Trauma Surgery & Acute Care Open最新文献

Background: Firearm-related injury is the leading cause of death among children and adolescents. There is a need to clarify the association of neighborhood environment with gun violence affecting children. We evaluated the relative contribution of specific social determinants to observed rates of firearm-related injury in children of different ages.

Methods: This was a population-based study of firearm injury in children (age <18 years) that occurred in Philadelphia census tracts (2015-2021). The exposure was neighborhood Social Deprivation Index (SDI) quintile. The outcome was the rate of pediatric firearm injury due to interpersonal violence stratified by age, sex, race, and year. Hierarchical negative binomial regression measured the risk-adjusted association between SDI quintile and pediatric firearm injury rate. The relative contribution of specific components of the SDI to neighborhood risk of pediatric firearm injury was estimated. Effect modification and the role of specific social determinants were evaluated in younger (<15 years old) versus older children.

Results: 927 children were injured due to gun violence during the study period. Firearm-injured children were predominantly male (87%), of black race (89%), with a median age of 16 (IQR 15-17). Nearly one-half of all pediatric shootings (47%) occurred in the quintile of highest SDI (Q5). Younger children represented a larger proportion of children shot in neighborhoods within the highest (Q5), compared with the lowest (Q1), SDI quintile (25% vs 5%; p<0.007). After risk adjustment, pediatric firearm-related injury was strongly associated with increasing SDI (Q5 vs Q1; aRR 14; 95% CI 6 to 32). Specific measures of social deprivation (poverty, incomplete schooling, single-parent homes, and rented housing) were associated with significantly greater increases in firearm injury risk for younger, compared with older, children. Component measures of the SDI explained 58% of observed differences between neighborhoods.

Conclusions: Neighborhood measures of social deprivation are strongly associated with firearm-related injury in children. Younger children appear to be disproportionately affected by specific adverse social determinants compared with older children. Root cause evaluation is required to clarify the interaction with other factors such as the availability of firearms and interpersonal conflict that place children at risk in neighborhoods where gun violence is common.

Level of evidence: Level III - Observational Study.

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been an established life-saving procedure for adult trauma patients, but the evidence for its use in pediatric patients is still under question. The purpose of this study was to examine the outcome of REBOA in pediatric patients.

Methods: We retrospectively analyzed observational cohort data from the American College of Surgeons-Trauma Quality Improvement Program from 2017 to 2019. We analyzed 183 506 trauma patients aged 7-18, and 111 patients were matched by propensity score analysis. Basic demographics, injury severity, trauma type, and clinical outcomes of the patients receiving REBOA and those not receiving REBOA were compared. In the REBOA patients, a subgroup analysis was performed to evaluate the potential influence of age and body weight on the outcomes of REBOA.

Results: After the pretreatment factors were balanced for the REBOA and no-REBOA groups, the patients in the REBOA group had more transfused packed red blood cells within the first 4 hours (3250 mL vs. 600 mL, p<0.001), and the mortality rate was higher in the REBOA group, but it did not reach statistical significance (56.8% vs. 36.5%, p=0.067). No significant difference was detected regarding in-hospital complications. In the subgroup analysis of the patients who received REBOA, we discovered no significant difference in mortality and complications between the subgroups when compared by age (>15 years old/≤15 years old) or weight (>58 kg or ≤58 kg).

Conclusions: Pediatric trauma patients who received REBOA were not significantly associated with an increased risk of mortality when compared with no-REBOA patients with matched basic demographics and pretreatment factors. Younger age and lighter body weight did not seem to influence the outcomes of REBOA regarding survival and complications.

Level of evidence: Level III.

Minimally invasive surgical techniques have demonstrated superior outcomes across various elective procedures. Laparoscopic surgery (LS) is established in general surgery with laparoscopic operations for acute appendicitis and cholecystitis being the standard of care. Robotic surgery (RS) has been associated with equivalent or improved postoperative outcomes compared with LS. This increasing uptake of RS in emergency general surgery has encouraged the adoption of robotic acute care programs across the world. The key elements required to build a sustainable RS program are an enthusiastic surgical team, intensive training, resources and marketing. This review is a comprehensive layout elaborating the step-by-step process that has helped our high-volume level I trauma center in establishing a successful robotic acute care surgery program.

Abstract:

Background: Emergency general surgery (EGS) often demands timely interventions, yet data for triage and timing are limited. This study explores the relationship between hospital arrival-to-operation time and mortality in EGS patients.

Study design: We performed a retrospective cohort study using an EGS registry at four hospitals, enrolling adults who underwent operative intervention for a primary American Association for the Surgery of Trauma-defined EGS diagnosis between 2021 and 2023. We excluded patients undergoing surgery more than 72 hours after admission as non-urgent and defined our exposure of interest as the time from the initial vital sign capture to the skin incision timestamp. We assessed the association between operative timing quintiles and in-hospital mortality using a mixed-effect hierarchical multivariable model, adjusting for patient demographics, comorbidities, organ dysfunction, and clustering at the hospital level.

Results: A total of 1199 patients were included. The median time to operating room (OR) was 8.2 hours (IQR 4.9-20.5 hours). Prolonged time to OR increased the relative likelihood of in-hospital mortality. Patients undergoing an operation between 6.7 and 10.7 hours after first vitals had the highest odds of in-hospital mortality compared with operative times <4.2 hours (reference quintile) (adjusted OR (aOR) 68.994; 95% CI 4.608 to 1032.980, p=0.002). A similar trend was observed among patients with operative times between 24.4 and 70.9 hours (aOR 69.682; 95% CI 2.968 to 1636.038, p=0.008).

Conclusion: Our findings suggest that prompt operative intervention is associated with lower in-hospital mortality rates among EGS patients. Further work to identify the most time-sensitive populations is warranted. These results may begin to inform benchmarking for triaging interventions in the EGS population to help reduce mortality rates.

Level of evidence: IV.