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Journal of Trauma and Acute Care Surgery, The
Journal Prestige (SJR): 1.747  Citation Impact (citeScore): 3 Number of Followers: 39  Hybrid journal (It can contain Open Access articles)ISSN (Print) 2163-0755 - ISSN (Online) 2163-0763 Published by LWW Wolters Kluwer  [330 journals]
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- Prognostic factors associated with venous thromboembolism following
traumatic injury: A systematic review and meta-analysis-
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Authors: Tran; Alexandre; Fernando, Shannon M.; Rochwerg, Bram; Hameed, Morad S.; Dawe, Phillip; Hawes, Harvey; Haut, Elliott; Inaba, Kenji; Engels, Paul T.; Zarychanski, Ryan; Siegal, Deborah M.; Carrier, Marc
Abstract:
INTRODUCTION Trauma patients are at increased risk of venous thromboembolism (VTE), including deep venous thrombosis and/or pulmonary embolism. We conducted a systematic review and meta-analysis summarizing the association between prognostic factors and the occurrence of VTE following traumatic injury.METHODS We searched the Embase and Medline databases from inception to August 2023. We identified studies reporting confounding adjusted associations between patient, injury, or postinjury care factors and risk of VTE. We performed meta-analyses of odds ratios using the random-effects method and assessed individual study risk of bias using the Quality in Prognosis Studies tool.RESULTS We included 31 studies involving 1,981,946 patients. Studies were predominantly observational cohorts from North America. Factors with moderate or higher certainty of association with increased risk of VTE include older age, obesity, male sex, higher Injury Severity Score, pelvic injury, lower extremity injury, spinal injury, delayed VTE prophylaxis, need for surgery, and tranexamic acid use. After accounting for other important contributing prognostic variables, a delay in the delivery of appropriate pharmacologic prophylaxis for as little as 24 to 48 hours independently confers a clinically meaningful twofold increase in incidence of VTE.CONCLUSION These findings highlight the contribution of patient predisposition, the importance of injury pattern, and the impact of potentially modifiable postinjury care on risk of VTE after traumatic injury. These factors should be incorporated into a risk stratification framework to individualize VTE risk assessment and support clinical and academic efforts to reduce thromboembolic events among trauma patients.LEVEL OF EVIDENCE Systematic Review and Meta-Analysis; Level III.
PubDate: Sun, 01 Sep 2024 00:00:00 GMT-
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- Identifying factors predicting outcomes after major trauma in older
patients: Prognostic systematic review and meta-analysis-
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Authors: Iddagoda; Mayura Thilanka; Trevenen, Michelle; Meaton, Claire; Etherton-Beer, Christopher; Flicker, Leon
Abstract:
INTRODUCTION Trauma is the most common cause of morbidity and mortality in older people, and it is important to determine the predictors of outcomes after major trauma in older people.METHODS MEDLINE, Embase, and Web of Science were searched, and manual search of relevant papers since 1987 to February 2023 was performed. Random-effects meta-analyses were performed. The primary outcome of interest was mortality, and secondary outcomes were medical complications, length of stay, discharge destination, readmission, and intensive care requirement.RESULTS Among 6,064 studies in the search strategy, 136 studies qualified the inclusion criteria. Forty-three factors, ranging from demographics to patient factors, admission measurements, and injury factors, were identified as potential predictors. Mortality was the commonest outcome investigated, and increasing age was associated with increased risk of in-hospital mortality (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.03–1.07) along with male sex (OR, 1.40; 95% CI, 1.24–1.59). Comorbidities of heart disease (OR, 2.59; 95% CI, 1.41–4.77), renal disease (OR, 2.52; 95% CI, 1.79–3.56), respiratory disease (OR, 1.40; 95% CI, 1.09–1.81), diabetes (OR, 1.35; 95% CI, 1.03–1.77), and neurological disease (OR, 1.42; 95% CI, 0.93–2.18) were also associated with increased in-hospital mortality risk. Each point increase in the Glasgow Coma Scale lowered the risk of in-hospital mortality (OR, 0.85; 95% CI, 0.76–0.95), while each point increase in Injury Severity Score increased the risk of in-hospital mortality (OR, 1.07; 95% CI, 1.04–1.09). There were limited studies and substantial variability in secondary outcome predictors; however, medical comorbidities, frailty, and premorbid living condition appeared predictive for those outcomes.CONCLUSION This review was able to identify potential predictors for older trauma patients. The identification of these factors allows for future development of risk stratification tools for clinicians.LEVEL OF EVIDENCE Systematic Review and Meta-Analysis; Level III.
PubDate: Sun, 01 Sep 2024 00:00:00 GMT-
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- Resiliency and immunological biomarkers: Important factors in health care
professionals-
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Authors: Hosseini; Maryam; Dokouhaki, Maryam; Karajizadeh, Mehrdad; Fazeli, Pooria; Paydar, Shahram
Abstract: No abstract available
PubDate: Sun, 01 Sep 2024 00:00:00 GMT-
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- FEATURED ARTICLES FOR CME CREDIT SEPTEMBER 2024
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Abstract: No abstract available
PubDate: Sun, 01 Sep 2024 00:00:00 GMT-
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- MEETINGS/COURSES
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Abstract: No abstract available
PubDate: Sun, 01 Sep 2024 00:00:00 GMT-
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- Type-specific whole blood still has a role in the era of low-titer O
universal donor transfusion for severe trauma hemorrhage-
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Authors: Milford; Elissa M.; Gurney, Jennifer M.; Beckett, Andrew; Strandenes, Geir; Reade, Michael C.
