Trauma Surgery & Acute Care Open最新文献

Background: This study aimed to assess the medical costs, and the combined costs of fatal firearm injury and fatal falls during a 5 year period. While fatal firearm injury represents a significant public health concern, the healthcare community is faced with the significant challenge of fatal falls, particularly in light of the elderly population growth.

Methods: Data were exported from the Web-based Injury Statistics Query and Reporting System database for fatal firearm and falls in patients aged between 15-85 years-old. The primary outcome was medical cost and the secondary outcome was combined costs (combination of medical costs and value of statistical life).

Results: The medical cost of fatal falls was significantly higher in 2015-2020 in all age groups. The combined cost was significantly higher in fatal firearm injury overall. We found the combined cost was higher in fatal falls after 2019 for patients in the 45-85+ age range. During 2015-2019, the percentage of fatal falls had a significant increase in all age ranges, with a rise in the slope in 2019 for patients over 65 years. The annual percent change (APC) for the proportion of fatal falls increased from 2015 to 2020, there was a significant increase in the slope after 2019 (2.81% APC before 2019 vs 6.95% after 2019).

Conclusion: Geriatric fatal falls have significantly higher medical costs compared with fatal firearm injury. The combined cost for fatal falls exceeded fatal firearm injury after 2019 which highlights the increasing socioeconomic burden of an aging population.

Level of evidence: Level III retrospective study.

Background: Mixed venous saturation (SvO2) is considered the gold standard to assess the adequacy of tissue oxygen delivery (DO2) in shock states. However, SvO2 monitoring is challenging as it requires an invasive catheter and frequent blood sampling. Non-invasive methods, including near-infrared spectroscopy, have demonstrated low sensitivity to tissue dysoxia.

Methods: We fabricated a new device that uses resonance Raman spectroscopy (RRS) to quantify oxyhemoglobin saturation (ShbO2) in the esophagus (eShbO2), tongue (tShbO2), and liver (hShbO2). In two rat models of hemorrhagic shock, we quantified (1) The correlation of RRS-measured ShbO2 to SvO2 during progressive hemorrhage (n=20) and (2) The value of these metrics to predict near-term mortality in fixed, severe hemorrhage (mean blood pressure =25 mm Hg; n=18).

Results: In model 1, eShbO2 (r=0.705, p<0.0001) and tShbO2 (r=0.724, p<0.0001) correlated well with SvO2 and with serum lactic acid (eShbO2-lactate r=0.708, p<0.0001; tShbO2-lactate r=0.830, p<0.0001). hShbO2 correlated poorly with both SvO2 and lactic acid. Using time-matched ShbO2-SvO2 pairs, the performance of ShbO2 to detect severe tissue hypoxia (SvO2<20%) was excellent (AUC 0.843 for eShbO2, 0.879 for tShbO2). In model 2, eShbO2 showed a maximized threshold of 40% with 83% of animals dying within 45 minutes of this cut-off, demonstrating accuracy as a monitoring device. This was similar for tShbO2, with a threshold of 50%, predicting death within 45 minutes in 76% of animals. ShbO2 showed superior sensitivity to invasive monitoring parameters, including MABP<30 mm Hg (sensitivity 59%), pulse pressure<15 mm Hg (sensitivity 50%), and heart rate>220 bpm (sensitivity 39%, p=0.004).

Conclusions: eShbO2 represents a new paradigm to assess the adequacy of DO2 to a tissue. It constitutes a promising monitoring method to evaluate tissue oxygen saturation in real time and non-invasively, correlating with SvO2 and time to death.

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

This study assesses the feasibility and acceptability of a Firearm Safe Storage Device Distribution Program. The distribution took place at the Break the Cycle of Violence Summit hosted by the Johns Hopkins Medicine, the Break the Cycle Hospital Violence Intervention Program, and the Johns Hopkins Bloomberg School of Public Health Center for Gun Violence Solutions. The findings will guide future efforts to distribute safe storage devices in clinical settings. Attendees of the Break the Cycle of Violence Summit could choose from three types of safe storage devices to provide to their patients within their practice. Those attendees who participated were asked to participate in an electronic survey to assess the feasibility and acceptability of the safe firearm storage device distribution at the Summit. 24 participants received safe storage devices at the Break the Cycle of Violence Summit. Of the 24 participants, 15 participated in our evaluation. 86% of participants distributed most of the devices by the time of the survey and 57% of participants stated that by having safe storage devices to distribute, they were more likely to provide safe gun storage counseling. All participants would like to see continued safe gun storage distribution programs in their community. The provision of free safe storage devices allowed for open conversations about firearms and safe storage with patients and clients. This study can be used as a model to guide future efforts in safe storage device distribution in a hospital or clinic-based setting and showed feasibility, effectiveness, and efficacy.

