Effects of COVID-19 Status on Hip Fracture Surgical Outcomes: An ACS NSQIP Study.

BACKGROUND: Studies have indicated that patients infected with the SARS-CoV-2 virus fare worse clinically after a traumatic injury, especially those who are older and have other comorbidities. OBJECTIVE: This study aims to understand the effects of Corona Virus Disease 19 (COVID-19) diagnosis on patients undergoing surgery for hip fractures. METHODS: This is a retrospective review of the 2021 American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Targeted Hip Fracture database for patients who underwent surgery. Two cohorts were formed based on patients' preoperative COVID-19 status, as tested within 14 days prior to the operation. Several clinical factors were compared. RESULTS: The COVID-positive cohort consisted of 184 patients, all of whom had a laboratory-confirmed or clinically suspected SARS-CoV-2 infection, while the COVID-negative cohort consisted of 12,211 patients with no infection. A lower proportion of COVID-positive patients had an emergent operation compared to the COVID-negative cohort (58.70% vs. 73.09%, p < .001). Preoperatively, the COVID-positive cohort showed higher rates of coagulopathy/bleeding disorders (22.83% vs. 14.12%), congestive heart failure (16.30% vs. 9.84%), diabetes mellitus (28.26% vs. 19.24%), and dementia (42.39% vs. 28.07%), with p ≤ .005 for all. Postoperatively, a higher proportion of COVID-positive patients died (9.78% vs. 5.40%) or had pneumonia (8.70% vs. 3.65%), hospital readmission within 30 days (10.87% vs. 6.76%), and pressure sores (8.15% vs. 4.55%), with p ≤ .033 for all. CONCLUSION: The diagnosis of COVID-19 in hip fracture patients was associated with higher rates of postoperative complications, including mortality, when compared to COVID-negative patients, indicating the severity of the viral infection.

A prospective comparative study of the functional results associated with the use of Björk flap tracheostomy versus standard tracheostomy.

BACKGROUND: Placement of a tracheostomy for patients requiring prolonged mechanical ventilation (PMV) improves patients' comfort, decreases dead space ventilation, allows superior airway hygiene, and reduces the incidence of ventilator-associated pneumonia. Controversy still exists regarding the role of standard tracheostomy (ST) as opposed to the less frequently done Björk flap tracheostomy (BFT). This study compares the functional outcomes of these two techniques. STUDY DESIGN: Seventy-nine patients receiving tracheostomy in a 12-month period: 38 BFT vs. 41 ST. Data included demographics, indications for PMV, ventilator days before tracheostomy, time to and a number of patients who passed the fiberoptic endoscopic evaluation of swallowing (FEES), time to and a number of patients decannulated. RESULTS: Indications in both groups were PMV from trauma (18/38 vs 15/41), pneumonia (13/38 vs 13/41), and ARDS (7/38 vs 11/4), respectively (p > 0.05). Patients in both groups did not differ with regard to age, sex, GCS, duration of PMV before tracheostomy, the time to and a number of patients who passed the 1st FEES. However, the number of days and the number of FEES required before the next successful FEES in the 20 BFT and 21 ST patients who failed the 1st was 9 (4) vs. 16 (5), and 2 (1) vs. 4 (1), respectively (p < 0.05). Additionally, the number of intraoperative complications in aggregate were 0/38 in the BFT as opposed to 6/41 in the ST group (p < 0.05). CONCLUSION: We conclude that BFT may be associated with an overall shorter time to restoration of normal swallowing when compared to ST.

Serial rotational thromboelastography (ROTEM) in mechanically ventilated patients with COVID-19 demonstrates hypercoagulopathy despite therapeutic heparinization.

Background: Clinical hypercoagulopathy in patients with COVID-19 has been anecdotally described, but there is lack of evidence due to the novelty of this disease. Our study reports the results of rotational thromboelastography (ROTEM) in relation to traditional laboratory coagulation tests and acute phase markers among a cohort of severely ill, mechanically ventilated patients with COVID-19. Methods: Patients with COVID-19 (N=21) with respiratory failure requiring mechanical ventilation were included in this prospective case series. ROTEM was serially obtained for all patients on three different days during their intensive care unit (ICU) stay and analyzed using repeated measures analysis. Demographic variables, symptoms at the time of presentation, ROTEM values, laboratory values for traditionally measured coagulation profiles, and acute phase reactants were analyzed, in addition to the use of anticoagulation and clinical hypercoagulopathic complications. Results: The average age of our cohort was 57.9 years old (SD=14.4) and 76.2% were male. The mortality rate was 14.3% (3 of 21). Two patients (12.5%) were identified to have new-onset deep vein thrombosis, two patients (12.5%) were found to have ≥3 episodes of central venous catheter thrombosis, and three patients (18.7%) had confirmed stroke. ROTEM demonstrated elevated EXTEM and INTEM clotting times, including elevated FIBTEM maximum clot firmness (MCFFIB). All patients treated with therapeutic anticoagulation still demonstrated hypercoagulopathy within the MCFFIB tests. Discussion: Repeated measure ROTEMs were able to detect hypercoagulopathy in ICU patients with COVID-19 despite therapeutic anticoagulation with heparin. Level of evidence: III.

