Journal of Trauma Nursing最新文献

Background: The low incidence of non-iatrogenic extremity vascular injuries in children, combined with the anatomical and physiological characteristics of children, poses challenges for diagnosis, operative treatment, and recovery. No national guidelines are available to inform the care of children with vascular injuries to the extremities.

Objective: The objective of this concise report is to describe the incidence and contributing mechanisms of injury resulting in pediatric extremity vascular trauma and summarize currently cited approaches for management.

Methods:

Data sources: English-language publications in PubMed and CINAHL that focus on extremity vascular injuries in children aged 0-17 years were reviewed.

Study selection: Publications from 2014 to the present were prioritized; however, as relevant research remains sparse, sentinel papers published before 2014 were also reviewed. Bibliographies from retrieved articles were also scanned. Retrospective studies, case studies, and single institution studies were included in the analysis.

Data extraction: Data were manually extracted from journal publications using established inclusion and exclusion criteria.

Results:

Data synthesis: A panel of pediatric trauma experts reviewed a total of 29 papers, seeking evidence-based methodology and brief summaries of the available literature.

Key themes: These injuries are rare, and the anatomical and physiological characteristics of pediatric vascular injuries mandate a multidisciplinary approach.

Conclusions: To minimize the consequences of extremity vascular injuries, successful treatment requires a high index of suspicion that allows for early diagnosis and prompt management. Clear recommendations regarding diagnosis and treatment are needed.

Background: Venous thromboembolism (VTE) following solid, blunt, isolated abdominal organ injuries remains a common posttrauma complication in adults. Accordingly, gaining a better understanding of the effect of early versus late VTE prophylaxis to reduce rates of this complication is prudent.

Objective: The purpose of this study is to evaluate the impact of early versus late VTE prophylaxis on clinical outcomes in adult trauma patients with isolated blunt solid abdominal organ injuries.

Methods: This retrospective cohort study utilized the American College of Surgeons Trauma Quality Improvement Program Participant Use File database between 2017 and 2021 to compare clinical outcomes between early (≤48 hours) and late (>48 hours) VTE prophylaxis, including deep vein thrombosis (DVT), pulmonary embolism (PE), and other secondary outcomes. This study included adult (age ≥ 16) trauma patients with severe (ISS > 15) and isolated Abbreviated Injury Scale (AIS) abdomen ≥ 3, all other body regions < 3, blunt American Association for the Surgery of Trauma (AAST) grade ≥ 3 solid abdominal organ injuries without traumatic brain injury (TBI) (AIS head < 2) who received early or late chemical VTE prophylaxis.

Results: A total of 3,365 non-TBI patients with isolated blunt solid abdominal organ injuries, with 2,033 patients (60.4%) receiving early VTE prophylaxis and 1,332 (39.6%) receiving late prophylaxis, were included. Early prophylaxis was associated with a 57% lower risk of DVT (OR 0.4, 95% CI [0.19, 0.98], p = .044).

Conclusion: Adult non-TBI trauma patients with isolated, moderate-severe, blunt solid abdominal organ injuries receiving early VTE prophylaxis have significantly lower odds of developing specifically DVT compared to patients receiving late prophylaxis.

Background: Blunt cerebrovascular injury (BCVI) is a rare but serious trauma complication linked to high stroke risk and mortality, often presenting without symptoms and delaying diagnosis. Despite known risk factors, data remain limited on outcomes, especially in patients with concurrent traumatic brain injury (TBI). Additionally, optimal management strategies, particularly for high-grade injuries, remain unclear.

Objective: The purpose of this study is to evaluate the incidence of BCVI, the associated risk factors, and outcomes for patients with BCVI with or without TBI to improve overall prognosis and outcomes in this patient population.

Methods: This retrospective cohort analysis utilized the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) database (2017-2021). The study population included adult (age ≥ 16 years) blunt trauma patients with Injury Severity Score (ISS) of ≥ 9 and severe isolated (Abbreviated Injury Scale [AIS] head and neck ≥ 3, all other regions < 3) BCVI. Patients were then stratified based on the presence or absence of concomitant mild-moderate TBI (AIS head ≤ 2). Clinical outcomes were compared between BCVI and non-BCVI patients, including incidence of ischemic stroke, mortality rate, intensive care unit length of stay, ventilator-free days, and BCVI risk factors such as cervical spine fracture, mandibular fracture, basilar skull fracture, and presenting Glasgow Coma Scale (GCS) ≤ 8.

Results: Of 2,172 patients with isolated BCVI, 1,262 (58.1%) had carotid artery injuries and 910 (41.9%) had vertebral artery injuries. Among non-TBI patients, BCVI was significantly associated with cervical spine fractures (OR: 11.60, p < .001), mandibular fractures (OR: 2.87, p < .001), GCS ≤ 8 (OR: 1.65, p = .001), and ischemic stroke (OR: 19.32, p < .001). Among TBI patients, BCVI was significantly associated with cervical spine fractures (OR: 6.79, p < .001), mandibular fractures (OR: 2.10, p < .001), and ischemic stroke (OR: 40.67, p < .001).

