Surgeons National Trauma Data Bank Research Articles

Prehospital Reverse Shock Index Times Glasgow Coma Scale as a Predictor for Trauma Intervention in Paediatric Trauma Patients

BackgroundPrevious studies have identified the reverse shock index x Glasgow Coma Scale (rSIG) as a tool for predicting the need for trauma intervention in pediatric patients. This study sought to investigate the utility of prehospital rSIG as a triage tool to predict the need for trauma-center level of care in a large pediatric cohort. MethodsData from the American College of Surgeons National Trauma Data Bank (NTDB) (2018–2020) were used. Patients aged 1–18 with valid values for prehospital systolic blood pressure (EMS SBP), prehospital heart rate (EMS HR), and EMS total GCS, were included. Prehospital rSIG was calculated as (EMS SBP/EMS HR) x EMS total GCS. Abnormal values for rSIG were defined as: ≤13.1, ≤16.5, and ≤20.1 for patients aged 1–6, 7–12, and 13–18, respectively. Injury severity was determined by Injury Severity Score (ISS). ISS 1–8 represented minor injury, 9–15 moderate injury, and 16 severe injury. Rates of hemorrhage control surgery, embolization, transfusion at 4 hours, mechanical ventilation, ICU stay 3 days, and mortality was compared between patients with abnormal vs. normal prehospital rSIG. Results120,941 patients were included in the analysis; 60269 (49.8 %) had an abnormal prehospital rSIG. Patients with abnormal prehospital rSIG had significantly higher rates of 1 trauma intervention (23.3 % vs 8.3 %, p < 0.0001) and mortality (2.7 % vs 0.1 %, p < 0.0001). When stratified by injury severity, rates of 1 trauma intervention were significantly higher for patients with abnormal prehospital rSIG in minor (2.8 % vs. 1.5 %, p < 0.0001), moderate (18.9 % vs 10.5 %, p < 0.0001), and severe injury (69.8 % vs 43.1 %). ConclusionPrehospital rSIG appears to be an independent predictor of both trauma intervention and mortality, regardless of injury severity, in the pediatric trauma population. Use of prehospital rSIG may prove useful in triage situations, particularly mass casualty incidents, to determine need for trauma-center care.

Pediatric Facial Fracture Associated Craniofacial and Cervical Spine Injury

Management of pediatric facial fractures depends on location and severity, age, and associated injuries. Accurate diagnosis of associated injuries is crucial for effective treatment. This study evaluates the incidence of associated injuries and seeks to determine the influencing factors to provide imaging guidance. A retrospective review of pediatric facial fractures from the American College of Surgeons National Trauma Data Bank from 2017 to 2021 was completed. Associated cervical spine (c-spine), skull fracture, traumatic brain injury (TBI), and intracranial bleeding were evaluated. Demographics, fracture patterns, mechanisms, protective devices, and the Glasgow Coma Scale (GCS) were reviewed. A total of 44,781 pediatric patients with 65,613 facial fractures were identified. Of the total, 5.47% had a c-spine injury, 21.86% had a skull fracture, 18.82% had TBI, and 5.76% had intracranial bleeding. Multiple fractures significantly increased the rate of all associated cranial and c-spine injuries. Single midface fractures had the highest c-spine, TBI, and intracranial bleeding rates. With increasing age, there was a significant increase in c-spine injury and TBI, while there was a decrease in skull fractures. Motor vehicle accidents and GCS &lt;13 were associated with significantly increased rates of all injuries. Among pediatric patients with facial fractures, 5.47% had a c-spine injury, 21.86% had a skull fracture, 18.82% had TBI, and 5.76% had intracranial bleeding. The authors’ findings recommend c-spine imaging in older age and cranial imaging in younger patients. Multiple facial fractures, fractures of the midface, decreased GCS, and motor vehicle accidents increase the need for both c-spine and cranial imaging.

Infection Is Not Associated With Plasma or Cryoprecipitate Transfusion Volumes in Trauma: A Retrospective Study Using the National Trauma Data Bank.