Abstract: Whole blood can be ABO-type specific (type-specific whole blood (TSWB)) or low-titer O universal donor (low-titer O whole blood (LTOWB)). Having previously used LTOWB, the US Armed Forces Blood Program began using TSWB in 1965 as a method of increasing the donor pool. In contrast to military practice, the Association for the Advancement of Blood and Biotherapies formerly the American association of blood banks (AABB), from its first guidelines in 1958 until 2018, permitted only TSWB. Attempting to reduce time to transfusion, the US military reintroduced LTOWB in the deployed environment in 2015; this practice was endorsed by the AABB in 2018 and is progressively being implemented by military and civilian providers worldwide. Low-titer O whole blood is the only practical solution prehospital. However, there are several reasons to retain the option of TSWB in hospitals with a laboratory. These include (1) as-yet ill-defined risks of immunological complications from ABO-incompatible plasma (even when this has low titers of anti-A and -B), (2) risks of high volumes of LTOWB including published historical advice (based on clinical experience) not to transfuse type-specific blood for 2 to 3 weeks following a substantial LTOWB transfusion, (3) uncertainty as to the optimal definition of “low titer,” and (4) expanding the potential donor pool by allowing type-specific transfusion. Several large randomized controlled trials currently underway are comparing LTOWB with component therapy, but none address the question of LTOWB versus TSWB. There are sufficient data to suggest that the additional risks of transfusing LTOWB to non–group O recipients should be avoided by using TSWB as soon as possible. Combined with the advantage of maintaining an adequate supply of blood products in times of high demand, this suggests that retaining TSWB within the civilian and military blood supply system is desirable. TSWB should be preferred when patient blood group is confirmed in facilities with a hematology laboratory, with LTOWB reserved for patients whose blood group is unknown.
PubDate: Mon, 20 May 2024 00:00:00 GMT-
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- The contrast-enhanced FAST exam in pediatric and adult thoracoabdominal
trauma-
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Authors: Kummer; Tobias; Shiue, Larissa T.; Fiterman Molinari, Daniel; Haefke, Brandon; Klinkner, Denise B.
Abstract:
No abstract available
PubDate: Mon, 20 May 2024 00:00:00 GMT-
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- Resuscitation for injured patients requiring massive transfusion: A
personal perspective-
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Authors: Lucas; Charles E.
Abstract: The past century has seen many advances in the field of resuscitation. This is particularly true in the subset of patients who sustain major injuries causing hemorrhagic shock (HS) and require massive transfusion of more than 10 U of blood within the first 24 hours. Controversies on how best to resuscitate these patients include the role of fresh whole blood, stored whole blood, fresh frozen plasma, platelets, colloid solutions, balanced electrolytes solution, vasopressors, and diuretics. This review summarizes the often-contradictory recommendations observed and studied by a single trauma surgeon working in a busy urban acute care center for 65 years.LEVEL OF EVIDENCE Level I.
PubDate: Thu, 09 May 2024 00:00:00 GMT-
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- The difficult cholecystectomy: What you need to know
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Authors: Seshadri; Anupamaa; Peitzman, Andrew B.
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This review discusses the grading of cholecystitis, the optimal timing of cholecystectomy, adopting a culture of safe cholecystectomy, understanding the common error traps that can lead to intraoperative complications, and how to avoid them.1–28 The Tokyo Guidelines, American Association for the Surgery of Trauma, Nassar, and Parkland scoring systems are discussed. The patient factors, physiologic status, and operative findings that predict a difficult cholecystectomy or conversion from laparoscopic to open cholecystectomy are reviewed. With laparoscopic expertise and patient conditions that are not prohibitive, early laparoscopic cholecystectomy is recommended. This is ideally within 72 hours of admission but supported up to the seventh hospital day. The majority of bile duct injuries are due to misidentification of normal anatomy. Strasberg's four error traps and the zones of danger to avoid during a cholecystectomy are described. The review emphasizes the importance of a true critical view of safety for identification of the anatomy. In up to 15% of operations for acute cholecystitis, a critical view of safety cannot be achieved safely. Recognizing these conditions and changing your operative strategy are mandatory to avoid harm. The principles to follow for a safe cholecystectomy are discussed in detail. The cardinal message of this review is, “under challenging conditions, bile duct injuries can be minimized via either a subtotal cholecystectomy or top-down cholecystectomy if dissection in the hepatocystic triangle is avoided”.21 The most severe biliary/vascular injuries usually occur after conversion from laparoscopic cholecystectomy. Indications and techniques for bailout procedures including the fenestrating and reconstituting subtotal cholecystectomy are presented. Seven percent to 10% of cholecystectomies for acute cholecystitis currently result in subtotal cholecystectomy. Level of evidence: III
PubDate: Wed, 10 Apr 2024 00:00:00 GMT-
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- Contemporary management of patients with multiple rib fractures: What you
need to know-
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Authors: Sarani; Babak; Pieracci, Fredric
Abstract:
Ten percent of all injured patients and 55% of patients with blunt chest trauma experience rib fractures. The incidence of death due to rib fractures is related to the number of fractured ribs, severity of fractured ribs, and patient age and comorbid conditions. Death due to rib fracture is mostly caused by pneumonia because of inability to expectorate and take deep breaths. Over the last 25 to 30 years, there has been renewed interest in surgical stabilization of rib fractures (SSRF), known colloquially as “rib plating.” This review will present what you need to know in regard to triage decisions on whether to admit a patient to the hospital, the location to which they should be admitted, criteria and evidentiary support for SSRF, timing to SSRF, and operative technique. The review also addresses the cost-effectiveness of this operation and stresses nonoperative treatment modalities that should be implemented prior to operation.
PubDate: Fri, 29 Mar 2024 00:00:00 GMT-
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- Whole blood resuscitation for injured patients requiring transfusion: A
systematic review, meta-analysis, and practice management guideline from
the Eastern Association for the Surgery of Trauma-
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Authors: Meizoso; Jonathan P.; Cotton, Bryan A.; Lawless, Ryan A.; Kodadek, Lisa M.; Lynde, Jennifer M.; Russell, Nicole; Gaspich, John; Maung, Adrian; Anderson, Christofer; Reynolds, John M.; Haines, Krista L.; Kasotakis, George; Freeman, Jennifer J.
