Increased knowledge of the temporal patterns in the distribution of trauma admissions could be beneficial to staffing and resource allocation efforts. However, little work has been done to understand ...how this distribution varies based on patient acuity, trauma mechanism or need for intervention. We hypothesize that temporal patterns exist in the distribution of trauma admissions, and that deep patterns exist when traumas are analyzed by their type and severity.
We conducted a cross-sectional observational study of adult patient flow at a level one trauma center over three years, 7/1/2013-6/30/2016. Primary thermal injuries were excluded. Frequency analysis was performed for patients grouped by ED disposition and mechanism against timing of admission; in subgroup analysis additional exclusion criteria were imposed.
10,684 trauma contacts were analyzed. Trauma contacts were more frequent on Saturdays and Sundays than on weekdays (p<0.001). Peak arrival time was centered around evening shift change (6-7pm), but differed based on ED disposition: OR and ICU or Step-Down admissions (p = 0.0007), OR and floor admissions (p<0.0001), and ICU or Step-Down and floor admissions (p<0.0001). Step-Down and ICU arrival times (p = 0.42) were not different. Penetrating injuries peaked later than blunt (p<0.0001). Trauma varies throughout the year; we establish a high incidence trauma season (April to late October). Different mechanisms have varying dependence upon season; Motorcycle crashes (MCCs) have the greatest dependence.
We identify new patterns in the temporal and seasonal variation of trauma and of specific mechanisms of injury, including the novel findings that 1) penetrating trauma tends to present at later times than blunt, and 2) critically ill patients requiring an OR tend to present later than those who are less acute and require an ICU or Step-Down unit. These patients present later than those who are admitted to the floor. Penetrating trauma patients arriving later than blunt may be the underlying reason why operative patients arrive later than other patients.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Severely injured patients often progress from early hypocoagulable to normal and eventually hypercoagulable states, developing increased risk for venous thromboembolism (VTE). Prophylactic ...anticoagulation can decrease this risk, but its initiation is frequently delayed for extended periods due to concerns for bleeding. To facilitate timely introduction of VTE chemoprophylaxis, we characterized the transition from hypo- to hypercoagulability and hypothesized that trauma-induced coagulopathy resolves within 24 hours after injury.
Serial blood samples were collected prospectively from critically injured patients for 120 hours after arrival at an urban Level I trauma center. Extrinsic thromboelastometry maximum clot firmness was used to classify patients as hypocoagulable (HYPO, <49 mm), normocoagulable (NORM, 49-71 mm), or hypercoagulable (HYPER, >71 mm) at each time point. Changes in coagulability over hospital course, VTE occurrence, and timing of prophylaxis initiation were analyzed.
898 patients (median Injury Severity Score, 13; mortality, 12%; VTE, 8%) were enrolled. Upon arrival, 3% were HYPO (90% NORM, 7% HYPER), which increased to 9% at 6 hours before down-trending. Ninety-seven percent were NORM by 24 hours, and 53% were HYPER at 120 hours. Median maximum clot firmness began in the NORM range, up-trended gradually, and entered the HYPER range at 120 hours. Patients with traumatic brain injury (TBI) followed a similar course and were not more HYPO at any time point than those without TBI. Failure to initiate prophylaxis by 72 hours was predicted by TBI and associated with VTE development (27% vs 16%, p < 0.05).
Regardless of injury pattern, trauma-induced coagulopathy largely resolves within 24 hours, after which hypercoagulability becomes increasingly more prevalent. Deferring initiation of chemoprophylaxis, which is often biased toward patients with intracranial injuries, is associated with VTE development.
Prognostic study, level III; Therapeutic, level IV.
