Shift in Prehospital Mode of Transportation for Trauma Patients During the COVID-19 Pandemic.

INTRODUCTION: Since the start of the COVID-19 pandemic, we experienced alterations to modes of transportation among trauma patients suffering penetrating injuries. Historically, a small percentage of our penetrating trauma patients use private means of prehospital transportation. Our hypothesis was that the use of private transportation among trauma patients increased during the COVID-19 pandemic and was associated with better outcomes. METHODS: We retrospectively reviewed all adult trauma patients (January 1, 2017 to March 19, 2021), using the date of the shelter-in-place ordinance (March 19, 2020) to separate trauma patients into prepandemic and pandemic patient groups. Patient demographics, mechanism of injury, mode of prehospital transportation, and variables such as initial Injury Severity Score, Intensive Care Unit (ICU) admission, ICU length of stay, mechanical ventilator days, and mortality were recorded. RESULTS: We identified 11,919 adult trauma patients, 9017 (75.7%) in the prepandemic group and 2902 (24.3%) in the pandemic group. The number of patients using private prehospital transportation also increased (from 2.4% to 6.7%, P < 0.001). Between the prepandemic and pandemic private transportation cohorts, there were reductions in mean Injury Severity Score (from 8.1 ± 10.4 to 5.3 ± 6.6: P = 0.02), ICU admission rates (from 15% to 2.4%: P < 0.001), and hospital length of stay (from 4.0 ± 5.3 to 2.3 ± 1.9: P = 0.02). However, there was no difference in mortality (4.1% and 2.0%, P = 0.221). CONCLUSIONS: We found that there was a significant shift in prehospital transportation among trauma patients toward private transportation after the shelter-in-place order. However, this did not coincide with a change in mortality despite a downward trend. This phenomenon could help direct future policy and protocols in trauma systems when battling major public health emergencies.

Evaluating the Regional Differences in Pediatric Injury Patterns During the COVID-19 Pandemic.

INTRODUCTION: Reports of pediatric injury patterns during the COVID-19 pandemic are conflicting and lack the granularity to explore differences across regions. We hypothesized there would be considerable variation in injury patterns across pediatric trauma centers in the United States. MATERIALS AND METHODS: A multicenter, retrospective study evaluating patients <18 y old with traumatic injuries meeting National Trauma Data Bank criteria was performed. Patients injured after stay-at-home orders through September 2020 ("COVID" cohort) were compared to "Historical" controls from an averaged period of equivalent dates in 2016-2019. Differences in injury type, intent, and mechanism were explored at the site level. RESULTS: 47,385 pediatric trauma patients were included. Overall trauma volume increased during the COVID cohort compared to the Historical (COVID 7068 patients versus Historical 5891 patients); however, some sites demonstrated a decrease in overall trauma of 25% while others had an increase of over 33%. Bicycle injuries increased at every site, with a range in percent change from 24% to 135% increase. Although the greatest net increase was due to blunt injuries, there was a greater relative increase in penetrating injuries at 7/9 sites, with a range in percent change from a 110% increase to a 69% decrease. CONCLUSIONS: There was considerable discrepancy in pediatric injury patterns at the individual site level, perhaps suggesting a variable impact of the specific sociopolitical climate and pandemic policies of each catchment area. Investigation of the unique response of the community during times of stress at pediatric trauma centers is warranted to be better prepared for future environmental stressors.

Bilateral Hyphema - An Unexpected Complication of Exercise Resistance Band Use: A Case Report.

BACKGROUND: Resistance bands commonly used for strength training exercise come with an unexpected risk for ocular trauma. CASE REPORT: In this report, we describe an unintended consequence of a 28-year-old man sustaining an unusual injury-bilateral hyphema-as a result of the use of elastic resistance bands. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Resistance bands are commonly used for strength training exercise and, in this case, a potentially severe, vision-threatening injury-traumatic hyphema-occurred. Traumatic hyphema occurs when blood pools in the anterior chamber of the eye, usually as the result of blunt force trauma or penetrating injury. Early recognition of this condition is imperative, as complications of traumatic hyphema, such as intraocular hypertension or rebleeding, can lead to permanent vision loss.

Racial Disparities Among Trauma Patients During the COVID-19 Pandemic.