Firearm Deaths are Increasing and Endemic in the USA: It is a Problem of Suicides and Not Homicides.

BACKGROUND: To analyze and report on the changes in epidemiology traumatic causes of death in the USA. METHODS: Data were extracted from the annual National Vital Statistics Reports (2008-2017) from Center for Disease Control and analyzed for trends during the time period given. Generalized additive model was applied to evaluate the significance of trend using R software. RESULTS: Firearm deaths (39,790) and firearm death rate (12.2/100,000) in 2017 were the highest reported, and this increasing trend was significant (p < 0.001) the last ten years. Deaths from motor vehicle crash (MVC) and firearm homicides did not change significantly during the same time period. Firearm deaths were lower than MVC deaths by 21% (8,197/39,790) in 2008, but after 10 years, the difference was only 1% (458/40,231). Years of life lost from firearms is now higher than MVC. Suicides by firearm in 2017 were the highest reported at 23,854/39,773 (60%). In 2017, suicides by firearm victims were predominantly white 20,328/23,562 (85%), men 20,362/23,562 (86%), and the largest group was between the ages of 55-64. CONCLUSIONS: Death from firearms in the USA is increasing and endemic. They were the highest ever reported in 2017 by the CDC. While deaths from MVC used to be the main cause of traumatic death in the USA, deaths from firearms now almost equal it. Calculated years of life lost from firearms is now more than from MVC. Most firearm deaths are not from homicides but are from suicides, and they are predominantly in white older males of the baby boomer generation (born 1946-1964).

Venous Thromboembolism in Geriatric Trauma Patients-Risk Factors and Associated Outcomes.

BACKGROUND: Venous thromboembolism (VTE) places elderly trauma patients at a high risk of morbidity. The purpose of this study was to determine the outcomes related to VTE in geriatric trauma patients, as well as to identify risk factors for the development of VTE in this population. We also assessed the impact of the type and timing of VTE prophylaxis, and the type of injuries, on development of VTE in geriatric trauma population. METHODS: We performed a 2-year retrospective review from American College of Surgeons-Trauma Quality Improvement Project (ACS-TQIP) databank from 2014 to 2016. A total of 354,272 patients aged 65 y or older who developed VTE after trauma were included in the study. RESULTS: Overall, 354,272 elderly trauma patients with complete records were identified from the year 2014 to 2016, and of this, 4290 (1.1%) patients developed in-hospital VTE. Male gender was more predominant in the VTE group (P < 0.001). Both the ICU length of stay and hospital length of stay (P < 0.001) were higher in the VTE group. Spine injury (P = 0.002), lower extremity injury (P < 0.001), age category 75-84 y (P < 0.001), age ≥85 y (P < 0.001), frailty (P < 0.001), severe traumatic brain injury (TBI) (GCS3-8) (P < 0.001), ventilator days (P < 0.001), and transfusion of plasma products in first 24 h of admission (P < 0.001) were independent predictors of developing VTE after trauma in the elderly. Higher injury severity score, TBI, and transfusion of packed red blood cells within 24 h were associated with longer time to initiate VTE prophylaxis. Time to initiate chemical deep vein thrombosis prophylaxis was significantly longer in those patients that developed VTE (3.73 ± 4.82 d), when compared with those patients without VTE ((1.81 ± 2.53 d) (P < 0.001). CONCLUSIONS: Our study demonstrates that ICU and hospital length of stay were higher in VTE group. Frailty, severe TBI, spine injury, lower extremity injury, longer duration of mechanical ventilation, and transfusion of plasma products in the first 24 h of hospital admission were independent predictors of developing VTE after trauma in elderly. Type and timing of VTE prophylaxis were not significant independent predictors of developing VTE after trauma, while higher injury severity score, TBI, and transfusion of packed red blood cells within 24 h were associated with longer time to initiate VTE prophylaxis. Future multi-institutional prospective studies are warranted to gather more evidence on this topic.

Early tracheostomy in patients with cervical spine injury reduces morbidity and improves resource utilization.

BACKGROUND: Aim of our study is to analyze the impact of Early Tracheostomy (ET) in patients with cervical-spine (C-spine) injuries. METHODS: We analyzed seven-year (2010-2016) ACS-TQIP databank and included all non-TBI trauma patients diagnosed with c-spine injuries. Patients were stratified into two groups based on the timing of tracheostomy (Early; ≤7days: Late; >7days). Outcomes were complications, hospital and ICU stay. Regression analysis was performed. RESULTS: We included 1139 patients. Mean age was 47 ± 12, median ISS was 18 [12-28], and median C-spine AIS was 4 [3-5]. 24.5% of the patients received ET. On regression analysis, patients who received ET had lower overall-complications (OR:0.57) and ventilator-associated pneumonia (OR:0.61). ET was associated with shorter duration of mechanical ventilation, and hospital and ICU stay. There was no difference in mortality rate. CONCLUSIONS: Early tracheostomy in patients with C-spine injuries was associated with lower rates of ventilator-associated-pneumonia, shorter duration of mechanical ventilation, and ICU and hospital stay.

