Nomogram for predicting in-hospital mortality in trauma patients undergoing resuscitative endovascular balloon occlusion of the aorta: a retrospective multicenter study.

Recently, resuscitative endovascular balloon occlusion of the aorta (REBOA) had been introduced as an innovative procedure for severe hemorrhage in the abdomen or pelvis. We aimed to investigate risk factors associated with mortality after REBOA and construct a model for predicting mortality. This multicenter retrospective study collected data from 251 patients admitted at five regional trauma centers across South Korea from 2015 to 2022. The indications for REBOA included patients experiencing hypovolemic shock due to hemorrhage in the abdomen, pelvis, or lower extremities, and those who were non-responders (systolic blood pressure (SBP) < 90 mmHg) to initial fluid treatment. The primary and secondary outcomes were mortality due to exsanguination and overall mortality, respectively. After feature selection using the least absolute shrinkage and selection operator (LASSO) logistic regression model to minimize overfitting, a multivariate logistic regression (MLR) model and nomogram were constructed. In the MLR model using risk factors selected in the LASSO, five risk factors, including initial heart rate (adjusted odds ratio [aOR], 0.99; 95% confidence interval [CI], 0.98-1.00; p = 0.030), initial Glasgow coma scale (aOR, 0.86; 95% CI 0.80-0.93; p < 0.001), RBC transfusion within 4 h (unit, aOR, 1.12; 95% CI 1.07-1.17; p < 0.001), balloon occlusion type (reference: partial occlusion; total occlusion, aOR, 2.53; 95% CI 1.27-5.02; p = 0.008; partial + total occlusion, aOR, 2.04; 95% CI 0.71-5.86; p = 0.187), and post-REBOA systolic blood pressure (SBP) (aOR, 0.98; 95% CI 0.97-0.99; p < 0.001) were significantly associated with mortality due to exsanguination. The prediction model showed an area under curve, sensitivity, and specificity of 0.855, 73.2%, and 83.6%, respectively. Decision curve analysis showed that the predictive model had increased net benefits across a wide range of threshold probabilities. This study developed a novel intuitive nomogram for predicting mortality in patients undergoing REBOA. Our proposed model exhibited excellent performance and revealed that total occlusion was associated with poor outcomes, with post-REBOA SBP potentially being an effective surrogate measure.

Liver Transplant After Severe Liver Trauma: The First Report in a Korean Adult.

Following a motor-vehicle accident, a 57-year-old man was diagnosed with a grade 4 liver injury (American Association for the Surgery of Trauma organ injury scale) with multiple contrast extravasations. He initially underwent nonoperative management, which included transcatheter arterial embolization. However, he experienced a hemorrhage after the first embo-lization procedure, and so the procedure was repeated. Thereafter, he was diagnosed with liver failure based on findings from computed tomography and liver function tests. On day 28 of hospitalization, the patient underwent deceased donor liver transplant. He experienced several complications, including acute renal failure, pneumonia, and bile leak. These were managed successfully, and the patient was discharged 4 months after the transplant. Although liver transplant procedure for hepatic trauma is technically challenging and risky, it should be considered a viable treatment option in some patients (such as patients with severe liver injury). This is the first reported case, to our knowledge, of a liver transplant performed successfully in a patient with severe hepatic trauma in Korea.

Artificial intelligence to predict in-hospital mortality using novel anatomical injury score.

The aim of the study is to develop artificial intelligence (AI) algorithm based on a deep learning model to predict mortality using abbreviate injury score (AIS). The performance of the conventional anatomic injury severity score (ISS) system in predicting in-hospital mortality is still limited. AIS data of 42,933 patients registered in the Korean trauma data bank from four Korean regional trauma centers were enrolled. After excluding patients who were younger than 19 years old and those who died within six hours from arrival, we included 37,762 patients, of which 36,493 (96.6%) survived and 1269 (3.4%) deceased. To enhance the AI model performance, we reduced the AIS codes to 46 input values by organizing them according to the organ location (Region-46). The total AIS and six categories of the anatomic region in the ISS system (Region-6) were used to compare the input features. The AI models were compared with the conventional ISS and new ISS (NISS) systems. We evaluated the performance pertaining to the 12 combinations of the features and models. The highest accuracy (85.05%) corresponded to Region-46 with DNN, followed by that of Region-6 with DNN (83.62%), AIS with DNN (81.27%), ISS-16 (80.50%), NISS-16 (79.18%), NISS-25 (77.09%), and ISS-25 (70.82%). The highest AUROC (0.9084) corresponded to Region-46 with DNN, followed by that of Region-6 with DNN (0.9013), AIS with DNN (0.8819), ISS (0.8709), and NISS (0.8681). The proposed deep learning scheme with feature combination exhibited high accuracy metrics such as the balanced accuracy and AUROC than the conventional ISS and NISS systems. We expect that our trial would be a cornerstone of more complex combination model.

