Trauma Center Patients Research Articles

Etiological and epidemiological analysis of patella fractures: evaluation of COVID-19 pandemic and lockdown era effects

Background: Patella fractures are relatively rare, but significant public health burden with consequences ranging from skin problems to extensor mechanism deficiencies and patellofemoral arthrosis due to their significant effects on pain, functionality, and quality of life. It was aimed to present basic etiological, and epidemiological information about patella fractures and to evaluate the impact of the COVID-19 Pandemic and lockdown era period. Methods: All patellar fractures admitted to a stage-1 trauma center between 2016 and 2022 were collected retrospectively. Patient's gender, age, side, fracture classification, trauma mechanism, treatment method, admission day and season, accompanying extremity, and non-musculoskeletal/visceral pathologies were recorded and analyzed. Results: A retrospective evaluation was conducted on 304 patients, with 181 (59.5%) males and 123 (40.5%) females, with an average age of 46±19 years. Most patients were between 30-65 (51.4%) and the most common cause was simple falls (74%). Fractures mostly occurred in the winter (35.2%) and on Sundays (19.7%). 9.9% of the patients were accompanied by extremity traumas and 6.9% by non-musculoskeletal injuries. Regarding the descriptive classification, transverse, distal pole, and proximal pole; and according to the AO/OTA classification, C1 was the most common. Conclusion: The incidence of patella fractures is increasing. Non-surgical treatment is a priority, and the complication rates of surgical treatment are considerable. The study, which presents etiological and epidemiological data of level-1 trauma center patients, is a suitable sample for Türkiye. The study is unique in showing the potential effects of COVID-19 on the patient profile and treatment management of patella fractures.

Ankle Fractures Treated with Locked Fibular Intramedullary Nailing: Description and Outcomes of a Minimally Invasive Open Technique

OBJECTIVES: To describe and report outcomes of a minimally invasive open intramedullary (IM) fibular nailing technique for fixation of ankle fractures. METHODS: Design: Case Series Setting: Urban Level 1 trauma center Patient Selection Criteria: Adult patients with ankle fractures (OTA 44A-C) treated with locked fibular IM nailing via a minimally invasive open technique for fracture and syndesmotic reduction between 2021 and 2024. Outcome Measures and Comparisons: Quality of reduction, complications, and patient-reported outcomes (PRO). RESULTS: A total of 150 consecutive patients operated by a single surgeon were included. Mean age was 53.3 (17-97) years, and mean BMI was 30.6 ± 7.4 kg/m2. 93(62%) patients were female, and 78 (52%) patients were Caucasian. 72 (48%) patients were obese, 40 (27.7%) patients were current/former smokers, 39 (26%) patients were diabetic, and 23 (15.3%) patients had open fractures. 37 (24.7%) patients had isolated lateral malleolus fractures, 48 (32%) had bimalleolar fractures, and 65(43.3%) had trimalleolar fractures. 123 (82%) patients had 2 syndesmotic screws placed, 26 (17.3%) had 1 screw, and 1 (0.7%) had none. Quality of reduction was good for 98%, fair for 2%, and poor for none per McLennan’s criteria. 113 patients (75.3%) were followed until clinical and radiographic union for a mean of 7.6 months (range 3-22) months). 110 patients (97.3%) went on to successful clinical and radiographic union following the index procedure. No patient had a superficial surgical-site infection, and 3 (2.6%) had deep surgical-site infections. 3 patients had a loss of reduction, and 6 patients had implant failure (5 broken syndesmotic screws, and 1 medial malleolus screw). 9 (8%) patients had unplanned reoperations (3 for debridement, 2 for loss of reduction, and 4 for removal of symptomatic implants). Mean ankle range of motion at final follow-up visit was 12.9° (0-40) of dorsiflexion, 39.6° (10-70) of plantarflexion, 23.5° (5-40) of inversion, and 18.2° (5-50) of eversion. Mean PROs at final follow-up visit were: Global Physical Health: 42.4 (23.5-67.6), Global Mental Health: 47.5 (21-67.6), Physical Function: 37.5 (14.7-57.8), Pain: 54.9 (22-72) and Mobility: 36.9 (16-65.3). CONCLUSIONS: Minimally invasive open fibular IM nailing allowed for excellent reduction and results in union with low rates of complications and good patient reported outcomes. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Distinct trajectories of neuropsychiatric symptoms in the 12 months following traumatic brain injury (TBI): a TRACK-TBI study.

