at both points in time were the long hospital stay, the demanding pathogen status and sometimes unclarified or not completely covered reimbursement of costs. Nevertheless, more than 80% of the specialist departments received backing from their hospital sponsors as well as their personnel for the continuing treatment of the wounded from Ukraine. The medical and professional challenges in the treatment of the wounded from Ukraine are, as expected, characterized by the demanding injury patterns of the musculoskeletal system and the colonization with multidrug-resistant pathogens. This results in along course of treatment, where the remuneration does not always cover the costs. Despite these challenges the solidarity in the hospitals of the trauma networks is unbroken. Simultaneously, there are numerous possibilities for improvement in order to enhance the prerequisites for future comparable humanitarian assistance jointly with politics.

Characteristics and Clinical Outcomes of Elderly Patients with Trauma Treated in a Local Trauma Center

Purpose: This study aimed to investigate the characteristics of elderly patients who visited a non-regional trauma center to examine the effects of old age on the clinical outcomes of patients.Methods: The medical charts of 159 patients with trauma who visited the National Health Insurance Service Ilsan Hospital between March 2020 and February 2022 were retrospectively analyzed.Results: Of the 159 patients, 41 were assigned to the elderly patient group (EPG) and 118 were assigned to the non-elderly patient group (NEPG). The average age of patients in each group was 75.5 and 38.2 years in the EPG and the NEPG, respectively. Comparing the injury mechanism between the two groups, pedestrian traffic accidents (TA) were the most common (24.4%), followed by slipping (19.5%), motorcycle TA, and bicycle TA (14.6%) in EPG. In the NEPG, motorcycle TA (28.0%) was the most common, followed by car TA (27.1%), and fall injury (16.9%), with a significant difference between the two groups (<i>p</i> < 0.001). The significant differences between the two groups were the injury severity score (ISS; <i>p</i> = 0.004), severe trauma (<i>p</i> = 0.045), intensive care unit admission (<i>p</i> = 0.028), emergency operation (<i>p</i> = 0.034), and mortality (<i>p</i> = 0.013). The statistically significant risk factors for mortality were old age (<i>p</i> = 0.024) and chest injury (<i>p</i> = 0.013).Conclusion: Patients in the EPG compared with the NEPG group showed different injury mechanisms. The EPG has a higher severity and mortality rate than the NEPG.

Preparation of hospitals for mass casualty incidents in Bavaria, Germany: care capacities for penetrating injuries and explosions in TerrorMASCALs

BackgroundIn a terror attack mass casualty incident (TerrorMASCAL), compared to a “normal” MASCAL, there is a dynamic course that can extend over several hours. The injury patterns are penetrating and perforating injuries. This article addresses the provision of material and personnel for the care of special injuries of severely injured persons that may occur in the context of a TerrorMASCAL.MethodsTo answer the research question about the preparation of hospitals for the care of severely injured persons in a TerrorMASCAL, a survey of trauma surgery departments in Bavaria (Germany) was conducted using a questionnaire, which was prepared in three defined steps based on an expert consensus. The survey is divided into a general, neurosurgical, thoracic, vascular and trauma surgery section. In the specialized sections, the questions relate to the implementation of and material and personnel requirements for special interventions that are required, particularly for injury patterns following gunshot and explosion injuries, such as trepanation, thoracotomy and balloon occlusion of the aorta.ResultsIn the general section, it was noted that only a few clinics have an automated system to notify off-duty staff. When evaluating the data from the neurosurgical section, the following could be established with regard to the performance of trepanation: the regional trauma centers do not perform trepanation but nevertheless have the required material and personnel available. A similar result was recorded for local trauma centers. In the thoracic surgery section, it could be determined that almost all trauma centers that do not perform thoracotomy have the required material available. This group of trauma centers also stated that they have staff who can perform thoracotomy independently. The retrograde endovascular aortic occlusion procedure is possible in 88% of supraregional, 64% of regional and 10% of local trauma centers. Pelvic clamps and external fixators are available at all trauma centers.ConclusionThe results of the survey show potential for optimization both in the area of framework conditions and in the care of patients. Consistent and specific training measures, for example, could improve the nationwide performance of these special interventions. Likewise, it must be discussed whether the abovementioned special procedures should be reserved for higher-level trauma centers.

Characteristics and In-Hospital Outcomes of Pediatric Traumatic Spinal Injuries in A Referral Trauma Center.

