Mean Injury Severity Score Research Articles

Does the injury pattern drive the surgical treatment strategy in multiply injured patients with major fractures?

The timing of definitive surgery in multiple injured patients remains a topic of debate, and multiple concepts have been described. Although these included injury severity as a criterion to decide on the indications for surgery, none of them considered the influence of injury distributions. We analyzed whether injury distribution is associated with certain surgical strategies and related outcomes in a cohort of patients treated according to principles of early and safe fixation strategies. In this retrospective cohort study, multiple injured patients were included if they were primarily admitted to a Level I trauma center, had an Injury Severity Score of ≥16 points, and required surgical intervention for major injuries and fractures. The primary outcome measure was treatment strategy. The treatment strategy was classified according to the timing of definitive surgery after injury: early total care (ETC, <24 hours), safe definitive surgery (SDS, <48 hours), and damage control (DC, >48 hours). Statistics included univariate and multivariate analyses of mortality and the association of injury distributions and surgical tactics. Between January 1, 2016, and December 31, 2022, 1,471 patients were included (mean ± SD age, 55.6 ± 20.4 years; mean Injury Severity Score, 23.1 ± 11.4). The group distribution was as follows: ETC, n = 85 (5.8%); SDS, n = 665 (45.2%); and DC, n = 721 (49.0%); mortality was 22.4% in ETC, 16.1% in SDS, and 39.7% in DC. Severe nonlethal abdominal injuries (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.4-3.5) and spinal injuries (OR, 1.6; 95% CI, 1.2-2.2) were associated with ETC, while multiple extremity injuries were associated with SDS (OR, 1.7; 95% CI, 1.4-2.2). Severe traumatic brain injury was associated with DC (OR, 1.3; 95% CI, 1.1-1.4). When a correction for the severity of head, abdominal, spinal, and extremity injuries, as well as differences in the values of admission pathophysiologic parameters were undertaken, the mortality was 30% lower in the SDS group when compared with the DC group (OR, 0.3; 95% CI, 0.2-0.4). Major spinal injuries and certain abdominal injuries, if identified as nonlethal, trigger definitive surgeries in the initial setting. In contrast, severe TBI was associated with delayed fracture care. Patients with major fractures and other injuries were treated by SDS (definitive care, <48 hours) when the pathophysiological response was adequate. The choice of a favorable surgical treatment appears to depend on injury patterns and physiological patient responses. Therapeutic/Care Management; Level IV.

Hollow viscus injury due to blunt abdominal trauma: a tertiary trauma center experience.

Hollow viscus injuries (HVIs) present less frequently than solid organ injuries in patients with blunt abdominal trauma, potentially leading to significantly increased morbidity and mortality rates. Modern imaging equipment, confidently used for diagnosing solid organ injuries, may fail to identify hollow viscus injuries. In this study, we aim to present our tertiary center's experience with this entity. Patients treated in our clinic from April 2011 to December 2021 for hollow viscus injury following blunt abdominal trauma were included in this study. We recorded and retrospectively evaluated patients' demographic data, injury site and mechanism, preoperative and perioperative findings, and mortality rates in a prospective database. Of the 607 blunt trauma patients, 35 (5.8%) had hollow viscus injuries, with 88.6% being male. Motor vehicle accidents were the leading cause of injury (80%). The mean duration between admission and surgical exploration was 26±21.2 hours. The mean Injury Severity Score was 21.8±13.6. Rigidity was the most frequent clinical finding (60%). The jejunum and ileum were the most frequently injured organs (54.1%). Mortality and morbidity rates were 11.4% and 17.1%, respectively. Nondeclining white blood cell (WBC) counts within 24 hours of admission, alongside any physical or radiological finding indicating an HVI, should prompt immediate surgical exploration.

Multiligament knee injuries. Ten years' experience at a public university, level I Trauma Center.

To describe our institutional experience and results in the surgical management of multiligament knee injuries (MLKI). Retrospective series of MLKI consecutively operated on at a single, level I Trauma Center. Data on patients' baseline characteristics, injuries, treatments, and outcomes were recorded up to one-year follow-up. Recorded outcomes included the Tegner-Lysholm Knee Scoring Scale (TLKSS), return to work, and patient satisfaction. MLKI incidence was 0.03% among 9897 orthopedic trauma admissions. Twenty-four patients of mean age 43.6years were included in analysis. The mean Injury Severity Score was 12.6. Five patients presented with knee dislocations and six had fracture-dislocations, two of them open fractures. There was one popliteal artery injury requiring a bypass and four common peroneal nerve palsies. Staged ligamental reconstruction was performed in all cases. There were seven postoperative complications. The median TLKSS was 80 and, though patient satisfaction was high, and dissatisfaction was largely restricted to recreational activities (only 58.3% satisfied). Seventeen patients returned to their previous employment. We found a high aggregation of fracture-dislocations secondary to road traffic accidents. One in four patients experienced complications, particularly stiffness. Complications were more common in cases involving knee dislocation. Most patients had good functional results, but 25% were unable to return to their previous work, which demonstrates the long-lasting sequelae of this injury.