Neuropsychiatric symptoms are common after traumatic brain injury (TBI) and often resolve within 3 months post-injury. However, the degree to which individual patients follow this course is unknown. We characterized trajectories of neuropsychiatric symptoms over 12 months post-TBI. We hypothesized that a substantial proportion of individuals would display trajectories distinct from the group-average course, with some exhibiting less favorable courses. Participants were level 1 trauma center patients with TBI (n = 1943), orthopedic trauma controls (n = 257), and non-injured friend controls (n = 300). Trajectories of six symptom dimensions (Depression, Anxiety, Fear, Sleep, Physical, and Pain) were identified using growth mixture modeling from 2 weeks to 12 months post-injury. Depression, Anxiety, Fear, and Physical symptoms displayed three trajectories: Stable-Low (86.2-88.6%), Worsening (5.6-10.9%), and Improving (2.6-6.4%). Among symptomatic trajectories (Worsening, Improving), lower-severity TBI was associated with higher prevalence of elevated symptoms at 2 weeks that steadily resolved over 12 months compared to all other groups, whereas higher-severity TBI was associated with higher prevalence of symptoms that gradually worsened from 3-12 months. Sleep and Pain displayed more variable recovery courses, and the most common trajectory entailed an average level of problems that remained stable over time (Stable-Average; 46.7-82.6%). Symptomatic Sleep and Pain trajectories (Stable-Average, Improving) were more common in traumatically injured groups. Findings illustrate the nature and rates of distinct neuropsychiatric symptom trajectories and their relationship to traumatic injuries. Providers may use these results as a referent for gauging typical v. atypical recovery in the first 12 months post-injury.

Utility of Structured Oculomotor, Balance, and Exercise Testing in Civilian Adults With Mild Traumatic Brain Injury.

Assessments of oculomotor, balance, and exercise function detect different responses to mild traumatic brain injury in sports-related mild traumatic brain injury. These assessments are understudied in the adult community mild traumatic brain injury population. We evaluated level 1 trauma center patients with nonsports-related mild traumatic brain injury on oculomotor functioning (near point of convergence and accommodation), balance (Balance Error Scoring System), and exercise tolerance (Buffalo Concussion Treadmill Test). A prospective, cohort study of adults with mild traumatic brain injury ( n = 36) were assessed at 1 wk and 1-mo post-mild traumatic brain injury ( n = 26) using near point of convergence, near point of accommodation, Balance Error Scoring System, Buffalo Concussion Treadmill Test, and the Rivermead Post Concussion Symptoms Questionnaire. Prevalence of test impairment and association between performance and mild traumatic brain injury-related symptom burden (Rivermead Post Concussion Symptoms Questionnaire scores) were characterized. Participants demonstrated varying levels of impairment (e.g., 33.3% oculomotor, 44.1% balance, and 55.6% exercise impairment at 1 wk). Participants displayed diverse impairment profiles across assessments. We observed medium-to-large correlations between poorer near point of convergence and Buffalo Concussion Treadmill Test performance and greater mild traumatic brain injury symptom burden. Clinical examinations of oculomotor function, balance, and exercise adopted from sports-related concussion assessments detect impairment in adult community members with mild traumatic brain injury. While findings warrant larger-scale replication, they imply that incorporating these simple, structured examinations into the assessment of mild traumatic brain injury may facilitate more personalized management strategies.

Functional Outcomes of Primary Arthrodesis (PA) Versus Open Reduction and Internal Fixation (ORIF) in the Treatment of Lisfranc Injuries.

To determine whether primary arthrodesis (PA) or open reduction and internal fixation (ORIF) results in better functional outcomes through patient-reported outcome measures (PROMs). Reoperation rates and surgical characteristics among the 2 groups are evaluated as well. A retrospective cohort study. Level 1 trauma center. Eighty-one patients treated using PA or ORIF for Lisfranc injuries between January 2010 and January 2019. PROMs were collected using the validated Foot and Ankle Ability Measure questionnaire. Follow-up ranged from 1 to 10 years posttreatment. Two hundred patients underwent ORIF, and 72 patients underwent PA. Eighty-one of 272 patients responded to the questionnaire. The Foot and Ankle Ability Measure revealed activities of daily living subscores for PA and ORIF of 69.78 ± 18.61 and 73.53 ± 25.60, respectively ( P = 0.48). The Sports subscores for PA (45.81 ± 24.65) and ORIF (56.54 ± 31.13) were not significantly different ( P = 0.11). Perceived levels of activities of daily living ( P = 0.32) and Sports ( P = 0.81) function, compared with preinjury levels, were also not significantly different between the 2 groups. Rates of reoperation were nearly identical for PA (28.1%) and ORIF (30.6%) ( P = 1.00). Our results suggest that neither PA nor ORIF is superior regarding functional outcomes or rates of reoperation in the surgical treatment of Lisfranc injuries when appropriately triaged by the treating surgeon. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Массовое одновременное поступление пострадавших в чрезвычайных ситуациях в лечебные медицинские организации: организационные проблемы и возможные пути их решения

