A Prospective Multicenter Comparison of Trauma and Injury Severity Score, American Society of Anesthesiologists Physical Status, and National Surgical Quality Improvement Program Calculator's Ability to Predict Operative Trauma Outcomes.

BACKGROUND: Trauma outcome prediction models have traditionally relied upon patient injury and physiologic data (eg, Trauma and Injury Severity Score [TRISS]) without accounting for comorbidities. We sought to prospectively evaluate the role of the American Society of Anesthesiologists physical status (ASA-PS) score and the National Surgical Quality Improvement Program Surgical Risk-Calculator (NSQIP-SRC), which are measurements of comorbidities, in the prediction of trauma outcomes, hypothesizing that they will improve the predictive ability for mortality, hospital length of stay (LOS), and complications compared to TRISS alone in trauma patients undergoing surgery within 24 hours. METHODS: A prospective, observational multicenter study (9/2018-2/2020) of trauma patients ≥18 years undergoing operation within 24 hours of admission was performed. Multiple logistic regression was used to create models predicting mortality utilizing the variables within TRISS, ASA-PS, and NSQIP-SRC, respectively. Linear regression was used to create models predicting LOS and negative binomial regression to create models predicting complications. RESULTS: From 4 level I trauma centers, 1213 patients were included. The Brier Score for each model predicting mortality was found to improve accuracy in the following order: 0.0370 for ASA-PS, 0.0355 for NSQIP-SRC, 0.0301 for TRISS, 0.0291 for TRISS+ASA-PS, and 0.0234 for TRISS+NSQIP-SRC. However, when comparing TRISS alone to TRISS+ASA-PS (P = .082) and TRISS+NSQIP-SRC (P = .394), there was no significant improvement in mortality prediction. NSQIP-SRC more accurately predicted both LOS and complications compared to TRISS and ASA-PS. CONCLUSIONS: TRISS predicts mortality better than ASA-PS and NSQIP-SRC in trauma patients undergoing surgery within 24 hours. The TRISS mortality predictive ability is not improved when combined with ASA-PS or NSQIP-SRC. However, NSQIP-SRC was the most accurate predictor of LOS and complications.

Comparison of National Surgical Quality Improvement Program Surgical Risk Calculator, Trauma and Injury Severity Score, and American Society of Anesthesiologists Physical Status to predict operative trauma mortality in elderly patients.

BACKGROUND: The Trauma and Injury Severity Score (TRISS) uses anatomical and physiologic variables to predict mortality. Elderly (65 years or older) trauma patients have increased mortality and morbidity for a given TRISS, in part because of functional status and comorbidities. These factors are incorporated into the American Society of Anesthesiologists Physical Status (ASA-PS) and National Surgical Quality Improvement Program Surgical Risk Calculator (NSQIP-SRC). We hypothesized scoring tools using comorbidities and functional status to be superior at predicting mortality, hospital length of stay (LOS), and complications in elderly trauma patients undergoing operation. METHODS: Four level I trauma centers prospectively collected data on elderly trauma patients undergoing surgery within 24 hours of admission. Using logistic regression, five scoring models were compared: ASA-PS, NSQIP-SRC, TRISS, TRISS-ASA-PS, and TRISS-NSQIP-SRC.Brier scores and area under the receiver operator characteristics curve were calculated to compare mortality prediction. Adjusted R2 and root mean squared error were used to compare LOS and predictive ability for number of complications. RESULTS: From 122 subjects, 9 (7.4%) died, and the average LOS was 12.9 days (range, 1-110 days). National Surgical Quality Improvement Program Surgical Risk Calculator was superior to ASA-PS and TRISS at predicting mortality (area under the receiver operator characteristics curve, 0.978 vs. 0.768 vs. 0.903; p = 0.007). Furthermore, NSQIP-SRC was more accurate predicting LOS (R2, 25.9% vs. 13.3% vs. 20.5%) and complications (R2, 34.0% vs. 22.6% vs. 29.4%) compared with TRISS and ASA-PS. Adding TRISS to NSQIP-SRC improved predictive ability compared with NSQIP-SRC alone for complications (R2, 35.5% vs. 34.0%; p = 0.046). However, adding ASA-PS or TRISS to NSQIP-SRC did not improve the predictive ability for mortality or LOS. CONCLUSION: The NSQIP-SRC, which includes comorbidities and functional status, had superior ability to predict mortality, LOS, and complications compared with TRISS alone in elderly trauma patients undergoing surgery. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level III.

