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Objective: The relationship between baseline (i.e., pre-injury) blood pressure and trauma outcomes in elderly patients is unknown. We therefore aimed to identify the independent impact of baseline systolic blood pressure (SBP) on inpatient mortality among elderly trauma patients., Methods: The 2004 to 2014 trauma registries of two Level I Trauma Centers were linked to electronic health records then reviewed to identify patients ≥65 years old with available baseline vital signs. Baseline SBP was defined as mean outpatient SBP within 2 years before injury. Trauma SBP was defined as first SBP reading after presentation for trauma. Baseline and Trauma SBP were classified as Low (<110 mm Hg), Normal (110-139 mm Hg), or High (≥140 mm Hg). Logistic multivariable regression models were constructed to assess the independent impact of Baseline SBP on inpatient mortality, controlling for demographics, comorbidities, injury mechanism/severity, and Trauma SBP., Results: Of 37,494 patient admissions, 4,233 met inclusion criteria. Median age was 81 years; 63.6% were female. Mortality was 5.39%. In unadjusted analyses, mortality rates were 11.01%, 5.28%, and 4.52% in the Low, Normal, and High Baseline SBP groups, respectively (p = 0.001). In multivariable analyses, patients with Low Baseline SBP had significantly increased mortality risk [OR 3.19 (95% CI 1.62-6.26), p = 0.001] compared to patients with Normal Baseline SBP, in particular when they presented with Low Trauma SBP (<110 mm Hg) [OR 6.14 (2.17-17.36), p = 0.001] or Normal Trauma SBP (110-139 mm Hg) [OR 3.87 (1.43-10.45), p = 0.008]. The mortality risk associated with Low Baseline SBP was particularly elevated among patients with a pre-existing diagnosis of hypertension [OR 4.78 (1.97-11.62), p = 0.001]., Conclusion: Low baseline pre-injury SBP is independently associated with more than a threefold increase in inpatient mortality among elderly trauma patients and a fivefold increase in mortality risk among patients with pre-existing hypertension. Given that blood pressure control in the elderly offers a long-term survival advantage, the paradoxical finding of decreased survival after trauma warrants further investigation., Level of Evidence: Prognostic/epidemiologic study, level III.

Background: There currently exists no preoperative risk stratification system for emergency surgery (ES). We sought to develop an Emergency Surgery Acuity Score (ESAS) that helps predict perioperative mortality in ES patients., Methods: Using the 2011 American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database (derivation cohort), we identified all surgical procedures that were classified as "emergent." A three-step methodology was then performed. First, multiple logistic regression models were created to identify independent predictors (e.g., patient demographics, comorbidities, and preoperative laboratory variables) of 30-day mortality in ES. Second, based on the relative impact of each identified predictor (i.e., odds ratio), using weighted averages, a novel score was derived. Third, using the 2012 ACS-NSQIP database (validation cohort), the score was validated by calculating its C statistic and evaluating its ability to predict 30-day mortality., Results: From 280,801 NSQIP cases, 18,439 ES cases were analyzed, of which 1,598 (8.7%) resulted in death at 30 days. The multiple logistic regression analyses identified 22 independent predictors of mortality. Based on the relative impact of these predictors, ESAS was derived with a total score range of 0 to 29. ESAS had a C statistic of 0.86; the probability of death at 30 days gradually increased from 0% to 36% then 100% at scores of 0, 11, and 22, respectively. In the validation phase, 19,552 patients were included, the mortality rate was 7.2%, and the ESAS C statistic stayed at 0.86., Conclusion: We have therefore developed and validated a novel score, ESAS, that accurately predicts mortality in ES patients. Such a score could prove useful for (1) preoperative patient counseling, (2) identification of patients needing close postoperative monitoring, and (3) risk adjustment in any efforts at benchmarking the quality of ES., Level of Evidence: Prognostic/epidemiologic study, level III.