Summary. The aim of the study is to identify problems in the organization of medical triage and medical care in trauma centers of different levels at mass simultaneous admission of victims in emergency situations and to determine possible ways to solve them. Study materials and methods. We analyzed the results of treatment of 136 emergency patients in Saratov and Saratov region trauma centers in 2010-2021. All patients were delivered by emergency medical teams (EMTs). Road traffic accidents (RTA) were the most frequent cause (76.0%) of traumatization of the patients, in the remaining cases (24.0%) carbon monoxide poisoning and burns caused by fires were the most common. The mean age of the victims was (39±7) years, of whom 71 (52.2%) were men, and 65 (47.8%) were women. The study was a total retrospective study, using patient medical histories as primary documentation. Patients older than 18 years were included in the study. Victims, who were delivered to trauma centers in addition to ambulance teams, were excluded from the study. Results of the study and their analysis. The results of the study show that of 136 accident victims delivered to trauma centers in Saratov and Saratov region, 76 cases (55.9%) proved to have errors in the organization of medical triage and medical care to the victims. Most of the errors can be conditionally divided into 2 large groups. The first group included 52 observations (38.2%) related to the organization of the admission of injured persons who arrived from the emergency area. The second group included cases of underestimation of the patient’s condition severity, wrong diagnosis, incompletely performed antishock or infusion therapy. The authors designated these errors as therapeutic — they occurred less frequently and were noted only in 9 cases (6.6%) — all these errors were made only in Level III trauma centers. Analysis of the study results showed that the main problem encountered by the management of trauma centers in Saratov region during mass simultaneous admission of victims in emergencies was the incorrect involvement of medical specialists in medical triage, which led to an increase in the timing of its implementation and in the timing of medical care — for example, the involvement of therapeutic specialists in the medical triage of surgical patients. To solve this problem, the authors propose to reverse the involvement of anesthesiology, surgery, and neurology medical specialists in the emergency departments of medical treatment organizations with their subsequent return to their departments as the workload in the emergency departments decreases.

Association of Liver Function Serum Markers and Unfavorable Outcomes in Traumatic Liver Injury Patients

OBJECTIVE To evaluate serum markers in liver function tests (LFT) at various intervals after traumatic liver injury to identify serum markers associated with unfavorable outcomes. METHODS A retrospective cohort analysis was conducted of trauma center patients older than 18 years with traumatic liver injury. Liver function test (LFT) results of patients with favorable and unfavorable outcomes were compared at different post-injury time points. Statistical significance was established as p-value less than 0.05. RESULTS Of the 206 patients with severe liver injuries in the unfavorable outcome group, 119 (57.8%) needed intervention. Aspartate amino-transferase (AST) and alanine transaminase (ALT) were seen to increase in correlation with injury severity at initial admission. On days 1-5 and 6-10 after admission, the unfavorable outcome group had a slower decline in AST. In the unfavorable group, total bilirubin (TB) and direct bilirubin (DB) levels rose significantly 5 days after the injury and were higher than normal with a higher odds ratio (OR) of unfavorable outcome 11-15 days after injury in multivariable analysis [OR (95% confidence intervals): 2.7 (1.02-7.37) and 6.9 (1.08-44.14), respectively]. CONCLUSIONS Liver function tests can help identify individuals at risk for traumatic liver injury complications. Elevated levels of TB and DB are statistically significantly associated with adverse outcomes, particularly after day 5 following the injury. Early repeating LFT in first five days after injury may be less beneficial in determining patient risk. Blood test results may be affected by the amount of fluid resuscitation, particularly on the first day of admission in cases of high- grade injuries. KEYWORDS aspartate aminotransferase, liver injury, liver function test, unfavorable outcome, alanine transaminase, bilirubin

Whole-body computed tomography after major blunt trauma: is it necessary?

