Cuidado intensivo COVID 19 a muy alta altitud / Critical care in COVID 19 at very high altitude

Objetivo: Describir la casuística de los pacientes críticamente enfermos COVID-19 atendidos en la Unidad de Cuidados Intensivos del Hospital del Norte, primer Hospital del Tercer Nivel de Complejidad de la ciudad de El Alto y Centro de Referencia Departamental. Metodología: Estudio retrospectivo transversal observacional. Se incluyen todos los pacientes residentes permanentes a muy alta altitud, ingresados en el periodo 25 Marzo 2020-25 Noviembre 2021. Para el análisis de los datos se utilizó estadística descriptiva y creación de una base de datos en el programa Excel v18. Resultados: Se ingresaron 373 pacientes, 212 (57%) varones, así como 161 (43%) mujeres. Se tiene una mortalidad corregida del 48%, la estancia promedio en la UCI es de 18 días, 26 (± 4) en el grupo de supervivientes y 11 (± 2) en el grupo de fallecidos. La edad promedio de supervivientes es de 47.25 años (± 12 años) y la edad promedio de fallecidos 56.58 años (± 14 años) con valor de p por t de Student de 0.004. La comorbilidad más frecuentemente encontrada fue la hipertensión arterial sistémica en 157 (42%) casos. Únicamente 2 casos contaban con vacuna antiCOVID-19. Discusión: La mortalidad corregida es similar a la casuística reportada en la literatura internacional en Unidades de Cuidados Intensivos. El presente estudio apoya el hecho que la altitud no afecta la evolución de los pacientes críticos COVID-19. Conclusión: Resulta imperativo describir la casuística concerniente a nuestros Centros Asistenciales.

Variability in Current Trauma Systems and Outcomes.

BACKGROUND: Complication rates may be indicative of trauma center (TC) performance. The complication rates between Level 1 and 2 TCs at the national level are unknown. Our study aimed to determine the relationship between American College of Surgeons (ACS)-verified and state-designated TCs and complications. STUDY DESIGN AND METHODS: This was a cohort review of the National Sample Program (NSP) from the National Trauma Data Bank, the world's largest validated trauma database. TCs were categorized by ACS or state Level 1 or 2. TCs not categorized as Level 1 or 2 were excluded. All 22 complications provided by the NSP were analyzed. Chi-squared analysis was used with statistical significance defined as P < 0.05. RESULTS: Of the 94 TCs in the NSP, 67 had ACS and 80 had state designations of Level 1 or 2. There were 38 ACS Level 1 TCs treating 87,340 patients and 29 ACS Level 2 TCs treating 35,763. There were 45 state Level 1 TCs treating 106,640 and 35 state Level 2 TCs treating 43,290. ACS Level 1 TCs had significantly higher complications compared to ACS Level 2 TCs (13.5% [11,776/87,340] vs. 10.1% [3,606/35,763], P < 0.0001). In addition, state Level 1 TCs had significantly more complications compared to state Level 2 TCs (4.4% [4,681/106,640] vs. 1.6% [673/43,290], P < 0.0001). CONCLUSION: Both ACS and state Level 2 TCs had significantly lower complication rates than ACS and state Level 1 TCs. Further investigations should look for the source and impact of this difference.

The Impact of Geographic Distribution on Trauma Center Outcomes: Do Center Outcomes Vary by Region?

BACKGROUND: The American College of Surgeons (ACS) publishes Resources for Optimal Care of the Injured Patient (Orange Book) to provide common requirements to verify trauma centers (TCs), throughout the United States. There are very few studies that assess the impact of geography on TC outcomes. Our study aimed to evaluate the differences in geographic regions in terms of injury-adjusted all-cause mortality at ACS Level 1, 2, and 3 TCs. METHODS: Review of the 2016 Research Data Set provided by the National Trauma Data Bank. TCs were categorized by the Research Data Set into geographic regions: Northeast, Midwest, South, and West. TCs were subcategorized into ACS Level 1, 2, or 3; all others were excluded. Injury-adjusted mortality was determined using observed/expected mortality (O/E) ratios, derived from TRISS methodology. Chi-squared and t-test analyses were used with significance defined as P-value<0.05. RESULTS: Among Level 1 TCs, the West (O/E = 0.62) and South (0.61) regions had significantly higher adjusted mortality rates than the Level 1s in the Midwest (0.52) and Northeast (0.52) (P < 0.05). Among Level 2s, the West (O/E = 0.61) and South (0.55) regions had significantly higher mortality than the Level 2s in the Midwest (0.40) and Northeast (0.35) (P < 0.05). Among Level 3 TCs, the South (O/E = 0.48) and the West (0.43) had significantly higher mortality than the Midwest (0.26) and Northeast (0.22) (P < 0.05). CONCLUSIONS: In the United States, injury-adjusted all-cause mortality rates are significantly higher in the South and West regions for ACS Level 1, 2, and 3 TCs compared with the Midwest and Northeast. This geographic disparity necessitates a deeper evaluation.

