Urban Trauma Center Research Articles

Role of preoperative CT imaging in penetrating thoraco-abdominal injuries: A multicenter study of urban trauma centers

IntroductionManagement of penetrating thoracoabdominal (PTA) injuries with signs of hemorrhage have warranted operative intervention but improved imaging capabilities have redefined interventions required. We examined outcomes of hemodynamically stable patients undergoing preoperative CT imaging with the hypothesis that CT imaging would decrease OR time without delaying OR arrival. MethodsA retrospective multicenter study was performed amongst four urban trauma centers examining hemodynamically stable patients with PTA injuries requiring operative intervention from January 2017–December 2021. The primary outcome was OR time. Secondary outcomes included length of stay (LOS), ICU LOS, and mortality. A multivariable logistic regression with random intercept for trauma center was fit to assess whether preoperative CT affected time in the OR. ResultsOf 534 hemodynamically stable patients with penetrating injuries, 322 (60.3 ​%) received preoperative CT. The median time in OR were 130 (IQR: 84,180) and 140 (IQR: 100, 180) minutes for patients with and without preoperative CT, respectively. Median time to OR was 68 (IQR: 47, 110) and 26 (IQR 17,38) minutes in patients with and without preop CT, respectively. Median ICU LOS were 0 vs 1 day, the median hospital LOS were 7 vs 8 days for patients with and without pre-op imaging respectively. The multivariable model showed that obtaining a pre-op CT scanning was not independently associated with time spent in OR. (Adjusted OR:0.94; 95 ​% CI: 0.85, 1.04). ConclusionIn patients with PTA injuries and hemodynamic stability, preoperative CT scanning was not associated with decreased OR time, postoperative complications, or mortality.

Stop the Bleed-Wait for the Ambulance or Get in the Car and Drive? A Post Hoc Analysis of an EAST Multicenter Trial.

Background: The Stop the Bleed campaign gives bystanders an active role in prehospital hemorrhage control. Whether extending bystanders' role to private vehicle transport (PVT) for urban penetrating trauma improves survival is unknown, but past research has found benefit to police and PVT. We hypothesized that for penetrating trauma in an urban environment, where prehospital procedures have been proven harmful, PVT improves outcomes compared to any EMS or advanced life support (ALS) transport.Methods: Post-hoc analysis of an EAST multicenter trial was performed on adult patients with penetrating torso/proximal extremity trauma at 25 urban trauma centers from 5/2019-5/2020. Patients were allocated to PVT and any EMS or ALS transport using nearest neighbor propensity score matching. Univariate analyses included Wilcoxon signed rank or McNemar's Test and logistic regression.Results: Of 1999 penetrating trauma patients in urban settings, 397 (19.9%) had PVT, 1433 (71.7%) ALS transport, and 169 (8.5%) basic life support (BLS) transport. Propensity matching yielded 778 patients, distributed equally into balanced groups. PVT patients were primarily male (90.5%), Black (71.2%), and sustained gunshot wounds (68.9%). ALS transport had significantly higher ED mortality (3.9% vs 1.9%, P = 0.03). There was no difference in in-hospital mortality rate, hospital LOS, or complications for all EMS or ALS only transport patients.Conclusion: Compared to PVT, ALS, which provides more prehospital procedures than BLS, provided no survival benefit for penetrating trauma patients in urban settings. Bystander education incorporating PVT for early arrival of penetrating trauma patients in urban settings to definitive care merits further investigation.

Geography of the Underserved: The Contribution of Rural Non-Trauma Hospitals to Trauma Care.