Introduction: Trauma is a significant health problem today. Also, it is the foremost reason for death among people ages 1-45; for this reason, the economic and social effect is more articulated. The whole-body CT scans have become a standard procedure in managing trauma patients in many trauma centers. We think that whole body CT will be beneficial in patients with blunt trauma. Thus, we aimed to examine patients with blunt trauma who applied to the emergency department and had whole-body CT scans. Methods: Patient who applied to blunt trauma and had whole-body CT scans to the emergency department of a tertiary training and research hospital between Jan 1, 2021, and Jan 1, 2022, were examined in this single-center, retrospective study. The study population was established based on inclusion and exclusion criteria. ISS, GCS, and whole-body CT scans were compared for mortality. Results: Cranial bone fracture (p= 0.001), epidural hemorrhage (p= 0.001), traumatic subarachnoid hemorrhage (p= 0.001), cerebral edema (p= 0.003), and thoracic contusion (p= 0.046) were significant for mortality. Also, the number of pathological regions in whole-body CT scans was not associated with mortality (p= 0.587). ISS (p=0.001) and GCS (p= 0.001) predicted mortality in patients who experienced whole-body CT scans. Conclusion: Based on our findings, we can detect organ and tissue injuries quickly and in detail using whole-body CT scanning after major blunt trauma. In addition, various protocols are needed in multiple trauma patients to reduce the number of unnecessary WBCT scans. Therefore, whole-body CT scans may be helpful for selection, as ISS and GCS are markers of mortality. Keywords: Whole-body Tomography, Trauma, Trauma Imaging

Functional Recovery, Symptoms, and Quality of Life 1 to 5 Years After Traumatic Brain Injury

Many level I trauma center patients experience clinical sequelae at 1 year following traumatic brain injury (TBI). Longer-term outcome data are needed to develop better monitoring and rehabilitation services. To examine functional recovery, TBI-related symptoms, and quality of life from 1 to 5 years postinjury. This cohort study enrolled trauma patients across 18 US level I trauma centers between 2014 and 2018. Eligible participants were enrolled within 24 hours of injury and followed up to 5 years postinjury. Data were analyzed January 2023. Mild TBI (mTBI), moderate-severe TBI (msTBI), or orthopedic traumatic controls (OTC). Functional independence (Glasgow Outcome Scale-Extended [GOSE] score 5 or higher), complete functional recovery (GOSE score, 8), better (ie, lower) TBI-related symptom burden (Rivermead Post Concussion Symptoms Questionnaire score of 15 or lower), and better (ie, higher) health-related quality of life (Quality of Life After Brain Injury Scale-Overall Scale score 52 or higher); mortality was analyzed as a secondary outcome. A total 1196 patients were included in analysis (mean [SD] age, 40.8 [16.9] years; 781 [65%] male; 158 [13%] Black, 965 [81%] White). mTBI and OTC groups demonstrated stable, high rates of functional independence (98% to 100% across time). While odds of independence were lower among msTBI survivors, the majority were independent at 1 year (72%), and this proportion increased over time (80% at 5 years; group × year, P = .005; independence per year: odds ratio [OR] for msTBI, 1.28; 95% CI, 1.03-1.58; OR for mTBI, 0.81; 95% CI, 0.64-1.03). For other outcomes, group differences at 1 year remained stable over time (group × year, P ≥ .44). Odds of complete functional recovery remained lower for persons with mTBI vs OTC (OR, 0.39; 95% CI, 0.28-0.56) and lower for msTBI vs mTBI (OR, 0.34; 95% CI, 0.24-0.48). Odds of better TBI-related symptom burden and quality of life were similar for both TBI subgroups and lower than OTCs. Mortality between 1 and 5 years was higher for msTBI (5.5%) than mTBI (1.5%) and OTC (0.7%; P = .02). In this cohort study, patients with previous msTBI displayed increased independence over 5 years; msTBI was also associated with increased mortality. These findings, in combination with the persistently elevated rates of unfavorable outcomes in mTBI vs controls imply that more monitoring and rehabilitation are needed for TBI.

