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BackgroundNecrotizing soft tissue infections (NSTI) are aggressive infections associated with significant morbidity and mortality. Despite multiple predictive models for the identification of NSTI, a subset of patients will not have an NSTI at the time of surgical exploration. We hypothesized there is a subset of patients without NSTI who are clinically indistinguishable from those with NSTI. We aimed to characterize the differences between NSTI and non-NSTI patients and describe a negative exploration rate for this disease process.MethodsWe conducted a retrospective review of adult patients undergoing surgical exploration for suspected NSTI at our county-funded, academic-affiliated medical center between 2008 and 2015. Patients were identified as having NSTI or not (non-NSTI) based on surgical findings at the initial operation. Pathology reports were reviewed to confirm diagnosis. The NSTI and non-NSTI patients were compared using χ2test, Fisher’s exact test, and Wilcoxon rank-sum test as appropriate. A p value ResultsOf 295 patients undergoing operation for suspected NSTI, 232 (79%) were diagnosed with NSTI at the initial operation and 63 (21%) were not. Of these 63 patients, 5 (7.9%) had an abscess and 58 (92%) had cellulitis resulting in a total of 237 patients (80%) with a surgical disease process. Patients with NSTI had higher white cell counts (18.5 vs. 14.9 k/mm3, p=0.02) and glucose levels (244 vs. 114 mg/dL, pConclusionsClinical differences between NSTI and non-NSTI patients are subtle. We found a 20% negative exploration rate for suspected NSTI. Close postoperative attention to this cohort is warranted as a small subset may progress.Level of evidenceRetrospective cohort study, level III.

BackgroundThe American College of Surgeons Bleeding Control Basic (BCon) course aimed at teaching hemorrhage control techniques in the USA had not yet been taught in Spain. The purpose of this study is to assess its implementation among students and healthcare employees in the Lozano Blesa University Hospital of Zaragoza, a middle-sized Spanish city.MethodsThe study was conducted in a University Hospital and at the University of Zaragoza, scheduling four free B-Con sessions from 2017 to 2018. Two groups were identified as forming the population: healthcare employees and medical students. An anonymous questionnaire was completed at the end of the course regarding content, applicability, usefulness, relevance, and satisfaction. Study variables were ranked from 0 to 10: poor (when graded from 0 to 3), fair (4 to 6) and good (7 to 10). Results were compared between the groups, expressed in percentages and χ2 tested to analyze significant differences if any.ResultsAmong the 83 individuals who completed the course, 46 were medical students and 37 healthcare employees; 61% women and 39% men; aged 21 years to 52 years. Attendees evaluated satisfaction with the highest grade (84%), followed by usefulness (73%), applicability (70%), and relevance (66%). There was no variable graded as poor. The comparison of perceptions between groups did not reveal statistical differences based on a 0.05 significance level.ConclusionWe concluded that the B-Con course was valued as good for relevance, usefulness, applicability, and satisfaction by the majority of the studied population.Level of evidenceLevel III.

BackgroundCar hijacking, known as “carjacking”, is a form of aggravated robbery of a vehicle from the driver frequently involving firearm and is common in South Africa. There is, however, little literature on the spectrum of injuries sustained by victims of car hijacking. The study aimed to describe the spectrum of gunshot wound-related (GSW) injuries and review our experience of management of victims of car hijacking in our trauma center based in South Africa.MethodsA retrospective review was conducted during an 8-year period from January 2010 to January 2018 on all patients who presented with any form of GSW after a car hijacking incident.ResultsDuring the 8-year study period, a total of 101 patients were identified. Seventy-four percent were male (75 of 101) and the mean age was 34 years. The mean time from injury to arrival at our trauma center was 7 hours (rural district: 10 hours, urban district: 4 hours; pDiscussionThe spectrum of injuries from GSW related to car hijacking commonly involves close range GSWs to multiple body regions. Torso trauma is common and a substantial proportion of victims require major operative interventions. The mortality from these injuries is significant.Level of EvidenceLevel III.

