Stimulant drugs are associated with violent and penetrating trauma.

BACKGROUND: Substance abuse is associated with traumatic injuries. Prior studies of drug use and injury have relied on urine drug of abuse screens, which have false positives, false negatives and inability to detect novel drugs. Our study characterizes the relationship between injury mechanism and drugs of abuse detected in serum via confirmatory testing. METHODS: This prospective observational study was conducted from Jan-Sept 2012 at a level 1 trauma center on trauma patients > 13 years who had blood drawn for routine tests. Demographic, injury and standard laboratory data were abstracted from patient charts. Comprehensive serum drug testing was done using liquid chromatography-time-of-flight mass spectrometry (LC-TOF/MS, LC1200-TOF/MS 6230, Agilent, Santa Clara, CA). RESULTS: Of 272 patients, 71.0% were male, 30.5% had violent injury type and 32.4% had a penetrating injury mechanism. Violent injury type and penetrating injury mechanisms were more frequent in patients who were male, younger age, Black, or Hispanic (p < 0.05 for all). LC-TOF/MS showed that 46.0% were positive for at least one drug. Stimulant drugs were associated with violent injury type (OR 2.9; 95% CI 1.64-5.15) and penetrating injury mechanism (OR 3.3; 95% CI 1.86-5.82). Tobacco use was associated with violent injury type (OR 3.9; 95% CI 2.25-6.77) and penetrating injury mechanism (OR 4.14; 95%CI 2.4-7.14). CONCLUSIONS: Many drugs are present in trauma patients that are not routinely detected on urine drug of abuse tests. Both stimulant drugs and cigarette smoking are indicators of multidimensional hazardous behaviors, which were associated with more violent and penetrating trauma.

The utility of chest X-ray as a screening tool for blunt thoracic aortic injury.

BACKGROUND: The early and accurate identification of patients with blunt thoracic aortic injury (BTAI) remains a challenge. Traditionally, a portable AP chest X-ray (CXR) is utilized as the initial screening modality for BTAI, however, there is controversy surrounding its sensitivity. The purpose of this study was to assess the sensitivity of CXR as a screening modality for BTAI. METHODS: After IRB approval, all adult (≥18 yo) blunt trauma patients admitted to LAC+USC (01/2011-12/2013) who underwent CXR and chest CT were retrospectively reviewed. Final radiology attending CXR readings were reviewed for mediastinal abnormalities (widened mediastinum, mediastinal to chest width ratio greater than 0.25, irregular aortic arch, blurred aortic contour, opacification of the aortopulmonary window, and apical pleural haematoma) suggestive of aortic injury. Chest CT final attending radiologist readings were utilized as the gold standard for diagnosis of BTAI. The primary outcome analyzed was CXR sensitivity. RESULTS: A total of 3728 patients were included in the study. The majority of patients were male (72.6%); mean age was 43 (SD 20). Median ISS was 9 (IQR 4-17) and median GCS was 15 (IQR 14-15). The most common mechanism of injury was MVC (48.0%), followed by fall (20.6%), and AVP (16.9%). The total number of CXRs demonstrating a mediastinal abnormality was 200 (5.4%). Widened mediastinum was present on 191 (5.1%) of CXRs, blurred aortic contour on 10 (0.3%), and irregular aortic arch on 4 (0.1%). An acute aortic injury confirmed by chest CT was present in 17 (0.5%) patients. Only 7 of these with CT-confirmed BTAI had a mediastinal abnormality identified on CXR, for a sensitivity of 41% (95% CI: 19-67%). CONCLUSION: The results from this study suggest that CXR alone is not a reliable screening modality for BTAI. A combination of screening CXR and careful consideration of other factors, such as mechanism of injury, will be required to effectively discriminate between those who should and should not undergo chest CT.

Candida Score as a Predictor of Worse Outcomes and Mortality in Severely Injured Trauma Patients with Positive Candida Cultures.

Invasive candidiasis is associated with worse outcomes and increased mortality in critically ill patients. The Candida score (CS) provides a clinical tool for identifying patients at risk for invasive candidiasis. Outcomes of severely injured trauma patients with positive candida cultures stratified by their CS have not been well described. In this retrospective observational study, all severely injured trauma patients (Injury Severity Score ≥16) admitted to the Los Angeles County and University of Southern California Medical Center from April 2008 to April 2014 with positive Candida cultures were included. Outcomes of patients with a low risk for invasive candidiasis (CS < 3) were compared with those with a high risk (CS ≥ 3). A CS ≥ 3 was significantly associated with higher mortality (35.9% vs 5.0%, P = 0.001), longer length of stay (LOS) (median 49.0 vs 28.0, P = 0.002), longer intensive care unit LOS (35.0 vs 20.0, P < 0.001), requirement for renal replacement therapy (38.5% vs 4.9%, P < 0.001), and increased ventilator days (22.0 vs 12.0, P < 0.001). Multivariable regression analysis revealed a CS ≥ 3 as a significant predictor for increased mortality [OR 6.983], longer LOS [regression coefficient (RC) 1.572] and intensive care unit LOS (RC 1.698), more frequent need for renal replacement therapy (OR 13.268), and increased ventilator days (RC 1.836). In conclusion, a CS ≥ 3 is significantly associated with increased mortality and worse outcomes in severely injured trauma patients with positive Candida cultures. The CS thus may serve as a clinical tool to predict outcomes in this patient population.