Impact of Triage Systems on Time to Diagnosis and Treatment of Traumatic Brain Injuries.

BACKGROUND: Intracerebral hemorrhage (ICH) is a potential complication from traumatic brain injury, with a 30-day mortality rate of 35-52%. Rapid diagnosis allows for earlier treatment, which impacts patient outcomes. A trauma activation (TA) is called when injury severity meets institutional criteria. The patient is immediately roomed, and a multispecialty team is present. A trauma evaluation (TE) occurs when injuries are identified after standard triage processes. OBJECTIVES: Our aim was to determine whether TA patients with ICH were diagnosed and treated more rapidly than TE patients. METHODS: This was a retrospective study of patients presenting to trauma centers within a large hospital system diagnosed with traumatic ICH between January 2018 and December 2018. Patients were categorized as TA or TE patients. The time to diagnosis was compared between groups, and additional times were evaluated, including time to imaging, computed tomography interpretation, and treatment. RESULTS: A total of 294 patients were included. Groups had similar demographic characteristics and medical history; there was no difference in head Abbreviated Injury Score, Injury Severity Score, or anticoagulant use. Time to diagnosis was decreased for TA patients compared with TE patients (p < 0.0001). In addition, TA patients received treatment sooner (median 107 min) than TE patients (184.5 min) (p < 0.0001). CONCLUSIONS: Diagnosis and treatment times were significantly faster in TA patients than in TE patients. Given the similarities in injury severity between groups, the increased time to treatment may be detrimental for patients. Trauma activations are a resource-heavy process, but TE delays care. These data suggest that an intermediary process may be beneficial.

Evaluation of pre-hospital cannabis exposure and hospital opioid utilization in a trauma population: A retrospective cohort.

PURPOSE: Cannabis utilization has increased over time for recreational and medical purposes due to its legalization or decriminalization. The effects of cannabis use on opioid utilization are not well understood. The primary objective was to evaluate the total opioid utilization, measured in morphine milligram equivalents (MME), in hospitalized trauma patients that tested positive for tetrahydrocannabinol (THC) on a urine drug screen (UDS). METHODS: This was a retrospective, cohort study in a level 1 trauma center between 10/17/17 and 12/31/19. Adult trauma patients (aged 15 years and older) who had a UDS completed within 48 h of hospital arrival were eligible for inclusion. Patients were excluded for a hospitalization >14 days, death within 24 h, severe alcohol withdrawal, prescribed cannabinoids, high daily opioid use prior-to-arrival, or transitioned to hospice or palliative care. Group assignments were determined based on the presence or absence of THC on the UDS. RESULTS: The analysis included 750 patients with 160 (21 %) THC positive patients. The population were primarily male (64.6 %), median age of 56 years [IQR 35-72], with blunt (93 %) injuries from motor vehicle crash or falls (79 %). The THC group was more likely to have other substances present, including amphetamines, benzodiazepines, opiates, and cocaine. The THC group had a higher median injury severity score (10 [IQR 5-17] vs. 9 [5-14], p = 0.0056), and maximum abbreviated injury score (3 [IQR 2-3] vs. 2 [IQR 2-3], p = 0.0009). The THC group had a total higher median opioid utilization during the hospitalization (155 [IQR 68-367] vs. 62 [IQR 13-175] MME; p < 0.0001), which included higher opioid use in the emergency department, floor, and intensive care unit. There were no significant differences in secondary outcomes except the THC group was more likely to receive an opioid prescription at discharge and more likely to require mechanical ventilation. Based on multivariable regression analyses, other variables were associated with increased opioid utilization. CONCLUSION: Pre-existing THC exposure may be associated with an increased hospital opioid utilization in a trauma population. However, other variables may also play a role in opioid utilization.

Can the positive buffer the negative? Testing the impact of protective childhood experiences on adjustment in adults following trauma exposure.

BACKGROUND: It is unclear if protective childhood experiences (PCEs), like emotional support and economic stability, exert influence on adulthood adjustment. Prior research suggests PCEs can promote childhood resilience through increased social connection. In contrast, research has demonstrated potential life-long negative impacts of adverse childhood experiences (ACEs) on psychological health. This study examined the role of PCEs and ACEs in psychological symptoms following potentially traumatic events (PTE) in adults. METHODS: Participants (N = 128) were adults admitted to two Level 1 Trauma Centers following violence, motor-vehicle crashes, or other accidents. Participants reported childhood experiences and completed assessments of depression, PTSD, and social support at one, four, and nine months post-PTE. RESULTS: Structural Equation Modeling was used to simultaneously model PCEs and ACEs as predictors of psychological symptoms over time, with potential mediation through social support. PCEs overall did not directly affect psychological symptoms nor indirectly through social support. However, the emotional support component of PCEs had an indirect effect on psychological symptoms at baseline through social support. ACEs predicted greater psychological symptoms at baseline and over time. CONCLUSION: PCEs consisting of childhood emotional support indirectly promote adjustment in adults after PTEs through initial social support, while ACEs exert direct effects on psychological symptoms.

