Urban Trauma Center Research Articles

Combined Anterior-Posterior Versus Posterior-Only Fixation of Stress-Positive Minimally Displaced Lateral Compression Type 1 (LC1) Pelvic Ring Injuries.

To compare hospital outcomes and late displacement between stress-positive minimally displaced lateral compression type 1 (LC1) pelvic ring injuries treated with combined anterior-posterior versus posterior-only fixation. Retrospective comparative cohort. Urban level one trauma centerPatients/Participants: LC1 injuries managed operatively. Anterior-posterior vs. posterior-only fixation. Physical therapy (PT) clearance, discharge location, hospital length of stay (LOS), inpatient morphine equivalent doses (MED), fracture displacement at follow-up. Groups were similar in demographic and injury characteristics (age, high energy mechanism, ASA score, stress displacement, and rami/sacral fracture classifications). Anterior-posterior fixation resulted in longer operative times (median difference (MD): 27.0 min., 95% confidence interval (CI): 17.0 to 40.0, p<0.0001) and had a trend of increased estimated blood loss (MD: 10 mL, CI: 0 to 30, p=0.07). Patients with anterior-posterior fixation required less inpatient MEDs (MD: -180.0, CI: -341.2 to -15.0, p=0.02), were more likely to clear PT by discharge (100% vs. 70%, proportional difference (PD): 30%, CI: 2.0% to 57.2%, p=0.02), were less likely to discharge to rehabilitation facilities (0% vs. 30%, PD: 30%, CI: 2.0% to 57.2%, p=0.02), and had a trend of less days to clear PT after surgery (MD: -1, CI: -2 to 0, p=0.09) and decreased LOS (MD: -1, CI: -4 to 1, p=0.17). Late fracture displacement did not differ between groups. Anterior-posterior fixation of LC1 injuries was associated with an improved early hospital course-specifically, reduced inpatient opioid use and an increased number of patients who could clear PT and discharge home. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes following ipsilateral great saphenous vein bypass for lower extremity arterial injuries

ObjectiveUse of autologous great saphenous vein (GSV) grafts for repair of extremity arterial injuries is well established. Contralateral great saphenous vein (cGSV) is traditionally used in the setting of lower extremity vascular injury given the risk of occult ipsilateral superficial and deep venous injury. We evaluated outcomes of ipsilateral GSV (iGSV) bypass in patients with lower extremity vascular trauma. MethodsPatient records at an ACS verified Level I urban trauma center between 2001 and 2019 were retrospectively reviewed. Patients who sustained lower extremity arterial injuries managed with autologous GSV bypass were included. Propensity-matched analysis compared the iGSV and cGSV groups. Primary graft patency was assessed via Kaplan-Meier analysis at 1-year and 3-years following the index operation. ResultsA total of 76 patients underwent autologous GSV bypass for lower extremity vascular injuries. 61 cases (80%) were secondary to penetrating trauma, and 15 patients (20%) underwent repair with iGSV bypass. Arteries injured in the iGSV group included popliteal (33.3%), common femoral (6.7%), superficial femoral (33.3%), and tibial (26.7%), while those in the cGSV group included common femoral (3.3%), superficial femoral (54.1%), and popliteal (42.6%). Reasons for using iGSV included trauma to the contralateral leg (26.7%), relative accessibility (33.3%), and other/unknown (40%). On unadjusted analysis, iGSV patients had a higher rate of 1-year amputation than cGSV patients (20% vs. 4.9%), but this was not statistically significant (P = 0.09). Propensity matched analysis also found no significant difference in 1-year major amputation (8.3% vs. 4.8%, P = 0.99). Regarding ambulatory status, iGSV patients had similar rates of independent ambulation (33.3% vs. 38.1%), need for assistive devices (58.3% vs. 57.1%), and use of a wheelchair (8.3% vs. 4.8%) compared cGSV patients at subsequent follow-up (P = 0.90). Kaplan-Meier analysis of bypass grafts revealed comparable primary patency rates for iGSV versus cGSV bypasses at 1-year (84% vs. 91%) and 3-years post-intervention (83% vs. 90%, P = 0.364). ConclusionIpsilateral GSV may be used as a durable conduit for bypass in cases of lower extremity arterial trauma where use of contralateral GSV is not feasible, with comparable long-term primary graft patency rates and ambulatory status.

