Trauma Surgery & Acute Care Open最新文献

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.

Many patients experience financial hardship after acute injuries or emergency surgery. Financial hardship, often referred to as "financial toxicity," comprises material hardship due to unexpected bills and income loss, psychosocial stress due to uncertainty of one's financial future, and negative coping behaviors such as forgoing necessary care due to costs. These factors combine to have detrimental effects on physical and mental health and prevent optimal recovery after injury or illness. Although there is a growing appreciation that acute care surgeons should understand and evaluate financial hardship in their own populations to facilitate the optimal recovery of their patients, consensus is lacking on the best ways to measure financial hardship among the trauma and emergency surgery patient population. This current opinion will define the scope of the problem and provide pragmatic first steps to enable the evaluation of long-term, patient-level financial outcomes at your institution-including specific questions that encompass the five domains and the five mediators of financial hardship. This effort presents an updated theoretical framework, challenges common terminology, and synthesizes the most relevant tools for measuring financial hardship, presenting recommended screening questions that can be immediately used to assess long-term financial outcomes in trauma and emergency surgery populations, and standardizing data collection across institutions and facilitating larger-scale investigations.

Background: The applicability of existing trauma activation criteria (TAC) and the need for geriatric-specific TAC for this vulnerable population has been debated. The goal of this study was to determine whether existing TAC are equally effective at identifying the need for high-intensity time-sensitive (HITS) interventions in older versus younger adults and their relationship to outcomes.

Methods: This multicenter, retrospective, cohort study collected data (2017-2019) securely from participating centers as National Trauma Data Bank files with trauma activation (TA) status: full (fTA), partial (pTA), none (nTA). HITS were derived from Trauma Quality Improvement Program process of care measures as critical interventions requiring trauma expertise including emergent airway management/ventilation, hemorrhage control surgery, blood transfusion, intracranial pressure monitoring, chest tube placement, and angiography. Older adults (≥65 years) were compared with younger adults (<65 years) on demographics, injury characteristics, and HITS status by TAC status using χ² tests.

Results: Twenty-five level I and 11 level II US TCs enrolled 216 960 patients (87.9% blunt, 18.7% fTA, median age: 54 years, median Injury Severity Score: 9, in-hospital mortality 3.3%). Overall, 10.3% of patients received a HITS intervention. Older adults were less likely to receive HITS compared with younger adults (fTA: 35.4% vs 39.3%, p<0.001; pTA: 5.1% vs 6.1%, p<0.001), but this difference was not significant in the adjusted analysis for fTA (adjusted OR: 0.97, 95% CI 0.92 to 1.02, p=0.25). Compared with non-HITS, HITS were associated with increased total mortality (in-hospital mortality+hospice) in both fTA (25.6% vs 4.3%, p<0.001) and pTA (15.2% vs 2.0%, p<0.001). Rates of undertriage were high in both younger and older adults (25% and 47%, respectively).

Conclusions: Meeting current TAC for highest level activation identifies patients needing HITS equally for younger and older adults, but high undertriage and overtriage remain problematic in both groups. This research highlights opportunities to address significant deficiencies in the accuracy and/or application of TAC for both younger and older adults.

Level of evidence: Level III, therapeutic/care management.