Were there losses in social support during the pandemic? Testing the impact of COVID-19 on psychological adjustment to trauma in United States adults.

Introduction: Social support is a key protective factor in the psychological adjustment of individuals to traumatic events. However, since March 2020, extant research has revealed evidence of increased loneliness, social isolation, and disconnection, likely due to COVID-19 pandemic-related recommendations that restricted day-to-day contact with others. Methods: In this investigation, we applied a case-control design to test the direct impacts of the pandemic on social support in United States adults recovering from a significant injury caused by PTSD-qualifying, traumatic events (e.g., motor vehicle crashes, violence, etc.). We compared individuals who experienced trauma during the pandemic, the "cases" recruited and evaluated between December 2020 to April 2022, to trauma-exposed "controls," recruited and evaluated pre-pandemic, from August 2018 through March 9, 2020 (prior to changes in public health recommendations in the region). Cohorts were matched on key demographics (age, sex, education, race/ethnicity, income) and injury severity variables. We tested to see if there were differences in reported social support over the first 5 months of adjustment, considering variable operationalizations of social support from social network size to social constraints in disclosure. Next, we tested to see if the protective role of social support in psychological adjustment to trauma was moderated by cohort status to determine if the impacts of the pandemic extended to changes in the process of adjustment. Results: The results of our analyses suggested that there were no significant cohort differences, meaning that whether prior to or during the pandemic, individuals reported similar levels of social support that were generally protective, and similar levels of psychological symptoms. However, there was some evidence of moderation by cohort status when examining the process of adjustment. Specifically, when examining symptoms of post-traumatic stress over time, individuals adjusting to traumatic events during COVID-19 received less benefit from social support. Discussion: Although negative mental health implications of the pandemic are increasingly evident, it has not been clear how the pandemic impacted normative psychological adjustment processes. These results are one of the first direct tests of the impact of COVID-19 on longitudinal adjustment to trauma and suggest some minimal impacts.

A Survey-Based Assessment of "Matter of Balance" Participant Fall-Related Experience.

BACKGROUND: Falls are a substantial cause of injury in older adults, which can be attributed to progressive lack of physical activity, associated comorbidities, social isolation, and chronic health conditions. Fall prevention courses are designed to educate participants on fall safety and increase activity levels and social engagement. OBJECTIVE: The purpose of this study was to evaluate the perceived effectiveness of a nationally recognized fall prevention course on self-reported fall frequency and lifestyle habits. METHODS: This was a single-group pretest-posttest study of a convenience sample of older adults enrolled in a group fall prevention program, A Matter of Balance, in a community setting between March 2019 and March 2020. Questionnaires were distributed at the first and final sessions of the course to evaluate participant perceptions of the program and its impact on their fall history, exercise habits, and social engagement. Comparisons were made using Wilcoxon rank sum tests. RESULTS: A total of 40 class members agreed to participate, with 29 (73%) completing both the presurvey and the postsurvey. Responses indicated no change in the number of falls or participants following an established exercise routine. However, of those who fell prior to the course, 75% reported a reduction in falls. In addition, the participants reported an overall increase in weekly exercise frequency. In those who reported fear of falling, 71% reported a reduction in fear following the course. CONCLUSIONS: The participants in this study self-reported a decrease in fall rate, a decrease in fear of falling, and an increase in exercise frequency. The course is not fall protective but can be considered an adjunct to fall prevention measures that include medical, medication, visual, and environmental management.

Incidence and Risk Factors Associated with Multi-Drug-Resistant Pathogens in a Critically Ill Trauma Population: A Retrospective Cohort Study.