No Reduction in Surgical Site Infection Obtained with Post-Operative Antibiotics in Facial Fractures, Regardless of Duration or Anatomic Location: A Systematic Review and Meta-Analysis.

Background: We performed a systematic review of the literature on antibiotic prophylaxis practices in open reduction, and internal fixation of, facial fracture(s) (ORIFfx). We hypothesized that prolonged antibiotic prophylaxis (PAP) would not decrease the rate of surgical site infections (SSIs). Methods: We performed a systematic review of four databases: PubMed, CENTRAL, EMBase, and Web of Science, from inception through January 15, 2017. Three independent reviewers extracted fracture location (orbital, mid-face, mandible), antibiotic use, SSI incidence, and time from injury to surgery. Mantel-Haenszel and generalized estimating equations were carried out independently for each fracture zone. Results: Of the 587 articles identified, 54 underwent full-text review, yielding 27 studies that met our inclusion criteria. Of these, 16 studies (n = 2,316 patients) provided data for mandible fractures, four studies (n = 439) for mid-face fractures, and six studies (n = 377) for orbital fractures. Pooled analysis of each fracture type's SSI rate showed no statistically significant association with the odds ratio (OR) of developing an SSI. For mandible fractures treated with ORIFfx, the OR for an SSI after 24-72 hours of prophylaxis relative to <24 hours was 0.85 (95% confidence interval [CI] 0.62-1.17), whereas for >72 hours compared with <24 hours, the OR was 1.42 (95% CI) 0.96-2.11). For mid-face fractures, there was no improvement in SSI rate from PAP (OR 1.05; 95% CI 0.20-5.63). Conclusions: We did not demonstrate a lower rate of SSI associated with PAP for any ORIFfx repair. Post-operative antibiotics for >72 hours paradoxically may increase the SSI risk after mandible fracture repairs.

Black Race and Body Mass Index Are Risk Factors for Rhabdomyolysis and Acute Kidney Injury in Trauma.

Purpose: Obesity has been shown in a single-center study to be a risk factor for rhabdomyolysis. More recently, sickle cell trait, known to be more prevalent in blacks, has been shown to be a risk factor for rhabdomyolysis. We hypothesized that in trauma patients, black race and a higher body mass index (BMI) are associated with risk for rhabdomyolysis and acute kidney injury (AKI). Materials and Methods: The National Trauma Data Bank (NTDB) was queried (2013-2015) to identify patients age ≥18 years and grouped by BMI: normal (18.5-24.99 kg/m2), underweight (16.5-18.49 kg/m2), overweight (25-29.99 kg/m2), obese (30-34.99 kg/m2), severely obese (35-39.99 kg/m2), and morbidly obese (≥40 kg/m2). A multivariable logistic regression model was used to assess whether a higher BMI or black race was associated with rhabdomyolysis or AKI. Results: After adjusting for covariates, severe obesity (odds ratio (OR) = 1.42, confidence interval (CI) = 1.01-1.99, p < .001), morbid obesity (OR = 1.46, CI = 1.04-2.06, p < .001), and black race (OR = 1.52, CI = 1.24-1.88, p < .001) were associated with higher risk for rhabdomyolysis. Patients that were overweight (OR = 1.17, CI = 1.11-1.24, p < .001), obese (OR = 1.32, CI = 1.24-1.41, p < .001), severely obese (OR = 1.72, CI = 1.59-1.86, p < .001), morbidly obese (OR = 1.77, CI = 1.64-1.92, p < .001), or black (OR = 1.31, CI = 1.24-1.38, p < .001) were associated with higher risk for AKI. Conclusions: Black race was associated with an increased risk of rhabdomyolysis as well as AKI in trauma. BMI ≥25 kg/m2 was associated with increased risk for AKI with the morbidly obese having the highest risk. BMI ≥35 kg/m2 was found to be associated with increased risk of rhabdomyolysis. Future studies should investigate the role for routine screening of these high-risk populations and other potential associated factors such as adherence to weight-based fluid resuscitation.

No increased risk of acute osteomyelitis associated with closed or open long bone shaft fracture.