To determine the proportion and characteristics of injured rural residents treated at urban trauma centers (TCs), urban non-trauma centers (NTCs), rural TCs, and rural NTCs. Timely treatment at a designated trauma center improves outcomes for patients with serious injuries, but rural residents have limited access to designated trauma centers. Rural non-trauma centers may constitute an underrecognized source of trauma care. We used the National Emergency Department Sample to conduct a retrospective, pooled cross-sectional study of ED visits among rural residents with injury severity score (ISS) ≥ 9 (indicating at least moderate injury). Hospitals were designated as a trauma (TC) or non-trauma center (NTC) and as rural or urban. We compared management, disposition, and outcomes among hospital types. Of 748,587 injured rural residents from 2016-2020, 384,113 (51.3%) were treated in rural NTCs, 232,845 (31.1%) in urban TCs, 116,493 (15.6%) in urban NTCs, and 15,137 (2.0%) in rural TCs. Injuries treated at rural NTCs were moderate in severity (ISS 9-15) in 76.6% of visits, severe (ISS 16-25) in 15.7%, and very severe (ISS > 25) in 1.1%. Urban TCs saw the highest proportion of very severe injuries (17.3%). Rural NTCs managed 77.5% of visits definitively, discharging 72.8%. They transferred 21.9% of patients. Length of stay was longest and hospital charges highest for patients treated in urban TCs, which also performed the most procedures. Rural NTCs had the shortest length of stay and lowest mean charges. Rural non-trauma centers provided initial care for more than half of injured rural residents, including 2 in 5 of those with the most severe injuries, and managed more than 3 in 4 definitively. These hospitals may be an under-recognized component of the US trauma system.

Schatzker IV tibial plateau fractures: are they always unicondylar?

The objectives of this study were to describe the incidence and morphology of medial tibial plateau fractures that extend into the lateral articular surface and to describe trends in their management. Retrospective. Level I Urban Trauma Center. Seventy consecutive patients sustaining OTA/AO 41 B1 and B3 fractures. Open reduction internal fixation of medial tibial plateau fractures. Incidence of medial tibial plateau fractures that extend into the lateral articular surface. Secondary outcomes include localization of lateral articular surface depression, neurovascular injury, and trends in surgical management. Seventy patients were included with 9 fractures (12.9%) isolated to the medial condyle (MC) and 61 fractures (87.1%) extending to the lateral condyle (LC). Compartment syndrome was present in 2 patients (2.9%), peroneal nerve palsy in 2 (2.9%), and arterial injury in 1 (1.4%). Initial external fixation was used more frequently in the LC group compared with the MC group (P = 0.028). Of the 61 fractures in the LC group, 49 (80.3%) included lateral articular surface depression which localized to the posteromedial quadrant of the lateral articular surface in 36 of 49 fractures (73.5%). Lateral articular surface depression depth ≥10.6 mm was associated with the use of dual incisions (P < 0.001). Schatzker IV fractures frequently extend to the lateral condyle and often present with depression of the posteromedial lateral articular surface. Fractures with lateral articular surface depression depth ≥10.6 mm were more likely to undergo fixation with dual incisions. Therapeutic level IV.

Whole Blood Program: Implementation in a Rural Trauma Center

BACKGROUND: The balanced transfusion of blood components plays a leading role in traumatic hemostatic resuscitation. Yet, previous whole blood studies have only focused on urban trauma center settings. OBJECTIVE: To compare component vs whole blood therapy on wastage rates and mortality in the rural setting. METHODS: This study was a nonrandomized, retrospective, observational, single-center study on a cold-stored whole blood program implementation for adult massive transfusions from 2020 to 2022 at a Level II trauma center. Trauma registry data determined the facility’s whole blood needs and facilitated sustainable blood supplies. Whole blood use protocols were established, and utilization and laboratory compliance for incompatible ABO antibody hemolysis was monitored and reviewed monthly at stakeholder and trauma services meetings. RESULTS: From 2018 to 2019, the facility initiated component therapy massive transfusions every 9 days (n = 41). Therefore, four units of low-titer, O-positive whole blood delivered fortnightly was determined to provide patient coverage and minimize wastage. Across the study time frame (2020–2022), there were n = 68 hemodynamically unstable patients, consisting of those receiving whole blood, n = 37, and patients receiving component therapy, n = 31. Mortality rates were significantly lower (p = .030) in the whole blood population (n = 3, 8%) compared to those solely receiving component therapy (n = 9, 29%). Wastage rates were constantly evaluated; in 2021, 43.4% was not utilized, and in 2022, this was reduced to 38.7%. Anecdotally, nurses appreciated the ease of administration and documentation of transfusing whole blood, as it negated ratio compliance. CONCLUSION: This evidence-based whole blood program provides vital care to severely injured trauma patients in a vast, rural region.

