Journal of Trauma and Acute Care Surgery最新文献

Background: Recovery from pediatric injury frequently requires transfer to an inpatient rehabilitation facility (IRF) for further convalescence. Waiting for disposition to such facilities can substantially prolong hospitalization. This study sought to determine the root causes of delayed discharge following medical readiness for pediatric patients. The authors hypothesized that insurance disparities and the day of week patients were deemed ready for discharge would significantly delay disposition.

Methods: A retrospective cohort study was performed by querying the authors' institutional database for patients admitted to a level 1 pediatric trauma center from January 1, 2016, to December 31, 2023. The date patients were documented as medically ready for discharge was identified and compared with the actual date of discharge. The root cause of delay was determined for each patient and factors contributing to extended discharge waits were analyzed.

Results: There were 162 patients identified with an average age of 9.4 ± 0.9 years and Injury Severity Score of 22.0 ± 1.9. The mean time to discharge after medical clearance was 3.6 ± 0.6 days which comprised 23 ± 6.1% of admission length on average. In-state residents had shorter waits than out-of-state residents (3.1 ± 0.5 vs. 6.2 ± 2.4 days, p = 0.016), as did those declared medically ready on Thursday or Friday (4.9 ± 1.4 vs. 3.0 ± 0.6 days, p = 0.012). The most common root causes of delay were rehabilitation bed availability, insurance authorization, and weekend delays. Having commercial insurance versus Medicaid had no impact. While waiting for rehabilitation, two patients (1.2%) developed pressure ulcers, one (0.6%) developed a deep vein thrombosis, and one (0.6%) developed a urinary tract infection. An average of 6.5% of inpatient monetary charges were incurred during the wait period.

Conclusion: Length of stay after severe pediatric injury is significantly impacted by time spent waiting for transfer to inpatient rehabilitation. Delayed transfer prevents optimal care and harms patient flow. Optimizing care transitions, identifying commonalities with other trauma centers, and considering government advocacy are warranted.

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

Background: Clearance of the pediatric cervical spine (CS) may pose a challenge following blunt trauma. Prior studies suggest that less than half of pediatric trauma centers (PTCs) have a written protocol for CS clearance. This study aimed to evaluate national practices for pediatric CS clearance in adult trauma centers (ATCs) and PTCs.

Methods: Western Pediatric Cervical Spine Study members were queried for hospital demographics and current CS clearance practices. Data included trauma center verification level and the number of yearly trauma activations. Study members provided information about CS clearance and included a copy of their CS clearance protocol, if applicable. Standalone PTCs were defined as level I or level II PTCs not combined with ATCs.

Results: Sixty-six of 80 institutions queried responded. Of 66 responding institutions, 15 were combined PTC/ATC, 16 were ATC only, and 36 were standalone PTCs (level I PTC, 29; level I ATC, 14; level II PTC, 5; level II ATC, 2; level III ATC, 1). The median number of pediatric (younger than 18 years) trauma admissions at each TC per year was 644 (interquartile range, 315-1,215). For CS clearance, 74% (49 of 66) of TCs had a written protocol. Standalone PTCs were more likely to have a written protocol (97% vs. 57%, p < 0.001) and require a magnetic resonance imaging for CS clearance in the obtunded patient (97.0% vs. 56.0%, p < 0.001). Among sites that had written CS clearance protocols, there were no differences between standalone PTCs and nonstandalone PTCs in the proportion of sites that included Nexus criteria, Canadian CS Rule, Pediatric Emergency Care Applied Research Network, mechanism of injury, Glasgow Coma Scale, or obtunded status.

Conclusion: There is variation among adult and pediatric TCs in the screening and clearance of the pediatric CS. Despite evidence suggesting the importance of protocols for evaluating the CS, approximately half of the nonstandalone PTCs do not have an established protocol.

Level of evidence: Observational/Case Series; Level III.

Background: Percutaneous endoscopic gastrostomy (PEG) tubes are used for patients requiring long-term feeding access but are often placed to facilitate hospital disposition. Given the associated procedural risks and potential for patient recovery, we aimed to investigate the rate of return to oral intake after PEG placement, procedural indications, and complications to better elucidate the risk-benefit balance of PEG placement.

Methods: We conducted a retrospective review of all patients who underwent nonelective PEG tube placement at our Level 1 trauma center from January 1, 2023, to March 1, 2024. Patient demographics, procedure details, time to resumption of oral intake, and outcome data were collected. Primary outcome was return to oral intake at discharge. Secondary outcomes included placement for disposition purposes and complication rate. Patients were followed for 1 year after discharge.