Combined head and abdominal blunt trauma in the hemodynamically unstable patient: What takes priority?

BACKGROUND: The management of hypotensive patients with severe combined head and abdominal trauma is challenging, regarding the need, timing, and sequence of craniotomy or laparotomy. The purpose of the present study was to determine whether rare situations requiring craniotomy prior to laparotomy can be identified on admission with simple clinical parameters. We hypothesized that hypotension is rarely associated with the need of a combined procedure, especially in patients with mildly depressed consciousness. METHODS: National Trauma Data Bank study, including adult blunt trauma patients with combined severe head (Abbreviated Injury Scale score, ≥ 3) and abdominal injury (Abbreviated Injury Scale score, ≥ 3). Data collection included demographic and clinical characteristics, laparotomy, and craniotomy within 24 hours of admission, types of intracranial pathologies, survival, and hospital stay. Multivariate regression analysis was used to determine factors predictive for the need of both operative procedures. RESULTS: Of 25,585 patients with severe combined head and abdominal trauma, 8,744 (34.2%) needed only laparotomy, 534 (2.1%) only craniotomy, and 394 (1.5%) required both procedures within 24 hours of admission. In the subgroup of 4,667 hypotensive patients, 2,421 (51.9%) underwent only laparotomy, 54 (1.2%) only craniotomy, and 79 (1.7%) both procedures within 24 hours of admission. Only 5 (0.7%) of 711 hypotensive patients with Glasgow Coma Scale (GCS) score above 8 who required a laparotomy also needed a craniotomy. Among clinical parameters available on patient's arrival, GCS score of 7 to 8 was independently associated with the highest need for craniotomy in hypotensive patients requiring laparotomy (odds ratio, 7.94; p = 0.004). CONCLUSION: The need for craniotomy in patients with severe combined head and abdominal injury requiring exploratory laparotomy is very low. In hypotensive patients requiring laparotomy, GCS score of 7 to 8 was an independent predictor of the need for craniotomy. In hemodynamically unstable patients with a GCS score greater than 8, it may be safer to proceed with a laparotomy first and address the head with a computed tomography scan at a later stage. LEVEL OF EVIDENCE: Therapeutic, Level IV.

Hit by a Train: Injury Burden and Clinical Outcomes.

BACKGROUND: Few data exist regarding the train vs. pedestrian (TVP) injury burden and outcomes. OBJECTIVE: This study aimed to examine the epidemiology and outcomes associated with TVP injuries. METHODS: This is a retrospective National Trauma Databank study (January 2007 to July 2012) including trauma patients sustaining TVP injury. Demographics, injury data, interventions, and outcomes were abstracted. Patients injured by a train were compared to patients who sustained an automobile vs. pedestrian (AVP) injury. RESULTS: Of the 152,631 patients struck by ground transportation during the study time frame, 1863 (1.2%) were TVP. Median TVP age was 38 years (interquartile range [IQR] 24-50 years), 81.6% were male, median Injury Severity Score (ISS) was 13 (IQR 6-24). TVP patients were more severely injured (ISS 13 vs. 9; p < 0.001) and required more proximal amputations (13.4% vs. 0.2%; p < 0.001) and cavitary operations (18.2% vs. 2.8%; p < 0.001). TVP patients had higher rates of intensive care unit admission, mechanical ventilation and transfusion, longer length of stay, and higher in-hospital mortality. On multivariable logistical regression, TVP was an independent predictor for higher injury burden, ISS ≥25 (adjusted odds ratio [AOR] 1.650), immediate operative need (AOR 7.535), and complications (AOR 1.317). CONCLUSIONS: TVP is associated with a significant injury burden. These patients have a significantly higher need for immediate operation and more complicated hospital course.