Abstract:
INTRODUCTION Whole blood (WB) resuscitation has reemerged as a resuscitation strategy for injured patients. However, the effect of WB-based resuscitation on outcomes has not been established. The primary objective of this guideline was to develop evidence-based recommendations on whether WB should be considered in civilian trauma patients receiving blood transfusions.METHODS An Eastern Association for the Surgery of Trauma working group performed a systematic review and meta-analysis using the Grading of Recommendations Assessment, Development and Evaluation methodology. One Population, Intervention, Comparison, and Outcomes question was developed to analyze the effect of WB resuscitation in the acute phase on mortality, transfusion requirements, infectious complications, and intensive care unit length of stay. English language studies including adult civilian trauma patients comparing in-hospital WB to component therapy were included. Medline, Embase, Cochrane CENTRAL, CINAHL Plus, and Web of Science were queried. GRADEpro (McMaster University; Evidence Prime, Inc.; Ontario) was used to assess quality of evidence and risk of bias. The study was registered on International Prospective Register of Systematic Reviews (CRD42023451143).RESULTS A total of 21 studies were included. Most patients were severely injured and required blood transfusion, massive transfusion protocol activation, and/or a hemorrhage control procedure in the early phase of resuscitation. Mortality was assessed separately at the following intervals: early (i.e., emergency department, 3 hours, or 6 hours), 24 hours, late (i.e., 28 days or 30 days), and in-hospital. On meta-analysis, WB was not associated with decreased mortality. Whole blood was associated with decreased 4-hour red blood cell (mean difference, −1.82; 95% confidence interval [CI], −3.12 to −0.52), 4-hour plasma (mean difference, −1.47; 95% CI, −2.94 to 0), and 24-hour red blood cell transfusions (mean difference, −1.22; 95% CI, −2.24 to −0.19) compared with component therapy. There were no differences in infectious complications or intensive care unit length of stay between groups.CONCLUSION We conditionally recommend WB resuscitation in adult civilian trauma patients receiving blood transfusions, recognizing that data are limited for certain populations, including women of childbearing age, and therefore this guideline may not apply to these populations.LEVEL OF EVIDENCE Systematic Review/Meta-Analysis; Level III.
PubDate: Wed, 27 Mar 2024 00:00:00 GMT-
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- The sensitivity of limited-sequence magnetic resonance imaging in
identifying pediatric cervical spine injury: A Western Pediatric Surgery
Research Consortium multicenter retrospective cohort study-
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Authors: Melhado; Caroline; Durand, Rachelle; Russell, Katie W.; Polukoff, Natalya E.; Rampton, John; Iyer, Rajiv R.; Acker, Shannon N.; Koehler, Richele; Prendergast, Connor; Stence, Nicholas; O'Neill, Brent; Padilla, Benjamin E.; Jamshidi, Ramin; Vaughn, Jennifer A.; Ronecker, Jennifer S.; Selesner, Leigh; Lofberg, Katrine; Regner, Michael; Thiessen, Jaclyn; Sayama, Christine; Spurrier, Ryan G.; Ross, Erin E.; Liu, Chia-Shang Jason; Chu, Jason; McNevin, Kathryn; Beni, Catherine; Robinson, Bryce R.H.; Linnau, Ken; Buckley, Robert T.; Chao, Stephanie D.; Sabapaty, Akanksha; Tong, Elizabeth; Prolo, Laura M.; Ignacio, Romeo; Sachs, Gretchen Floan; Kruk, Peter; Gonda, David; Ryan, Mark; Pandya, Samir; Koral, Korgun; Braga, Bruno P.; Auguste, Kurtis; Jensen, Aaron R.; on behalf of the Western Pediatric Surgery Research Consortium Cervical Spine Injury Study Group
Abstract:
INTRODUCTION Clinical clearance of a child's cervical spine after trauma is often challenging because of impaired mental status or an unreliable neurologic examination. Magnetic resonance imaging (MRI) is the criterion standard for excluding ligamentous injury in children but is constrained by long image acquisition times and frequent need for anesthesia. Limited-sequence magnetic resonance imaging (LSMRI) is used in evaluating the evolution of traumatic brain injury and may also be useful for cervical spine clearance while potentially avoiding the need for anesthesia. The purpose of this study was to assess the sensitivity and negative predictive value of LSMRI as compared with criterion standard full-sequence MRI as a screening tool to rule out clinically significant ligamentous cervical spine injury.METHODS We conducted a 10-center, 5-year retrospective cohort study (2017–2021) of all children (0–18 years) with a cervical spine MRI after blunt trauma. Magnetic resonance imaging images were rereviewed by a study pediatric radiologist at each site to determine if the presence of an injury could be identified on limited sequences alone. Unstable cervical spine injury was determined by study neurosurgeon review at each site.RESULTS We identified 2,663 children younger than 18 years who underwent an MRI of the cervical spine with 1,008 injuries detected on full-sequence studies. The sensitivity and negative predictive value of LSMRI were both>99% for detecting any injury and 100% for detecting any unstable injury. Young children (younger than 5 years) were more likely to be electively intubated or sedated for cervical spine MRI.CONCLUSION Limited-sequence magnetic resonance imaging is reliably detects clinically significant ligamentous injury in children after blunt trauma. To decrease anesthesia use and minimize MRI time, trauma centers should develop LSMRI screening protocols for children without a reliable neurologic examination.LEVEL OF EVIDENCE Diagnostic Test/Criteria; Level III.