Results: Of 233 patients identified, 59.7% resumed oral intake by time of discharge, 18.7% of which had returned to normal feeding. The median time to discharge from PEG placement was 11 days (interquartile range, 3-30 days). Furthermore, 37.3% of PEGs were placed for hospital disposition. The overall complication rate was 24.5% (46% Clavien-Dindo grade 3 or higher). Patients who had a PEG placed for disposition resumed an oral diet at a median of 5.5 days versus 17.5 days in those not done for disposition (p < 0.01). There were similar overall complication rates but a significantly higher proportion of Clavien-Dindo grade ≥3 complications (p = 0.02) in the PEG placed for disposition group. Overall, 19.7% of PEGs were placed in patients who were nutritionally independent by discharge, experienced in-hospital mortality, or were discharged to hospice.

Conclusion: Most patients who received a nonelective PEG resumed oral intake prior to discharge. Over one third of procedures were done to facilitate patient disposition, and nearly half of all complications required procedural intervention. Delaying PEG placement until closer to discharge may reduce unnecessary procedures and the associated complications.

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

Background: Previous trials have found a modest survival benefit from tranexamic acid (TXA) administration after polytrauma, but the early discrimination of the survival benefit observed suggests that the clinical effect of TXA may be multifactorial, not solely through bleeding reduction. Plasmin is known to directly cleave and activate complement proteins, and TXA can inhibit plasmin generation. We hypothesized that polytrauma patients who received TXA would demonstrate less complement activation compared with placebo controls.

Methods: Patient plasma was obtained from 53 polytrauma patients enrolled in the Pre-hospital Antifibrinolytics for Traumatic Coagulopathy and Hemorrhage (PATCH) trial of prehospital TXA (1 g bolus plus 1 g drip over 8 hours) versus placebo in the emergency department, at 8 hours, and at 24 hours after admission. Complement activation and regulatory markers were measured via multiplex, and plasmin-antiplasmin levels via enzyme-linked immunosorbent assay. Pairwise comparisons of analytes between TXA and placebo at each time point were performed with significance set at p < 0.05.

Results: The median age was 41.0 years (interquartile range, 28-57 years), 69.8% were male, the median Injury Severity Score was 38.0 (27.0-50.0), and all included patients were blunt mechanism. At early time points (emergency department and 8 hours), patients who received TXA did not demonstrate a reduction in C3a, C5a, sC5b-9, or plasmin-antiplasmin relative to placebo. At 24 hours, there was a significant increase in both C3a (274.0 vs. 416.6 ng/mL, p = 0.0024) and C5a (9.4 vs. 11.6 ng/mL, p = 0.0462) in the TXA group.

Conclusion: A 1 g bolus plus 1 g drip of TXA paradoxically increased complement activation at 24 hours in the TXA group. These findings support that TXA is essential in the inflammatory pathway after trauma. The delayed increase in complement may reflect the timing of TXA dosing and the shift to urokinase as the main plasminogen activator at later time points after injury. These results raise important questions about the optimal dosing of TXA in trauma patients.

Level of evidence:

Background: Methicillin-resistant Staphylococcus aureus (MRSA) nasal swab screening in a general intensive care unit population has been shown to have a high negative predictive value (NPV) and is used to guide antibiotic stewardship. Trauma populations may be more susceptible to hospital-acquired pneumonia. The purpose of this study is to assess the utility of the MRSA nasal swab in predicting MRSA pneumonia in a trauma population. We hypothesize that the NPV of MRSA nasal swabs in the trauma population will be sufficient to rule out MRSA ventilator-associated pneumonia and therefore withhold MRSA empiric antibiotic treatment.

Methods: A retrospective review of trauma intensive care unit patients who received an MRSA nasal swab from 2020 to 2023 was performed. Positive and negative MRSA nasal swab groups were compared, and sensitivity, specificity, positive predictive value, and NPV were calculated. Methicillin-resistant S. aureus pneumonia was defined as the presence of ≥105 MRSA colonies on respiratory culture.

Results: A total of 163 patients were screened, and 22 patients (13.5%) had positive MRSA nasal swabs. There were no significant differences in age, body mass index, smoking, or chronic obstructive pulmonary disease between the swab positive and swab negative groups. Sensitivity and specificity were 66.7% and 91.8%, respectively, with a positive predictive value of 45.4% and NPV of 96.4%. Five patients (3.1%) developed MRSA pneumonia, and all but one of these had a positive MRSA nasal swab. Area under the curve for the MRSA nasal test was calculated to be 0.793.

