Trauma Surgery & Acute Care Open最新文献

Background: Unlike in Western countries, trauma center consolidation has not progressed in Japan. This raises the question of who are the appropriate providers for the decreased number of trauma surgeries. Emergency surgeons performing trauma surgeries lack sufficient cases for skill refinement, while on the other hand, surgeons performing elective surgeries face the dilemma of not being able to handle trauma across organs due to subspecialization. In this context, our institution has deliberately not pursued subspecialization and has been addressing various trauma surgery cases by regularly handling a wide range of general surgery fields.

Objective and methods: We examined the types, sites, target organs, and procedures of trauma surgeries performed under general anesthesia at our institution from April 2012 to December 2023. Additionally, we investigated the content and annual trends of non-trauma surgeries performed during the same period to assess the appropriateness of general surgeons handling trauma surgeries and to consider future sustainability.

Results: Trauma surgeries averaged around six cases per year, accounting for approximately 1% of the total surgeries performed. Most surgeries were related to abdominal organs, which could mostly be managed with techniques from the field of gastrointestinal surgery. Although there were fewer cases, it seemed possible to handle surgeries for neck, chest, and vascular trauma through routine clinical practice such as thyroid surgery, lung and mediastinal tumor surgeries, and peripheral vascular surgeries. Issues identified include a decrease in non-gastrointestinal cases as subspecialization progresses, and an increasing proportion of laparoscopic surgeries leading to a rise in inexperienced young surgeons in open surgery.

Conclusion: Handling trauma surgeries with fewer cases seemed possible by broadly addressing the scope of general surgery in routine clinical practice.

Background: Trauma audit filters, based on standards of care, serve as quality indicators and screening tools for patient cases to be assessed at interdisciplinary morbidity and mortality conferences. These conferences aim to identify potential opportunities for improvement in the care of trauma patients. This study aimed to determine the performance of individual audit filters in predicting opportunities for improvement and their relevance as screening tools for morbidity and mortality conferences.

Methods: We conducted a single-center registry-based retrospective cohort study based on registered data collected between 2013 and 2022 from the Karolinska University Hospital in Sweden. Performance was measured using sensitivity, specificity, positive predictive value, negative predictive value, and Matthews correlation coefficient for 10 audit filters used at the Karolinska University Hospital.

Results: Our analysis included 8309 patients. Audit filters demonstrated inconsistent agreement with opportunities for improvement with a Matthews correlation coefficient ranging from -0.088 (95% CI -0.129 to -0.044) for "Injury Severity Score >15 and no team activation" to 0.092 (95% CI 0.058 to 0.126) for "> 60 min until first major intervention." The Matthews correlation coefficient for all audit filters combined was 0.118 (95% CI 0.104 to 0.131).

Conclusion: No individual audit filter or combination thereof performed well in predicting opportunities for improvement, which suggests that the current method of screening for morbidity and mortality conferences should be revisited.

Level of evidence: Level III, prognostic/epidemiological.

Background: The concurrent use of antithrombotic agents and intoxicants in older trauma patients (≥65) poses a potential risk for adverse outcomes. As the prevalence of substance use among older adults rises, understanding the impact of these combined factors on trauma outcomes is crucial. This study evaluates the impact of combined intoxication and antithrombotic use on trauma outcomes in older adults.

Methods: We conducted a secondary analysis of data from an Eastern Association for the Surgery of Trauma-sponsored multicenter prospective observational study involving 15 Level I and II trauma centers from February 2018 to June 2019. Included patients were on antithrombotic therapy and had blood alcohol concentration (BAC) and/or urine toxicology (UT) samples collected at trauma evaluation. Intoxication was defined as BAC >0.08 mg/dL or a positive UT. Patient demographics, injury characteristics, and outcomes were analyzed using linear and logistic regression models.

Results: Of 2793 trauma patients on antithrombotics, 862 met inclusion criteria, with 155 (18.0%) testing positive for intoxicants. Positive tests were associated with younger age (74 years vs 79 years, p<0.001), lower Charlson Comorbidity Index (4 vs 5, p<0.001), and similar Injury Severity Scores (6 vs 9, p=0.38). Patients with positive tests had more penetrating mechanisms of injury (11.0% vs 3.7%, p=0.01) and similar hospital stays (3 days vs 4 days, p=0.311). ICU admission rates were lower (32.9% vs 42.2%, p=0.041), with no difference in ICU length of stay or mortality. Higher ICU admissions (p=0.039) and increased ICU stays were seen in those on two substances (OR: 5.26, 95% CI 0.76 to 9.76, p=0.022).

Conclusions: Older trauma patients on antithrombotic therapy with concurrent intoxicant use did not exhibit worse clinical outcomes, despite higher rates of penetrating injuries and polysubstance use. These findings underscore the importance of tailored discharge planning and comprehensive care strategies for this vulnerable population.

Level of evidence: Level III, prognostic/epidemiological.

Gun violence is a health crisis that disparately affects non-Hispanic black males, where victims get stuck in a cycle of recurrent violence perpetuated by systemic inequities. Hospital-based violence intervention programs (HVIPs) decrease violent reinjury by addressing social drivers/determinants of health. Many HVIPs solely focus on inpatient interventions. We designed a novel three-pronged continuum of care model: the Bedside, Clinic, Community (BCC) model as a longitudinal approach for equitable service delivery. Our HVIP, Interrupting Violence in Youth and Young Adults (IVYY), serves victims of community violence. The first pillar provides 'Bedside' care for inpatients; the second uses a multidisciplinary 'Clinic' to address medical and social concerns; and the third 'Community' pillar consists of partnerships with local grassroots organizations. Throughout the intervention, IVYY provides pathways for education, mental health, housing, employment, financial, and legal aid. In the first year of service, IVYY enrolled 299 patients who received 1168 inpatient visits. 26.1% were considered high risk and were seen in the IVYY clinic. Community partners provided innumerable resources to IVYY participants. By implementing the BCC model, we provide longitudinal care that addresses patient needs at every stage of their journey.