INTRODUCTION: Given the disparate effects of the COVID-19 pandemic on people of color, we hypothesized that patients of color experienced a disproportionate increase in trauma during the COVID-19 pandemic. MATERIALS AND METHODS: We compared trauma patients arriving in the 3 y before our statewide stay-at-home mandate on March 20, 2020 (PRE) to those arriving in the year afterward (POST). In addition to race/ethnicity, we assessed patient demographics and other clinical variables. Chi-squared, Fisher's exact, and Mann-Whitney U tests were used for univariate analyses. A multivariable logistic regression was performed to assess for associations with mortality. RESULTS: During the study period, 8583 patients were included in the PRE group and 2883 were included in the POST group. There were increases in penetrating trauma (PRE 14.7%, POST 23.1%; P < 0.001) and mortality rates (PRE 3.20%, POST 4.60%; P < 0.001). From PRE to POST, the percentage of Black patients increased from 35.0% to 38.3% (P = 0.01) and the percentage of Hispanic patients increased from 19.2% to 23.0% (P < 0.001). After a multivariable analysis, Asian patients experienced an independent increase in mortality from PRE to POST (odds ratio 2.00, 95% confidence interval 1.13-3.54, P = 0.02). CONCLUSIONS: Penetrating trauma and mortality rates increased during the pandemic. There was a simultaneous increase in the percentage of Black and Hispanic trauma patients. Asian patient mortality increased significantly after the start of the pandemic independent of other variables. Identifying racial/ethnic disparities is the first step in finding ways to improve dissimilar outcomes.

Impact of COVID-19 pandemic on hand injuries.

BACKGROUND: The aim of the study was to evaluate etiologies of hand injuries in emergency department (ED), to compare the etiologies of hand injuries at the time of this study with the previous year, to assess whether novel coronavirus-2019 (COVID-19) pandemic affected the treatment decisions, and to investigate the COVID-19 infection rate within the first 14 days after admission. METHODS: A total of 229 patients admitted to ED with hand injury between March 15 and April 30, 2020, were included in the study. The control group consisted of 439 ED admissions with hand injury in the previous year (March 15-April 30, 2019). Data including age, sex, cause of trauma, treatment, and COVID-19 infection status within 14 days after ED admission were compared between groups. RESULTS: The mean age was 32.30±15.63 years in the study group and 30.85±18.54 years in the control group. The number of patients consulted to the surgery department decreased by 52.6% and the number of patients admitted to ED with hand injuries de-creased by 47.6% during the pandemic, compared to the previous year (p=0.0001). The incidence of home accidents increased and the glass cuts and penetrating/perforating injuries were the most common causes during the pandemic most of which occurred at home. CONCLUSION: The COVID-19 pandemic-mandated social restrictions led to a significant decrease in the number of ED admissions with hand injuries and the type of injuries. The incidence of home accidents increased with more time spent indoors. This study may be a useful guide for ED admissions of hand injury cases and management planning in the current and future pandemics.

Adolescent Trauma During the COVID Pandemic: Just Like Adults, Children, or Someone Else?

COVID-19 stay-at-home (SAH) orders were impactful on adolescence, when social interactions affect development. This has the potential to change adolescent trauma. A post-hoc multicenter retrospective analysis of adolescent (13-17 years-old) trauma patients (ATPs) at 11 trauma centers was performed. Patients were divided into 3 groups based on injury date: historical control (CONTROL:3/19/2019-6/30/2019, before SAH (PRE:1/1/2020-3/18/2020), and after SAH (POST:3/19/2020-6/30/2020). The POST group was compared to both PRE and CONTROL groups in separate analyses. 726 ATPs were identified across the 3 time periods. POST had a similar penetrating trauma rate compared to both PRE (15.8% vs 13.8%, P = .56) and CONTROL (15.8% vs 14.5%, P = .69). POST also had a similar rate of suicide attempts compared to both PRE (1.2% vs 1.5%, P = .83) and CONTROL (1.2% vs 2.1%, P = .43). However, POST had a higher rate of drug positivity compared to CONTROL (28.6% vs 20.6%, P = .032), but was similar in all other comparisons of alcohol and drugs to PRE and POST periods (all P > .05). Hence ATPs were affected differently than adults and children, as they had a similar rate of penetrating trauma, suicide attempts, and alcohol positivity after SAH orders. However, they had increased drug positivity compared to the CONTROL, but not PRE group.