Background: Packed red blood cell (PRBC) transfusion has been shown to increase nosocomial infection risk in the injured population; however, the post-traumatic infectious risk profiles of non-PRBC blood products are less clear. We hypothesized that plasma (fresh frozen plasma [FFP]), platelet (PLT), and cryoprecipitate administration would not be associated with increased rates of nosocomial infections. Patients and Methods: We performed a retrospective, matched, case-control study utilizing the American College of Surgeons National Trauma Data Bank data for 2019. We included all patients who received any volume of PRBC within four hours of presentation. Our outcome of interest was any infection. Controls were matched to cases using individual matching with a desired 1:3 case:control ratio. Bivariable analysis according to infection status, and multivariable logistic regression modeling the development of infection were then performed upon the matched data. Results: A total of 1,563 infectious cases were matched to 3,920 non-infectious controls. First four-hour transfusion volumes for FFP, PLT, and cryoprecipitate in the infection group exceeded those in the control group. The first four-hour FFP transfusion volume (per unit odds ratio [OR], 1.02; 95% confidence interval [CI], 0.99-1.04; p = 0.28) and cryoprecipitate transfusion volume (per unit OR, 1.01; 95% CI, 0.99-1.02; p = 0.43) were similar in cases and controls whereas PLT transfusion volume (per unit OR, 0.92; 95% CI, 0.86-0.98; p = 0.01) was lower in cases of infection than in controls. Conclusions: Fresh frozen plasma, PLT, and cryoprecipitate transfusion volumes were not independent risk factors for the development of nosocomial infection in a trauma population. PLT transfusion volume was associated with less infection.

Epidemiology of Gunshot-Related Spinal Injuries and Related Risk Factors for In-Hospital Mortality in the United States from 2015-2019: A National Trauma Data Bank Analysis.

Firearm injuries in the U.S. pose a significant public health burden, but data on gunshot wounds (GSWs) specifically involving the spine are scarce. We examined epidemiological trends in GSWs to the spine and associated spinal cord injury (SCI) and mortality rates. This was a cross-sectional study of data from level I-III trauma centers in the U.S. participating in the American College of Surgeons National Trauma Data Bank (ACS NTDB) in 2015-2019. We identified adult and pediatric patients presenting with GSW and evaluated those with Abbreviated Injury Scale codes indicating spinal involvement and SCI. We assessed in-hospital mortality and GSW-related SCI. A total of 5,021,316 patients were enrolled in the ACS NTDB. Of the 107,233 patients (2.1% of total) presenting with GSW, 9023 (8.4%) patients had spine involvement. Overall rates of GSW and spinal GSW were similar across years. The most common cause of spinal GSW injury was assault (86.7%). The cervical spine was involved in 24.2% of patients, thoracic spine in 42.8%, and lumbar spine in 39.7%. Cervical SCI was present in 8.7% of all spinal GSW (35.7% of cervical GSW), thoracic SCI in 17.4% (40.6% of thoracic GSW), and lumbar SCI in 8.1% (20.3% of lumbar GSW). The mean patient age was 29.0 ± 12.2 years, 88.5% were male, 62.4% were black, 23.7% were white, and 13.9% were another race. Blood alcohol content was ≥0.08 in 12.1%, and illicit drugs were positive in 24.4%. In-hospital mortality was high in patients with spinal GSWs (8.1%), and mortality was significantly higher with cervical involvement (18.1%), cervical SCI (30.7%), or thoracic incomplete SCI (13.6%) on univariate analysis. On multi-variate analysis of age (excluding patients <16 years of age), sex, Injury Severity Score (ISS), complete SCI, and spinal area of involvement, only greater patient age (age 40-65 years: adjusted odds ratio [aOR] 1.52, 95% confidence interval [CI] 1.09-2.11, p = 0.014; age >65 years: aOR 3.90, 95% CI 2.10-7.27, p < 0.001) and higher ISS (ISS 9-15: aOR 6.65, 95% CI 2.38-18.54, p < 0.001; ISS 16-24: aOR 18.13, 95% CI 6.65-49.44, p < 0.001; ISS >24: aOR 68.44, 95% CI 25.39-184.46, p < 0.001) were independently associated with in-hospital mortality risk after spinal GSW. These results demonstrate that spinal GSW is not uncommon and that older patients with more severe systemic injuries have higher in-hospital mortality risk.

Association of Time to Definitive Hemostasis With Mortality in Patients With Solid Organ Injuries.

