Blunt thoracic aortic injury (BTAI) occurs in <1% of all trauma admissions. Considering the advent of multiple thoracic endovascular aortic repair (TEVAR) devices over the past decade, improved ...outcomes of TEVAR supported in the literature, rapid diagnosis, and improved preoperative planning of BTAI using computed tomography imaging, we hypothesized that the national incidence of TEVAR in BTAI has increased while open repair has decreased. In addition, we hypothesized that the mortality risk in BTAI patients undergoing TEVAR would be lower than open repair.
This was a retrospective analysis of the National Trauma Data Bank from 2007 to 2015. The primary end points of interest included the incidence of TEVAR and open repair, as well as mortality in BTAI patients undergoing intervention. Covariates were included in a multivariable analysis to determine risk for mortality in BTAI patients undergoing open repair versus TEVAR.
We identified 3,628 BTAI patients undergoing intervention. Of these, 3,226 underwent TEVAR (87.9%), and 445 (12.1%) underwent open repair. Compared with open repair, TEVAR had a shorter mean length of stay (LOS) (19.8 vs. 21.3 days, P < 0.05) and lower rates of acute kidney injury (AKI) (5.6% vs. 9.0%, P < 0.05) and mortality (8.8% vs. 12.8%, P < 0.05). Open repair had greater risk for mortality than TEVAR (odds ratio = 1.63, confidence intervals = 1.19-2.23, P < 0.05).
The rate of open repair decreased from 7.4% in 2007 to 1.9% in 2015, whereas TEVAR increased from 12.1 to 25.7% during the same time period. We confirmed previous findings that endovascular repair is associated with decreased mortality, LOS, and major complications, including AKI. Future investigations should focus on identifying the ideal patient candidate for TEVAR and elucidate precise indications for TEVAR in BTAI.
Background
Patient-related risk factors for the development of postoperative pulmonary complications (PPCs) include age ≥ 60-years, congestive heart failure, hypoalbuminemia and smoking. The effect ...of obesity is unclear and has not been shown to independently increase the likelihood of PPCs in trauma patients undergoing trauma laparotomy. We hypothesized the likelihood of mortality and PPCs would increase as body mass index (BMI) increases in trauma patients undergoing trauma laparotomy.
Methods
The Trauma Quality Improvement Program (2010–2016) was queried to identify trauma patients ≥ 18-years-old undergoing trauma laparotomy within 6-h of presentation. A multivariable logistic regression analysis was used to determine the likelihood of PPCs and mortality when stratified by BMI.
Results
From 8,330 patients, 2,810 (33.7%) were overweight (25–29.9 kg/m
2
), 1444 (17.3%) obese (30–34.9 kg/m
2
), 580 (7.0%) severely obese (35–39.9 kg/m
2
), and 401 (4.8%) morbidly obese (≥ 40 kg/m
2
). After adjusting for covariates including age, injury severity score, chronic obstructive pulmonary disease, smoking, and rib/lung injury, the likelihood of PPCs increased with increasing BMI: overweight (OR = 1.37, CI 1.07–1.74,
p
= 0.012), obese (OR = 1.44, CI 1.08–1.92,
p
= 0.014), severely obese (OR = 2.20, CI 1.55–3.14,
p
< 0.001), morbidly obese (OR = 2.42, CI 1.67–3.51,
p
< 0.001), compared to those with normal BMI. In addition, the adjusted likelihood of mortality increased for the morbidly obese (OR = 2.60, CI 1.78–3.80,
p
< 0.001) compared to those with normal BMI.
Conclusion
Obese trauma patients undergoing emergent trauma laparotomy have a high likelihood for both PPCs and mortality, with morbidly obese trauma patients having the highest likelihood for both. This suggests obesity should be accounted for in risk prediction models of trauma patients undergoing laparotomy.