A multicenter evaluation of pediatric emergency department injury visits during the COVID-19 pandemic

BackgroundInjuries, the leading cause of death in children 1–17 years old, are often preventable. Injury patterns are impacted by changes in the child’s environment, shifts in supervision, and caregiver stressors. The objective of this study was to evaluate the incidence and proportion of injuries, mechanisms, and severity seen in Pediatric Emergency Departments (PEDs) during the COVID-19 pandemic.MethodsThis multicenter, cross-sectional study from January 2019 through December 2020 examined visits to 40 PEDs for children < 18 years old. Injury was defined by at least one International Classification of Disease-10th revision (ICD-10) code for bodily injury (S00–T78). The main study outcomes were total and proportion of PED injury-related visits compared to all visits in March through December 2020 and to the same months in 2019. Weekly injury visits as a percentage of total PED visits were calculated for all weeks between January 2019 and December 2020.ResultsThe study included 741,418 PED visits for injuries pre-COVID-19 pandemic (2019) and during the COVID-19 pandemic (2020). Overall PED visits from all causes decreased 27.4% in March to December 2020 compared to the same time frame in 2019; however, the proportion of injury-related PED visits in 2020 increased by 37.7%. In 2020, injured children were younger (median age 6.31 years vs 7.31 in 2019), more commonly White (54% vs 50%, p < 0.001), non-Hispanic (72% vs 69%, p < 0.001) and had private insurance (35% vs 32%, p < 0.001). Injury hospitalizations increased 2.2% (p < 0.001) and deaths increased 0.03% (p < 0.001) in 2020 compared to 2019. Mean injury severity score increased (2.2 to 2.4, p < 0.001) between 2019 and 2020. Injuries declined for struck by/against (− 4.9%) and overexertion (− 1.2%) mechanisms. Injuries proportionally increased for pedal cycles (2.8%), cut/pierce (1.5%), motor vehicle occupant (0.9%), other transportation (0.6%), fire/burn (0.5%) and firearms (0.3%) compared to all injuries in 2020 versus 2019.ConclusionsThe proportion of PED injury-related visits in March through December 2020 increased compared to the same months in 2019. Racial and payor differences were noted. Mechanisms of injury seen in the PED during 2020 changed compared to 2019, and this can inform injury prevention initiatives.

Balloon Rises Above: REBOA at Zone 1 May Be Superior to Resuscitative Thoracotomy.

The use of Zone 1 REBOA for life-threatening trauma has increased dramatically. The Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database was queried for blunt and penetrating trauma between 2013 and 2021. Outcomes were examined both for mechanisms of injury combined and separately and for combinations of abdominal injury with and without traumatic brain injury and chest injuries (Abbreviated Injury Scale [AIS] score >2). A total of 531 patients underwent REBOA (408 with blunt injury and 123 with penetrating injury) and 1,603 (595 with blunt injury and 1,008 with penetrating injury) underwent resuscitative thoracotomy (RT). Mean age was 38.5 ± 16 years and mean injury severity score was 34.5 ± 21; 57.7% had chest AIS score of more than 2, 21.8% had head AIS score of more than 2, and 37.3% had abdominal AIS score of more than 2. Admission Glasgow Coma Scale was 4.9 + 4, and systolic blood pressure at aortic occlusion (AO) was 22 + 40 mmHg. No differences in outcomes in REBOA or RT patients were identified between institutions (p > 0.5). After inverse probability weighting, Glasgow Coma Scale, age, injury severity score, systolic blood pressure at AO, CPR at AO, and blood product transfusion, REBOA was superior to RT in both blunt (odds ratio [OR] 4.7, 95% CI 1.9 to 11.7) and penetrating (OR 4.9, 95% CI 1.7 to 14) injuries, across all spectrums of injury (p < 0.01). Overall mortality was significantly higher for AO more than 90 minutes compared with less than 30 minutes in blunt (OR 4.6, 95% CI 1.5 to 15) and penetrating (OR 5.4, 95% CI 1.1 to 25) injuries. Duration of AO more than 60 minutes was significantly associated with mortality after penetrating abdominal injury (OR 5.1, 95% CI 1.1 to 22) and abdomen and head (OR 5.3, 95% CI 1.6 to 18). In-hospital survival is higher for patients undergoing REBOA than RT for all injury patterns. Complete AO by REBOA or RT should be limited to less than 30 minutes. Neither hospital and procedure volume nor trauma verification level impacts outcomes for REBOA or RT.