OBJECTIVES: Osteomyelitis of the long bones can result from hematogenous spread, direct inoculation or from a contiguous focus of infection. The association of osteomyelitis after long bone fractures has widely been believed to be true by practicing surgeons since the 1950s, even though the evidence has been poor. We hypothesized that long bone shaft fracture and major bone surgery are independent risk factors for osteomyelitis in adult trauma patients. METHODS: The National Trauma Data Bank (NTDB) was queried between 2007 and 2015 for patients ≥18 years of age presenting after trauma. Patients with long bone shaft fractures (femur, tibia/fibula, humerus) were identified and rate of acute osteomyelitis was calculated. Univariable logistic regression was performed. A multivariable logistic regression was performed to identify risk factors for development of acute osteomyelitis. RESULTS: From 5,494,609 patients, 358,406 were identified to have long bone shaft fractures (6.5%) with the majority being tibia/fibula (44.3%). The osteomyelitis rate in long bone shaft fractures was 0.05%. Independent risk factors for osteomyelitis included major humerus surgery and major tibia/fibula surgery. The strongest risk factor was non-pseudomonas bacteremia. Long bone shaft fractures were not found to be an independent risk factor for osteomyelitis (p > 0.05). CONCLUSIONS: Long bone shaft fractures are not independently associated with increased risk for osteomyelitis. Major extremity surgery on the humerus and tibia/fibula, but not femur, are independent risk factors for osteomyelitis. However, the strongest risk factor is non-pseudomonas bacteremia.

The role of the American Society of anesthesiologists physical status classification in predicting trauma mortality and outcomes.

BACKGROUND: Trauma prediction scores such as Revised Trauma Score (RTS) and Trauma and Injury Severity Score (TRISS)) are used to predict mortality, but do not include comorbidities. We analyzed the American Society of Anesthesiologists physical status (ASA PS) for predicting mortality in trauma patients undergoing surgery. METHODS: This multicenter, retrospective study compared the mortality predictive ability of ASA PS, RTS, Injury Severity Score (ISS), and TRISS using a complete case analysis with mixed effects logistic regression. Associations with mortality and AROC were calculated for each measure alone and tested for differences using chi-square. RESULTS: Of 3,042 patients, 230 (8%) died. The AROC for mortality for TRISS was 0.938 (95%CI 0.921, 0.954), RTS 0.845 (95%CI 0.815, 0.875), and ASA PS 0.886 (95%CI 0.864, 0.908). ASA PS + TRISS did not improve mortality predictive ability (p = 0.18). CONCLUSIONS: ASA PS was a good predictor of mortality in trauma patients, although combined with TRISS it did not improve predictive ability.

Analysis of non-obstetric vaginal and vulvar trauma: risk factors for operative intervention.

Vaginal and vulvar trauma may occur accidentally or because of an act of violence. Due to its rarity, little is known about risk factors effecting need for operative intervention. We sought to perform a large descriptive analysis of adult non-obstetric vulvovaginal trauma (VVT) and elucidate risk factors for requiring operative intervention. A retrospective analysis of the National Trauma Data Bank was performed between 2007 and 2015. Patients ≥ 16 years old with vaginal or vulvar trauma were identified. Risk factors for surgical intervention were identified using a multivariable logistic regression analysis. From 2,040,235 female patients, 2445 (< 0.2%) were identified to have VVT with the majority being injury to the vagina (68.6%). In patients with injury to the vagina, age > 65 (OR = 0.41, CI 0.26-0.62, p < 0.001), Injury Severity Score > 25 (OR = 0.66, CI 0.50-0.86, p = 0.01) and victims of rape (OR = 0.39, 95% CI 0.26-0.57, p < 0.001) were less likely to require operative intervention. In patients with injury to the vulva, age > 65 (OR = 0.45, CI 0.21-0.94, p = 0.02), victims of rape (OR = 0.26, CI 0.08-0.87, p = 0.01) and gunshot violence (OR = 0.10, CI 0.02-0.59, p = 0.02) were less likely to require operative intervention, but those with a concomitant injury to the vagina were more likely to require operative intervention (OR = 2.56, CI 1.63-4.03, p < 0.001). Injuries to the vagina or vulva occur in < 0.2% of traumas. Interestingly, in both vulvar and vaginal trauma, older age, and involvement in rape were associated with lower risk for operative intervention. A combined injury to the vagina and vulva increases the need for operative intervention.

Perioperative blood transfusion is associated with an increased risk for post-surgical infection following pancreaticoduodenectomy.