IMPORTANCE: Severely injured patients experiencing hemorrhagic shock often require massive transfusion. Earlier transfusion with higher blood product ratios (plasma, platelets, and red blood cells), ...defined as damage control resuscitation, has been associated with improved outcomes; however, there have been no large multicenter clinical trials. OBJECTIVE: To determine the effectiveness and safety of transfusing patients with severe trauma and major bleeding using plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio. DESIGN, SETTING, AND PARTICIPANTS: Pragmatic, phase 3, multisite, randomized clinical trial of 680 severely injured patients who arrived at 1 of 12 level I trauma centers in North America directly from the scene and were predicted to require massive transfusion between August 2012 and December 2013. INTERVENTIONS: Blood product ratios of 1:1:1 (338 patients) vs 1:1:2 (342 patients) during active resuscitation in addition to all local standard-of-care interventions (uncontrolled). MAIN OUTCOMES AND MEASURES: Primary outcomes were 24-hour and 30-day all-cause mortality. Prespecified ancillary outcomes included time to hemostasis, blood product volumes transfused, complications, incidence of surgical procedures, and functional status. RESULTS: No significant differences were detected in mortality at 24 hours (12.7% in 1:1:1 group vs 17.0% in 1:1:2 group; difference, −4.2% 95% CI, −9.6% to 1.1%; P = .12) or at 30 days (22.4% vs 26.1%, respectively; difference, −3.7% 95% CI, −10.2% to 2.7%; P = .26). Exsanguination, which was the predominant cause of death within the first 24 hours, was significantly decreased in the 1:1:1 group (9.2% vs 14.6% in 1:1:2 group; difference, −5.4% 95% CI, −10.4% to −0.5%; P = .03). More patients in the 1:1:1 group achieved hemostasis than in the 1:1:2 group (86% vs 78%, respectively; P = .006). Despite the 1:1:1 group receiving more plasma (median of 7 U vs 5 U, P < .001) and platelets (12 U vs 6 U, P < .001) and similar amounts of red blood cells (9 U) over the first 24 hours, no differences between the 2 groups were found for the 23 prespecified complications, including acute respiratory distress syndrome, multiple organ failure, venous thromboembolism, sepsis, and transfusion-related complications. CONCLUSIONS AND RELEVANCE: Among patients with severe trauma and major bleeding, early administration of plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio did not result in significant differences in mortality at 24 hours or at 30 days. However, more patients in the 1:1:1 group achieved hemostasis and fewer experienced death due to exsanguination by 24 hours. Even though there was an increased use of plasma and platelets transfused in the 1:1:1 group, no other safety differences were identified between the 2 groups. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01545232
Trauma-induced coagulopathy is a major driver of mortality following severe injury. Viscoelastic goal-directed resuscitation can reduce mortality after injury. The TEG 5000 system is widely used for ...viscoelastic testing. However, the TEG 6s system incorporates newer technology, with encouraging results in cardiovascular interventions. The purpose of this study was to validate the TEG 6s system for use in trauma patients.
Multicenter noninvasive observational study for method comparison conducted at 12 US Levels I and II trauma centers. Agreement between the TEG 6s and TEG 5000 systems was examined using citrated kaolin reaction time (CK.R), citrated functional fibrinogen maximum amplitude (CFF.MA), citrated kaolin percent clot lysis at 30 minutes (CK.LY30), citrated RapidTEG maximum amplitude (CRT.MA), and citrated kaolin maximum amplitude (CK.MA) parameters in adults meeting full or limited trauma team criteria. Blood was drawn ≤1 hour after admission. Assays were repeated in duplicate. Reliability (TEG 5000 vs. TEG 6s analyzers) and repeatability (interdevice comparison) was quantified. Linear regression was used to define the relationship between TEG 6s and TEG 5000 devices.
A total of 475 patients were enrolled. The cohort was predominantly male (68.6%) with a median age of 49 years. Regression line slope estimates (ß) and linear correlation estimates (p) were as follows: CK.R (ß = 1.05, ρ = 0.9), CFF.MA (ß = 0.99, ρ = 0.95), CK.LY30 (ß = 1.01, ρ = 0.91), CRT.MA (TEG 6s) versus CK.MA (TEG 5000) (ß = 1.06, ρ = 0.86) as well as versus CRT.MA (TEG 5000) (ß = 0.93, ρ = 0.93), indicating strong reliability between the devices. Overall, within-device repeatability was better for TEG 6s versus TEG 5000, particularly for CFF.MA and CK.LY30.
The TEG 6s device appears to be highly reliable for use in trauma patients, with close correlation to the TEG 5000 device and equivalent/improved within-device reliability. Given the potential advantages of using the TEG 6s device at the site of care, confirmation of agreement between the devices represents an important advance in diagnostic testing.
Diagnostic test, level II.
The EAST mission includes fostering research and providing career development opportunities. EAST has awarded for 20 years a Research Scholarship to a promising young investigator. The Research ...mentorship efforts were expanded 5 yrs ago with the INVEST-C Hack-a-thon. INVEST-C provides an intensive, short-term engagement to propel junior faculty toward establishing research independence. This study investigates the impact of these programs on academic productivity.