Introduction The Golden Hour is a term used in the trauma setting to refer to the first 60 minutes after injury. Traditionally, definitive care within this period was believed to dramatically increase a patient's survival. Though the period of 60 minutes is unlikely to represent a point of distinct inflection in survival, the effect of time to definitive care on survival remains incompletely understood. This study aims to measure the association of time to definitive hemostasis with mortality in patients with solid organ injuries as well as the effect of survival bias and a form of selection bias known as indication by severity on the relationship between time to treatment and survival. Methodology This is a retrospective cohort study using data obtained from the American College of Surgeons National Trauma Data Bank (NTDB) from the years 2017 through 2019 selecting patients treated for blunt liver, spleen, or kidney injury who required angioembolization or surgical hemostasis within six hours. A Cox proportional hazards regression was used to analyze time to death. The association of probability of death with time was examined with a multivariate logistic regression initially treating the relationship as linear and subsequently transforming time to hemostasis with restricted cubic splines to model a non-linear association with the outcome. To model survival and indication by severity bias, we created a computer-generated data set and used LOESS regressions to display curves of the simulated data. Results The multivariate Cox proportional hazards analysis shows a coefficient of negative 0.004 for minutes to hemostasis with an adjusted hazard ratio of 0.9959 showing the adjusted hazard of death slightly diminishes with each increasing minute to hemostasis. The likelihood ratio chi-square difference between the model with time to hemostasis included as a linear term versus the model with the restricted cubic spline transformation is 97.46 (p<0.0001) showing the model with restricted cubic splines is a better fit for the data. The computer-generated data simulating treatment of solid organ injury with no programmed bias displays an almost linear association of mortality with increased treatment delay. When indications by severity bias and survival bias are introduced, the risk of death decreases with time to hemostasis as in the real-world data. Conclusion Decreasing mortality with increasing delay to hemostasis in trauma patients with solid organ injury is likely due to confounding due to indication by severity and survival bias. After taking these biases into account, the association of delayed hemostasis with better survival is not likely due to the benefit of delay but rather the delay sorts patients by severity of injury with those more likely to die being treated first. These biases are extremely difficult to eliminate which limits the ability to measure the true effect of delay with retrospective data. The findings may however be of value as a predictive model to anticipate the acuity of a patient after an interval of unavoidable delay such as with a long transfer time.

A serial cross-sectional study of trends and predictors of prescription controlled substance-related traumatic injury

Pre-injury drug use is a key contributor to traumatic injury. However, limited research has examined trends and predictors of controlled substance-related trauma. The present study aims to provide better clarity on the specific role of prescription-controlled substances (PCS) in traumatic injury events.The data source was the American College of Surgeons National Trauma Data Bank. Trends by injury mechanism and intent for patients with PCS and no-confirmed substances were compared from 2007 to 2014. Logistic regression models were also performed to examine the association between substance use and injury mechanism and intent for data across the study period.Of 405,334 trauma patients, 328,623 (81.1%) had no-confirmed substances and 76,711 (18.9%) had PCS detected. The majority of events in the PCS and no-confirmed substance groups were classified as unintentional. Motor vehicle traffic (MVT), falls, other transport, and cut/pierce injuries accounted for approximately 80% of all injuries. From 2007 to 2014, the proportion of injuries with PCS increased for all injury mechanisms and injury intents. The injury mechanisms of fire/burn, firearm, machinery, poisoning, and other transport were significantly more likely to have PCS relative to MVT injuries. For injury intent, self-harm was more likely to have a toxicology test positive for PCS, while assault was less likely to have a toxicology test positive for PCS compared to unintentional injuries.PCS-related traumatic injuries increased significantly over time and across injury mechanisms and intents. These findings can be used to inform prescribing and understand risk factors to reduce the likelihood of PCS-related traumatic injury.

Socioeconomic and Psychosocial Predictors of Magnetic Resonance Imaging After Cervical and Thoracic Spine Trauma in the United States

Socioeconomic factors are known to influence outcomes after spinal trauma, but it is unclear how these factors affect health care utilization in acute care settings. We aimed to elucidate if sociodemographic and psychosocial factors are associated with obtaining magnetic resonance imaging (MRI), a costly imaging modality, after cervical or thoracic spine fracture. Data from the 2012-2016 American College of Surgeons National Trauma Data Bank were used. We assessed the relationship between receipt of MRI and patient-level sociodemographic and psychosocial factors as well as hospital characteristics while correcting for injury-specific characteristics. Multiple logistic regression was performed to assess for associations between these variables and MRI after spine trauma. A total of 213,071 patients met the inclusion criteria, of whom 13.0% had an MRI (n= 27,757). After adjusting for confounders in multivariate regression, patients had increased odds of MRI if they were Hispanic (odds ratio [OR], 1.09; P= 0.001) or black (OR, 1.14; P < 0.001) or were diagnosed with major psychiatric disorder (OR, 1.06; P= 0.009), alcohol use disorder (OR, 1.05; P < 0.001), or substance use disorder (OR, 1.10; P < 0.001). Patients with Medicare (OR, 0.88; P < 0.001) or Medicaid (OR, 0.94; P < 0.011) were less likely to have an MRI than were those with private insurance, whereas patients treated in the Northeast (OR, 1.48; P < 0.001) or at for-profit hospitals (OR, 1.12; P < 0.001) were more likely. After adjusting for injury severity and spinal cord injury diagnosis, psychosocial comorbidities and for-profit hospital status were associated with higher odds of MRI, whereas public insurance was associated with lower odds. Results highlight potential biases in the provision of MRI as a costly imaging modality.

