Trauma Quality Improvement Program Database Research Articles

Balanced blood component resuscitation in trauma: Does it matter equally at different transfusion volumes?

BackgroundIt remains unclear whether the association between balanced blood component transfusion and lower mortality is generalizable to trauma patients receiving varying transfusion volumes. We sought to study the role red blood cell transfusion volume plays in the relationships between red blood cell:platelet and red blood cell:fresh frozen plasma ratios and 4-hour mortality. MethodsAdult patients in the 2013 to 2018 American College of Surgeons Trauma Quality Improvement Program database receiving ≥6 red blood cell, ≥1 platelet, and ≥1 fresh frozen plasma within 4 hours were included. The following 4 cohorts were defined based on 4-hour red blood cell transfusion volume: (1) 6 to 10 units, (2) 11 to 15 units, (3) 16 to 20 units, and (4) >20 units. The association between red blood cell:fresh frozen plasma, red blood cell:platelet, and 4-hour mortality was evaluated discretely for each red blood cell transfusion volume category, statistically adjusting for confounders. ResultsA total of 14,549 patients were included. In patients receiving 6 to 10 units of red blood cells, red blood cell:platelet ratios were not associated with 4-hour mortality, and only red blood cell:fresh frozen plasma ≥4:1 were associated with significantly higher odds of 4-hour mortality compared to 1:1. For patients receiving >10 red blood cell units, increasing red blood cell:platelet and red blood cell:fresh frozen plasma ratios were consistently associated with increased odds of 4-hour mortality. For example, in red blood cell volumes of 11 to 15, 16 to 20, and >20 units, risk-adjusted 4-hour mortality odds ratios for red blood cell:platelet ≥4:1 were 2.27 (1.47–3.51), 3.32 (2.26–4.90), and 3.01 (2.33–3.88), respectively. ConclusionThe association between balanced blood component transfusion and 4-hour mortality is not homogenous in trauma patients requiring different transfusion volumes and is specifically less evident in patients receiving lower volumes. Such findings should be considered in the current and future blood shortage crises across the nation.

1303: IMPACT OF ANTIPLATELET AND ANTICOAGULANT AGENTS ON EMERGENT SURGERY FOR ORTHOPEDIC TRAUMAS

Introduction: Traumatic injuries bring about an increasing and significant challenge to healthcare systems worldwide. Most traumatic injuries are orthopedic in nature commonly caused by falls and road traffic accidents. A large concern relates to older patients taking anticoagulants and/or antiplatelets (AP/AC) prior to an injury due to the increased risk of hemorrhagic complications. This study utilized the Michigan Trauma Quality Improvement Program (MTQIP) database to determine the effect that AP/AC have on outcomes following emergent surgery for orthopedic traumas. Methods: Patients were included with age >18 years, Maximum Extremity or Pelvic Girdle severity value of abbreviated injury score (AIS) >2, injury severity score (ISS) >5, underwent extremity-related operation (based on the MTQIP Hospital Procedures ICD-10 codes), and underwent a procedure within 24 hours of ED admission. Patients were excluded if they had an AIS >3 in other body region, or no signs of life at initial evaluation. Results: Within the 4,030 patients analyzed, 97 were in the warfarin with or without (+/-) aspirin cohort, 146 in the direct oral anticoagulants (DOAC) +/- aspirin cohort, 140 in the clopidogrel +/- aspirin cohort, and 2,981 in the no AP/AC cohort (control group). After controlling for demographic, comorbid, and clinical characteristics, no significant difference in mortality rates was observed in the treatment groups (p>0.05). However, our subgroup analysis did reveal a significantly higher mortality rate within the warfarin and aspirin subgroup as compared to the control group (odds ratio [OR], 5.849; confidence interval [CI], 1.557-21.975, p=0.009). With regards to hospital complications, there was a significant increase in this outcome within all treatment groups, DOAC +/- aspirin (OR, 1.898; CI, 1.252-2.879, p=0.003), warfarin +/- aspirin (OR, 3.06; CI, 1924-4.868, p< 0.001), clopidogrel +/- aspirin (OR, 2.345; CI, 1.56-3.526, p< 0.001) groups. Conclusions: Patients on AP/AC who experience an orthopedic trauma requiring an emergent operation do not have an increased risk of mortality compared to patients not on AP/AC except for patients on warfarin and aspirin prior to admission.

Recent trends in the management of isolated high-grade splenic injuries: A nationwide analysis.

