Scanning the aged to minimize missed injury: An EAST multicenter study.

BACKGROUND: Despite the high incidence of blunt trauma in older adults, there is a lack of evidence-based guidance for computed tomography (CT) imaging in this population. We aimed to identify an algorithm to guide use of a Pan-Scan (Head/C-spine/Torso) or a Selective Scan (Head/C-spine ± Torso). We hypothesized that a patient's initial history and exam could be used to guide imaging. METHODS: We prospectively studied blunt trauma patients aged 65+ at 18 Level I/II trauma centers. Patients presenting >24 h after injury or who died upon arrival were excluded. We collected history and physical elements and final injury diagnoses. Injury diagnoses were categorized into CT body regions of Head/C-spine or Torso (chest, abdomen/pelvis, and T/L spine). Using machine learning and regression modeling as well as a priori clinical algorithms based, we tested various decision rules against our dataset. Our priority was to identify a simple rule which could be applied at the bedside, maximizing sensitivity (Sens) and negative predictive value (NPV) to minimize missed injuries. RESULTS: We enrolled 5,498 patients with 3,082 injuries. Nearly half (47.1%, n = 2,587) had an injury within the defined CT body regions. No rule to guide a Pan-Scan could be identified with suitable Sens/NPV for clinical use. A clinical algorithm to identify patients for Pan-Scan, using a combination of physical exam findings and specific high-risk criteria, was identified and had a Sens of 0.94 and NPV of 0.86 This rule would have identified injuries in all but 90 patients (1.6%) and would theoretically spare 11.9% (655) of blunt trauma patients a torso CT. CONCLUSIONS: Our findings advocate for Head/Cspine CT in all geriatric patients with the addition of torso CT in the setting of positive clinical findings and high-risk criteria. Prospective validation of this rule could lead to streamlined diagnostic care of this growing trauma population. LEVEL OF EVIDENCE: Level 2, Diagnostic Tests or Criteria.

Prehospital tourniquet application in extremity vascular trauma: Improved functional outcomes.

BACKGROUND: Support for prehospital tourniquet use has increased, with recent data suggesting that tourniquet usage decreases shock without increasing limb complications. We hypothesized that prehospital tourniquet application in extremity vascular trauma, compared with no prehospital tourniquet application, is associated with lower rates of delayed amputation and better functional mobility. METHODS: We retrospectively studied adult patients with extremity vascular trauma at an urban civilian Level 1 trauma center (June 2016-May 2021). Outcomes of interest included delayed amputation and mobility at hospital discharge, measured by the Activity Measure for Post-Acute Care "6 Clicks" Basic Mobility Score. The "6 Clicks" Basic Mobility Score was documented by physical therapy; higher scores indicate more independent mobility. Injury mechanism, initial lactate, 24-hour transfusions, mortality, and acute kidney injury were also collected. Comparisons were performed using χ2 analysis and Fisher Exact and Wilcoxon rank-sum tests. RESULTS: Of 232 patients, prehospital tourniquet application was not associated with mortality or lactate level (both P > .05). The prehospital tourniquet application group had more transfusions, lower rates of acute kidney injury, and fewer delayed amputations (all P < .05). Ninety-one patients (45 prehospital tourniquet application and 46 without prehospital tourniquet application) were evaluated for "Moving between Bed and Chair" in the "6 Clicks" Basic Mobility Score, with patients in the prehospital tourniquet application group demonstrating higher levels of independence (P = .034). CONCLUSION: Prehospital tourniquet application was associated with favorable outcomes, including higher functional mobility and decreased delayed amputation. This suggests that tourniquet use should be encouraged in the civilian setting to improve outcomes and reduce the risk of limb loss.

Associations Between Psychiatric Diagnoses on Length of Stay and Mortality After Rib Fracture: A Retrospective Analysis.