Impact of Live Tissue Training on Provider Confidence for Operative Trauma Management.

Readiness of military health care providers is essential to maintain a prepared fighting force and remains a central issue for today's military. Maintaining skills regarding operative management of trauma is becoming more difficult if not located at an urban trauma center. Live tissue training may be used to practice skills in a facility that does not have exposure to high acuity trauma. The goal of our live tissue skills course is to train health care providers and ancillary staff in the management of various injury complexes and improve confidence and familiarity with management using a porcine model. A live tissue skills course using a porcine model was offered to surgical residents, attendings, and operating room technicians. Before completing the course, each participant completed a survey assessing comfort level, previous training experiences, and deployments. Operative management was simulated with a standardized sequence of abdominal and thoracic injuries. After the course, each participant then completed a survey assessing comfort level, benefit of the course, and comparison to inanimate simulation training. Survey information was obtained via participant completion of a multiple-choice confidential questionnaire. Responses were collected from 34 participants at our institution. Average abdominal trauma comfort increased from 2.79 to 3.73, with no participants reporting feeling not comfortable at all post-lab. Average thoracic trauma comfort increased from 2.47 to 3.48, with one participant reporting feeling not comfortable at all post-lab. Overall, 85% of participants reported the course to be very beneficial in improving their knowledge, 83% reported the course to be very beneficial compared to inanimate simulators, and 92% reported high fidelity of the live tissue training course. Perceived as highly beneficial, live tissue training increased comfort with operative trauma management by surgical residents, attendings, and technicians supporting continued utilization. Further evaluation of live tissue courses would be advantageous in assessing surgical skill improvement, including comparison with simulation training.

Markers of Futile Resuscitation in Traumatic Hemorrhage: A Review of the Evidence and a Proposal for Futility Time-Outs during Massive Transfusion.

The reduction in the blood supply following the 2019 coronavirus pandemic has been exacerbated by the increased use of balanced resuscitation with blood components including whole blood in urban trauma centers. This reduction of the blood supply has diminished the ability of blood banks to maintain a constant supply to meet the demands associated with periodic surges of urban trauma resuscitation. This scarcity has highlighted the need for increased vigilance through blood product stewardship, particularly among severely bleeding trauma patients (SBTPs). This stewardship can be enhanced by the identification of reliable clinical and laboratory parameters which accurately indicate when massive transfusion is futile. Consequently, there has been a recent attempt to develop scoring systems in the prehospital and emergency department settings which include clinical, laboratory, and physiologic parameters and blood products per hour transfused as predictors of futile resuscitation. Defining futility in SBTPs, however, remains unclear, and there is only nascent literature which defines those criteria which reliably predict futility in SBTPs. The purpose of this review is to provide a focused examination of the literature in order to define reliable parameters of futility in SBTPs. The knowledge of these reliable parameters of futility may help define a foundation for drawing conclusions which will provide a clear roadmap for traumatologists when confronted with SBTPs who are candidates for the declaration of futility. Therefore, we systematically reviewed the literature regarding the definition of futile resuscitation for patients with trauma-induced hemorrhagic shock, and we propose a concise roadmap for clinicians to help them use well-defined clinical, laboratory, and viscoelastic parameters which can define futility.

Tranexamic Acid and Pulmonary Complications: A Secondary Analysis of an EAST Multicenter Trial.