The feasibility of nonoperative management for high-grade blunt splenic injuries (BSIs) has been suggested in recent studies. The purpose of this study was to assess nationwide trends in the management of isolated high-grade BSIs. We hypothesized that isolated high-grade BSIs are more frequently being managed nonoperatively. The American College of Surgeons Trauma Quality Improvement Program database was queried to identify patients (16 years or older) with isolated high-grade BSIs (Abbreviated Injury Scale, ≥3) between 2013 and 2019. Patients were divided into two groups based on their hemodynamic status (hemodynamically stable [HS] and hemodynamically unstable [HU]). The primary outcome was the rate of total splenectomy each year, and the secondary outcome was the use of splenic angioembolization (SAE). Multiple regression models were created to estimate annual trends in splenectomy and SAE. A total of 6,747 patients with isolated high-grade BSIs were included: 5,714 (84.7%) and 1,033 (15.3%) in HS and HU groups, respectively. In the HS group, the rate of overall splenectomy was significantly decreased (from 22.9% in 2013 to 12.6% in 2019; odds ratio [OR] for 1-year increment, 0.850; 95% confidence interval [CI], 0.815-0.886; p < 0.001), and the use of SAE was significantly increased (from 12.5% in 2013 to 20.9% in 2019; OR, 1.107; 95% CI, 1.065-1.150; p < 0.001). In the HU group, the overall splenectomy rate was unchanged (from 69.8% in 2013 to 50.8% in 2019; OR, 0.931; 95% CI, 0.865-1.002; p = 0.071), whereas SAE was significantly increased (from 12.7% in 2013 to 28.8% in 2019; OR, 1.176; 95% CI, 1.079-1.284; p < 0.001). We observed significant trends toward more frequent use of nonoperative management in high-grade BSIs with hemodynamic stability. Further studies are warranted to define the role of SAE, especially in patients with hemodynamic instability. Therapeutic/Care Management; Level IV.

Association Between Hemorrhage Control Interventions and Mortality in US Trauma Patients With Hemodynamically Unstable Pelvic Fractures

Management of hemodynamically unstable pelvic fractures remains a challenge. Hemostatic interventions are used alone or in combination. There is a paucity of data on the association between the pattern of hemorrhage control interventions and outcomes after a severe pelvic fracture. To characterize clinical outcomes and study the patterns of hemorrhage control interventions in hemodynamically unstable pelvic fractures. In this cohort study, a retrospective review was performed of data from the 2017 American College of Surgeons Trauma Quality Improvement Program database, a national multi-institutional database of trauma patients in the United States. Adult patients (aged ≥18 years) with pelvic fractures who received early transfusions (≥4 units of packed red blood cells in 4 hours) and underwent intervention for pelvic hemorrhage control were identified. Use and order of preperitoneal pelvic packing (PP), pelvic angioembolization (AE), and resuscitative endovascular balloon occlusion of the aorta (REBOA) in zone 3 were examined and compared against the primary outcome of mortality. The associations between intervention patterns and mortality, complications, and 24-hour transfusions were further examined by backward stepwise regression analyses. Data analyses were performed in September 2021. Primary outcomes were rates of 24-hour, emergency department, and in-hospital mortality. Secondary outcomes were major in-hospital complications. A total of 1396 patients were identified. Mean (SD) age was 47 (19) years, 975 (70%) were male, and the mean (SD) lowest systolic blood pressure was 71 (25) mm Hg. The median (IQR) Injury Severity Score was 24 (14-34), with a 24-hour mortality of 217 patients (15.5%), ED mortality of 10 patients (0.7%), in-hospital mortality of 501 patients (36%), and complication rate of 574 patients (41%). Pelvic AE was the most used intervention (774 [55%]), followed by preperitoneal PP (659 [47%]) and REBOA zone 3 (126 [9%]). Among the cohort, 1236 patients (89%) had 1 intervention, 157 (11%) had 2 interventions, and 3 (0.2%) had 3 interventions. On regression analyses, only pelvic AE was associated with a mortality reduction (odds ratio [OR], 0.62; 95% CI, 0.47 to 0.82; P < .001). Preperitoneal PP was associated with increased odds of complications (OR, 1.39; 95% CI, 1.07 to 1.80; P = .01). Increasing number of interventions was associated with increased 24-hour transfusions (β = +5.4; 95% CI, +3.5 to +7.5; P < .001) and mortality (OR, 1.57; 95% CI, 1.05 to 2.37; P = .03), but not with complications. This study found that among patients with pelvic fracture who received early transfusions and at least 1 invasive pelvic hemorrhage control intervention, more than 1 in 3 died, despite the availability of advanced hemorrhage control interventions. Only pelvic AE was associated with a reduction in mortality.

