Patients with blunt cerebrovascular injuries are at risk of thromboembolic stroke. Although primary prevention with antithrombotic therapy is widely used in this setting, its effectiveness is not ...well defined and requires further investigation. The aim of this study was to evaluate the utility of magnetic resonance imaging (MRI)-detected ischemic brain lesions as a possible future outcome for randomized clinical trials in this patient population.
This prospective observational study included 20 adult blunt trauma patients admitted to a level I trauma center with a screening neck CTA showing extracranial carotid or vertebral artery injury. All subjects lacked initial evidence of an ischemic stroke and were managed with antithrombotic therapy and observation and then underwent brain MRI within 30 days of the injury to assess for ischemic lesions. The MRI scans included diffusion, susceptibility, and Fluid-attenuated Inversion Recovery (FLAIR) sequences, and were reviewed by two neuroradiologists blinded to the computed tomography angiography (CTA) findings.
Eleven CTAs were done in the emergency department upon admission. There were 12 carotid artery dissections and 11 unilateral or bilateral vertebral artery injuries. Median interval between injury and MRI scan was 4 days (range, 0.1-14; interquartile range, 3-7 days). Diffusion-weighted imaging evidence of new ischemic lesions was present in 10 (43%) of 23 of the injured artery territories. In those injuries with ischemic lesions, the median number was 8 (range, 2-25; interquartile range, 5-8). None of the lesions were symptomatic. Blunt cerebrovascular injury was associated with a higher mean ischemic lesion count (mean count of 3.17 vs. 0.14, p < 0.0001), with the association remaining after adjusting for injury severity score (p < 0.0001).
In asymptomatic blunt trauma patients with CTA evidence of extracranial cerebrovascular injury and treated with antithrombotic therapy, nearly half of arterial injuries are associated with ischemic lesions on MRI.
Therapeutic/care management, level IV.
To determine the prevalence and awareness of pelvic floor disorder symptoms among female adolescents.
Cross-sectional study via a written, anonymous survey of adolescents. The survey was composed of ...validated measures for determination of symptom prevalence.
Pediatric and adolescent gynecology clinic in the southeast United States.
Female adolescents ages 14-21 years.
None.
We used χ2 analyses for categorical variables and t test for continuous variables.
Two hundred sixteen questionnaires were completed. The mean age of respondents was 17.1 (±2.1) years and most respondents had at least heard about urinary (UI) and fecal incontinence (FI; 62.9%). The prevalence of any UI was 31.5%. Urgency UI (UUI) was reported by 15.7% and stress UI was reported by 6.9% of adolescents; 8.8% of participants experienced UUI and stress UI symptoms. FI and pelvic organ prolapse symptoms were reported by 0.9%. There were no differences in reported prevalence rates of UI (31.7% vs 27.9%), FI (1.4% vs 0%), or pelvic organ prolapse (1.4% vs 0%) between younger (14-17 years) and older (18-21 years) adolescent participants, respectively (all P > .05). Although UI was fairly prevalent among respondents, most stated that it had a minimal effect on daily living.
UI symptoms were common among female adolescents, with UUI being the most reported. Early education regarding pelvic floor disorder symptoms might lead to prevention or empowerment to seek treatment as adolescents age.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
BACKGROUND
Understanding geographic patterns of injury is essential to operating an effective trauma system and targeting injury prevention. Choropleth maps are helpful in showing spatial ...relationships but are unable to provide estimates of spread or degrees of confidence. Funnel plots overcome this issue and are a recommended graphical aid for comparisons that allow quantification of precision. The purpose of this project was to demonstrate the complementary roles of choropleth maps and funnel plots in providing a thorough representation of geographic trauma data.
METHODS
This is a retrospective analysis of emergency medical service transport data of adult patients in Alabama from July 2015 to June 2020. Choropleth maps of case volume and observed-to-expected ratios of incidence were created using US Census Bureau data. Funnel plots were created to relate incidence rate to county population. Subgroup analyses included patients with critical physiology, penetrating, blunt, and burn injuries.