Thyroidectomy is a common operation, performed by general surgeons and otolaryngologists. Few studies compare complication rates between these two specialties. We hypothesized that there would be no ...difference in the incidence of postoperative complications including recurrent laryngeal nerve (RLN) injury, hypocalcemia, or hematoma based on the surgical specialty performing the thyroidectomy. The 2016–2017 National Surgical Quality Improvement Program Targeted Thyroidectomy database was queried for patients who underwent thyroidectomy for both benign and malignant thyroid diseases. Thyroidectomies performed by general surgeons were compared to those performed by otolaryngologists. Multivariate logistic regression was used to identify risk factors associated with RLN injury, hematoma, and hypocalcemia. From 11,595 patients, 6313 (54.4%) were performed by general surgeons and 5282 (45.6%) by otolaryngologists. Goiter (43.7%) and nodule/neoplasm (40.8%) were the most common indications for the general surgery and otolaryngology cohorts respectively. General surgeons used an energy vessel sealant device more frequently (77.7% vs. 51.5%,
p
< 0.001), whereas RLN monitoring (67.4% vs. 58.3%,
p
< 0.001) and drain placement (44.3% vs. 14.8%,
p
< 0.001) were utilized more often by otolaryngology. After controlling for covariates, thyroidectomy by general surgeons had an increased associated risk of RLN injury (OR = 1.26, CI = 1.07–1.48,
p
= 0.006) and post-operative hypocalcemia (OR = 1.17, CI = 1.00–1.37, p = 0.046). Thyroidectomy volume is relatively equally distributed among general surgeons and otolaryngologists. Operation by a general surgeon is associated with an increased risk for RLN injury and postoperative hypocalcemia. This discrepancy may be explained by case volume, training, and/or completion of an endocrine surgery fellowship; however, this discrepancy still merits ongoing attention.
Background
The utilization and impact of various ratios of transfusions for pediatric trauma patients (PTPs) receiving a massive transfusion (MT) are unknown. Therefore, we sought to determine the ...risk for mortality in PTPs receiving an MT of ≥ 6 units of packed red blood cells (PRBC) within 24 h. We compared PRBC: plasma ratio of > 2:1 (Unbalanced Ratios, UR) versus ≤ 2:1 (Balanced Ratios, BR), hypothesizing decreased risk of mortality with BR.
Methods
The Trauma Quality Improvement Program was queried (2014–2016) for PTPs receiving a MT. A multivariable logistic regression model was used to determine risk of mortality.
Results
From 239 PTPs receiving an MT, 98 (41%) received an UR, whereas 141 (59%) received a BR. The median ratios, respectively, were 2.7:1 and 1.2:1. Compared to BR patients, UR patients had no differences in injury severity score (ISS), hypotension on admission, and intensive care unit stay (all
p
> 0.05). The mortality rates for BR and UR were similar (46.1% vs. 52.0%,
p
= 0.366). Controlling for age, ISS, and severe head injury, UR demonstrated similar risk of mortality compared to BR (
p
= 0.276). Additionally, ≥ 4:1 ratio versus ≤ 2:1 showed no difference in associated risk of mortality (
p
= 0.489).
Conclusion
In contrast to adult studies, this study demonstrated that MT ratios of > 2:1 and even ≥ 4:1 were associated with similar mortality compared to BR for PTPs. These results suggest pediatric MT resuscitation may not require strict BR as has been shown beneficial in adult trauma patients. Future prospective studies are needed to evaluate the optimal ratio for PTP MT resuscitation.
Level of evidence
III; Retrospective Care Management Study.
Purpose
The proportion of geriatric trauma patients (GTPs) (age ≥ 65 years old) with chest wall injury undergoing surgical stabilization of rib fractures (SSRF) nationally is unknown. We hypothesize ...a growing trend of GTPs undergoing SSRF, and sought to evaluate risk of respiratory complications and mortality for GTPs compared to younger adults (18–64 years old) undergoing SSRF.
Methods
The Trauma Quality Improvement Program (2010–2016) was queried for patients with rib fracture(s) who underwent SSRF. GTPs were compared to younger adults. A multivariable logistic regression analysis was performed.
Results
From 21,517 patients undergoing SSRF, 3,001 (16.2%) were GTPs. Of all patients undergoing SSRF in 2010, 10.6% occurred on GTPs increasing to 17.9% in 2016 (
p
< 0.001) with a geometric-mean-annual increase of 11.5%. GTPs had a lower median injury severity score (18 vs. 22,
p
< 0.001), but had a higher rate of mortality (4.7% vs. 1.2%,
p
< 0.001). After controlling for covariates, GTPs had an increased associated risk of mortality (OR 4.80, CI 3.62–6.36,
p
< 0.001). On a separate multivariate analysis for all trauma patients with isolated chest Abbreviated Injury Scale 3, GTPs were associated with a similar four-fold risk of mortality (OR 4.21, CI 1.98–6.32,
p
< 0.001).
