Journal of Trauma and Acute Care Surgery最新文献

Introduction: Rib fractures remain a significant source of trauma admissions. In 2020, the Pennsylvania Trauma System Foundation standards changed to allow patients with more than three rib fractures to be admitted to level IV centers. The primary aim of this study was to evaluate outcomes of patients with more than three uncomplicated rib fractures admitted to level IV trauma centers.

Methods: Our network database was queried for patients with isolated uncomplicated rib fractures between 2018 and 2022. Patients were stratified based on evaluation before or after the change in standards. Patients evaluated at level IV centers were compared for demographics, injury characteristics, transfer rate, and outcomes. Finally, 1:1 propensity score matching was used to create a matched group of patients with more than three rib fractures to assess outcomes based on admission to level IV versus level I/II centers.

Results: A total of 1,070 patients with isolated rib fractures were admitted over the study period. Level IV centers evaluated 360 patients with 132 (36.6%) and 228 (63.3%) in the pre- and poststandard change periods. There was a significant reduction in transfers for isolated rib fractures (56% vs. 21% p < 0.01). Compared with patients with three or less rib fractures, those with more than three fractures had similar hospital length of stay (median [interquartile range (IQR)], 3 [2-5] vs. 2 [1-4]; p = 0.29) and mortality (0% vs. 2.3%, p = 0.22). After propensity match, there was no difference in age (median [IQR], 71 [60-81] vs. 73 [65-85]; p = 0.24), injury characteristics, hospital length of stay (median [IQR], 2.5 [2-5] vs. 2 [1-4]; p = 0.37), and mortality (1.7% vs. 0%, p = 0.30).

Conclusion: Change in state admission standards allowed for a reduction in transfer of patients with more than three isolated rib fractures. In a group of matched patients with more than three rib fractures, level IV centers had similar outcomes to level I or II centers.

Level of evidence: Clinical Research, Retrospective Study; Level III.

Background: Air medical transport (AMT) offers a survival advantage to trauma patients for several reasons, including time-savings over ground transport. Triage guidelines suggest AMT use when there are significant time-savings, but how much time needs to be saved to confer a benefit is unclear. Our objective was to define the time-savings threshold for which AMT has a survival benefit over ground transport.

Methods: Retrospective cohort of adult trauma patients transported ≤40 miles by ground or air in the Pennsylvania Trauma Outcomes Study 2000 to 2017. Geographic information system network analysis generated the counterfactual transport mode times, and we calculated a time-savings of AMT for each patient. We used restricted cubic splines to allow for non-linear effects of time-saved within multilevel logistic regression to identify a threshold of AMT time-savings associated with survival. Subgroups of patients meeting physiologic or anatomic criteria from the National Field Triage Guidelines (NFTG) and those with a positive Air Medical Prehospital Triage (AMPT) Score were analyzed.

Results: There were 280,271 patients included. The NFTG subgroup had survival advantage starting at 13 minutes of AMT time-saved (adjusted odds ratio, 1.14; 95% confidence interval, 1.01-1.30). The AMPT subgroup had survival advantage starting at 23 minutes with the greatest magnitude of improvement (adjusted odds ratio, 1.22; 95% confidence interval, 1.01-1.48). Among patients that did not meet either NFTG criteria or the AMPT score, no amount of time-saved by AMT was associated with survival (p > 0.05). Sensitivity analysis accounting for injury severity in scene time showed the survival benefit starting at 17 minutes of AMT time-saved for the NFTG subgroup and remained 23 minutes in the AMPT subgroup.

Conclusion: Among patients meeting physiologic or anatomic NFTG criteria, a ≥ 13- to 17-minute AMT time-savings threshold was associated with improved survival. There is heterogeneity among this threshold among different patient groups that may be due to other benefits of AMT, such as advanced capabilities. These findings can inform AMT triage guidelines.

Level of evidence: Therapeutic; Level IV.

