Journal of Trauma and Acute Care Surgery最新文献

Background: Postamputation pain in amputees is a major cause of morbidity. Studies have highlighted the impact of preemptive surgical intervention of the amputated nerves for treatment of postamputation pain. The study aimed to analyze the role of targeted muscle reinnervation (TMR) at the time of limb loss in addressing both residual limb pain and phantom limb pain.

Methods: A randomized controlled trial (RCT) in acutely injured patients undergoing above-knee amputation (AKA) (n = 97) were randomized into two groups with equal allocation, i.e., group A with TMR (intervention) and group B with conventional stump formation (control) at the time of amputation using mixed block randomization. The timeframe for the outcome analysis was 48 hours and 12 weeks postamputation. The psychological well-being was assessed using the Hospital Anxiety and Depression Scale (HADS), McGill Pain Questionnaire (MPQ), and functionality using Patient Reported Outcomes Measurement Information System (PROMIS) pain questionnaires. The anatomical evaluation of the severed nerve was done at 12 weeks with high-frequency ultrasonography.

Results: The majority of the patients were males (n = 92, 94.8%) with a mean age of 32.5 years. The mean Mangled Extremity Severity Score (MESS) was comparable (p = 0.98) between the groups. The difference of the mean NRS of the residual limb pain (1.8 vs. 3.3) and phantom limb pain (1.2 vs. 2.6) was statistically significant between the two groups (p = 0.001). The psychological scores HADS, MPQ, and PROMIS were statistically significant. The neuroma size measured using ultrasound at 12 weeks was statistically significant between the groups (p < 0.05).

Conclusion: The preemptive surgical intervention of amputated nerve at the time of amputation by TMR techniques significantly reduces the postoperative residual limb pain and phantom limb pain at 3 months follow up.

Level of evidence: Randomized Controlled Trial with no negative criteria; Level I.

Introduction: Most centers use a tiered operating room (OR) posting system. This system is based on patient physiology and the potential for deterioration of their condition because of the pathology that requires operative intervention. If those criteria are respected, then meeting those time goals should result in better patient outcomes. We sought to determine the effect of patients meeting the time goals within the tiered posting systems on patient outcomes.

Methods: A retrospective review at a single academic center was performed on all patients posted for the OR by the acute care surgery (ACS) service over a 9-year period. The posting system was E1, E2, E4, E12, and Add On/Elective, which designated emergent and the number of hours they were to go to the OR after posting. Only emergent cases with one operation were included for analysis, and cases were further stratified by day and night.

Results: There were 7,520 patients with 4,544 meeting final inclusion criteria with 2,042 daytime cases and 2,502 nighttime cases. The 30-day mortality was significantly higher in the daytime patients who did not meet the posting goal (4.4% vs. 2.5%, p = 0.024). In a regression analysis controlling for age, Charlson Comorbidity Index, and shock index, failure to reach the OR in a timely fashion remained an independent predictor of death (adjusted odds ratio, 2.1 [95% confidence interval, 1.2-3.8]; p = 0.014). There was no difference in nighttime cases.

Conclusion: Acute care surgery care is predicated on timely intervention. Tiered OR posting systems are intended to get patients to the OR to achieve early source control and prevent further deterioration. There is a price to pay when those goals are not reached with an increased risk of death.

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

Background: Teaching hospitals serve as referral centers for pediatric trauma care. However, the impact of interhospital transfer on outcomes in pediatric traumatic brain injury (TBI) within urban teaching hospitals remains unclear. Hence, we examined whether transferred pediatric TBI patients to urban teaching hospitals experienced different outcomes from directly admitted patients, hypothesizing that results would be comparable.

Methods: We conducted a cross-sectional study of pediatric TBI hospitalizations from 2016 to 2021 using the National Inpatient Sample database. Patients were categorized as direct admissions or transfers. Propensity score matching (1:2 with replacement) was performed using demographic, clinical, and hospital-level variables. Outcomes included in-hospital mortality, medical complications, length of stay (LOS), and postdischarge rehabilitation referral.