REBOA in trauma and the risk of venous thromboembolic complications: A matched-cohort study

BackgroundResuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has been used as a damage control procedure in trauma patients. We hypothesized that REBOA increases risk of venous thromboembolic (VTE) complications. MethodsThis was an American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) database study. Excluded were transfers, deaths within 24 h, and severe head injuries. Included were trauma patients receiving REBOA within 4 h from arrival. Outcomes in the two groups were compared after using propensity score matching (PSM) for demographic and clinical characteristics, body area abbreviated injury scale, injury severity score, pelvis and lower extremity fractures, angiographic intervention, preperitoneal pelvic packing, pharmacological VTE prophylaxis, laparotomy, laparotomy and specific orthopedic procedures. ResultsAfter PSM, 339 REBOA patients were matched with 663 patients with No REBOA. REBOA patients were significantly more likely to develop pulmonary embolism (PE) (5.3% vs. 2.7%, p = .037) and VTE (14.7% vs. 10.0%, p = .025). ConclusionREBOA is associated with an increased risk of PE and VTE complications. Patients managed with REBOA should receive adequate thromboprophylaxis and be monitored closely for VTE complications.

Angioembolization in Severe Pelvic Trauma is Associated with Venous Thromboembolism

IntroductionManagement of hemorrhage from pelvic fractures is complex and requires multidisciplinary attention. Pelvic angioembolization (AE) has become a key intervention to aid in obtaining definitive hemorrhage control. We hypothesized that pelvic AE would be associated with an increased risk of venous thromboembolism (VTE). MethodsAll adults (age >16) with a severe pelvic fracture (Abbreviated Injury Scale ≥ 4) secondary to a blunt traumatic mechanism in the 2017-2019 American College of Surgeons Trauma Quality Improvement Program database were included. Patients who did not receive VTE prophylaxis during their admission were excluded. Patients who underwent pelvic AE during the first 24 h of admission were compared to those who did not using propensity score matching. Matching was performed based on patient demographics, admission physiology, comorbidities, injury severity, associated injuries, other hemorrhage control procedures, and VTE prophylaxis type, and time to initiation of VTE prophylaxis. The rates of VTE (deep vein thrombosis and pulmonary embolism) were compared between the matched groups. ResultsOf 72,985 patients with a severe blunt pelvic fracture, 1887 (2.6%) underwent pelvic AE during the first 24 h of admission versus 71,098 (97.4%) who did not. Pelvic AE patients had a higher median Injury Severity Score and more often required other hemorrhage control procedures, with laparotomy being most common (24.7%). The median time to initiation of VTE prophylaxis in pelvic AE versus no pelvic AE patients was 60.1 h (interquartile range = 36.6-98.6) versus 27.7 h (interquartile range = 13.9-52.4), respectively. After propensity score matching, pelvic AE patients were more likely to develop VTE compared to no pelvic AE patients (11.8% versus 9.5%, P = 0.03). ConclusionsPelvic AE for control of hemorrhage from severe pelvic fractures is associated with an increased risk of in-hospital VTE. Patients who undergo pelvic AE are especially high risk for VTE and should be started as early as safely possible on VTE prophylaxis.

Case volume and rate are associated with outcomes in geriatric trauma: A case for geriatric trauma centers?

Increased morbidity and mortality in geriatric trauma patients are usually due to decreased physiologic reserve and increased comorbidities. It is unclear whether geriatric trauma case volume and rates correlate with survival. We hypothesized that geriatric patients would have increased survival when treated in high-case volume and rate trauma centers. A retrospective cohort study was conducted using the Trauma Quality Improvement Program database between 2015 and 2019. Geriatric trauma patients (≥65 years) with severe injury (Injury Severity Score ≥16) were included. Geriatric case volume (GCV) was defined as the mean annual number of treated geriatric trauma patients, while geriatric case rate (GCR) was the mean annual number of elderly trauma patients divided by all trauma patients in each center. Trauma centers were classified into low-, medium-, and high-volume and rate facilities based on GCV and GCR. The association of GCV and GCR with in-hospital mortality and complication rates was assessed using the generalized additive model (GAM) and multivariate generalized linear mixed model adjusted for patient characteristics (age, sex, Injury Severity Score, Revised Trauma Score, and Modified Frailty Index) as fixed-effect variables and hospital characteristics as random effect variables. A total of 164,818 geriatric trauma patients from 812 hospitals were included in the analysis. The GAM plots showed that the adjusted odds of in-hospital mortality decreased as GCV and the GCR increased. The generalized linear mixed model revealed that both high GCV and high GCR hospitals had lower mortality rates than low GCV and GCR hospitals (adjusted odds ratio [95% confidence interval], high GCV and high GCR centers; 0.82 [0.72-0.92] and 0.81 [0.73-0.90], respectively). Both high geriatric trauma volume and rates were associated with decreased mortality of geriatric trauma patients. Consolidation of care for elderly patients with severe injury in specialized high-volume centers may be considered. Therapeutic/Care Management; Level III.