The Age of Undertriage: Current Trauma Triage Criteria Underestimate The Role of Age and Comorbidities in Early Mortality.

BACKGROUND: National guidelines recommend that prehospital and emergency department (ED) criteria identify patients who might benefit from trauma center triage and highest-level trauma team activation. However, some patients who are seemingly "stable" in the field and do not meet the standard criteria for trauma activation still die. OBJECTIVES: The purpose of this study was to identify these at-risk patients to potentially improve triage algorithms. METHODS: Patients enrolled in the National Trauma Data Bank (2007-2012) were included. All adult blunt trauma patients that were stable in the field and upon arrival to the ED (defined as a Glasgow Coma Scale score of 13-15, a heart rate ≤120 beats/min, systolic blood pressure ≥90 mm Hg, and diastolic blood pressure ≤200 mm Hg) and did not meet the standard criteria for the highest-level trauma team activation as defined by the American College of Surgeons were included. Demographic, clinical, and injury data including comorbidities, ED vitals, and outcome were collected. Regression models were used to identify independent risk factors for mortality. RESULTS: A total of 1,003,350 patients were stable in both the field and ED. Of these 11,010 (1.1%) died, including 1785 (0.2%) who died within 24 hours of hospital admission. The mortality in patients ≥60 years of age was 2.6%, and in patients ≥60 years of age with either a cerebrovascular accident (CVA) or congestive heart failure (CHF) was 5.4%. Age ≥60 years was a significant independent predictor of early mortality (odds ratio [OR] 4.53, p < 0.001). CHF (OR 1.88, p < 0.001) and a history of stroke (OR 1.52, p < 0.001) were also significant independent predictors of mortality. CONCLUSIONS: Despite apparent evidence of both prehospital stability and stability upon arrival to the ED, patients ≥60 years of age and with a history of CHF or CVA have a significantly increased risk of early mortality after blunt trauma. These patients are at risk for subsequent clinical deterioration and should be considered for early transfer to a trauma center with highest-level activation.

Severe Bleeding in Pelvic Fractures: Considerations in Planning Damage Control.

Severe bleeding due to pelvic fractures may require damage control procedures, such as preperitoneal packing. In many cases, preperitoneal packing is performed without full abdominal exploration. There are concerns that such an approach may miss major iliac vascular injuries or other intraabdominal injuries. This analysis assessed the incidence of iliac vascular and intraabdominal injuries in patients with pelvic fractures. The National Trauma Data Bank was queried for blunt trauma patients. Patients with severe pelvic fractures were observed. Common or external iliac vascular lacerations (CEIVL) and associated intraabdominal injuries were recorded. The study comprised 42,122 patients with pelvic fractures, of which 3,221 (7.6%) were severe pelvic fractures. The incidence of CEIVL in patients with severe pelvic fractures was 10.7 per cent. Patient age greater than or equal to 65 years was an independent predictor of CEIVL. A total of 34.3 per cent of severe pelvic fracture patients had severe associated intraabdominal injuries, including injuries to the bladder (26.5%) and bowel (16.7%). Severe pelvic fractures are associated with a high incidence of iliac vascular and intraabdominal injuries. Preperitoneal pelvic packing without abdominal exploration may miss these injuries.

Implementation of Trauma Center and Massive Transfusion Protocol Improves Outcomes for Major Trauma Patients: A Study at a Single Institution in Korea.