Conclusion: This is one of the largest studies to date to examine the utility of the MRSA nasal swab in the trauma population. The high NPV (96.5%) for the prediction of MRSA culture growth and ventilator-associated pneumonia suggests that MRSA nasal swabs may be a useful tool for antibiotics stewardship in the trauma population.

Level of evidence: Retrospective Cohort Study, Therapeutic Care/Management; Level IV.

Background: Traumatic brain injury (TBI) patients on antiplatelet medications lack definitive treatment for reversal of platelet inhibition and restoration of injury-induced platelet dysfunction. The use of platelet transfusions in this patient population remains controversial. Cold-stored platelets (CSPs) may be hemostatically superior to their room temperature platelet (RTP) counterparts for hemostatic resuscitation, but their impact on post-transfusion platelet function has yet to be assessed clinically. We aimed to evaluate the effect of CSP or RTP on post-transfusion platelet function in TBI patients on antiplatelet medications. We hypothesized that CSP would better restore platelet function based on the extensive in vitro data suggesting hemostatic superiority.

Methods: We performed a post hoc analysis of a randomized controlled trial comparing CSP and RTP in TBI patients on antiplatelet medications. Platelet hemostatic function was determined pretransfusion and posttransfusion using VerifyNow or thromboelastography with platelet mapping (TEG-PM). Clinical outcomes included 30-day mortality, need for neurosurgical intervention, and follow-up Rotterdam scores.

Results: Of the 94 patients with available data, 49 received CSP and 45 received RTP. Baseline characteristics and pre-transfusion assay measurements were similar between groups. Cold-stored platelet recipients had fewer neurosurgical procedures compared with RTP recipients (4.1% vs. 20.0%, p = 0.016). Room temperature platelet recipients showed a greater increase in TEG-PM kaolin maximum amplitude after transfusion compared with CSP recipients (2.4 mm vs. 0.6 mm, p = 0.004). No other differences were observed between RTP and CSP transfusions.

Conclusion: Despite a reduction in neurosurgical events, CSP did not significantly improve observed platelet function in TBI patients on antiplatelet medications. Our findings highlight the disconnect between platelet function assays and clinical results and suggest transfusion of CSP versus RTP has minimal effect on platelet hemostatic function. A definitive trial is needed to assess the efficacy of differentially stored products in the bleeding patient, with consideration placed on how platelet hemostatic function is assessed.

Level of evidence: Prognostic/epidemiologic; Level III.

Background: Polytrauma patients frequently experience long-term health impacts, including cognitive impairments. While traumatic brain injury (TBI) is a recognized nonmodifiable cause, polytrauma patients are likely to face cognitive challenges potentially linked to systemic inflammation and multiple surgical interventions even in the absence of TBI. This review aims to describe the incidence and identify factors associated with cognitive dysfunction in adult multiple injury patients without Frank TBI.

Methods: A systematic search was conducted across MEDLINE, CINAHL, EMBASE, and Scopus databases on August 17, 2023, to identify studies reporting on cognitive dysfunction in adults with polytrauma, excluding brain injuries. The Critical Appraisal Skills Programme checklists guided study appraisal, and findings were narratively synthesized.

Results: From 2719 articles identified (including one through citation searching), 47 were fully screened, yielding 10 cohort studies for inclusion. The reported incidence of cognitive dysfunction among multiple injury patients without TBI varied widely, from 0% to 60%, with a majority (eight out of ten studies) noting incidences of 30% or higher. No consensus was found for a relationship of other studied factors with cognitive dysfunction. Injury Severity Score was found to not be associated with cognitive dysfunction in selected studies which analyzed this factor.

Conclusion: This review suggests a high prevalence of cognitive dysfunction in multiple injury patients without TBI. The evidence base is limited by heterogeneity of the inclusion criteria, and the cognitive outcome measures.

Implications of key findings: Multiple injury is associated with long term cognitive dysfunction even without primary brain injury. This aspect of the disease of multiple injury needs further characterization to identify predictors and potential preventive and therapeutic interventions. Standardized reporting is also required to be able to monitor incidence and prevalence.

Level of evidence: Systematic Review; Level II.

Background: Limited longitudinal research has been conducted on health outcomes during the first 15 years after combat-related lower limb amputation.

