There is a lack of data on the outcomes of thoracic damage control surgery (TDCS). This study aimed to describe the characteristics and outcomes of patients undergoing TDCS.
This is a retrospective ...analysis of the American College of Surgeons-Trauma Quality Improvement Program database (2017-2021). All trauma patients who underwent emergency thoracotomy and packing with temporary closure were included. Patients were stratified based on the age groups (pediatric <18 y, adults 18-64 y, and older adults ≥65 y). Our primary outcome measures included 6-h, 24-h, and in-hospital mortality. Secondary outcomes were major complications.
We identified 14,192 thoracotomies, out of which 213 underwent TDCS (pediatric n = 17, adults n = 175, and older adults n = 21). The mean (SD) age was 37 (18), and 86% were male. The mean shock index was 1.1 (0.4) on presentation with a median IQR Glasgow Coma Scale of 4 3-14, and 22.1% had a prehospital cardiac arrest. The study population was profoundly injured with a median injury severity scoreand chest-abbreviated injury scale of 26 17-38 and 4 3-5, respectively, with lung (76.5%) being the most injured intrathoracic organs. Overall, the rates of 6-h, 24-h, and in-hospital mortality were 22.5%, 33%, and 53%, respectively, and 51% developed major complications. There was no significant difference in terms of in-hospital mortality (P = 0.800) and major complications (0.416) among pediatrics, adults, and older adults.
One in three patients undergoing TDCS die within the first 24 h, and more than half of them develop major complications and die in the hospital, with no difference among pediatric, adults, and older adults. Future efforts should be directed to improve the survival of these severely injured, metabolically depleted, challenging patients.
Firearm violence and school shootings remain a significant public health problem. This study aimed to examine how publicly available data from all 50 states might improve our understanding of the ...situation, firearm type, and demographics surrounding school shootings.
School shootings occurring in the US for 53 years ending in May 2022 were analyzed, using primary data files that were obtained from the Center for Homeland Defense and Security. Data analyzed included situation, injury, firearm type, and demographics of victims and shooters. We compared the ratio of fatalities per wounded after stratifying by type of weapon. Rates (among children) of school shooting victims, wounded, and fatalities per 1 million population were stratified by year and compared over time.
A total of 2,056 school shooting incidents involving 3,083 victims were analyzed: 2,033 children, 5 to 17 years, and 1,050 adults, 18 to 74 years. Most victims (77%) and shooters (96%) were male individuals with a mean age of 18 and 19 years, respectively. Of the weapons identified, handguns, rifles, and shotguns accounted for 84%, 7%, and 4%, respectively. Rifles had a higher fatality-to-wounded ratio (0.45) compared with shooters using multiple weapons (0.41), handguns (0.35), and shotguns (0.30). Linear regression analysis identified a significant increase in the rate of school shooting victims (β = 0.02, p = 0.0003), wounded (β = 0.01, p = 0.026), and fatalities (β = 0.01, p = 0.0003) among children over time.
Despite heightened public awareness, the incidence of school shooting victims, wounded, and fatalities among children has steadily and significantly increased over the past 53 years. Understanding the epidemic represents the first step in preventing continued firearm violence in our schools.
Our study compares the delayed outcomes of operative versus nonoperative management of pancreatic injuries.
We analyzed the 2017 Nationwide Readmissions Database on adult (≥18 years) trauma patients ...with pancreatic injuries. Patients who died on index admission were excluded. Patients were stratified into operative (OP) and non-operative (NOP) groups and compared for outcomes within 90 days of discharge. Multivariable regression analyses were performed.
We identified 1553 patients (NOP = 1092; OP = 461). The Mean (SD) age was 3917 years, 31% of patients were female, and 77% had blunt injuries. Median ISS was 17 9–25 and 74% had concomitant non-pancreatic intraabdominal injuries. On multivariable analysis, operative management was independently associated with increased odds of 90-day readmissions (aOR = 1.47; p = 0.03), intraabdominal abscesses (aOR = 2.7; p < 0.01), pancreatic pseudocyst (aOR = 2.4; p = 0.04), and need for percutaneous or endoscopic management (aOR = 5.8; p < 0.001).
Operative management of pancreatic injuries is associated with higher rates of delayed complications compared to non-operative management. Surgically treated pancreatic trauma patients may need close surveillance even after discharge.