BACKGROUND: This study evaluated the effectiveness and clinical outcomes of the implementation of a trauma center and massive transfusion protocol (TCMTP) in a developing country without a well-established trauma system. METHODS: We included patients (1) aged >15 years, (2) with an Injury Severity Score >15, (3) who received ≥10 units of packed red blood cells (PRBCs) within 24 h, (4) who directly visited our institution from 2010 to 2016, and (5) who survived for ≥24 h. Patients treated during the post-TCMTP period (2015-2016) were compared with historical groups treated pre-TCMTP (2010-2012) and interim-TCMTP (2013-2014). Demographics, transfusion and fluid therapy performance, and clinical outcomes were compared between the three groups. RESULTS: Overall, 190 patients were included: 64, 64, and 62 patients in the pre-TCMTP, interim-TCMTP, and post-TCMTP groups, respectively. Comparison between the three groups revealed significant differences in the fresh-frozen plasma/PRBC ratio (p = 0.001) and crystalloid infusion (p = 0.007); these variables gradually increased from pre- to post-TCMTP. Conversely, colloid infusion showed a reduction post-TCMTP (p < 0.001). Kaplan-Meier curves revealed that the 90-day survival rate was significantly higher in the post-TCMTP group (pre-TCMTP: 45.3 vs. 75.8%, p = 0.001; interim-TCMTP: 56.3 vs. 75.8%, p = 0.027). In Cox regression hierarchical survival analysis, TCMTP showed a hazard ratio for mortality of 0.380 after adjusting for all potentially confounding factors. CONCLUSIONS: Our results suggest that building trauma centers and establishing a massive transfusion protocol according to the specific situations of a country will help improve outcomes for major trauma patients, even in developing countries without a well-established trauma system.

Early Versus Late Tracheostomy in Trauma Patients: A Propensity-Matched Cohort Study of 5 Years' Data at a Single Institution in Korea.

BACKGROUND: Although there have been many studies dealing with tracheostomy timing in trauma patients, the optimal timing is still being debated. This study aimed to compare outcomes between early tracheostomy (ET) and late tracheostomy (LT) in trauma populations to estimate the optimal timing of tracheostomy after intubation. METHODS: We retrospectively reviewed the 5 years' data of trauma patients who underwent tracheostomy during their acute intensive care unit (ICU) stay. The cases were divided into two groups: ET was defined as tracheostomy performed within 7 days after intubation, and LT, after the seventh day. Propensity score matching was utilized using a 1-to-1 matching technique, and outcomes between two groups were compared. RESULTS: Among 236 enrolled patients, 76 met the criteria for ET and 160 were included for LT. Using propensity matching, 70 patients who met the criteria for ET were matched to 70 patients in the LT. Based on the comparison of outcomes after matching, ET showed significantly shorter values than LT in overall ventilator duration, length of stay at the ICU, and post-tracheostomy ventilation duration. Furthermore, the incidence of pneumonia was significantly lower with ET than with LT, although the rate of postoperative complications showed no significant differences. CONCLUSIONS: We suggest that ET should be considered in trauma patients needing prolonged mechanical ventilation. Also, we recommend that surgeons perform tracheostomy as early as within 7 days after intubation to not only reduce the ventilation and ICU days but also prevent pneumonia without worrying about an increase in postoperative complications.

Negative computed tomography can safely rule out clinically significant intra-abdominal injury in the asymptomatic patient after blunt trauma: Prospective evaluation of 1193 patients.

BACKGROUND: Computed tomography of the abdomen and pelvis (CTAP) is highly specific for injury identification and commonly used in the evaluation of blunt trauma patients. Despite this, there is no consensus on the required clinical observation period after negative imaging, often impacting patient flow and hospital cost. The purpose of this study was to evaluate the use of CTAP after blunt trauma and the need for observation after negative imaging. METHODS: A prospective analysis at a large Level I trauma center was conducted from November 2014 to May 2015. All blunt trauma patients, older than 14 years with CTAP on admission were included. Symptomatic patients were defined as having abdominal pain or external signs of trauma on admission. The main outcome was missed injury. RESULTS: Over the study period, there were 1,468 blunt trauma admissions, of which 1,193 patients underwent CTAP. Eight hundred six (67.6%) patients were evaluable on admission (Glasgow Coma Scale score, 15), and of these, 327 (40.6%) were symptomatic, 479 (59.4%) asymptomatic. Among the evaluable asymptomatic patients, there were 65 (13.6%) positive computed tomography scans including 11 patients with grade III, IV, or V solid organ injury and three that required operation. In the 414 evaluable asymptomatic patients with negative imaging, median length of stay was 3 days, and there were zero missed injuries. All images were reviewed by an attending radiologist. CONCLUSION: Abdominal imaging after trauma is justified in the appropriate clinical setting to evaluate for significant abdominal injury regardless of symptomatology. In asymptomatic, evaluable patients with a negative CTAP, clinically significant abdominal injury is unlikely, and these patients may be considered for early discharge or disposition to another treatment service. LEVEL OF EVIDENCE: Diagnostic, level III; Therapy, level IV.