Anti-inflammatory effects of tranexamic acid (TXA) in reducing trauma endotheliopathy may protect from acute lung injury. Clinical data showing this benefit in trauma patients is lacking. We hypothesized that TXA administration mitigates pulmonary complications in penetrating trauma patients. This is a post-hoc analysis of a multicenter, prospective, observational study of adults (18+ years) with penetrating torso and/or proximal extremity injury presenting at 25 urban trauma centers. Tranexamic acid administration in the prehospital setting or within three hours of admission was examined. Participants were propensity matched to compare similarly injured patients. The primary outcome was development of pulmonary complication (ARDS and/or pneumonia). A total of 2382 patients were included, and 206 (8.6%) received TXA. Of the 206, 93 (45%) received TXA prehospital and 113 (55%) received it within three hours of hospital admission. Age, sex, and incidence of massive transfusion did not differ. The TXA group was more severely injured, more frequently presented in shock (SBP < 90 mmHg), developed more pulmonary complications, and had lower survival (P < 0.01 for all). After propensity matching, 410 patients remained (205 in each cohort) with no difference in age, sex, or rate of shock. On logistic regression, increased emergency department heart rate was associated with pulmonary complications. Tranexamic acid was not associated with different rate of pulmonary complications or survival on logistic regression. Survival was not different between the groups on logistic regression or propensity score-matched analysis. Tranexamic acid administration is not protective against pulmonary complications in penetrating trauma patients.

Pancreaticoduodenectomy in high-grade pancreatic and duodenal trauma

IntroductionHigh-grade pancreaticoduodenal injuries are highly morbid and may require complex surgical management. Pancreaticoduodenectomy (Whipple procedure) is sometimes utilized in the management of these injuries, but guidelines on its use are lacking. This paper aims to present our 14-year experience in management of high-grade pancreaticoduodenal injuries at our busy, urban trauma center. MethodsA retrospective review was performed on patients (ages >15 years) presenting with high-grade (AAST-OIS Grades IV and V) injuries to the pancreas or duodenum at our Southeastern Level 1 trauma center. Inclusion criteria included high-grade injury and requirement of Whipple procedure based on surgeon discretion. Patients were divided into two groups: (1) those who underwent Whipple procedures during the index operation and (2) Whipple candidates. Whipple candidates included patients who received Whipples in a staged fashion or who would have benefited from the procedure but either died or were salvaged to another procedure. Demographics, injury patterns, management, and outcomes were compared. Primary outcome was survival to discharge. ResultsOf 66,272 trauma patients in this study period, 666 had pancreatic or duodenal injuries, and 20 met inclusion criteria. Of these, 6 had Whipples on the index procedure and 14 were Whipple candidates (among whom 7 had staged Whipples, 6 died before completing a Whipple, and 1 was salvaged). Median (IQR) age was 28 (22.75–40) years. Patients were 85 % male, 70 % Black. GSWs comprised 95 % of injuries. All patients had at least one concomitant injury, most commonly major vascular injury (75 %), colonic injury (65 %), and hepatic injury (60 %). In-hospital mortality among Whipple patients was 15 %. ConclusionsComplex pancreaticoduodenal injuries requiring pancreaticoduodenectomy are rare but life-threatening. In such patients, hemorrhage was the leading cause of death in the first 24 h. Approximately half underwent damage control surgery with staged Whipple Procedures. However, pancreaticoduodenectomy at the initial operation is feasible in highly selective patients, depending on the extent of injury, physiologic status, and resuscitation.

The Management and Outcomes in Blunt Splenic Injury: A Comparison Between a Rural and Urban Trauma Center

Introduction: The management of blunt splenic trauma (BST) has evolved over the last 20 years, with nonoperative management in hemodynamically stable patients prevailing as the standard of care. Nonoperative management includes angioembolization of the splenic artery. Although non-operative management has increased in use, there is limited standardization of practices for the management of blunt splenic trauma. The objective was to compare outcomes for BST and the use of angioembolization between a Level 1 urban trauma center, Ascension St. John Hospital, Detroit MI (ASJH) and a Level 2 rural trauma center, Munson Medical Center, Traverse City MI (MMC). Methods: Our study used registry data comprising all patients from 1/2015-12/2021 who presented to ASJH and MMC with BST. Patients were divided into operative intervention versus non-operative management groups. Data collected included timing of intervention, length of stay, severity scores, blood product requirements and concomitant injuries. The management and outcomes between the two institutions were compared. Data were analyzed using Student’s t-test, the χ2 test, the Mann-Whitney U test and logistic regression. Results: Data were collected on 93 patients from ASJH and 189 patients from MMC. Splenic injury grade was scored from one to five, with 60.0% of patients scoring grade three or higher and 62.1% of patients having active blush identified on imaging. Eighty-four patients (28.4%) had operative intervention and 24 patients (8.5%) underwent angioembolization. ASJH had an angioembolization rate of 15.1% vs 5.3% at MMC (p=0.006). When comparing the two hospitals, patient groups were different in terms of race (p=0.001), fresh frozen plasma administered (p=0.046) and presenting systolic blood pressure (p=0.001). In patients with active blush, after adjusting for hemoglobin on arrival, ASJH patients were 3.8 times more likely to have angioembolization than patients at Munson (p=0.02). TRISS and race dropped out of the model. Conclusions: There is a significant difference in the rate of non-operative management between the hospitals. Higher rates of angioembolization at an urban center may reflect a difference in resource distribution between urban and rural centers.