Abstract: Hemorrhage remains one of the leading causes of death from traumatic injury in both the civilian and military populations. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive technique that can be used to treat hemorrhage in the critically ill. An alternative to maximally invasive methods such as resuscitative thoracotomy, REBOA is a temporizing measure to prevent exsanguination and allow for transition to definitive hemorrhage control. It is easily deployed by trained users and does not require surgical expertise to place. Its use has increased over the past decade with a growing body of literature that suggests it improves outcomes in select hemorrhagic trauma patients compared with patients who do not receive REBOA. REBOA has also been used for select nontraumatic cases. Judicious patient selection, knowing the technical aspects of placing REBOA, and clarity regarding its indications are key to maximize its efficacy as a mitigatory tool in hemorrhagic shock. This "What You Need To Know" review presents current evidence regarding use of REBOA for the acute care surgeon.

Level of evidence: Level V.

Background: In-house call (IHC) has previously been shown to result in increased burnout in acute care surgeons (ACSs). There is wide variation, however, in the implementation and culture of work surrounding IHC across trauma centers and within the demographics of practicing ACSs. We hypothesized that local work practices and culture surrounding IHC as well as sex of ACSs would impact burnout.

Methods: Continuous physiologic data were collected over 6 months from 224 ACSs who wore a fitness wearable. Acute care surgeons were sent daily surveys to record work, personal activities, and feelings of burnout. The Maslach Burnout Inventory was completed by ACSs at the beginning and end of the study period.

Results: Forty-eight (21.5%) of ACS reported being expected to complete the usual workday after IHC, 94 (42.2%) were expected to finish work from IHC, and 81 (36.3%) were expected to leave immediately after IHC was over. Acute care surgeons expected to complete a usual workday postcall were more likely to be burned out, and IHC resulted in a greater increase in their daily feelings of burnout than among ACSs who reported working in other work cultures. Females showed higher levels of daily burnout than males but no difference in the degree to which IHC led to burnout.

Conclusion: In-house call results in increased burnout in all ACSs; however, IHC had a larger impact on daily feelings of burnout in ACSs expected to work without adjustments to their work schedule postcall. Although female ACSs reported higher levels of daily burnout than male ACSs, IHC increased daily feelings of burnout equally between the two sexes. Taken together, these findings necessitate caution about work expectations surrounding IHC and suggest a need for the deliberate creation of a postcall culture for ACS.

Level of evidence: Prognostic and Epidemiological; Level III.

Introduction: Traumatic brain injury (TBI) patients on antiplatelet therapy face higher mortality because of impaired platelet function, which may be treated by platelet transfusion. The value of testing platelet function in this cohort remains controversial. We aimed to evaluate the relationship between platelet function assays and outcomes in TBI patients on antiplatelet therapy receiving platelet transfusions. We hypothesized that the magnitude of change in platelet assay performance following a transfusion would predict meaningful clinical outcomes.

Methods: A cohort of patients, aged 18 to 89 years, with a history of preinjury antiplatelet therapy or who required platelet transfusion, and who were deemed at risk for neurosurgical intervention, was selected from a prospective randomized controlled trial of platelet transfusion for TBI. Pre- and posttransfusion blood samples were drawn. Platelet hemostatic function assays (PHFAs) included thromboelastography with platelet mapping (TEG-PM) and VerifyNow. Logistic regression models assessed the association of temporal assay results with 30-day all-cause mortality, need for craniotomy, and initial and follow-up Rotterdam scores.

Results: Data from 94 TBI patients (43% female) with a median age of 76 years were analyzed. The 30-day mortality rate was 14%. VerifyNow aspirin assay was able to capture increases in platelet function following a platelet transfusion in patients on aspirin (significant positive Δ = 65 aspirin response units, p < 0.001). Thromboelastography with platelet mapping parameters detected improved platelet function following transfusion, although the absolute value of changes was minimal. Thromboelastography with platelet mapping parameters predicted important clinical outcomes on logistic regression, although no significant associations with clinical outcomes were identified by the change in PHFA after transfusion or after adjusting for multiple comparisons.