INTRODUCTION: Concurrent psychiatric diagnoses adversely impact outcomes in surgical patients, but their relationship to patients with rib fracture after trauma is less understood. We hypothesized that psychiatric comorbidity would be associated with increases in hospital length of stay (LOS) and mortality risk after rib fracture. MATERIALS AND METHODS: The 2017 National Inpatient Sample was queried for adult patients who were admitted with rib fracture after trauma. Mental health disorders were categorized into 34 psychiatric diagnosis groups (PDGs) using clinical classifications software refined for International Classification of Diseases-10. Outcomes of interest were LOS and mortality. Bivariable analysis determined associations between PDGs, patient demographics, hospital characteristics, and outcomes. Logistic regression was performed to identify adjusted effects on mortality, and linear regression was performed to identify effects on LOS. RESULTS: Of 32,801 patients, median age was 61 y (IQR 46-76), and median LOS was 5 d (IQR 3-9). No PDGs were associated with increased odds of mortality. Concurrent diagnosis of schizophrenia spectrum (Coeff. 3.5, 95% CI 2.7-4.4, P < 0.001) or trauma- or stressor-related (Coeff. 1.6, 95% CI 0.9-2.5, P < 0.001) disorders demonstrated the greatest association with prolonged LOS. Increased odds of death and prolonged hospital stay were also associated with male sex, non-White patient race, and surgery occurring at urban and public hospitals. CONCLUSIONS: Psychiatric comorbidities are associated with death after rib fracture but are associated with increased LOS. These findings may help promote multidisciplinary patient management in trauma.

Digital learning: The reach of podcasts and YouTube on trauma surgery education.

BACKGROUND: Physicians, medical students, and health care professionals are charged with staying current throughout their training. No studies have examined the scope of trauma surgery-related podcasts and videos. Our goal was to characterize and evaluate the growing number of trauma-related podcasts and YouTube channels. METHODS: We conducted a search across 3 podcasting platforms (Google Podcasts, Apple Podcasts, and Spotify) and 1 video-sharing site (YouTube) for podcasts published up to November 11, 2022. We queued platforms for "Trauma" and "Trauma Surgery." We included podcasts or video channels in English that focused on trauma surgery or trauma survivorship and recovery. Descriptive analyses were used to determine the characteristics of podcasts and YouTube channels, reported as counts. RESULTS: We identified 91 podcasts and 103 YouTube channels dedicated to trauma recovery and/or trauma surgery. The longest running podcast was the "TraumaCast," and the oldest YouTube channel was "TraumaPro." The podcast with the most episodes was "Trauma Therapist," and the YouTube channel with the most episodes was the Arizona Trauma Association. Podcasts were aimed at public audiences, whereas YouTube channels focused on providers. A large proportion of content is not created by licensed professionals. CONCLUSIONS: Our study shows that popular trauma-focused podcasts target the general population, not health care professionals. The content creators behind these digital platforms seek to educate the public on the recovery process after traumatic injury. We must better understand the advantages and pitfalls of these ubiquitous resources.

Development of Imaging Criteria for Geriatric Blunt Trauma Patients.

INTRODUCTION: Current decision tools to guide trauma computed tomography (CT) imaging were not validated for use in older patients. We hypothesized that specific clinical variables would be predictive of injury and could be used to guide imaging in this population to minimize risk of missed injury. METHODS: Blunt trauma patients aged 65 y and more admitted to a Level 1 trauma center intensive care unit from January 2018 to November 2020 were reviewed for histories, physical examination findings, and demographic information known at the time of presentation. Injuries were defined using the patient's final abbreviated injury score codes, obtained from the trauma registry. Abbreviated injury score codes were categorized by corresponding CT body region: Head, Face, Chest, C-Spine, Abdomen/Pelvis, or T/L-Spine. Variable groupings strongly predictive of injury were tested to identify models with high sensitivity and a negative predictive value. RESULTS: We included 608 patients. Median age was 77 y (interquartile range, 70-84.5) and 55% were male. Ground-level fall was the most common injury mechanism. The most commonly injured CT body regions were Head (52%) and Chest (42%). Variable groupings predictive of injury were identified in all body regions. We identified models with 97.8% sensitivity for Head and 98.8% for Face injuries. Sensitivities more than 90% were reached for all except C-Spine and Abdomen/Pelvis. CONCLUSIONS: Decision aids to guide imaging for older trauma patients are needed to improve consistency and quality of care. We have identified groupings of clinical variables that are predictive of injury to guide CT imaging after geriatric blunt trauma. Further study is needed to refine and validate these models.

What If We Do Not Operate? Outcomes of Nonoperatively Managed Emergency General Surgery Patients.