Prevalence and clinical significance of incidental findings in chest and abdominopelvic CT scans of trauma patients; A cross-sectional study

BackgroundImaging may inadvertently reveal pathologies unrelated to their performing purpose, known as incidental findings (IF). This study aimed to assess the prevalence, clinical significance, and documentation of IFs in chest and abdominopelvic computed tomography (CT) scans of trauma patients. MethodsThis observational study was conducted at two urban level-1 trauma centers from March 2019 through April 2022. Official radiology reports of trauma patients who underwent chest and/or abdominopelvic CT scans at the emergency department (ED) were explored, and IF were extracted. Predictive factors of the presence of IFs and their documenting were investigated. ResultsOut of 656 chest and 658 abdominopelvic CT scans, 167 (25.37%) and 212 (32.31%) scans harbored at least one IF, respectively. Patients with IFs tended to be of higher age and female in both chest (age: 48 [IQR: 35–62] vs. 34 [IQR: 25–42.5]; female: 31.14% vs 14.66%, p < 0.001 for both) and abdominopelvic CT scans (age: 41 [IQR: 30–57.5] vs 33 [IQR: 25–43], female: 26.42% vs. 13.96%, p < 0.001 for both). As for documentation of significant IFs, only 49 of 112 chest IFs (43.8%) and 55 of 176 abdominopelvic IFs (31.3%) were documented. Investigating factors associated with documentation of clinically significant IFs, shorter length of hospital stay (1.5 (IQR: 0–4) vs. 3 (IQR: 2–8), p = 0.003), and discharging by ED physicians (documentation rate: 13.2% vs 42.6%, p < 0.001) were associated with poorer documentation of IFs only in abdominopelvic scans. ConclusionCT imaging in ED trauma patients often reveals incidental findings, especially in older patients. Over 50% of these findings are clinically significant, yet they are frequently ignored and not documented. Physicians need to be more vigilant in recognizing and documenting these incidental findings and informing patients of the need for further evaluation.

Four-screw compression plate fixation for diaphyseal humerus fractures.

While many humeral shaft fractures can be successfully treated with nonoperative management, compression plating techniques using at least three or four screws on either side of the fracture are the current gold standard. We hypothesized that a less rigid construct using compression with only two screws on either side of the fracture can provide adequate strength for uneventful fracture union. This is a retrospective review of all the patients who underwent open reduction and compression plate fixation for acute diaphyseal humerus fractures (ADHFs) at an academic Level-1 urban trauma center between 2018 and 2023. Patients treated with compression plating using only two screws and three or four plate-holes on either side of the fracture (Group 1) were matched one-to-one with patients treated using the conventional number of screws (three or more on either side of the fracture - Group 2). The incidence of nonunion/malunion, infection, and implant failure was compared among the two groups. There were eleven matched patients in both groups. The nonunion, infection complications, and hardware failure rates were 0% and 9.1% for the control group (Group 2) and four-screw group (Group 1) respectively. This difference was not statistically significant (p = 1.00). Although convention dictates the use of six or more bicortical screws (at least three bicortical screws on each side of the fracture), four-screw bicortical fixation may be a feasible option for ADHFs treated with large fragment compression plating techniques.