Polygenic risk for mental disorders as predictors of posttraumatic stress disorder after mild traumatic brain injury

Many patients with mild traumatic brain injury (mTBI) are at risk for mental health problems such as posttraumatic stress disorder (PTSD). The objective of this study was to determine whether the polygenic risk for PTSD (or for related mental health disorders or traits including major depressive disorder [MDD] and neuroticism [NEU]) was associated with an increased likelihood of PTSD in the aftermath of mTBI. We used data from individuals of European ancestry with mTBI enrolled in TRACK-TBI (n = 714), a prospective longitudinal study of level 1 trauma center patients. One hundred and sixteen mTBI patients (16.3%) had probable PTSD (PCL-5 score ≥33) at 6 months post-injury. We used summary statistics from recent GWAS studies of PTSD, MDD, and NEU to generate polygenic risk scores (PRS) for individuals in our sample. A multivariable model that included age, sex, pre-injury history of mental disorder, and cause of injury explained 7% of the variance in the PTSD outcome; the addition of the PTSD-PRS (and five ancestral principal components) significantly increased the variance explained to 11%. The adjusted odds of PTSD in the uppermost PTSD-PRS quintile was nearly four times higher (aOR = 3.71, 95% CI 1.80–7.65) than in the lowest PTSD-PRS quintile. There was no evidence of a statistically significant interaction between PTSD-PRS and prior history of mental disorder, indicating that PTSD-PRS had similar predictive utility among those with and without pre-injury psychiatric illness. When added to the model, neither MDD-PRS nor NEU-PRS were significantly associated with the PTSD outcome. These findings show that the risk for PTSD in the context of mTBI is, in part, genetically influenced. They also raise the possibility that an individual’s PRS could be clinically actionable if used—possibly with other non-genetic predictors—to signal the need for enhanced follow-up and early intervention; this precision medicine approach needs to be prospectively studied.

Schedule II Narcotics are often Unnecessary for Pain Control in Patients with Pelvic or Acetabular Fractures

Objectives: Determine if patients with pelvic and acetabular fractures require scheduled II narcotics after discharge. Design: Retrospective case series. Setting: Level I Trauma Center Patients: 124 consecutive patients with operatively managed pelvic (OTA 61B or C) and acetabular fractures (OTA 62A, 62B or C) Intervention: A multimodal oral pain regimen was prescribed at discharge with schedule II narcotic only if needed for pain control. Main Outcome: Primary outcomes were defined as the need for schedule II narcotic at discharge or in follow up. Measurements: Prescription of narcotic on follow up or return to ER for inadequate pain control. Visual Analog Pain Scale score. Results: Ninety-two patients (74%) with adequate follow-up were included for the final analysis, including patients with 25 acetabular fractures, 50 pelvic fractures, and 17 combined injuries. Sixty-four patients (69.6%) were multiply-injured patients. Four (4.3%) patients were discharged with a Schedule II narcotic. Of the remaining patients (n=88), two (2.2%) required delayed prescription of a Schedule II narcotic after discharge and 5 (5.4%) presented to the ED for pain control. There were no readmissions for pain. Overall 81 of 92 (88.0%) patients had pain controlled without schedule II narcotics or ED presentation. The mean VAS pain score for all patients was 4.1±3.6 from 5 to 21 days, 3.2±3.4 at 22 to 60 days, and 2.7±3.3 at greater than 60 to 180 days after discharge, there was no significant difference between groups Conclusion: Multimodal pain control regimens without schedule II narcotics in the immediate postoperative follow-up period can be effective in managing pain in the majority of patients with pelvic or acetabular fractures. Level of Evidence: IV; case series Keywords: narcotics, pain control, acetabular fractures, pelvic fractures

Spine

The December 2022 Spine Roundup360 looks at: Deep venous thrombosis prophylaxis protocol on a Level 1 trauma centre patient database; Non-specific spondylodiscitis: a new perspective for surgical treatment; Disc degeneration could be recovered after chemonucleolysis; Three-level anterior cervical discectomy and fusion versus corpectomy- anterior cervical discectomy and fusion “hybrid” procedures: how does the alignment look?; Rivaroxaban or enoxaparin for venous thromboembolism prophylaxis; Surgical site infection: when do we have to remove the implants?; Determination of a neurologic safe zone for bicortical S1 pedicle placement; Do you need to operate on unstable spine fractures in the elderly: outcomes and mortality; Degeneration to deformity: when does the patient need both?