Mortality rates of severe traumatic brain injury patients: impact of direct versus nondirect transfers.

BACKGROUND: Direct transport of patients with severe traumatic brain injury (sTBI) to trauma centers (TCs) that can provide definitive care results in lower mortality rates. This study investigated the impact of direct versus nondirect transfers on the mortality rates of patients with sTBI. METHODS: Data on patients with TBI admitted between January 1, 2012, and December 31, 2013, to our Level I TC were obtained from the trauma registry. Data included patient age, sex, mechanism, and type of injury, comorbidities, Glasgow Coma Scale, Injury Severity scores, prehospital time, time to request and to transfer, time to initiation of multimodality monitoring and goal-directed therapy protocol, dwell time in the emergency department (EDT), and mortality. Data, reported in means ± standard deviation, were analyzed with the Student t-test and chi-square. Statistical significance was accepted at a P value < 0.05. RESULTS: sTBI direct transfer to TC versus transfer from non-TCs (NTC): Of the 1187 patients with TBI admitted to our TC, 768 (64.7%) were admitted directly from the scene, whereas 419 (35.3%) were admitted after secondary transfer. One hundred seventy-one (22.2%) of the direct transfers had Glasgow Coma Scale < 8 (sTBI) and 92 (21.9%) of the secondary transfers had sTBI. The transfer time: Time from scene to arrival to the EDT was significantly shorter for TC versus NTCs 43 ± 14 versus 77 ± 26 min, respectively (P < 0.05). EDT dwell time before transfer and time from injury to arrival to TC were 4.2 ± 2.1 and 6.2 ± 8.3 h, respectively. Mortality: There was a statistically significant lower mortality for patients with sTBI transferred directly from the scene to TCs as opposed to patients secondarily transferred, 33/171 (19.3%) versus 33/92 (35.8%), respectively (P < 0.05). CONCLUSIONS: To decrease TBI-related mortality, patients with suspected sTBI should be taken directly to a Level I or II TC unless they require life-saving stabilization at NTCs.

Acute presentation of congenital diaphragmatic hernia requiring damage control laparotomy in an adult patient.

Congenital diaphragmatic hernias constitute an infrequent but potentially serious presentation of bowel obstruction in the adult patient. Herein, we present a rare case of an adult patient with strangulation of colon within a Morgagni's hernia where timely recognition and intervention were life-saving. An 18-year-old female presented with an acute abdomen, respiratory failure, and shock secondary to a strangulated, previously undiagnosed Morgagni hernia requiring emergency laparotomy, reduction of hernia contents and resection of non-viable colon. The patient underwent repair of the hernia with restoration of bowel continuity and reconstruction of her abdominal wall in sequential fashion. Although congenital diaphragmatic hernias have been previously described in the adult population, there are few if any reports of such pathology presenting in such an acute, life-threatening fashion. This case highlights the importance of a high index of suspicion, early recognition, and timely surgical intervention for this rare, potentially fatal condition.

The impact of early flow and brain oxygen crisis on the outcome of patients with severe traumatic brain injury.

BACKGROUND: Multimodality monitoring and goal-directed therapy may not prevent blood flow and brain oxygen (Flow/BrOx) crisis. We sought to determine the impact of these events on outcome in patients with severe traumatic brain injury (sTBI). METHODS: Twenty-four patients with sTBI were treated to maintain intracranial pressure (ICP) less than or equal to 20 mm Hg, cerebral perfusion pressure (CPP) greater than or equal to 60 mm Hg, brain oxygen greater than or equal to 20 mm Hg, and near infrared spectroscopy greater than or equal to 60%. Flow/BrOx crisis events were recorded. The 14-day predicted mortality was compared with actual mortality. RESULTS: Nonsurvivors had a significantly higher number of crisis events nonresponsive to treatment (P < .05). Mortality was 87.5% in patients with greater than or equal to 20 events versus 6.3% in patients with less than 20 events. The predicted mortality was 58%, whereas actual mortality was 33.3% (8/24), yielding a 42% reduction in mortality. CONCLUSIONS: A multimodality monitoring and goal-directed therapy may decrease mortality in sTBI. However, Flow/BrOx crisis events still occur and predict a poor outcome.

Non-surgical management of spontaneous splenic rupture due to Babesia microti infection.

Babesiosis is an emerging tick-borne infection. We describe 2 hospitalized patients from the United States with spontaneous splenic rupture attributable to Babesia microti infection. The first patient was a 36-year-old previously healthy man with a low-grade splenic rupture not requiring surgical intervention. The second was a 70-year-old healthy man whose splenic rupture required proximal splenic artery embolization. Since the spleen is an important organ involved in controlling Babesia infection, management of splenic rupture in an infected patient using an organ preserving approach when appropriate may be preferred.