Upper Extremity Musculoskeletal Injuries Presenting to an Emergency Department Before and During the Initial COVID-19 Pandemic Surge.

The SARS-CoV-2 (COVID-19) pandemic significantly impacted emergency department volume and acuity. The Delta and Omicron variants contributed to additional surges. We describe the impact that the initial pandemic phase had on frequency and severity of typically non-life-threatening emergencies using upper extremity injuries as a model for other potentially emergent presentation as compared to pre-pandemic times. We do this using the epidemiology of pre-defined significant upper extremity injuries at our facility as a specific example of what occurred at an urban trauma center. We conducted a comparison of two 6-month periods: between March 2019 and August 2019 (prior to COVID-19) and between March 2020 and August 2020 after the onset of the initial COVID-19 wave. We performed a retrospective chart review of patients who presented with upper extremity injury chief complaints using analysis of the electronic medical record at a single urban tertiary care trauma center in the Midwestern United States. We investigated examination findings, imaging, frequency of surgical procedures and final diagnosis. In the 2019 study period, there were 31,157 ED patients, including 429 with upper extremity injuries, of which 108 patients had significant injuries. In the 2020 study period, there were 24,295 patient presentations, of which 118 of 296 upper extremity presentations were significant. We a priori defined significant injury as follows: fractures, dislocations, neurovascular injuries, or need for operative intervention within 24 hours of ED presentation. Specifically, 25.2% of injuries were significant pre-COVID-19 and 39.9% (p < 0.001) during the initial COVID-19 surge. The absolute number and percentage of significant injuries increased from pre-COVID-19 compared to the initial COVID-19 surge despite an overall 22% decrease in total patient volume. The incidence of significant upper extremity musculoskeletal injuries increased during the pandemic even though the overall number of ED presentations for upper extremity musculoskeletal injuries decreased.

Trauma team on call: Why are we all so stressed?

BackgroundAcute stress is a known contributor to surgical outcomes. While trauma care is widely acknowledged to be stressful, understanding of specific sources of practitioner stress across learner levels is currently limited. Implementing tailored stress mitigation techniques is not possible without an increased understanding of the specific stress triggers. The objective of this study was to explore sources of acute stress for trauma care providers across various learner levels. MethodsSemi-structured interviews were undertaken following major trauma activations at a Level 1 urban trauma center. Interviews were conducted with medical students, surgical residents, and surgical attendings, exploring their perception of acute stress during the preceding event. Interviews were transcribed, coded and analyzed for emerging themes. Results38 trauma team shifts were observed including major trauma activations. 58 interviews were conducted with 4 medical students, 7 junior residents, 4 senior residents, and 7 trauma surgery attendings. Three predominant themes related to sources of acute stress where identified: “performance”, “stress contagion” and “fear of the unknown”. While all three themes were identified across all learner levels, emphasis and context for a given theme varied based on an individual's position within the team hierarchy. ConclusionsThree recurring sources of stress identified amongst all learner levels within the trauma team: “performance”, “stress contagion” and “fear of the unknown”. These themes offer concrete targets for future development of stress mitigation efforts.