Are Pediatric Trauma Transfers Justified?: A Unique Viewpoint From a Transferring Institution.

Definitions of pediatric overtriage and unnecessary transfers for injured children have been instituted from a viewpoint of referral centers and have doubtful value for effecting interventions at referring centers. This study provides a unique insight into the factors prompting transfers at a peripheral institution. The trauma registry of a level 2 pediatric trauma center was accessed, and pediatric transfers out to 2 level 1 pediatric trauma centers were identified over a period of 4 years. The outcomes of these patients at the accepting institutions were charted for descriptive analysis. The study identified 46 patients transferred out with a transfer rate of 6.6% when compared with total admissions. The mean Injury Severity Score (ISS) was 6.5, and the mean length of stay (LOS) at the receiving institution was 2.8 days. The reason for transfer from a specialty standpoint revealed 21 neurosurgical, 12 burn, 6 orthopedic, 4 faciomaxillary, and 2 ophthalmology patients. Overall transfer rate was 6.6%. Pediatric overtriage when defined as LOS < 24 hours at the receiving institution was 46.7%. Fifty percent of pediatric overtriage was prompted by need for a pediatric neurosurgery consult with medicolegal concern being cited as reason for transfer. Secondary overtriage when defined as LOS < 24 hours, no pediatric intensive care admission, no surgical intervention, and ISS < 9 was found in 13 patients (30.9%). The proportion of patients with Medicaid insurance was not different for the admissions (43.5%) when compared with the transfers (42.7%). Existing definitions of overtriage have limited value in effecting interventions to reduce unnecessary transfers. Identifying specific factors at referring institutions including providing local availability of pediatric surgical specialists will potentially help mitigate injury-related pediatric overtriage.

Have Incidence and Severity of Craniomaxillofacial Fractures Changed Since SARS-CoV-2?

An increase in severity and a decrease in incidence of craniomaxillofacial fractures (CMFs) were identified during the first several months of the SARS-CoV-2 pandemic. It is unclear if these changes have persisted in the current timeframe. The investigators hypothesize that the incidence and severity of CMF will not return to baseline prepandemic (control) levels as the pandemic stabilizes and becomes endemic. This retrospective cohort study enrolled subjects who presented to Harborview Medical Center a Level 1 trauma center for the evaluation and management of CMF. Inclusion criteria were 1) Presentation timeline 2018 through 2022, 2) CMF identified by the 10th International Classification of Disease. Exclusion criteria were: 1) Undocumented etiology of facial fracture and 2) inadequate/unclear documentation otherwise. The predictor variable was year of injury relating to the start of the pandemic. The groups were the prepandemic (2018, 2019) and postpandemic (2020, 2021. 2022). The primary outcome variable was the CMF diagnosis identified using the corresponding International Classification of Disease, 10th Edition codes. The secondary outcome variables were mechanism of injury and injury severity. The covariates were age, sex, race/ethnicity, admission status, alcohol intoxication, toxicology screen, reimbursement source, abuse reported, and abuse investigated. Univariate and bivariate analyses were performed with statistical significance at P<.05. The sample was composed of 5203 subjects. The annual volumes of subjects presenting with CMF were consistent over the study period (2018, 2019, 2020, 2021, 2022 n=1018, 963, 1020, 1062, 1140, respectively). The incidence of Hispanics increased (2018, 2019, 2020, 2021, 2022: 11.1, 9.6, 12.2, 13.9, 13.2% (P<.05)) as did firearm CMF injuries (2018, 2019, 2020, 2021, 2022: 4.13, 4.98, 4.71, 7.16, 6.75% (P<.05)). The Injury Severity Score and Abbreviated Injury Scale were both lower postpandemic compared to prepandemic; mean Injury Severity Score post [18.27±12.46] versus pre [19.25±12.89] (P<.05), mean Abbreviated Injury Scale post [2.94±1.15] versus pre [3.04±1.14] (P<.05). While the severity of CMF decreased postpandemic, Hispanic and firearm CMF increased. The overall CMF incidence remained the same. The significant rise in firearm injuries warrants further study.

Management of pediatric renal trauma: Results from the American Association for Surgery and Trauma Multi-Institutional Pediatric Acute Renal Trauma Study.

