Journal of Trauma and Acute Care Surgery最新文献

Background: Extracorporeal membrane oxygenation (ECMO) has emerged as a critical intervention in the management of patients with trauma-induced cardiorespiratory failure. This study aims to compare outcomes in patients with severe thoracic injuries with and without venovenous extracorporeal membrane oxygenation (VV-ECMO).

Methods: We performed a retrospective cohort study on Trauma Quality Improvement Program (2017-2021) and included all patients with isolated blunt thoracic injuries with Abbreviated Injury Scale score of ≥4 who required intubation. Patients were divided into two groups based on VV-ECMO and were compared using propensity score matching with the primary outcome of mortality.

Results: A total of 14,106 patients with severe thoracic injuries were identified. Propensity score matching resulted in two groups of 812 VV-ECMO and 812 non-VV-ECMO groups. Venovenous ECMO group had significantly lower in-hospital mortality rates (22.3% vs. 37.3%, p < 0.001). However, VV-ECMO group had significantly higher rates of complications including cardiac arrest (27.7% vs. 10.6%), pulmonary embolism (7.6% vs. 2.1%), ventilator-associated pneumonia (16.7% vs. 4.2%), unplanned intubation (11.9% vs. 8.5%), unplanned intensive care unit (ICU) admission (8.4% vs. 4.9%), and unplanned return to operation room (10.1% vs. 2.6%) (p < 0.001, for all). Patients in VV-ECMO group had significantly higher hospital (29.46 ± 26.37 vs. 13.59 ± 13.3 days) and ICU (22.96 ± 19.38 vs. 9.38 ± 9.05 days) length of stay (p < 0.001, for both). In VV-ECMO group, the mean ± SD time to perform VV-ECMO was 5.54 ± 5.91 days. Each day earlier initiation of VV-ECMO resulted in decreased hospital and ICU length of stay by 67.1% and 59.9%, respectively (p < 0.001 for both). Among patients without acute respiratory distress syndrome (n = 435 in each group after repeated PS matching), we observed significantly lower mortality rates in VV-ECMO group (26.9% vs. 40%, p < 0.001).

Conclusion: While VV-ECMO in isolated blunt thoracic trauma patients is associated with higher survival rates even in non-acute respiratory distress syndrome cases, it is associated with higher incidence of complications. These findings emphasize earlier consideration of VV-ECMO in severe blunt thoracic trauma.

Level of evidence: Retrospective Study; Level III.

Abstract: Observational studies assessing causal effects of interventions are subject to indication (selection) bias, which may be difficult to eliminate using traditional multivariable techniques. When properly specified, propensity score-adjusted analysis may offer an advantage traditional regression by ensuring that investigators explicitly assess comparability of baseline prognostic factors between the treated and untreated. However, it is important to note that the effectiveness of a propensity score-adjusted analysis depends on the variables selected for the model and the analytic approach. Noninclusion of important prognostic factors and model misspecification among other errors may in fact increase bias; thus, in performing propensity score analysis, these errors must be minimized as much as possible or assessed using sensitivity analysis to ensure validity.

Background: Tissue-plasminogen activator-challenged thromboelastography (tPA-TEG) predicts massive transfusion and mortality better than conventional rapid thromboelastography (rTEG), with little concordance between their lysis values (LY30). We hypothesized that the main fibrinolytic inhibitors plasminogen activator inhibitor-1 (PAI-1) and α-2 antiplasmin (A2AP), as well as markers of fibrinolytic activation (plasmin-antiplasmin [PAP], tPA-PAI-1 complex, tPA activity), would correlate more strongly with tPA-TEG versus rTEG LY30 and may explain the recent findings of four distinct fibrinolytic phenotypes in trauma based on these two TEG methodologies.

Methods: Adult trauma patients (n = 56) had tPA-TEG, rTEG, and plasma obtained on arrival to the emergency department with institutional review board approval. Plasminogen activator inhibitor-1 activity, A2AP, PAP, and tPA-PAI-1 complex as well as tPA activity were measured. Data were analyzed using Spearman's correlations and analysis of variance.

