Search

Nearly 10% of pregnant women suffer traumatic injury. Clinical outcomes for pregnant trauma patients (PTPs) with severe injuries have not been well studied. We sought to describe outcomes for PTPs presenting with severe injuries, hypothesizing that PTPs with severe injuries will have higher rates of complications and mortality compared to less injured PTPs. A post-hoc analysis of a multi-institutional retrospective study at 12 Level-I/II trauma centers was performed. Patients were stratified into severely injured (injury severity score [ISS] > 15) and not severely injured (ISS < 15) and compared with bivariate analyses. From 950 patients, 32 (3.4%) had severe injuries. Compared to non-severely injured PTPs, severely injured PTPs were of similar maternal age but had younger gestational age (21 vs 26 weeks, p = 0.009). Penetrating trauma was more common in the severely injured cohort (15.6% vs 1.4%, p < 0.001). The severely injured cohort more often underwent an operation (68.8% vs 3.8%, p < 0.001), including a hysterectomy (6.3% vs 0.3%, p < 0.001). The severely injured group had higher rates of complications (34.4% vs 0.9%, p < 0.001), mortality (15.6% vs 0.1%, p < 0.001), a higher rate of fetal delivery (37.5% vs. 6.0%, p < 0.001) and resuscitative hysterotomy (9.4% vs. 0%, p < 0.001). Only approximately 3% of PTPs were severely injured. However, severely injured PTPs had a nearly 40% rate of fetal delivery as well as increased complications and mortality. This included a resuscitative hysterotomy rate of nearly 10%. Significant vigilance must remain when caring for this population., (© 2024. The Author(s).)

Introduction: Massive transfusion activations (MTAs) are commonly used in the care of the trauma patient. However, MTA for trauma patients constitutes only a small fraction of MTA at our institution. The aim of this study was to characterize MTA in non-trauma patients to better understand how this strategy is employed at a larger tertiary hospital., Methods: All MTA involving non-trauma patients from January 2017 to April 2019 were reviewed. Patients with unclear indications for MTA were excluded. Data collected included patient demographics, reason for MTA, transfusion ratios, use of adjunctive antifibrinolytics, use of viscoelastic testing, and vasopressor administration at the time of MTA., Results: There were 328 patients and 353 MTA identified over the study period. The mean age was 52.0 years and 40.9% were male. Patients were most commonly under the care of a medical service (55.2%), while 25.3% were obstetric patients and 19.5% were surgical patients. Compliance with 1:1:1 transfusion ratios was low. Concomitant vasopressor use was high (70.8%), while antifibrinolytic agents (13.0%) and viscoelastic testing (19.0%) were used less commonly. The overall mortality of the study population was 56.1%., Conclusions: Massive transfusion activations are frequently used in non-trauma patients. There was a low rate of adherence to 1:1:1 transfusion ratios as well as utilization of adjuncts and tools that could allow for targeted resuscitation. Understanding practice patterns relating to MTA may allow for an opportunity for improvement.

Introduction: Enoxaparin dosed by an anti-Xa trough level is effective at reducing venous thromboembolism (VTE) in trauma patients. We identified the patient characteristics associated with higher enoxaparin dosing based on anti-Xa trough levels., Methods: A retrospective review was conducted on trauma patients admitted between August 2014 and February 2018 who received enoxaparin dosed by the anti-Xa trough level. Patients who received enoxaparin < 50 mg every 12 hours were compared to those who required ≥ 50 mg every 12 hours., Results: Of the 246 patients included, 32 (13.0%) required enoxaparin ≥ 50 mg every 12 hours to achieve the prophylactic trough level. Factors associated with a higher dose of enoxaparin were male (96.8% vs. 3.2%, P < .01), younger age (39.5 vs. 52.7 years, P < .01), higher creatinine clearance (CrCl) (125.9 vs. 93.7 mL/min, P < .01), higher body surface area (2 m 2 vs. 1.8 m 2 , P < .01), and higher injury severity score (18.4 vs. 10.8, P < .01). Height, weight, and body mass index were not significant factors. On regression analysis, CrCl was the only independent predictor for higher enoxaparin dose. There was an increased deep venous thrombosis rate in the higher dose cohort (12.5% vs. 0, P < .01) but no significant differences in transfusion rates., Conclusion: Trauma patients who require higher enoxaparin doses to achieve prophylactic anti-Xa trough levels have a higher CrCl. Patients with high CrCl may benefit from an initial higher dose of enoxaparin to achieve a target anti-Xa level in a shorter time interval to decrease VTE risk.