Post-traumatic Liver Pseudoaneurysms: Rare but Serious Sequela

IntroductionThe liver is the most commonly injured organ after blunt abdominal trauma. Nonoperative management is the standard of care in stable individuals. Liver injuries, particularly high-grade injuries, can develop pseudoaneurysms (PSAs), which can rupture and cause life-threatening bleeding, even after hospital discharge. There is no consensus on whether patients should receive predischarge contrast computed tomography (CT) screening, or at what time interval after injury, nor which patients are at the highest risk for PSA. The purpose of this study was to identify the rates of PSA in our population and potential risk factors for their formation. MethodsThe trauma registry at our Level 1 urban trauma center was queried for patients admitted with liver injuries between 2015 and 2021. Demographic information was collected from the registry. Individual charts were then reviewed for timing of CT scans, CT findings, interventions, and complications. Liver injury grade was assessed using radiology reports or operative findings. The frequency of PSAs was then analyzed using descriptive statistics using Microsoft Excel and SPSS for odds ratio. ResultsA total of 172 patients were admitted with liver injuries during the study period. 130 patients received a CT scan diagnosing liver injury, 42 were diagnosed with liver injury intraoperatively. Of the 130 patients (59.9%) which received follow-up CT scans, six (6.5%) developed PSA, four of which being from penetrating injuries (odds ratio, 6.95). ConclusionsThis study demonstrated a low incidence of PSA consistent with the known literature. We found the majority of the PSA developed following penetrating injury. This may represent a significant indication for follow-up imaging regardless of grade. A larger study will be necessary to identify those most at risk for PSA formation and determine the best PSA screening algorithm.

Demographics and Patterns of Injury in Patients with Sharp Penetrating Trauma admitted to a Greater Manchester Major Trauma Centre: A Retrospective Five-Year Study

Background: Sharp penetrating trauma represents 4.1%-6.9% of all major trauma cases in the UK. The incidence of Sharp penetrating trauma is rising, with 47,000 offences in England and Wales in 2019. There has been limited published data on the victims of sharp penetrating trauma. Methods: We performed a single centre retrospective case note review of patients admitted to an urban major trauma centre following an assault with a sharp object from 1st January 2014 to the 31st December 2018. Data was collected on demographics, injury pattern, management, and outcome. Results: In total, 686 patients were included in the study. There was a year-on-year increase of admissions with sharp penetrating trauma from 100 admissions in 2014, to 194 in 2018. The majority of patients were male, with a mean age of 31, and 73% of our patients were of Caucasian ethnicity. Patients presented most frequently on weekends (53%). The length of stay increased over the study period from 2.3 days in 2014 to 4.0 days in 2018. The thorax was the most commonly injured body region, involved in 29% of presentations, followed by the abdomino-pelvis (21%). 51% of patients presented with multiple injuries, and the average number of stab wounds per patient increased from 1.95 in 2014 to 2.40 in 2018. Conclusion: Our study has demonstrated the incidence and severity of sharp penetrating trauma is increasing in central Manchester. The authors advocate the creation of a national knife crime database to further the implementation of prevention strategies.

Patients of Obese Representation Require Longer Operative Times: An Evaluation of Acetabular and Pelvic Ring Operative Duration.

Recent literature has determined that operative times for the obese population are greater for both elective and nonelective orthopedic procedures. If time allotted for a given surgical procedure is used as a measure of procedural difficulty, then consideration can be given for using an additional coding modifier (i.e., Modifier 22) for the increased skill and effort associated with longer procedures. A retrospective chart review was conducted on all patients who underwent surgical treatment for an acute fracture about the pelvis at an urban level-1 trauma center from October 1, 2010 through October 31, 2018. After allowing for both inclusion and exclusion criteria, 102 patients with acetabular fractures and 55 patients with pelvic ring injuries were included in this investigation. The obese population within the acetabular fracture cohort demonstrated significantly longer mean times for the duration of surgery, total time in spent in the operating room, and duration under anesthesia (P values of 0.038, 0.05 and 0.035, respectively). Similar results were observed with the pelvic ring injury cohort, with significantly longer procedural times (P = 0.019), total time in the operating room (P = 0.034), and total duration under anesthesia (P = 0.0395). A trend towards a greater risk of infection was found in obese patients (7%) when compared with nonobese patients (1.6%) within the acetabular fracture subset (P = 0.093). Operative duration for acetabular fractures and pelvic ring injuries is significantly longer in the obese population. Furthermore, this indicates that a Modifier 22 may be justified for the surgical treatment of these injuries in the obese and morbidly obese patient populations.

The Use of Shape-Memory Alloy Staples (Nitinol) in the Treatment of Pubic Symphyseal Disruptions: Clinical Results and Radiographic Outcomes.