Results: The median age was 34 years, 75% were male, and the New Injury Severity Score was 14. Mortality was 25%, and 23% required a massive transfusion. There was a significant negative correlation between PAI-1 activity and A2AP with tPA-TEG LY30 (r = -0.77, p < 0.0001 and r = -0.62, p < 0.0001). There was a significant positive correlation between PAP complex and tPA-TEG LY30 (r = 0.74, p < 0.0001). There was no correlation between any fibrinolytic analyte and rTEG LY30. When stratified by phenotype, patients with hypofibrinolysis and nonpathologic fibrinolysis had higher active PAI-1 (p < 0.05) and A2AP levels (p < 0.05), lower PAP (p < 0.05), and tPA-PAI-1 complex (p < 0.05). Tissue-plasminogen activator activity was higher in hyperfibrinolysis relative to the other three groups (p < 0.05).

Conclusion: Tissue-plasminogen activator-TEG LY30 more accurately reflects fibrinolysis phenotypes in trauma patients than conventional TEG methods. This provides an explanation for tPA-TEG's superior performance over rTEG in predicting clinical outcomes.

Level of evidence: Basic Science; N/A.

Background: As increased attention is placed on optimizing long-term outcomes of trauma patients by addressing mental health, little is known regarding the interplay of pre- and postinjury mental health on long-term financial and functional outcomes.

Methods: Patients from 19 Level 1 and 2 trauma centers took part in serial surveys 1 to 24 months postdischarge. Preinjury mental health diagnoses were identified using trauma registry data and postinjury mental health symptoms from survey data. Outcomes included (1) health-related quality of life from the EuroQol-5D-5L and (2) elements of financial toxicity (e.g. medical debt, job/income loss, nonmedical bills, unaffordable care). Multivariable models were created, adjusting for patient, injury, and treatment factors, to evaluate the association of preinjury mental health diagnoses and postinjury mental health symptoms on health-related quality of life and financial toxicity.

Results: A total of 1,017 patients completed 1,297 surveys from July 2021 to December 2023, at a median of 6 months postinjury. Forty-six percent were female, the median age was 67.5 years, and 89% had blunt injuries. Thirty-two percent of patients had a preinjury mental health diagnosis, and 49% had self-reported mental health symptoms postdischarge. Patients with preinjury mental health diagnoses had higher odds of postinjury mental health symptoms (adjusted odds ratio, 3.6 [2.6-4.9]; p < 0.001); however, 55% of those with postinjury symptoms had no preinjury diagnosis. Postinjury symptoms alone were associated with worse health-related quality of life or financial toxicity. Notably, patients with new postinjury mental health symptoms (no preinjury mental health diagnosis) had the highest rate of foregone postinjury care because of costs (26% vs. 14%, p < 0.01).

Conclusion: More than one-in-two patients had peri-injury mental health conditions, and patients with postinjury mental health symptoms experienced worse financial and functional outcomes. Addressing postinjury mental health may potentially improve long-term health-related quality of life of trauma survivors; however, efforts are needed to ensure that patients can afford the care needed for optimal health.

Level of evidence: Prognostic and Epidemiological; Level IV.

Background: There is conflicting evidence regarding emergency medical service (EMS) provider level of training and outcomes in trauma. We hypothesized that advanced life support (ALS) provider transport is associated with lower mortality compared with basic life support transport.

Methods: We performed secondary analysis of a combined prehospital and in-hospital database of trauma patients utilizing ESO electronic medical records from 2018 to 2022. We included encounters with patients aged 15 years to 100 years transported by ground to a Level I or II trauma center with trauma-specific ICD-10-CM codes. Patients dead upon EMS arrival and transfers were excluded. We matched patients using 1:1 nearest neighbor propensity scores based on demographic, injury, and EMS characteristics, prehospital vitals, and trauma center designation. The exposure variable was EMS level of training and outcome was mortality. We conducted subgroup analyses on predefined cohorts (age > 50 years, mechanism of injury, prehospital EMS time > 30 minutes).