Thoracic Endovascular Aortic Repair Versus Open Repair: Analysis of the National Trauma Data Bank.

BACKGROUND: Blunt thoracic aortic injuries (BTAIs) carry a substantial mortality rate. Our study aimed to compare the outcomes of thoracic endovascular aortic repair (TEVAR) with open repair from trauma centers across the United States using the National Trauma Data Bank-Research Data Set (RDS). MATERIALS AND METHODS: The National Trauma Data Bank-RDS was reviewed for thoracic aortic injures and repair methods. Patients were divided into two groups: TEVAR versus open repair. Demographics and outcomes were compared between groups. Mortality rate was adjusted using the observed/expected mortality (O/E), with TRISS methodology by using the Revised Trauma Score with the Injury Severity Score. Chi-square test and t-test were used with significance defined as P < 0.05. RESULTS: Within the 2016 RDS, there were 275 cases that underwent operative repair for BTAI. Of the 275 operative cases, 62.5% (172/275) had TEVAR and 37.5% (103/275) underwent open repair. Mean age in TEVAR group was 41 and open repair group was 36 (P > 0.05). Mean Injury Severity Score for TEVAR was 36 versus 35 for open repair (P > 0.05). Mean Revised Trauma Score was 6.7 in TEVAR versus 5.5 in open group (P > 0.05). TEVAR patients had significantly lower crude mortality rate versus open repair (11% versus 25.2%, P < 0.005). When adjusted using O/E, the TEVAR group also had significantly less deaths versus open repair (0.40 versus 0.68, P < 0.000008). CONCLUSIONS: For BTAIs, thoracic endovascular aortic repairs were superior to open repair on injury-adjusted, all-cause mortality.

The impact of teaching status on trauma center clinical outcomes in the United States.

Teaching status/academic ranking may play a role in the variations in trauma center (TC) outcomes. Our study aimed to determine the relationship between TC teaching status and injury-adjusted, all-cause mortality in a national sampling.Retrospective review of the National Sample Program (NSP) from the National Trauma Data bank (NTDB). TCs were categorized based on teaching status. Adjusted mortality was determined by observed/expected (O/E) mortality ratios, derived using TRauma Injury Severity Score methodology from the Injury Severity Score and Revised Trauma Score. Chi-square and t test analyses were utilized with a statistical significance defined as P <.05.Of the 94 TCs in the NSP, 46 were university, 38 were community teaching, and 10 were community nonteaching. For the University TCs, 62.8% were American College of Surgeons (ACS) level 1 and 81.2% state level 1. Of the community teaching TCs, 39.0% was ACS level 1 and 35.1% was state level 1. Of the community nonteaching TCs, 0% was ACS level 1 and 11.1% was state level 1. University TCs had a significantly higher O/E mortality rate than community teaching (0.75 vs 0.71; P = .04). There were no differences in O/E between community teaching and nonteaching TCs (0.71 vs 0.70; P = .70).Community teaching and nonteaching TCs have lower injury-adjusted, all-cause mortality rates than University Centers. Future studies should further investigate key differences between University TCs and community teaching TC to evaluate possible quality and performance improvement measures.

The impact of level of the American College of Surgeons Committee on Trauma verification and state designation status on trauma center outcomes.