Resuscitative Endovascular Balloon Occlusion of the Aorta is Associatedwith Increased Risk of Extremity Compartment Syndrome.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used as a temporizing procedure to control intra-abdominal or pelvic bleeding. Theoretically, occlusion of the aorta and the resulting ischemia-reperfusion of the lower extremities may increase the risk of extremity compartment syndrome (CS). To date, no study has addressed systematically the incidence and risk factors of CS following REBOA intervention. The purpose of this study was to address this knowledge gap. Adult trauma patients from the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) database (2016-2019) were included. Patients who received REBOA within 4h of admission were compared to patients without REBOA after propensity score matching for demographics, vital signs on admission, comorbidities, injury severity of different body regions, pelvic and lower extremity fractures, vascular trauma to the lower extremities, fixation for fractures, angioembolization (AE) for pelvis, preperitoneal pelvic packing (PPP), laparotomy, and venous thromboembolism (VTE) prophylaxis. The primary outcomes were rates of lower extremity CS and fasciotomy and acute kidney injury (AKI). Secondary outcomes included mortality. There were 534 patients who received REBOA matched with 1043 patients without REBOA. Overall, patients in the REBOA group had significantly higher rates of CS than no REBOA patients [5.4% vs 1.1%, p < 0.001, OR: 5.39]. The risk of CS remained significantly higher in the subgroups of patients with or without pelvic or lower extremity fractures, as well as in the subgroup of patients with associated extremity vascular injury [11.2% vs 1.5%, p < 0.001, OR: 8.12].The fasciotomy and AKI rates were significantly higher in the REBOA group (5.8% vs 1.2%, p < 0.001 and 12.9% vs 7.4%, p< 0.001 respectively). REBOA use is associated with a higher risk of lower extremity CS, fasciotomy and AKI, especially in patients with associated lower extremity vascular injuries. These complications should be taken into account when considering REBOA use, and close observation for this complication should always be part of the routine monitoring.

Outcomes in Pediatric Trauma Patients Who Receive Blood Transfusion

IntroductionIncreased blood volumes, due to massive transfusion (MT), are known to be associated with both infectious and noninfectious adverse outcomes. The aim of this study was to assess the association between MT and outcomes in pediatric trauma patients, and, secondarily, determine if these outcomes are differential by age once MT is reached. MethodsPediatric patients (ages 1-18 y old) in the ACS pediatric Trauma Quality Improvement Program (TQIP) database (2015-2018) who received blood were included. Patients were stratified by MT status, which was defined as blood product volume of 40 mL/kg within 24 h of admission (MT+) and compared to children who received blood products but did not meet the MT threshold (MT-). Defined MT + patients were matched 1:1 to MT-patients via propensity score matching of characteristics before comparisons. Adjusted logistic regression was performed on univariably significant outcomes of interest. ResultsThere were 2318 patients in the analytic cohort. Patients who received MT had higher rates of deep venous thrombosis (DVT) (2.5% versus 1.0%, P < 0.001), acute kidney injury (AKI) (1.5% versus 0.0%, P = 0.022), CLABSI (4.0% versus 2.0% P = 0.008), and severe sepsis (2.3% versus. 1.1%, P = 0.02). On logistic regression MT was an independent risk factor for these outcomes. There was no differential effect of MT on these outcomes based on age. ConclusionsOutcomes associated with blood transfusion in pediatric trauma patients are low overall, but rates of DVT, AKI, CLABSI, and sepsis are higher in those who receive MT+ with no differences based on age.

Preperitoneal Pelvic Packing for Hypotension: Should There Be a Real Concern for Increased Risk of Venous Thromboembolism?: Commentary on an article by Joseph T. Patterson, MD, et al.: "Preperitoneal Pelvic Packing for Hypotension Has a Greater Risk of Venous Thromboembolism Than Angioembolization. Management of Refractory Hypotension in Closed Pelvic Ring Injury".