PubDate: Mon, 25 Mar 2024 00:00:00 GMT-
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- Prevalence and outcomes of high versus low ratio plasma to red blood cell
resuscitation in a multi-institutional cohort of severely injured children
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Authors: Mehl; Steven C.; Vogel, Adam M.; Glasgow, Amy E.; Moody, Suzanne; Kotagal, Meera; Williams, Regan F.; Kayton, Mark L.; Alberto, Emily C.; Burd, Randall S.; Schroeppel, Thomas J.; Baerg, Joanne E.; Munoz, Amanda; Rothstein, William B.; Boomer, Laura A.; Campion, Eric M.; Robinson, Caitlin; Nygaard, Rachel M.; Richardson, Chad J.; Garcia, Denise I.; Streck, Christian J.; Gaffley, Michaela; Petty, John K.; Greenwell, Cynthia; Pandya, Samir; Waters, Alicia M.; Russell, Robert T.; Yorkgitis, Brian K.; Mull, Jennifer; Pence, Jeffrey; Santore, Matthew T.; MacArthur, Taleen A.; Klinkner, Denise B.; Safford, Shawn D.; Trevilian, Tanya; Cunningham, Megan; Black, Christa; Rea, Jessica; Spurrier, Ryan G.; Jensen, Aaron R.; Farr, Bethany J.; Mooney, David P.; Ketha, Bavana; Dassinger, Melvin S. III; Goldenberg-Sandau, Anna; Roman, Janika San; Jenkins, Todd M.; Falcone, Richard A. Jr; Polites, Stephanie
Abstract:
BACKGROUND The benefit of targeting high ratio fresh frozen plasma (FFP)/red blood cell (RBC) transfusion in pediatric trauma resuscitation is unclear as existing studies are limited to patients who retrospectively met criteria for massive transfusion. The purpose of this study is to evaluate the use of high ratio FFP/RBC transfusion and the association with outcomes in children presenting in shock.METHODS A post hoc analysis of a 24-institution prospective observational study (April 2018 to September 2019) of injured children younger than 18 years with elevated age-adjusted shock index was performed. Patients transfused within 24 hours were stratified into cohorts of low ( 0.05).CONCLUSION Despite increased injury severity, patients who received a high ratio of FFP/RBC had comparable rates of mortality. These data suggest high ratio FFP/RBC resuscitation is not associated with worst outcomes in children who present in shock. Massive transfusion protocol activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers.LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
PubDate: Mon, 18 Mar 2024 00:00:00 GMT-
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- Identifying community safety and policy-based injury prevention
opportunities to reduce golf cart injuries-
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Authors: DeJesus; Jana; Chavez, Carlos; Zou, Jazzalyn; Brahmbhatt, Kush; O'Daniel, Elizabeth; Schaeffer, August; Shah, Nikhil R.; Nguyen, Hoang; Matson, Julie; Radhakrishnan, Ravi; Naik-Mathuria, Bindi
Abstract:
BACKGROUND In small US communities, golf cart utilization has become increasingly more common. In the past 3 years, the incidence and severity of pediatric golf cart–related trauma evaluated at our trauma center have noticeably increased. Thus, the aim of this study was to analyze trends, identify risk and protective factors, and provide community-level recommendations to improve golf cart safety for children in a coastal community.METHODS A retrospective cross-sectional study of our institutional trauma registry was performed. The registry was queried for golf cart injuries between 2012 and 2022. Demographics, accident details, hospital course, and outcomes were reviewed. Data analysis involved quantitative statistics. Incident locations were mapped, including additional data from the County emergency medical service. In addition, customer education at four prominent golf rental shops was observed.RESULTS Annual golf cart–related traumas doubled starting in 2020. Of 235 total patients, 105 (46%) were children. Median age was 11.5 years (range, 2–17 years). Fifty-five percent were female, and 67% were non-Hispanic White. Eighty percent were out-of-county residents. The most common injury location was extremity (56%). The median Injury Severity Score was 4, and 3% died. Only 10% of children were restrained. Forty-one percent were ejected, and most (84%) were front-facing passengers. Ejection was associated with more severe injury (odds ratio, 4.13; p = 0.01). Most injuries occurred during 5 to 10 pm (47%), weekends, and summertime. Nighttime injuries were more severe than daytime (p = 0.04). A hotspot of crashes was identified in a zone where golf carts were restricted. Rental stores provided education on seat belt use, car seat use for infants, and off-limit zones. However, rules were not enforced.CONCLUSION Our results inform the following golf cart injury prevention opportunities: raising awareness of injury risks to children in high-tourist areas, partnering with rental stores to enforce rules, improving signage, adding protected lanes, and adopting a no nighttime operation policy.LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
PubDate: Fri, 08 Mar 2024 00:00:00 GMT-
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- Recovery after moderate to severe TBI and factors influencing functional
outcome: What you need to know-
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Authors: Golden; Katherine; Borsi, Lydia; Sterling, Ally; Giacino, Joseph T.
Abstract:
Traumatic brain injury (TBI) represents a major cause of death and disability, significantly impacting the lives of 2.5 million people annually in the United States. Long-term natural history studies have clarified that functional recovery continues for up to a decade, even among those who sustain severe TBI. Despite these findings, nihilistic attitudes regarding prognosis persist among clinicians, highlighting the need for improved understanding of the natural history of recovery from TBI and the factors that influence outcome. Recent advances in neuroimaging technologies and blood-based biomarkers are shedding new light on injury detection, severity classification and the physiologic mechanisms underlying recovery and decline postinjury. Rehabilitation is an essential component of clinical management after moderate to severe TBI and can favorably influence mortality and functional outcome. However, systemic barriers, including healthcare policy, insurance coverage and social determinants of health often limit access to inpatient rehabilitation services. Posttraumatic amnesia and confusion contribute to morbidity after TBI; however, early initiation and sustained provision of rehabilitation interventions optimize long-term outcome. Evidence-based reviews have clearly shown that cognitive rehabilitation strategies can effectively restore or compensate for the cognitive sequelae of TBI when used according to existing practice guidelines. Neurostimulant agents are commonly employed off-label to enhance functional recovery, however, only amantadine hydrochloride has convincingly demonstrated effectiveness when used under tested parameters. Noninvasive brain stimulation procedures, including transcranial direct current stimulation and transcranial magnetic stimulation, have emerged as promising treatments in view of their ability to modulate aberrant neuronal activity and augment adaptive neuroplasticity, but assessment of safety and effectiveness during the acute period has been limited. Understanding the natural history of recovery from TBI and the effectiveness of available therapeutic interventions is essential to ensuring appropriate clinical management of this complex population.