Nitinol is a shape-memory alloy that has many diverse applications in the field of orthopedics. There have been no previous investigations reporting clinical or radiographic outcomes of the use of nitinol staples in the definitive stabilization of the pubic symphysis. A retrospective chart review was completed on 42 patients who underwent operative stabilization of pubic symphyseal disruption at an urban level-1 trauma center. Patients treated with pelvic staples alone, or in conjunction with traditional plates and screws, were compared with those treated without the use of a shape memory alloys. Thirty-four patients were included for final analysis (8 staples and 26 controls) in this investigation. Three of eight patients in the pelvic staple group had implant failures, with two having a loss of reduction (25%); this was not significantly different from the seven hardware failures (P = 0.61) seen in the control group without any loss of reduction (P = 0.17). Failures in the nitinol staple group occurred earlier at 17.3 days compared with the control group at 101.7 days (P = 0.003). There were no significant differences between groups with regards to any of the other pre- or postoperative variables investigated. The use of nitinol staples vs. traditional plate and screw constructs for stabilizing the pubic symphysis did not result in more clinical failures. The hardware failures identified in the nitinol staple group occurred significantly earlier in the postoperative period, and were associated with a loss of reduction of the pubic symphysis.

How much paediatric major trauma is truly paediatric? Experience from a level 1 urban Major Trauma Centre

Background: At its inception, there was no formal provision for children within the English major trauma network. There are now combined and stand-alone centres, but the scarcity of paediatric trauma facilities in some regions can result in long patient transfers and impact patient outcomes. The objective of this study was to determine the proportion of paediatric trauma patients who may benefit from input by adult services or may be safely managed within the local adult MTC, either because of patient physiology or injury patterns. Methods: All trauma presentations to our urban MTC aged ≤16 over a 3-year period were retrospectively identified and grouped, based on age and weight. ‘Young adult’ mechanisms of trauma and patient destinations (whether paediatric or adult wards) were determined. Results: There were 847 paediatric trauma cases recorded with a mean age of 9 and a male preponderance. Based on age and weight, 10–45% of cases could be considered physiologically adult-like, and 22–28% pubertal. Almost all penetrating trauma occurred in males, increasing with age. 14% of all admissions were managed on adult wards, with frequency increasing with patient age and with mechanism of actions (MOIs) relating to interpersonal violence. Conclusion: In this dataset, nearly half of paediatric trauma was ‘pubertal’ or ‘adult’ in their physiology and of these most presented with ‘young adult’ MOIs. These children likely benefit from combined paediatric and adult trauma services; where these do not exist, some older patients may be safely managed within local adult MTCs.

Effect of the Covid-19 Lockdown Regulations on the Severe Trauma Burden in an Urban Trauma Centre in Johannesburg, South Africa

Effect of the Covid-19 Lockdown Regulations on the Severe Trauma Burden in an Urban Trauma Centre in Johannesburg, South Africa

Trauma recidivism is pervasive and is associated with mental and social health opportunities