Timing and Associated Factors for Sepsis-3 in Severe Trauma Patients: A 3-Year Single Trauma Center Experience.

BACKGROUND: We hypothesized that the recent change of sepsis definition by sepsis-3 would facilitate the measurement of timing of sepsis for trauma patients presenting with initial systemic inflammatory response syndrome. Moreover, we investigated factors associated with sepsis according to the sepsis-3 definition. METHODS: Trauma patients in a single level I trauma center were retrospectively reviewed from January 2014 to December 2016. Exclusion criteria were younger than 18 years, Injury Severity Score (ISS) <15, length of stay <8 days, transferred from other hospitals, uncertain trauma history, and incomplete medical records. A binary logistic regression test was used to identify the risk factors for sepsis-3. RESULTS: A total of 3,869 patients were considered and, after a process of exclusion, 422 patients were reviewed. Fifty patients (11.85%) were diagnosed with sepsis. The sepsis group presented with higher mortality (14 [28.0%] vs. 17 [4.6%], P<0.001) and longer intensive care unit stay (23 days [range, 11 to 35 days] vs. 3 days [range, 1 to 9 days], P<0.001). Multivariate analysis demonstrated that, in men, high lactate level and red blood cell transfusion within 24 hours were risk factors for sepsis. The median timing of sepsis-3 was at 8 hospital days and 4 postoperative days. The most common focus was the respiratory system. CONCLUSIONS: Sepsis defined by sepsis-3 remains a critical issue in severe trauma patients. Male patients with higher ISS, lactate level, and red blood cell transfusion should be cared for with caution. Reassessment of sepsis should be considered at day 8 of hospital stay or day 4 postoperatively.

Isolated iliac vascular injuries and outcome of repair versus ligation of isolated iliac vein injury.

OBJECTIVE: The incidence of morbidity and mortality for iliac vascular injuries in the literature are likely overestimated owing to associated injuries. Data for isolated iliac vascular injuries are very limited. No large studies have reported the incidence of morbidity for repair versus ligation of isolated iliac vein injuries. METHODS: Patients in the National Trauma Data Bank (NTDB; 2007-2012) with at least one iliac vascular injury were analyzed. Isolated iliac vessels were defined as cases with Abbreviated Injury Scale severity score of greater than 3 for extraabdominal injuries and an Organ Injury Scale grade of greater than 3 for intraabdominal injuries. RESULTS: Overall, 6262 iliac vascular injuries (2809 penetrating, 3453 blunt) were identified in 271,076 patients with abdominal trauma (2.3%). There were 3379 patients (1841 penetrating, 1538 blunt) with isolated iliac vascular injuries (1.2%) and 557 patients (514 penetrating, 43 blunt) with combined iliac artery and vein injuries (0.2%). The 30-day mortality rate was 16.5% for isolated iliac vein injury, 19.3% for isolated iliac artery injury, and 48.7% for combined isolated iliac artery and vein injury. The 30-day mortality rate was 23.4% for isolated iliac vascular injuries compared with 39.0% for nonisolated iliac vascular injuries (P < .001). Patients with isolated iliac vein injuries had morbidity rates of deep venous thrombosis (repair, 14.6%; ligation, 14.1%; P = .875), pulmonary embolism (repair, 1.8%; ligation, 0.5%; P = .38), fasciotomy (repair, 9.3%; ligation, 14.6%; P = .094), amputation (repair, 1.8%; ligation, 2.6%; P = .738), acute kidney injury (repair, 5.8%; ligation, 4.7%; P = .627). Multivariate logistic regression demonstrated that ligation of isolated iliac vein injuries had an odds ratio of 2.2 for mortality compared with repair (95% confidence interval, 1.08-4.66). CONCLUSIONS: Isolated iliac vascular injuries are associated with a high incidence of mortality, especially for combined venous and arterial injury, but mortality is significantly lower than in patients with nonisolated iliac vascular injuries. In patients with isolated iliac vein injuries, mortality was higher in patients who underwent ligation compared with repair; however, the rates of deep venous thrombosis, pulmonary embolism, fasciotomy, amputation, and acute kidney injury were not different between the treatment groups. These data lend credence to the assessment that repair of iliac vein injuries is preferable to ligation whenever feasible.