Commentary Patterson et al. investigated whether there is a difference in the incidence of venous thromboembolism (VTE) in patients with hypotension and pelvic fractures who were managed either with preperitoneal pelvic packing (PPP) or angioembolization (AE). They used the American College of Surgeons Trauma Quality Improvement Program (TQIP) database. The matching of patients was possible using a propensity score approach. The primary outcome was the risk of VTE after matching on the propensity score for treatment, whereas the secondary outcomes included inpatient development of deep vein thrombosis, pulmonary embolism, or respiratory failure, mortality, unplanned reoperation, sepsis, surgical site infection, hospital length of stay, and intensive care unit length of stay. Patterson et al. report that PPP was associated with 9.8% (95% confidence interval [CI], 3.5% to 16.1%) greater absolute risk of VTE (relative risk [RR], 1.5 [95% CI, 1.2 to 1.9]; p = 0.003), 6.5% (95% CI, 1.2% to 11.9%) greater absolute risk of deep vein thrombosis (RR, 1.4 [95% CI, 1.1 to 1.8]; p = 0.04), and 4.9% (95% CI, 0.6% to 9.2%) greater absolute risk of respiratory failure (RR, 3.3 [95% CI, 1.1 to 9.8]; p = 0.03) compared with AE. Interestingly, the incidences of pulmonary embolism and mortality were nearly significant but they were not significantly different by treatment when analyzed separately. The authors conclude that the VTE risk among patients with hemodynamically unstable pelvic fractures was 16% for patients receiving PPP and 6% for patients receiving AE, and this 10% difference in the risk of clinically relevant VTE was attributed to PPP treatment. Patterson et al. cited authors who recommended that screening duplex ultrasounds should be conducted in patients receiving PPP. Although this study raises concerns in relation to the safety of PPP from the VTE point of view, the design and the results must be analyzed judiciously, as it would be unreasonable to develop the view that AE should be given preferential use or even that PPP should not be used, when it has been established for years as an appropriate, lifesaving intervention, especially in situations in which AE may not be readily available. First, of the 29,403 patients who met the inclusion criteria, 366 patients (1.2%) (183 in each group) were suitable for comparison after propensity score matching. That implies that 98.8% of patients were excluded from the analysis. Despite the effort of the authors to match the 2 groups utilizing an optimized propensity score, one remains skeptical whether the 2 groups are indeed comparable, as hypotension was defined as systolic blood pressure of <90 mm Hg at admission before intervention. However, hypotension is a dynamic parameter, and one would have expected patients who then underwent angiography to have achieved hemodynamic restoration (at least a transient response) prior to undergoing the intervention. In contrast, PPP would have been utilized in patients presenting in an extremis (near-death) physiological state, in whom the timing of the intervention is critical, and PPP would have been used as a lifesaving procedure. Therefore, the final suggestion made by the authors to perhaps consider the preferential use of AE, if available, is erroneous. Second, the analysis was based on a small number of VTE events, only 40 in total. Third, the authors themselves highlighted other limitations, including the retrospective nature of the study, the risk of the existence of inconsistent and/or inaccurately coded variables in the database, VTE events occurring after discharge not being captured, the timing of the presentation of VTE possibly being dissimilar between the 2 treatment modalities (PPP and AE), the pelvic fracture type of the injury not being available, and the exact timing of the occurrence of the VTE diagnosis not being able to be determined. Fourth, there was no reference to the incidence of complications that may occur after AE, such as gluteal muscle necrosis, infections, impotence, bladder necrosis, nerve damage, chronic buttock pain, and colonic, ileal, and ureteral infarction, among others1. Taking all of the above into consideration, one may argue that the message of this study must be interpreted with great caution. The 2 procedures should not be considered as antagonists but rather complementary. It should not be forgotten that PPP can address both venous and arterial bleeding, whereas AE can address only arterial bleeding. As previously highlighted according to the PRISM (“Prompt-Individualised-Safe Management”) algorithm of care2, treatment should be individualized on the basis of the availability of local resources, the ongoing evaluation of the hemodynamic condition of the patient, and the expertise of the local surgical team. A prospective randomized study is needed to provide further evidence regarding the controversial finding of this study.

Surgical Rib Fixation in Obese Patients with Isolated Flail Chest Improves Outcomes: A Matched Cohort Study.

Obesity is associated with adverse outcomes after major operations. The role of operative rib fixation (RF) in obese patients with flail chest is not clear. The presence of other associated injuries may complicate the interpretation of outcomes. This study compared outcomes after RF to nonoperative management (NOM) in obese patients with isolated flail chest injury. Adult obese patients (BMI > 29.9) with flail chest were identified from the Trauma Quality Improvement Program (TQIP) database (2016-2018). Hospital transfers, death within 72h, and extrathoracic injuries were excluded. RF patients were propensity score matched (1:2) to similar NOM patients. Multivariate regression identified independent factors predicting adverse outcomes. Overall, 367 patients with isolated flail chest who underwent RF were matched with 734 in the NOM group. After matching, the mortality rate was significantly lower in the RF group (1.4% vs. 3.7%; p < 0.05). RF had longer HLOS (15.7days vs. 12.8days; p < 0.05) and ICU LOS (10.1days vs. 8.6days; p < 0.05), shorter ventilator days (9.2days vs. 11.5days; p < 0.05), and a higher rate of venous thromboembolism (7.1% vs. 3.5%, p < 0.05). On multivariate analysis, RF was associated with decreased mortality (OR 0.27; p < 0.05). Early RF (≤ 72h) was associated with shorter ICU stay and mechanical ventilation. RF for isolated flail chest in obese patients is associated with decreased mortality and fewer ventilator days. When performed early, fixation decreases the need for prolonged ventilator use and ICU stay. A more aggressive VTE prophylaxis should be considered in patients undergoing RF.