Effect of Trauma Mechanism of Injury on Post-Traumatic Stress Disorder and Depression Screening

INTRODUCTION: Few data exist guiding surgeons on the management of trauma-induced mental health issues. We hypothesize that the mechanism of injury (MoI) affects posttraumatic stress disorder (PTSD) and depression in trauma patients. METHODS: This is a retrospective cohort study of adult Level I trauma center patients from March 2018 to June 2021 completing a 3-month follow-up screening for PTSD with PCL-5 and depression with PHQ-9 scoring. Demographics and hospitalization details were culled from electronic medical records. MoI was categorized as blunt: low energy, blunt: high energy, and penetrating type by CDC Field Triage Guidelines. Baseline characteristics were compared. Scores were dichotomized before generating logistic and ordinal regression models. RESULTS: A total of 1,148 trauma patients underwent follow-up screening for PTSD and depression. MoI included 67.6% blunt: high energy, 23.2% blunt: low energy, and 9.2% penetrating trauma. Penetrating patients were more likely to screen PTSD positive (odds ratio [OR] 1.72, 95% CI 0.98 to 2.93) and blunt: low energy patients were less likely (OR 0.49, 95% CI 0.28 to 0.84). MoI did not significantly influence depression screening. Patients with previous depression history were more likely to screen positive for PTSD (OR 2.80, 95% CI 1.70 to 4.61) and experience higher depression scores (OR 2.36, 95% CI 1.61 to 3.47; Figure).Figure.: ISS, injury severity score; PTSD, posttraumatic stress disorder.CONCLUSION: Mechanism of injury influences psychiatric sequelae in trauma patients. Compared wth blunt mechanisms, penetrating trauma patients were more likely to screen positive for PTSD. Blunt: low energy provided a protective effect. Routine PTSD screening, especially after penetrating trauma, may identify patients requiring further investigation and intervention.

Interventional angiography utilization for adult trauma patients in Trauma Centers across the United States: An observational study using the National Trauma Data Bank.

Angiography and embolization are part of trauma management protocols for various injuries. This study examines the use of angiography and embolization use in trauma care across Trauma Centers in the United States.We used the National Trauma Data Bank (NTDB) 2017 dataset in this retrospective observational study. Adult trauma patients (≥16 years) who underwent conventional angiography with or without embolization were included. A univariate analysis was carried out to describe patients’ demographic and injury characteristics as well as the time to angiography, angiography details, complications, and outcome (survival to hospital discharge: yes/no). One-year period prevalence proportion of angiography procedure was determined.A total of 4242 patients were included. The 1-year period prevalence proportion of angiography procedure with or without embolization was 0.53% (95% confidence intervals: 0.527–0.529). The median age was 41 years (interquartile range: 27–58) with most patients being in the age group 16 to 64 (83.8%) and males (72.6%). Over half of the patients, 55.4% had an embolization procedure performed in addition to angiography. The mean time to angiography was 263.77 ± 750.19 minutes. The most common embolization sites were the pelvis (24.9%), spleen (11.8%), and liver (9%).This study described angiography and embolization utilization in adult trauma patients in Trauma Centers in the US. Its findings provide the basis for future studies to examine more closely angiography/embolization utilization in specific subpopulations, and to create standardized risk stratification tools for trauma patients who are candidates for this procedure.

The influence of inter-hospital transfers on mortality in severely injured patients

PurposeThe importance of treating severely injured patients in higher-level trauma centers is undisputable. However, it is uncertain whether severely injured patients that were initially transported to a lower-level trauma center (i.e., undertriage) benefit from being transferred to a higher-level trauma center.MethodsThis observational study included all severely injured patients (i.e., Injury Severity Score ≥ 16) that were initially transported to a lower-level trauma center within eight ambulance regions. The exposure of interest was whether a patient was transferred to a higher-level trauma center. Primary outcomes were 24-h and 30-day mortality. Generalized linear models including inverse probability weights for several potential confounders were constructed to evaluate the association between transfer status and mortality.ResultsWe included 165,404 trauma patients that were transported with high priority to a trauma center, of which 3932 patients were severely injured. 1065 (27.1%) patients were transported to a lower-level trauma center of which 322 (30.2%) were transferred to a higher-level trauma center. Transferring undertriaged patients to a higher-level trauma center was significantly associated with reduced 24-h (relative risk [RR] 0.26, 95%-CI 0.10–0.68) and 30-day mortality (RR 0.65, 0.46–0.92). Similar results were observed in patients with critical injuries (24-h: RR 0.35, 0.16–0.77; 30-day: RR 0.55, 0.37–0.80) and patients with traumatic brain injury (24-h: RR 0.31, 0.11–0.83; 30-day: RR 0.66, 0.46–0.96).ConclusionsA minority of the undertriaged patients are transferred to a higher-level trauma center. An inter-hospital transfer appears to be safe and may improve the survival of severely injured patients initially transported to a lower-level trauma center.