IntroductionRecidivism after orthopedic trauma results in greater morbidity and costs. Prior studies explored the effects of social and medical factors affecting the frequency of return to the hospital with new, unrelated injury. Identification of mental, social and other risk factors for trauma recidivism may provide opportunities for mitigation. The purposes of this study are to determine the rates of subsequent, unrelated injury noted among orthopedic trauma patients at a large urban trauma center and to evaluate what patient and injury features are associated with greater rates of trauma recidivism. We hypothesize higher rates of new injuries will be related to ballistic trauma and other forms of assault, alcohol and recreational drug use, unemployment, and unmarried status among our trauma patients. MethodsA series of 954 skeletally mature patients at a level 1 trauma center over a 5 year period were included in the study. All were treated operatively for thoracolumbar, pelvic ring, acetabulum, and/or proximal or shaft femoral fractures from a high energy mechanism. Retrospective review of demographic, injury, medical, and social factors, and subsequent care was performed. Trauma recidivism was defined as returning to the emergency department for treatment of any new injury. A backward stepwise logistic regression statistical analysis was used to identify independent predictors of recidivism. ResultsMean age of all patients was 41.2 years, and 73.2% were male. 136 patients (14.3%) returned with a new injury within a mean of 21 months. These trauma recidivists were more likely to sustain a GSW (22.1% vs 11.4%, p = 0.001). They had higher rates of substance use, including tobacco (57.4% vs 41.8%, p = 0.001) and recreational drugs (50.7% vs 34.4%, p = 0.001), and were less likely to be married (10% vs 25.9%, p<0.001). Mental illness was pervasive, noted in 56.6% of patients with new injury (vs 32.8%, p<0.001). Medicaid insurance was most common in the trauma recidivist population (58.1% vs 35.0%, p = 0.001), and 12.5% were uninsured. Completing high school or more education was protective (93% non-recidivist (vs 79%, p = 0.001). Sixty-nine patients (50.7%) were repeat trauma recidivists within the study period. Independent predictors of new injury included recreational drug use (OR 1.64, p = 0.05) and history of assault due to GSW or other means (OR 1.67, p = 0.05). History of pre-existing mental illness represented the greatest risk factor for trauma recidivism (OR 2.55, p<0.001). DiscussionNew injuries resulting in emergency department presentation after prior orthopedic trauma occurred in 14.3% and were associated with history of assault, lower education, Medicaid insurance, tobacco smoking and recreational drug use. Mental illness was the greatest risk factor. Over half of patients with these additional injuries were repeat trauma recidivists, returning for another new injury within less than 2 years. Awareness of risk factors may promote focused education and other interventions to mitigate this burden. Level of EvidenceLevel 3 retrospective, prognostic

Preoperative CT Scanning in Hemodynamically Stable Thoracoabdominal Gunshot Wounds: Outcomes from a Long-Term Single-Institution Pilot Study

INTRODUCTION: Emergent operative exploration is the standard of care for penetrating thoracoabdominal trauma. With advanced CT imaging, preoperative scans may be obtained efficiently for operative planning. This study aims to determine if CT imaging before operative exploration for hemodynamically stable thoracoabdominal gunshot wound injuries adversely affects patient outcomes. METHODS: This was a retrospective chart review was performed between 2014 and 2019 at an urban trauma center to identify hemodynamically stable patients who suffered penetrating thoracoabdominal gunshot wound and had operative intervention. Patients were then stratified into 2 groups: (1) those who received CT imaging before operative intervention, and (2) those who went straight to the operating room (OR). RESULTS: A total of 113 patients were identified. A total of 64 (56.6%) received CT imaging, and 49 (43.4%) went straight to the OR (Table). There were no differences in mortality (p = 0.25), hospital length of stay (p = 0.17), ICU length of stay (p = 0.14), ventilator days (p = 0.37), and postoperative complications (p > 0.05). Time spent in the OR and time from emergency department to end of operation were similar between groups (p = 0.051). Multivariable analysis demonstrated risk factors for time greater than 150 minutes includes Injury Severity Score, age, sex, and blood product administration. Multivariate regression displayed that for each unit of PRBC given, OR time were more likely to increase (p < 0.001). Table. - Patient Demographics and Outcome Data Demographics Overall Sample (N = 113) Group A: CT Scan before Going to the Operating Room (N = 64) Group B: Straight to the Operating Room (N = 49) p Value Age, y, mean (SD) 25.57 (7.60) 24.30 (6.74) 27.22 (8.38) 0.042 Race, % (White, Black, other, unknown) 8.0, 86.7, 1.8, 3.5 3.1, 92.2, 1.6, 3.1 14.3, 79.6, 2.0, 4.1 0.175 Sex, % (male, female) 92, 8 90.6, 9.4 93.9, 6.1 0.530 Injury Severity Score, mean (SD) 16.95 (9.42) 16.34 (8.76) 17.73 (10.26) 0.220 Hospital days, mean (SD) 11.06 (8.12) 10.42 (7.87) 11.90 (8.44) 0.142 Ventilator days, mean (SD) 2.07 (4.15) 1.95 (4.65) 2.22 (3.43) 0.370 MTP activation, n (%) 31.9% 17.2% 51% <0.0001 Total number of blood products, mean (SD) 4.00 (6.24) 2.09 (3.26) 6.49 (8.11) <0.0001 Mortality, n (%) 0.9% 0% 2.0% 0.251 CONCLUSION: Obtaining a CT scan before operative intervention in hemodynamically stable patients with thoracoabdominal gunshot wound did not affect mortality, hospital length of stay, or ventilator days, indicating that obtaining CT scans before operative intervention may be safe in select patients. This pilot serves as the basis for an ongoing regional multi-institutional study.