Objective:To evaluate the characteristics and in-hospital outcomes of traumatic spinal injuries among children admitted to a local trauma center in Iran. Methods:Patients aged 0-18 years who had been admitted to Shahid Kamyab trauma center for acute traumatic spinal injury (Mashhad, Iran) between 2011 and 2018 were evaluated retrospectively. Various demographic, clinical, radiological, and outcome variables were recorded and analyzed.Results:A total of 127,300 trauma patients were evaluated and amongst them, 61 children had spinal trauma. The mean age was 11.1 and there was no significant sex preponderance (54% males). Most of the injuries were occurred in summer (34.4%) and the most common trauma mechanism was motor vehicle accidents (55.7%) followed by falling (36.1%). Almost all patients (95.1%) had vertebral fractures, which were in the cervical, thoracic, and lumbosacral area in order to decrease incidence. 67.2% of patients were managed non-surgically. The mean hospital stay was 8.9 days and 82.0% of patients had been discharged with normal motor function. Conclusion:Pediatric spinal trauma is less studied entity in the field of traumatology due to the lower prevalence of these injuries in pediatric patients worldwide. But our study shows a higher prevalence of such injuries in the pediatric population. Although controversial, the leading cause of these injuries is motor vehicle accidents. Fortunately, short term in-hospital outcome seems to be good in such injuries.

Non-Operative Management of Traumatic Gallbladder Bleeding with Cystic Artery Injury: A Case Report

<p>Gallbladder injuries are rare in cases of blunt abdominal trauma and are usually associated with damage to other internal organs. If the physician does not suspect gallbladder injury and check imaging studies carefully, it may be difficult to distinguish a gallbladder injury from gallbladder stone, hematoma, or bleeding. Therefore, in order not to miss the diagnosis, the clinical findings and correlation should be confirmed. In the present case, a 60-year-old male presented to a local trauma center complaining of pain in the upper right quadrant and chest wall following a motor vehicle collision. Abdominal computed tomography (CT) showed a hepatic laceration and hematoma in the parenchyma in segments 4, 5, and 6 and active bleeding in the lumen of the gallbladder. Traumatic gallbladder injuries generally require surgery, but in this case, non-operative management was possible with cautious follow-up consisting of abdominal CT and angiography with repeated physical examinations and hemodynamic monitoring in the intensive care unit.</p>

Infrastructure, logistics and clinical practice management of acute trauma hemorrhage and coagulopathy: a survey across German trauma centers

PurposeEarly detection and management of acute trauma hemorrhage and coagulopathy have been associated with improved outcomes, but local infrastructure, logistics and clinical strategies may differ.MethodsTo assess local differences in infrastructure, logistics and clinical management of acute trauma hemorrhage and coagulopathy we have conducted a web-based survey amongst clinicians working in DGU®-certified supraregional, regional and local trauma centers.Results137/1875 respondents completed the questionnaire yielding a response rate of 7.3%. The majority specified to work as head of department or senior consultant (95%) in trauma/orthopedic surgery (80%) of supraregional (38%), regional (34%) or local (27%) trauma centers. Conventional coagulation assays are most frequently used to monitor bleeding trauma patients. Only half of the respondents (53%) rely on extended coagulation tests, e.g. viscoelastic hemostatic assays. Tests to assess preinjury use of direct oral anticoagulants and platelet inhibitors are still not widely available and vary according to level of care. Conventional blood products are widely available but there remain differences between trauma centers of different level of care to access other hemostatic therapies, e.g. coagulation factor concentrates. Trauma centers of higher level of care are more likely to implement treatment protocols.ConclusionThis survey confirms still existing differences in infrastructure, logistics and clinical practice management for the detection of acute trauma hemorrhage and coagulopathy amongst DGU®-certified supraregional, regional and local trauma centers. Further work is recommended to locally implement diagnostics, therapies and treatment algorithms compliant to current guidelines to ensure the best possible outcomes in bleeding trauma patients.

