Urban Trauma Center Research Articles

Shorter times to packed red blood cell transfusion are associated with decreased risk of death in traumatically injured patients.

Hemorrhage is a leading cause of death in traumatically injured patients. Currently, the importance of earlier administration of packed red blood cells (pRBC) to improve outcomes is limited. We evaluated the association of earlier pRBC administration and mortality when compared with later transfusion initiation. This single-center retrospective cohort study of trauma patients transported by a single helicopter service from the scene of injury to an urban academic trauma center included patients receiving at least one unit of pRBC within 24 hours of hospital arrival. The final cohort included patients transported to the trauma center between March 11, 2010, and October 30, 2013. The helicopter service carries two units of pRBC for protocol-driven prehospital transfusion. Logistic regression was used to model odds of death, and 95% confidence intervals were calculated. The 94 patients meeting inclusion criteria had a mean (SD) age of 43 (19) years; 87 (93%) of 94 were white, 66 (70%) of 94 were male, and 88(94%) of 94 sustained blunt force injuries. Median Injury Severity Score was 29 (range, 2-75), and 31 (33%) of 94 died within 30 days. Most patients [82/94 (87%)] received their first pRBC transfusion during transport or within one hour of arrival at the emergency department (ED). For the 82 patients receiving a first pRBC transfusion within one hour of ED arrival, each 10-minute increase in time to transfusion increased the odds of death [OR, 1.27 (95% CI, 1.01-1.62; p = 0.044)], controlling for TRISS. At 30 days, 29/82 (35%) patients who received a pRBC transfusion within one hour of ED arrival, and 2 (16%) of 12 patients who received delayed transfusion were deceased (difference, 19%; 95% CI, -5% to 42%). In this study, delays in time to pRBC administration of as short as 10 minutes were associated with increased odds of death for patients receiving ultra-early pRBC transfusion. Expedient prehospital and ED transfusion capabilities may improve outcomes after trauma. Therapeutic/care management study, level III.

Delayed interventions and mortality in trauma damage control laparotomy

In damage control laparotomy, operative principles include hemorrhage and contamination control. However, required components of initial damage control laparotomy are unknown, and nonemergency injury repair is sometimes delayed for resuscitation, angiography, or nonabdominal operations. The frequency and effects of delayed interventions are unknown. A retrospective review of patients undergoing damage control laparotomy at a single, urban trauma center was performed. Interventions initially performed at the second laparotomy were considered delayed interventions. In the study, 330 damage control laparotomy patients survived to reoperation. Of all interventions, 13.9% were first performed at the second laparotomy, including 11.9% of visceral interventions and 27.2% of vascular interventions. Overall, 29.7% of patients underwent an unplanned re-exploration, and 21.8% of patients underwent re-exploration for hemorrhage control. There was no significant increase in mortality (33.3% vs 23.9%, P=.09), intra-abdominal infection (37.9% vs 28.0%; P=.10), anastomotic leak (8.0% vs 5.8%, P=.45), or enterocutaneous fistula formation (9.2% vs 9.1%, P=1.00) with delayed interventions overall. However, mortality was increased in patients undergoing delayed vascular interventions (59.1% vs 22.8%, P=.003), unplanned re-exploration (45.9% vs 18.1%, P<.001) and re-exploration for hemorrhage control (50.0% vs 19.8%, P<.001). Delayed interventions are common in damage control laparotomy, with abdominal interventions often spread over multiple explorations. Mortality is increased in patients undergoing emergent re-exploration and with delayed repair of major vascular injuries. Ideal treatment of damage control laparotomy patients may include addressing injuries more completely at the first laparotomy instead of deferring care for other priorities.

Mechanical Construct Characteristics Predisposing to Non-union After Locked Lateral Plating of Distal Femur Fractures.