PubDate: Tue, 05 Mar 2024 00:00:00 GMT-
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- Contemporary management and outcomes of blunt traumatic American
Association for the Surgery of Trauma Organ Injury Scale grades III and IV
pancreatic injuries in children: A Trauma Quality Improvement Program
analysis-
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Authors: Rauh; Jessica L.; Neff, Lucas P.; Forssten, Maximilian Peter; Ribeiro, Marcelo A. F. Jr.; Sarani, Babak; Mohseni, Shahin
Abstract:
BACKGROUND The Trauma Quality Improvement Program (TQIP) database has delineated management strategies and outcomes for adults with American Association for the Surgery of Trauma Organ Injury Scale grades III and IV pancreatic injuries and suggests that nonoperative management (NOM) is a viable option for these injuries. However, management strategies vary for children following significant pancreatic injuries and outcomes for these intermediate/high-grade injuries have not been sufficiently studied. Our aim was to describe the management and outcomes for grades III and IV pancreatic injuries using TQIP. We hypothesize that pediatric patients with intermediate/high-grade injuries can be safely managed with NOM.METHODS All pediatric patients (younger than 18 years) registered in TQIP between 2013 and 2021 who suffered a grade III or IV pancreatic injury due to blunt trauma were included in the current study. Patient demographics, clinical characteristics, complications, and in-hospital mortality were compared between the different treatment strategies for pancreatic injury: NOM versus drainage and/or pancreatic resection.RESULTS A total of 580 patients meeting the inclusion criteria were identified. A total of 416 pediatric patients suffered a grade III pancreatic injury; 79% (n = 332) were NOM, 7% (n = 27) received a drain, and 14% (n = 57) underwent a pancreatic resection. A further 164 patients suffered a grade IV pancreatic injury; 77% (n = 126) were NOM, 11% (n = 18) received a drain, and 12% (n = 20) underwent a pancreatic resection. No differences in overall injury severity or demographical data were observed between the treatment groups. No difference in in-hospital mortality was detected between the different management strategies. Patients who received a drain had a longer hospital length of stay.CONCLUSION The majority of children with American Association for the Surgery of Trauma Organ Injury Scale grades III and IV pancreatic injuries are managed nonoperatively. Nonoperative management is a reasonable strategy for these injuries and results in equivalent in-hospital adverse outcome profiles as pancreatic drainage or resection with a shorter hospital length of stay.LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
PubDate: Mon, 29 Jan 2024 00:00:00 GMT-
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- Socioeconomic disparities based on shooting intent in pediatric firearm
injury-
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Authors: Cain; Cary M.; Oluyomi, Abiodun O.; Levine, Ned; Pompeii, Lisa; Rosales, Omar; Naik-Mathuria, Bindi
Abstract:
BACKGROUND Pediatric firearm injury is often associated with socioeconomically disadvantaged neighborhoods. Most studies only include fatal injuries and do not differentiate by shooting intent. We hypothesized that differences in neighborhood socioeconomic disadvantage would be observed among shooting intents of fatal and nonfatal cases.METHODS A linked integrated database of pediatric fatal and nonfatal firearm injuries was developed from trauma center and medical examiner records in Harris County, Texas (2018–2020). Geospatial analysis was utilized to map victim residence locations, stratified by shooting intent. Area Deprivation Index (ADI), a composite measure of neighborhood socioeconomic disadvantage at the census tract level was linked to shooting intent. Differences in high ADI (more deprived) versus low ADI among the shooting intents were assessed. Unadjusted and adjusted regression models assessed differences in ADI scores across shooting intent, adjusted models controlled for age, gender, and race/ethnicity.RESULTS Of 324 pediatric firearm injuries, 28% were fatal; 77% were classified as interpersonal violence, 15% unintentional, and 8% self-harm. Differences were noted among shooting intent across the ADI quartiles; with increases in ADI score, the odds of interpersonal violence injuries compared with self-harm injuries significantly increased by 5%; however, when adjusting for individual-level variables of age, gender, and race and ethnicity, no significant differences in ADI were noted.CONCLUSION Our results suggest that children living in disadvantaged neighborhoods are more likely to be affected by interpersonal firearm violence compared with self-harm; however, when differences in race/ethnicity are considered, the differences attributable to neighborhood-level disadvantage disappeared. Resources should be dedicated to improving structural aspects of neighborhood disadvantage, which disproportionately impact racial/ethnic minoritized populations. Furthermore, firearm self-harm injuries occurred among children living in the less disadvantaged neighborhoods. Understanding the associations among individual and neighborhood-level factors are important for developing streamlined injury prevention interventions by shooting intent.LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
PubDate: Mon, 29 Jan 2024 00:00:00 GMT-
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- A protocol-driven approach to reduce lengths of stay for pediatric blunt
liver and spleen injury patients-
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Authors: Wang; Chen Chia; Gupta, Ashwin; Stone, Michelle; Milovancev, Monica; Townsend, Kelsie; Zhao, Shilin; Greeno, Amber
Abstract:
BACKGROUND Our institution updated blunt liver and spleen injury (BLSI) protocols in 2019 in adherence to updated American Pediatric Surgery Association recommendations. This retrospective study compares resource utilization for pediatric BLSI patients treated under old and updated guidelines.METHODS Blunt liver and spleen injury patients without severe non-abdomen injuries younger than 18 years treated with prior (April 2015 to June 2019) and updated (June 2019 to December 2022) guidelines were retrospectively reviewed and compared. Each patient received an adjusted Injury Severity Score (ISS) to control for non-BLSI injuries. Multivariate analysis examined protocol group differences while controlling for adjusted ISS and BLSI grades. Primary outcomes were intensive care unit (ICU) length of stay (LOS), hospital LOS (analyzed using Cox regression), and patient costs (linear regression). Secondary outcomes include readmission in 2 weeks and death rates (logistic regression).RESULTS A total of 176 and 170 BLSI patients were treated with old and updated protocols, respectively. Patient demographics, average BLSI grade, and adjusted ISS were similar in both groups. Patients treated with old protocols indicate decreased hazard, showing significantly more days before ICU discharge (coefficient, −0.3868; p < 0.0009) and hospital discharge (coefficient, −0.5507; p < 0.0001). Patient costs (coefficient, 0.0921; p = 0.1874) trend toward being lower in the new protocol. Readmission rates were significantly higher in the new protocol (coefficient, −1.1731; p = 0.0465), and death rates (coefficient, 0.0519; p = 0.9710) were comparable.CONCLUSIONS Blunt liver and spleen injury patients treated under new American Pediatric Surgery Association guidelines compared with old guidelines had significant decreases in ICU and hospital LOS, a decreasing trend in costs, and comparable death rates but higher readmission rates. Future studies with larger sample sizes and detailed cost analysis would explore whether updated guidelines reduce patient costs and help elucidate the veracity or potential cause of the increased readmission rates.LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
PubDate: Fri, 26 Jan 2024 00:00:00 GMT-
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- Use of a statewide solid organ injury procotcol to optimize triage,
treatment, and transfer for pediatric abdominal trauma-
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Authors: Swendiman; Robert A.; Russell, Katie W.; Larsen, Kezlyn; Eyre, Matthew; Fenton, Stephen J.