562 Burn Bed Availability in the Northeast Region During the COVID-19 Pandemic

IntroductionThe coronavirus disease pandemic has placed enormous strain on all medical services with ICU capabilities throughout the Northeast region. The surge in ICU beds might severely limit burn centers to accept burn patients in a regional mass casualty incident.MethodsBurn bed data was collected by a regional burn disaster consortium. Open burn bed census was collected via telephone from each burn center in the consortium on April 15th, May 7th, May 21st, June 4th and June 18th of 2020. This data was compared to published data from 2009 to 2016.ResultsThe results are listed in Table 1. Lowest available burn bed was 35 beds on April 15th, 2020.ConclusionsAlthough a disaster may impact surrounding local and state hospitals, it does not always impact a burn center’s ability to transfer patients from a local trauma center or nearby burn center. A pandemic however affects a larger region and impacts all hospitals within that region.Peak ICU utilization in the Northeast was between the second and third week of April. During the peak utilization time, burn bed census was about 50% of the historical average. Burn bed census did not return to historical average until May 7, 2020. If a mass casualty event occurred in the pandemic region, the Northeast region would have to reach out to other ABA designated regions for assistance.Historically, burn mass casualty plans are based on the capacity to move burn patients to other burn centers in order to relieve surge capacity at the affected center. This data illustrates that, in a pandemic, burn beds are being utilized for non-burn patients. The ability to follow these plans will be greatly impacted.

Location of trauma care resources with inter-facility patient transfers

Traumatic injury is the third leading cause of death in the United States and is the leading cause of death among people aged 1–44. Regional trauma care systems can significantly reduce this mortality rate if resources are located and used appropriately. Trauma centers are categorized as able to either provide total care (Level I or II) or prompt care (Level III and IV). We study trauma system planning by introducing an integer programming model to optimally relocate existing air ambulances, locate new air ambulances, and upgrade Level III and IV trauma centers to Level I or II trauma centers within a mature trauma system. The goal of these models to improve timely access to care and ensure the appropriate level of care is provided to severely injured patients. A novel aspect of the modeling approach is the inclusion of patient transfers from Level III/IV trauma centers to Level I/II trauma centers. Patient transfers are of particular importance after mass casualty events when a surge of trauma patients can overwhelm local trauma center capacity. As a result, we introduce a mass casualty incident response stochastic programming model to optimally relocate air ambulances within the trauma system following a mass casualty incident but before patient demand is known with certainty. The two models inform planning decisions by considering the interrelated response decisions. We construct case studies for both models based on the Wisconsin, USA trauma care system. The results highlight the importance of relocating air ambulances for increasing the number of patients transported directly to a Level I/II trauma center. The results also indicate that considering patient transfers within the model can significantly alter the optimal locations of trauma care resources compared to when transfers are not considered.

Severe Sea Lion Bites in Urban Cold-Water Swimmers.

A series of sea lion bites in open-water swimmers recently gained the attention of the national and international media. Pinniped (the clade including seals and sea lions) bites historically have been in people who hunt or handle marine mammals. As populations of humans and pinnipeds continue to grow, interactions with animals by those participating in recreational activities are likely to become more frequent. In December of 2017 and January of 2018, four sea lion (Zalophus californianus) bites in humans occurred at a popular open-water recreational swimming area in San Francisco, California. Three swimmers required treatment at a local trauma center and two required surgery. Two of the wounds were potentially life threatening; one swimmer required a field tourniquet to stop bleeding from the antecubital fossa, and the bite in another narrowly missed the femoral artery. The purpose of this report is to offer an in-depth discussion of antimicrobial use and rabies postexposure prophylaxis in patients with severe pinniped bites. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Information from this report can be used in conjunction with input from local experts to develop a thoughtful therapeutic plan for patients with severe pinniped bites. Doxycycline is the first-line antibiotic therapy, but broader coverage may be needed for severe wounds with the potential for contamination. The likelihood of rabies is low, and rabies postexposure prophylaxis should be reserved for cases that involve unusually aggressive animal behavior or other factors suggestive of rabies.

Western Trauma Association critical decisions in trauma: Preferred triage and initial management of the burned patient.

This is a recommended management algorithm from the Western Trauma Association addressing the management of victims of burn injury. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, these recommendations are based primarily on published retrospective studies, clinical guidelines, and the expert opinion of members of the Western Trauma Association in conjunction with partner members of the American Burn Association. The algorithm and accompanying comments represent one safe and sensible approach that can be followed at most trauma centers. We recognize that there may be patient or institutional factors that warrant deviation from the published algorithm. We would encourage institutions to use this document as a starting point toward a dialog with local burn centers to collaboratively create a patient-centered care experience for the victims of minor burn injuries arriving at local trauma centers.