Pubmed records, NIH Reporter data, and SCOPUS h-index was acquired for all scholarship SCH awardees from 2002-2021 (n = 20) and all INVEST-C INV participants (2017-2020, n = 19). Current type of practice, total number of funding awards, and timing of first award were ascertained. INVEST-C participants were also surveyed on an annual basis to track their progress. Medians (IQR) are reported and compared (ANOVA).
Median publications (PUB) of SCH awardees was 56 IQR 33-88, h-index 16 (12-21), and 25% with > = 1 NIH grant since their SCH. Amongst the last 10 awardees with a minimum of 2 yrs from SCH, 40% have received a NIH award compared with a mean NIH funding rate of 18.5% over the same time period. For those remaining in academics (90% SCH), PUB were higher for those >5 yrs (66, 51-115) vs. <5 yrs from their SCH (33, 22-59, p = 0.05), but there was no difference in h-index (16, IQR 14-25, vs 15, 9-19, p = NS). Comparing the most recent 5 yrs of SCH to INV group, there was no difference in academic productivity as measured by total PUB (SCH 33, IQR 22-59 vs INV 34, IQR 18-44, p = 0.7) or h-index (INV 9, 5-14, p = 0.1). However, no attendee held research funding prior to INV, but 31.6% (6/19) have subsequently acquired > = 1 funding award (11 non-NIH, 1 NIH) in the short interval since participation.
Investments in research activities have translated to significant extramural funding. Those in the last 5 yrs have been particularly fruitful with INV participants already achieving equal median academic productivity to SCH recipients.
Level III, Epidemiologic, Cohort.
Machine learning techniques have demonstrated superior discrimination compared to conventional statistical approaches in predicting trauma death. The objective of this study is to evaluate whether ...machine learning algorithms can be used to assess risk and dynamically identify patient-specific modifiable factors critical to patient trajectory for multiple key outcomes after severe injury.
SuperLearner, an ensemble machine-learning algorithm, was applied to prospective observational cohort data from 1494 critically-injured patients. Over 1000 agnostic predictors were used to generate prediction models from multiple candidate learners for outcomes of interest at serial time points post-injury. Model accuracy was estimated using cross-validation and area under the curve was compared to select among predictors. Clinical variables responsible for driving outcomes were estimated at each time point.
SuperLearner fits demonstrated excellent cross-validated prediction of death (overall AUC 0.94-0.97), multi-organ failure (overall AUC 0.84-0.90), and transfusion (overall AUC 0.87-0.9) across multiple post-injury time points, and good prediction of Acute Respiratory Distress Syndrome (overall AUC 0.84-0.89) and venous thromboembolism (overall AUC 0.73-0.83). Outcomes with inferior data quality included coagulopathic trajectory (AUC 0.48-0.88). Key clinical predictors evolved over the post-injury timecourse and included both anticipated and unexpected variables. Non-random missingness of data was identified as a predictor of multiple outcomes over time.
Machine learning algorithms can be used to generate dynamic prediction after injury while avoiding the risk of over- and under-fitting inherent in ad hoc statistical approaches. SuperLearner prediction after injury demonstrates promise as an adaptable means of helping clinicians integrate voluminous, evolving data on severely-injured patients into real-time, dynamic decision-making support.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Delayed notification and lack of early information hinder timely hospital based activations in large scale multiple casualty events. We hypothesized that Twitter real-time data would produce a unique ...and reproducible signal within minutes of multiple casualty events and we investigated the timing of the signal compared with other hospital disaster notification mechanisms.
Using disaster specific search terms, all relevant tweets from the event to 7 days post-event were analyzed for 5 recent US based multiple casualty events (Boston Bombing BB, SF Plane Crash SF, Napa Earthquake NE, Sandy Hook SH, and Marysville Shooting MV). Quantitative and qualitative analysis of tweet utilization were compared across events.
Over 3.8 million tweets were analyzed (SH 1.8 m, BB 1.1m, SF 430k, MV 250k, NE 205k). Peak tweets per min ranged from 209-3326. The mean followers per tweeter ranged from 3382-9992 across events. Retweets were tweeted a mean of 82-564 times per event. Tweets occurred very rapidly for all events (<2 mins) and represented 1% of the total event specific tweets in a median of 13 minutes of the first 911 calls. A 200 tweets/min threshold was reached fastest with NE (2 min), BB (7 min), and SF (18 mins). If this threshold was utilized as a signaling mechanism to place local hospitals on standby for possible large scale events, in all case studies, this signal would have preceded patient arrival. Importantly, this threshold for signaling would also have preceded traditional disaster notification mechanisms in SF, NE, and simultaneous with BB and MV.