BACKGROUND/PURPOSE: Perioperative blood transfusion is common after pancreaticoduodenectomy (PD) and may predispose patients to infectious complications. The purpose of this study is to examine the association between perioperative blood transfusion and the development of post-surgical infection after PD. METHODS: Patients who underwent PD from 2014 to 2015 were identified in the NSQIP pancreas-specific database. Logistic regression analysis was used to compute adjusted odds ratios (aOR) to identify an independent association between perioperative red blood cell transfusion (within 72 h of surgery) and the development of post-operative infection after 72 h. RESULTS: A total of 6869 patients underwent PD during this time period. Of these, 1372 (20.0%) patients received a perioperative blood transfusion. Patients receiving transfusion had a higher rate of post-operative infection (34.7% vs 26.5%, p < 0.001). After adjusting for significant covariates, perioperative transfusion was independently associated the subsequent development of any post-operative infection (aOR 1.41 [1.23-1.62], p < 0.001), including pneumonia (aOR 2.01 [1.48-2.74], p < 0.001), sepsis (aOR 1.62 [1.29-2.04], p < 0.001), and septic shock (aOR 1.92 [1.38-2.68], p < 0.001). CONCLUSION: There is a strong independent association between perioperative blood transfusion and the development of subsequent post-operative infection following PD.

Risk Factors for Post-Operative Sepsis and Septic Shock in Patients Undergoing Emergency Surgery.

Background: Sepsis after emergency surgery is associated with a higher mortality rate than elective surgery, and total hospital costs increase by 2.3 times. This study aimed to identify risk factors for post-operative sepsis or septic shock in patients undergoing emergency surgery. Methods: A retrospective cohort analysis was performed using the National Surgical Quality Improvement Program (NSQIP) by identifying patients undergoing emergency surgery between 2012 and 2015 and comparing those who developed post-operative sepsis or septic shock (S/SS) with those who did not. Patients with pre-operative sepsis or septic shock were excluded. Multiple logistic regression was used to identify risk factors for the development of S/SS in patients undergoing non-elective surgery. Results: Of 122,281 patients who met the inclusion criteria, 2,399 (2%) developed S/SS. Risk factors for S/SS were American Society of Anesthesiologists Physical Status (ASA PS) class 2 or higher (odds ratio [OR] 2.57; 95% confidence interval [CI] 2.19-3.02; p < 0.0001), totally dependent (OR 2.00, 95% CI 1.38-2.83; p = 0.00021) or partially dependent (OR 1.62, 95% CI 1.35-2.00; p < 0.0001) functional status, and male gender (OR 1.31; 95% CI 1.18-1.45; p < 0.0001). Compared with colorectal procedures, patients undergoing pancreatic (OR 2.33, CI 1.40-3.87; p = 0.00108) and small intestine (OR 1.27; CI 1.12-1.44; p = 0.00015) surgery were more likely to develop S/SS. Patients undergoing biliary surgery (OR 0.38; CI 0.30-0.48; p < 0.0001) were less likely to develop S/SS. Conclusions: Risk factors for the development of sepsis or septic shock are ASA PS class 2 or higher, partially or totally dependent functional status, and male gender. Emergency pancreatic or small intestinal procedures may confer a higher risk. Greater vigilance and early post-operative screening may be of benefit in patients with these risk factors.

National Trends of Thoracic Endovascular Aortic Repair versus Open Thoracic Aortic Repair in Pediatric Blunt Thoracic Aortic Injury.

BACKGROUND: Blunt thoracic aortic injury (BTAI) occurs in <1% of all trauma admissions. Thoracic endovascular aortic repair (TEVAR) has become the preferred treatment modality in adult patients with BTAI, but its use in pediatrics is currently not supported by device manufacturers and lacks United States Food and Drug Administration approval. We hypothesized that there would also be an increased use of TEVAR in the pediatric population, thus conferring a lower risk of mortality compared with open thoracic aortic repair (OTAR). METHODS: The National Trauma Data Bank (2007-2015) was queried for patients ≤17 years with BTAI. The primary outcomes were the incidences of TEVAR and OTAR. Secondary outcome was risk of mortality in those undergoing intervention. A multivariable logistic regression model was used to determine the risk of mortality in OTAR versus TEVAR. RESULTS: We identified 650 pediatric BTAI patients with 159 (24.5%) undergoing intervention. Of these, 124 underwent TEVAR (78.0%) and 35 (22.0%) underwent OTAR. The rate of TEVAR steadily increased from 2007 to 2015 (15.4% vs. 27.1%, P < 0.001). Patients receiving OTAR and TEVAR had a similar injury severity score and rate of hypotension on admission (P > 0.05). Compared with OTAR, TEVAR patients had a higher rate of any traumatic brain injury (TBI) (63.7% vs. 37.1%, P = 0.005) and shorter hospital and intensive care unit length of stay (LOS) (16.4 vs. 21.4 days, P = 0.02; 10.1 vs. 12.2 days, P = 0.01). TEVAR and OTAR, even when stratified by ≤14 years and 15-17 years, had no difference in risk for mortality (odds ratio 1.20, confidence interval 0.29-5.01, P = 0.80). CONCLUSIONS: The rate of TEVAR in pediatric BTAI nearly doubled from 2007 to 2015. Compared with OTAR, TEVAR was associated with a shorter hospital LOS despite a higher rate of TBI. There was no difference in risk for mortality between TEVAR and OTAR. Longitudinal studies to determine the long-term efficacy and complication rates, including reintervention, development of endoleak, and/or need for further operations, are needed as this technology is being rapidly adopted for pediatric trauma patients.