Pediatric renal trauma is rare and lacks sufficient population-specific data to generate evidence-based management guidelines. A nonoperative approach is preferred and has been shown to be safe. However, bleeding risk assessment and management of collecting system injury are not well understood. We introduce the Multi-institutional Pediatric Acute Renal Trauma Study (Mi-PARTS), a retrospective cohort study designed to address these questions. This article describes the demographics and contemporary management of pediatric renal trauma at Level I trauma centers in the United States. Retrospective data were collected at 13 participating Level I trauma centers on pediatric patients presenting with renal trauma between 2010 and 2019. Data were gathered on demographics, injury characteristics, management, and short-term outcomes. Descriptive statistics were used to report on demographics, acute management, and outcomes. In total, 1,216 cases were included in this study. Of all patients, 67.2% were male, and 93.8% had a blunt injury mechanism. In addition, 29.3% had isolated renal injuries, and 65.6% were high-grade (American Association for the Surgery of Trauma Grades III-V) injuries. The mean Injury Severity Score was 20.5. Most patients were managed nonoperatively (86.4%), and 3.9% had an open surgical intervention, including 2.7% having nephrectomy. Angioembolization was performed in 0.9%. Collecting system intervention was performed in 7.9%. Overall mortality was 3.3% and was only observed in patients with multiple injuries. The rate of avoidable transfer was 28.2%. The management and outcomes of pediatric renal trauma lack data to inform evidence-based guidelines. Nonoperative management of bleeding following renal injury is a well-established practice. Intervention for renal trauma is rare. Our findings reinforce differences from the adult population and highlights opportunities for further investigation. With data made available through Mi-PARTS, we aimed to answer pediatric specific questions, including a pediatric-specific bleeding risk nomogram, and better understanding indications for interventions for collecting system injuries. Prognostic and Epidemiological; Level IV.

Neglected upper-extremity fractures at a severe trauma center in the Republic of Korea

Purpose: Missed injuries and delayed diagnoses are likely when diagnosing patients with severe trauma. This research aimed to investigate the incidence of missed fractures in the upper extremities by retrospectively analyzing factors leading to an overlooked diagnosis.Methods: We retrospectively investigated patients hospitalized with newly diagnosed upper-extremity fractures after an initial diagnosis at Severe Trauma Center of Pusan National University Hospital. We analyzed the accompanying injuries, Injury Severity Score (ISS), reasons for a missed diagnosis, and treatment results.Results: Twenty-four patients and 27 cases were identified. The incidence of fracture was 0.4%, and the average diagnostic period was 33 days. The mean ISS was 24.3. Among the 27 cases of neglected fractures there were 1 intercondylar fracture of the humerus, 11 were radial or ulnar forearm fractures , six were carpus or metacarpal fractures, and nine were phalangeal fractures. Among the 24 patients with a delayed diagnosis, 21 patients had orthopedic-related fractures at other sites at the time of initial diagnosis. There were 12 cases of fracture in the ipsilateral limb. At final follow-up, 15 patients exhibited &lt;50% of normal range of motion in the injured area.Conclusion: A neglected upper-extremity fracture can result in missing the optimal surgery window and rehabilitation period, culminating in poor outcomes. Therefore, an orthopedic surgeon must conduct repeated, careful physical examinations with appropriate consideration of the injury mechanisms.

Urgent care-seeking and injury severity for intimate partner violence during COVID-19: a Canadian retrospective chart review

BackgroundEarly reports raised alarms that intimate partner violence (IPV) increased during the COVID-19 pandemic, but initial studies showed that visits to emergency departments (EDs) decreased. This study assessed the impact of the prolonged pandemic and its associated restrictions on both rates of urgent care-seeking and injury severity for IPV.MethodsData from the Kingston Health Sciences Centre’s (KHSC) ED were utilized to compare IPV presentations during ‘Pre-COVID’ (December 17, 2018 – March 16, 2020) and ‘COVID’ (March 17, 2020 – June 16, 2021), as well as three periods of heightened local restrictions: ‘Lockdown-1’ (March 17 – June 12, 2020), ‘Lockdown-2’ (December 26, 2020 – February 10, 2021) and ‘Lockdown-3’ (April 8 – June 2, 2021). The primary outcomes were incidence rate of IPV visits and injury severity, which was assessed using the Clinical Injury Extent Score (CIES) and Injury Severity Score (ISS).ResultsA total of 128 individuals were included. This sample had mean age of 34 years, was comprised of mostly women (97%), and represented a variety of intimate relationship types. Some individuals presented multiple times, resulting in a total of 139 acute IPV presentations. The frequency of IPV visits during COVID was similar to the Pre-COVID time period (67 vs. 72; p = 0.67). Incidence rate was 13% higher during COVID, though this difference was non-significant (6.66 vs. 5.90; p = 0.47). IPV visit frequency varied across lockdown periods (11 in Lockdown-1, 12 in Lockdown-2 and 6 in Lockdown-3), with the highest incidence rate during Lockdown-2 (12.71). There were more moderate and severe injuries during COVID compared to Pre-COVID, but mean CIES was not statistically significantly different (1.91 vs. 1.69; p = 0.29), nor was mean ISS (11.88 vs. 12.52; p = 0.73).ConclusionsDuring the 15-months following the start of COVID-19, there were small, but non-significant increases in both incidence rate and severity of IPV presentations to the KHSC ED. This may reflect escalation of violence as pandemic restrictions persisted and requires further investigation.