Direct to OR resuscitation of abdominal trauma: An NTDB propensity matched outcomes study.

Direct to operating room resuscitation (DOR) is used by some trauma centers for severely injured trauma patients as an approach to minimize time to hemorrhage control. It is unknown whether this strategy results in favorable outcomes. We hypothesized that utilization of an emergency department operating room (EDOR) for resuscitation of patients with abdominal trauma at an urban Level I trauma center would be associated with decreased time to laparotomy and improved outcomes. We included patients 15 years or older with abdominal trauma who underwent emergent laparotomy within 120 minutes of arrival both at our institution and within a National Trauma Data Bank sample between 2007 to 2019 and 2013 to 2016, respectively. Our institutional sample was matched 1:1 to an American College of Surgeons National Trauma Databank sample using propensity score matching based on age, sex, mechanism of injury, and abdominal Abbreviated Injury Scale score. The primary outcome was time to laparotomy incision. Secondary outcomes included blood transfusion requirement, intensive care unit (ICU) length of stay (LOS), ventilator days, hospital LOS, and in-hospital mortality. Two hundred forty patients were included (120 institutional, 120 national). Both samples were well balanced, and 83.3% sustained penetrating trauma. There were 84.2% young adults between the ages of 15 and 47, 91.7% were male, 47.5% Black/African American, with a median Injury Severity Score of 14 (interquartile range [IQR], 8-29), Glasgow Coma Scale score of 15 (IQR, 13-15), 71.7% had an systolic blood pressure of >90 mm Hg, and had a shock index of 0.9 (IQR, 0.7-1.1) which did not differ between groups (p > 0.05). Treatment in the EDOR was associated with decreased time to incision (25.5 minutes vs. 40 minutes; p ≤ 0.001), ICU LOS (1 vs. 3.1 days; p < 0.001), transfusion requirement within 24 hours (3 units vs. 5.8 units packed red blood cells; p = 0.025), hospital LOS (5 days vs. 8.5 days, p = 0.014), and ventilator days (1 day vs. 2 days; p ≤ 0.001). There were no significant differences in in-hospital mortality (22.5% vs. 15.0%; p = 0.14) or outcome-free days (4.9 days vs. 4.5 days, p = 0.55). The use of an EDOR is associated with decreased time to hemorrhage control as evidenced by the decreased time to incision, blood transfusion requirement, ICU LOS, hospital LOS, and ventilator days. These findings support DOR for patients sustaining operative abdominal trauma. Therapeutic/Care Management, Level III.

The Impact of Flame Burn Injuries on Patients Who Sustain Mild Injuries From Motor Vehicle Crashes.

The purpose of this study was to determine the differences in patient outcomes between motor vehicle crash (MVC) victims with an ISS < 15 and those with a similar ISS and a flame burn injury. Data for patients involved in a MVC with a GCS ≥12 and an ISS < 15 with and without flame burn injury were reviewed from the American College of Surgeons National Trauma Data Bank between 2007 and 2017. International Classification of Diseases-9 and -10 revisions and External Injury Codes were used to identify patients who were divided into MVC only (Group 1) and MVC with additional flame burn injury (Group 2). In-hospital mortality was the primary outcome whereas secondary outcomes included ICU admission, ICU length of stay (LOS), hospital LOS, sepsis, deep vein thrombosis, acute respiratory distress syndrome, and pneumonia. Simple linear regression was used in the form of odds ratios to investigate risk factors for mortality and secondary outcomes. The mean LOS and ICU LOS were longer in Group 2 (5.9 vs 4.0 days, p-value <0.001, and 1.2 vs 0.6 days, p-value <0.001, respectively), with more patients being admitted to the ICU as well (22.9% vs 17.3%, p-value <0.001). Also, there were significantly higher rates of pneumonia (0.8% vs 0.5%, p-value 0.0014), deep vein thrombosis (0.6% vs 0.4%, p-value 0.028), and acute respiratory distress syndrome (0.5% vs 0.3%, p-value 0.004) in Group 2. Patients in Group 1 were older and more likely had hypertension, congestive heart failure, and COPD. There was no significant difference in mortality between Groups by odds ratios (OR 0.85, p-value 0.743) or raw percentages (0.3% vs 0.3%, p-value = 0.874). MVC victims with mild injuries who also sustain a burn injury are more likely to require admission to the ICU regardless of their comorbidities and more likely to develop respiratory complications, especially pneumonia and an increase in ICU and hospital LOS.

Utilization of Brain Tissue Oxygenation Monitoring and Association with Mortality Following Severe Traumatic Brain Injury.