Introduction: The impact of anticoagulation (AC) on traumatic brain injury (TBI) outcomes remains varied in the literature. Previous studies often relied on single-center data, small sample sizes, or lacked adjustments for key confounding variables. This study used the population-based Trauma Quality Improvement Program (TQIP) database to analyze the effect of AC on isolated TBI mortality, hypothesizing that AC's impact varies with TBI severity.

Methods: This retrospective cohort study analyzed data from 2020 to 2021 TQIP database. Patients with isolated TBI were identified using International Classification of Diseases, 10th revision codes. Exclusions included patients <18 years, penetrating trauma, and non-head injuries with Abbreviated Injury Scale (AIS) score >3. The majority of patients taking AC were in their 50s and above; therefore, they were stratified into AC and non-AC cohorts. Propensity score analysis adjusted for age, gender, and head AIS, stratified by TBI severity (mild, moderate, severe). Primary outcomes were in-hospital mortality and neurosurgical intervention (NSI), including craniotomy and intracranial pressure monitoring. Statistical analyses were performed using Stata V.17.0, with significance at p<0.05.

Results: Among 118,775 patients with isolated TBI, 96,802 were >50 years, with 26,444 (27%) taking AC. Unadjusted mortality was higher in the AC group (6%) compared with the non-AC group (3%; ∆3%, p<0.001). Adjusted mortality differences showed significant AC effects in mild (∆1.3%, 95% CI 1.04% to 1.57%, p<0.001) and moderate TBI (∆7.9%, 95% CI 4.46% to 11.43%, p<0.001), but not severe TBI (∆3.14%, 95% CI 0.07% to 7.04%, p=0.11). No significant AC effect on NSI was observed after adjustment.

Discussion: Preinjury AC increases mortality in patients with isolated TBI, with the magnitude of its impact varying by TBI severity. Future studies should explore AC's influence on intracranial blood volume and progression to further elucidate its role in TBI outcomes.

Level of evidence: Level 3.

Background: Surgical stabilization of ribs (SSRF) has been associated with shorter durations of mechanical ventilation and hospital and intensive care unit lengths of stay (LOS). Vizient is a national organization that provides detailed quality data, including the LOS index, benchmarked to comparable-sized and acuity health systems.

Aims: Identify factors associated with shorter and expected LOS index among patients undergoing SSRF.

Method: We performed a retrospective review of all adult trauma patients who underwent SSRF from November 2021 to May 2023 at our American College of Surgeons Level 1 trauma center. Logistic regression on key patient characteristics was performed to assess associations with LOS index <1.

Results: 37 (69%) patients had an LOS index <1, whereas 17 (32%) had an expected LOS index >1. Patients with a LOS index <1 had lower injury severity scores (ISS) (16.9 SD=11.2 vs 21.7 SD=10.5, p=0.029) and were more commonly working full-time preinjury (n=16, 43%) compared with patients with a LOS index >1 (n=8, 47%, p=0.042). LOS index >1 was also associated with higher body mass index (BMI), government insurance, and polytrauma.

Conclusion: Focused, early interventions in patients with higher BMI, polytrauma, and higher ISS scores may help lower the LOS index among patients undergoing SSRF.

Background: Older adults have the highest incidence of traumatic brain injury and are often on antiplatelet therapy. This study examines the association between preinjury antiplatelet agent use and intracranial hemorrhage in geriatric emergency department (ED) patients with blunt head injury from a fall.

Methods: We conducted a secondary analysis of the GREAT STOP project, a large prospective study of geriatric ED patients who sustained head trauma. This project enrolled patients from two level one trauma centers over 1 year beginning 1 August 2019. Trained research associates enrolled patients who met study criteria. The primary outcome was intracranial hemorrhage. Rates of intracranial hemorrhage were compared between patients who were prescribed preinjury antiplatelet agents versus those who were not on any antiplatelet or anticoagulant therapy.

Results: 3709 patients were included in the final analysis. Overall, 12.8% (475) had intracranial hemorrhage, and 6.4% (237) had a significant intracranial hemorrhage. Delayed intracranial hemorrhage occurred in 0.3% (10) of patients with one of these classified as a significant intracranial hemorrhage (1). Patients on aspirin or dual antiplatelet therapy had increased adjusted ORs of intracranial hemorrhage compared with patients not on antiplatelet therapy (1.4, 95% CI 1.1 to 1.8; and 1.7, 95% CI 1.1 to 2.6, respectively). Use of P2Y12 inhibitors alone did not show this effect (1.0, 95% CI 0.6 to 1.6).

Conclusions: In geriatric ED patients who have sustained blunt head trauma from a fall, aspirin and especially dual antiplatelet therapy are associated with a significant risk of intracranial hemorrhage, while P2Y12 antiplatelet agents do not appear to carry this risk. The benefits from the use of these agents in older patients need to be weighed against their risk for fall and potential fall-related injury such as intracranial hemorrhage.