Conclusion: Higher absolute pre- and posttransfusion values of TEG-PM were associated with decreased mortality, decreased need for neurosurgical intervention, and decreased risk of progression of hemorrhage in TBI patients taking antiplatelet agents, although neither the change in TEG-PM after transfusion nor any other PHFA value predicted outcomes.

Level of evidence: Prognostic and Epidemiological; Level III.

Background: Venous thromboembolism (VTE) is common after major injury. This elevated VTE risk likely continues beyond hospital discharge, but a lack of postdischarge surveillance limits our understanding of this complication and opportunities for improving outcomes. We aimed to characterize the incidence and risk factors of trauma patients who developed a VTE in the first year after discharge from their index hospital admission.

Methods: We used data from adult inpatients (18 years or older) from 35 American College of Surgeons - Committee on Trauma-verified Level 1 and Level 2 trauma centers in a statewide trauma quality improvement program from 2018 to 2023. The incidence and timing of a postdischarge VTE were identified from linked longitudinal insurance claims data, and multivariable logistic regression was performed to identify predictors of a postdischarge event.

Results: Of 34,421 trauma registry and claims matched patients identified, 1,487 (4.3%) developed a VTE within the first year after discharge from the trauma center, compared with 280 VTE events (0.8%) diagnosed during the index admission. The incidence of VTE remained elevated well after discharge, with 40% occurring in the first 30 days and 73% within the first 3 months. Multiple patient, injury, and treatment factors were associated with postdischarge VTE risk, including having an operation, a significant spine injury, Black race, and receiving a blood transfusion.

Conclusion: The risk of VTE extends well beyond the index hospitalization for trauma patients, as the majority of events occur after discharge. Understanding and improving VTE outcomes in trauma patients will require a longitudinal patient record that captures these complications. Postdischarge VTEs are an underrecognized trauma-related morbidity but are also very treatable through a better understanding of the risk factors and the optimal prophylactic strategy.

Level of evidence: Prognostic and Epidemiologic; Level III.

Background: Pneumatosis intestinalis (PI) is a rare radiographic finding that can range from being a benign process to needing emergency surgery. Sufficiently powered studies are lacking, and recommendations for management remain unclear. The purpose of this study was to identify key predictors of pathologic PI using physical examination, laboratory, and radiographic findings.

Methods: A retrospective cohort study was conducted at two quaternary academic centers (2010-2020). A total of 334 consecutive patients 18 years or older with radiographic evidence of PI were identified. Patients were excluded if they pursued comfort care or if there was concurrent radiographic evidence of vaso-occlusive process. Pathologic PI was defined as presence of ischemic and/or perforated bowel on exploratory laparotomy or death prior to planned surgery.

Results: Of the 334 patients included in our study, 91 (27%) underwent exploratory laparotomy, of which 59 (65%) had ischemic and/or perforated bowel. These latter patients and 10 other patients who died before exploratory laparotomy defined the pathologic PI cohort. A stepwise model was created for predicting pathologic disease. Significant predictors were the presence of portal venous gas, multisegment PI, vasopressor use, peritonitis, increasing leukocyte count, and end organ injury, which were used to construct a nomogram for clinical use.

Conclusion: A nomogram score based on presence of portal venous gas, multisegment PI, vasopressor use, peritonitis, leukocytosis, and end organ injury may help predict the probability of pathologic PI and therefore can inform surgical decision making.

Level of evidence: Epidemiologic Study; Level III.

Background: Trauma-informed care (TIC) is a framework designed to understand and address the impacts of trauma, ensuring physical, psychological, and emotional safety for all involved. It seeks to prevent retraumatization and promote a sense of control and empowerment across diverse populations.

Method: This Trauma Prevention Coalition survey study assessed TIC implementation among members from 13 of the 16 participating organizations, focusing on prevalence, awareness, and training gaps.