Decreased incidence of venous thromboembolism found in trauma patients with positive blood alcohol concentration on admission.

BACKGROUND: The reported incidence of venous thromboembolism (VTE) disease in trauma is 1-58% and is considered a preventable cause of mortality. Positive blood alcohol concentration (BAC) is found in 8-45% of trauma admissions; however, its association with VTE is controversial. OBJECTIVES: We hypothesized that a positive BAC on admission would be associated with a lower rate of VTE in a large national database of trauma patients. METHODS: We queried the largest United States trauma registry, National Trauma Data Bank (2007-2015), for any patient with positive BAC on admission. The primary outcome was VTE and the secondary outcome was mortality. A multivariable logistic regression model was used for analysis. RESULTS: From 2,725,032 patients (70.1% male, 29.9% female), 1,800,216 (66.1%) had a negative BAC while 924,816 (33.9%) had a positive BAC. A positive BAC was associated with lower rates of VTE (OR = 0.88, CI = 0.86-0.90, p < 0.001) and mortality (OR = 0.91, CI = 0.90-0.93, p < 0.001). CONCLUSION: In a large national database, trauma patients with a positive BAC were associated with a lower rate of VTE compared to those with negative BAC. Additionally, trauma patients with positive BAC had a lower association with mortality. These findings remained after adjustment of well-known risk factors for VTE and mortality, respectively.

Risk of hysterectomy and salpingectomy or oophorectomy compared to repair after pelvic gynecologic trauma.

PURPOSE: Pelvic gynecologic trauma (PGT) includes injury to the uterus, ovaries or fallopian tubes. We hypothesized Injury Severity Score (ISS) ≥ 25, hypotension on admission and age ≥ 51 (average age for menopause) would be independent risk factors for resection compared to repair. METHODS: A retrospective analysis of the National Trauma Data Bank was performed between 2007 and 2015. RESULTS: Of 2,040,235 female patients, 1938 (< 0.1%) presented with PGT with the majority sustaining injury to the ovary or fallopian tubes (52.9%). Most patients were managed nonoperatively (77.1 vs 22.9%). On multivariable analysis, in patients with injury to the uterus, ISS ≥ 25 (OR 3.52, CI 1.67-7.48, p < 0.05) was associated with higher risk for hysterectomy compared to repair. In patients with injury to the ovaries or fallopian tubes, gunshot wound (OR 3.73, CI 1.43-9.68, p < 0.05) was associated with a higher risk for salpingectomy or oophorectomy compared to repair. Age ≥ 51 and hypotension on admission were not independent risk factors for resection in patients with PGT. Operative treatment was associated with a lower risk for mortality in patients with an injury to the uterus (OR 0.27, CI 0.14-0.51, p < 0.001) or ovaries/fallopian tubes (OR 0.37, CI 0.19-0.72, p < 0.001) compared to those managed nonoperatively. CONCLUSION: In the largest study reported, PGT occurred in < 0.1% of traumas involving women. Patients with ISS ≥ 25 have higher risk for hysterectomy compared to repair. Gunshot injuries have higher risk for salpingectomy or oophorectomy compared to repair. Hypotension on arrival or age ≥ 51 are not independent risk factors for resection in PGT. Operative management is associated with lower risk of mortality in PGT patients.

Analysis of trauma patients with unplanned returns to the operating room.