Adding to the story, did penetrating trauma really increase? changes in trauma patterns during the COVID-19 pandemic: A multi-institutional, multi-region investigation.

BACKGROUND: Results from single-region studies suggest that stay at home orders (SAHOs) had unforeseen consequences on the volume and patterns of traumatic injury during the initial months of the Coronavirus disease 2019 (COVID-19). The aim of this study was to describe, using a multi-regional approach, the effects of COVID-19 SAHOs on trauma volume and patterns of traumatic injury in the US. METHODS: A retrospective cohort study was performed at four verified Level I trauma centers spanning three geographical regions across the United States (US). The study period spanned from April 1, 2020 - July 31, 2020 including a month-matched 2019 cohort. Patients were categorized into pre-COVID-19 (PCOV19) and first COVID-19 surge (FCOV19S) cohorts. Patient demographic, injury, and outcome data were collected via Trauma Registry queries. Univariate and multivariate analyses were performed. RESULTS: A total 5,616 patients presented to participating study centers during the PCOV19 (2,916) and FCOV19S (2,700) study periods.  Blunt injury volume decreased (p = 0.006) due to a significant reduction in the number of motor vehicle collisions (MVCs) (p = 0.003). Penetrating trauma experienced a significant increase, 8% (246/2916) in 2019 to 11% (285/2,700) in 2020 (p = 0.007), which was associated with study site (p = 0.002), not SAHOs. Finally, study site was significantly associated with changes in nearly all injury mechanisms, whereas SAHOs accounted for observed decreases in calculated weekly averages of blunt injuries (p < 0.02) and MVCs (p = 0.003). CONCLUSION: Results of this study suggest that COVID-19 and initial SAHOs had variable consequences on patterns of traumatic injury, and that region-specific shifts in traumatic injury ensued during initial SAHOs. These results suggest that other factors, potentially socioeconomic or cultural, confound trauma volumes and types arising from SAHOs. Future analyses must consider how regional changes may be obscured with pooled cohorts, and focus on characterizing community-level changes to aid municipal preparation for future similar events.

Trends in Violent Penetrating Injuries During the First Year of the COVID-19 Pandemic.

Importance: Public health measures instituted to reduce the spread of COVID-19 led to severe disruptions to the structure of daily life, and the resultant social and financial impact may have contributed to an increase in violence. Objective: To examine the trends in violent penetrating injuries during the first COVID-19 pandemic year compared with previous years. Design, Setting, and Participants: This retrospective cross-sectional study was performed to compare the prevalence of violent penetrating injuries during the first COVID-19 pandemic year, March 2020 to February 2021, with the previous 5 years, March 2015 to February 2020. This study was performed among all patients with a violent penetrating injury presenting at Boston Medical Center, an urban, level I trauma center that is the largest safety-net hospital and busiest trauma center in New England. Data were analyzed from January 4 to November 29, 2021. Main Outcomes and Measures: The primary outcomes were the incidence and timing of emergency department presentation for violent penetrating injuries during the first year of the COVID-19 pandemic compared with the previous 5 years. Patient demographics and injury characteristics were also assessed. Results: A total of 2383 patients (median [IQR] age, 29.5 [23.4-39.3] years; 2032 [85.4%] men and 351 [14.6%] women) presenting for a violent penetrating injury were evaluated, including 1567 Black patients (65.7%), 448 Hispanic patients (18.8%), and 210 White patients (8.8%). There was an increase in injuries during the first pandemic year compared with the previous 5 years, with an increase in shootings (mean [SD], 0.61 [0.89] injuries per day vs 0.46 [0.76] injuries per day; P = .002) but not stabbings (mean [SD], 0.60 [0.79] injuries per day vs 0.60 [0.82] injuries per day; P = .78). This surge in firearm violence began while Massachusetts was still under a stay-at-home advisory and before large-scale racial justice protests began. Patients presenting with violent penetrating injuries in the pandemic surge months (April-October 2020) compared with the same period in previous years were disproportionately male (153 patients [93.3%] vs 510 patients [87.6%]; P = .04), unemployed (70 patients [57.4%] vs 221 patients [46.6%]; P = .03), and Hispanic (40 patients [26.0%] vs 99 patients [17.9%]; P = .009), with a concurrent decrease in White patients (0 patients vs 26 patients [4.7%]), and were more likely to have no previous history of violent penetrating injury (146 patients [89.0%] vs 471 patients [80.9%]; P = .02). Conclusions and Relevance: These findings suggest that unprecedented measures implemented to mitigate the spread of COVID-19 were associated with an increase in gun violence. As the pandemic abates, efforts at community violence prevention and intervention must be redoubled to defend communities against the epidemic of violence.