Results: Out of 28,548 total patients, 15,324 were successfully matched with 7,239 (47.2%) interhospital transfers. Baseline demographics, clinical, and hospital characteristics were well balanced between the two groups (all standardized mean differences <10%). Unadjusted in-hospital mortality was similar between transferred and directly admitted patients (3.6% vs. 3.4%, p = 0.49). However, transferred patients experienced longer LOS (median, 2 days; interquartile range, 1-6; p < 0.001), fewer discharges to rehabilitation (5.7% vs. 6.7%, p < 0.001), and higher complications (deep vein thrombosis, 1.2 vs. 0.9; p = 0.04; urinary tract infection, 1.6 vs. 1.1; p = 0.005). After multivariable adjustment, transfer status was not associated with mortality (odds ratio [OR], 1.06; 95% confidence interval [CI], 0.89-1.28) and rehabilitation discharge (OR, 0.92; 95% CI, 0.80-1.06). However, transfer remained independently associated with longer LOS (OR, 1.31; 95% CI, 1.24-1.39) and higher complications (OR, 1.25; 95% CI, 1.09-1.44).

Conclusion: Interhospital transfer was not associated with mortality or rehabilitation discharge among pediatric TBI patients treated at urban teaching hospitals. However, longer LOS and higher complications among transferred patients raise equity and system efficiency concerns. While statistically significant, these differences were modest and may not be clinically meaningful, warranting further research with more granular data.

Level of evidence: Original article, cross-sectional study; Level III.

Background: The pediatric brain injury guidelines (kBIG) are a newly established clinical triage tool for managing pediatric traumatic brain injuries (TBIs). However, the kBIG classification does not include pneumocephalus, raising uncertainty about how to classify and manage patients with this finding. In this study, we sought to determine the risk of neurosurgical intervention, injury progression, and intensive care unit (ICU) admission in children with low- to moderate-risk TBIs and pneumocephalus.

Methods: We conducted a retrospective cohort study of pediatric trauma patients (younger than 18 years) after blunt mechanism trauma with an Abbreviated Injury Scale head score of >1 treated at a level 1 pediatric trauma center between January 2018 and April 2024. We applied the kBIG criteria to this cohort and excluded kBIG3 patients from the analysis. Demographics, presence of pneumocephalus, injury type, repeat head computed tomography, and neurosurgical intervention were extracted. Progression was defined as new or worsening bleed on repeat computed tomography. Neurosurgical treatment was defined as any operative intervention performed by a neurosurgeon.

Results: We included 832 pediatric trauma patients classified as kBIG0, kBIG1, and kBIG2 TBIs. Pneumocephalus was present in 143 patients (18.1%). There was no significant difference in neurosurgical intervention rates (0.2% vs. 0.7%; p = 0.5), injury progression (12% vs. 9.8%; p = 0.7), ICU admission 8.1% vs. 9.7%; p = 0.5), or ICU length of stay (1 [1-1] vs. 1 [1-1], p = 0.7) between patients with and without pneumocephalus.

Conclusion: In this study, we found that pneumocephalus is an uncommon finding in low- to moderate-risk blunt head injuries. Patients with pneumocephalus had no increased risk of neurosurgical treatment or injury progression compared with those without. These findings suggest that pneumocephalus does not confer additional clinical risk and may be safely excluded from consideration when applying the kBIG classification to guide management in otherwise low- to moderate-risk patients.

Level of evidence: Retrospective Cohort Study; Level V.

Abstract: Intracranial hypertension (ICH) has long been recognized as a major challenge in the management of patients with severe traumatic brain injury. Although it has become widely accepted that patients with unremarkable brain computed tomography scans may not require invasive intracranial pressure (ICP) monitoring, the threshold for using such monitoring in other severe traumatic brain injury patients should be low. Intraparenchymal monitors and external ventricular drains are both effective monitoring techniques. No specific prophylactic interventions are available to prevent ICH. Instead, initial management focuses on maintaining physiological parameters in the normal range and intervening promptly when deviations occur. Management of elevated intracranial pressure proceeds along a series of interventions that begins with the least invasive and least complex measures and progressively escalates to those with greater scope and risk. However, the sequence of these steps is not rigorously defined, and considerable latitude may be exercised according to a specific patient's individual situation. Choosing the appropriate therapies for different patients requires the clinician to have a deep understanding of the pathophysiology of ICH.

Introduction: Evaluating triage efficiency, particularly undertriage (UT), is an important quality improvement activity for trauma centers and supports selection of optimal trauma activation criteria. This study aimed to compare two existing methods (Cribari Matrix Method [CMM] and the Standardized Triage Assessment Tool [STAT]) to a novel method using eight High-Intensity Time-Sensitive (HITS) interventions adapted from Trauma Quality Improvement Program process-of-care measures.

Methods: This multicenter, retrospective study identified trauma patients admitted from 2017 to 2019 using trauma registry data including trauma activation status: full trauma activation (fTA+) or nonfull trauma activation (fTA-). Undertriage rate was assessed using CMM (Injury Severity Score >15 and fTA-), STAT (CMM UT and Need for Trauma Interventions +), and HITS interventions (HITS+ and fTA-); UT denominator was all fTA- patients. Among fTA- patients, UT patients were compared with appropriately triaged patients on total mortality (in-hospital death plus hospice) using multivariable generalized linear mixed models.