Stop the Bleed: Now Wait for EMS or Get in the Car and Drive? A Secondary Analysis of an Eastern Association for the Surgery of Trauma Multicenter Trial

INTRODUCTION: The Stop the Bleed campaign asks that bystanders take an active role in controlling hemorrhage after trauma. However, whether extending the bystanders’ duty to perform private vehicle transport (PVT) results in improved survival is unknown. We hypothesized that in urban penetrating trauma, where prehospital procedures have shown to be harmful, PVT would result in improved outcomes compared with advanced life support (ALS) transport. METHODS: Post hoc analysis of an EAST multicenter, prospective observational trial was performed on adult patients with penetrating torso or extremity trauma at 25 urban trauma centers. Patients were allocated to PVT or ALS using nearest neighbor propensity score matching. Wilcoxon signed-rank or McNemar test and logistic regression were performed for univariate and multivariate analyses. RESULTS: Of 1,830 total patients, 397 (21.7%) had PVT, and 1,433 (78.3%) had ALS transport. Propensity matching yielded 778 patients, distributed equally into balanced groups. Patients were primarily male (n = 702, 90.2%), Black (n = 537, 69%), and injured by gunshot wounds (n = 497, 63.9%). ALS transport had significantly higher emergency department (4.8% vs 1.9%, p = 0.02) and overall mortality (5.4% vs 2.8%, p = 0.02). Logistic regression demonstrated PVT was associated with survival (odds ratio 0.30, 95% CI 0.10 to 0.84, p = 0.02). Variables associated with mortality included increasing Injury Severity Score and thoracic injuries (Table 1). Complications did not differ between groups. Table 1. - Logistic Regression Analysis of Patient and Injury Factors on Mortality Parameter Odds Ratio 95% CI p Value Age, y 1.02 0.98–1.05 0.40 Male 2.95 0.31–27.8 0.34 Injury Severity Score 1.10 1.07–1.13 0.001 Private vehicle transport 0.30 0.10–0.84 0.02 Thoracic injury 8.39 2.64–36.6 0.001 Abdomen injury 2.10 0.80–5.52 0.13 Pelvis injury 0.92 0.18–4.76 0.92 Extremity injury 1.18 0.47–2.97 0.72 CONCLUSION: Immediate PVT in lieu of prehospital procedures (by ALS) may improve outcomes in urban penetrating trauma. Bystander education incorporating PVT in this specific patient population could save lives.

Evaluation of resuscitation with angiography, percutaneous techniques and operative repair (RAPTOR): hybrid suite introduction and initial use at a level I urban trauma centre.

The aim of this study was to describe the utilization of the RAPTOR suite (hybrid theatre) for trauma patients. Ideally, this is used to achieve haemorrhage control in time-critical patients that may require damage control surgery (DCS) and/or interventional radiological (IR) procedures concurrently. A single-centre, retrospective study identifying all trauma patients that were treated at the level I trauma centre during 2011-2016 was performed. Patients that underwent treatment in the RAPTOR suite were described. Subgroup analyses were performed for trauma patients that underwent interventions within 60min and patients who underwent a combination of DCS + angioembolization in the RAPTOR suite or in other locations (OR, radiology). Since its introduction in 2011, 1% of all procedures performed in the RAPTOR suite were trauma related. From 2011 until 2016, 43 trauma patients underwent treatment in the RAPTOR suite. The majority of patients (81%) suffered blunt injury. Most patients were male (70%), with a mean age of 43years. The mean ISS was 38. In 56% (n = 24) the MTP was activated and in 40% (n = 17) a CT scan was performed prior to treatment. Damage control surgery alone, angioembolization alone and a combination of DCS and angioembolization were performed in 37% (n = 16), 23% (n = 10) and 40% (n = 17) of patients, respectively. Median time to the hybrid suite, procedure time and total time were 56min (15-704), 160min (42-404), and 251min (93-788), respectively. In the first 5years following introduction of a hybrid theatre in an urban level I trauma centre, only 1% of patients using the resource has injury-related pathology. Earlier identification of patients requiring this facility may improve timely access and management for this select group of patients needing urgent control of bleeding.