The aim of this study was to describe the utilization patterns of brain tissue oxygen (PbtO2) monitoring following severe traumatic brain injury (TBI) and determine associations with mortality, health care use, and pulmonary toxicity. We conducted a retrospective cohort study of patients from United States trauma centers participating in the American College of Surgeons National Trauma Databank between 2008 and 2016. We examined patients with severe TBI (defined by admission Glasgow Coma Scale score≤8) over the age of 18years who survived more than 24h from admission and required intracranial pressure (ICP) monitoring. The primary exposure was PbtO2 monitor placement. The primary outcome was hospital mortality, defined as death during the hospitalization or discharge to hospice. Secondary outcomes were examined to determine the association of PbtO2 monitoring with health care use and pulmonary toxicity and included the following: (1) intensive care unit length of stay, (2) hospital length of stay, and (3) development of acute respiratory distress syndrome (ARDS). Regression analysis was used to assess differences in outcomes between patients exposed to PbtO2 monitor placement and those without exposure by using propensity weighting to address selection bias due to the nonrandom allocation of treatment groups and patient dropout. A total of 35,501 patients underwent placement of an ICP monitor. There were 1,346 (3.8%) patients who also underwent PbtO2 monitor placement, with significant variation regarding calendar year and hospital. Patients who underwent placement of a PbtO2 monitor had a crude in-hospital mortality of 31.1%, compared with 33.5% in patients who only underwent placement of an ICP monitor (adjusted risk ratio 0.84, 95% confidence interval 0.76-0.93). The development of the ARDS was comparable between patients who underwent placement of a PbtO2 monitor and patients who only underwent placement of an ICP monitor (9.2% vs. 9.8%, adjusted risk ratio 0.89, 95% confidence interval 0.73-1.09). PbtO2 monitor utilization varied widely throughout the study period by calendar year and hospital. PbtO2 monitoring in addition to ICP monitoring, compared with ICP monitoring alone, was associated with a decreased in-hospital mortality, a longer length of stay, and a similar risk of ARDS. These findings provide further guidance for clinicians caring for patients with severe TBI while awaiting completion of further randomized controlled trials.

Occupational vs. non-occupational equestrians: Differences in demographics and injury patterns

IntroductionNineteen million people participate in horseback riding activities in the US, and the horse industry employs more than 460,000 full-time workers. Emergency department data suggest young female amateurs and male professionals are most at risk of death from horse-related injuries. However, there has been no investigation into factors that may increase severe injury and mortality risk in these populations. This study investigates demographics and injury pattern differences between occupational and non-occupational horse-related injuries in the US. MethodsThe 2017 American College of Surgeons National Trauma Databank (ACS NTDB) was analyzed for horse-related injury using ICD 10 codes. Demographics, injury data, protective device use, and hospital procedures were analyzed. Occupational versus non-occupational injuries based on incident location (farm, sports, recreational, residential) were compared using ANOVA or Pearson's Chi-squared test. ResultsOf 3911 incidents, the most common injury mechanism was falling from the horse, but occupational and non-occupational farm injuries showed higher incidence of being struck by a horse. One-third required surgery. Upper extremity injuries were most common. Occupational injuries more often affected upper extremities of working age, minority males with commercial insurance. Non-occupational injuries most often affected heads of women at the extremes of age. Helmet use was higher in occupational, non-occupational sports, and non-occupational recreation injuries, and severe head injury incidence was decreased in these groups. Complications and discharge dispositions were not different across groups. ConclusionsIn the largest trauma center study to date, we have shown equine-related trauma to be common and affect a predictable demographic that may permit injury prevention initiatives. Helmets may reduce severe head injury, but the efficacy of protective clothing remains to be validated.

Influence of psychosocial and sociodemographic factors in the surgical management of traumatic cervicothoracic spinal cord injury at level I and II trauma centers in the United States.