Results: Out of 948 participants, 91% (n = 861) were affiliated with trauma centers. In adult trauma centers: 19.3% were from Level I, 9.4% from Level II, 5.4% from Level III, 3.1% from Level IV, and 1.2% from Level V. In addition, 1.2% were from nonadult trauma centers, and 2.5% worked in centers serving both adult and pediatric patients. In pediatric centers: 18.6% were from Level I, 13.0% from Level II, 1% from Level III, and 67.0% from nonpediatric centers. Trauma-informed care principles were integrated into the core values of 35.5% of trauma centers, while 64.5% had not adopted them. Only 17.0% had TIC training plans, with 57.7% lacking or unaware of such plans. Bivariate regression analysis indicated that TIC integration decreased for Level II, Level IV, and nontrauma centers compared with Level I adult trauma centers, but increased for Level III. In pediatric centers, TIC integration decreased for Level II, Level III, Level IV, and nontrauma centers compared with Level I. Pediatric trauma centers showed a higher TIC integration rate (71.6%) compared with adult centers (39.4%, p < 0.01).

Conclusion: TIC adoption varies significantly across trauma center levels, with higher prevalence in pediatric and Level I centers. The study underscores the need for comprehensive TIC training within trauma care systems.

Level of evidence: Therapeutic/care management; Level III.

Background: Older adults who survive injury frequently experience functional decline, and interventions preventing this decline are needed. We therefore evaluated the association between early primary care physician (PCP) follow-up and nursing home admission or death among injured older adults.

Methods: We performed a retrospective, population-based cohort study of community-dwelling older adults (65 years or older) discharged alive after injury-related hospitalization (2009-2020). The exposure of interest was early PCP visit (within 14 days of discharge). The primary outcome was time to death or nursing home admission in the year after discharge. Cox proportional hazards models were used to evaluate the relationship between early PCP visit and this outcome, adjusting for baseline characteristics.

Results: Among 93,482 patients (63.7% female; mean age, 79.8 years), 24,167 (25.9%) had early follow-up with their own PCP and 6,083 (6.5%) with a different PCP. In the year after discharge, 16,676 patients (17.8%) died or were admitted to a nursing home. After risk adjustment, early follow-up with one's own PCP was associated with a 15% reduction in the hazard of death or nursing home admission relative to no follow-up (hazard ratio, 0.85; 95% confidence interval, 0.83-0.87). Follow-up with a different PCP was not associated with the outcome (hazard ratio, 0.99; 95% confidence interval, 0.95-1.03). These relationships were consistent across all age, sex, frailty, and injury severity strata.

Conclusion: Among injured older adults, early follow-up with their own PCP was associated with increased time alive and at home. These findings suggest strategies to integrate PCPs into postinjury care of older adults should be explored.

Level of evidence: Therapeutic/Care Management; Level III.

Introduction: Trauma and hemorrhagic shock lead to microcirculatory disturbances related to endothelial injury and endothelial glycocalyx (EG) degradation. Improved outcomes following trauma and hemorrhagic shock have been linked to protection of the EG layer, which is a topic of increasing investigation. Early tranexamic acid (TXA) administration following trauma and hemorrhagic shock improves outcomes in clinic studies. Recent translational studies have also shown that early TXA administration protects the EG following shock insults; the impact on blood-endothelial cell interactions is unknown. Platelet adherence to vascular endothelium may contribute to microcirculatory disturbances; the effects of TXA on this phenomenon are uncertain. Microfluidic devices have been used to study the behavior of endothelial cells and platelets under flow conditions. We hypothesize that the protective effect of TXA against EG degradation would prevent shock-induced platelet adhesion to the microvasculature. This was studied in a microfluidic cell culture model under a controlled microenvironment.

Methods: Microfluidic endothelial cell cultures were exposed to flow conditions under control or hypoxia-epinephrine exposure. Tranexamic acid was added to the perfusate at various times in control and experimental groups. Endothelial glycocalyx thickness, degradation products, and platelet adhesion to the endothelium were measured.

Results: Tranexamic acid protected the glycocalyx from degradation following hypoxia-reoxygenation-epinephrine exposure. Platelet adhesion to the endothelium was significantly reduced by TXA in a time sensitive manner.

Conclusion: Tranexamic acid may protect the microvasculature from perfusion abnormalities following shock conditions. This is likely due to inhibition of platelet adhesion and mitigating thromboinflammation at the endothelium in the microvasculature.