Conclusions: Patients with BCVI had significantly higher odds of presenting with cervical spine and mandibular fractures in addition to ischemic stroke compared to those without BCVI. Understanding the risk factors for BCVI can help guide further investigations and support prompt diagnosis, optimizing care, and improving patient outcomes.

Background: The Glasgow Coma Scale has been a standard tool for assessing consciousness in trauma patients for five decades, but its utility is limited by the omission of brainstem reflexes such as pupillary response.

Objective: This study aimed to compare the prognostic accuracy of the Pediatric Glasgow Coma Scale (pGCS) and the Pediatric Glasgow Coma Scale - Pupils Score (pGCS-P) in predicting mortality and functional outcomes among pediatric patients with traumatic brain injury (TBI).

Methods: This single-center observational cohort study was conducted from May 2022 to May 2023 at Bursa Training and Research Hospital, Health Sciences University, Turkey. Pediatric patients (age <18 years) presenting with TBI were evaluated for level of consciousness and pupillary responses on admission. Both the pGCS and pGCS-P scores were calculated for each patient. For patients with anisocoria but preserved light reflexes in both pupils, scoring adjustments were made.

Results: Of the 134 patients studied, 59.7% were male, and the mean (SD) age was 6.3 (5.4) years. In-hospital mortality was 12.7%, and 5.1% had unfavorable functional outcomes (UFOs) at discharge. Both the pGCS-P and pGCS demonstrated excellent ability to predict mortality (AUC, 0.97, 95% CI: 0.94-0.99 and 0.97, 95% CI: 0.94-0.96, respectively). There was no statistically significant difference in prognostic performance between the two scores using either binomial (p = .165) or nonparametric (p = .445) analyses (p >.05).

Conclusions: In pediatric patients with TBI, the prognostic accuracy of the pGCS with pupil response (pGCS-P) was comparable to that of the pGCS alone for predicting mortality and UFOs. Incorporation of the pupil score did not significantly improve prognostic discrimination in this cohort.

Background: Geriatric trauma patients frequently require massive transfusion, yet clear guidelines on transfusion futility thresholds (TFTs) remain underdeveloped, particularly in patients with thoracoabdominal injuries and concomitant traumatic brain injury (TBI).

Objective: To investigate TFT in geriatric trauma patients with moderate-to-severe chest and/or abdominal injuries with or without TBI.

Methods: This retrospective cohort analysis of the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) database from 2017 to 2021 investigated geriatric trauma patients (age ≥65) with moderate-severe abdominal (abbreviated injury score [AIS] abdomen ≥ 2) and/or chest (AIS chest ≥ 2) injuries with or without concomitant TBI. Outcomes included mortality, transfusion threshold, ventilation-free days, complications, and intensive care unit length of stay (ICU-LOS).

Results: There were 1,072 non-TBI and 289 TBI patients included in this analysis. The TFT was 12 units of packed red blood cells (pRBCs) among non-TBI patients and 6 units of pRBCs among TBI patients within 4 hr of arrival. Patients exceeding the TFT in both groups had significantly higher odds of 48-hr mortality (OR: 3.949, 95% CI: [2.270, 6.870], p < .001; OR: 6.426, 95% CI: [1.772, 23.311], p = .005). Non-TBI patients exceeding the TFT had higher odds of developing acute kidney injury (AKI) (OR: 2.606, 95% CI: [1.136, 5.980], p = .024), severe sepsis (OR: 6.146, 95% CI: [1.485, 25.445], p = .012), and a significantly longer ICU-LOS (B: 3.445, 95% CI: [0.903, 5.987], p = .008).

Conclusion: Among geriatric trauma patients with abdominal and/or chest injuries with or without concomitant moderate-severe TBI, those exceeding the TFT had significantly higher odds of 48-hr mortality. Additionally, non-TBI patients exceeding the TFT had higher odds of severe sepsis and AKI. This study offers strong evidence for the establishment of massive transfusion guidelines specific to the geriatric population, particularly with or without TBI.

Background: There is mixed evidence on the optimal timing of veno-venous extracorporeal membrane oxygenation (VV-ECMO) following significant trauma.

Objective: This study aims to assess the timing of VV-ECMO initiation and its effect on clinical outcomes in adult patients with moderate-severe blunt thoracic trauma.