Socioeconomic factors can bias clinician decision-making in many areas of medicine. Psychosocial characteristics such as diagnosis of alcoholism, substance abuse, and major psychiatric disorder are emerging as potential sources of conscious and unconscious bias. We hypothesized that these psychosocial factors, in addition to socioeconomic factors, may impact the decision to operate on patients with a traumatic cervicothoracic fracture and associated spinal cord injury (SCI). We performed a cohort analysis using clinical data from 2012-2016 in the American College of Surgeons (ACS) National Trauma Data Bank at academic level I and II trauma centers. Patients were eligible if they had a diagnosis of cervicothoracic fracture with SCI. Using ICD codes, we evaluated baseline characteristics including race; insurance status; diagnosis of alcoholism, substance abuse, or major psychiatric disorder; admission drug screen and blood alcohol level; injury characteristics and severity; and hospital characteristics including geographic region, non-profit status, university affiliation, and trauma level. Factors significantly associated with surgical intervention in univariate analysis were eligible for inclusion in multivariate logistic regression. We identified 6,655 eligible patients, of whom 62% underwent surgical treatment (n=4,137). Patients treated non-operatively were more likely to be older; be female; be Black or Hispanic; have Medicare, Medicaid, or no insurance; have been assaulted; have been injured by a firearm; have thoracic fracture; have less severe injuries; have severe TBI; be treated at non-profit hospitals; and be in the Northeast or Western U.S. (all P<0.01). After adjusting for confounders in multivariate analysis, only insurance status remained associated with operative treatment. Medicaid patients (OR=0.81; P=0.021) and uninsured patients (OR=0.63; P<0.001) had lower odds of surgery relative to patients with private insurance. Injury severity and facility characteristics also remained significantly associated with surgical management following multivariate regression. Psychosocial characteristics such as diagnosis of alcoholism, substance abuse, or psychiatric illness do not appear to bias the decision to operate after traumatic cervicothoracic fracture with SCI. Baseline sociodemographic imbalances were explained largely by insurance status, injury, and facility characteristics in multivariate analysis.

Trends in Geriatric Ground-Level Falls: Report from the National Trauma Data Bank

Ground-level falls (GLF) are typically reported as a minor mechanism of injury; however, they represent a significant portion of hospitalized geriatric trauma patients as they can result in multisystem injury in this subset of the population. Our study aimed to analyze trends in geriatric trauma falls on the national level. We performed a 5-y (2011-2015) analysis of the American College of Surgeons National Trauma Data Bank (ACS-NTDB) and included all geriatric trauma patients (age ≥ 65 y) who presented with GLF. GLF was identified using ICD-9 E CODES. Our outcome measures were national incidence of GLF, and overall discharge disposition and trauma center level discharge disposition following GLF. We used Cochran Armitage test and multivariate regression analysis. We analyzed a total of 1,017,326 geriatric trauma patients, of which 39% had had a fall as a mechanism of injury. Among those who fell, mean age was 78 ± 7, 63% were females, and 85% were whites. The incidence of falls significantly increased over the study period, and was noted to be proportional to age, with a plateau beyond age 85 y old. The rate of discharge to SNF and/or Rehab significantly increased over the study period; however, discharge to home and mortality rates trended downwards over the study period. Discharge to SNF and/or Rehab was significantly lower among level I trauma centers compared to other level trauma centers. Conversely, discharge to home was higher in level I trauma centers compared to other level trauma centers. Around one in three elderly trauma patients were admitted following a GLF with an overall increased incidence of falls over time. Although overall mortality rates decreased, there was an increase in adverse discharge disposition and loss of functional independence over the study period, mostly among those admitted to non-level I trauma centers.

Incorporating age improves the Glasgow Coma Scale score for predicting mortality from traumatic brain injury

BackgroundThe Glasgow Coma Scale (GCS) score has been adapted into categories of severity (mild, moderate, and severe) and are ubiquitous in the trauma setting. This study sought to revise the...

How Common Are Civilian Blast Injuries in the National Trauma Databank, and What Are the Most Common Mechanisms and Characteristics of Associated Injuries?

Recent military conflicts have produced substantial improvements in the care of service members who experience blast injuries. As conflicts draw down, it is important to preserve and improve skills gained in combat. It is unknown whether civilian blast injuries can serve as a surrogate for military blast trauma. To guide further research, it is crucial to understand the volume, severity, and distribution of civilian blast injury in the civilian population. (1) What proportion of US trauma admissions are a result of blast injury? (2) What are the common mechanisms, and what is the demographic breakdown of civilian patients presenting to trauma centers after blast injuries? (3) What is the severity, and what are the characteristics of injuries sustained by civilian patients after blast injuries? We queried the American College of Surgeons National Trauma Databank (NTDB), a national aggregation of trauma registry data which captures robust mechanism of injury and wounding pattern information, for any patient admitted for trauma and an initial mechanism of injury corresponding to a predefined list of ICD-9 and ICD-10 external cause of injury codes related to blast injuries and reported as a proportion of all trauma-related admissions. Mechanisms were categorized into similar groups, and data were collected regarding demographics as well as location and intentionality of blast (that is, unintentional, the result of assault, or self-inflicted). Patient injuries were characterized by ICD-9 or ICD-10 diagnosis codes and sorted according to the body area affected and severity of injury, measured via the Injury Severity Score (ISS). The ISS is a measure of trauma severity, with scores ranging from 1 to 75 points based on injury severity, which is calculated according to injury scores in six separate body domains (head or neck, face, chest, abdomen or pelvis, extremities, external). A score of 1 represents a minor trauma to one region, while a score of 75 indicates injuries deemed nonsurvivable in one or more domains. Data were limited to trauma admissions in 2016. Patients injured by blast mechanisms represented 0.3% (2682 of 968,843) of patients in NTDB-participating trauma centers who were treated after a blast injury in the year 2016; 86% (2315 of 2682) of these patients were men, and the mean ± SD age was 38 ± 21 years. Blast injuries most commonly occurred after detonation of fireworks (29% [773 of 2682]) or explosion of gas or pressurized containers (27% [732 of 2682]). The most commonly injured area of the body was the upper extremity (33% [894 of 2682]), followed by the face (28% [747 of 2682]), lower extremity (11% [285 of 2682]), thorax (10% [280 of 2682]), and head (10% [259 of 2682]). Fifty-eight percent (1564 of 2682) of patients had at least one burn injury. A total of 2% (51 of 2682) of the injuries were fatal, with a mean ISS score of 6 ± 8; 23% (608 of 2682) of patients presented with injuries classified as severe (ISS > 8). Civilian blast-associated injuries are not common, but they can be severe, and in many (though not all) respects they seem similar to those described in published case series of military blast victims. Key differences include age and gender (civilian injuries more commonly involve women and older patients than do those in military studies). The potential of civilian blast patient care as a surrogate for study and clinical experience for military surgeons in the interwar period-as recommended by the National Academies of Sciences, Engineering, and Medicine report-is supported by our preliminary results. Future interventions or training programs would likely need to rely on multisite or targeted partnerships to encounter appropriate numbers of patients with blast injuries. Level IV, prognostic study.