RESULTS
We identified 65,247 trauma incidents during the study period. The overall statewide incidence rate was 133 per 10,000 persons. The highest number of incidents occurred in the most populous counties (Jefferson, 10,768; Mobile, 5,642). Choropleth maps for overall incidence and subgroups highlighted that spatial distribution of overall case volume and observed-to-expected ratios are not always congruent. Funnel plots identified possible and probable outliers, and revealed skewed or otherwise unique patterns among injury subgroups.
CONCLUSION
This study demonstrates the complementarity of choropleth maps and funnel plots in describing trauma patterns. Comprehensive geospatial analyses may help guide a data-driven approach to trauma system optimization and injury prevention. Combining maps of case counts, incidence, and funnel plots helps to not only identify geographic trends in data but also quantify outliers and display how far results fall outside the expected range. The combination of these tools provides a more comprehensive geospatial analysis than either tool could provide on its own.
LEVEL OF EVIDENCE
Prognostic and Epidemiologic; Level IV.
ObjectivesFollowing up trauma patients after discharge, to evaluate their subsequent quality of life and functional outcomes, is notoriously difficult, time consuming, and expensive. Automated ...systems are a conceptually attractive solution. We prospectively assessed the feasibility of using a series of automated phone calls administered by Emmi Patient Engagement to survey trauma patients after discharge.MethodsRecruitment into the study was incorporated into the patient discharge process by nursing staff. For this pilot, we included trauma patients discharging home and who were able to answer phone calls. A script was created to evaluate the Extended Glasgow Outcome Scale and the EuroQol EQ-5D to assess functional status and quality of life, respectively. Call attempts were made at 6 weeks, 3 months, 6 months, and 1 year after discharge.ResultsA total of 110 patients initially agreed to participate. 368 attempted patient encounters (calls or attempted calls) took place, with 104 (28.3%) patients answering a least one question in the study. 21 unique patients (19.1% of those enrolled) completed 27 surveys.ConclusionsAutomated, scripted phone calls to survey patients after discharge are not a feasible way of collecting functional and quality of life data.Level of evidenceLevel II/prospective.
Uncontrolled truncal hemorrhage remains the most common cause of potentially preventable death after injury. The notion of earlier hemorrhage control and blood product resuscitation is therefore ...attractive. Some systems have successfully implemented prehospital advanced resuscitative care (ARC) teams. Early identification of patients is key and is reliant on rapid decision-making and communication. The purpose of this simulation study was to explore the feasibility of early identification of patients who might benefit from ARC in a typical U.S. setting.
We conducted a prospective observational/simulation study at a level I trauma center and two associated EMS agencies over a 9-month period. The participating EMS agencies were asked to identify actual patients who might benefit from the activation of a hypothetical trauma centerbased ARC team. This decision was then communicated in real time to the study team.
63 patients were determined to require activation. The number of activations per months ranged from 2 to 15. The highest incidence of calls occurred between 4pm to midnight. Of the 63 patients, 33 were transported to the trauma center. The most common presentation was with penetrating trauma. The median age was 27 years (IQR 24-45), 75% were male, and the median injury severity score was 11 (IQR 7-20). Based on injury patterns, treatment received, and outcomes, it was determined that 6 of 33 (18%) patients might have benefited from ARC. Three of the patients died en-route to or soon after arrival at the trauma center.
The prehospital identification of patients who might benefit from ARC is possible but faces challenges. Identifying strategies to adapt existing processes may allow better utilization of the existing infrastructure and should be a focus of future efforts.
IVStudy TypeEpidemiological.
The insertion of a chest tube is a common procedure in trauma care, and the Advanced Trauma Life Support program teaches the insertion of chest tubes as an essential and life-saving skill. It is also ...recognized that the insertion of chest tubes is not without risks or complications. The purpose of this study was to evaluate complications of chest tube placement in a level 1 trauma center compared with those placed in surrounding referral hospitals.