INTRODUCTION: Although two-thirds of patients with emergency general surgery (EGS) conditions are managed nonoperatively, their long-term outcomes are not well described. We describe outcomes of nonoperative management in a cohort of older EGS patients and estimate the projected risk of operative management using the NSQIP Surgical Risk Calculator (SRC). MATERIALS AND METHODS: We studied single-center inpatients aged 65 y and more with an EGS consult who did not undergo an operation (January 2019-December 2020). For each patient, we recorded the surgeon's recommendation as either an operation was "Not Needed" (medical management preferred) or "Not Recommended" (risk outweighed benefits). Our main outcome of interest was mortality at 30 d and 1 y. Our secondary outcome of interest was SRC-projected 30-day postoperative mortality risk (median % [interquartile range]), calculated using hypothetical low-risk and high-risk operations. RESULTS: We included 204 patients (60% female, median age 75 y), for whom an operation was "Not Needed" in 81% and "Not Recommended" in 19%. In this cohort, 11% died at 30 d and 23% died at 1 y. Mortality was higher for the "Not Recommended" cohort (37% versus 5% at 30 d and 53% versus 16% at 1 y, P < 0.05). The SRC-projected 30-day postoperative mortality risk was 3.7% (1.3-8.7) for low-risk and 5.8% (2-11.8) for high-risk operations. CONCLUSIONS: Nonoperative management in older EGS patients is associated with very high risk of short-term and long-term mortality, particularly if a surgeon advised that risks of surgery outweighed benefits. The SRC may underestimate risk in the highest-risk patients.

Are trauma surgical societies adequately addressing mental health after injury?

BACKGROUND: Survivors of physical trauma, their home caregivers, and their medical providers all have an increased risk of developing psychological distress and trauma-related psychiatric disease. The purpose of this study was to describe the frequency and change over time of trauma society research presentations regarding mental health to identify opportunities for growth. METHODS: Archives from 2018 to 2020 from the American Association for the Surgery of Trauma, the Eastern Association for the Surgery of Trauma, and the Western Trauma Association were reviewed. The studies that measured mental illness, psychosocial distress, and other psychosocial factors were assessed: for (1) the use of patient-reported outcome measures ; (2) the association of psychosocial variables with outcomes; and (3) the interventions investigated. Change over time was assessed using χ2 analysis. RESULTS: Of 1,239 abstracts, 57 (4.6%) addressed at least 1 mental health-related factor. Mental health was more frequently studied over time (2018 [3.2%]; 2019 [3.5%]; 2020 [7.7%]; P = .003). The most frequently measured factors were post-traumatic stress disorder, quality of life, general mental health, and depression. Seventeen (29.8%) abstracts addressed substance abuse, most commonly opioid abuse. Seven (12.3%) abstracts measured mental health in caregivers or medical providers. Patient-reported outcome measures were used in 32 studies (56.1%). Two-thirds of studies reported findings suggesting that mental illness impairs trauma-related outcomes. Only 5 (8.8%) investigated interventions designed to reduce adverse outcomes. CONCLUSION: Although academic discussion of mental health after trauma increased from 2018 to 2020, the topic remains a limited component of annual programs, patient-reported outcome measures remain underutilized, and intervention studies are rare.

Race and trauma mortality: The effect of hospital-level Black-White patient race distribution.

BACKGROUND: Race-related health disparities have been well documented in the United States. In some settings, Black patients have better outcomes in hospitals that serve high proportions of Black patients. We hypothesized that Black trauma patients would have lower mortality in high Black-serving (H-BS) hospitals. METHODS: We identified all adult patients with Black or White race and with an Injury Severity Score of ≥4 from the 2017 National Inpatient Sample. We collected hospital identifier, mechanism, age, sex, comorbidities, urban-rural location, insurance, zip code income quartile, and injury severity calculated from International Classification of Diseases, Tenth Revision, codes. We used a previously published method to group hospitals by proportion of Black patients served: HB-S (top 5%), medium Black serving (5-25%), and low Black serving (L-BS; bottom 75%). Adjusted logistic regression using an interaction variable between race and hospital service rank (reference: White patients in H-BS) was used to identify factors associated with mortality. RESULTS: We analyzed 184,080 trauma patients (median age, 72 years [interquartile range, 55-84 years]; Injury Severity Score, 9 [4-10]), of whom 11.7% were Black. Overall mortality was 4%. Of 2,376 hospitals, 126 (5.3%) were H-BS and 469 (19.7%) were medium Black serving. Furthermore, 29.8% of Black and 3.6% of White patients were treated at H-BS hospitals, while 71.7% of White and 23.6% of Black patients were treated at L-BS hospitals (p < 0.001). Black patients had the lowest mortality at H-BS hospitals (odds ratio [OR], 0.76 [0.64-0.92]) and the highest mortality (OR, 1.43 [1.13-1.80]) at L-BS hospitals. White patients had the lowest mortality at L-BS hospitals (OR, 0.76 [0.64-0.92]). CONCLUSION: After adjusting for patient and hospital factors, disparities exist such that Black and White patients have the best outcomes in hospitals that treat those patients most frequently, suggesting potential for racial bias at the institutional level. Further efforts must be made to promote equitable treatment at all hospitals and reduce these disparities. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level IV.