Isolated facial fractures transferred for higher level of care

BackgroundIsolated facial fractures (IFF) have been identified as overtriaged injuries in multiple single-center studies. We sought to describe IFF in a national database. MethodsThe 2019 Trauma Quality Improvement Program database was queried for all patients with facial fractures and Abbreviated Injury Score<1 for other body regions. Descriptive statistics were performed. ResultsOf 1,097,190 trauma patients, 36,077 (3.3%) had IFF. Median age was 39 [26–89], 92% had blunt mechanism, median Glasgow Coma Scale 15 [15-15], and vital signs were normal (ED systolic blood pressure 137 [125–153], ED pulse 86 [73–99]). 0.3% required unplanned intubation. 25.7% underwent operation after a median interval 26.4 [14.4–47.9] hours. IFF patients represented 4.4% of interfacility transfers and were more likely to have been transferred (34.4% vs 25%, p < 0.001). Hospital stay was 3 [2–4] days. ConclusionsIFF are rarely surgical emergencies and frequently nonoperative, yet are disproportionately represented among transfers. IFFs may represent an opportunity for outpatient follow-up or telehealth consultation to decrease resource utilization.

Angioembolization versus preperitoneal packing for severe pelvic fractures: A propensity matched analysis

BackgroundWhether AE or PPP would be associated with survival among hemodynamically unstable pelvic fracture remains controversial. Study designThis is a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program database from 2016 to 2018. Patients >16 years with a severe pelvic fracture (abbreviated injury scale 3–5) who underwent AE or PPP were recruited. The primary outcome was in-hospital survival. Data were evaluated using a propensity-score matching (PSM) analysis. ResultsA total of 1123 patients met our inclusion criteria. Of these, AE and PPP were performed in 964 (85.8%) and 159 (14.2%) patients, respectively. Concomitant hemorrhage control laparotomy was performed in 25.6% and 82.4% of AE and PPP patients, respectively. In 220 PSM patients, the mortality rate between AE and PPP groups was not significantly different (30.9% vs. 38.2%, P = 0.321). ConclusionsThough patients’ characteristics differed between AE and PPP groups, comparable propensity-matched patients with severe pelvic fractures showed no significant difference in in-hospital survival. PPP was more likely to be selected for severe pelvic fractures necessitating laparotomy.

Massive blood transfusion following older adult trauma: The effect of blood ratios on mortality.

Massive blood transfusion (MBT) following older adult trauma poses unique challenges. Despite extensive evidence on optimal resuscitative strategies in the younger adult patients, there is limited research in the older adult population. We used the Trauma Quality Improvement Program (TQIP) database from 2013 to 2017 to identify all patients over 65 years old who received a MBT. We stratified our population into six fresh-frozen plasma:packed red blood cell (FFP:pRBC) ratio cohorts (1:1, 1:2, 1:3, 1:4, 1:5, 1:6+). Our primary outcomes were 24-h and 30-day mortality. We constructed multivariable regression models with 1:1 group as the baseline and adjusted for confounders to estimate the independent effect of blood ratios on mortality. A total of 3134 patients met our inclusion criteria (median age 73 ± 7.6 years, 65% male). On risk-adjusted multivariable analysis, 1:1 FFP:pRBC ratio was independently associated with lowest 24-h mortality (1:2 odds ratio [OR]1.60, 95% confidence interval [CI]1.25-2.06, p < 0.001) and 30-day mortality (1:2 OR 1.44, 95% CI 1.15-1.80, p=0.002). Compared to all other ratios, the 1:1 FFP:pRBC ratio had the lowest 24-h and 30-day mortality following older adult trauma consistent with findings in the younger adult population.

Lucky number 13: Association between center-specific chest wall stabilization volumes and patient outcomes.

Chest wall stabilization (CWS) improves outcomes for patients with chest wall injury (CWI). We hypothesized that patients treated at centers with higher annual CWS volumes experience superior outcomes. A retrospective study of adults with acute CWI undergoing surgical stabilization of rib or sternal fractures within the 2019 Trauma Quality Improvement Program database, excluding those with 24-hour mortality or any Abbreviated Injury Scale body region of six, was conducted. Hospitals were grouped in quartiles by annual CWS volume. Our primary outcome was a composite of in-hospital mortality, ventilator-associated pneumonia, acute respiratory distress syndrome, sepsis, and unplanned intubation or intensive care unit readmission. Regression was controlled for age, sex, Injury Severity Scale, flail chest, medical comorbidities, and Abbreviated Injury Scale chest. We performed cut-point analysis and compared patient outcomes from high- and low-volume centers. We included 3,207 patients undergoing CWS at 430 hospitals with annual volumes ranging from 1 to 66. There were no differences between groups in age, sex, or Injury Severity Scale. Patients in the highest volume quartile (Q4) experienced significantly lower rates of the primary outcome (Q4, 14%; Q3, 18.4%; Q2, 17.4%; Q1, 22.1%) and significantly shorter hospital and intensive care unit lengths of stay. Q4 versus Q1 had lower adjusted odds of the primary outcome (odds ratio, 0.58; 95% confidence interval, 0.43-0.80). An optimal cut point of 12.5 procedures annually was used to define high- and low-volume centers. Patients treated at high-volume centers experienced significantly lower rates of the primary composite outcome, in-hospital mortality, and deep venous thrombosis with shorter lengths of stay and higher rates of home discharge. Center-specific CWS volume is associated with superior in-hospital patient outcomes. These findings support efforts to establish CWI centers of excellence. Further investigation should explore the impact of center-specific volume on patient-reported outcomes including pain and postdischarge quality of life. Prognostic and Epidemiologic; Level III.