To identify discrete construct characteristics related to overall construct rigidity that may be independent predictors of nonunion after lateral locked plate (LLP) fixation of distal femur fractures. Retrospective case-control study. Three level-1 urban trauma centers. Two hundred and seventy-one supracondylar femoral fractures treated with LLP at 3 affiliated level 1 urban trauma centers between August 2004 and December 2010. Nonunion was defined as a secondary procedure for poor healing. Construct variables included: (1) combined plate design and material variable, (2) Plate length, (3) # screws proximal to fracture, (4) total screw density (TSD), (5) proximal screw density (PSD), (6) presence of a screw crossing the main fracture, and (7) rigidity score multivariable analysis was performed using logistic regression to identify independent risk factors for nonunion. LLP fixation. Nonunion. Nonunion rate was 13.3% (n = 36). There was a significant association between plate design/material and nonunion with 41% of stainless constructs and 10% of titanium constructs resulting in a nonunion (P < 0.001). Rigidity scores reached significance (P = 0.001) with constructs resulting in a nonunion having higher scores. No significant univariate differences with respect to number of proximal screws, plate length, total screw density, or proximal screw density were observed between healed fractures and those with nonunion. Results of the multivariate analysis confirmed that the primary significant independent predictor of nonunion was plate design/material (odds ratio, 6.8; 95% CI, 2.9-16.1; P < 0.001). When treating distal femur fractures with LLP, combined plate design and material variable has a highly significant influence on the risk of nonunion independent of any other construct variable. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Contemporary management of civilian penetrating cervicothoracic arterial injuries

The management of arterial injury at the thoracic outlet has long hinged on the fundamental principles of extensile exposure and vascular anastomosis. Nonetheless, treatment options for such injuries have evolved to include both endovascular stent placement and temporary vascular shunts. The purpose of this study was to evaluate our recent experience with penetrating cervicothoracic arterial injuries in light of these developments in trauma care. Patients with penetrating injuries to the innominate, carotid, subclavian, or axillary arteries managed at a single civilian trauma center between 2000 and 2013 were categorized as the modern era (ME) cohort. The management strategies and outcomes pertaining to the ME group were compared to those of previously reported experience (PE) concerning injuries to the innominate, carotid, subclavian, or axillary arteries at the same institution from 1974 to 1988. Over the two eras, there were 202 patients: 110 in the ME group and 92 in the PE group. Most of the injuries in both groups were managed with primary repair (45% vs. 46%; p = 0.89). A similar proportion of injuries in each group was managed with anticoagulation alone (14% vs. 10%; p = 0.40). In the ME group, two cases were managed with temporary shunt placement, and endovascular stent placement was performed in 12 patients. Outcomes were similar between the groups (bivariate comparison): mortality (ME, 15% vs. PE, 14%; p = 0.76), amputation following subclavian or axillary artery injury (ME, 5% vs. PE, 4%; p = 0.58), and posttreatment stroke following carotid injury (ME, 2% vs. PE, 6%; p = 0.57). Experience with penetrating arterial cervicothoracic injuries at a high-volume urban trauma center remained remarkably similar with respect to both anatomic distribution of injury and treatment. Conventional operative exposure and repair remain the cornerstone of treatment for most civilian cervicothoracic arterial injuries. Therapeutic study, level V.

Outcomes of trauma admission for falls: influence of race and age on inhospital and post-discharge mortality

BackgroundRacial disparities in trauma outcomes occur, but disparities in fall mortality are unknown. The objective of this study was to determine inhospital and 1-year fall mortality among patients discharged from an urban trauma center. MethodsWe conducted a retrospective analysis of fall patients in our trauma registry (1997 to 2008) linked to the National Death Index to determine postdischarge mortality. Statistical analysis included chi-square tests, multivariable logistic regression, and Cox proportional hazards models. ResultsThere were 7,541 fall admissions. There was no clinically significant difference in inhospital mortality between blacks and whites with age stratification. One year after discharge, blacks younger than 65 years were more likely to die of disease (hazard ratio, 1.37; 95% confidence interval, 1.14 to 1.62). ConclusionsAlthough rates of inhospital mortality are similar, blacks younger than 65 years have a higher risk of dying after discharge due to disease when stratified by age highlighting the need for continued medical follow-up and prevention efforts.