Background: Acute pain due to rib fractures causes significant in-hospital morbidity and impacts patients' quality of life after discharge. Intraoperative transthoracic cryoneurolysis of the intercostal nerves can improve postoperative pain; however, non-surgical patients are provided limited analgesia options. Here, we describe our experience with a bedside cryoanalgesia technique for management of acute rib fracture pain.

Methods: Five patients at a single level I trauma center completed bedside intercostal nerve cryoneurolysis (INC) using a handheld cryotherapy device and ultrasound guidance. Relative pain ratings (scale 0-10/10) and maximal incentive spirometry (IS_max) volumes were taken prior to the procedure as a baseline. Patients were observed for 24 hours after procedure, with relative pain ratings and IS_max recorded at 1, 8, 16, and 24 hours after procedure.

Results: Our patients were 29-88 years old and had one to five single-sided rib fractures. At baseline, they had high pre-procedure pain ratings (7-10/10) and IS_max volumes of 800-2000 mL. Many had improvements in their pain rating but little change in their IS_max at 1 hour (1-5/10 and 1000-2000 mL, respectively) and 8 hours (1-5/10 and 1250-2400 mL, respectively). IS_max volumes improved by 16 hours (1500-2400 mL) with comparable pain ratings (0-5/10). At 24 hours, pain ratings and IS_max ranged from 0 to 8/10 and from 1500 mL to 2400 mL, respectively. Each patient had improved pain control and IS_max volumes compared with their pre-procedure values. All patients reported the procedure as an asset to their recovery at discharge.

Conclusions: Our study demonstrates patients with rib fractures may experience improved pain ratings and IS_max values after INC. Percutaneous INC appears to be a viable adjunct to multimodal pain control for patients with rib fractures and should be considered in patients with difficult pain control. Further studies are required to fully assess INC safety, efficacy, post-discharge outcomes, and utility in patients with altered mental status or on mechanical ventilation.

Level of evidence: Level V, case series.

Background: Postgraduate education for advanced practice providers (APPs) is a rapidly evolving field and includes residencies and fellowships designed to help narrow the gap between physicians and APPs. The current state of trauma APP postgraduate programs in the U.S. is unknown. The aim of this study is to identify the APP postgraduate programs in the U.S. dedicated to trauma training and to understand the baseline characteristics of these programs and their curriculums, including which technical skills and bedside procedures a trauma APP should be expected to perform.

Methods: This is a cross-sectional study of all identifiable APP postgraduate programs in trauma surgery in the U.S. through June 2022. A survey tool designed to better understand training programs and curriculums was created. A web-based survey using Qualtrics was sent to the program directors of the identifiable trauma programs. Descriptive statistics were calculated as appropriate.

Results: Eight programs were identified as primarily trauma training programs. Six programs completed the entire survey, and one program completed 50% of the survey. Programs vary in the number of graduates, clinical rotations, and educational curriculums, though all programs offer didactics and simulation curriculums for procedure skill development. Most programs are not accredited.

Conclusion: This is the first study developed to understand the content and curriculums of postgraduate trauma programs for APPs. There are only a handful of programs dedicated to trauma training, and their educational offerings are diverse, with similarities across programs in expected procedural competency. There is a need for trauma programs to invest in and further standardize APP training.

Level of evidence: IV.

Advanced practice providers (APPs) have become essential to trauma teams in the United States during the last few decades. The optimal utilization of APPs is not yet known and is likely highly variable secondary to many factors. We discuss three aspects of the multidisciplinary approach to caring for trauma patients. First, a review of the literature demonstrates that APPs in trauma improve quality of care, patient throughput, and decrease cost. We then report on models of APP utilization by comparing five trauma centers across the country, concluding that utilization remains highly variable due to several system and provider factors. The final portion of this review highlights current billing and coding practices in integrated teams considering recent changes to Centers for Medicare and Medicaid rules in 2024.

Background: Rectal trauma carries significant morbidity, particularly if there is a delay in diagnosis. Digital rectal examination has a relatively low sensitivity. Proctoscopy and sigmoidoscopy are available but can be limited in situations with increased fecal burden or uncooperative patients. We suggest more sensitive bedside techniques are necessary to diagnose low rectal injury, and here present a case report to demonstrate proof of concept using hydrogen peroxide to directly visualize an injury.

Methods: Digital rectal examination was performed in a patient after multiple gunshot wounds and was negative for gross blood. Suspicion for low rectal injury remained high, and hydrogen peroxide was used to evaluate bullet trajectory. Approximately 25 mL of 3% hydrogen peroxide was instilled into the bullet tract.

Results: Hydrogen peroxide evaluation of the bullet tract was performed in less than 1 min with minimal supplies and preparation. It revealed an extraperitoneal injury where the rectal examination had been falsely negative.

Conclusion: Hydrogen peroxide may be used to evaluate a suspected penetrating injury of the rectum. Considering the potential of this modality to diagnose injuries in a timely and reliable manner, additional investigation may be warranted.