Assault-related Orbital Trauma at an Urban Level I Trauma Center: Racial Segregation and Other Neighborhood-level Social Determinants.

To report the demographics of assault-related orbital fractures over a 7-year period treated at a level I urban trauma center, as well as describe and analyze the variation in assault rates across different racial/ethnic neighborhoods for patients residing in Milwaukee County. A retrospective chart review was conducted for patients who sustained assault-related orbital fractures from January 1, 2013, through December 31, 2019, at the Froedtert & Medical College of Wisconsin, in Milwaukee, Wisconsin. A series of negative binomial regression models evaluating the association of neighborhood (i.e., US census tract) racial/ethnic composition, poverty, unemployment, percentage female head-of-household, and education level with neighborhood rate of orbital trauma was conducted. A total of 410 adult patients with orbital fractures attributed to assault were identified during the seven-year period, of whom 326 (80%) resided in Milwaukee County. Among these patients, 242 (74%) were male, 260 (81%) were single, and 206 (63%) were non-Hispanic Black. Majority non-Hispanic Black, Hispanic, and Other-type minority neighborhoods have 5.30, 3.35, and 3.94 times higher incidence rates of orbital assault, respectively, compared with the majority of non-Hispanic White neighborhoods. The elevated incidence rates were significantly attenuated across all minority neighborhoods after accounting for neighborhood factors of poverty, unemployment, and low education level. Low education had the strongest association with the incidence of assault-related orbital fractures, followed by unemployment. Results indicate that minority neighborhoods suffer from compounded burdens of both social and economic disadvantage as well as violent assaults. Additional resources allocated to poor minority communities are needed.

COMPARISON OF ULTRASOUND-GUIDED ERECTOR SPINAE PLANE BLOCK WITH INTERCOSTAL NERVE BLOCK FOR TRAUMA-ASSOCIATED CHEST WALL PAIN

BackgroundPain associated with chest wall trauma is a major issue in the emergency department (ED). However, it may be challenging to select among the various analgesic procedures. ObjectiveOur aim was to compare single-shot erector spinae plane block (ESPB) with intercostal nerve block (ICNB) under ultrasound guidance for pain management in thoracic trauma. MethodsThis study was a randomized nonblinded clinical trial performed in a level I urban trauma center. A convenience sample of patients with isolated chest wall trauma and initial Numeric Rating Scale pain scores (NRS 0) > 5 were included. Exclusion criteria were large pain area, surgical interventions, discharged from the ED, and presence of contraindications to lidocaine. Pain scores at 20 min and 60 min (NRS 20 and 60) and at disposition (disp) were recorded. ResultsTwenty-seven patients in the ESPB and 23 in the ICNB groups were enrolled. Mean values of NRS 0, 20, 60, and disp for the ESPB vs. ICNB groups were 8.0 vs. 7.4, 5.2 vs. 6.1, 4.1 vs. 5.4, and 4.3 vs. 5.8, respectively (p = 0.07, p = 0.04, p = 0.001, and p < 0.001, respectively). Four patients in the ESPB and 8 patients in the ICNB groups required administration of adjunctive doses of fentanyl for satisfactory pain control (p = 0.09). ConclusionsUltrasound-guided ESPB was superior to ICNB regarding pain control during the ED stay period of patients with painful chest wall trauma. We recommend ESPB in the ED for pain control in blunt or penetrating thoracic trauma.

290 Trauma Patients in Police Custody - Who Are They and How Were They Injured?

The United States has the highest incarceration rate in the world by a large margin, with 629 individuals incarcerated for every 100,000 citizens in 2019. Individuals in police custody represent a vulnerable subset of trauma patients at risk for disparate care. Though the literature on mortality of persons in police custody is growing, less research exists on morbidity. Hence, we sought to characterize traumatic injuries of persons in police custody at a single urban trauma center. We hypothesized that the injuries sustained by patients in policy custody would be the same as the injured population in general and would be from blunt force trauma, such as motor vehicle collisions.

