Journal of Trauma and Acute Care Surgery最新文献

Background: Unintentional traumatic injuries pose a significant public health challenge, impacting not only injured individuals but also their families. Existing research has largely focused on the effects of a child's injury on their family, with limited attention to the consequences of parental injury on children's health. This study aims to explore the consequences of unintentional parental injury on children's health outcomes, health care utilization, and socioeconomic barriers to care.

Methods: We utilized data from the National Health Interview Survey (NHIS) for 2020, 2021, and 2023, creating parent-child dyads where the parent was injured. Injury was defined by a positive response to experiencing an injury and seeking medical consultation after. Children aged 5 years to 17 years and their parents were included. Three outcome domains were examined: health outcomes, health care utilization, and socioeconomic health impacts. Bivariate and logistic regression analyses were conducted to assess the impact of parental injury on these outcomes.

Results: We identified 414 (weighted = 1,338,068) injured parent-child dyads and 10,352 noninjured dyads. Children of injured parents had higher odds of being diagnosed with attention-deficit hyperactivity disorder/attention-deficit disorder (odds ratio [OR], 1.69; 95% confidence interval [CI], 1.31-2.40; p = 0.005), higher Washington Group Composite Disability Scores (OR, 1.77; 95% CI, 1.25-2.47; p = 0.001), and increased injury odds (OR, 2.29; 95% CI, 1.58-3.28; p < 0.001). They also showed higher rates of urgent care visits, with significantly higher emergency department visits (OR, 1.49; 95% CI, 1.02-2.13; p = 0.03). Financial toxicity was significant, with increased odds of delaying (OR, 2.37; 95% CI, 1.14-5.40; p = 0.03) or avoiding care (OR, 3.06; 95% CI, 1.06-7.76; p = 0.02) due to cost.

Conclusion: This study highlights the broad-reaching impact of parental injury on children, including worse health outcomes, increased health care utilization, and significant financial barriers. These findings underscore the need for comprehensive trauma care that addresses the holistic needs of families, incorporating strategies to mitigate both health and socioeconomic challenges.

Level of evidence: Prognostic/Epidemiological; Level II.

Background: Traumatic brain injury (TBI) contributes to substantial morbidity and mortality worldwide. Tranexamic acid (TXA) has been shown to reduce mortality in patients with traumatic intracranial hemorrhage (ICH) when given within 2 hours of injury. Although TXA is an antifibrinolytic, most studies have observed no difference in ICH progression; recent studies suggest that TXA may reduce cerebral edema in TBI. Our objective was to determine if prehospital TXA administered within 2 hours of injury is associated with surrogates of cerebral edema in patients with moderate or severe TBI.

Methods: We performed a retrospective analysis of a multinational prehospital trial of TXA administered within 2 hours of injury in patients with moderate or severe TBI. Patients with prehospital Glasgow Coma Scale score of <13 and systolic blood pressure of >90 mm Hg were randomized to placebo, 2-g TXA bolus, or 1-g TXA bolus followed by 1 g 8-hour TXA infusion. Patients who received an intracranial pressure (ICP) monitor were selected for analysis. Baseline demographic, injury severity, and infusion characteristics were compared between TXA dosing cohorts. Proportion of hours spent with ICP of >20 mm Hg, cerebral perfusion pressure (CPP) of <60 mm Hg, and need for craniectomy were compared between groups.

Results: A total of 108 patients with ICP monitors made up the study population (placebo, n = 31; 1 g + 1 g, n = 38; 2-g bolus, n = 39). No differences were identified in age, sex, Abbreviated Injury Scale head, Glasgow Coma Scale, Injury Severity Score, crystalloid and blood product infused in first 24 hours, Marshall score, ICH, or mortality between the three treatment arms. No differences in proportions of hours in which ICP of >20 mm Hg or CPP of <60 mm Hg were identified between treatment arms; rate of craniectomy was also similar.