Intracranial pressure monitoring in severe blunt head trauma: does the type of monitoring device matter?

OBJECTIVE Intracranial pressure (ICP) monitoring has become the standard of care in the management of severe head trauma. Intraventricular devices (IVDs) and intraparenchymal devices (IPDs) are the 2 most commonly used techniques for ICP monitoring. Despite the widespread use of these devices, very few studies have investigated the effect of device type on outcomes. The purpose of the present study was to compare outcomes between 2 types of ICP monitoring devices in patients with isolated severe blunt head trauma. METHODS This retrospective observational study was based on the American College of Surgeons Trauma Quality Improvement Program database, which was searched for all patients with isolated severe blunt head injury who had an ICP monitor placed in the 2-year period from 2013 to 2014. Extracted variables included demographics, comorbidities, mechanisms of injury, head injury specifics (epidural, subdural, subarachnoid, intracranial hemorrhage, and diffuse axonal injury), Abbreviated Injury Scale (AIS) score for each body area, Injury Severity Score (ISS), vital signs in the emergency department, and craniectomy. Outcomes included 30-day mortality, complications, number of ventilation days, intensive care unit and hospital lengths of stay, and functional independence. RESULTS During the study period, 105,721 patients had isolated severe traumatic brain injury (head AIS score ≥ 3). Overall, an ICP monitoring device was placed in 2562 patients (2.4%): 1358 (53%) had an IVD and 1204 (47%) had an IPD. The severity of the head AIS score did not affect the type of ICP monitoring selected. There was no difference in the median ISS; ISS > 15; head AIS Score 3, 4, or 5; or the need for craniectomy between the 2 device groups. Unadjusted 30-day mortality was significantly higher in the group with IVDs (29% vs 25.5%, p = 0.046); however, stepwise logistic regression analysis showed that the type of ICP monitoring was not an independent risk factor for death, complications, or functional outcome at discharge. CONCLUSIONS This study demonstrated that compliance with the Brain Trauma Foundation guidelines for ICP monitoring is poor. In isolated severe blunt head injuries, the type of ICP monitoring device does not have any effect on survival, systemic complications, or functional outcome.

Efficacy of Uncross-Matched Type O Packed Red Blood Cell Transfusion to Traumatic Shock Patients: a Propensity Score Match Study.

A new blood bank system was established in our trauma bay, which allowed immediate utilization of uncross-matched type O packed red blood cells (UORBCs). We investigated the efficacy of UORBC compared to that of the ABO type-specific packed red blood cells (ABO RBCs) from before the bank was installed. From March 2016 to February 2017, data from trauma patients who received UORBCs in the trauma bay were compared with those of trauma patients who received ABO RBCs from January 2013 to December 2015. Propensity matching was used to overcome retrospective bias. The primary outcome was 24-hour mortality, while the secondary outcomes were in-hospital mortality and intensive care unit (ICU) length of stay (LOS). Data from 252 patients were reviewed and UORBCs were administered to 64 patients. The time to transfusion from emergency room admission was shorter in the UORBC group (11 [7-16] minutes vs. 44 [29-72] minutes, P < 0.001). After propensity matching, 47 patients were included in each group. The 24-hour mortality (4 [8.5%] vs. 9 [13.8%], P = 0.135), in-hospital mortality (14 [29.8%] vs. 18 [38.3%], P = 0.384), and ICU LOS (9 [4-19] days vs. 5 [0-19] days, P = 0.155) did not differ significantly between groups. The utilization of UORBCs resulted in a faster transfusion but did not significantly improve the clinical outcomes in traumatic shock patients in this study. However, the tendency for lower mortality in the UORBC group suggested the need for a large study.

Injuries sustained during contact with law enforcement: An analysis from US trauma centers.