The Role of Social Work in Providing Mental Health Services and Care Coordination in an Urban Trauma Center Emergency Department

This study examined the role of emergency department (ED) social workers and identified predictors of receipt of social work services and length of ED stay. Comprehensive reviews were conducted of medical records of all patients (N=49,354) treated in a level 1 trauma center ED from January 1, 2012, to March 31, 2013. Content analysis of chart notes was used to categorize the types of social work services provided. Poisson regression was used to assess associations between demographic and clinical characteristics, receipt of social work services, and length of ED stay. Social work services were provided to 18,532 (38%) patients. Most were mental health services (54%), followed by care coordination (31%) and material support or other referrals (15%). Patients seen by social workers had complex presentations, involving mental disorder diagnoses (18%), substance use disorder diagnoses (29%), comorbid diagnoses (32%), and injuries (51%); a quarter of patients had multiple ED visits (26%). In adjusted regression analysis, females (relative risk [RR]=1.15), patients not discharged home (RR=1.44), and those with two or more comorbid diagnoses (RR=1.80), injuries due to assault (RR=1.37), and traumatic brain injury (RR=1.20) were more likely to receive social work services. Such services were associated with an increased length of ED stay (RR=1.34). Social workers provided services to patients with multifaceted needs resulting from complex presentations. Provision of social work services modestly increased length of ED stay. Triage algorithms are needed to target efficiencies, systematize provision of ED social work services, and improve access to services for all patients.

Second Place Award Immediate versus delayed operative treatment of low-energy tibial plateau fractures.

Background:Current management of tibial plateau fractures requires careful soft-tissue management. Often a staged approach with temporary external fixation followed by delayed internal fixation is recommended. While proven in high-energy injuries, its relevance in treating low-energy fractures has not been investigated. The goal of the current study was to assess the short-term complication rates in low-energy tibial plateau fractures treated early (<48 hr). As a secondary aim, we investigated whether surgical approach would affect rates of wound complications.Methods:This is a retrospective analysis of patients treated operatively for low-energy tibial plateau fractures at a level-1 urban trauma center between January 1, 2000 and January 1, 2010. Schatzker type 1-3 fractures were considered “low-energy,” despite stated mechanism. Statistical analysis was performed using chi-square and Fischer’s exact tests.Results:We analyzed 49 patients. From these, 29 received early (<48 hr) definitive surgery, while 20 had surgery delayed (>48 hr). The early treatment group had an infection rate of 3.4% and total complication rate of 20.6%. The delayed treatment group had an infection rate of 5.0% and total complication rate of 25%. There was no significant difference with respect to superficial infection (P=1.0), deep infection (P=0.48), or total complications (P=0.74) Additionally, infection rates did not differ between surgical approaches (P=1.0, 1.0).Conclusions:Early surgical fixation (<48 hr) of low-energy tibial plateau fractures can be performed safely. Additionally, a midline approach did not increase soft-tissue complications and could be utilized in a patient with a prior midline incision, or one who will soon require a knee arthroplasty.

Levetiracetam Prophylaxis for Post-traumatic Brain Injury Seizures is Ineffective: A Propensity Score Analysis.

Early seizures after severe traumatic brain injury (TBI) have a reported incidence of up to 15%. Prophylaxis for early seizures using 1 week of phenytoin is considered standard of care for seizure prevention. However, many centers have substituted the anticonvulsant levetiracetam without good data on the efficacy of this approach. Our hypothesis was that the treatment with levetiracetam is not effective in preventing early post-traumatic seizures. All trauma patients sustaining a TBI from January 2007 to December 2009 at an urban level-one trauma center were retrospectively analyzed. Seizures were identified from a prospectively gathered morbidity database and anticonvulsant use from the pharmacy database. Statistical comparisons were made by Chi square, t tests, and logistic regression modeling. Patients who received levetiracetam prophylaxis were matched 1:1 using propensity score matching with those who did not receive the drug. 5551 trauma patients suffered a TBI during the study period, with an overall seizure rate of 0.7% (39/5551). Of the total population, 1795 were diagnosed with severe TBI (Head AIS score 3-5). Seizures were 25 times more likely in the severe TBI group than in the non-severe group [2.0% (36/1795) vs. 0.08% (3/3756); OR 25.6; 95% CI 7.8-83.2; p<0.0001]. Of the patients who had seizures after severe TBI, 25% (9/36) received pharmacologic prophylaxis with levetiracetam, phenytoin, or fosphenytoin. In a matched cohort by propensity scores, no difference was seen in seizure rates between the levetiracetam group and no-prophylaxis group (1.9 vs. 3.4%, p=0.50). In this propensity score-matched cohort analysis, levetiracetam prophylaxis was ineffective in preventing seizures as the rate of seizures was similar whether patients did or did not receive the drug. The incidence of post-traumatic seizures in severe TBI patients was only 2.0% in this study; therefore we question the benefit of routine prophylactic anticonvulsant therapy in patients with TBI.