Re-evaluating the Use of High Sensitivity Troponin to Diagnose Blunt Cardiac Injury

IntroductionBlunt cardiac injury (BCI) can be challenging diagnostically, and if misdiagnosed, can lead to life-threatening complications. Our institution previously evaluated BCI screening with troponin and electrocardiogram (EKG) during a transition from troponin I to high sensitivity troponin (hsTnI), a more sensitive troponin I assay. The previous study found an hsTnI of 76 ng/L had the highest capability of accurately diagnosing a clinically significant BCI. The aim of this study was to determine the efficacy of the newly implemented protocol. MethodsPatients diagnosed with a sternal fracture from March 2022 to April 2023 at our urban level-1 trauma center were retrospectively reviewed for EKG findings, hsTnI trend, echocardiogram changes, and clinical outcomes. The BCI cohort and non-BCI cohort ordinal measures were compared using Wilcoxon's two-tailed rank sum test and categorical measures were compared with Fisher's exact test. Youden indices were used to evaluate hsTnI sensitivity and specificity. ResultsSternal fractures were identified in 206 patients, of which 183 underwent BCI screening. Of those screened, 103 underwent echocardiogram, 28 were diagnosed with clinically significant BCIs, and 15 received intervention. The peak hsTnI threshold of 76 ng/L was found to have a Youden index of 0.31. Rather, the Youden index was highest at 0.50 at 40 ng/L (sensitivity 0.79 and specificity 0.71) for clinically significant BCI. ConclusionsScreening patients with sternal fractures for BCI using hsTnI and EKG remains effective. To optimize the hsTnI threshold, this study determined the hsTnI threshold should be lowered to 40 ng/L. Further improvements to the institutional protocol may be derived from multicenter analysis.

Patient Factors Associated With Prolonged Length of Stay After Traumatic Brain Injury.

Background For traumatic brain injury (TBI) survivors, recovery can lead to significant time spent in the inpatient/rehabilitation settings. Hospital length of stay (LOS) after TBI is a crucial metric of resource utilization and treatment costs. Risk factors for prolonged LOS (PLOS) after TBI require further characterization. Methodology We conducted a retrospective analysis of patients with diagnosed TBI at an urban trauma center. PLOS was defined as the 95th percentile of the LOS of the cohort. Patients with and without PLOS were compared using clinical/injury factors. Analyses included descriptive statistics, non-parametric analyses, and multivariable logistic regression for PLOS status. Results The threshold for PLOS was >24 days. In the cohort of 1,343 patients, 77 had PLOS. PLOS was significantly associated with longer mean intensive care unit (ICU) stays (16.4 vs. 1.5 days), higher mean injury severity scores (18.6 vs. 13.8), lower mean Glasgow coma scale scores (11.3 vs. 13.7) and greater mean complication burden (0.7 vs. 0.1). PLOS patients were more likely to have moderate/severe TBI, Medicaid insurance, and were less likely to be discharged home.In the regression model, PLOS was associated with ICU stay, inpatient disposition, ventilator use, unplanned intubation, and inpatient alcohol withdrawal. Conclusions TBI patients with PLOS were more likely to have severe injuries, in-hospital complications, and Medicaid insurance. PLOS was predicted by ICU stay, intubation, alcohol withdrawal, and disposition to inpatient/post-acute care facilities. Efforts to reduce in-hospital complications and expedite discharge may reduce LOS and accompanying costs.Further validation of these results is needed from larger multicenter studies.

Stress and Coping in Emergency Nurses Following Trauma Patient Care: A Qualitative Grounded Theory Approach.

Experiencing symptoms of traumatic stress may be the cost of caring for trauma patients. Emergency nurses caring for trauma patients are at risk for traumatic stress reactions. This study explored the stress and coping behaviors experienced by emergency nurses who provide trauma care. Focus groups were held at three urban trauma centers in the Midwestern United States: a Level I pediatric trauma center, a Level I adult trauma center, and a Level III adult trauma center. Data were collected between December 2009 and March 2010. Data analysis was guided by the principles of grounded theory. Line-by-line coding and constant comparative analysis techniques were used to identify recurring constructs. A total of 48 emergency nurses participated. Recurring constructs emerged in the data analysis and coding, revealing four major themes: care of the trauma patient, professional practice, personal life, and support. Nurse job engagement, burnout, and professional and personal relationships are influenced by trauma patient care. The study's resulting themes of care of the trauma patient, professional practice, personal life, and support resulted in the development of the "trauma nursing is a continual experience theory" that can be used as a framework to address these effects. Intentional support and timely interventions based on this new theory can help mitigate the effects of traumatic stress experienced by trauma nurses.