Association of Prehospital Step 1 Vital Sign Criteria and Vital Sign Decline with Increased Emergency Department and Hospital Death

This study analyzed data from the 2017 American College of Surgeons National Trauma Data Bank to examine the effects of pre-hospital Field Triage Decision Scheme Step 1 vital sign criteria (S1C) and vital sign decline on subsequent emergency department (ED) and hospital death in emergency medical services (EMS) transported trauma victims. Patient and injury characteristics, transport time, and ED and hospital disposition were collected. S1C (respiratory rate [RR]<10, RR>29 breaths/min, systolic blood pressure [SBP]<90 mmHg, Glasgow Coma Scale [GCS]<14) were recorded at the injury scene and hospital arrival. Decline was defined as a change ≥ 1 standard deviation (SD) into or within an S1C range. S1C and decline were analyzed relative to ED and hospital death using logistic regression. Of 333,213 included patients, 54,849 (16.5%) met Step 1 criteria at the scene, and 21,566(6.9%) declined en route. The ED death rate was 0.4% (n= 1,188), and the hospital death/hospice rate was 4.0% (11,624 of 287,675). Patients who met S1C at the scene or who declined were more likely to require longer hospital lengths of stay, ICU admission, and surgical intervention. S1C and decline patients had higher odds of death in both the ED (S1C odds ratio [OR] 15.1, decline OR 2.4, p values < 0.001) and hospital (S1C OR 4.8, decline OR 2.0, p values < 0.001) after adjusting for patient demographics, transport time and mode, injury severity, and injury mechanism. Each S1C and decline measure was independently predictive of death. This study quantifies the mortality risks associated with individual S1C and validates their use as an indicator for injury severity and pre-hospital triage tool.

Occupational vs Non-Occupational Equestrians: Differences in Demographics and Injury Patterns

ABSTRACT Introduction : Nineteen million people participate in horseback riding activities in the US, and the horse industry employs more than 460,000 full-time workers. Emergency department data suggest young female amateurs and male professionals are most at risk of death from horse-related injuries. However, there has been no investigation into factors that may increase severe injury and mortality risk in these populations. This study investigates demographics and injury pattern differences between occupational and non-occupational horse-related injuries in the US. Methods : The 2017 American College of Surgeons National Trauma Databank (ACS NTDB) was analyzed for horse-related injury using ICD 10 codes. Demographics, injury data, protective device use, and hospital procedures were analyzed. Occupational versus non-occupational injuries based on incident location (farm, sports, recreational, residential) were compared using ANOVA or Pearson's Chi-squared test. Results : Of 3,911 incidents, the most common injury mechanism was falling from the horse, but occupational and non-occupational farm injuries showed higher incidence of being struck by a horse. One-third required surgery. Upper extremity injuries were most common. Occupational injuries more often affected upper extremities of working age, minority males with commercial insurance. Non-occupational injuries most often affected heads of women at the extremes of age. Helmet use was higher in occupational sports, non-occupational sports, and non-occupational recreation injuries, and severe head injury incidence was decreased in these groups. Complications and discharge dispositions were not different across groups. Conclusions : In the largest trauma center study to date, we have shown equine-related trauma to be common and affect a predictable demographic that may permit injury prevention initiatives. Helmets may reduce severe head injury, but the efficacy of protective clothing remains to be validated.