Early changes within the lymphocyte population are associated with the development of multiple organ dysfunction syndrome in trauma patients.

BackgroundEarly survival following severe injury has been improved with refined resuscitation strategies. Multiple organ dysfunction syndrome (MODS) is common among this fragile group of patients leading to prolonged hospital stay and late mortality. MODS after trauma is widely attributed to dysregulated inflammation but the precise mechanics of this response and its influence on organ injury are incompletely understood. This study was conducted to investigate the relationship between early lymphocyte responses and the development of MODS during admission.MethodsDuring a 24-month period, trauma patients were recruited from an urban major trauma centre to an ongoing, observational cohort study. Admission blood samples were obtained within 2 h of injury and before in-hospital intervention, including blood transfusion. The study population was predominantly male with a blunt mechanism of injury. Lymphocyte subset populations including T helper, cytotoxic T cells, NK cells and γδ T cells were identified using flow cytometry. Early cytokine release and lymphocyte count during the first 7 days of admission were also examined.ResultsThis study demonstrated that trauma patients who developed MODS had an increased population of NK dim cells (MODS vs no MODS: 22 % vs 13 %, p < 0.01) and reduced γδ-low T cells (MODS vs no MODS: 0.02 (0.01–0.03) vs 0.09 (0.06–0.12) × 10^9/L, p < 0.01) at admission. Critically injured patients who developed MODS (n = 27) had higher interferon gamma (IFN-γ) concentrations at admission, compared with patients of matched injury severity and shock (n = 60) who did not develop MODS (MODS vs no MODS: 4.1 (1.8–9.0) vs 1.0 (0.6–1.8) pg/ml, p = 0.01). Lymphopenia was observed within 24 h of injury and was persistent in those who developed MODS. Patients with a lymphocyte count of 0.5 × 109/L or less at 48 h, had a 45 % mortality rate.ConclusionsThis study provides evidence of lymphocyte activation within 2 h of injury, as demonstrated by increased NK dim cells, reduced γδ-low T lymphocytes and high blood IFN-γ concentration. These changes are associated with the development of MODS and lymphopenia. The study reveals new opportunities for investigation to characterise the cellular response to trauma and examine its influence on recovery.

PC170. Management Challenges in Patients With Blunt Abdominal Aortic Injuries

Blunt abdominal aortic injuries (BAAI) are rare, accounting for only 5% of all blunt aortic traumas. We reviewed the incidence, management, and outcomes of patients with BAAI at a Level I urban trauma center over a 10-year period. Through our trauma registry, we retrospectively reviewed all patients who presented with BAAI to a Level I urban trauma center from 2004 to 2014. Medical records and autopsy data were used to analyze the severity and location of aortic trauma, associated injuries, treatment methods, and outcomes. We identified 38 total patients with blunt aortic injuries. Blunt thoracic aortic trauma accounted for 85% of the injuries. BAAI were identified in 6 patients (15%). The median age of BAAI patients was 41 years (range, 29-82 years). Motor vehicle collision was the etiology in 4 patients and pedestrian struck in 2 patients. Median injury severity score (ISS) was 66.5 (range, 34-75). There were 5 injuries of the infrarenal aorta (2 intimal tears, 1 dissection, 1 pseudoaneurysm, 1 free rupture) and 1 free rupture at the level of the left renal artery. All patients sustained additional spine or other bony fractures. There were 11 associated solid organ and bowel injuries in 4 patients. In-hospital mortality was 50%, which included both free ruptures and one case of infrarenal aortic dissection in the setting of brain death. Laparotomy and repair of an aortic tear at the level of the left renal artery was performed on one free aortic rupture, with a hospital course complicated by multiple organ resections, intra-abdominal sepsis, and death secondary to aortic rupture 8 days after initial repair. The patient with the infrarenal aortic pseudoaneurysm was treated with aortic stent graft cuffs, with survival to discharge after a course complicated by respiratory failure from lung injuries. Two patients with intimal tears were managed nonoperatively to discharge. Two of the survivors were found to be isolated blunt abdominal aortic traumas, without concomitant intra-abdominal injuries, while the third survivor sustained additional blunt gastric, small bowel, and colon injuries. In contrast, both free aortic ruptures were associated with multiple solid organ and bowel injuries. BAAIs are rare events with high mortality rates. Management decisions are challenging and must be made in the setting of complex injuries across multiple systems.