Background: Emergency surgery (ES) is acknowledged to be riskier than nonemergency surgery (NES). Yet, little is known about the relative impact of individual perioperative risk factors on 30-day outcomes in ES versus NES., Methods: Using the 2011-2012 American College of Surgeons National Surgical Quality Improvement Program nationwide database, the 20 most common ES procedures were identified by Current Procedural Terminology code. Current Procedural Terminology codes with less than 300 observations in either ES or NES were excluded. Emergency surgery cases were defined as "emergent" and "nonelective" per American College of Surgeons National Surgical Quality Improvement Program criteria. Multivariable regression models were constructed to identify predictors of 30-day major morbidity and mortality (MMM) in each group, controlling for demographics, American Society of Anesthesiologists class, comorbidities, preoperative laboratory values, and procedure type. The odds ratios of independent predictors of MMM in ES and NES were derived then individually compared between the two groups; "effect modification" of procedure status (ES vs. NES) on each risk factor was subsequently calculated., Results: Of 986,034 patients, 170,131 met inclusion criteria (59,949 ES; 110,182 NES). The overall risk of MMM was significantly higher in ES versus NES (16.75% vs. 9.73%, p < 0.001; odds ratio, 1.18; 95% confidence interval, 1.12-1.24; p < 0.001). Of 40 ES- and 38 NES-identified independent risk factors, preoperative transfusion and white blood cell count of 4.5 × 10/μL or less carried significantly higher relative risk of MMM in ES versus NES. Conversely, ascites, preoperative anemia, and white blood cell count of 11 × 10/μL to 25 × 10/μL carried greater relative risk for MMM in NES. Four procedures (laparoscopic cholecystectomy, laparotomy, and umbilical and incisional herniorrhaphy) were inherently riskier in ES versus NES. The effect modification of ES (vs. NES) ranged between 0.68 (0.52-0.88) for ascites and 2.56 (1.67-3.92) for umbilical hernia repair., Conclusions: Perioperative risk factors and procedure type impact postoperative morbidity and mortality differently in ES versus NES. Instead of using the same risk-adjustment model for both ES and NES, as currently practiced, our findings strongly suggest the need to benchmark emergent and elective surgeries separately., Level of Evidence: Prognostic/epidemiologic study, level III.

Background: The Boston Marathon bombing was the first major, modern US terrorist event with multiple, severe lower extremity injuries. First responders, including trained professionals and civilian bystanders, rushed to aid the injured. The purpose of this review was to determine how severely bleeding extremity injuries were treated in the prehospital setting in the aftermath of the Boston Marathon bombing., Methods: A database was created and populated by all the Boston Level I trauma centers following the Boston Marathon bombing. Data regarding specific injuries, extremities affected, demographics, prehospital interventions (including tourniquet types), and outcomes were extracted., Results: Of 243 injured, 152 patients presented to the emergency department within 24 hours. Of these 152 patients, there were 66 (63.6% female) experiencing at least one extremity injury, with age ranging from younger than 15 years to 71 years, and with a median Injury Severity Score (ISS) of 10 (range, 1-38). Of the 66 injured patients, 4 had upper limbs affected, 56 had injuries on the lower limbs only, and 6 had combined upper and lower limbs affected. The extremity Abbreviated Injury Scale (AIS) scores had a median of 3 (range, 1-4). There were 17 lower extremity traumatic amputations in 15 patients. In addition, there were 10 patients with 12 lower extremities experiencing major vascular injuries. Of 66 injured patients, 29 patients had recognized extremity exsanguination at the scene. In total, 27 tourniquets were applied: 16 of 17 traumatic amputations, 5 of 12 lower extremities with major vascular injuries, and 6 additional limbs with major soft tissue injury. All tourniquets were improvised, and no commercial, purpose-designed tourniquets were identified. Among all 243 patients, mortality was 0%., Conclusion: After the Boston Marathon bombings, extremity exsanguination at the point of injury was either left untreated or treated with an improvised tourniquet in the prehospital environment. An effective, prehospital extremity hemorrhage control posture should be translated to all civilian first responders in the United States and should mirror the military's posture toward extremity bleeding control. The prehospital response to extremity exsanguination after the Boston Marathon bombing demonstrates that our current practice is an approach, lost in translation, from the battlefield to the homeland., Level of Evidence: Epidemiologic study, level V.