A Criteria to Reduce Interhospital Transfer of Traumatic Brain Injuries in Greater East Texas.

BACKGROUND: Traumatic brain injury (TBI) due to single-level falls (SLF) are frequent and often require interhospital transfer. This retrospective cohort study aimed to assess the safety of a criteria for non-transfer among a subset of TBI patients who could be observed at their local hospital, vs mandatory transfer to a level 1 trauma center (L1TC). METHODS: We conducted a 7-year review of patients with TBI due to SLF at a rural L1TC. Patients were classified as transfer/non-transfer according to the Brain Injuries in Greater East Texas (BIGTEX) criteria. The primary outcome measure was the occurrence of a critical event defined as deteriorating repeat head computed tomography (CT) scan or neurological status, neurosurgical intervention, or death. RESULTS: Of the 689 included patients, 63 (9.1%) were classified as non-transfer. Although there were 4 cases with a neurological change and one with a head CT change among the non-transfer group, there were no neurosurgical procedures or deaths. The Cox Proportional Hazard model showed a near 3-fold increased risk of experiencing a critical event if classified as a non-transfer. The multivariable regression model showed patients with an Abbreviated Injury Scale (AIS) of 3 was twice as likely to experience a critical event, with an AIS of 4, three times, and 3 times more likely to be classified to transfer. DISCUSSION: The BIGTEX criteria identify a subset of patients who can safely be observed at their local hospital. To confirm the safety and efficacy of this transfer criteria recommendation, a prospective study is warranted.

The clinical application of incisional negative pressure wound therapy in severe subcutaneous emphysema: A case series.

Severe subcutaneous emphysema (SSE) is the presence of a high-volume accumulation of air in the subcutaneous tissue caused by traumatic injuries, infections, iatrogenic causes, or can also manifest spontaneously. A variety of techniques have been reported, with varying levels of success. We present a multicenter case series detailing four patients who developed SSE and were treated with Incisional Negative Pressure Wound Therapy (INPWT). All patients significantly improved with the INPWT treatment within 6 to 48 h. Our experience suggests INPWT is a valuable procedure available for treating SSE and recommend prospective randomized studies be conducted to determine targeted patient selection and clinical application of INPWT among the SSE patient population.

Hospitalization and readmission after single-level fall: a population-based sample.

BACKGROUND: Single-level falls (SLFs) in the older US population is a leading cause of hospital admission and rates are increasing. Unscheduled hospital readmission is regarded as a quality-of-care indication and a preventable burden on healthcare systems. We aimed to characterize the predictors of 30-day readmission following admission for SLF injuries among patients 65 years and older. METHODS: We conducted a retrospective cohort study using the Nationwide Readmission Database from 2018 to 2019. Included patients were 65 and older, admitted emergently following a SLF with a primary injury diagnosis. Hierarchical logit regression was used to model factors associated with readmission within 30 days of discharge. RESULTS: Of 1,338,905 trauma patients, 65 years or older, 61.3% had a single-level fall as the mechanism of injury. Among fallers, the average age was 81.1 years and 68.5% were female. SLF patients underwent more major therapeutic procedures (56.3% vs. 48.2%), spent over 2 million days in the hospital and incurred total charges of over $28 billion annually. Over 11% of SLF patients were readmitted within 30 days of discharge. Increasing income had a modest effect, where the highest zip code quartile was 9% less likely to be readmitted. Decreasing population density had a protective effect of readmission of 16%, comparing Non-Urban to Large Metropolitan. Transfer to short-term hospital, brain and vascular injuries were independent predictors of 30-day readmission in multivariable analysis (OR 2.50, 1.31, and 1.42, respectively). Palliative care consultation was protective (OR 0.41). The subsequent hospitalizations among those 30-day readmissions were primarily emergent (92.9%), consumed 260,876 hospital days and a total of $2.75 billion annually. CONCLUSIONS: SLFs exact costs to patients, health systems, and society. Transfer to short-term hospitals at discharge, along with brain and vascular injuries were strong predictors of 30-day readmission and warrant mitigation strategy development with consideration of expanded palliative care consultation.

Use of a Modified ABTHERA ADVANCE™ Open Abdomen Dressing with Intrathoracic Negative-Pressure Therapy for Temporary Chest Closure After Damage Control Thoracotomy.