Results: We identified 30,735 ALS and 1,758 basic life support encounters, representing 1,154 pairs following propensity matching. Mortality was lower among patients transported by ALS providers (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.18-0.88; p = 0.023). Mortality was also lower in the subgroups of patients aged > 50 years (OR, 0.35; 95% CI, 0.13-0.98; p = 0.046), and in patients with mechanisms of injury excluding falls (OR, 0.35; 95% CI, 0.13-0.98; p = 0.047). In those with prolonged prehospital time, the association approached significance (OR, 0.30; 95% CI, 0.08-1.08; p = 0.067). In those with mechanisms of injury of fall, the association was not significant.

Conclusion: In this retrospective, propensity matched cohort study using a national sample of trauma patients, attendance by ALS providers was associated with reduced mortality. This was observed in the entire cohort, in those aged > 50 years, and those with a higher-risk mechanism of injury. It approached significance in those with prolonged prehospital time.

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

Background: American College of Surgeons (ACS) trauma center verification has demonstrated improved outcomes at individual centers, but its impact on statewide Trauma Quality Improvement Program (TQIP) Collaboratives is unknown. A statewide TQIP Collaborative, founded in 2011, noted underperformance in six of eight patient cohorts identified in the TQIP Collaborative report. We hypothesized that requiring ACS verification for level I and II trauma centers would result in improved outcomes for the state collaborative.

Methods: The ACS verification requirement was tied to ongoing Trauma Commission funding. Trauma centers were required to apply for an ACS consultative visit by 2017 and were given until 2023 to achieve ACS verification. The effect of this intervention was measured in the number of centers achieving verification and in the performance of the TQIP Collaborative semiannual reports.

Results: In 2015, only 1 of 15 (7%) trauma centers were ACS verified, and 4 had undergone consultative visits. By 2023, 11 of 12 (92%) trauma centers achieved ACS verification. Following this intervention, the observed-to-expected odds ratio for all-patient morbidity and mortality improved from 1.60 to 1.17, and variation among patient-specific cohorts narrowed from 0.97-1.82 to 0.96-1.48 (Figure 2). Performance in all six underperforming patient-specific cohorts improved over the study period.

Conclusion: ACS verification for level I and II trauma centers improves TQIP Collaborative performance. Statewide Collaboratives should consider ACS verification as a requirement for participation.

Level of evidence: Economic and Value-Based Evaluations, Level III.

Background: Preinjury antithrombotic (AT) use is associated with worse outcomes for geriatric (65 years or older) patients with traumatic brain injury (TBI). Previous studies have found that use of AT outside established guidelines is widespread in TBI patients.

Methods: In this single-center retrospective cross-sectional study, we examined inappropriate AT use among geriatric patients presenting with traumatic intracranial hemorrhage. We reviewed records of patients 65 years or older with preinjury AT use who presented to a Level 1 trauma center with traumatic intracranial hemorrhage between 2016 and 2023. Patient demographics and AT indications/types were extracted. Appropriateness of AT use was determined using established guidelines.

Results: The cohort comprised 207 patients (56.5% male; median age, 77 years). Fall was the most common mechanism of injury (87.9%). At initial presentation, 87.0% of patients had mild TBI (Glasgow Coma Scale scores 13-15). The two most common indications for AT use were atrial fibrillation (41.5%) and venous thromboembolism (14.5%). Anticoagulation therapy was used by 51.7% of patients, antiplatelet therapy by 40.1%, and both by 8.2%. Prescribed AT agents included warfarin (23.2%), direct oral anticoagulants (36.2%), aspirin (32.4%), and clopidogrel (15.0%). Per clinical guidelines, 31 patients (15.0%) were determined to be inappropriately on AT therapy. On multivariable analysis, venous thromboembolism (odds ratio [OR], 5.32; 95% confidence interval [CI], 1.80-15.71; p = 0.002) and arterial stent (OR, 4.69; 95% CI, 1.53-14.37; p = 0.007) were associated with inappropriate AT use; aspirin was the most common inappropriately prescribed AT (OR, 3.59; 95% CI, 1.45-8.91; p = 0.006).