Abstract:
BACKGROUND The Utah Pediatric Trauma Network (UPTN) is a non-competitive collaboration of all 51 hospitals in the state of Utah with the purpose of improving pediatric trauma care. Created in 2019, UPTN has implemented evidence-based guidelines based on hospital resources and capabilities with quarterly review of data collected in a network-specific database. A blunt solid organ injury (SOI) protocol was developed to optimize treatment of these injuries statewide. The purpose of this study was to review the effectiveness of the SOI guideline.METHODS The UPTN REDCap® database was retrospectively reviewed from 2021 through 2022. We compared admissions from the Level 1 pediatric trauma center (PED1) to non-pediatric hospitals (non-PED1) of children with low-grade (I-II) and high-grade (III-V) SOIs.RESULTS In 2 years, 172 patients were treated for blunt SOI, with or without concomitant injuries. There were 48 (28%) low-grade and 124 (72%) high-grade SOIs. 33 (69%) patients were triaged with low-grade SOI injuries at a non-PED1 center, and 17 (35%) were transferred to the PED1 hospital. Most had multiple injuries, but 7 (44%) were isolated, and none required a transfusion or any procedure/operation at either hospital. Of the 124 patients with high-grade injuries, 41 (33%) primarily presented to the PED1 center, and 44 (35%) were transferred there. Of these, 2 required a splenectomy and none required angiography. Thirty-nine children were treated at non-PED1 centers without transfer, and 4 required splenectomy and 6 underwent angiography/embolization procedures. No patient with an isolated SOI died.CONCLUSION Implementation of SOI guidelines across UPTN successfully allowed non-pediatric hospitals to safely admit children with low-grade isolated SOI, keeping families closer to home, while standardizing pediatric triage for blunt abdominal trauma in the state.LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
PubDate: Fri, 26 Jan 2024 00:00:00 GMT-
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- Reverse shock index multiplied by the motor component of the Glasgow Coma
Scale predicts mortality and need for intervention in pediatric trauma
patients-
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Authors: Smida; Tanner; Bonasso, Patrick; Bardes, James; Price, Bradley S.; Seifarth, Federico; Gurien, Lori; Maxson, Robert; Letton, Robert
Abstract:
BACKGROUND Timely identification of high-risk pediatric trauma patients and appropriate resource mobilization may lead to improved outcomes. We hypothesized that reverse shock index times the motor component of the Glasgow Coma Scale (GCS) (rSIM) would perform equivalently to reverse shock index times the total GCS (rSIG) in the prediction of mortality and the need for intervention following pediatric trauma.METHODS The 2017–2020 National Trauma Data Bank data sets were used. We included all patients 16 years or younger who had a documented prehospital and trauma bay systolic blood pressure, heart rate, and total GCS. We excluded all patients who arrived at the trauma center without vital signs and interfacility transport patients. Receiver operating characteristic curves were used to model the performance of each metric as a classifier with respect to our primary and secondary outcomes, and the area under the receiver operating characteristic curve (AUROC) was used for comparison. Our primary outcome was mortality before hospital discharge. Secondary outcomes included blood product administration or hemorrhage control intervention (surgery or angiography)
PubDate: Fri, 26 Jan 2024 00:00:00 GMT-
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- Pediatric thoracic cage fractures—Mind the sternum: A retrospective
analysis of the ACS-TQIP database-
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Authors: di Natale; Anthony; Mak, Allison L.; Hwang, Rosa; Allukian, Myron III; Nace, Gary W. Jr; Nance, Michael L.