Pediatric Blunt Splenic Trauma: Disparities in Management and Outcomes

IntroductionWhile nonoperative management has become widely accepted, whether nonoperative management of blunt splenic trauma is standardized across pediatric trauma centers and different racial groups warrants further investigation. Using the National Trauma Database, the purpose of this study was to quantify the differences in the management of pediatric splenic trauma across different pediatric trauma centers, with respect to injury severity, race, ethnicity, and insurance. MethodsPatients under 20 y of age with blunt splenic trauma reported to the 2018 and 2019 National Trauma Data Bank were identified. Primary outcomes were splenectomy, embolization, transfusion, mortality, injury severity score (ISS), and length of hospital stay (LOS) and length of intensive care unit stay. Continuous data and categorical data were analyzed using ANOVA and Chi-squared test, respectively. Nearest 1:1 neighbor matching was performed between minority patients and White patients. P < 0.05 for all comparative analyses was considered statistically significant. ResultsOf the total cohort (n = 1919), 70.3% identified as White, while 21.6% identified as Black or Hispanic. The mortality rate was 0.3%. Among different race categories, the frequency of spleen embolization (P = 0.99), splenectomy (P = 0.99), blood transfusion (P = 1), and mortality (P = 1), were not significantly different. After controlling for ISS and age with propensity score matching, the mean hospital LOS remained significantly higher in minority patients, with a mean of 5.44 d compared to 4.72 d (P = 0.05). Mean length of intensive care unit stay was not significantly different after propensity matching, with a mean of 1.79 d and 1.56 spent in the ICU for minority and White patients respectively (P = 0.17). While propensity score matching preserved statistical significance, the ISS for the minority group remained 1.12 times higher than the ISS of the Caucasian group. There was no statistically significant difference among races with respect to different payment methods and insurance status, although Black and Hispanic patients were proportionally underinsured. ConclusionsWhile minority patients had a relatively higher number of operative interventions and longer hospital and ICU stays, after propensity score matching, mean ISS remained higher in the minority group. Our findings suggest that injury severity is likely to influence the difference in LOS between the two groups. Furthermore, our data highlight how nonoperative management is not standardized across pediatric trauma centers.

A retrospective observational study of injury patterns associated with powered circular saw in subjects presenting to the emergency department of a tertiary care hospital.

Powered circular saw-related injuries (PCSRIs) are responsible for a sizable proportion of occupational injuries presented to the emergency department (ED). The present study portrays the mechanisms, injury patterns, epidemiological parameters, and outcomes among subjects presenting with PCSRI to the ED. This retrospective observational study was conducted in the ED of a tertiary care hospital in eastern India. Clinical records of subjects with PCSRI from June 2019 to June 2022 were reviewed. Data pertaining to patients' demographic profiles and the patterns and mechanisms of injury were retrieved. The Modified Hand Injury Severity Score (MHISS) and the Injury Severity Score (ISS) were calculated. Statistical analysis was performed using R version 4.1.0. A total of 175 subjects' data were analyzed. The median age was 34.5 years, and all subjects were men. The mean year of experience of the subjects was 6.2. The most common job category was carpentry (n = 63 [36%]), followed by "do it yourself work" (n = 26 [14.8%]). One hundred twenty-two (69.7%) subjects had hand injuries (HIs), and the left hand was involved in 85 (69.6%) subjects. The index finger was involved in 36 (29.5%) subjects, followed by the thumb (n = 31 [25.4%]). Laceration (n = 155 [88.5%]) was the most common injury pattern. The subjects' mean ISS and mean MHISS were 8.52 and 45, respectively. PCSRI is associated with moderate-to-severe HIs that are most common in occupational settings. Young male carpenters involved in wood and plywood work are more prone to injuries.

Association between injury severity scores and clinical outcomes in patients with traumatic spinal injury in an aging Japanese society.