Thoracic computed tomography is an effective screening modality in patients with penetrating injuries to the chest

BackgroundThe precise role of thoracic CT in penetrating chest trauma remains to be defined. We hypothesized that thoracic CT effectively screens hemodynamically normal patients with penetrating thoracic trauma to surgery vs. expectant management (NOM). MethodsA ten-year review of all penetrating torso cases was retrospectively analyzed from our urban University-based trauma center. We included hemodynamically normal patients (systolic blood pressure ≥90) with penetrating chest injuries that underwent screening thoracic CT. Hemodynamically unstable patients and diaphragmatic injuries were excluded. The sensitivity, specificity, positive predictive value and negative predictive value were calculated. ResultsA total of 212 patients (mean injury severity score=24, Abbreviated Injury Score for Chest=3.9) met inclusion criteria. Of these, 84.3% underwent NOM, 9.1% necessitated abdominal exploration, 6.6% underwent exploration for retained hemothorax/empyema, 6.6% underwent immediate thoracic exploration for significant injuries on chest CT, and 1.0% underwent delayed thoracic exploration for missed injuries. Thoracic CT had a sensitivity of 82%, specificity of 99%, positive predictive value of 90%, a negative predictive value of 99%, and an accuracy of 99% in predicting surgery vs. NOM. ConclusionsThoracic CT has a negative predictive value of 99% in triaging hemodynamically normal patients with penetrating chest trauma. Screening thoracic CT successfully excludes surgery in patients with non-significant radiologic findings.

Establishing a Traumatic Brain Injury Program of Care: Benchmarking Outcomes after Institutional Adoption of Evidence-Based Guidelines.

Traumatic brain injury (TBI) is a widespread global disease, often with widely varying outcomes. Standardization of care and adherence to established guidelines are central to the effort to improve outcomes. At our level I urban trauma center, we developed and implemented a Joint Commission-certified TBI Program of Care in 2011 and compared our post-implementation patient data set with historical controls, using the International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) prognostic model. Historical controls were drawn from the San Francisco General Hospital Traumatic Coma Data Bank (SFGH/TCDB) from 1987 to 1996. Recent era patients were drawn from the NeuroTracker database, a customized electronic medical record used in our clinical practice. Descriptive statistics were calculated. Adherence to four quality-of-care metrics on the clinical service was tracked for 2011-2013. The IMPACT prognostic model was used to calculate expected versus observed mortality for current and historical patient groups. In the historical control group, 832 patients were identified and 6-month mortality was available for 592. Observed 6-month mortality was 49%. In the recent era patient group, 211 patients were identified and 6-month mortality was 38%. The IMPACT prognostic model was applied to each patient group. Areas under the curve for each analysis were >0.85 and goodness of fit was satisfactory, indicating good performance of the IMPACT model. Comparison of observed versus expected deaths in the recent versus the control patient sets revealed a drop of 59% in early mortality. The greatest reductions in mortality were observed in the group of patients with IMPACT-predicted mortality ≤50%. Significant progress has been made in reducing the percentage of unexpected deaths in TBI patients. It is likely that major factors include more aggressive management and tracking of compliance with the implementation of guidelines for the management of TBI patients.

The impact of short prehospital times on trauma center performance benchmarking: An ecologic study.