Abstract:
BACKGROUND The thoracic cage is an anatomical entity formed by the thoracic spine, ribs, and sternum. As part of this osteoligamentous complex, the sternum contributes substantially to the stability of the thoracic spine. This study investigates the influence of a concomitant sternal fracture (SF) on the treatment and hospital course of pediatric patients with a thoracic vertebral fracture (TVF).METHODS The Trauma Quality Improvement Program data sets from 2016 to 2020 were reviewed. Patients aged 0 year to 19 years with TVF with or without SF following blunt trauma were identified using the Abbreviated Injury Scale codes and selected for further data collection. Patients with transverse or spinous process fractures or incomplete data were excluded. Data collected included demographics, mechanisms of injury, clinical variables, procedures, intensive care unit admission and length of stay, total length of stay and in-hospital mortality. Continuous variables were analyzed with Wilcoxon rank sum test, categorical variables with χ2 test.RESULTS A total of 13,434 patients were identified, of which 10,292 had isolated TVF (TVF), 788 TVF and concomitant SF (TVF + SF), 2,225 isolated SF (excluded), and 126 incomplete data (excluded). Motor vehicle collisions were the most common mechanism of injury in both groups (TVF, 75%; TVF + SF, 88%), followed by falls (TVF: 23%, TVF + SF: 12%). Spinal cord injuries were more common among TVF + SF patients (6.4% vs. 4%). Median injury severity score (17 vs. 12), age (17 vs. 15 years), LOS (5 vs. 3 days), and mortality (5.6% vs. 2.3%) were significantly higher and the need for operative treatment (69% vs. 56%) and ICU admission (53% vs. 36%) significantly more frequent in patients with TVF + SF.CONCLUSION Concomitant SF occur in 7% of all pediatric patients with TVF and are associated with increased morbidity and mortality. This combination of injuries is likely the result of greater energy transmission and injury potential.LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
PubDate: Fri, 26 Jan 2024 00:00:00 GMT-
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- Establishing pediatric age-adjusted shock index cut points in trauma
patients younger than 1 year-
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Authors: Marlor; Derek; Flint, Jennifer; Noel-MacDonnell, Janelle R.; Cruz-Centeno, Nelimar; Stewart, Shai; Elman, Meredith; Juang, David
Abstract:
PURPOSE Shock Index is used to predict injury severity and adverse outcomes in trauma patients, but pediatric age-adjusted shock index (SIPA) has superior performance in pediatric patients older than 1 year. Pediatric age-adjusted shock index scores younger than 1 year have not been well studied. This project aimed to establish and evaluate SIPA cut point data points for patients younger than 1 year.METHODS Using age-based vital signs, we developed cut point values for patients younger than 1 year using our institutional trauma data. All trauma patients younger than 12 months were included, and clinical outcomes were recorded. Pediatric age-adjusted shock index cut points were defined using age-specific vital sign limits (SIPA-VS) and tested against optimal cut points defined by receiver operating characteristic analysis (SIPA-ROC) and a cut point of 1.2 (SIPA-Nordin), which is used for patients aged 1 to 4 years. Student's t test, χ2 tests, analysis of variance, and test characteristics were used to analyze groups.RESULTS A total of 609 pediatric trauma patients younger than 12 months were identified from 2018 to 2022. Pediatric age-adjusted shock index scores were calculated for 483 patients. There were 406 patients with blunt trauma and 17 with penetrating. SIPA-Nordin was elevated in 81.6% (n = 397) of patients, compared with SIPA-VS 21% (n = 101) and SIPA-ROC 31% (n = 150). In comparison with SIPA-Nordin, both SIPA-VS and SIPA-ROC score exhibited superior specificity and negative predictive values for multiple outcomes. Elevated SIPA-ROC scores had statistically significant associations with intensive care unit admission, mechanical ventilation, severe anemia, transfusion during hospital admission, and in-hospital mortality.CONCLUSION Pediatric age-adjusted shock index is a useful tool in identifying patients at risk for several complications of severe traumatic injury. Pediatric age-adjusted shock index cut points had high negative predictive value and specificity for many outcomes. This study proposes cut point values that may aid in clinical decision making for trauma patients younger than 1 year.LEVEL OF EVIDENCE Diagnostic Test/Criteria; Level IV.
PubDate: Tue, 16 Jan 2024 00:00:00 GMT-
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- Trends and variation in cervical spine imaging utilization across
children's hospitals for pediatric trauma-
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Authors: Ross; Erin E.; Ourshalimian, Shadassa; Spurrier, Ryan G.; Chaudhari, Pradip P.
Abstract:
BACKGROUND Cervical spine (c-spine) evaluation is a critical component in trauma evaluation, and although several pediatric c-spine evaluation algorithms have been developed, none have been widely implemented. Here, we assess rates of c-spine imaging use across children's hospitals, specifically temporal trends in imaging use, variation across hospitals in imaging used, and timing of magnetic resonance imaging in admitted patients.METHODS Data from the Children's Hospital Associations Pediatric Health Information System were abstracted from 2015 to 2020. Patients younger than 18 years seen in the emergency department with an International Classification of Diseases, Tenth Revision, code indicative of trauma and c-spine plain radiograph or computed tomography (CT) in the emergency department were included. Data visualization and descriptive statistics were used to assess rates of imaging use by age, year, hospital, injury severity, and day of service. Changes in rates of imaging use over time were evaluated via simple linear regression.RESULTS Across 25,238 patient encounters at 35 children's hospitals, there was an increase in use of c-spine CT from 2015 to 2020 (28.5–36.5%). There was substantial interinstitutional variation in rates of use of plain radiographs versus CT for initial evaluation of the c-spine across all age groups. Magnetic resonance imaging was obtained more than 3 days after admission in 31.5% of intensive care patients who received this imaging.CONCLUSION Increasing use of CT, substantial interinstitutional variation in rates of use of plain radiographs versus CT, and heterogenous timing of magnetic resonance imaging for evaluation of the pediatric c-spine demonstrate the growing need for development and implementation of an age-specific c-spine evaluation algorithm to guide judicious use of diagnostic resources.LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
PubDate: Wed, 10 Jan 2024 00:00:00 GMT-
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- Does destination make a difference' Outcomes after a policy change
affecting cutoff times for prehospital transport-
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Authors: Renaud; Elizabeth; Cummings, Olivia; Vanover, Melissa; Tanzer, Joshua Ray; McCarthy, Andrew
Abstract:
BACKGROUND Facilitating primary triage and care at pediatric trauma centers (PTCs) can improve outcomes for children after trauma. However, scene location and regional emergency medical services regulations may result in initial evaluation occurring at nonpediatric facilities with later transportation to PTCs for definitive care. In this study, we assessed the results of a change in transport time cutoff from 30 to 45 minutes on pediatric patient outcomes.METHODS After institutional review board approval, the Pediatric Trauma Database at a level 1 PTC was queried for patients seen before (January 1, 2015, to December 31, 2017) and after (January 1, 2018, to December 31, 2020) the implementation of a policy increasing transport cutoff time from 30 to 45 minutes. Patient outcomes were compared by transport status and Injury Severity Score (ISS) using generalized linear regression analysis.RESULTS A total of 505 patients were seen before policy changes, and 413 patients, after policy changes. Both groups had similar numbers of severely injured patients (ISS, ≥15; pre, 64 [13%]; post, 61 [15%]). Average transport time increased after change (pre, 20 minutes [95% confidence interval, 18–22 minutes]; post, 29 minutes [95% confidence interval, 26–33 minutes]; p = 0.0252), consistent with policy compliance. The proportion of transferred patients did not change after policy implementation (p = 0.5856), and the complications among all patients with an ISS of ≥15 did not significantly decrease (pre, 75%; post, 65.6%). However, those patients with an ISS of ≥15 admitted directly from the scene had a lower frequency of complications after the policy changes (pre, 76%; post, 59%; p = 0.0319), and in the postperiod, transferred patients with an ISS of ≥15 had a higher complication rate than those admitted directly from the scene (p < 0.0001).CONCLUSION Direct scene admission to a PTC is associated with a lower complication profile for patients with higher ISS. Methods to ensure adherence to cutoff thresholds for emergency medical services transport may have a positive benefit on patient outcomes.LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
PubDate: Wed, 10 Jan 2024 00:00:00 GMT-
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- Ccr2-dependent monocytes exacerbate intestinal inflammation and modulate
gut serotonergic signaling following traumatic brain injury-
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Authors: El Baassiri; Mahmoud G.; Raouf, Zachariah; Jang, Hee-Seong; Scheese, Daniel; Duess, Johannes W.; Fulton, William B.; Sodhi, Chhinder P.; Hackam, David J.; Nasr, Isam W.