Conclusion: No association could be identified between TXA treatment and ICP elevation, CPP depression, or need for craniectomy. These results question TXA's potential impact on cerebral edema. Further study is needed to confirm this finding based on the exploratory nature and limited number of subjects in this study.

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

Background: Increased time to surgery is a well-established risk factor for complication and mortality among patients undergoing hip fracture fixation. However, few studies have been completed evaluating the association between time to surgery and complication rates in patients undergoing operative fixation of pelvic ring injuries.

Methods: A retrospective cohort study was performed at a Level I trauma center including all patients with operative pelvic ring injuries from 2015 to 2022. Time from hospital admission to surgery, basic demographics, and comorbidities were determined for all patients. Systemic complications including acute respiratory distress syndrome, pneumonia, sepsis, deep venous thrombosis, pulmonary embolus, ileus, acute kidney injury, myocardial infarction, and mortality were recorded. The association between time to surgery and overall complications and each complication individually was estimated using multivariable statistical models.

Results: A total of 1,056 patients were included in the final cohort. Patients who underwent surgery within 48 hours (n = 724) had an overall lower complication rate (17.8%) compared with those patients (n = 332) who underwent surgery greater than 48 hours after admission (34.9%). Each additional hour delay to surgery from admission was associated with a 0.4% increased odds of any complication. With respect to specific complications, each additional hour also increased the odds of sepsis (0.7%), deep venous thrombosis (0.3%), acute kidney injury (0.3%), myocardial infarction (0.5%), and pneumonia (0.4%). The odds of overall complication was 2.10 when patients underwent surgery within 42 hours after admission and increased at every time point afterwards.

Conclusion: Among patients with pelvic ring injuries, increased time to surgery was associated with an increased odds of systemic complication. This underscores the importance of aggressive resuscitation and prompt surgical intervention to reduce morbidity and improve overall patient outcomes.

Level of evidence: Prognostic and Epidemiological; Level III.

Background: Our purpose was to investigate whether neighborhood deprivation is associated with outcomes in a multicenter population of children with suspected or confirmed child physical abuse. We hypothesized that community level social determinants of health are associated with worse outcomes following child physical abuse.

Methods: This multicenter retrospective review included children (18 years or younger) admitted with suspected or confirmed physical abuse at six pediatric trauma centers. A national Area Deprivation Index (ADI) score was assigned to each patient based on home address. Area Deprivation Index was divided into quartiles using the distribution of our dataset. Exclusion of a caregiver at discharge was used as a proxy for confirmed physical abuse. Descriptive statistics and stepwise logistic regression were used to identify covariates. Multiple logistic regression was used to test for associations between ADI and caregiver exclusion.

Results: Of 1,105 included patients, 512 had confirmed abuse. These patients were younger (median [interquartile range], 0.50 [1.50] vs. 0.83 [1.67]; p = 0.002), more likely to be Black or African American (28.3% vs. 19.5%, p < 0.001), and had higher ADI scores (81.0 [35.0] vs. 66.0 [60.0], p < 0.001). A dose-dependent relationship between ADI and caregiver exclusion was identified. Compared with those from the least vulnerable neighborhoods (ADI first quartile), patients from the most vulnerable neighborhoods (ADI fourth quartile) had 2.65 (95% confidence interval, 1.73-4.08; p < 0.001) times higher odds of confirmed abuse. Despite no differences in Injury Severity Scores (8.0 [6.0] vs. 9.0 [10.0], p = 0.163), they also had longer lengths of hospital stay (1.0 [2.0] vs. 3.0 [2.8], p = 0.002) and higher mortality (1.5% vs. 5.0%, p = 0.028).

Conclusion: This large multicenter experience demonstrates a dose-dependent relationship between socioeconomic disadvantage and child physical abuse. We further demonstrate that disadvantage is associated with worse outcomes, including increased mortality, in child physical abuse. These findings provide objective data and lead to suggestions for interdisciplinary and multiscale approaches to primary prevention of child physical abuse.