Preperitoneal Pelvic Packing for Hypotension Has a Greater Risk of Venous Thromboembolism Than Angioembolization: Management of Refractory Hypotension in Closed Pelvic Ring Injury.

Patients with traumatic pelvic ring injury may present with hypotension secondary to hemorrhage. Preperitoneal pelvic packing (PPP) and angioembolization (AE) are alternative interventions for management of hypotension associated with pelvic ring injury refractory to resuscitation and circumferential compression. We hypothesized that PPP may be independently associated with increased risk of venous thromboembolism (VTE) compared with AE in patients with hypotension and pelvic ring injury. Adult patients with pelvic ring injury and hypotension managed with PPP or AE were retrospectively identified in the Trauma Quality Improvement Program (TQIP) database from 2015 to 2019. Patients were matched on a propensity score for receiving PPP based on patient, injury, and treatment factors. The primary outcome was the risk of VTE after matching on the propensity score for treatment. The secondary outcomes included inpatient clinically important deep vein thrombosis, pulmonary embolism, respiratory failure, mortality, unplanned reoperation, sepsis, surgical site infection, hospital length of stay, and intensive care unit (ICU) length of stay. In this study, 502 patients treated with PPP and 2,439 patients treated with AE met inclusion criteria. After propensity score matching on age, smoking status, Injury Severity Score, Tile B or C pelvic ring injury, bilateral femoral fracture, serious head injury, units of plasma and platelets given within 4 hours of admission, laparotomy, and level-I trauma center facility designation, 183 patients treated with PPP and 183 patients treated with AE remained. PPP, compared with AE, was associated with a 9.8% greater absolute risk of VTE, 6.5% greater risk of clinically important deep vein thrombosis, and 4.9% greater risk of respiratory failure after propensity score matching. PPP for the management of hypotension associated with pelvic ring injury is associated with higher rates of inpatient VTE events and sequelae compared with AE. Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

CIGARETTE SMOKING IS ASSOCIATED WITH DECREASED MORTALITY IN CRITICALLY ILL TRAUMA PATIENTS.

Background: Smoking may offer pathophysiologic adaptations that increase survivability in certain patients with cardiovascular disease. We sought to identify if smoking increases survivability in trauma patients, hypothesizing that critically ill trauma patients who smoke have a decreased risk of mortality compared with non-smokers. Methods: The Trauma Quality Improvement Program (2010-2016) database was queried for trauma patients with intensive care unit admissions. A multivariable logistic regression model was performed. Results: From the 630,278 critically ill trauma patients identified, 116,068 (18.4%) were current cigarette smokers. Critically ill trauma smokers, compared with non-smokers, had a higher rate of pneumonia (7.8% vs. 6.9%, P< 0.001) and lower mortality rate (4.0% vs. 8.0%, P< 0.001). After controlling for covariates, smokers had a decreased associated risk of mortality compared with non-smokers (OR = 0.55, CI = 0.51-0.60, P< 0.001), and no difference in the risk of major complications (OR = 0.98, CI = 0.931.03, P = 0.44). The same analysis was performed using age as a continuous variable with associated decreased risk of mortality (OR 0.57 (CI 0.53-0.62), P< 0.001). Conclusion: Critically ill trauma smokers had a decreased associated mortality risk compared with non-smokers possibly due to biologic adaptations such as increased oxygen delivery developed from smoking. Future basic science and translational studies are needed to pursue potential novel therapeutic benefits without the deleterious long-term side effects of smoking.