Aim: Pedestrian fatalities commonly involve alcohol. We sought to characterize alcohol intoxication among pedestrians struck by vehicles and examine correlations between admission time and injury severity., Methods: The Los Angeles County Trauma and Emergency Medicine Information System database was reviewed for pedestrians struck by vehicles over a 16-year period starting January 2000. Subjects aged ≥18 years with available time and day of admission were selected. Patients with available blood alcohol content (BAC) were analyzed and those with positive (+) BAC (≥ 0.01%) were compared with those with negative (-) BAC. The primary outcome was mortality., Result: 35 840 patients met criteria, with 12 122 (33.8%) tested for BAC. 71.2% were (+) BAC. The proportion of (+) BAC pedestrians peaked at 02:00 (48.9% of admitted pedestrians, 88.5% of BAC tested pedestrians). Patients with a (+) BAC were more likely hypotensive (3.5% vs 2.7%, P = .019) and admitted with a Glasgow Coma Scale ≤ 8 (9.4% vs 7.1%, P < .001). Overall mortality was 4.6%. Those admitted from 06:00 to 11:00 had the highest odds of mortality in (+) BAC patients (4.7%, adjusted odds ratio 3.16, adjusted P < .001)., Conclusion: Pedestrians struck by vehicles during late hours are commonly intoxicated. These findings could help legislators to implement changes and strategies to decrease the risk and burden of injury in intoxicated pedestrians.

Background: The purpose of this study was to investigate trends in tracheostomy (TR) utilization among trauma patients over the last decade and explore its impact on mortality among elderly trauma patients., Methods: Patients 18 years or older with at least 72 h on the ventilator were selected from the National Trauma Databank research datasets 2007 to 2015. Patients were divided into three groups based on age: 18-60, 61-80, and > 80 years and proportions of patients undergoing a TR were depicted. Elderly (> 80 years) were divided into two groups, based on whether they underwent a TR. The primary outcome was mortality. A Cox regression model with a time-dependent variable was utilized to account for survival bias., Results: Over the 9-year study period 284,774 patients met inclusion criteria. Of those, 21,465 (7.5%) were older than 80 years. Elderly patients were significantly less likely to undergo a TR (13.1% vs. 21.5% in the 18-60 years and 20.4% in the 61-80 years group, p < 0.01) and this trend continued throughout the study period. Among the elderly patients, those who underwent TR were more likely to have a severe (AIS ≥ 3) thoracic, abdominal, and/or spinal injury, but not head injury and were less likely to have a history of cerebrovascular accident (5.9% vs. 7.7%, p < 0.01). The overall mortality was significantly higher in elderly patients who did not undergo a TR (46.9% vs. 17.6%, p < 0.01). The adjusted hazard ratio for elderly patients undergoing a TR was 0.36 (adjusted p < 0.01)., Conclusion: In ventilated trauma patients, tracheostomy is less likely to be utilized in the elderly population compared to younger age groups. Amongst the elderly patients, performance of tracheostomy was associated with a significantly higher overall survival. Delaying or avoiding this procedure in the elderly trauma patient predominantly based on age might not be justified., Study Type: Prognostic/epidemiological., Level of Evidence: III or IV.

Trauma patients have a high risk for venous thromboembolism (VTE) such that an increased enoxaparin dose is necessary to reduce related complications. Given that most trauma patients require an enoxaparin dose of at least 40 mg every 12 hours for VTE prophylaxis, we sought to identify which patients require enoxaparin 30 mg every 12 hours and hypothesized that both weight and low creatinine clearance (CrCl) would more likely determine enoxaparin dosing than age, body mass index (BMI), or body surface area (BSA). Single institution data were collected on trauma patients between August 2014 and February 2018 to compare trauma patients who required enoxaparin 30 mg to those who required ≥40 mg every 12 hours. Of the 245 patients included, 86 (35.1%) required enoxaparin at 30 mg to achieve the goal anti-factor Xa trough level. Factors associated with low dose enoxaparin were older age (59.6 vs. 46.2 years, P ≤ .01) and lower CrCl (81.5 mL/min vs. 93.7 mL/min, P ≤ .01). Weight, BSA, and BMI did not alter the dose of enoxaparin. A regression model determined that only CrCl predicted the need for low dose enoxaparin (adjusted odds ratio .982, 95% CI: .975-.990, P < .01). Although an initial dose of enoxaparin 40 mg is appropriate for most trauma patients, patients with low CrCl should receive 30 mg. Increased age and low weight were not associated with the need for a lower enoxaparin dose.