A retrospective matched cohort study of trauma patients was performed between those who underwent chest tube placement at the level 1 trauma center and those with a chest tube placed before transfer to the level 1 center between 2004 and 2013. Conditional logistic regression was used to compare the likelihood of complications and death between chest tube placement groups.
Four thousand two hundred and sixteen trauma patients had a chest tube placed at the level 1 center, and 364 patients had a chest tube placed at an outside hospital before transfer. Two hundred and eighty-one patients were matched. Patients with a chest tube placed outside the trauma center had an increased likelihood of malposition (OR 7.2, 95% CI 3.6-14.6), residual hemothorax (OR 6.3, 95% CI 3.4-11.6), residual pneumothorax (OR 6.7, 95% CI 3.9-11.4), and having a second chest tube placed (OR 3.77, 95% CI 2.37-6.01). However, the patients with a chest tube placed outside of the trauma center were also less likely to develop pneumonia (OR 0.32, 95% CI 0.14-0.73). There were no differences in the odds of developing an empyema, the need for video-assisted thoracoscopic surgery, thoracotomy, or death.
There are opportunities for improving the care of patients who require chest tubes at both referring hospitals and the receiving trauma center. Improving the care of patients who require intercostal drainage requires a systems-based approach, focusing on training and quality improvement.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
To determine if topical vancomycin and tobramycin powder reduces the incidence of surgical site infection after pelvic ring and acetabulum fracture surgery.
Retrospective cohort study.
University of ...Alabama at Birmingham, Academic Level I Trauma Center.
Two hundred nineteen patients (140 meeting inclusion criteria) with pelvic and acetabular fractures who underwent open reduction and internal fixation from March 2012 to November 2013.
One gram vancomycin and 1.2 g tobramycin powder applied deep in the surgical wound of the treatment group.
Postoperative infection rate.
One hundred forty patients were included. Control group (n = 69) and treatment group (n = 71) were similar for sex, age, ethnicity, and body mass index. There was no difference between groups with regards to renal function postoperative day 2 (P = 0.24). The risk of infection was 14.5% and 4.2% (P = 0.04) for the control and treatment groups, respectively. No significant effect of antibiotic treatment was observed overall after adjusting for EBL (odds ratio 0.20, 95% confidence interval, 0.02-1.06). Of note, a nonsignificant 71% increase was observed among those with ≥1 L EBL (odds ratio 1.71, 95% confidence interval, 0.02-147.02).
Topical antibiotics possibly reduce the incidence of surgical site infection after open pelvic and acetabulum fixation without increasing risk of renal impairment. The protective effect of topical antibiotics may be limited to patients with minimal intraoperative blood loss.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Background
Acute kidney injury (AKI) impairs electrolyte balance, alters fluid homeostasis and decreases toxin excretion. More recent data suggest it also affects the physiology of distant organs.
...Methods
We performed a prospective cohort study which invloved 122 premature infants birth weight (BW) ≤1200 g and/or gestational age (GA) <31 weeks to determine relationships between AKI and bronchopulmonary dysplasia (BPD)/mortality. Days until oxygen discontinuation was compared between those with and without AKI in survivors who received oxygen for ≥24 h.
Results
Acute kidney disease, defined by a rise in serum creatinine (SCr) of ≥0.3 mg/dl or an increase in SCr of ≥150 %, occurred in 36/122 (30 %) of the premature infants. Those with AKI had a 70 % higher risk of oxygen requirement or of dying at 28 days of life relative risk (RR) 1.71, 95 % confidence interval (CI) 1.22–2.39;
p
< 0.002. This association remained after controlling for GA, pre-eclampsia, 5 min Apgar score and percentage maximum weight change (max % weight Δ) in the first 4 days (RR 1.45, 95 % CI 1.07–1.97);
p
< 0.02). Similar findings were noted for receipt of mechanical ventilation/death by day 28 (adjusted RR 1.53, 95 % CI 1.05–2.22;
p
< 0.03). Those without AKI were 2.5-fold more likely to come off oxygen hazard ratio (HR) 1.3–5;
p
< 0.02) than those with AKI, even when controlling for GA, pre-eclampsia, 5 min Apgar and max % weight Δ (multivariate HR 2.0, 95 % CI 0.9–4.0;
p
< 0.06).