BACKGROUND: Injuries sustained by civilians from interaction with police are a polarizing contemporary sociopolitical issue. Few comprehensive studies have been published using national hospital-based data. The aim of this study was to examine the epidemiology of these injuries to better understand this mechanism of injury. METHODS: Patients entered into the National Trauma Data Bank (NTDB) (January 2007 to December 2012) with E-codes E970.0 to E976.0 (International Classification of Diseases, Ninth Revision, Clinical Modification), identifying injuries associated with law enforcement in the course of legal action, were enrolled. Patients' demographics, injury characteristics, procedures, and outcomes were collected and analyzed. Patients injured by other civilians (E960.0-E968.0) were used for comparison. RESULTS: Of 4,146,428 patients in the NTDB, 7,203 (0.17%) were injured during interaction with police. The numbers of patients in consecutive study years were 858, 1,103, 1,148, 1,274, 1,316, and 1,504. The incidence of these injuries was stable over time (0.17-0.18%) (p = 0.129). Patients had a median age of 31 years (range, 0-108), and 94.3% were male. Median injury severity score was 9 (interquartile range [IQR], 4-17). The most common mechanism of injury was gunshot wound (44%).Patients were white, 43%; black, 30%; Hispanic, 17%; Asian, 1%; and Other, 9%. As a proportion of the total race-specific NTDB trauma population, there was an average of 1.13 white patients, 2.71 Hispanic patients, and 3.83 black patients per 1,000. Mechanism, injury severity score, and outcomes did not vary by race. Compared to patients injured by civilians, patients injured by police are more likely to be white (43% vs 25%, p < 0.001) and injured by gunshot wounds (44% vs 32%, p < 0.001). CONCLUSIONS: Based on data from trauma centers across the United States, the rate of injuries sustained during interactions with police has been stable over time. Gunshot wounds are the most common mechanism of injury. Proportionally, black patients are the most frequently injured race. When compared to patients injured by civilians, however, patients injured by police are more likely to be white. This study provides a step toward a better understanding of police-associated injuries. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Optimal timing for repair of peripheral nerve injuries.

BACKGROUND: Data regarding outcomes after peripheral nerve injuries is limited, and the optimal management strategy for an acute injury is unclear. The aim of this study was to examine timing of repair and specific factors that impact motor-sensory outcomes after peripheral nerve injury. METHODS: This was a single-center, retrospective study. Patients with traumatic peripheral nerve injury from January 2010 to June 2015 were included. Patients who died, required amputation, suffered brachial plexus injury, or had missing motor-sensory examinations were excluded. Motor-sensory examinations were graded 0 to 5 by the Modified British Medical Research Council system. Operative repair of peripheral nerves was analyzed for patient characteristics, anatomic nerve injured, level of injury, associated injuries, days until repair, and repair method. RESULTS: Three hundred eleven patients met inclusion criteria. Two hundred fifty-eight (83%) patients underwent operative management, and 53 (17%) underwent nonoperative management. Those who required operative intervention had significantly more penetrating injuries 85.7% versus 64.2% (p < 0.001), worse initial motor scores 1.19 versus 2.23 (p = 0.004), and worse initial sensory examination scores 1.75 versus 2.28 (p = 0.029). Predictors of improved operative motor outcomes on univariate analysis were Injury Severity Score less than 15 (p = 0.013) and male sex (p = 0.006). Upper arm level of injury was a predictor of poor outcome (p = 0.041). Multivariate analysis confirmed male sex as a predictor of good motor outcome (p = 0.014; Adjusted Odds Ratio, 3.88 [1.28-11.80]). Univariate analysis identified distal forearm level of injury (p = 0.026) and autograft repair (p = 0.048) as predictors of poor sensory outcome. Damage control surgery for unstable patients undergoing laparotomy (p = 0.257) and days to nerve repair (p = 0.834) did not influence motor-sensory outcome. Outcomes did not differ significantly in patients who underwent repair 24 hours or longer versus those who were repaired later. CONCLUSION: Outcomes were primarily influenced by patient characteristics and injury level rather than operative characteristics. Peripheral nerve injuries can be repaired after damage control surgery without detriment to outcomes. LEVEL OF EVIDENCE: Prognostic study, level III.

Association between pediatric blunt splenic injury volume and the splenectomy rate.