Changes in trends during the COVID-19 lockdown: An urban, Level-1 trauma center's experience.

BACKGROUND: A community lockdown has a profound impact on its citizens. Our objective was to identify changes in trauma patient demographics, volume, and pattern of injury following the COVID-19 lockdown. METHODS: A retrospective review was conducted at a Level-1 Trauma Center from 2017 to 2020. RESULTS: A downward trend in volume is seen December-April in 2020 (R2 = 0.9907). February through April showed an upward trend in 2018 and 2019 (R2= 0.80 and R2 = 0.90 respectively), but a downward trend in 2020 (R2 = 0.97). In April 2020, there was 41.6% decrease in total volume, a 47.4% decrease in blunt injury and no decrease in penetrating injury. In contrast to previous months, in April the majority of injuries occurred in home zip codes. CONCLUSIONS: A community lockdown decreased the number of blunt trauma, however despite social distancing, did not decrease penetrating injury. Injuries were more likely to occur in home zip codes.

Increases in Violence and Changes in Trauma Admissions During the COVID Quarantine.

BACKGROUND: The COVID-19 pandemic caused an abrupt change to societal norms. We anecdotally noticed an increase in penetrating and violent trauma during the period of stay-at-home orders. Studying these changes will allow trauma centers to better prepare for future waves of COVID-19 or other global catastrophes. METHODS: We queried our institutional database for all level 1 and 2 trauma activations presenting from the scene within our local county from March 18 to May 21, 2020 and matched time periods from 2016 to 2019. Primary outcomes were overall trauma volume, rates of penetrating trauma, rates of violent trauma, and transfusion requirements. RESULTS: The number of penetrating and violent traumas at our trauma center during the period of societal quarantine for the COVID-19 pandemic was more than any historical total. During the COVID-19 time period, we saw 39 penetrating traumas, while the mean value for the same time period from 2016 to 2019 was 26 (P = .03). We saw 45 violent traumas during COVID; the mean value from 2016 to 2019 was 32 (P = .05). There was also a higher rate of trauma patients requiring transfusion in the COVID cohort (6.7% vs 12.2%). DISCUSSION: Societal quarantine increased the number of penetrating and violent traumas, with a concurrent increased percentage of patients transfused. Despite this, there was no change in outcomes. Given the continuation of the COVID-19 pandemic, quarantine measures could be re-implemented. Data from this study can help guide expectations and utilization of hospital resources in the future.

Examining Violence Against Women at a Regional Level 1 Trauma Center During the COVID-19 Pandemic.

INTRODUCTION: There is a growing concern that certain public health restrictions imposed to prevent the spread of coronavirus disease 2019 (COVID-19) could result in more violence against women (VAW). We sought to determine if the rates and types of VAW changed during the COVID-19 pandemic at our level 1 trauma center (L1TC). METHODS: We performed a retrospective review of female patients who presented to our L1TC because of violence from 2019 through 2020. Patients were grouped into a pre-COVID or COVID period. The primary aim of this study was to compare rates of VAW between groups. Secondary aims sought to evaluate for any difference in traumatic mechanism between periods and to determine if a temporal relationship existed between COVID-19 and VAW rates. RESULTS: There was no difference in rates of VAW between the pre-COVID and COVID period (3.1% vs 3.6%, P = .6); however, rates of penetrating trauma were greater during the COVID period (38.2% vs 10.3%, P = .01). After controlling for patient age and race, the odds of penetrating trauma increased during the pandemic (OR 5.8, 95% CI 1.6-28.5, P < .01). From February 2020 through October 2020, there was a direct relationship between rates of COVID-19 and VAW (r2 .78, P < .01). CONCLUSION: Rates of VAW were unchanged between the pre-COVID and COVID periods, yet the odds of penetrating VAW were 5 times greater during the pandemic. Moving forward, trauma surgeons must remain vigilant for signs of violence and ensure that support services are available during future crises.