Examining adverse childhood experiences and Black youth's engagement in a hospital-based violence intervention program using administrative data.

Stemming from poverty and systemic racism, Black youth are disproportionately represented in hospital-based violence intervention programs (HVIPs) due to greater violence exposure. HVIPs are a critical intervention that have been shown to reduce rates of reinjury in urban hospitals and trauma centers across the United States; however, they are plagued by low enrollment and engagement rates. Few studies have examined factors related to engagement, particularly among Black youth. Guided by Trauma Theory and Critical Race Theory, this study uses a retrospective cohort design. Between-group differences of adverse childhood experiences (ACEs) among engaged youth compared to nonengaged youth who were violently injured and recruited for a HVIP were examined using chi-square and logistic regression. ACEs were approximated using a novel approach with administrative data. Results indicated that the total ACE score was not significantly associated with engagement status. Individual ACEs were tested across age groups. This study highlights a novel approach to understanding ACEs among a hard-to-reach population and illuminates the significant level of ACEs faced by violence-exposed Black youth at young ages. Considering theory, Black families may be more reluctant to engage due to fear and past harms in social service systems stemming from systemic racism. Though ACEs did not predict engagement in this study, considering the high rates of ACEs experienced by Black youth and their families in the context of systemic racism suggests that HVIPs should acknowledge historical harms and foster trauma-informed and healing-centered interactions during recruitment and later stages of engagement.

Impact of COVID-19 pandemic on interhospital transfer of patients with major trauma in Korea: a retrospective cohort study

BackgroundInterhospital transfer (IHT) is necessary for providing ultimate care in the current emergency care system, particularly for patients with severe trauma. However, studies on IHT during the pandemic were limited. Furthermore, evidence on the effects of the coronavirus disease 2019 (COVID-19) pandemic on IHT among patients with major trauma was lacking.MethodThis retrospective cohort study was conducted in an urban trauma center (TC) of a tertiary academic affiliated hospital in Daegu, Korea. The COVID-19 period was defined as from February 1, 2020 to January 31, 2021, whereas the pre-COVID-19 period was defined as the same duration of preceding span. Clinical data collected in each period were compared. We hypothesized that the COVID-19 pandemic negatively impacted IHT.ResultsA total of 2,100 individual patients were included for analysis. During the pandemic, the total number of IHTs decreased from 1,317 to 783 (− 40.5%). Patients were younger (median age, 63 [45–77] vs. 61[44–74] years, p = 0.038), and occupational injury was significantly higher during the pandemic (11.6% vs. 15.7%, p = 0.025). The trauma team activation (TTA) ratio was higher during the pandemic both on major trauma (57.3% vs. 69.6%, p = 0.006) and the total patient cohort (22.2% vs. 30.5%, p < 0.001). In the COVID-19 period, duration from incidence to the TC was longer (218 [158–480] vs. 263[180–674] minutes, p = 0.021), and secondary transfer was lower (2.5% vs. 0.0%, p = 0.025).ConclusionWe observed that the total number of IHTs to the TC was reduced during the COVID-19 pandemic. Overall, TTA was more frequent, particularly among patients with major trauma. Patients with severe injury experienced longer duration from incident to the TC and lesser secondary transfer from the TC during the COVID-19 pandemic.

Implementing Resuscitative Endovascular Balloon Occlusion of the Aorta in a Rural Level II Trauma Center.