Background: Access to centers with extracorporeal membrane oxygenation (ECMO) capabilities varies by region and may affect overall outcomes. We assessed the outcomes of trauma patients requiring ECMO support and compared the overall survival of all patients with trauma at facilities with and without ECMO capabilities., Methods: A retrospective review of the National Trauma Data Bank was performed to identify all trauma patients receiving care at ECMO and non-ECMO centers. Baseline patient characteristics and outcomes were analyzed. Adjusted odds ratio (OR) was used to compare survival at ECMO and non-ECMO facilities., Results: Between 2007 and 2015, a total of 5 781 123 patients with trauma were identified with 1 983 986 (34%) admitted to an ECMO facility and 3 797 137 (66%) admitted to a non-ECMO facility. A total of 522 (0.03%) patients required ECMO. Both the number of patients with trauma requiring ECMO support and the number of trauma facilities utilizing ECMO increased over the 9-year-study period (4.9 to 13.8 patients per 100 000 admissions, and 18 to 77 centers, respectively). The mortality for ECMO patients was 40.5%. Patients with trauma admitted to ECMO facilities had more severe injuries (injury severity score: 9.0 vs 8.0; P < .001). The overall mortality was 3.3%. The adjusted OR for mortality associated with admission to an ECMO facility vs a non-ECMO facility was 0.96 (95% confidence interval: 0.95-0.97; adjusted P < .001)., Conclusions: The use of ECMO for patients with trauma is expanding. Our study demonstrates a survival benefit associated with admission to a facility with ECMO capabilities. Thus, access to ECMO is a potential quality metric for trauma centers., (© 2020 Wiley Periodicals, Inc.)

Elderly patients are at high risk for mortality after injury, and prevention is imperative. Several studies have captured the value of traffic calming or environmental modifications; however, limited data support its use during focused times of the day to reduce pedestrian trauma. This study's aim was to identify when the elderly are more likely to be injured from pedestrian trauma. The Los Angeles County Trauma and Emergency Medicine Information System database was reviewed for all adult pedestrians who were struck by vehicles from 2000 to 2015. Elderly (≥65 years) patients were compared with nonelderly (range, 18-64 years) patients with respect to the time of admission and mortality. The proportion of elderly pedestrian injuries peaked between 9 and 10 am (23%). Compared with their nonelderly counterparts, the elderly were more likely to have a Glasgow Coma Scale ≤ 8 (11% vs 7%, P < 0.01), be hypotensive (6% vs 3%, P < 0.01), and have a higher Injury Severity Score (median 9 vs 5, P < 0.01). Mortality was significantly higher in the elderly (14% vs 4%, P < 0.01). Elderly pedestrians had an almost 5-fold higher adjusted odds ratio for death: 4.72 ( P < 0.01). Preventative strategies with lower speed limits or high surveillance during these hours in highly populated areas may result in a decreased incidence of these injuries.

Rapid transfer of trauma patients to a trauma center for definitive management is essential to increase survival. The utilization of helicopter transportation for this purpose remains heavily debated. The purpose of this study was to characterize the trends in helicopter transportations of trauma patients in the United States over the last decade. Subjects with a primary mode of either ground or helicopter transportation were selected from the National Trauma Data Bank datasets 2007 to 2015. Over this period, the proportion of patients transported by a helicopter decreased significantly in a linear fashion from 17 per cent in 2007 to 10.2 per cent in 2015 ( P < 0.001). The overall mortality of this population was 7.6 per cent and remained unchanged over the study period ( P = 0.545). Almost 3 of 10 subjects (29.4%) transported by a helicopter had an Injury Severity Score <9. The proportion of elderly (>65 years) patients requiring helicopter transportation increased by 69.1 per cent, whereas their associated mortality decreased by 21.5 per cent. The use of a helicopter for the transportation of trauma patients has significantly decreased over the last decade without any significant change in mortality, possibly indicating more effective utilization of available resources. Overtriage of patients with minor injuries remained relatively unchanged.