Social media data has demonstrated that this mechanism is a powerful, predictable, and potentially important resource for optimizing disaster response. Further investigated is warranted to assess the utility of prospective signally thresholds for hospital based activation.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
OBJECTIVES:Examine the effect of different types of firearms on readmission due to acute stress disorder (ASD) and/or post-traumatic stress disorder (PTSD) in firearm-injury victims.
...BACKGROUND:Survivors of firearm-related injuries suffer long-term sequelae such as disability, work loss, and deterioration in the quality of life. There is a paucity of data describing the long-term mental health outcomes in these patients.
METHODS:We performed a 5-year (2011–2015) analysis of the Nationwide Readmission Database. All adult patients with firearm injuries were stratified into 3 groups by firearm typehandgun, shotgun, and semiautomatic rifle. Outcome measures were the incidence and predictors of ASD/PTSD.
RESULTS:A total of 100,704 victims of firearm-related injuries were identified, of which 13.3% (n = 13,393) were readmitted within 6 months of index hospitalization, 6.7% (n = 8970) of these due to ASD/PTSD. Mean age was 34 ± 14 years, 88% were men. Of those readmitted due to ASD/PTSD, 24% (n = 2153) sustained a handgun-related injury on index hospitalization, 12% (n = 1076) shotgun, and 64% (n = 5741) semiautomatic gun (P = 0.039). On regression analysis, semiautomatic gun and shotgun victims had higher odds of developing ASD/PTSD upon readmission odds ratio (OR)2.05 (1.10–4.12) and OR1.41 (1.08–2.11) compared to handgun. Female sex OR1.79 (1.05–3.05) and younger age representing those younger than 25 years OR4.66 (1.12–6.74) were also independently associated with higher odds of ASD/PTSD.
CONCLUSIONS:Apart from the lives lost, survivors of semiautomatic rifle- and shotgun-related injuries suffer long-term mental health sequalae. These secondary and debilitating mental health outcomes are important considerations for capturing the overall burden of the disease.
The novel coronavirus COVID-19 has been implicated in a number of extra-pulmonary manifestations including rhabdomyolysis. It is hypothesized to be secondary to direct muscle damage from the virus. ...The usual treatment of rhabdomyolysis is resuscitation with aggressive fluid management to prevent acute renal failure. However, the combination of blunt thoracic trauma and COVID pneumonia has posed additional challenges for critical care management. A 68-year-old male presented to our institution after being found down for an unknown duration of time. He was diagnosed symptomatic COVID pneumonia. His traumatic injuries included 4 rib fractures, a rectus sheath hematoma, and rhabdomyolysis with a creatinine kinase (CK) level of 16,716 U/L. He was initially treated with steroids, prone positioning, and aggressive fluid administration. Despite treatment his CK level peaked at 146,328 U/L. Here we present the case of trauma and COVID-induced rhabdomyolysis with an extremely elevated CK level.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
We aimed to examine biomarkers for screening unhealthy alcohol use in the trauma setting.
Self-report tools are the practice standard for screening unhealthy alcohol use; however, their collection ...suffers from recall bias and incomplete collection by staff.
We performed a multi-center prospective clinical study of 251 adult patients who arrived within 24 hours of injury with external validation in another 60 patients. The Alcohol Use Disorders Identification Test served as the reference standard. The following biomarkers were measured: (1) PEth; (2) ethyl glucuronide; (3) ethyl sulfate; (4) gamma-glutamyl-transpeptidase; (5) carbohydrate deficient transferrin; and (6) blood alcohol concentration (BAC). Candidate single biomarkers and multivariable models were compared by considering discrimination (AUROC). The optimal cutpoint for the final model was identified using a criterion for setting the minimum value for specificity at 80% and maximizing sensitivity. Decision curve analysis was applied to compare to existing screening with BAC.
PEth alone had an AUROC of 0.93 95% confidence interval (CI): 0.92-0.93 in internal validation with an optimal cutpoint of 25 ng/mL. A 4- variable biomarker model and the addition of any single biomarker to PEth did not improve AUROC over PEth alone ( P > 0.05). Decision curve analysis showed better performance of PEth over BAC across most predicted probability thresholds. In external validation, sensitivity and specificity were 76.0% (95% CI: 53.0%-92.0%) and 73.0% (95% CI: 56.0%-86.0%), respectively.Conclusion and Relevance: PEth alone proved to be the single best biomarker for screening of unhealthy alcohol use and performed better than existing screening systems with BAC. PEth may overcome existing screening barriers.
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