BackgroundThis study aimed to compare treatment outcomes between patients with severe pelvic fractures treated at a representative trauma center that was established in Korea since 2015 and matched cases treated in the USA.MethodsTwo cohorts were selected from a single institution trauma database in South Korea (Ajou Trauma Data Bank (ATDB)) and the National Trauma Data Bank (NTDB) in the USA. Adult blunt trauma patients with a pelvic Abbreviated Injury Scale >3 were included. Patients were matched based on covariates that affect mortality rate using a 1:1 propensity score matching (PSM) approach. We compared differences in outcomes between the two groups, performed survival analysis for the cohort after PSM and identified factors associated with mortality. Lastly, we analyzed factors related to outcomes in the ATDB dataset comparing a period prior to the implementation of the trauma center according to US standards, an interim period and a postimplementation period.ResultsAfter PSM, a total of 320 patients (160 in each cohort) were identified for comparison. Inhospital mortality was significantly higher in the ATDB cohort using χ2 test, but it was not statistically significant when using Kaplan-Meier survival curves and Cox regression analysis. Moreover, the mortality rate was similar comparing the NTDB cohort to ATDB data reflecting the post-trauma center establishment period. Older age, lower systolic blood pressure (SBP) and Glasgow Coma Scale (GCS) at admission were factors associated with mortality.DiscussionMortality rate after severe pelvic fractures was significantly associated with older age, lower SBP and GCS scores at admission. Efforts to establish a trauma center in South Korea led to improvement in outcomes, which are comparable to those in US centers.Level of evidenceLevel IV.

Background: Although the effects of the trauma center(TC) were researched in several studies, there have been few studies on changes in the regional mortality due to the implementation of a TC.An emergency medical center (EMC) and TC were implemented at Nagasaki University Hospital (NUH) for the first time in the Nagasaki medical region of Japan in April 2010 and October 2011, respectively, and they have cooperated with each other in treating trauma patients. The purpose of this study was to investigate the effects on the early mortality at population level of a TC working in cooperation with an EMC. Methods: This is a retrospective study using standardized regional data (ambulance service record) in Nagasaki medical region from April 2007 through March 2017. We included 19,045 trauma patients directly transported from the scene. The outcome measures were prognosis for one week. To examine the association between the implementation of the EMC and TC and mortality at a region, we fit adjusted logistic regression models. Results: The number of patients of each fiscal year increased from 1492 in 2007 to 2101 in 2016.The number of all patients transported to NUH decreased until 2009 to 70, but increased after implementation of the EMC and TC. Overall mortality of all patients in the region improved from 2.3% in 2007 to 1.0% in 2016.In multivariate logistic regression model, odds ratio of death was significantly smaller at 2013 and thereafter if the data from 2007 to 2011 was taken as reference. Conclusions: Implementation of the EMC and TC was associated with early mortality in trauma patients directly transported from the scene by ambulance. Our analysis suggested that the implementation of EMC and TC contributed to the improvement of the early mortality at a regional city with 500000 populations. Level of evidence: Level III., Trauma Surgery and Acute Care Open, 4(1), art.no.e00029; 2019

BackgroundThis study set out to review a large series of trauma laparotomies from a single center and to compare those requiring damage control surgery (DCS) with those who did not, and then to interrogate a number of anatomic and physiologic scoring systems to see which best predicted the need for DCS.MethodsAll patients over the age of 15 years undergoing a laparotomy for trauma during the period from December 2012 to December 2017 were retrieved from the Hybrid Electronic Medical Registry (HEMR) at the Pietermaritzburg Metropolitan Trauma Service (PMTS), South Africa. They were divided into two cohorts, namely the DCS and non-DCS cohort, based on what was recorded in the operative note. These groups were then compared in terms of demographics and spectrum of injury, as well as clinical outcome. The following scores were worked out for each patient: Penetrating Abdominal Trauma Index (PATI), Injury Severity Score, Abbreviated Injury Scale-abdomen, and Abbreviated Injury Scale-chest.ResultsA total of 562 patients were included, and 99 of these (18%) had a DCS procedure versus 463 (82%) non-DCS. The mechanism was penetrating trauma in 81% of cases (453 of 562). A large proportion of trauma victims were male (503 of 562, 90%), with a mean age of 29.5±10.8. An overall mortality rate of 32% was recorded for DCS versus 4% for non-DCS (pConclusionDCS is indicated in a subset of severely injured trauma patients. A pH Levels of evidenceLevel III.