•Most patients with traumatic pancreatic injury were treated non-operatively.•Operative treatment was associated with longer hospital length of stay and worse outcomes within 90 days post-discharge.•Worse outcomes included unplanned readmissions, abscesses, pancreatic insufficiency, and the need for drainage.•No difference in delayed pancreatitis, sepsis, and 90-day mortality between both groups.
The incorporation of dedicated palliative care (PC) services in the care of the critically injured trauma patient is not yet universal. Preexisting data demonstrate both economic and clinical value ...of PC consults, yet patient selection and optimal timing of these consults are poorly defined, possibly leading to underutilization of PC services. Prior studies in geriatric patients have shown benefits of PC when PC clinicians are engaged earlier during hospitalization. We aim to compare hospitalization metrics of early versus late PC consultation in trauma patients.
All patients 18 years or older admitted to the trauma service between January 1, 2019, and March 31, 2021, who received a PC consult were included. Patients were assigned to EARLY (PC consult ≤3 days after admission) and LATE (PC consult >3 days after admission) cohorts. Demographics, injury and underlying disease characteristics, outcomes, and financial data were compared. Length of stay (LOS) in the EARLY group is compared with LOS-3 in the LATE group.
A total of 154 patient records met the inclusion criteria (60 EARLY and 94 LATE). Injury Severity Score, head Abbreviated Injury Scale score, and medical comorbidities (congestive heart failure, dementia, previous stroke, chronic obstructive pulmonary disease, malignancy) were similar between the groups. The LATE group was younger (69.9 vs. 75.3, p = 0.04). Patients in the LATE group had significantly longer LOS (17.5 vs. 7.0 days, p < 0.01) and higher median hospital costs ($53,165 vs. $17,654, p < 0.01). Patients in the EARLY group had reduced ventilator days (2.4 vs. 7.0, p < 0.01) and reduced rates of tracheostomies and surgical feeding tubes (1.7% vs. 11.7%, p = 0.03).
Trauma patients with early PC consultation had shorter LOS, reduced ventilator days, reduced rates of invasive procedures, and lower costs even after correcting for delay to consult in the late group. These findings suggest the need for mechanisms leading to earlier PC consult in critically injured patients.
Therapeutic/Care Management; Level IV.
Frailty has been known to negatively affect the outcomes of geriatric trauma patients. However, there is a lack of data on the effect of frailty on the outcomes of geriatric trauma patients with ...concomitant burn injuries. The aim of our study was to compare the outcomes of frail versus nonfrail geriatric trauma patients with concomitant burn injuries.
We performed a retrospective analysis of American College of Surgeons Trauma Quality Improvement Program (2018). We included geriatric (≥65 y) trauma patients who sustained a concomitant burn injury with ≥10% Total Body Surface Area affected. Patients with body region-specific AIS ≥4 were excluded. Patients were stratified into Frail and Nonfrail, using 5-factor modified Frailty Index. Primary outcomes measured were mortality. Secondary outcomes measured were complications, and hospital and intensive care unit (ICU) length of stay (LOS). Multivariable logistic regression was performed to identify independent predictors of mortality.
A total of 574 patients were identified, of which 172(30%) were Frail. Mean age was 74 ± 7 y and median interquartile range ISS was 31-10. Overall, the rate of mortality was 23% and median hospital LOS was 143-31. After controlling for potential confounding factors, frailty was not identified as an independent predictor of mortality (adjusted odds ratio:1.059, P = 0.93) and complications (adjusted odds ratio:1.10, P = 0.73). However, frail patients had longer hospital (β: 5.01, P = 0.002) and ICU LOS (β: 2.12, P < 0.001).
Among geriatric trauma patients with concomitant burn injuries, frailty is associated with longer hospital and ICU LOS, and higher rates of thrombotic complications, but not higher mortality or overall complications. Future research should investigate the impact of early assessment of frailty as well as tailored interventions on outcomes in this population.
There is a paucity of data on factors that influence the decision regarding withdrawal of life supporting treatment (WLST) in geriatric trauma patients. We aimed to identify predictors of WLST in ...geriatric trauma patients.
This retrospective analysis of the American College of Surgeons- Trauma Quality Improvement Program (2017-2019) included all severely injured (Injury Severity Score >15) geriatric trauma patients (≥65 years). Multivariable logistic regression was performed to identify independent predictors of WLST.