OBJECTIVES: Trauma patients undergoing damage-control surgery may have a planned return to the operating room. In contrast, little is known about unplanned returns to the operating room (uROR) in trauma. The aim of this study was to identify risk factors for uROR in trauma patients. It is hypothesized that blunt trauma patients with uROR have higher mortality when compared to penetrating trauma patients with uROR. Additionally, it is hypothesized that trauma patients with uROR after thoracotomy have higher mortality than patients with uROR after laparotomy. MATERIAL AND METHODS: A retrospective analysis of the National Trauma Data Bank from 2011-2015 including any adult patient with an uROR was performed. RESULTS: From 3.447.320 patients, 9.269 (0.2%) were identified to have uROR. In a multivariable logistic regression analysis, 27 independent predictors were identified for risk of uROR with the strongest independent risk factor being compartment syndrome (OR= 10.50, CI= 9.35-11.78, p <0.001). Blunt (compared to penetrating) mechanism was associated with higher risk for mortality in patents with uROR (OR= 1.69, CI= 1.14-2.51, p <0.001) as was re-incision thoracotomy (RT) compared to re-incision laparotomy (RL) (OR= 2.22, CI= 1.29-3.84, p <0.001). CONCLUSION: The strongest risk factor for uROR in trauma is compartment syndrome. Both a blunt (compared to penetrating) mechanism and RT (compared to RL) are independent risk factors for mortality in patients undergoing an uROR.

Humerus fracture and combined venous injury increases limb loss in axillary or subclavian artery injury.

OBJECTIVE: Axillosubclavian vessel injury is rare, with most cases occurring after penetrating trauma. A prior database (2002-2006) analysis demonstrated an overall limb loss rate of 2.9%, with no difference between isolated arterial axillosubclavian vessel injury and combined artery/vein axillosubclavian vessel injury. Given increases in advanced vascular surgical techniques, as well as improved multidisciplinary care and expeditious diagnosis with computed tomography angiography, we hypothesized the national rate of limb loss in patients with arterial axillosubclavian vessel injury has decreased. In addition, we attempted to identify current predictors for limb loss in arterial axillosubclavian vessel injury. Finally, we hypothesized that combined artery/vein axillosubclavian vessel injury, as well as associated brachial plexus injury will have a higher risk for limb-loss and mortality compared to isolated arterial axillosubclavian vessel injury. METHODS: A retrospective analysis of the National Trauma Data Bank was performed between 2007 and 2015. All patients ≥ 18 years of age with arterial axillosubclavian vessel injury were included. The primary outcome was limb loss. After a univariable logistic regression model identified significant covariates, we performed a multivariable logistic regression for analysis. RESULTS: Of the total 5,494,609 trauma admissions, 3807 patients had arterial axillosubclavian vessel injury (<0.1%). Of these, 3137 (82.4%) had isolated arterial axillosubclavian vessel injury and 670 (17.6%) had combined artery/vein axillosubclavian vessel injury. The overall limb loss rate was 2.4% (from 2.9% in 2006, p = 0.47). After adjusting for covariates, independent risk factors for limb loss included a combined artery/vein axillosubclavian vessel injury (odds ratio = 3.54, confidence interval = 2.06-6.11, p < 0.001), blunt mechanism (odds ratio = 7.81, confidence interval = 4.21-14.48, p < 0.001), open repair (odds ratio = 2.37, confidence interval = 1.47-3.82, p < 0.001), and open proximal humerus fracture (odds ratio = 8.50, confidence interval = 4.97-14.54, p < 0.001). An associated brachial plexus injury was not associated with limb loss ( p = 0.37). Combined artery/vein axillosubclavian vessel injury was associated with higher risk for mortality compared to isolated arterial axillosubclavian vessel injury (odds ratio = 2.17, confidence interval = 1.73-2.71, p < 0.001). CONCLUSIONS: The national rate of limb loss in trauma patients with arterial axillosubclavian vessel injury has not changed in the past decade. A combined artery/vein axillosubclavian vessel injury is an independent risk factor for limb loss, as well as open repair. However, the strongest risk factor is an open proximal humerus fracture. An associated brachial plexus injury is not associated with increased risk of limb loss. Patients with combined artery/vein axillosubclavian vessel injury have a twofold increased risk of death compared to patients with isolated arterial axillosubclavian vessel injury.

Decreased National Rate of below the Knee Amputation in Patients with Popliteal Artery Injury.