Association of day-of-injury plasma glial fibrillary acidic protein concentration and six-month posttraumatic stress disorder in patients with mild traumatic brain injury

Several proteins have proven useful as blood-based biomarkers to assist in evaluation and management of traumatic brain injury (TBI). The objective of this study was to determine whether two day-of-injury blood-based biomarkers are predictive of posttraumatic stress disorder (PTSD). We used data from 1143 individuals with mild TBI (mTBI; defined as admission Glasgow Coma Scale [GCS] score 13–15) enrolled in TRACK-TBI, a prospective longitudinal study of level 1 trauma center patients. Plasma glial fibrillary acidic protein (GFAP) and serum high sensitivity C-reactive protein (hsCRP) were measured from blood collected within 24 h of injury. Two hundred and twenty-seven (19.9% of) patients had probable PTSD (PCL-5 score ≥ 33) at 6 months post-injury. GFAP levels were positively associated (Spearman’s rho = 0.35, p < 0.001) with duration of posttraumatic amnesia (PTA). There was an inverse association between PTSD and (log)GFAP (adjusted OR = 0.85, 95% CI 0.77–0.95 per log unit increase) levels, but no significant association with (log)hsCRP (adjusted OR = 1.11, 95% CI 0.98–1.25 per log unit increase) levels. Elevated day-of-injury plasma GFAP, a biomarker of glial reactivity, is associated with reduced risk of PTSD after mTBI. This finding merits replication and additional studies to determine a possible neurocognitive basis for this relationship.

Can we really make catheter-associated urinary tract infections a never event? A level 1 trauma center's experience with prophylactic antibiotic bladder irrigation.

Hospital-acquired catheter-associated urinary tract infections (CAUTIs) are considered "never events" and are reportable to Centers for Medicare and Medicaid Services as a quality indicator. Despite protocols to determine appropriate removal of urinary catheters as soon as possible, severely injured trauma patients often require prolonged catheterization during ongoing resuscitation or develop retention requiring catheter replacement, exposing them to risk for CAUTI. We evaluated whether prophylactic antibiotic bladder irrigation reduces the incidence of CAUTI in critically ill trauma patients. As a quality initiative, gentamicin bladder catheter irrigation (GBCI) was performed on a level 1 trauma center's patients at risk for CAUTI in 2021, defined by indwelling Foley catheterization for a minimum of 3 days. We then conducted a retrospective study using a comparison cohort of 2020 admissions as the control group. Catheter-associated urinary tract infection rates per 1,000 catheterized days were compared between these two groups. Patients with traumatic bladder injuries were excluded. Our cohort included 342 patients with a median hospitalization of 11 (7-17) days, Injury Severity Score of 17 (10-26), and 6 (4-11) days of catheterization. Eighty-six patients, catheterized for 939 at-risk days, received twice-daily GBCI compared with 256, catheterized for 2,114 at-risk days, who did not. Zero patients in the GBCI group versus nine patients in the control group developed CAUTI. The incidence of CAUTI in the GBCI group was significantly less than in the control group (0/1,000 vs. 4.3/1,000 catheterized days, p = 0.018). Prophylactic antibiotic bladder irrigation was associated with a zero incidence of CAUTI among trauma patients at risk for CAUTI. This practice holds promise as effective infection prophylaxis for such patients. The optimal duration and frequency of irrigation remain to be determined. Therapeutic/care management, Level III.

Disparities in Demographics and Outcomes Based on Trauma Center Ownership.