Results: Thirty-seven Level I/II trauma centers enrolled 158,696 patients (88.0% blunt, 21.7% fTA+, median age of 55 years, median Injury Severity Score of 9, 4.4% total mortality). Undertriage rate was lowest using the HITS interventions method (3.8%) versus STAT (5.1%) and CMM (11.1%) (both p < 0.001). Compared with CMM or STAT, the HITS interventions method showed significantly higher adjusted odds ratio for total mortality in UT versus appropriately triaged: adjusted odds ratio (95% confidence interval) of CMM, 6.67 (6.13-7.26); STAT, 12.55 (11.40-13.82), and HITS, 15.04 (13.48-16.78).

Conclusion: Compared with CMM and STAT, HITS interventions method not only reduced the number of patients categorized as UT but also isolated those at the highest risk of mortality. Thus, HITS interventions method provides a streamlined, data-driven means to calculate UT rates using registry data and guides performance improvement reviews to patients who were not fTA but might have benefited from full trauma team intervention.

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

Background: Despite two large randomized controlled trials (RCT) designed to assess tranexamic acid (TXA) for traumatic brain injury (TBI) patients, its use and optimal dosing strategy in TBI remains uncertain. We sought to assess functional and mortality outcomes associated with prehospital TXA administration for TBI patients using Bayesian techniques.

Methods: We performed a post hoc analysis of the prehospital TXA for TBI RCT where TBI patients received TXA as a 1-g bolus followed by a 1-g infusion (standard), 2-g bolus (bolus), or placebo. Bayesian regression models were created to assess the association of early prehospital TXA administration in TBI patients using posterior probabilities for 6-month functional outcomes, as well as 28-day and 6-month mortality.

Results: Patients receiving prehospital TXA (standard or bolus) displayed a 78.1% probability of having improved functional neurologic outcomes at 6 months compared with placebo. When compared with placebo, the Bolus cohort displayed a 95.3% probability of improved functional neurologic outcomes at 6 months, a 95.3% probability of decreased mortality at 28 days, and a 70.7% probability of decreased mortality at 6 months. The Standard cohort displayed a less than 50% probability of benefit compared with placebo for all outcomes measured.

Conclusion: A prehospital 2 g TXA bolus dosing strategy demonstrated a high probability of benefit compared with both placebo and Standard cohorts for functional neurologic and mortality outcomes in patients with moderate to severe TBI.

Level of evidence: Therapeutic; Level III.

Background: The Utah Pediatric Trauma Network (UPTN), established in 2019, is a collaboration of hospitals in Utah that have implemented evidence-based guidelines to optimize pediatric trauma care. This study aimed to determine whether the establishment of the UPTN correlated with a change in the amount and character of preventable transfers (PTs) to the state's only Level I pediatric trauma center.

Methods: Children with traumatic injuries transferred between 2013 and 2023 were retrospectively analyzed. The exposure was a transfer that occurred after the establishment of the UPTN on January 1, 2019. A PT was a child discharged within 48 hours of arrival without surgical intervention or advanced imaging studies.

Results: During this period, 6,036 children were transferred. There were 3,025 transferred pre-UPTN, while 3,011 were transferred post-establishment. The rate of preventable transfer before the establishment was 36% versus 29% after (p < 0.001). Following the establishment of the UPTN, there was a significant change in the proportion of each injury type that was transferred. A lower percentage of patients had an intracranial bleed (15% vs. 20%, p < 0.001), isolated skull fracture (6.8% vs. 8.8%; p = 0.004), or a blunt solid organ injury (4.3% vs. 5.5%, p = 0.031). There was an increase in the proportion of transferred patients that had an orthopedic injury (36% vs. 28%, p < 0.001) with a significant decrease in PT rate (10% vs. 15%, p = 0.003). In addition, after the UPTN was established, the preventable transfer rate for intracranial bleed significantly decreased from 47% to 37% (p < 0.001).

Conclusion: In this study, we found that following the establishment of a trauma network that standardized pediatric trauma guidelines across a region, the rate of preventable transfer decreased. Traumatic brain injuries saw the largest decrease in the proportion of transfers and the rate of preventable transfers. These findings give evidence of trauma networks being a practical tool for decreasing overtriage.

Level of evidence: Prognostic/Epidemiological; Level III.