There were 155,583 patients included. Mean age was 77 ± 7 years, 55% were male, 97% sustained blunt injury, and the median Injury Severity Score was 17 16-25. Overall WLST rate was 10.8%. On MLR analysis, increasing age (adjusted odds ratio aOR, 1.35; 95% confidence interval CI, 1.33-1.37; p < 0.001), male sex (aOR, 1.14; 95% CI, 1.09-1.18; p < 0.001), White race (aOR, 1.44; 95% CI, 1.36-1.52; p < 0.001), frailty (aOR, 1.42; 95% CI, 1.34-1.50; p < 0.001), government insurance (aOR, 1.27; 95% CI, 1.20-1.33; p < 0.001), presence of advance directive limiting care (aOR, 2.55; 95% CI, 2.40-2.70; p < 0.001), severe traumatic brain injury (aOR, 1.80; 95% CI, 1.66-1.95; p < 0.001), ventilator requirement (aOR, 12.73; 95% CI, 12.09-13.39; p < 0.001), and treatment at higher level trauma centers (Level I aOR, 1.49; 95% CI, 1.42-1.57; p < 0.001; Level II aOR, 1.43; 95% CI, 1.35-1.51; p < 0.001) were independently associated with higher odds of WLST.
Our results suggest that nearly one in 10 severely injured geriatric trauma patients undergo WLST. Multiple patient and hospital related factors contribute to decision making and directed efforts are necessary to create a more standardized process.
Prognostic and Epidemiological; Level III.
We aimed to examine impact of trauma center (TC) surgical stabilization of rib fracture (SSRF) volume on outcomes of patients undergoing SSRF.
Blunt rib fracture patients who underwent SSRF were ...included from ACS-TQIP2017-2021. TCs were stratified according to tertiles of SSRF volume:low (LV), middle, and high (HV). Outcomes were time to SSRF, respiratory complications, prolonged ventilator use, mortality.
16,872 patients were identified (LV:5470,HV:5836). Mean age was 56 years, 74% were male, median thorax-AIS was 3. HV centers had a lower proportion of patients with flail chest (HV41% vs LV50%), pulmonary contusion (HV44% vs LV52%) and had shorter time to SSRF(HV58 vs LV76 h), less respiratory complications (HV3.2% vs LV4.5%), prolonged ventilator use (HV15% vs LV26%), mortality (HV2% vs LV2.6%) (all p < 0.05). On multivariable regression analysis, HV centers were independently associated with reduced time to SSRF(β = −18.77,95%CI = −21.30to-16.25), respiratory complications (OR = 0.67,95%CI = 0.49–0.94), prolonged ventilator use (OR = 0.49,95%CI = 0.41–0.59), but not mortality.
HV SSRF centers have improved outcomes, however, there are variations in threshold for SSRF and indications must be standardized.
Level III.
Therapeutic/Care Management.
•Surgical stabilization of rib fractures (SSRF) at centers with high operative experience in SSRF has improved outcomes.•There are wide variations in the threshold of performing SSRF between high-volume and low-volume centers.•Centers performing 21 annual SSRF cases may be considered as SSRF centers of excellence.
This study aims to evaluate the temporal trends of mortality among frail versus non-frail older adult trauma patients during index hospitalization.
We performed a 3-year (2017–2019) analysis of ...ACS-TQIP. We included all older adult (age ≥65 years) trauma patients. Patients were stratified into two groups (Frail vs. Non-Frail). Outcomes were acute (<24 h), early (24–72 h), intermediate (72 hours-1 week), and late (>1 week) mortality.
A total of 1,022,925 older adult trauma patients were identified, of which 19.7 % were frail. The mean(SD) age was 77(8) years and 57.4 % were female. MedianIQR ISS was 94–10 and both groups had comparable injury severity (p = 0.362). On multivariable analysis, frailty was not associated with acute (aOR 1.034; p = 0.518) and early (aOR 1.190; p = 0.392) mortality, while frail patients had independently higher odds of intermediate (aOR 1.269; p = 0.042) and late (aOR 1.835; p < 0.001) mortality. On sub-analysis, our results remained consistent in mild, moderate, and severely injured patients.
Frailty is an independent predictor of mortality in older adult trauma patients who survive the initial 3 days of admission, regardless of injury severity.