Level of evidence: Prognostic and Epidemiological; Level III.

Background: Craniofacial trauma affects approximately 3 million individuals in the United States annually. Historically, low overall data quality and inadequate sample size have limited the development of clinical practice guidelines for prophylactic antibiotic use in facial fractures. We sought to examine the current use patterns and effects of prophylactic antibiotics in non-operative facial fractures.

Methods: A prospective analysis of adult patients with nonoperative facial fractures was conducted across 19 centers from January 2022 to December 2023. Kruskal-Wallis H, Mann-Whitney U, Pearson's χ2, Fisher's exact tests, and logistic regression models were used to evaluate the association between antibiotic duration (no antibiotics, ≤24 hours, and >24 hours) and facial fracture-associated infectious complications.

Results: Among 1,835 patients, 1,168 (63.7%) received no antibiotics and 667 (36.4%) received antibiotics (≤24 hours, n = 264 (14.4%); >24 hours, n = 403 (22.0%). Nineteen (1.0%) patients developed infectious complications (0.7% in the no antibiotic group vs. 1.7% with antibiotics). Most patients (99.0%) did not develop an infection despite the majority (63.7%) receiving no antibiotics. Injuries were predominately closed fractures (86.3%), without mucosal disruption (83.9%) or foreign bodies (97.7%). Antibiotic administration had a statistically significant association with the occurrence of infectious complications (p = 0.050). However, no significant association was seen between antibiotic duration and infectious complications following multivariable logistic regression, adjusting for confounders (≤24 hours: adjusted odds ratio, 1.24; 95% confidence interval, 0.30-5.14; p = 0.766; >24 hours: adjusted odds ratio, 1.32; 95% confidence interval, 0.37-4.69; p = 0.668).

Conclusion: Despite most patients not receiving antibiotics, infection rates remained low. This indicates prophylactic antibiotic use does not reduce the risk of fracture-associated infections for most injury patterns. While a randomized trial is optimal to validate these data, at this time, there is no evidence to support presumptive antibiotics for closed non-operative facial fractures.

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

Introduction: Hemorrhage is a leading cause of death in pediatric patients. Accumulating data suggest that low-titer group O whole blood (LTOWB) improves clinical outcomes in the pediatric population. We examined what ratio of LTOWB to total blood product conferred a survival benefit in transfused pediatric trauma patients.

Methods: We retrospectively examined a cohort of injured subjects younger than 18 years from the Trauma Quality Improvement Program database who received any quantity of LTOWB and no documented prehospital cardiac arrest. We created a variable representing the volume of transfused LTOWB divided by the total volume of all transfused blood products administered within the first 4 hours of admission, that is, the proportion of LTOWB transfused. We analyzed increasing proportions of transfused LTOWB to determine whether there was an inflection point conferring increased survival.

Results: From 2020 to 2022, 1,122 subjects were included in the analysis. The median (interquartile range) age was 16 (14-17) years. Firearms were the most common mechanism at 47% followed by collisions at 44%. The median composite injury severity score was 25 (16-34). Survival was 91% at 6 hours, 89% at 12 hours, and 88% at 24 hours. We noted an inflection point with improved survival at an LTOWB proportion of ≥30% of total volume of blood products received. The odds of survival at 6, 12, and 24 hours for those receiving ≥30% LTOWB was 1.85 (1.02-3.38), 2.09 (1.20-3.36), and 1.80 (1.06-3.08), and 3.55 (1.66-7.58), 3.71 (1.89-7.27), and 2.69 (1.44-5.02) when excluding those who died within 1 hour, respectively.

Conclusion: Among LTOWB recipients, we found that a strategy of using LTOWB comprising at least 30% of the total transfusion volume within the first 4 hours was associated with improved survival at 6, 12, and 24 hours.