Detection of malnutrition in geriatric trauma patients : Areassessment

Malnutrition in geriatric trauma patients is associated with an increased risk of complications and mortality and is therefore akey risk factor. The assessment of the affected patients plays an important role in improving the outcome of this growing patient group. In 2016 aquestionnaire was sent to 571 departments specialized in traumatology and orthopedics throughout Germany. The following were recorded: level of care, expertise in geriatric trauma, nutrition-based screening procedures and nutritional ward round procedures. The response rate was 57% (n = 325) and closely reflected the treatment reality in Germany with respect to the level of care (superregional, regional or local trauma center and those without special qualifications). In 14% (n = 45) the participants were German Society for Trauma Surgery(DGU)-certified centers for age-related traumatology, while afurther 5% (n = 15) were in the process of certification. The nutritional status was assessed in 56% (n = 181) of the clinics. Most frequently used was the body mass index (74%) followed by the mini nutritional assessment (30%), laboratory parameters (29%) and nutritional risk screening 2002 (19%). Some additional methods were specified. In approximately half of the departments nutritional ward rounds took place in regular wards (50%) and intensive care units (57%). The high response rate of this study seems to show the particular interest for malnutrition in geriatric trauma patients. This is reflected in an increase in the participating clinics compared to past surveys and also the more regularly performed assessment of nutritional status and implementation of nutritional visits. The establishment of suitable and time-effective screening instruments and their implementation are still achallenge.

Penetrating knife injury to the skull: A case report in pediatric neurosurgical care

Isolated penetrating head injury in children is rare and is usually accidental. Each case is unique since the penetrating object and the trajectory through the brain parenchyma vary greatly among patients. We present a three-year-old girl who presented with a kitchen utility knife penetrating her left midface, skull, and brain abutting the anterior cerebral vasculature. Though the patient initially presented to a local trauma center, there were no pediatric nor vascular neurosurgeons on staff. Thus, she was transferred to our tertiary facility for definitive surgical management. A pediatric and vascular neurosurgeon worked together to remove the knife safely and the underlying vasculature remained intact. Postoperatively, the patient did well and was neurologically intact. Though penetrating cranial injury is rare in the pediatric population, such complex cases of brain injury can be properly managed with good outcome by an interdisciplinary team of specialists in tertiary care centers and can result in an excellent surgical and functional outcome for the patient.

A Geographic Simulation Model for the Treatment of Trauma Patients in Disasters.

Though the US civilian trauma care system plays a critical role in disaster response, there is currently no systems-based strategy that enables hospital emergency management and local and regional emergency planners to quantify, and potentially prepare for, surges in trauma care demand that accompany mass-casualty disasters. A proof-of-concept model that estimates the geographic distributions of patients, trauma center resource usage, and mortality rates for varying disaster sizes, in and around the 25 largest US cities, is presented. The model was designed to be scalable, and its inputs can be modified depending on the planning assumptions of different locales and for different types of mass-casualty events. To demonstrate the model's potential application to real-life planning scenarios, sample disaster responses for 25 major US cities were investigated using a hybrid of geographic information systems and dynamic simulation-optimization. In each city, a simulated, fast-onset disaster epicenter, such as might occur with a bombing, was located randomly within one mile of its population center. Patients then were assigned and transported, in simulation, via the new model to Level 1, 2, and 3 trauma centers, in and around each city, over a 48-hour period for disaster scenario sizes of 100, 500, 5000, and 10,000 casualties. Across all 25 cities, total mean mortality rates ranged from 26.3% in the smallest disaster scenario to 41.9% in the largest. Out-of-hospital mortality rates increased (from 21.3% to 38.5%) while in-hospital mortality rates decreased (from 5.0% to 3.4%) as disaster scenario sizes increased. The mean number of trauma centers involved ranged from 3.0 in the smallest disaster scenario to 63.4 in the largest. Cities that were less geographically isolated with more concentrated trauma centers in their surrounding regions had lower total and out-of-hospital mortality rates. The nine US cities listed as being the most likely targets of terrorist attacks involved, on average, more trauma centers and had lower mortality rates compared with the remaining 16 cities. The disaster response simulation model discussed here may offer insights to emergency planners and health systems in more realistically planning for mass-casualty events. Longer wait and transport times needed to distribute high numbers of patients to distant trauma centers in fast-onset disasters may create predictable increases in mortality and trauma center resource consumption. The results of the modeled scenarios indicate the need for a systems-based approach to trauma care management during disasters, since the local trauma center network was often too small to provide adequate care for the projected patient surge. Simulation of out-of-hospital resources that might be called upon during disasters, as well as guidance in the appropriate execution of mutual aid agreements and prevention of over-response, could be of value to preparedness planners and emergency response leaders. Study assumptions and limitations are discussed. Carr BG , Walsh L , Williams JC , Pryor JP , Branas CC . A geographic simulation model for the treatment of trauma patients in disasters. Prehosp Disaster Med. 2016;31(4):413-421.