Emergency medical service (EMS) prehospital times vary between regions, yet the impact of local prehospital times on trauma center (TC) performance is unknown. To inform external benchmarking efforts, we explored the impact of EMS prehospital times on the risk-adjusted rate of emergency department (ED) death and overall hospital mortality at urban TCs across the United States. We used a novel ecologic study design, linking EMS data from the National EMS Information System to TCs participating in the American College of Surgeons' Trauma Quality Improvement Program (TQIP) by destination zip code. This approach provided EMS times for populations of injured patients transported to TQIP centers. We defined the exposure of interest as the 90th percentile total prehospital time (PHT) for each TC. TCs were then stratified by PHT quartile. Analyses were limited to adult patients with severe blunt or penetrating trauma, transported directly by land to urban TQIP centers. Random-intercept multilevel modeling was used to evaluate the risk-adjusted relationship between PHT quartile and the outcomes of ED death and overall hospital mortality. During the study period, 119,740 patients met inclusion criteria at 113 TCs. ED death occurred in 1% of patients, and overall mortality was 7.2%. Across all centers, the median PHT was 61 minutes (interquartile range, 53-71 minutes). After risk adjustment, TCs in regions with the shortest quartile of PHTs (<53 minutes) had significantly greater odds of ED death compared with those with the longest PHTs (odds ratio, 2.00; 95% confidence interval, 1.43-2.78). However, there was no association between PHT and overall TC mortality. At urban TCs, local EMS prehospital times are a significant predictor of ED death. However, no relationship exists between prehospital time and overall TC risk-adjusted mortality. Therefore, there is no evidence for the inclusion of EMS prehospital time in external benchmarking analyses.

Uncertain Patency of Covered Stents Placed for Traumatic Axillosubclavian Artery Injury

Traumatic axillosubclavian artery injuries (ASAIs) are uncommon but devastating. There is increasing acceptance of covered stent use for ASAIs. However, epidemiologic and long-term outcomes data are limited. We investigated national trends in ASAI management and our institutional outcomes after emergent covered stent placement and open surgical repairs for ASAIs. A review of the National Trauma Data Bank from 2010 to 2012 was performed for epidemiologic data. International Classification of Diseases and procedure codes were used to identify ASAIs and therapy type. A single-center, retrospective review of consecutive patients with ASAIs between January 2010 and August 2014 was also performed. National Trauma Data Bank review included 511,286 patients with 520 ASAIs, yielding an incidence of 0.1%. Endovascular therapy was used in 76 patients (14.7%) vs open repair in 280 patients (53.8%). Nonoperative or unknown treatment was used in 164 (31.5%). From 2010 to 2012, endovascular interventions increased from 11.3% to 17.2% (p < 0.05). Endovascular therapy was used more frequently in blunt compared with penetrating trauma (59.2% vs 40.8%; p < 0.005). Our institutional review identified 10 ASAIs treated with covered stents with a median follow-up of 117 days (interquartile range 13 to 447 days) and 70% lost to follow-up. No treatment-related mortality or amputation occurred. Stent occlusion occurred in 30% at a median of 132 days (interquartile range 30 to 223 days). Three patients with ASAIs were initially treated with open surgery, 2 died and the third required ligation. Covered stents are being used increasingly for ASAIs nationwide, despite variable reports of durability. Follow-up is poor in urban trauma centers and might be responsible for the variable patency. Population-based efforts to improve compliance among trauma patients can help improve covered stent patency in ASAI.

Hepatitis C Virus Antibody Testing

Hepatitis C Virus Antibody Testing

Ionised calcium levels in major trauma patients who received blood in the Emergency Department

BackgroundExsanguination and coagulopathy remain one of the leading causes of preventable trauma related death. Low ionised calcium levels have been associated with hypotension and increased mortality and may inhibit clot...

Surgical factors contributing to nonunion in femoral shaft fracture following intramedullary nailing

PurposeTo explore the possible surgical factors related with nonunion in femoral shaft fracture following intramedullary nailing. MethodsWe retrospectively analyzed totally 425 patients with femoral shaft fracture in level I urban trauma center, including 254 males and 171 females, with an average age of 37.6 (ranging from 21 to 56) years old. The inclusion criteria included: (1) traumatically closed fracture of femoral shaft, with preoperative films showing non-comminuted fracture, such as transverse fracture, oblique fracture or spiral fracture; (2) closed reduction and fixation with interlocking intramedullary nail at 3–7 days after trauma; (3) complete follow-up data available. The relationship between the following factors (fracture site, reduction degree, direction of nail insertion and nail size) and nonunion was studied. ResultsThe incidence of femoral nonunion was 2.8% in patients with closed simple fracture undergoing interlocking intrameduallary nailing, including 11 cases of hypertrophic nonunion. Nonunion was related significantly to distal fracture, unsatisfactory reduction and unreamed nail (p < 0.05). There was no significant difference between antegrade nail and retrograde nail (p > 0.05). ConclusionsNonunion in femoral shaft facture following interlocking intramedullary nailing is related to fracture site, fracture reduction and nail diameter. The choice of reamed nails or unreamed nails depends on the fracture site and reduction degree.