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

Background: Red blood cell (RBC) aggregation can be initiated by calcium and tissue factor, which may independently contribute to microvascular and macrovascular thrombosis after injury and transfusion. Previous studies have demonstrated that increased blood storage duration may contribute to thrombotic events. The aims of this study were to first determine the effect of blood product components, age, and hematocrit (HCT) on the aggregability of RBCs, followed by measurement of RBC aggregability in two specific injury models including traumatic brain injury (TBI) and hemorrhagic shock.

Methods: Human whole blood (WB) units were obtained following the standard 21-day storage period. Whole blood was separated into components including RBCs, platelet-rich plasma (PRP), and platelet-poor plasma (PPP) via serial centrifugation and diluted to a standardized HCT on Days 2 and 23 following isolation. Finally, WB was collected from murine models of TBI and hemorrhagic shock at sequential, postinjury timepoints. Whole blood and component groups were analyzed for RBC aggregability with calcium and tissue factor initiated electrical impedance aggregometry.

Results: At both timepoints, nondiluted HCT RBCs demonstrated similar aggregability to standardized-HCT RBCs when diluted with phosphate buffered saline (PBS). Red blood cells diluted with PRP and PPP demonstrated significantly higher aggregation than RBCs diluted with PBS at both timepoints. Reconstitution with PRP and PPP demonstrated similar aggregability. Murine RBCs demonstrated increased aggregation at the 4-hour postinjury timepoint following TBI and decreased aggregation at the 1-hour postinjury following hemorrhagic shock.

Conclusion: Neither hemoconcentration or age of donated blood products affect the calcium and tissue-factor dependent aggregability of RBCs. Further, RBC aggregation is increased in the presence of plasma, not platelets-indicating a potential role for plasma in regulating RBC aggregation. Finally, injury patterns including TBI and hemorrhagic shock may influence hypercoagulability or coagulopathy via change in RBC aggregability.

Background: Hospital presumptive eligibility (HPE) emergency Medicaid programs offset patient bills at hospitalization and can provide long-term Medicaid coverage. We characterized postdischarge outpatient health care utilization among HPE Medicaid trauma patients and identified patient access facilitators and barriers once newly insured. We hypothesized utilization would be increased among HPE trauma patients compared with other HPE patients, but that challenges in access to care would remain.

Methods: We performed a convergent mixed methods study of California HPE beneficiaries using a 2016 to 2021 customized statewide longitudinal claims dataset from the Department of Health Care Services. We compared adults 18 years and older with a diagnosis to other HPE patients. Patients were tracked for 2 months postdischarge to evaluate health care utilization: outpatient specialist visits, emergency room (ER) visits, readmissions, and mental health. Thematic analysis of semistructured interviews with HPE Medicaid patients aimed to understand facilitators and barriers to access to care (n = 20).

Results: Among 199,885 HPE patients, 39,677 (19.8%) had a primary diagnosis of trauma. In the 2 months postdischarge, 40.8% of trauma vs. 36.6% of nontrauma accessed outpatient specialist services; 18.6% vs. 17.2% returned to ED, 8.4% vs. 10.2% were readmitted; and 1.4% vs. 1.8% accessed mental health services. In adjusted analyses, trauma HPE patients had 1.18 increased odds of accessing outpatient specialist services ( p < 0.01). Patients cited HPE facilitators to accessing care: rapid insurance acquisition, outpatient follow-up, hospital staff support, as well as ongoing barriers to access (HPE program information recall, lack of hospital staff follow up postdischarge, and difficulty navigating a complex health care system).

Conclusion: Hospital presumptive eligibility Medicaid is associated with higher rates of outpatient specialist visits and fewer readmissions following injury, suggesting improved trauma patient access. Opportunities to improve appropriateness of health care utilization include more robust and longitudinal education and engagement with HPE Medicaid patients to help them navigate newfound access to services.

Level of evidence: Prognostic and Epidemiological; Level III.