Methods: This retrospective cohort study utilized the American College of Surgeons Trauma Quality Improvement Program Participant Use File (ACS-TQIP-PUF) database between 2015 and 2023 to evaluate the clinical effects of VV-ECMO in adult patients (≥18 years) with blunt, moderate-severe thoracic and thoraco-abdominal trauma. Outcomes of interest included in-hospital mortality, intensive care unit length of stay (ICU-LOS), complications such as deep vein thrombosis, pulmonary embolism, acute kidney injury, and discharge disposition.

Results: There were 412 adult patients with moderate-severe blunt thoracic and thoraco-abdominal trauma who received VV-ECMO, of which 256 (61.8%) were initiated within ≤7 days and 105 (25.4%) after 7 days. Patients with VV-ECMO initiation within ≤7 days had no difference in mortality rates (adjusted odds ratio [aOR] .655, p = .246) but had five fewer ICU-LOS days (β: -5.364, p = .002). Additionally, patients receiving early VV-ECMO were less likely to be discharged home (aOR: .192, p = .017) than all other discharge dispositions. No differences were observed in transfusion needs or complication rates.

Conclusion: Initiation of VV-ECMO within ≤7 days was associated with significantly shorter ICU-LOS and comparable odds of mortality, without significant differences in complications or adverse events, including transfusion requirements and venous thromboembolism. Trauma and critical care societies should consider these findings when revisiting existing ECMO protocols concerning the early initiation of VV-ECMO to improve outcomes in this population.

Background: Resuscitative thoracotomy, performed in only 10%-15% of pediatric thoracic trauma cases, yields a dismally low survival rate of 3.4%. As such, an investigation into the mechanisms of such high mortality associated with this emergent procedure is warranted.

Objective: This study aims to evaluate the clinical outcomes of initially hemodynamically stable pediatric patients requiring an emergency department thoracotomy (EDT) at pediatric trauma centers (PTC), combined adult/PTCs (CTC), and adult-only trauma centers (ATC).

Methods: The American College of Surgeons-Trauma Quality Improvement Program database (2017-2021) was utilized in this retrospective cohort analysis to evaluate outcomes among initially hemodynamically stable pediatric (age <18) patients with moderate-severe Abbreviated Injury Score (AIS chest >2) blunt or penetrating thoracic trauma undergoing an EDT. The primary outcome of interest was mortality (defined as emergency department, 24-hour, and in-hospital mortality) evaluated by trauma center type.

Results: A total of 314 patients were identified, with 219 patients (69.7%) treated at ATCs, 77 patients (24.5%) treated at CTCs, and 18 patients (5.7%) treated at PTCs. There was no significant association between 24-hour mortality and treatment at a CTC when compared to treatment at an ATC for patients with penetrating (odds ratio [OR] 0.02, 95% confidence interval [CI] [0.00, 1444.90], p = .501) or blunt (OR 0.26, 95% CI [0.01, 7.98], p = .440) injuries.

Discussion: Among initially hemodynamically stable pediatric trauma patients with moderate-severe blunt or penetrating thoracic injuries undergoing EDT, patients treated at a CTC, when compared to an ATC, showed comparable mortality.

Background: Pediatric massive transfusion protocol activation is rare, even in high-volume trauma centers. Maintaining competency in these low-frequency, high-risk events is challenging and often impedes balanced resuscitation.

Objective: This project aims to evaluate the effectiveness of a pediatric massive transfusion protocol dose book in improving packed red blood cell to plasma ratios during massive transfusion events.

Methods: This pre-post quality improvement study was conducted over 5 years (June 2019-March 2024) at an urban Midwestern U.S. pediatric Level I trauma center. Inclusion criteria were trauma patients under 18 years who received ≥40 mL/kg of blood products within the first 24 hours. The intervention was a novel weight-based dose book designed to guide balanced resuscitation. The primary outcome was adherence to a 1:1 packed red blood cell to plasma ratio.

Results: Among 29 massive transfusion activations, the average packed red blood cell-to-plasma ratio improved from 3.38:1 (preimplementation) (n = 14) to 1.37:1 (postimplementation) (n = 15).

Conclusion: Implementing a pediatric massive transfusion protocol dose book improved adherence to balanced blood product administration during massive transfusion events.

Injury is the leading cause of death and a frequent cause of disability in children and negatively affects physical health, mental health, and quality of life in both the short- and long-term. The goal of a pediatric trauma system is to optimize the care for children within a state or region encompassing the entire continuum of care, regardless of where children live or where traumatic events occur. This continuum includes injury prevention, prehospital care, emergency department care, interfacility transport, acute and critical inpatient care, inpatient and outpatient rehabilitation, and reintegration into the community and primary care medical home. A systems-based approach requires distinct elements of structure and function to perform together in an interrelated and cohesive manner to improve care quality. In this case, it represents a sequential practice of evidence-based evaluation and management along the continuum of care. To improve outcomes after injury, a cohesive system must effectively provide optimal care for the "right child, at the right place, at the right time" across this continuum.