Age-related injury patterns resulting from knife violence in an urban population.

Interpersonal violence involving knives is a major public health problem. The majority of patients are young people in urban areas, but little is known about age-specific patterns of injury and recent trends in injury characteristics. We performed a retrospective cohort study of all patients presenting to an urban major trauma centre with stab injuries resulting from assault between 2012 and 2018. A total of 3583 patients were included. Young people (age under 25) were more likely to have sustained multiple stab wounds compared to older people (43% vs 35%, p < 0.001) and had significantly higher rates of stab injuries involving the lower limbs, groin and buttocks. The annual number of injuries increased steadily during the study period in patients aged under 25 (r2 = 0.82, p = 0.005) and those over 25 (r2 = 0.95, p < 0.001). Over time, limb and junctional injuries accounted for an increasing proportion of stab wounds in young people, overtaking torso injuries as most common pattern of injury by the end of the study period. These findings illustrate the influence of age on injury patterns resulting from knife violence, and support the expansion of outreach initiatives promoting bystander-delivered haemorrhage control of extremity wounds.

960 Referral Documentation in Orthopaedic Trauma

Abstract Aim We aimed to measure and improve documentation and decision making for on-call Orthopaedic Trauma referrals. Method Documentation for all referrals to the Orthopaedic Trauma Service, at a major urban trauma centre, in Scotland, over a defined period was reviewed. The audit conducted between February 2020 and November 2021. Documentation was scored. Two further audit cycles were performed after the introduction of an electronic “contact note” system. Results There was a dramatic improvement between cycle 1 and cycle 3 of available documentation 76% versus 98%. Documentation was available on the day of referral for 60% of cases reviewed by cycle 3 versus 30% for cycle 1; 98% complete documentation was available by day 2 during cycle 3. The system was rated high satisfactory by 90%% of users. Conclusions Complete documentation was more widely and more quickly available after the introduction of an electronic note keeping system. The system was user friendly and rated high satisfactory. We believe the system improved patient safety.

Initial Assessment of a Regional Military-Civilian Partnership on Trauma Surgery Skills Sustainment.

Trauma surgery skills sustainment and maintenance of combat readiness present a major problem for military general surgeons. The Military Health System (MHS) utilizes the knowledge, skills, and abilities (KSA) threshold score of 14,000 as a measure of annual deployment readiness. Only 9% of military surgeons meet this threshold. Most military-civilian partnerships (MCPs) utilize just-in-time training models before deployment rather than clinical experiences in trauma at regular intervals (skills sustainment model). Our aim is to evaluate an established skills sustainment MCP utilizing KSAs and established military metrics. Three U.S. Navy active duty general surgeons were embedded into an urban level-1 trauma center taking supervised trauma call at regular intervals prior to deployment. Operative density (procedures/call), KSA scores, trauma resuscitation exposure, and combat casualty care relevant cases (CCC-RCs) were reviewed. During call shifts with a Navy surgeon present an average 16.4 trauma activations occurred; 32.1% were category-1, 27.6% were penetrating, 72.4% were blunt, and 33.8% were admitted to the intensive care unit. Over 24 call shifts of 24 hours in length, 3 surgeons performed 39 operative trauma cases (operative density of 1.625), generating 11,683 total KSA points. Surgeons 1, 2, and 3 generated 5109, 3167, and 3407 KSA points, respectively. The three surgeons produced a total of 11,683 KSA points, yielding an average of 3,894 KSA points/surgeon. In total, 64.1% of operations fulfilled CCC-RC criteria. Based on this initial evaluation, a military surgeon taking two calls/month over 12 months through our regional skills sustainment MCP can generate more than 80% of the KSA points required to meet the MHS KSA threshold for deployment readiness, with the majority being CCC-RCs. Intangible advantages of this model include exposure to multiple trauma resuscitations while possibly eliminating just-in-time training and decreasing pre-deployment requirements.