BACKGROUND/PURPOSE: While pediatric trauma centers are shown to have lower splenectomy rate as compared to adult trauma centers, it remains unknown whether other institutional factors such as case volumes would have an impact on the splenectomy rate in pediatric blunt splenic injury (BSI). METHODS: Pediatric patients who sustained BSI were identified from the National Trauma Data Bank 2007-2014. A hierarchical logistic regression model was built to evaluate differences in risk-adjusted splenectomy rate and in-hospital mortality in between trauma centers with different pediatric BSI case volumes. RESULTS: A total of 7621 children who met criteria were treated at trauma centers with different pediatric BSI case volumes (0-60, 61-120, 121-180, 181-240 cases during 2007-2014 for Group 1, 2, 3, and 4, respectively). High volume centers were shown to have decreased splenectomy rates (odds ratios [OR] 0.50 and 0.64, 95% confidence intervals [CI] 0.30-0.83, 0.44-0.95 for Groups 3 and 4, respectively) with an additional survival benefit in Group 4 (OR 0.452, 95%CI 0.257-0.793) when compared to the lowest volume centers (Group 1). CONCLUSIONS: Higher pediatric BSI case volume was associated with lower splenectomy rate with an additional survival benefit. Trauma centers' volume in pediatric BSI may be an important factor for the improved splenic preservation. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

Comparison of outcomes in severe pediatric trauma at adult trauma centers with different trauma case volumes.

BACKGROUND: In addition to trauma center levels and types, trauma volume may be an important factor impacting outcomes in severe pediatric trauma. METHODS: All severely injured pediatric patients treated at adult trauma centers were identified from the National Trauma Data Bank. All qualifying centers were stratified into four groups based on the cumulative pediatric trauma case volumes with ISS >15: lowest (group 1), lower (group 2), higher (group 3), and highest (group 4) volume centers. Mortality rates among the groups were compared. RESULTS: A total of 3747 patients were stratified into group 1 (n=2122, median annual pediatric trauma volume 3 cases/year), group 2 (n=842, 15 cases/year), group 3 (n=494, 24 cases/year), and group 4 (n=289, 43 cases/year). In the hierarchical logistic regression analysis, the highest volume centers (group 4) were shown to have improved mortality (odds ratio 0.474, 95% confidence interval [CI] 0.301-0.747) compared to the lowest volume centers (group 1). Odds ratios of group 4 against group 1 for subgroups were 0.634 (age<10, 95% CI 0.335-1.198), 0.491 (blunt injury, 95% CI 0.310-0.777), and 0.495 (level 1 center, 95% CI 0.312-0.785). CONCLUSIONS: In severe pediatric trauma treated at adult trauma centers, higher volume centers were associated with improved mortality in comparison to the lower volume centers. LEVEL OF EVIDENCE: Level III, therapeutic/care management, retrospective comparative study without negative criteria.

Trauma experts versus pediatric experts: comparison of outcomes in pediatric penetrating injuries.

BACKGROUND: While pediatric trauma centers (PTCs) can uniquely care for pediatric patients, adult trauma centers (ATCs) may be more accessible. Evidence is scarce regarding outcomes of pediatric patients with penetrating trauma treated at PTCs versus ATCs. MATERIALS AND METHODS: We performed a retrospective study using the National Trauma Data Bank to identify pediatric patients aged ≤18 y with penetrating injuries from 2007 to 2012, treated at stand-alone PTCs or ATCs. We excluded patients treated at combined PTC or ATC, transferred between hospitals, with gunshot wounds (GSW) to the head, or dead on arrival. Eligible patients numbered 26,276 (PTC, n = 3737; ATC, n = 22,539). The primary outcome was in-hospital mortality. The secondary outcome was discharge location as a potential surrogate for functional outcome. Univariate and multivariate analyses assessed trauma center type as an independent risk factor for outcomes. RESULTS: Patients treated at ATCs were more likely to have Injury Severity Score >15, Glasgow Coma Scale <9, GSW, cardiovascular injuries, and emergent operations (P < 0.001). Adjusted odds ratios (ORs) for mortality favored PTCs but without statistical significance (OR, 0.592; P = 0.054). In subgroup analyses, children with aged ≤12 y, those with GSW injury mechanism, and those who underwent emergent operations at PTCs were more frequently discharged home versus elsewhere (OR, 0.327, 0.483, and 0.394; P values <0.001, <0.001, and 0.004, respectively). CONCLUSIONS: Children with penetrating injuries demonstrated equivalent survival outcomes whether they were treated at PTCs or ATCs. Younger pediatric patients may have superior functional outcomes when treated at PTCs.