Ownership may influence trauma center (TC) location. For-profit (FP) TCs require a favorable payor mix to thrive, whereas not-for-profit (NFP) centers may rely on government funding, grants, and patient volume. We hypothesized that the demographics of trauma patients would be different for NFP and FP TCs due to ownership type. We also hypothesized that these demographic differences might be associated with outcomes such as length of stay, reported complications, and mortality. We used the Florida Agency for Health Care Administration (AHCA) 2016-2017 inpatient dataset to examine differences in outcomes by trauma center ownership type. Negative binomial and logistical regression was used to compare trauma ownership, length of stay (LOS), reported complications, and mortality of severely injured nonelderly adult trauma patients. Our study analyzed risk factors and outcomes for 10,700 trauma alert patients. Patients treated at FP TCs were less likely to be Black (OR 0.70, 95% CI: 0.62-0.78), to be uninsured (OR 0.40, 95% CI 0.36-0.45), have Medicare (OR 0.53, 95% CI 0.43-0.66), or Medicaid (OR 0.57, 95% CI 0.50-0.65) (all P<0.001). Patients treated at FP centers were less likely to have comorbidities (OR 0.89, 95% CI 0.82-0.96) and were associated with a longer LOS (0.10, 95% 0.05-0.15, P<0.001) in nonelderly adult trauma patients. FP TCs were associated with fewer reported complications (OR 0.83, 95% CI 0.74-0.94) and were associated with a higher likelihood of mortality in nonelderly adults (OR 1.70, 95% CI 1.35-2.12, P<0.001). Among this cohort of severe International Classification of Diseases-based injury severity score (ICISS) patients, complications were less likely, but LOS and mortality were increased among FP TC patients. FP centers cared for fewer patients who were Black, uninsured, or who were Medicare/Medicaid/noncommercial insurance.

Electric scooters as a source of orthopedic injuries at a Level-I trauma center

IntroductionElectric scooter rentals are offered by major ridesharing companies as a new and alternative method for urban travel in major metropolitan areas. The correlation between motorized electric scooter rental services and orthopedic injuries has not been well scrutinized. The purpose of our study is to evaluate orthopedic injuries sustained by motorized scooter riders and their potential correlation with patient demographics and associated injuries. MethodsWe retrospectively reviewed level 1 trauma center patients with orthopedic injuries sustained while riding motorized electric scooters from 4/2019–11/2019. Demographics, fracture characteristics, and patient management were examined. ResultsSixty-two patients sustained 86 orthopedic injuries. There were 56 (65.1%) upper extremity and 29 (33.7%) lower extremity injuries. Six patients (9.7%) suffered open injuries and 30 (48.4%) sustained injuries that required surgery. Anatomic location of the injury was associated with both the presence of open fracture and needing surgery (P = 0.016 and P less than 0.001, respectively). Also, the presence of multiple orthopedic injuries was associated with the need for surgery (P less than 0.001). Scooter collision events were significantly associated with multiple orthopedic and the presence of non-orthopedic injuries (P less than 0.01 and P less than 0.01). ConclusionElectric scooter accidents can result in orthopedic injuries, many of which require surgery. Caution should be exercised when riding electric scooters, and special attention should be given by trauma centers and emergency departments to patients who present after electric scooter injury as the potential for orthopedic injury is high with this mechanism of injury.

Modification of the TRISS: simple and practical mortality prediction after trauma in an all-inclusive registry.

Numerous studies have modified the Trauma Injury and Severity Score (TRISS) to improve its predictive accuracy for specific trauma populations. The aim of this study was to develop and validate a simple and practical prediction model that accurately predicts mortality for all acute trauma admissions. This retrospective study used Dutch National Trauma Registry data recorded between 2015 and 2018. New models were developed based on nonlinear transformations of TRISS variables (age, systolic blood pressure (SBP), Glasgow Coma Score (GCS) and Injury Severity Score (ISS)), the New Injury Severity Score (NISS), the sex-age interaction, the best motor response (BMR) and the American Society of Anesthesiologists (ASA) physical status classification. The models were validated in 2018 data and for specific patient subgroups. The models' performance was assessed based on discrimination (areas under the curve (AUCs)) and by calibration plots. Multiple imputation was applied to account for missing values. The mortality rates in the development and validation datasets were 2.3% (5709/245363) and 2.5% (1959/77343), respectively. A model with sex, ASA class, and nonlinear transformations of age, SBP, the ISS and the BMR showed significantly better discrimination than the TRISS (AUC 0.915 vs. 0.861). This model was well calibrated and demonstrated good discrimination in different subsets of patients, including isolated hip fractures patients (AUC: 0.796), elderly (AUC: 0.835), less severely injured (ISS16) (AUC: 878), severely injured (ISS ≥ 16) (AUC: 0.889), traumatic brain injury (AUC: 0.910). Moreover, discrimination for patients admitted to the intensive care (AUC: s0.846), and for both non-major and major trauma center patients was excellent, with AUCs of 0.940 and 0.895, respectively. This study presents a simple and practical mortality prediction model that performed well for important subgroups of patients as well as for the heterogeneous population of all acute trauma admissions in the Netherlands. Because this model includes widely available predictors, it can also be used for international evaluations of trauma care within institutions and trauma systems.