•Frailty is known as a predictor of worse clinical outcomes and mortality following injury.•The timing of increased mortality rates in frail patients during hospitalization remains unclear.•Frailty is an independent predictor of mortality in older adult trauma patients who survive the initial 3 days of admission.•Early frailty assessment in identifying high-risk individuals is of paramount importance.
Long-term readmission data for venous thromboembolism (VTE) after spinal fractures is limited. We aimed to evaluate the 1-month and 6-month VTE readmission rates in non-operatively managed traumatic ...spinal fractures.
Analysis of the 2017 NRD. Adults (≥18 years) with a primary diagnosis of spinal fracture who were managed non-operatively were included. Patients that died on index admission, were on pre-injury anticoagulants, and those with spinal cord injuries were excluded. Outcomes were rates of DVT, PE, and VTE during index admission, and at 1-month and 6-months after discharge. Multivariate regression analysis was performed to identify independent predictors of 6-month readmission with VTE.
41,337 patients were identified. Mean age was 61 ± 22 years, and the median ISS was 179–22. Vertebral fractures were: 11% sacrococcygeal; 29% lumbar; 19% thoracic; 20% cervical; and 21% multiple levels. During the index admission, 392(0.9%) patients developed DVT, 281(0.7%) developed PE, and 601(1.5%) VTE. Within 1-month of discharge, 177(0.4%) patients were readmitted with DVT, 142(0.3%) with PE, and 268(0.6%) with VTE. Within 6-months of discharge, 352(0.9%) patients were readmitted with DVT, 250(0.6%) with PE, and 513(1.2%) with VTE. Among those who were readmitted within 6-months with VTE, mortality was 6.7%. On multivariate analysis, older age(OR = 1.01,p < 0.01), higher ISS(OR = 1.03,p < 0.001), thoracic level of spinal fracture(OR = 1.37,p = 0.04), and discharge to skilled nursing facility, rehabilitation center, or care facility(OR = 1.73,p < 0.001) were independently associated with 6-month readmission due to VTE.
VTE risk and associated mortality remains high for 6-months after non-operatively managed traumatic spinal fracture. Further studies regarding optimal duration and choice of thromboprophylactic agents are warranted.
•Long-term readmission data for venous thromboembolism (VTE) after spinal fractures is limited.•There is a shift towards non-operative management for stable spinal fractures without evidence of neurologic deficits or SCI.•VTE risk and associated mortality remains high for 6-months after non-operatively managed traumatic spinal fracture.•Further studies regarding optimal duration and choice of thromboprophylactic agents are warranted.
Early cholecystectomy (CCY) for acute biliary pancreatitis (ABP) is recommended but there is a paucity of data assessing this approach in frail geriatric patients. This study compares outcomes of ...frail geriatric ABP patients undergoing index admission CCY versus nonoperative management (NOM) with endoscopic retrograde cholangiopancreatography (ERCP).
Retrospective analysis of the Nationwide Readmissions Database (2017). All frail geriatric (≥65 years) patients with ABP were included. Patients were grouped by treatment at index admission: CCY versus NOM with ERCP. Propensity score matching was performed in a 1:2 ratio. Primary outcomes were 6-month readmissions, mortality, and length of stay (LOS). Secondary outcome was 6-month failure of NOM defined as readmission for recurrent ABP, unplanned pancreas-related procedures, or unplanned CCY. Sub-analysis was performed to compare outcomes of unplanned CCY versus early CCY.
29,130 frail geriatric patients with ABP were identified and 7,941 were matched (CCY, 5,294; NOM, 2,647). Patients in the CCY group had lower 6-month rates of readmissions for pancreas-related complications, unplanned readmissions for pancreas-related procedures, overall readmissions, and mortality, and fewer hospitalized days (p<0.05). NOM failed in 12% of patients, and 7% of NOM patients were readmitted within 6 months to undergo CCY, of which 56% were unplanned. Patients who underwent unplanned CCY had higher complication rates, hospital costs, longer hospital LOS, and higher mortality compared to early CCY (p<0.05).
For frail geriatric patients with ABP, early CCY was associated with lower 6-month rates of complications, readmissions, mortality, and fewer hospitalized days. Nearly one in seven failed NOM within six months, and one-third of these required unplanned CCY. Early CCY should be prioritized for frail geriatric ABP patients when feasible.