Conclusions
In premature infants, AKI is associated with BPD/mortality. As AKI could lead to altered lung physiology, interventions to ameliorate AKI could improve long-term BPD.
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DOBA, EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, IZUM, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, SIK, UILJ, UKNU, UL, UM, UPUK, VKSCE, VSZLJ, ZAGLJ
Helicopters are widely used to facilitate the transport of trauma patients, from the scene of an incident to the hospital. However, the use of helicopters may not always be appropriate. The aim of ...this project was to conduct a geospatial analysis of helicopter transport to a Level I trauma center.
Retrospective geospatial analysis of trauma registry data, 2013 to 2018. We included all adult (≥16) trauma patients brought to the trauma center directly from the scene. Data were geocoded and analyzed using arcGIS. Drive times and flight times were calculated using Google Maps. Flight times included the time required to reach the incident location.
Two thousand eight hundred ninety-three patients were identified, and 1,911 had incident locations recorded and were therefore included in the analysis. The median age was 41 years (interquartile range IQR, 27-58 years). Twenty-four percent of the patients had suffered severe injuries (Injury Severity Score ISS, 16-25), 17% very severe injuries (ISS > 25), 24% moderately severe injuries, and 36% minor injuries (ISS, 1-8). The overall geographical distribution was centroidal, although with a concentration of case volume in the vicinity, and to the northeast, of the trauma center. Median flight time was 60 minutes (IQR, 52-69 minutes), and median drive time 65 minutes (IQR, 54-86 minutes). In 33% of the patients, the calculated drive time to the trauma center was shorter than the calculated flight time when considering the time for the helicopter to reach the scene.
The majority of patients taken to our level I trauma center by helicopter are injured in relatively close proximity. One in four patients is severely or very severely injured, but one third of the patients have only minor injuries. Over a quarter of trauma patients might have reached hospital more quickly if they had been taken by road, rather than helicopter.
Epidemiological/geographical study, level V.
Aeromedical retrieval is an essential component of contemporary emergency care systems. However, in many locations, ground emergency medical services are dispatched to the scene of an incident first ...to assess the patient and then call for a helicopter if needed. The time to definitive care therefore includes the helicopter's flight to the scene, flight to the trauma center, and nonflying time. Mission ground time (MGT) includes the time required to get the helicopter airborne, as well as time spent at the scene, packaging and loading the casualty into the aircraft. Estimates of MGT typically vary from 10 to 30 min. The impact of MGT duration on population coverage—the number of residents that could be taken to a trauma center within a set time—is not known. The aim of this study was to compare population coverage for different durations of MGT in a single state.
Coverage was calculated using elliptical coverage areas (“isochrones”) based on the location of helicopter bases and Level I and Level II trauma centers. The calculations were performed using Microsoft Excel, assuming a cruising speed of 133 knots (246 km/h), and mapped using arcGIS. The access time threshold was set at 60 min, and we evaluated MGTs of 10, 15, 20, 25, and 30 min.
MGT has a marked impact on population coverage. The effect is, furthermore, not linear. When considering the state's three Level I trauma centers, decreasing MGT from 30 to 10 min increased population coverage from 61.2% to 84.2%. When also considering Level II centers, decreasing MGT from 30 min to 10 min increased coverage by 20%.
Elliptical isochrones, with allowance for MGT, provide realistic estimates of population coverage. MGT significantly impacts the proportion of the population that can be taken to a Level I and/or Level II Trauma Center within a set time. The impact is not linear, reflecting the uneven distribution of the population. Consideration should be given to minimizing MGT to preserve the benefits of aeromedical retrieval.
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