Undiagnosed pharyngeal perforation following a penetrating neck trauma in a 5-year-old child: a proposed treatment algorithm.

External penetrating wounds of the neck leading to pharyngeal perforations are relatively uncommon. The small area of the neck contains the vital vascular, aerodigestive and nervous structures, which are difficult to access surgically. Pharyngeal perforations are challenging to treat, especially in children, as primary wound inspection may be difficult, leading to life-threatening complications like retropharyngeal abscesses, mediastinitis or airway compromise. The following is a case report of a 5-year-old girl who had a road traffic accident causing a neck laceration with a pharyngeal tear, which was only identified during emergency neck exploration in the operating room. A review of known literature and a proposed algorithm for managing penetrating neck injuries with pharyngeal injury is described.

Five-Year Management of Vascular Injuries of the Extremities in the "Real-World" Setting in Northeastern Greece: The Role of Iatrogenic Traumas.

BACKGROUND: Vascular trauma comprises a diagnostic and surgical challenge. Aim of this study was to present the vascular traumas treated in our Tertiary Hospital during the last 5 years. METHODS: We retrospectively reviewed the surgical records of our vascular department and documented the site and type of vascular injuries of the extremities along with the concurrence of musculoskeletal injuries. The type and outcome of surgical interventions were also recorded. RESULTS: Fifty-eight cases of vascular trauma were recorded (39 in the upper and 19 in the lower extremities). Overall, iatrogenic traumas accounted for 41.3% of cases. The arterial injuries of the upper limb were blunt and penetrating in 27% and 67%, respectively. The most affected artery in the upper limb was the radial artery (37.8%), followed by the ulnar artery (27%) and the brachial artery (24.3%). Orthopedic injuries were recorded in 19% of patients. Management involved simple revascularization, bypass operations, patch arterioplasty and endovascular management in 48.7%, 33.3%, 5.1%, and 5.1%, respectively. The most affected site in the lower extremity was the common femoral artery (36.8%) followed by the popliteal artery (21%). Bone fractures were reported in 5 cases (26.3%). The surgical management involved bypass, simple revascularization, patch arterioplasty in 42.1%, 26.3%, and 21%, respectively. Endovascular management was performed in 10.5%. CONCLUSIONS: A considerable percentage of iatrogenic vascular injuries was recorded, affecting both the upper and lower limbs. Despite the trend toward centralization of vascular services, a basic service of vascular surgery should be available in most sites to ensure that patients with vascular injuries receive fast and appropriate care.

Amplifying inequity: The compounding impact of COVID-19 and violence.

While "stay-at-home" orders for COVID-19 were in effect, many American cities witnessed a rise in community and interpersonal violence. Our own institution, the largest regional trauma facility and Boston's safety net hospital, saw a paradoxical rise in penetrating violent trauma admissions despite decreases in other hospital admissions, leading to our most violent summer in five years. It has been established that minoritized and marginalized communities have faced the harshest impacts of the pandemic. Our findings suggest that the conditions created by the COVID-19 pandemic have amplified the inequities that exist in communities of color that place them at risk for exposure to violence. The pandemic has served to potentiate the impacts of violence already plaguing the communities and patients we serve.

Changes in traumatic mechanisms of injury in Southern California related to COVID-19: Penetrating trauma as a second pandemic.