Background: The purpose was to examine the incidence of positive cultures in a highly susceptible subset of trauma patients admitted to the surgical intensive care unit (SICU) for mechanical ventilation and to examine the impact of their timing on outcomes., Patients and Methods: A retrospective review was conducted of blunt trauma patients admitted to the SICU for mechanical ventilation at a level I trauma center over a five-year period. All urine, blood, and sputum cultures were abstracted. Patients with at least one positive culture were compared with those with negative or no cultures. The primary outcome was mortality. A Cox regression model with a time-dependent variable was utilized to calculate the adjusted hazard ratio (AHR)., Results: The median age of 635 patients meeting inclusion criteria was 46 and 74.2% were male. A total of 298 patients (46.9%) had at least one positive culture, with 28.9% occurring within two days of admission. Patients with positive cultures were more likely to be severely injured with an injury severity score (ISS) ≥16 (68.5% vs. 45.1%, p < 0.001). Overall mortality was 22%. Patients who had their first positive culture within two and three days from admission had a significantly higher AHR for mortality (AHR: 14.46, p < 0.001 and AHR: 10.59, p = 0.028, respectively) compared to patients with a positive culture at day six or later., Conclusions: Early positive cultures are common among trauma patients requiring mechanical ventilation and are associated with higher mortality. Early identification with "damage control cultures" obtained on admission to aid with early targeted treatment might be justified.

Although guidelines for the performance of an emergency department thoracotomy (EDT) are available, high level evidence remains scarce potentially leading to variation in decisions and practices among trauma surgeons. The National Trauma Databank was queried for all subjects who died in the emergency department (ED) between 2007 and 2011. Trauma centers were divided into four quartiles based on the rate of EDT among ED deaths. A total of 31,623 subjects admitted to 729 trauma centers met inclusion criteria. Most of of these centers (n = 328, 53%) never performed an EDT during the study period. Very few outlier centers (1.1%) performed this procedure in 50.0 per cent or more of all patients who died in the ED. Trauma centers in the highest quartiles in performing EDT were more likely to intervene with both surgical and nonsurgical procedures in patients who died in the ED, independent of the performance of an EDT. There are significant variations among trauma centers in the management of trauma patients who expire in the ED. Further research at a national level toward standardizing the management of the trauma patient in extremis and the decision to perform an EDT is necessary, given the extremely low survival associated with this procedure.

Importance: While assault is commonly reported or suspected in children with traumatic wounds, a recent overview of these injuries, especially those requiring trauma surgery consultation is lacking in the literature., Objectives: Explore the incidence, demographics and injury patterns of children presenting to trauma centers following an assault., Design: Retrospective review of the National Trauma Data Bank 2007 to 2011., Setting and Participants: Subjects up to 18 years old with "assault" reported as the intent of injury. Patients were divided into infants (<2 years), young children (2-5 years), children (6-11 years), and adolescents (12-18 years)., Main Outcomes and Measures: Mechanism of injury, injury severity and mortality based on age groups and race., Results: Of 609,207 children, 58,299 (9.6%) were victims of an assault. The median age was 16 years and 81% were male, with a median injury severity score (ISS) of 8. The majority of patients were adolescents (76%), followed by infants (17%) and young children (4%). There was a stepwise increase in the proportion of assaulted Black children with increasing age (23.2% for infants and up to 46.7% for adolescents, trend p < 0.01, effect size: 0.175) while the opposite applied for White children (46.0% for infants and down to 19.5% for adolescents, trend p < 0.01, effect size: -0.230). With increasing age, White subjects had the highest trend of being assaulted during an unarmed fight or brawl (p < 0.01, effect size: 0.393), while for Black victims the highest trend was noted for assault with a firearm (p < 0.01, effect size: 0.323). Almost 2 out of 3 infants sustained severe head trauma (59%). The overall mortality was 8%, highest among young children, where it reached 16% (p < 0.01)., Conclusions: Up to 10% of children admitted following trauma are victims of assault with traumatic brain injuries predominant in infants and firearm injuries predominant in adolescents. Injury patterns largely correlate to age and race. Assault in children is associated with a high mortality risk. These data highlight the magnitude of the problem and calls for further involvement of trauma surgeons to improve outcomes, bring awareness and promote preventative strategies to eliminate assault in children., (Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)