This study's purpose is to develop a low-cost implementation of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in a rural level-2 trauma center. Literature and training to this point have involved urban level-1 trauma centers. This study examines the effectiveness of an in-house training program on trauma patient outcomes by comparing data from a matched historical control group of pre-REBOA patients (n = 32) to the REBOA intervention group (n = 17). The REBOA group had a similar ED to OR LOS (1.45 vs 1.79 hrs, P = .346) and similar ED LOS (1.36 vs 2.21 hrs, P = .01) as the historical control group. Although the REBOA group had a higher transfusion volume (6235.06 vs 2268.75milliliters, P = .005), survival bias could be a factor. Resuscitative Endovascular Balloon Occlusion of the Aorta is considered a safe and affordable option for level-2 trauma centers without increasing complications or delaying time to the operating room.

The Epidemiology, Management, and Outcomes of Civilian Gunshot Wounds to the Upper Extremity at an Urban Trauma Center.

Gunshot wounds (GSWs) create significant morbidity in the United States. Upper extremity (UE) GSWs are at high risk of combined injuries involving multiple organ systems and may require variable treatment strategies. This study details the epidemiology, management, and outcomes of civilian UE GSWs at an urban level 1 trauma center. Using the University of Pennsylvania Trauma Registry, all adult patients with UE GSWs from 2015 to 2020 who were at least 6-months postinjury were studied for demographics, injury pattern, operative details, and postoperative outcomes. Fisher exact and Wilcoxon rank sum tests were used to determine differences in treatment modalities and outcomes. In 360 patients, the most common victim was young (x̄ = 29.5 y old), African American (89.4%), male (94.2%), and had multiple GSWs (70.3%). Soft tissue-only trauma (47.8%) and fractures (44.7%) predominated. Presence of fracture was independently predictive of neurologic, vascular, and tendinous injuries (P < 0.001). Most soft tissue-only injuries were managed nonoperatively (162/173), whereas fractures frequently required operative intervention (115 of 161, P < 0.001). Despite a prevalence of comminuted (84.6%) and open (43.6%) fractures, hardware complications (7.5%) and wound infection (1.1%) occurred infrequently. Civilian GSWs to the UE with only soft tissue involvement can often be managed conservatively with antibiotic administration, bedside washout, and local wound care. Even with combined injuries and open fractures, single-stage operative debridement and fracture care with primary or secondary closure often prevail. As civilian ballistic trauma becomes more frequent in the United States, these data help inform patient expectations and guide management.

Changes in interpersonal violence and utilization of trauma recovery services at an urban trauma center in the United States during the COVID-19 pandemic: a retrospective, comparative study.

This study investigated changes in interpersonal violence and utilization of trauma recovery services during the COVID-19 pandemic. At an urban level I trauma center, trauma recovery services (TRS) provide education, counseling, peer support, and coordination of rehabilitation and recovery to address social and mental health needs. The COVID-19 pandemic prompted considerable changes in hospital services and increases in interpersonal victimization. A retrospective analysis was conducted between September 6, 2018 and December 20, 2020 for 1,908 victim-of-crime patients, including 574 victims of interpersonal violence. Outcomes included length of stay associated with initial TRS presentation, number of subsequent emergency department visits, number of outpatient appointments, and utilization of specific specialties within the year following the initial traumatic event. Patients were primarily female (59.4%), single (80.1%), non-Hispanic (86.7%), and Black (59.2%). The mean age was 33.0 years, and 247 patients (49.2%) presented due to physical assault, 132 (26.3%) due to gunshot wounds, and 76 (15.1%) due to sexual assault. The perpetrators were primarily partners (27.9%) or strangers (23.3%). During the study period, 266 patients (mean, 14.9 patients per month) presented before the declaration of COVID-19 as a national emergency on March 13, 2020, while 236 patients (mean, 25.9 patients per month) presented afterward, representing a 74.6% increase in victim-of-crime patients treated. Interactions with TRS decreased during the COVID-19 period, with an average of 3.0 interactions per patient before COVID-19 versus 1.9 after emergency declaration (P<0.01). Similarly, reductions in length of stay were noted; the pre-COVID-19 average was 3.6 days, compared to 2.1 days post-COVID-19 (P=0.01). While interpersonal violence increased, TRS interactions decreased during the COVID-19 pandemic, reflecting interruption of services, COVID-19 precautions, and postponement/cancellation of elective visits. Future direction of hospital policy to enable resource and service delivery to this population, despite internal and external challenges, appears warranted.