Risk factors for complications and in-hospital mortality: An analysis of 19,834 open pelvic ring fractures

BackgroundOpen pelvic fractures are rare injuries, associated with high patient morbidity and mortality. Few studies have investigated the impact of patient demographics, comorbidities, and injury related factors on complication and mortality rates. The purpose of this study was to: (1) identify the overall incidence of complications and mortality after open pelvic fractures, (2) compare patient factors between those who did and did not develop complications, (3) identify perioperative independent risk factors for complications and mortality. MethodsA query was performed for patients with open pelvic fractures between 2007 and 2017 using the American College of Surgeons National Trauma Data Bank. Patient and injury specific variables were collected and complications were identified using International Classification of Disease Ninth and Tenth edition Codes. Patient demographic and perioperative data was compared using Fisher’s exact test and chi-square test for categorical variables, and Welch’s t-test for continuous variables. Using pooled data from multiple imputations, logistic regressions were used to calculate odds ratios and confidence intervals of independent risk factors for complications. ResultsA total of 19,834 open pelvic fracture cases were identified, with 9622 patients (48.5%) developing at least one complication. Patients who developed complications were older (35.0 vs 38.1 years), and had higher Injury Severity Scores (17.7 vs 26.5), lower Glasgow Coma Scores (14.2 vs 11.7), and a larger proportion presenting with hypotension (21% vs 6.9%). After pooled regression involving 19 factors, these were the strongest independent predictors of inpatient complication and mortality. ConclusionWe report a mortality rate of 14%, with an inclusive complication rate of 48.5%. Evaluating risk factors for morbidity and mortality for this devastating orthopaedic injury provides knowledge of an inherently sparse population. Level of EvidenceLevel II, Retrospective study.

Nationwide analysis of resuscitative thoracotomy in pediatric trauma: Time to differentiate from adult guidelines?

Emergency department thoracotomy (EDT) for pediatric patients is uncommon, and practice patterns have not been evaluated. We examined the indications and outcomes for EDT by trauma center designation using a nationwide database. Patients 16 years or younger who underwent EDT within 30 minutes of arrival from 2013 to 2016 were identified in the American College of Surgeons National Trauma Data Bank. Patient demographic information, indications for EDT, and outcomes were analyzed. Outcomes were compared between centers with and without pediatric trauma center designation. A total of 114 patients were identified for analysis with a mean ± SD age of 10.3 ± 4.7 years. Patients were predominantly male (69%) with a median Injury Severity Score of 26 (interquartile range, 18-42). Penetrating trauma occurred in 56%. Overall, mortality was 90% and was similar in penetrating and blunt trauma (88% vs. 94%; p = 0.34). There were no survivors among the 53 patients (46%) who arrived with no signs of life. Among the 11 patients (10%) who survived, median length of stay was 26 days (interquartile range, 6-28 days). Overall, 8% of EDT was performed at free-standing pediatric trauma centers, 45% at adult centers, and 47% at combined trauma centers. Mortality rates and indications were similar among trauma centers regardless of designation status. In a national population-based data set, the mortality after pediatric EDT is high, and many of these procedures are performed at nonpediatric trauma centers. Regardless of injury mechanism, EDT is not appropriate in children without signs of life on arrival. Pediatric guidelines are needed to increase awareness of the poor outcomes and limited indications for EDT. Therapeutic, level IV.

360 Contemporary Diagnostic Evaluation of Traumatic Penile Injuries

The external nature of the male genitalia exposes it to increased risk of traumatic injury. Herein, we sought to evaluate the National Trauma Data Bank (NTDB) to assess the rate of penile injury in order to better understand the evaluation and management of this subset of injured patients. Traumatic cases from 2011 - 2014 were reviewed utilizing the American College of Surgeons National Trauma Data Bank (ACS-NTDB). Patient demographics, incident variables, associated injuries, hospital course, surgical intervention, rate of catheterization, imaging, and disposition were reviewed using the international Classification for Disease (10th edition) codes for penile injuries. 2,257 cases of penile trauma were identified. 71% of victims were under 35 years of age, with 23% of victims 18 years of age and younger. Traumatic injuries included 52% penetrating (N=1196), 35% blunt (N=796), <1% burn (N=1), and 12% unknown. Of these traumatic penile injuries, 15% (N = 342) underwent urethral catheterization, with 13% (N=300) undergoing cystourethroscopy and 6% (N=148) undergoing retrograde urethrogram (RUG). 92% (N = 1095) of penetrating penile trauma and 95% (N=759) of blunt penile trauma did not undergo retrograde urethrogram.