Acute Fibrinolysis Shutdown after Injury Occurs Frequently and Increases Mortality: A Multicenter Evaluation of 2,540 Severely Injured Patients

Fibrinolysis is a physiologic process that maintains microvascular patency by breaking down excessive fibrin clot. Hyperfibrinolysis is associated with a doubling of mortality. Fibrinolysis shutdown, an acute impairment of fibrinolysis, has been recognized as a risk factor for increased mortality. The purpose of this study was to assess the incidence and outcomes of fibrinolysis phenotypes in 2 urban trauma centers. Injured patients included in the analysis were admitted between 2010 and 2013, were 18 years of age or older, and had an Injury Severity Score (ISS) > 15. Admission fibrinolysis phenotypes were determined by the clot lysis at 30 minutes (LY30): shutdown ≤ 0.8%, physiologic 0.9% to 2.9%, and hyperfibrinolysis ≥ 3%. Logistic regression was used to adjust for age, arrival blood pressure, ISS, mechanism, and facility. There were 2,540 patients who met inclusion criteria. Median age was 39 years (interquartile range [IQR] 26 to 55 years) and median ISS was 25 (IQR 20 to 33), with a mortality rate of 21%. Fibrinolysis shutdown was the most common phenotype (46%) followed by physiologic (36%) and hyperfibrinolysis (18%). Hyperfibrinolysis was associated with the highest death rate (34%), followed by shutdown (22%), and physiologic (14%, p < 0.001). The risk of mortality remained increased for hyperfibrinolysis (odds ratio [OR] 3.3, 95% CI 2.4 to 4.6, p < 0.0001) and shutdown (OR 1.6, 95% CI 1.3 to 2.1, p= 0.0003) compared with physiologic when adjusting for age, ISS, mechanism, head injury, and blood pressure (area under the receiver operating characteristics curve 0.82, 95% CI 0.80 to 0.84). Fibrinolysis shutdown is the most common phenotype on admission and is associated with increased mortality. These data provide additional evidence of distinct phenotypes of coagulation impairment and that individualized hemostatic therapy may be required.

Patient choice in opt-in, active choice, and opt-out HIV screening: randomized clinical trial

Study question What is the effect of default test offers—opt-in, opt-out, and active choice—on the likelihood of acceptance of an HIV test among patients receiving care in an emergency department?Methods...

Emergency Department Frequent Utilization for Non-Emergent Presentments: Results from a Regional Urban Trauma Center Study.

ObjectivesFirst, to test a model of the drivers of frequent emergency department utilization conceptualized as falling within predisposing, enabling, and need dimensions. Second, to extend the model to include social networks and service quality as predictors of frequent utilization. Third, to illustrate the variation in thresholds that define frequent utilization in terms of the number of emergency department encounters by the predictors within the model.Data SourcePrimary data collection over an eight week period within a level-1 trauma urban hospital’s emergency department.Study DesignRepresentative randomized sample of 1,443 adult patients triaged ESI levels 4–5. Physicians and research staff interviewed patients as they received services. Relationships with the outcome variable, utilization, were tested using logistic regression to establish odds-ratios.Principal Findings70.6 percent of patients have two or more, 48.3 percent have three or more, 25.3 percent have four or more, and 14.9 percent have five or more emergency department visits within 12 months. Factors associated with frequent utilization include gender, race, poor mental health, mental health drugs, prescription drug abuse, social networks, employment, perceptions of service quality, seriousness of condition, persistence of condition, and previous hospital admittance.ConclusionsInterventions targeting associated factors will change global emergency department encounters, although the mutability varies. Policy interventions to address predisposing factors such as substance abuse or access to mental health treatment as well as interventions that speak to enabling factors such as promoting the resiliency of social networks may result in decreased frequency of emergency department utilization.