Conclusion: Overall, 15% of geriatric TBI patients with preinjury AT use were prescribed this therapy outside of current guidelines. Trauma providers should remain vigilant in identifying such patients and collaborate across multidisciplinary teams to implement interventions that minimize inappropriate AT use.

Level of evidence: Prognostic and Epidemiological Study; Level IV.

Background: Combat-related injuries have evolved in urban warfare because of close-contact engagements and high-energy blast injuries, with rapid medical evacuation improving survival rates. This study analyzes injury patterns and outcomes in the Gaza conflict, emphasizing the need to optimize trauma care protocols in modern combat environments, particularly because of the unique proximity of conflict zones to tertiary trauma centers.

Methods: A retrospective study was conducted at a single center involving 189 patients evacuated by helicopter to a Level I tertiary trauma center. Subgroup analysis based on Injury Severity Scores was performed.

Results: Shrapnel impacts were the leading cause of injuries (58.7%), followed by blast injuries (48.1%) and gunshot wounds (30.7%). Extremity injuries were most common (61.4%), with 46.3% of patients needing surgery within 24 hours, mainly orthopedic procedures (75.3%). The average hospital stay was 21.9 days. In-hospital mortality rate was 4.2% (two patients). Infections occurred in 17.9% of cases, with fungal infections at 8.9% and bacterial infections at 15.3%.

Conclusion: In modern urban warfare, effective medical interventions play a crucial role in mitigating challenges. This study emphasizes the importance of rapid evacuation and advanced trauma management, reflected in low in-hospital mortality rates, highlighting the significance of timely interventions, personal protective equipment, specialized orthopedic trauma care, and robust infection control measures.

Level of evidence: Prognostic and Epidemiological; Level III.

Background: Given the high mortality and morbidity of emergency general surgery (EGS), designing and implementing effective quality assessment tools is imperative. Currently accepted EGS risk scores are limited by the need for manual extraction, which is time-intensive and costly. We developed an automated institutional electronic health record (EHR)-linked EGS registry that calculates a modified Emergency Surgery Score (mESS) and a modified Predictive OpTimal Trees in Emergency Surgery Risk (POTTER) score and demonstrated their use in benchmarking outcomes.

Methods: The EHR-linked EGS registry was queried for patients undergoing emergent laparotomies from 2018 to 2023. Data captured included demographics, admission and discharge data, diagnoses, procedures, vitals, and laboratories. The mESS and modified POTTER (mPOTTER) were calculated based off previously defined variables, with estimation of subjective variables using diagnosis codes and other abstracted treatment variables. This was validated against ESS and the POTTER risk calculators by chart review. Observed versus expected (O:E) 30-day mortality and complication ratios were generated.

Results: The EGS registry captured 177 emergent laparotomies. There were 32 deaths (18%) and 79 complications (45%) within 30 days of surgery. For mortality, the mean difference between the mESS and ESS risk predictions for mortality was 3% (SD, 10%) with 86% of mESS predictions within 10% of ESS. The mean difference between the mPOTTER and POTTER was -2% (SD, 11%) with 76% of mPOTTER predictions within 10% of POTTER. Observed versus expected ratios by mESS and ESS were 1.45 and 1.86, respectively, and for mPOTTER and POTTER, they were 1.45 and 1.30, respectively. There was similarly good agreement between automated and manual risk scores in predicting complications.

Conclusion: Our study highlights the effective implementation of an institutional EHR-linked EGS registry equipped to generate automated quality metrics. This demonstrates potential in enhancing the standardization and assessment of EGS care while mitigating the need for extensive human resources investment.

Level of evidence: Prognostic and Epidemiologic Study; Level III.