The Injury Severity Score (ISS) is widely used to evaluate patients with multiple injuries. This study investigated the association between ISS and clinical outcomes of patients with spinal cord injury (SCI) in an aging Japanese population. This retrospective cohort study investigated patients admitted to a Japanese university hospital. In the study, 89 patients with traumatic SCI were included. Traumatic SCI was categorized as monotrauma or polytrauma, and the ISS was used to evaluate trauma severity. Spearman's correlation coefficient was used to estimate the correlation between ISS and the American Spinal Injury Association (ASIA) motor score, Barthel Index (activities of daily living assessment), and the European Quality of Life (QOL) scale (EQ5d) as an assessment of QOL at admission or the last follow-up with the adjustment for age, sex, and body mass index. Return to home and work were analyzed using the chi-squared test after the ISS was divided into three groups (<14, 14-19, and 20). The mean ISS was significantly higher for polytrauma than monotrauma. Significant negative correlations between the ISS and ASIA motor scores at the first visit (P < .001, r = -0.37) and the last follow-up (adjusted, P = .007, r = -0.30) were observed. The Barthel Index was also negatively correlated with ISS at the first visit (P = .04, r = -0.21) and at the last follow-up period (P < .001, r = -0.35). Moreover, ISS was significantly negatively correlated with EQ5d score at the last follow-up (P = .01, r = -0.28). The chi-squared test demonstrated that patients with an ISS of < 14 returned home (P = .03), while those with an ISS of < 19 returned to work (P = .02). ISS is associated with paralysis, activities of daily living, QOL, and lifestyle in patients with SCI and is an important initial injury assessment method.

Predictors of mortality among older major trauma patients.

Older trauma patients have a higher mortality yet are more likely to be under-triaged compared to younger patients. Studies have suggested that current trauma team activation criteria are suboptimal for older patients. The objective was to describe trauma care delivered, patient outcomes, and to identify variables independently associated with mortality. We performed a health records review from 2014 to 2020 of older (age ≥ 65 years) trauma patients presenting to a level one trauma centre with any of the following: injury severity score (ISS) > 12, and all trauma team activations or admission to the trauma ward. The primary outcome was 30-day all-cause mortality. Secondary outcomes included injury mechanism and trauma care delivered. Multivariable logistic regression was used to identify factors independently associated with 30-day all-cause mortality. Multiple imputation was used to deal with missing data. We enrolled 1,380 patients (mean age 80 years, mean ISS 18); 26.8% had multimorbidity (≥ 2 chronic conditions) and 65.9% met criteria for polypharmacy (≥ 5 medications). The most common mechanism was fall from standing height (61.1%). Thirty-day all-cause mortality occurred in 239 (17.3%) patients. A Glasgow coma scale (GCS) < 15 (odds ratio [OR] = 5.55; 95% CI 3.73-8.24), ISS > 15 (OR = 3.75, 95% CI 2.35-6.01), age ≥ 85 years (OR = 2.04, 95% CI 1.29-3.22), anticoagulation with a direct oral anticoagulant (DOAC) or warfarin (OR = 1.59, 95% CI 1.08-2.35) and multimorbidity (OR = 1.53, 95% CI 1.06-2.22) were significantly associated with increased risk 30-day mortality (C-statistic = 0.82, 95% CI 0.79-0.85). Dementia (OR = 0.61, 95% CI 0.40-0.95) and time to CT scan > 60 min (OR = 0.50, 95% CI 0.34-0.74) were associated with decreased mortality risk. We identified five factors associated with increased 30-day mortality in older trauma patients: GCS < 15, ISS > 15, age ≥ 85years, anticoagulation, and multimorbidity. These factors should be considered when developing modified trauma team activation criteria for older adults.

Incidence and characteristics of vascular trauma at a level 2 trauma center

ObjectiveDespite the significant number of trauma patients treated at level 2 trauma centers (L2TCs) in the United States, most of the literature describing vascular trauma is from level 1 trauma centers (L1TCs). Currently, trauma center designation criteria do not require vascular surgery as a necessary component service. MethodsA retrospective chart review was performed for all trauma patients with a vascular surgery consultation seen at our L2TC between 2013 and 2018. Patient demographics, injury characteristics, and outcomes were collected and analyzed with descriptive statistics. ResultsOf the 3062 trauma patients evaluated at our L2TC, 110 (3.6%) had a vascular surgery consultation. Operative intervention was performed in 35.2% of consults, and 1.0% of all trauma patients had a vascular intervention. Average age was 57 years, and the majority were male (n = 75; 68.2%). Mean Injury Severity Score was 12.0 ± 9.6, and blunt injury (n = 77; 87.5%) was more common than penetrating (n = 11; 12.5%). The most common location of injury was the lower extremity (n = 23; 74.2%), followed by upper extremity (n = 3; 9.7%), chest (n = 2; 6.5%), neck (n = 2; 6.5%), and pelvis (n = 1; 3.2%). Endovascular interventions were performed by the vascular surgery service in 67.7% (n = 21) of all injuries. There was one amputation (3.2%) and one postoperative mortality (3.2%). ConclusionsAt our L2TC, postoperative morbidity and mortality rates at 30 days were substantially lower compared with previously reported data. However, mean injury severity score and the incidence of penetrating and polytrauma were also lower at our institution. Most patients were managed nonoperatively, but when they did require an operation, endovascular therapies were more commonly implemented. Vascular surgery should be considered an integral service in trauma level designation, and there is a need for further investigation of these outcomes in L2TCs.