Methods: This retrospective analysis of Departments of Defense and Veterans Affairs health data included casualty records of 4,814 service members who sustained either a single traumatic (n = 612) or delayed (n = 427) lower limb amputation or moderate/serious lower limb injury without amputation (n = 3,775) in Operations Iraqi and Enduring Freedom 2001-2017. Outcomes were clinical diagnoses during the first 15 years postinjury, including pain-related, behavioral health, cardiovascular, and bone disorders. Longitudinal analyses tested for associations between injury group and postinjury years and interactions between injury group and postinjury years and outcomes.

Results: The results showed high prevalence of diagnostic outcomes, particularly early postinjury pain and behavioral health diagnoses following amputation. Longitudinal analyses generally showed significant decreases in prevalence of outcomes, although some persisted at substantial rates (pain, insomnia, depression) or increased during later postinjury years (osteoarthritis, cardiovascular disorders, posttraumatic stress disorder). After adjusting for covariates, longitudinal analyses showed significant interactions between amputation groups (versus limb injury) and postinjury years. During early postinjury years, amputation generally was associated with significantly more total diagnoses and higher odds ratios for pain, behavioral health, and bone diagnoses. During later postinjury years 10 to 15, however, traumatic amputation was associated with significantly fewer total diagnoses and similar or lower rates for pain and behavioral health diagnoses.

Conclusion: The results indicate that traumatic and delayed lower limb amputations were associated with different longitudinal patterns for some pain-related, behavioral health, and bone disorders during the first 15 years postinjury. Amputation was associated with marginally higher rates of diabetes but not hypertension, lipidemia, or obesity. These results can inform clinical guidelines for postinjury treatment pathways, including multidisciplinary amputation care for many years postinjury.

Level of evidence: Retrospective/Epidemiologic; Level IV.

Abstract: Since its founding in 2011, the International Relations Committee (IRC) of the American Association for the Surgery of Trauma (AAST) has promoted global collaboration and knowledge exchange across the international acute care surgical community. Its efforts have expanded global engagement and diversity in scholarly activities within the AAST. This paper reviews the IRC's history, initiatives, and achievements, highlights current opportunities, and outlines future plans to further advance international dialogue, knowledge sharing, and education in acute care surgery.

Background: The ability of statewide prehospital pediatric blood transfusion protocols to identify patients who receive early in-hospital blood transfusion is unknown. We aimed to characterize these protocols and compare their test characteristics.

Methods: The National Trauma Data Bank was used for this study. Pediatric (1-15 years of age) patients enrolled in the National Trauma Data Bank from 2017 to 2020 and transported by emergency medical services were analyzed. Components of available statewide transfusion protocols were abstracted by a single investigator using a standardized template. Test characteristics and associated 95% confidence intervals were calculated for each protocol using early in-hospital transfusion as the reference standard. We defined early transfusion as blood product administration within 4 hours of hospital arrival. Prehospital heart rate, systolic blood pressure, and Glasgow Coma Scale values were available in the data set. Shock index was calculated as heart rate/systolic blood pressure. Altered mental status (AMS) was defined as a Glasgow Coma Scale score of <15. Head injury was defined as an Abbreviated Injury Scale head score of >1. Intoxication was defined as a blood ethanol level of >80 mg/dL.

Results: Of the 78,430 patients analyzed, 2,125 (2.7%) received early transfusion. Four statewide prehospital transfusion protocols were included (Maryland [age-defined hypotension plus age-defined tachycardia or AMS without head injury or intoxication], West Virginia [at least two: systolic blood pressure < 70+ (2(age)); AMS without head injury; heart rate >130 beats per minute; shock index >1], Delaware [systolic blood pressure <70 mm Hg or elevated age-adjusted pediatric shock index], and Pennsylvania [age-defined hypotension or shock index >1 or AMS without head injury]). Test characteristics varied widely across protocols (Maryland: sensitivity of 8.0% [6.7-9.4%], specificity of 99.7% [99.6-99.7%]; West Virginia: sensitivity of 44.0% [41.1-46.9%], specificity of 86.9% [86.6-87.2%]; Delaware: sensitivity of 53.6% [51.2-55.9%], specificity of 81.2% [80.9-81.5%]; Pennsylvania: sensitivity of 58.7% [56.2-61.1%], specificity of 72.3% [72.0-72.7%]).

Conclusion: Few statewide prehospital pediatric transfusion protocols exist. Existing protocols have variable inclusion criteria with suboptimal and wide-ranging sensitivity and specificity for the outcome of early in-hospital transfusion.

Level of evidence: Prognostic and Epidemiological; Level III.