Are We Underestimating the Morbidity of Single Rib Fractures?

PURPOSE: Previous studies suggest that patients with multiple rib fractures have poor outcomes, but it is unknown how isolated single rib fractures (SRF) are associated with morbidity or mortality. We hypothesized that patients with poor outcomes after SRF can be identified by demographics and comorbidities. The purpose of this study was to model adverse outcome after single rib fractures. MATERIALS AND METHODS: We used the 2016 National Inpatient Sample to identify patients with SRF associated with blunt trauma using ICD-10 coding. Comorbidities and abbreviated injury score (AIS) were also extracted. Patients with non-chest trauma were excluded. The primary outcome was an adverse composite outcome of death, pneumonia, tracheostomy, or hospitalization longer than twelve days. One-third of the cohort was reserved for validation. Backward selection multivariable modeling identified factors associated with adverse composite outcome. The model was used to create a nomogram to predict adverse composite outcome. The nomogram was then tested using the validation cohort. RESULTS: 2,398 patients with isolated SRF were divided into training (n = 1,598) and validation sets (n = 800). The average age was 69 and the majority were male (66%) and received care at academic institutions (61.6%). The adverse composite outcome occurred in 20.8%: 61 deaths (2.5%), 67 tracheostomies (2.8%), 319 pneumonias (13.3%), and 165 patients with hospital length of stay greater than twelve days (6.9%). Results of stepwise multivariable modeling had a C-statistic of 0.700. The multivariable model was used to create a nomogram which had a c-statistic of 0.672 in the validation cohort. CONCLUSION: 20% of isolated SRF patients had an adverse outcome. Demographics and comorbidities can be used to identify and triage high-risk patients for specialized care and proper counseling.

Opioids and Injury Deaths: A population-based analysis of the United States from 2006 to 2017.

INTRODUCTION: In the United States, the opioid epidemic claims over 130 lives per day due to overdoses. While the use of opioids in trauma patients has been well-described in the literature, it is unknown whether prescription opioid use is associated with mortality after trauma. We hypothesized that legally obtained prescription opioid consumption would be positively associated with injury-related deaths in the United States. METHODS: Cross-sectional time-series data was compiled using state-level mortality data from the Centers for Disease Control and Prevention Multiple Causes of Death database and prescription opioid shipping data to each state using the US Department of Justice Automated Reports and Consolidated Ordering System Retail Drug Summary reports from 2006 to 2017, with opioids shipped used as a proxy for local opioid consumption. Oxycodone and hydrocodone amounts were converted to morphine equivalent doses (MEDs). Our primary outcome was an association between MEDs and injury mortality rates at the state-level. We analyzed total injury-related deaths and subgroups of unintentional deaths, suicides, and homicides. We modeled the data using fixed effects regression to reduce bias from unmeasured differences between states. RESULTS: Data were available for all states and the District of Columbia. Opioid deliveries increased through 2012 and then declined. Total injury-related mortalities have been increasing steadily since 2012. Opioid MEDs did not show a consistent or statistically significant relationship with injury-related mortality, including with any subgroups of unintentional deaths, suicides, and homicides. CONCLUSION: In every state examined, there was no consistent relationship between the amount of prescription opioids delivered and total injury-related mortality or any subgroups, suggesting that there is not a direct association between prescription opioids and injury-related mortality. This is the first study to combine national mortality and opioid data to investigate the relationship between legally obtained opioids and injury-related mortality. The US opioid epidemic remains a significant challenge that requires ongoing attention from all stakeholders in our medical and public health systems.