BackgroundResuscitative endovascular balloon occlusion of the aorta (REBOA) is regaining popularity in the treatment of traumatic non-compressible torso bleeding. Advances in invasive radiology coupled with new damage control measures assisted in the refinement of the technique with promising outcomes. The literature continues to have substantial heterogeneity about REBOA indications, applications, and the challenges confronted when implementing the technique in a level I trauma center. Scoping reviews are excellent platforms to assess the diverse literature of a new technique. It is for the first time that a scoping review is adopted for this topic. Advances in invasive radiology coupled with new damage control measures assisted in the refinement of the technique with promising outcomes. The literature continues to have substantial heterogeneity about REBOA indications, applications, and the challenges confronted when implementing the technique in a level I trauma center. Scoping reviews are excellent platforms to assess the diverse literature of a new technique. It is for the first time that a scoping review is adopted for this topic.MethodsCritical search from MEDLINE, EMBASE, BIOSIS, COCHRANE CENTRAL, PUBMED and SCOPUS were conducted from the earliest available dates until March 2018. Evidence-based articles, as well as gray literature at large, were analyzed regardless of the quality of articles.ResultsWe identified 1176 articles related to the topic from all available database sources and 57 reviews from the gray literature search. The final review yielded 105 articles. Quantitative and qualitative variables included patient demographics, study design, study objectives, methods of data collection, indications, REBOA protocol used, time to deployment, zone of deployment, occlusion time, complications, outcome, and the level of expertise at the concerned trauma center.ConclusionGrowing levels of evidence support the use of REBOA in selected indications. Our data analysis showed an advantage for its use in terms of morbidities and physiologic derangement in comparison to other resuscitation measures. Current challenges remain in the selective application, implementation, competency assessment, and credentialing for the use of REBOA in trauma settings. The identification of the proper indication, terms of use, and possible advantage of the prehospital and partial REBOA are topics for further research.Level of evidenceLevel III.

IntroductionTrauma and injury are significant contributors to the global burden of disease, with 5 million deaths and 250 million disability-adjusted life years lost in 2015. This burden is disproportionally borne by low- and middle-income countries (LMICs). Solutions are complex, but one area for improvement is basic trauma education. The American College of Surgeons has developed the Trauma Evaluation and Management (TEAM) course as an introduction to trauma care for medical students. We hypothesized that the TEAM course would be an effective educational program in LMICs and result in increased knowledge gains and retention similar to students in high-income countries (HICs).MethodsThe TEAM course was taught and students evaluated at two sites, one LMIC (Ghana) and one HIC (USA), after obtaining approval from the HIC Institutional Review Board and medical schools at both sites. Participation was optional for all students and results were de-identified. The course was administered by a single educator for all sessions. Multiple-choice exams were given before and after the course, and again 6 months later.ResultsA total of 62 LMIC and 64 HIC students participated in the course and completed initial testing. Demographics for the two groups were similar, as was participant attrition over time. LMIC students started with a relative knowledge deficit, scoring lower on both pre-course and post-course tests than HIC students, but gained more knowledge during the initial teaching session. After 6 months, the LMIC students continued to improve, whereas the HIC students’ knowledge had regressed. Most students recommended course expansion.ConclusionThe TEAM course is a useful tool to provide the basic principles of trauma care to students in LMICs, and should be expanded. Further study is needed to determine the impact of TEAM education on patient care in LMICs.Level of evidenceLevel III; Care Management

IntroductionRib fractures in elderly patients are associated with increased morbidity and mortality. Predicting which patients are at risk for complications is an area of debate. Current models use anatomic, physiologic or laboratory parameters in isolation to answer this question. The ‘RibScore’ is an anatomic model that assesses fracture severity. Given that frailty is a major driver of adverse outcomes in the elderly, we hypothesize that the combined analysis of fracture severity, physiologic reserve and current pulmonary function are better predictors of respiratory compromise in this population.MethodsThis is a retrospective chart review of 263 trauma patients age ≥55 from January 2014 to June 2017. Criteria included blunt mechanism and ≥ 1 rib fracture identified by CT. Variables indicating adverse pulmonary outcomes were defined by: pneumonia, respiratory failure and tracheostomy. Three models were assessed: (1) RibScore, (2) Modified Frailty Index (mFI) and (3) initial partial pressure of carbondioxide (PaCO2).ResultsA total of 263 patients met inclusion criteria. 13% developed pulmonary complications. Increased RibScore, mFI and PaCO2 were each statistically associated with risk of complications. Receiver operating characteristics area under the curve analysis of individual models predicted complications with the following concordance statistic (CS): anatomic (RibScore) yielded a CS of 0.79 (95% CI 0.69 to 0.89); physiologic (mFI) yielded a CS of 0.83 (95% CI 0.75 to 0.91) and laboratory (PaCO2) yielded a CS of 0.88 (95% CI 0.80 to 0.95). The PaCO2 had the highest discriminative ability of the three individual models. Combining all three models yielded the best performance with a CS of 0.90 (95% CI 0.81 to 0.97).DiscussionThe RibScore maintains discriminative ability in the elderly. However, models based on mFI and PaCO2 individually outperform the RibScore. A combination of all three models yields the highest discriminative ability. This combined approach is best for assessing the severity of rib fractures and prediction of complications in the elderly.Level of evidencePrognostic Study, Level III.