Should Regionalization Only Be in 1 Direction?

The article by Matsushima et al1 gives a new perspective on regionalizationof care for trauma. Inelderlypatientswhohave been treated at level 1 and level 2 trauma centers in Pennsylvania, the authors noted a 25%decrease inmortality for those atcenters that treatmore than 100 geriatric patients annually. Thesehigh-volumegeriatric trauma centers have lower rates of major complications, even lower incidences of failure to rescue after a major complication when compared with centerswith fewer than 100 suchpatients annually. Conversely, at institutions that have larger numbers of nongeriatric traumapatients, therewasa significantlyhigher rateofmajor complications for elderly individuals. While theauthorscommentedthat thisobservationshould be used to “consider the needs of specific subgroups such as the elderly” and to drive the decision to allocate hospital resources to geriatric trauma, I look at it differently. Their data clearly show that large nongeriatric trauma volumesmay adversely affect the outcomes of geriatric trauma patients. Remember that trauma is a young person disease; so is it safer to divert elderly patients away from the large urban trauma centers and keep them in their community level 2 trauma hospitals? Regionalization of trauma care has increased survival throughout the United States. The rapid transport of critically injured patients to level 1 centers has been shown to improveoutcomes. So, is thismodel also true for the geriatric patients?While the authors did not analyze the age distribution of patients in their hospitals, tertiary, level 1 university hospitals typically have a younger age demographic than community hospitals, which are typically level 2 centers. Similarly, the trauma experienced by geriatric patients is much different than that experienced by younger patients. Most geriatric injuries are from falls, which yield orthopedic andneurosurgicalproblems;very fewarepenetrating fromviolence. They also havemore chronic problems than those seen in younger patients. I propose that thedatapresentedbyMatsushimaetal1 support the concept of regionalizing geriatric care to community hospital, level 2 trauma centers. Those are the ones that may verywell bebetter equipped tohandle the local geriatricpopulation than the tertiary, high-volume, level 1 trauma centers. There are benefits to this particular regionalization. First, elderly patients would be able to be cared for near their home and their families. Second, community doctorswould be able to participate in the care of their patients. Third, local rehabilitation centers—both long termand short term—wouldbenefit from close relationships to the patients at the local hospitals. Fourth, many community hospitals that are now experiencingdecreasing inpatientvolumesanddecreasing revenues would be able to make a new model for revenue generationand serving their local communitybydeveloping level 2 trauma services. Matsushima et al1 suggest that this is already happening. The Figure in their article shows a weak correlation between geriatric to nongeriatric volumes at trauma centers. Specifically, the 0.75 correlation noted, if significant, likely would be less so if the 2 outliers in the right upper portion of the graph were removed. That suggests that many geriatric patients are already being treated at local trauma centers. The article suggests that these patients are in fact being appropriately treated. The authors are well positioned to develop a model of regionalization of care to centers appropriate for age and injury and can establish the ratio of geriatric/nongeriatric trauma patients who will get these unique patients the best care.

Retroperitoneal Pelvic Packing in the Management of Hemodynamically Unstable Pelvic Fractures: A Level I Trauma Center Experience

Our objective is to evaluate the mortality and outcomes of hemodynamically unstable patients with pelvic fractures treated with a protocol that directs the patient to either early pelvic angiography or early retroperitoneal pelvic packing. This is a retrospective review of prospectively collected database at a local trauma center. Hemodynamically unstable pelvic fracture patients received treatment according to our hospital protocol during two different time periods. Before June 2008, these patients underwent early angiography (ANGIO group, n=13), and from June 2008 onward, these patients underwent early pelvic packing and subsequent angiography if there was continued hemorrhage from the pelvis (PACKING group, n=11). The mechanism of injury, physiologic parameters, blood transfusion requirements, time to intervention, trauma scores, and mortality were recorded. Mean time to intervention in the ANGIO group was longer than that in the PACKING group, although this was not statistically significant (139.5 minutes vs. 78.8 minutes, respectively, p=0.248). Mortality in the ANGIO group was higher than that in the PACKING group; however, this was also not significant (69.2% vs. 36.3%, p=0.107). After univariate analysis, factors associated with mortality included systolic blood pressure, Glasgow Coma Score, Injury Severity Score, Revised Trauma Score, Trauma and Injury Severity Score, pH, and base excess. In the PACKING group, one patient died of uncontrolled hemorrhage from a liver laceration. In the ANGIO group, three patients died of uncontrolled hemorrhage from the pelvic fracture. Early experience in our institution suggests that early pelvic packing with subsequent angiography if needed is as good as angiography with embolization in treating patients with hemodynamically unstable pelvic fractures.