BACKGROUND Damage control surgery (DCS) is an established emergency operative concept, initially described and most often utilized in abdominal trauma. DCS prioritizes managing acute hemorrhage and contamination, leaving the abdominal wall fascia open and covering the existing wound with a temporary abdominal wall closure, most commonly negative-pressure wound therapy (NPWT). The patient undergoes aggressive resuscitation to optimize physiology. Once achieved, the patient is returned to the operating room for definitive surgical intervention. There is limited evidence suggesting that using damage control thoracotomy within the chest cavity improves mortality and morbidity rates. Our review failed to find a case in which NPWT using ABTHERA ADVANCE™ Open Abdomen Dressing has been successfully used in the setting of thoracic trauma. CASE REPORT This case series describes 2 examples of NPWT as a form of temporary chest closure in penetrating and blunt thoracic injury. The first case was a penetrating self-inflicted stab wound to the chest. The NPWT was applied as a form of temporary thoracotomy, closure at the index surgery. The second case was a blunt injury to the chest of a polytrauma patient following a motor vehicle accident. The patient sustained rib fractures on his left side and had a bilateral pneumothorax. An emergent thoracotomy was performed due to delayed intrathoracic bleeding noted on hospital day 11, and NPWT was applied as described above, in the first case. CONCLUSIONS These cases suggest that damage control thoracotomy with intrathoracic placement of a modified ABTHERA ADVANCE™ Open Abdomen Dressing negative-pressure system may be an effective and life-saving technique with the potential for positive outcomes in these high-risk patients.

Agricultural Injury Surveillance Using a Regional Trauma Registry.

BACKGROUND: The burden of traumatic injury among workers in agriculture is substantial. Surveillance can inform injury prevention efforts to reduce farmworkers' risk. We posited that the regional trauma registry can provide surveillance for agricultural injury requiring trauma-center care. METHODS: The Northeast Texas regional trauma registry was queried for patients injured in agricultural settings during 2016-2019 occurring in the 23,580 square mile study area subdivided into 219 US Census Zip Code Tract Area (ZCTA). Population at risk was estimated from the 2017 Census of Agriculture. Kuldorff's SaTScan identified case hot spots. A multivariable, geographically weighted regression model was fit for cases/1000 workers. RESULTS: In total, 273 cases occurred, (mean 68 cases per year [95% confidence interval 55.1-80.9]) among 96 ZCTA. The mean injury rate was 3.9 (95% confidence interval 3.4-4.3) cases per 1000 farmworkers. Animals and farm machinery were the most common injury mechanisms, 52.0% and 20.9%, respectively. Trauma ZCTA demonstrated more farms (median 170 versus 95.5, P < 0.001), greater farm acreage (53,900 acres versus 32,800, P = 0.004), and higher median total product sales ($6.5 million versus $3.9 million, P < 0.001). Six hot spots were identified with relative risks from 2.85 to 5.31. The multivariable model of cases/1000 workers demonstrated significant associations with workers per ZCTA (a mean ß-coefficient of 0.004 with P values <0.05 in 145 of 219 [66.5%] ZCTA) and percent rural population (ß = -6.62, P values <0.05 in 76.1% of ZCTA). CONCLUSIONS: Regional trauma registry data, combined with census data and spatial analyses, can identify actionable geographic areas of high agriculture-related injury risk.

Elderly trauma associated with high-risk recreational activity: A population-based study, United States, 2010 through 2016.

BACKGROUND: Understanding trends in prevalence and etiology is critical to public health strategies for prevention and management of injury related to high-risk recreation in elderly Americans. METHODS: The National Emergency Department Sample from 2010 through 2016 was queried for patients with a principal diagnosis of trauma (ICD-9 codes 800.0-959.9) and who were 55 years and older. High-risk recreation was determined from e-codes a priori. Primary outcome measures were mortality and total hospital charges. RESULTS: Of the 29,491,352 patient cohort, 458,599 (1.56%) engaged in high-risk activity, including those age 85 and older. High-risk cases were younger (median age 61 vs 70) and majority male (71.87% vs 39.24%). The most frequent activities were pedal cycling (45.81%), motorcycling (29.08%), and off-road vehicles (9.13%). Brain injuries (8.82% vs 3.88%), rib/sternal fractures (13.35% vs 3.53%), and cardiopulmonary injury (5.25% vs 0.57%) were more common among high-risk cases. Mortality (0.75% vs 0.40%) and total median hospital charges ($3,360 vs $2,312) were also higher for high-risk admissions, where the odds of mortality increased exponentially per year of age (odds ratio, 1.06; 99.5% CI, 1.05-1.08). High-risk recreation was associated with more than $1 billion in total hospital charges and more than 100 deaths among elderly Americans per year. CONCLUSION: Morbidity, mortality, and resource utilization due to high-risk recreation extend into the ninth decade of life. The patterns of injury described here offer opportunities for targeted injury prevention education to minimize risk among this growing segment of the United States population.