BACKGROUND: Popliteal arterial injury (PAI) is the second most common infrainguinal arterial injury after femoral artery injury with an incidence < 0.2%. A 2003 analysis of the National Trauma Data Bank (NTDB) reported a below the knee amputation (BKA) rate of 7.1% in patients with PAI as well as higher risk in those with an associated fracture or nerve injury. Given advances in vascular surgical techniques, improved multidisciplinary care, and expeditious diagnosis with computed tomography angiography, we hypothesized that the national rate of BKA in patients with PAI has decreased and sought to identify risk factors for BKA in patients with PAI. METHODS: A retrospective analysis of the NTDB was performed from 2007 to 2015. Patients ≥15 years of age with PAI were included and grouped by mechanism of injury (blunt versus penetrating). Interfacility transfers were excluded. The primary outcome of interest was BKA. Univariable and multivariable analyses were performed to identify predictors of BKA in patients with PAI. RESULTS: From 4,385,698 patients, 5,143 were identified with PAI (<0.2%) with most involved in a blunt mechanism (56.8%). The overall limb loss rate was 5.1% (decreased from 7.1% in 2003, P = 0.0037). After adjusting for covariates, a blunt mechanism (odds ratio [OR] = 3.53, confidence intervals [CI] = 2.49-5.01, P < 0.001) and open proximal tibia/fibula fracture or dislocation (OR = 2.71, CI = 2.08-3.54, P < 0.001) were independent risk factors for BKA in patients with PAI. A combined popliteal vein injury (PVI) did not increase the risk for BKA (P = 0.64). CONCLUSIONS: The national rate of limb loss in trauma patients with PAI has decreased from 7.1 to 5.1%. A blunt mechanism of injury as well as proximal open tibia/fibula fracture or dislocation continue to be the independent risk factors for BKA. Confirming a previous report, we found a combined PVI not to be associated with higher risk for BKA. Future prospective research to determine other possible contributing factors such as intraoperative hemodynamics and utilization of vascular shunt and fasciotomy appears warranted.

National risk factors for blunt cardiac injury: Hemopneumothorax is the strongest predictor.

BACKGROUND: Blunt cardiac injury (BCI) can occur after chest trauma and may be associated with sternal fracture (SF). We hypothesized that injuries demonstrating a higher transmission of force to the thorax, such as thoracic aortic injury (TAI), would have a higher association with BCI. METHODS: We queried the National Trauma Data Bank (NTDB) from 2007-2015 to identify adult blunt trauma patients. RESULTS: BCI occurred in 15,976 patients (0.3%). SF had a higher association with BCI (OR = 5.52, CI = 5.32-5.73, p < 0.001) compared to TAI (OR = 4.82, CI = 4.50-5.17, p < 0.001). However, the strongest independent predictor was hemopneumothorax (OR = 9.53, CI = 7.80-11.65, p < 0.001) followed by SF and esophageal injury (OR = 5.47, CI = 4.05-7.40, p < 0.001). CONCLUSION: SF after blunt trauma is more strongly associated with BCI compared to TAI. However, hemopneumothorax is the strongest predictor of BCI. We propose all patients presenting after blunt chest trauma with high-risk features including hemopneumothorax, sternal fracture, esophagus injury, and TAI be screened for BCI. SUMMARY: Using the National Trauma Data Bank, sternal fracture is more strongly associated with blunt cardiac injury than blunt thoracic aortic injury. However, hemopneumothorax was the strongest predictor.

Perforated Peptic Ulcer Surgery: Decreased Length of Stay but No Difference in Mortality with Laparoscopic Repair.

BACKGROUND: Perforated peptic ulcer (PPU) surgery mortality ranges 1% to 24%. We hypothesized a decrease in length of stay (LOS) with laparoscopic surgical repair (LSR) compared with open surgical repair (OSR). METHODS: Patients undergoing PPU surgery 2005 to 2015 were identified in NSQIP. LSR was compared with OSR 2005 to 2015. LSR 2005 to 2010 was compared with 2011 to 2015. OSR 2005 to 2010 was compared with 2011 to 2015. The primary outcome was LOS. Secondary outcomes were mortality and morbidity. RESULTS: Between 2005 and 2015, LSR had a decreased LOS, was more likely to wean from the ventilator, but had no significant difference in mortality compared with OSR. There was no significant difference in mortality for LSR or OSR over time. CONCLUSIONS: When patients are appropriately selected, LSR for PPU is a viable alternative to OSR, decreasing LOS and pulmonary complications. This demonstrates significant benefit to patients and hospital throughput.

A Propensity Score Analysis of Clostridium difficile Infection among Adult Trauma Patients.