Clinical outcomes for patients on antiplatelet and anticoagulants in thoracoabdominal trauma

IntroductionTrauma outcomes can be greatly affected by antiplatelet and anticoagulant (AP/AC) use. The goal of this study was to compare outcomes in trauma patients on AP/AC undergoing emergent surgery for thoracoabdominal trauma at 35 level 1 and 2 trauma centers from 2014 to 2021. MethodsThis was a retrospective cohort study of 2460 adult patients with a chest, abdomen, or pelvis abbreviated injury score (AIS) of 2 or more who underwent surgery within 24 h of admission. These patients were segregated into four main cohorts based on antiplatelet/anticoagulation use: those not on AP/AC, those taking direct-acting oral anticoagulants (DOACs), those taking clopidogrel, and those taking warfarin. Patients were excluded if they had surgery >24 h after presentation, were dead on arrival, or had any other body system AIS score of 3 or higher. ResultsThe mean injury severity score (ISS) in all four groups ranged from 16.3 to 18.6 (p = 0.834) with a mean time to operating room from 208 to 478 min (p < 0.001). Laparotomy was performed in 60 to 71 % (p > 0.01) of patients, regardless of AP/AC status, and thoracic procedures were performed in 3.1 to 9.3 % (p = 0.42) of patients. In-hospital mortality and hospice rates were highest in the clopidogrel group at 21.9 %, followed by warfarin at 13 %, DOACs at 15 %, and no AP/AC at 7.63 % (p = 0.008). Serious complications occurred in 61 % of patients on warfarin, 50 % of those on DOACs, and 44 % of those on clopidogrel. All of these groups demonstrated significantly higher complication rates than patients in the no AP/AC control group at 25 % (p < 0.001). Total transfusion of packed red blood cells and fresh frozen plasma did not differ significantly between the groups; however, 24-h platelet transfusion did. Patients on clopidogrel received 14 packs of platelets, while those on warfarin and DOACs received 8 and 13 packs respectively (p = 0.011). Patients on warfarin had the longest hospital length of stay (LOS) at 13 days and ICU LOS at 9 days, compared to those on DOACs (8 and 4), those on clopidogrel (7 and 3), and those not taking AC/AP (7 and 4) (hospital LOS p = 0.03, ICU LOS p = 0.019). Those on AC/AP were also noted to be significantly older than those on neither, with those taking these medications averaging out to be approximately 69 years old and those not on these medications averaging 37 years old (p < 0.001). ConclusionThere was significantly higher mortality in patients on clopidogrel and increased length of stay and risk of serious complications in patients taking DOACs and warfarin. In patients on AP/AC there was also a significantly longer time to surgery than in those not taking either. Given these associations trauma surgeons should consider intervening sooner on patients taking AP/AC on admission, as the delay to intervention may contribute to the risks for trauma patients and result in worse outcomes as well as higher rates of mortality.

Prehospital Transport Time and Outcomes for Pediatric Trauma: A National Study

IntroductionHistorically, emergency medical services have aimed to deliver trauma patients to definitive care within the 60 min (min) “Golden Hour” to optimize survival. There is little evidence to support or refute this for pediatric trauma. The objective of this investigation was to describe national trends in prehospital transport time, in relation to the “Golden Hour,” and pediatric trauma outcomes. MethodsRetrospective cohort study of patients (<15 y old) receiving emergency medical services trauma transport between 2017 and 2019. Transport time (less than or greater than 60 min) was the exposure variable, and analyses were adjusted for injury severity score (ISS). Continuous variables with a normal distribution were compared by t-test was and skewed variables were compared by Mann-Whitney U-test. Categorical variables were compared by Chi-Square test. Results54,489 patients met our criteria: 49,628 blunt and 4861 penetrating. Most patients (62.2%) had transport times less than 60 min: 30,389 (61.2%) blunt and 3479 (71.6%) penetrating. The overall mortality rate was 1.6%, 1.2% for blunt and 5.5% for penetrating. For blunt trauma, mortality was higher for transport times less than 60 min (1.5%). For penetrating trauma, mortality was lower for transport times less than 60 min (0.7%). Mean ISS was greater for blunt (7.9) compared to penetrating trauma (7.1), and greater for both trauma types with transport times less than 60 min. For both trauma types, mean length of stay was significantly longer for transport times greater than 60 min, when adjusting for ISS (P < 0.001). ConclusionsWe did not find evidence that prehospital transport within the “Golden Hour” had a substantial association with survival, though it may be associated with length of stay. There are many factors contributing to trauma outcomes, so efforts should continue to expand access and pediatric readiness.