Optimal time to thoracoscopy for trauma patients with retained hemothorax

BackgroundRetained hemothorax remains a common problem after thoracic trauma with associated morbidity and prolonged hospitalizations. The goal of this study was to examine the impact of time to video assisted thoracoscopic surgery (VATS) on pulmonary morbidity using a large, national data set. MethodsPatients undergoing VATS for retained hemothorax within the first 14 days postinjury were identified from the Trauma Quality Improvement Program database over 5 years, ending in 2016. Demographics, mechanism, severity of injury, severity of shock, time to VATS, pulmonary morbidity, and mortality were recorded. Multivariable logistic regression analysis was performed to determine independent predictors of pulmonary morbidity. Youden’s index was then used to identify the optimal time to VATS. ResultsFrom the Trauma Quality Improvement Program database, 3,546 patients were identified. Of these, 2,355 (66%) suffered blunt injury. The majority were male (81%) with a median age and Injury Severity Score of 46 and 16, respectively. The median time to VATS was 134 hours. Both pulmonary morbidity (13 vs 17%, P = .004) and hospital length of stay (9 vs 12 days, P < .0001) were significantly reduced in patients undergoing VATS before 3.9 days. Multivariable logistic regression identified VATS during the first 7 days as the only modifiable risk factor significantly associated with reduced pulmonary morbidity (odds ratio 0.52; 95% confidence interval 0.43–0.63, P < .0001). ConclusionPatients undergoing VATS for retained hemothorax have significant morbidity and prolonged length of stay. VATS within the first week of admission results in fewer pulmonary complications and shorter length of stay. In fact, the optimal time to VATS was identified as 3.9 days and was the only modifiable risk factor associated with decreased pulmonary morbidity.

Clinical Benefits of Early Concurrent Use of Cryoprecipitate and Plasma Compared With Plasma Only in Bleeding Trauma Patients.

The effectiveness of cryoprecipitate (Cryo) in trauma has not been well established; the benefits of Cryo might have been overestimated in previous studies since the difference in the total amount of administered clotting factors was not considered. We aimed to evaluate the benefits of the concurrent use of Cryo in combination with fresh frozen plasma (FFP) for bleeding trauma patients. Retrospective cohort study. The American College of Surgeons Trauma Quality Improvement Program database between 2015 and 2019. Patients who received greater than or equal to 5 units of packed RBCs and at least 1 unit of FFP within the first 4 hours after arrival to a hospital were included and dichotomized according to whether Cryo was used within the first 4 hours of hospital arrival. None. The outcomes of patients treated with Cryo and FFP were compared with those treated with FFP only using propensity score-matching analysis. The dose of administered clotting factors in each group was balanced. The primary outcome was inhospital mortality, and the secondary outcome was the occurrence rate of adverse events. A total of 24,002 patients (Cryo+FFP group: 6,018; FFP only group: 17,984) were eligible for analysis, of whom 4,852 propensity score-matched pairs were generated. Significantly lower inhospital mortality (1,959 patients [40.4%] in the Cryo+FFP group vs 2,142 patients [44.1%] in the FFP only group; odds ratio [OR], 0.86; 95% CI, 0.79-0.93) was observed in the Cryo+FFP group; no significant difference was observed in the occurrence rate of adverse events (1,857 [38.3%] vs 1,875 [38.6%]; OR, 1.02; 95% CI, 0.94-1.10). Several sensitivity analyses showed similar results. Cryo use combined with FFP was significantly associated with reduced mortality in bleeding trauma patients. Future randomized controlled trials are warranted to confirm these results.

Fibrinogen supplementation for the trauma patient: Should you choose fibrinogen concentrate over cryoprecipitate?

Trauma-induced coagulopathy is frequently associated with hypofibrinogenemia. Cryoprecipitate (Cryo), and fibrinogen concentrate (FC) are both potential means of fibrinogen supplementation. The aim of this study was to compare the outcomes of traumatic hemorrhagic patients who received fibrinogen supplementation using FC versus Cryo. We performed a 2-year (2016-2017) retrospective cohort analysis of the American College of Surgeons Trauma Quality Improvement Program database. All adult trauma patients (≥18 years) who received FC or Cryo as an adjunct to resuscitation were included. Patients with bleeding disorders, chronic liver disease, and those on preinjury anticoagulants were excluded. Patients were stratified into those who received FC, and those who received Cryo. Propensity score matching (1:2) was performed. Outcome measures were transfusion requirements, major complications, hospital, and intensive care unit lengths of stay, and mortality. A matched cohort of 255 patients who received fibrinogen supplementation (85 in FC, 170 in Cryo) was analyzed. Overall, the mean age was 41 ± 19 years, 74% were male, 74% were white and median Injury Severity Score was 26 (22-30). Compared with the Cryo group, the FC group required less units of packed red blood cells, fresh frozen plasma, and platelets, and had shorter in-hospital and intensive care unit length of stay. There were no significant differences between the two groups in terms of major in-hospital complications and mortality. Fibrinogen supplementation in the form of FC for the traumatic hemorrhagic patient is associated with improved outcomes and reduced transfusion requirements as compared with Cryo. Further studies are required to evaluate the optimal method of fibrinogen supplementation in the resuscitation of trauma patients. Therapeutic/Care Management; Level III.