Background: Multi-drug resistance is considered a serious health threat particularly in the intensive care unit (ICU) setting. Studies evaluating multi-drug-resistant (MDR) pathogens in critically ill trauma patients are limited. The objectives were to describe the incidence of MDR, extensive-drug-resistant (XDR), and pan-drug-resistant (PDR) organism growth in ICU patients admitted with traumatic injuries and to identify any risk factors associated with MDR growth. Patients and Methods: This was a retrospective single-center cohort study of all ICU adult patients identified via the institution's trauma registry from January 1, 2016 to August 31, 2017. Patients were included if they had positive culture growth with susceptibility data taken during the index hospitalization. Patients were excluded if their cultures were drawn within 48 hours of emergency department triage. Study groups were defined based on the presence of at least one MDR pathogen during the index hospitalization. Results: A total of 2,578 charts were reviewed and 95 patients (mean age, 60 years; 66 males [69%]) with 201 total cultures were included. The majority of positive cultures were from respiratory (69%) and urinary (16%) sources. Of the 201 positive cultures, the majority of species identified was Enterobacteriaceae (47%), Staphylococcus (32%), Enterococcus (7%), Acinetobacter (5%), and Pseudomonas (3%). Of the 95 patients with positive cultures, the incidence of MDR, XDR, and PDR organisms was found to be 31%, 17%, and 0%, respectively. Augmented renal clearance (ARC) was the only risk factor associated with an increased risk for MDR organism growth (adjusted odds ratio 9.78, 95% confidence interval [CI] 2.56-37.41; p = 0.001). Conclusions: In this cohort of critically ill trauma patients, the incidence of an MDR pathogen occurred in 31% of patients. This is the first study to find an association of ARC and multi-drug resistance, which should be further validated as a potential cause for MDR organisms.

Prevention of fall-related injuries in the elderly: An Eastern Association for the Surgery of Trauma practice management guideline.

BACKGROUND: Fall-related injuries among the elderly (age 65 and older) are the cause of nearly 750,000 hospitalizations and 25,000 deaths per year in the United States, yet prevention research is lagging. Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, the Eastern Association for the Surgery of Trauma produced this practice management guideline to answer the following injury prevention-related population, intervention, comparator, outcomes (PICO) questions:PICO 1: Should bone mineral-enhancing agents be used to prevent fall-related injuries in the elderly?PICO 2: Should hip protectors be used to prevent fall-related injuries in the elderly?PICO 3: Should exercise programs be used to prevent fall-related injuries in the elderly?PICO 4: Should physical environment modifications be used to prevent fall-related injuries in the elderly?PICO 5: Should risk factor screening be used to prevent fall-related injuries in the elderly?PICO 6: Should multiple interventions tailored to the population or individual be used to prevent fall-related injuries in the elderly? METHODS: A comprehensive search and review of all the available literature was performed. We used the GRADE methodology to assess the breadth and quality of the data specific to our PICO questions. RESULTS: We reviewed 50 articles that met our inclusion and exclusion criteria as they applied to our PICO questions. CONCLUSION: Given the data constraints, we offer the following suggestions and recommendations:PICO 1: We conditionally recommend vitamin D and calcium supplementation for frail elderly individuals.PICO 2: We conditionally recommend hip protectors for frail elderly individuals, in the appropriate environment.PICO 3: We conditionally recommend evidence-based exercise programs for frail elderly individuals.PICO 4: We conditionally recommend physical environment modification for frail elderly people.PICO 5: We conditionally recommend frailty screening for the elderly.PICO 6: We strongly recommend risk stratification with targeted comprehensive risk-reduction strategies tailored to particular high-risk groups. LEVEL OF EVIDENCE: Systematic review, level III.

The role of laparoscopy in trauma: a ten-year review of diagnosis and therapeutics.

Minimally invasive surgery has found many applications in general surgery. The role of laparoscopy in trauma has been debated as a diagnostic, as well as therapeutic, tool in hemodynamically stable patients. This study evaluated laparoscopy in the trauma population. A retrospective review of all laparoscopies performed in hemodynamically stable trauma patients from 1996 until 2006 was conducted. Mechanisms of injury, perioperative data, and demographic variables were analyzed using descriptive statistics and Student's t test. Exploratory diagnostic laparoscopy was performed on 102 patients. Laparoscopy was negative for 65 per cent of patients; 12 per cent of these were converted to laparotomy due to adhesions, hemoperitoneum, or surgeon preference. None of the conversions revealed intra-abdominal injury at laparotomy. An injury was diagnosed at laparoscopy in the remaining 35 per cent, with 55 per cent conversion rate to repair the injury. Therapeutic laparoscopy included serosal repair, hemorrhage control, diaphragmatic repair, and other standard laparoscopic treatments. No patient required re-exploration, there were no missed injuries or other complications, and no patient died in this study. Laparoscopy has an important diagnostic and therapeutic role in selected hemodynamically stable trauma patients. Using a minimally invasive approach can reduce the potential morbidity of negative laparotomy.