Conclusion
Spanning 7 years of data, the proportion of GTPs undergoing SSRF increased by over 7%. Although GTPs undergoing SSRF had lesser injuries, their risk of mortality was four times higher than other adult trauma patients undergoing SSRF, which was similar to their increased background risk of mortality. Ultimately, SSRF in GTPs should be considered on an individualized basis with careful attention to risk–benefit ratio.
Background
Utilization of ICP monitors for pediatric patients is low and varies between centers. We hypothesized that in more severely injured patients (GCS 3–4), there would be a decreased mortality ...associated with invasive monitoring devices.
Methods
The pediatric Trauma Quality Improvement Program (TQIP) was queried for patients aged ≤ 16 years meeting criteria for invasive monitors. Our primary outcome was mortality. Patients with ICP monitoring were compared to those without. A logistic regression was used to examine the risk of mortality.
Results
Of 3,808 patients, 685 (18.0%) underwent ICP monitoring. ICP monitors were associated with increased risk of mortality (OR 1.82, CI 1.36–2.44,
p
< 0.001). A secondary analysis including type of invasive ICP monitor and dividing GCS into 3 categories revealed both intraventricular drain (OR 1.89, CI 1.3–2.7,
p
= 0.001) and intraparenchymal pressure monitor (OR 1.86, CI 1.32–2.6,
p
< 0.001) to be independently associated with an increased likelihood of mortality regardless of GCS, while intraparenchymal oxygen monitoring was not (OR 0.47, CI 0.11–2.05,
p
= 0.316). The strongest effect was seen in those patients with a GCS of 5–6.
Conclusion
ICP monitors are an independent risk factor for mortality, particularly with intraventricular drains and intraparenchymal monitors in patients with a GCS 5–6.
Traumatic esophageal injury is a highly lethal but rare injury with minimal data in the trauma population. We sought to provide a descriptive analysis of esophageal trauma (ET) to identify the ...incidence, associated injuries, interventions, and outcomes. We hypothesized that blunt trauma is associated with higher risk of death than penetrating trauma. The Trauma Quality Improvement Program (2010–2016) was queried for patients with ET. Patients with blunt and penetrating trauma were compared using chi-square and Mann-Whitney U tests. A multivariable logistic regression model was used to determine risk of mortality. Of 1,403,466 adult patients, 651 (<0.01%) presented with ET. The most common associated thoracic injuries were rib fractures (38.7%) and pneumothorax (26.7%). More patients with a penetrating mechanism underwent open repair of the esophagus than those with blunt mechanism (46.2% vs 11.7%, P < 0.001). After controlling for covariates, there was no difference in risk of mortality between blunt and penetrating trauma (P = 0.65). The mortality rate for patients with esophageal injury surviving greater than 24 hours was 7.5 per cent. In this large national database analysis, ET was rare and most commonly associated with rib fractures and pneumothorax. Contrary to our hypothesis, the risk of mortality was equivalent between blunt and penetrating ET.
Purpose
The COVID-19 pandemic resulted in increased penetrating trauma and decreased length of stay (LOS) amongst the adult trauma population, findings important for resource allocation. Studies ...regarding the pediatric trauma population are sparse and mostly single-center. This multicenter study examined pediatric trauma patients, hypothesizing increased penetrating trauma and decreased LOS after the 3/19/2020 stay-at-home (SAH) orders.
Methods
A multicenter retrospective analysis of trauma patients ≤ 17 years old presenting to 11 centers in California was performed. Demographic data, injury characteristics, and outcomes were collected. Patients were divided into three groups based on injury date: 3/19/2019–6/30/2019 (CONTROL), 1/1/2020–3/18/2020 (PRE), 3/19/2020–6/30/2020 (POST). POST was compared to PRE and CONTROL in separate analyses.