BackgroundIt is not mandatory for Japanese trauma centers to have an operating room (OR) and OR team available 24 hours a day/7 days a week. Therefore, emergency laparotomy/thoracotomy is performed in the emergency department (ED). The present study was conducted to assess the safety of this practice.MethodsThe data were reviewed from 88 patients who underwent emergency trauma laparotomy and/or thoracotomy performed by our acute care surgery group during the period from April 2013 to December 2017. Operation was performed in the ED for 43 of 88 patients (51%, ED group), and in the OR for 45 of 88 patients (49%, OR group). The perioperative outcomes of the two groups were compared.ResultsCompared with the OR group, the ED group had a higher Injury Severity Score (30±15 vs. 13±10, pDiscussionEmergency trauma laparotomy and/or thoracotomy outcomes were related to injury severity. The resources for trauma operations in the ED seemed suboptimal. The outcome of trauma operations may be improved by reviewing the protocols for anesthetic care, and by the usage of REBOA rather than aortic cross-clamping.Level of evidenceIV

BackgroundTraumatic brain injuries (TBIs) are a common cause of emergency department (ED) visits and hospital admissions in Kampala, Uganda. The objective of this study was to assess determinants of ED discharge disposition based on patient demographic and injury characteristics. Four ED outcomes were considered: discharge home, hospital admission, death, and others.MethodsThis prospective study was conducted at Mulago National Referral Hospital, Kampala, Uganda, from May 2016 to July 2017. Patients of all age groups presenting with TBI were included. Patient demographics, external causes of injury, TBI characteristics, and disposition from EDs were noted. Injury severity was estimated using the Glasgow Coma Scale (GCS), Kampala Trauma Score (KTS), and the Revised Trauma Score (RTS). A multinomial logistic regression model was used to estimate conditional ORs of hospital admission, death, and other dispositions compared with the reference category “discharged home”.ResultsA total of 3944 patients were included in the study with a male versus female ratio of 5.5:1 and a mean age of 28.5 years (SD=14.2). Patients had closed head injuries in 62.9% of cases. The leading causes of TBIs were road traffic crashes (58.8%) and intentional injuries (28.7%). There was no significant difference between the four discharge categories with respect to age, sex, mode of arrival, cause of TBI, place of injury, type of head injury, transport time, and RTS (p>0.05). There were statistically significant differences between the four discharge categories for a number of serious injuries, GCS on arrival, change in GCS, and KTS. In a multinomial logistic regression model, change in GCS, area of residence, number of serious injuries, and KTS were significant predictors of ED disposition.DiscussionThis study provides evidence that ED disposition of patients with TBI is differentially affected by injury characteristics and is largely dependent on injury severity and change in GCS during ED stay.Level of evidenceLevel II.

IntroductionRoad traffic injuries (RTIs) are the leading cause of preventable death in Qatar; consequently, the country has participated in the Decade of Action for Road Safety (DoARS) coordinated by the United Nations Road Safety Collaboration (UNRSC). Its goal is to reduce the number of road traffic deaths and injuries by 50% by 2020, by implementing road safety activities, in the areas of road safety management, safer roads, safer vehicles, safer road users and postcrash response, the five pillars. This study will evaluate the initiatives and programs implemented in Qatar, during the initial period of the DoARS.MethodsA retrospective process evaluation of the compliance of national road safety activities in Qatar, with global indicators for the DoARS set by the UNRSC was conducted. A web-based online and electronic media search, in both official languages of Qatar: Arabic and English, for data and information on completed or ongoing road safety initiatives and activities implemented in Qatar, from January 1, 2011 to December 31, 2016, was supplemented by personal consultation with relevant stakeholders in the road safety field.ResultsThere was complete compliance for Pillars 1 (Road Safety Management) and 2 (Safer Roads), whereas Pillars 4 (Safer Road Users) and 5 (Postcrash Response) met most of the DoARS indicators, and Pillar 3 (Safer Vehicles) complied with none.ConclusionQatar must continue to implement its present road safety activities within the Action Plan for the DoARS to achieve its goals by 2020. It must, however, implement more new efforts to require safer vehicles and make road users safer, especially those at the highest risk, that is, young drivers, occupants and workers.Level of EvidenceLevel IV.