The American College of Surgeons (ACS) Committee on Trauma (COT) verification and State designation of trauma centers (TCs) into Level 1 or 2 establishes a distinction based on resources, trauma volume, and educational commitment. The ACS COT and individual states each verify TCs to differentiate performance levels. We aim to determine the relationship between ACS and State Level 1 versus 2, and injury-adjusted, all-cause mortality in a national sampling.TCs were identified by review of the National Sample Program (NSP) from the National Trauma Data Bank (NTDB)-the largest validated trauma database in the nation-of the year 2013. TCs were categorized by ACS or State Level 1 or 2 status, all others were excluded. Adjusted mortality was determined using observed/expected mortality (O/E) ratios, derived by trauma and injury severity score (TRISS) methodology. Chi-squared and t test analyses were used for categorical variables, with a statistical significance defined as P-value <.05.Of the 94 TCs in the NSP, 67 had ACS and 80 had State designations. There were 38 ACS Level 1 TCs and 29 ACS Level 2. For State designations, there were 45 as State Level 1 and 35 State Level 2. ACS Level 1 TCs had a similar O/E compared with ACS Level 2 verified centers (0.73 vs 0.75, chi-square, P = .36). Level 1 TCs designated by their state, had a similar O/E compared with State Level 2 centers (0.70 vs 0.74, chi-square, P = .08).Both ACS and State Level 1 and 2 trauma centers performed similarly on injury adjusted, all-cause mortality.

Survival of trauma patients needing CPR shortly after arrival: The NationalTrauma Data Bank Research Data Set.

BACKGROUND: Cardio Pulmonary Resuscitation (CPR) for traumatized patients in the field portends poor survival but the outcome of trauma patients who arrive in-extremis and undergo CPR shortly after arrival has not been well studied. The purpose of our review is to evaluate survival to discharge for trauma patients with CPR from 1 to 120 minutes (min) after arrival. METHODS: The NTDB Research Data Set (RDS) was reviewed. Patients with vitals in the field who underwent CPR from 1 to 120 min after arrival were divided according to injury type and Injury Severity Score (ISS). Survival to discharge outcomes were determined in patients that underwent CPR from 1-60 min and 61-120 min after arrival. RESULTS: The RDS contained 968,665 patients and 9,365 (0.96%) had CPR from 1 to 120 min after arrival. For blunt injuries with CPR from 1 to 60 min, survival was similar for all levels of ISS (8.5-10.2%, p > 0.05). Blunt injury patients with CPR 61-120 min and ISS 1-15 had significantly higher survival rate compared to ISS >25 (36.1% vs 8.7%, p < 0.00003). For penetrating injuries and CPR from 1 to 60 min, survival was similar for all levels of ISS (4.3-6.8%, p > 0.05); Blunt and penetrating patients with CPR from 61 to 120 min, and ISS 1-15 had the highest survivals at 36.1 and 36.4%. CONCLUSION: Trauma patients who undergo CPR shortly after arrival have a survival rate of (4.3%-36.4%). Over one-third of blunt and penetrating injuries and low ISS who had CPR from 61 to 120 min after arrival survived. Trauma patients who arrest shortly after arrival warrant an aggressive approach.

Prevalence and ethnic/racial disparities in the distribution of pediatric injuries in South Florida: implications for the development of community prevention programs.

BACKGROUND: The state of Florida continues to report significant gender, ethnic and racial disparities in trauma incidence, access to care and outcomes in the adult population. Our objective was to assess pediatric injury profiles and ethnic/racial disparities of specific injuries in a Regional Trauma Center (TC) in South Florida. METHODS: Retrospective data from November 2011 to December 2015 were obtained from the Level 2 TC registry for children ≤21 years old. Demographic, injury pattern, geographic area, injury scores and treatment data were analyzed. RESULTS: One thousand six hundred ten patients, ages 0-21 years were cared for at the TC from 2011 to 2015.73% were males. Mean age = 15.7 years. Mortality was 2.3%. Using zip code data and using geographic mapping, we identified two main clusters where injuries were occurring. A multinomial regression analysis demonstrated that Hispanics had higher risks of falls (RR 10.4, 95% CI 2.7-29), motorcycle accidents (RR 3.7, 95% CI 1.7-8.2) and motor vehicle accidents (RR 6.4, 95% CI 3.6-11.4). Black/African American children had higher risks of gunshot wounds and resultant mortality (p < 0.01). CONCLUSION: There were racial, ethnic and gender disparities in the patterns of injury and outcomes among the youth attended at our TC. Geographic mapping allowed us the identification of the zones in South Florida where injuries were occurring. Understanding the differences and using geographic mapping to identify regions of higher prevalence will complement planning for prevention programs.