BACKGROUND: Clostridium difficile infection (CDI) is now the most common cause of health-care-associated infection and carries a mortality rate ranging from 5-30%. Previously, trauma patients in whom CDI developed were thought to represent a unique younger at-risk population. This study aimed to establish the incidence of CDI among adult trauma patients. We hypothesized that these patients would have increased risk of death, intensive care unit (ICU) length of stay (LOS), and hospital LOS compared with trauma patients without CDI. PATIENTS AND METHODS: A retrospective study of all adult trauma patients admitted for greater than 48 hours to a single Level I trauma center between 2014 and 2016 was conducted. Analysis was performed using 1-to-5 propensity score matching with the aim to analyze the relationship between CDI, death, and other outcome variables. RESULTS: Between 2014 and 2016, of 4893 trauma patients admitted for >48 hours, 27 (0.6%) patients received a diagnosis of CDI. These patients had a mean age of 55.6 years, mean injury severity score (ISS) of 22.4, and mortality rate of 9.1%. Of these patients, 22 were able to find appropriate propensity score matches. After adjusting for important covariables, there was no significant difference in death between CDI and non-CDI patients (odds ratio = 0.39, 95% confidence interval [CI]: 0.06-2.57, adjusted p = 0.66). In addition, there was no significant difference in ICU LOS between the two groups (relative mean [RM]: 1.55, 95% CI: 1.04-2.33, adjusted p = 0.0971). The CDI patients, however, did have a significantly longer hospital LOS, compared with non-CDI patients (RM = 1.39, 95% CI: 1.16-1.66, adjusted p = 0.0017). CONCLUSIONS: Among trauma patients admitted >48 hours CDI occurred at a rate of 0.6%, much lower than anticipated. Patients in whom CDI developed had a significantly longer hospital LOS however, had no significant difference in odds of mortality or ICU LOS compared to patients without CDI.

Rising mortality in patients with combined burn and trauma.

Combined trauma in the burn patient has been previously shown to have higher mortality. With improved critical care and multidisciplinary approach, we hypothesized the risk of mortality in combined burn and trauma has decreased. A retrospective analysis of trauma, burn and combined burn-trauma patients in the National Trauma Data Bank was performed comparing years 2007-2015 to years 1994-2002. The impact of burn injuries on mortality in patients with minor trauma has decreased (OR 2.45, CI 2.26-2.66, p<0.001 compared to OR 4.04, CI 4.51-4.66, p<0.001) in years 2007-2015 while the impact of burn injuries on mortality in patients with severe trauma has increased (OR 1.37, CI 1.29-1.47, p<0.001 compared to OR 1.26, CI 1.05-1.51, p<0.001). When controlling for known risk factors of mortality in burn and trauma, the contribution of the severity of trauma on mortality in combined burn-trauma patients with total body surface area ≥20% is negligible. In contrast, an increase in percentage of total body surface area burned is associated with a step-wise increase in mortality for all combined burn-trauma patients. However, the largest impact is seen in patients with minor trauma. This population represents a unique overlap of patients where future collaborative research can help identify best practices and improve outcomes.

National Trends of Thoracic Endovascular Aortic Repair Versus Open Repair in Blunt Thoracic Aortic Injury.

BACKGROUND: Blunt thoracic aortic injury (BTAI) occurs in <1% of all trauma admissions. Considering the advent of multiple thoracic endovascular aortic repair (TEVAR) devices over the past decade, improved outcomes of TEVAR supported in the literature, rapid diagnosis, and improved preoperative planning of BTAI using computed tomography imaging, we hypothesized that the national incidence of TEVAR in BTAI has increased while open repair has decreased. In addition, we hypothesized that the mortality risk in BTAI patients undergoing TEVAR would be lower than open repair. METHODS: This was a retrospective analysis of the National Trauma Data Bank from 2007 to 2015. The primary end points of interest included the incidence of TEVAR and open repair, as well as mortality in BTAI patients undergoing intervention. Covariates were included in a multivariable analysis to determine risk for mortality in BTAI patients undergoing open repair versus TEVAR. RESULTS: We identified 3,628 BTAI patients undergoing intervention. Of these, 3,226 underwent TEVAR (87.9%), and 445 (12.1%) underwent open repair. Compared with open repair, TEVAR had a shorter mean length of stay (LOS) (19.8 vs. 21.3 days, P < 0.05) and lower rates of acute kidney injury (AKI) (5.6% vs. 9.0%, P < 0.05) and mortality (8.8% vs. 12.8%, P < 0.05). Open repair had greater risk for mortality than TEVAR (odds ratio = 1.63, confidence intervals = 1.19-2.23, P < 0.05). CONCLUSIONS: The rate of open repair decreased from 7.4% in 2007 to 1.9% in 2015, whereas TEVAR increased from 12.1 to 25.7% during the same time period. We confirmed previous findings that endovascular repair is associated with decreased mortality, LOS, and major complications, including AKI. Future investigations should focus on identifying the ideal patient candidate for TEVAR and elucidate precise indications for TEVAR in BTAI.