BACKGROUND: The COVID-19 pandemic resulted in a statewide stay-at-home (SAH) order in California beginning March 19, 2020, forcing large-scale behavioral changes and taking an emotional and economic toll. The effects of SAH orders on the trauma population remain unknown. We hypothesized an increase in rates of penetrating trauma, gunshot wounds, suicide attempts, and domestic violence in the Southern California trauma population after the SAH order. METHODS: A multicenter retrospective analysis of all trauma patients presenting to 11 American College of Surgeons levels I and II trauma centers spanning seven counties in California was performed. Demographic data, injury characteristics, clinical data, and outcomes were collected. Patients were divided into three groups based on injury date: before SAH from January 1, 2020, to March 18, 2020 (PRE), after SAH from March 19, 2020, to June 30, 2020 (POST), and a historical control from March 19, 2019, to June 30, 2019 (CONTROL). POST was compared with both PRE and CONTROL in two separate analyses. RESULTS: Across all periods, 20,448 trauma patients were identified (CONTROL, 7,707; PRE, 6,022; POST, 6,719). POST had a significantly increased rate of penetrating trauma (13.0% vs. 10.3%, p < 0.001 and 13.0% vs. 9.9%, p < 0.001) and gunshot wounds (4.5% vs. 2.4%, p = 0.002 and 4.5% vs. 3.7%, p = 0.025) compared with PRE and CONTROL, respectively. POST had a suicide attempt rate of 1.9% and a domestic violence rate of 0.7%, which were similar to PRE (p = 0.478, p = 0.514) and CONTROL (p = 0.160, p = 0.618). CONCLUSION: This multicenter Southern California study demonstrated an increased rate of penetrating trauma and gunshot wounds after the COVID-19 SAH orders but no difference in attempted suicide or domestic violence rates. These findings may provide useful information regarding resource utilization and a target for societal intervention during the current or future pandemic(s). LEVEL OF EVIDENCE: Epidemiological, level IV.

Penetrating trauma during a global pandemic: Changing patterns in interpersonal violence, self-harm and domestic violence in the Covid-19 outbreak.

INTRODUCTION: The restrictions imposed on social activity in response to the Covid-19 pandemic have had a profound impact globally. In the UK, the NHS was placed on a war-footing, with elective surgery, face-to-face outpatient clinics, and community care facilities all scaled back as a temporary measure to redistribute scarce resources. There has been concern during this period over increasing levels of violence in the domestic setting, as well as self-harm. METHODS: Data was collected on all patients presenting with traumatic penetrating injuries during the 'lockdown' period of 23rd March to 29th April 2020. Demographics and injury details were compared with the same period in the two preceding years. RESULTS: Overall trauma fell by 35% compared with the previous year. Over one in four penetrating injuries seen were a result of self-harm, which was significantly higher than in previous years (11% in 2019, 2% in 2018). There were two cases of injuries due to domestic violence, while a total of 4 cases of injury arose in separate violent domestic incidents. Self-harm commonly involved penetrating injury to the neck. DISCUSSION: Our centre has seen an increase in the proportion of penetrating injuries as a result of both self-harm and violence in the domestic setting. The number of penetrating neck injury cases, which can represent suicidal intent or a major presentation of psychiatric illness, is of particular concern. We must further investigate the effect of social restrictions on violent injury, and how home confinement may influence a changing demographic picture of victims.

Different Crises, Different Patterns of Trauma. The Impact of a Social Crisis and the COVID-19 Health Pandemic on a High Violence Area.

BACKGOUND: Santiago, Chile underwent two separate periods of crisis over the past year. The first period, the 'social crisis,' extended over thirteen weeks in late 2019 into early 2020 due to protests over income inequality and the government response to social unrest. The second period, the 'health crisis,' began in March 2020 with Chile's first case of COVID-19 and escalated rapidly to include 'stay at home orders,' traffic restrictions, and the shuttering of most businesses. We wished to evaluate the impact of these crisis periods on trauma epidemiology. METHODS: We performed a retrospective review of the South-East Metropolitan Health Service Trauma Registry. Trauma admissions, operative volume, and in-hospital mortality were evaluated during the crisis period and the year prior. RESULTS: The social crisis saw increased levels of trauma, both blunt and penetrating, relative to the time period immediately preceding. The health crisis saw an increase in penetrating trauma with a concomitant decline in blunt trauma. Both crisis periods had decreased levels of trauma, overall, compared to the year prior. There were no statistically significant differences in in-hospital trauma mortality. CONCLUSION: Different crises may have different patterns of trauma. Crisis periods that include extended periods of lockdown and curfew may lead to increasing penetrating trauma volume. Governments and health officials should anticipate the aggregate impact of these measures on public health and develop strategies to actively mitigate them. LEVEL OF EVIDENCE: III.