Analysis of Trauma Characteristics Between the Older and Younger Adult Patient from the Pan Asian Trauma Outcome Study Registry (PATOS)

Objective Asia is experiencing a demographic shift toward an aging population at an unrivaled rate. This can influence the characteristics and outcomes of trauma. We aim to examine different characteristics of older adult trauma patients compared to younger adult trauma patients and describe factors that affect the outcomes in Asian countries. Methods This is a retrospective, international, multicenter study of trauma across participating centers in the Pan Asian Trauma Outcome Study (PATOS) registry, which included trauma cases aged ≥18 years, brought to the emergency department (ED) by emergency medical services (EMS) from October 2015 to November 2018. Data of older adults (≥65 years) and younger adults (<65 years) were analyzed and compared. The primary outcome measure was in-hospital mortality, and secondary outcomes were disability at discharge and hospital and intensive care unit (ICU) length of stays. Results Of 39,804 trauma patients, 10,770 (27.1%) were older adults. Trauma occurred more among older adult women (54.7% vs 33.2%, p < 0.001). Falls were more frequent in older adults (66.3% vs 24.9%, p < 0.001) who also had higher mean Injury Severity Score (ISS) compared to the younger adult trauma patient (5.4 ± 6.78 vs 4.76 ± 8.60, p < 0.001). Older adult trauma patients had a greater incidence of poor Glasgow Outcome Scale (GOS) (13.4% vs 4.1%, p < 0.001), higher hospital mortality (1.5% vs 0.9%, p < 0.001) and longer median hospital length of stay (12.8 vs 9.8, p < 0.001). Multiple logistic regression revealed age (adjusted odds ratio [AOR] 1.06, 95%CI 1.02–1.04, p < 0.001), male sex (AOR 1.60, 95%CI 1.04–2.46, p = 0.032), head and face injuries (AOR 3.25, 95%CI 2.06–5.11, p < 0.001), abdominal and pelvic injuries (AOR 2.78, 95%CI 1.48–5.23, p = 0.002), cardiovascular (AOR 2.71, 95%CI 1.40–5.22, p = 0.003), pulmonary (AOR 3.13, 95%CI 1.30–7.53, p = 0.011) and cancer (AOR 2.03, 95%CI 1.02–4.06, p = 0.045) comorbidities, severe ISS (AOR 2.06, 95%CI 1.23–3.45, p = 0.006), and Glasgow Coma Scale (GCS) ≤8 (AOR 12.50, 95%CI 6.95–22.48, p < 0.001) were significant predictors of hospital mortality. Conclusions Older trauma patients in the Asian region have a higher mortality rate than their younger counterparts, with many significant predictors. These findings illustrate the different characteristics of older trauma patients and their potential to influence the outcome. Preventive measures for elderly trauma should be targeted based on these factors.

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.

External Ventricular Drains versus Intraparenchymal Pressure Monitors in the Management of Moderate to Severe Traumatic Brain Injury: Experience at Two Academic Centers over a Decade

The choice between external ventricular drain (EVD) and intraparenchymal monitor (IPM) for managing intracranial pressure in moderate-to-severe traumatic brain injury (msTBI) patients remains controversial. This study aimed to investigate factors associated with receiving EVD versus IPM and to compare outcomes and clinical management between EVD and IPM patients. Adult msTBI patients at 2 similar academic institutions were identified. Logistic regression was performed to identify factors associated with receiving EVD versus IPM (model 1) and to compare EVD versus IPM in relation to patient outcomes after controlling for potential confounders (model 2), through odds ratios (ORs) and 95% confidence intervals (CIs). Of 521 patients, 167 (32.1%) had EVD and 354 (67.9%) had IPM. Mean age, sex, and Injury Severity Score were comparable between groups. Epidural hemorrhage (EDH) (OR 0.43, 95% CI 0.21-0.85), greater midline shift (OR 0.90, 95% CI 0.82-0.98), and the hospital with higher volume (OR 0.14, 95% CI 0.09-0.22) were independently associated with lower odds of receiving an EVD whereas patients needing a craniectomy were more likely to receive an EVD (OR 2.04, 95% CI 1.12-3.73). EVD patients received more intense medical treatment requiring hyperosmolar therapy compared to IPM patients (64.1% vs. 40.1%). No statistically significant differences were found in patient outcomes. While EDH, greater midline shift, and hospital with larger patient volume were associated with receiving an IPM, the need for a craniectomy was associated with receiving an EVD. EVD patients received different clinical management than IPM patients with no significant differences in patient outcomes.