Abstract:
BACKGROUND Traumatic brain injury (TBI) leads to acute gastrointestinal dysfunction and mucosal damage, resulting in feeding intolerance. C-C motif chemokine receptor 2 (Ccr2+) monocytes are crucial immune cells that regulate the gut's inflammatory response via the brain-gut axis. Using Ccr2ko mice, we investigated the intricate interplay between these cells to better elucidate the role of systemic inflammation after TBI.METHODS A murine-controlled cortical impact model was used, and results were analyzed on postinjury days 1 and 3. The experimental groups included (1) sham C57Bl/6 wild type (WT), (2) TBI WT, (3) sham Ccr2ko, and (4) TBI Ccr2ko. Mice were euthanized on postinjury days 1 and 3 to harvest the ileum and study intestinal dysfunction and serotonergic signaling using a combination of quantitative real-time polymerase chain reaction, immunohistochemistry, fluorescein isothiocyanate-dextran motility assays, and flow cytometry. Student's t test and one-way analysis of variance were used for statistical analysis, with significance achieved when p < 0.05.RESULTS Traumatic brain injury resulted in severe dysfunction and dysmotility of the small intestine in WT mice as established by significant upregulation of inflammatory cytokines iNOS, Lcn2, TNFα, and IL1β and the innate immunity receptor toll-like receptor 4 (Tlr4). This was accompanied by disruption of genes related to serotonin synthesis and degradation. Notably, Ccr2ko mice subjected to TBI showed substantial improvements in intestinal pathology. Traumatic brain injury Ccr2ko groups demonstrated reduced expression of inflammatory mediators (iNOS, Lcn2, IL1β, and Tlr4) and improvement in serotonin synthesis genes, including tryptophan hydroxylase 1 (Tph1) and dopa decarboxylase (Ddc).CONCLUSION Our study reveals a critical role for Ccr2+ monocytes in modulating intestinal homeostasis after TBI. Ccr2+ monocytes aggravate intestinal inflammation and alter gut-derived serotonergic signaling. Therefore, targeting Ccr2+ monocyte-dependent responses could provide a better understanding of TBI-induced gut inflammation. Further studies are required to elucidate the impact of these changes on brain neuroinflammation and cognitive outcomes.
PubDate: Mon, 08 Jan 2024 00:00:00 GMT-
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- Factors associated with trauma recidivism in young children
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Authors: Stephens; Caroline Q.; Melhado, Caroline G.; Shui, Amy M.; Yap, Ava; Moses, Willieford; Jensen, Aaron R.; Newton, Christopher
Abstract:
BACKGROUND Trauma recidivism is associated with future trauma-associated morbidity and mortality. Previous evidence suggests that socioeconomic factors predict trauma recidivism in older children (10–18 years); however, risk factors in US children 10 years and younger have not been studied. We sought to determine the factors associated with trauma recidivism in young children 10 years and younger.METHODS We conducted a retrospective cohort study of pediatric trauma patients 10 years and younger who presented to a single American College of Surgeons-verified Level I pediatric trauma center from July 1, 2017, to June 30, 2021. All patients were evaluated for prior injury during trauma registry entry. Characteristics at the index injury were collected via chart review. Patients were geocoded to assess Social Vulnerability Index. Logistic regression examined factors associated with recidivism. Best subset selection was used to compare multivariable models and identify the most predictive and parsimonious model. Statistical significance was set at p < 0.05.RESULTS Of the 3,518 patients who presented in the study period, 169 (4.8%) experienced a prior injury. Seventy-six percent (n = 128) had one prior injury presentation, 18% (n = 31) had two prior presentations, and 5.9% (n = 10) had three or more. Falls were the most common mechanism in recidivists (63% vs. 52%, p = 0.009). Child physical abuse occurred in 6.5% of patients, and 0.9% experienced penetrating injury. The majority (n = 137 [83%]) were discharged home from the emergency department. There was no significant difference in the frequency of penetrating injury and child physical abuse between recidivists and nonrecidivists. Following logistic regression, the most parsimonious model demonstrated that recidivism was associated with comorbidities, age, falls, injury location, nontransfer, and racialization. No significant associations were found with Social Vulnerability Index and insurance status.CONCLUSION Medical comorbidities, young age, injury location, and falls were primarily associated with trauma recidivism. Support for parents of young children and those with special health care needs through injury prevention programs could reduce trauma recidivism in this population.LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
PubDate: Mon, 08 Jan 2024 00:00:00 GMT-
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