BackgroundInjuries due to encounters with animals can be serious, but are often discussed anecdotally or only for isolated types of encounters. We sought to characterize animal-related injuries presenting to US emergency departments (ED) to determine the impact of these types of injuries.MethodsAll ED encounters with diagnosis codes corresponding to animal-related injury were identified using ICD-9-CM codes from the 2010 2014 National Emergency Department Sample (NEDS). Outcomes assessed included inpatient admission, mortality, and healthcare cost. Survey methodology was applied to univariate and multivariate analyses. Weighted numbers are presented.ResultsThere were 6 457 534 ED visits resulting from animal-related injuries identified. Bites from non-venomous arthropods (n=2 648 880; 41%), dog bites (n=1 658 295; 26%) and envenomation from hornets, wasps or bees (n=812 357; 13%) constitute the majority of encounters. There were 210 516 patients (3%) admitted as inpatients. Inpatient admission was most common for those suffering from venomous snakes or lizard bites (24%, n=10 332). Death was infrequent occurring in 1162 patients (0.02% of all ED presentations). The greatest number of deaths was due to bites from non-venomous arthropods (24% of deaths, n=278) whereas rat bites proved the most lethal (6.5 deaths per 10 000 bites). Among persons aged 85 years or greater, odds of hospital admission for any animal-related injury was 6.42 (95% CI 5.57 to 7.40) and the OR for death was 27.71 (95% CI 10.38 to 73.99). Female sex was associated with improved survival (OR 0.55, 95% CI 0.41 to 0.73) and lower rates of hospital admission (OR 0.77, 95% CI 0.75 to 0.79). The total healthcare cost for these animal encounters during the observed time period was $5.96 billion (95% CI $5.43 to $6.50 billion).ConclusionThe morbidity, mortality, and healthcare cost due to animal encounters in the USA is considerable. Often overlooked, this particular mechanism of injury warrants further public health prevention efforts.Level of EvidenceLevel IV.

BackgroundThe National Trauma Data Bank (NTDB) has served as a global benchmark for trauma care quality and outcomes. Herein, we compared patient characteristics, trauma management, and outcomes between Japanese emergency and critical care centers and US level 1 trauma centers using the Japanese Trauma Data Bank (JTDB) and NTDB.MethodsA retrospective cohort matching (1:1) study was performed. Patients treated in 2013 with an Injury Severity Score ≥9 were included. The primary outcome measure was in-hospital mortality. The secondary outcome measures included the hospital length of stay and the rate of use of radiological diagnostic modalities.ResultsA total of 14 960 pairs with well-balanced characteristics were generated from 22 535 and 112 060 eligible patients in the JTDB and NTDB, respectively. Before matching, the in-hospital mortality was higher in the JTDB than in the NTDB (7.6% vs. 6.1%; OR, 1.28; 95% CI 1.21 to 1.35). However, after matching, the in-hospital mortality was lower in the JTDB cohort (4.2% vs. 5.8%; OR, 0.72; 95% CI 0.65 to 0.80). CT scans were used in >80% of JTDB patients, which was more than 1.5 times as often as the use in the NTDB cohort. In subgroup analyses, only patients who received a blood transfusion had a poorer survival outcome in the JTDB compared with the NTDB (OR, 1.32; 95% CI 1.07 to 1.64).DiscussionWe observed marked differences in trauma care between Japan and the USA. Although the quality of the recent Japanese trauma care appears to be approaching that of the USA, it may be further improved, such as by the establishment of transfusion protocols.Level of evidenceLevel IV.

BackgroundEarly operative intervention for hip fractures in the elderly is advised to reduce mortality and morbidity. Postoperative complications impose a significant burden on patient outcomes and cost of medical care. Our aim was to determine the relationship between time to surgery and postoperative complications/mortality in patients with hip fracture.MethodsThis is a retrospective review of data collected from our institution’s trauma registry for patients ≥65 years old with isolated hip fracture and subsequent surgery from 2015 to 2017. Patients were stratified into two groups based on time to surgery after admission: group 1: 48 hours. Demographic variables included age, gender, race, and Injury Severity Score (ISS). The outcome variables included intensive care unit length of stay (ICU-LOS), deep venous thrombosis (DVT), pulmonary embolism (PE) rate, mortality, and 30-day readmission rates. Analysis of variance was used for analysis, with significance defined as a p value ResultsA total of 485 patients with isolated hip fracture required surgical intervention. Of those, 460 had surgery 48 hours postadmission. The average ISS was the same in both groups. The average ICU-LOS was significantly higher in the >48 hours group compared with the DiscussionTime to surgery may affect overall ICU-LOS in patients with hip fracture requiring surgical intervention. Time to surgery does not affect complication rates, 30-day readmission, or mortality. Future research should investigate long-term outcomes such as functional status and disability-adjusted life years.Level of evidenceIII. Retrospective/ prognostic cohort study