Integrated Musculoskeletal Rehabilitation Care at a Comprehensive Combat and Complex Casualty Care Program

Objective The purpose of this study is to describe the musculoskeletal rehabilitation model used to care for combat and severely wounded or ill US military service members at an integrated Comprehensive Combat and Complex Casualty Care center located at Naval Medical Center San Diego. Methods Through a collaborative and iterative process, providers from the various services included at the Comprehensive Combat and Complex Casualty Care program developed a description of the integration of services provided at this location. Results After construction of the facility in 2007, the program has provided services for approximately 2 years. Eighteen different health care providers from 10 different specialties provide integrated musculoskeletal services, which include primary care, physical therapy, occupational therapy, vestibular therapy, gait analysis, prosthetics, recreational therapy, and chiropractic care. At the time of this writing (early 2009), the program had provided musculoskeletal rehabilitation care to approximately 500 patients, 58 with amputations, from the operational theater, Veterans Affairs, other military treatment facilities, and local trauma centers. Conclusion The complex nature of combat wounded and polytrauma patients requires an integrated and interdisciplinary team that is innovative, adaptable, and focused on the needs of the patient. This article presents a description of the model and the experiences of our musculoskeletal rehabilitation team; it is our hope that this article will assist other centers and add to the small but emerging literature on this topic.

Platelet Rich Concentrate: Basic Science and Current Clinical Applications

Improvements in resuscitation, dissemination of ATLS protocols, and growth of regional and local trauma centers has increased the survivability after severe traumatic injuries. Furthermore, advances in medical management have increased life expectancy and also patients with orthopaedic injuries. While mechanical stabilization has been a hallmark of orthopaedic fracture care, orthobiologics are playing an increasing role in the management of these patients with complex injuries. Platelet-rich concentrate is an autologous concentration of platelets and growth factors, including transforming growth factor-beta (TGF-beta), vascular endothelial growth factor (VEGF), and platelet-derived growth factor (PDGF). The enhancement of bone and soft tissue healing by the placement of supraphysiologic concentration of autologous platelets at the site of tissue injury or surgery is supported by basic science and clinical studies. Due to the increased concentration and release of these factors, platelet-rich plasma can potentially enhance the recruitment and proliferation of tenocytes, stem cells, and endothelial cells. A better understanding of platelet function and appropriate clinical use is essential in achieving the desired outcomes of platelet-rich concentrate in orthopaedic clinical applications.

Effective trauma center partnerships to address firearm injury: a new paradigm.

Firearm violence is the second leading cause of injury-related death. This study examined the use of local trauma centers as lead organizations in their communities to address firearm injury. Three trauma centers in cities with populations less than 100,000 were linked with a university-based firearm injury research center. A trauma surgeon director and coordinator partnered with communities, recruited and directed advisory boards, established a local firearm injury surveillance system, and informed communities using community-specific profiles. Primary process and outcome measures included completeness of data, development of community-specific profiles, number of data-driven consumer media pieces, number of meetings to inform policy makers, and an analysis of problems encountered. Local trauma centers in smaller communities implemented a firearm injury surveillance system, produced community-specific injury profiles, and engaged community leaders and policy makers to address firearm injury. Community-specific profiles demonstrated consistent firearm suicide rates (6.58-6.82 per 100,000) but variation in firearm homicide rates (1.08-12.5 per 100,000) across sites. There were 63 data-driven media pieces and 18 forums to inform community leaders and policy makers. Completeness of data elements ranged from 57.1% to 100%. Problems experienced were disconnected data sources, multiple data owners, potential for political fallout, limited trauma center data, skills sets of medical professionals, and sustainability. Trauma centers, when provided resources and support, with the model described, can function as lead organizations in partnering with the community to acquire and use community-specific data for local firearm injury prevention.

Tracheobronchial injuries

A 27-year-old man, formerly in good health, arrived at the local trauma center after a high-speed rollover motor vehicle crash. He was in frank shock, with bilateral tension pneumothoraces. The team intubated him immediately and placed bilateral chest tubes. A computed tomography scan of the head showed severe traumatic brain injury with diffuse axonal injury and intraventricular bleeding. Additional injuries included bilateral full-thickness burns to his lower extremities, multiple facial fractures, multiple rib fractures, and pulmonary contusion.