Results
1677 patients were identified across all time periods (CONTROL: 631, PRE: 479, POST: 567). POST penetrating trauma rates were not significantly different compared to both PRE (11.3 vs. 9.0%,
p
= 0.219) and CONTROL (11.3 vs. 8.2%,
p
= 0.075), respectively. POST had a shorter mean LOS compared to PRE (2.4 vs. 3.3 days,
p
= 0.002) and CONTROL (2.4 vs. 3.4 days,
p
= 0.002). POST was also not significantly different than either group regarding intensive care unit (ICU) LOS, ventilator days, and mortality (all
p
> 0.05).
Conclusions
This multicenter retrospective study demonstrated no difference in penetrating trauma rates among pediatric patients after SAH orders but did identify a shorter LOS.
Purpose
Pediatric genitalia injury represents 0.6% of all pediatric trauma. It is crucial for providers to understand whether pediatric patients are at risk for violent mechanisms, such as rape, ...assault, or other abuse. Therefore, we sought to perform a large database analysis of pediatric and adolescent female genitalia trauma, comparing mechanisms of injury (i.e., sexual abuse) and need for operative intervention between adolescent and pediatric cohorts.
Methods
The National Trauma Data Bank was queried (years 2007–2015) for female patients ≤ 16 years old with external genitalia (vaginal or vulvar) trauma. Two groups were compared: pediatrics (< 12 years old) and adolescents (12–16 years old).
Results
Out of 303,992 female patients, 3206 (1.1%) were identified to have genitalia trauma with the majority being pediatric patients (92.1%) and with injury to the vagina (62.6%). Pediatric patients with vaginal injury were less likely to be victims of rape (4.1% vs. 17.3%,
p
< 0.001) and assault (2.1% vs. 7.2%,
p
< 0.001) but more likely to be victims of other abuse (9.5% vs. 3.4%,
p
= 0.003). More of the adolescent patients with vaginal trauma required repair (58.7% vs. 43.2%,
p
< 0.001). Pediatric patients with injury to the vulva were less likely to be victims of rape (0.7% vs. 2.8%,
p
= 0.01) and motor vehicle accidents (4.2% vs. 11.0%,
p
< 0.001).
Conclusion
Genitalia trauma occurs in 1.1% of pediatric and adolescent trauma cases with the vagina being more commonly injured compared to the vulva. Adolescent patients with vaginal injuries were more likely to be victims of rape and assault and required repair more often, while those with vulvar injuries were more likely due to motor vehicle accidents. Health care providers must be aware of these at-risk populations and the differences between them to identify female victims of violence and provide resources to assist with recovery.
Purpose: Several single-center studies have demonstrated same-day discharge (SDD) to be safe in adults undergoing laparoscopic appendectomy (LA) for non-perforated appendicitis (NPA). The proportion ...of SDD appendectomy patients nationally is unknown. We sought to identify the incidence of SDD among patients undergoing LA after NPA hypothesizing a similar risk of complications including superficial surgical site infections (SSSIs), post-operative intra-abdominal abscess, and 30-day readmission rates. Materials and methods: The 2016-2017 ACS-NSQIP Procedure-Targeted Appendectomy database was queried for adults undergoing LA with no intraoperative findings of perforation or abscess. Patients with SDD were compared to those discharged within two days. A multivariable logistic regression model was used for analysis. Results: From 16,931 patients undergoing LA, 3988 (23.6%) were SDD. Compared to those with a longer hospital stay, patients with SDD were of similar age (p = 0.29) and less likely to have a contaminated wound-class (58.5% vs. 62.6%, p < 0.001). After adjusting for age and comorbidities, patients with SDD had a similar risk of 30-day readmission (p = 0.088) and post-operative abscess (p = 0.739) but lower risk of SSSI (OR: 0.48, 0.28-0.82, p = 0.008), compared to those discharged within two days. Conclusions: Nearly a quarter of patients with NPA undergoing LA are discharged the same day. The risk of 30-day readmission is similar compared to those with a longer index hospital stay. Interestingly, the risk of SSSI is lower, however this may be related to differences in wound classification and/or selection bias. Regardless, SDD for NPA patients appears safe and should be utilized whenever possible.
PDF
