The Journal of Trauma

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Pediatric extremity vascular trauma: It matters where it is treated

imageBACKGROUND
Extremity vascular injuries in children are rare events that present unique therapeutic challenges. The absence of a pediatric-specific protocol for definitive care of these injuries risks variability in treatment practices and outcomes. Using a nationwide data set, we investigated variations in the management and outcomes of pediatric patients with peripheral vascular trauma and characterized differences based on hospital category.
METHODS
Retrospective cohort study using the American College of Surgeons (ACS) National Trauma Data Bank to identify patients 16 years or younger with extremity vascular trauma admitted in calendar year 2016. Hospitals were categorized as ACS-verified pediatric trauma centers (Level I or II), ACS-verified adult trauma centers (Level I or II), or other hospitals (all other trauma centers and nondesignated hospitals). Patient data were evaluated by hospital category.
RESULTS
Among 164,882 pediatric admissions, 702 patients were identified for analysis. There were 430 (61.3%) patients with upper-extremity injuries, 270 (38.5%) with lower-extremity injuries, and 2 (0.2%) had both. Mean age was 11.5 years, and 51.6% were blunt-injured. Overall, 40.2% were admitted to pediatric trauma centers, 28.9% to adult trauma centers, and 30.9% to other hospitals. Hospitals without ACS trauma center verification had a significantly higher amputation rate than any ACS-verified adult or pediatric center (p = 0.013).
CONCLUSION
The incidence of pediatric extremity vascular injury is low. Hospitals with ACS trauma center verification have greater pediatric limb salvage rates than those without verification. Future study should seek to identify specific regional or resource-related factors that contribute to this disparity.
LEVEL OF EVIDENCE
Epidemiological, level III.

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https://journals.lww.com/jtrauma/Fulltext/2020/04000/Pediatric_extremity_vascular_trauma__It_matters.1.aspx

Human neural stem cell transplant location–dependent neuroprotection and motor deficit amelioration in rats with penetrating traumatic brain injury

imageBACKGROUND
Penetrating traumatic brain injury induces chronic inflammation that drives persistent tissue loss long after injury. Absence of endogenous reparative neurogenesis and effective neuroprotective therapies render injury-induced disability an unmet need. Cell replacement via neural stem cell transplantation could potentially rebuild the tissue and alleviate penetrating traumatic brain injury disability. The optimal transplant location remains to be determined.
METHODS
To test if subacute human neural stem cell (hNSC) transplant location influences engraftment, lesion expansion, and motor deficits, rats (n = 10/group) were randomized to the following four groups (uninjured and three injured): group 1 (Gr1), uninjured with cell transplants (sham+hNSCs), 1-week postunilateral penetrating traumatic brain injury, after establishing motor deficit; group 2 (Gr2), treated with vehicle (media, no cells); group 3 (Gr3), hNSCs transplanted into lesion core (intra); and group 4 (Gr4), hNSCs transplanted into tissue surrounding the lesion (peri). All animals were immunosuppressed for 12 weeks and euthanized following motor assessment.
RESULTS
In Gr2, penetrating traumatic brain injury effect manifests as porencephalic cyst, 22.53 ± 2.87 (% of intact hemisphere), with p value of <0.0001 compared with uninjured Gr1. Group 3 lesion volume at 17.44 ± 2.11 did not differ significantly from Gr2 (p = 0.36), while Gr4 value, 9.17 ± 1.53, differed significantly (p = 0.0001). Engraftment and neuronal differentiation were significantly lower in the uninjured Gr1 (p < 0.05), compared with injured groups. However, there were no differences between Gr3 and Gr4. Significant increase in cortical tissue sparing (p = 0.03), including motor cortex (p = 0.005) was observed in Gr4 but not Gr3. Presence of transplant within lesion or in penumbra attenuated motor deficit development (p < 0.05) compared with Gr2.
CONCLUSION
In aggregate, injury milieu supports transplanted cell proliferation and differentiation independent of location. Unexpectedly, cortical sparing is transplant location dependent. Thus, apart from cell replacement and transplant mediated deficit amelioration, transplant location–dependent neuroprotection may be key to delaying onset or preventing development of injury-induced disability.
LEVEL OF EVIDENCE
Preclinical study evaluation of therapeutic intervention, level VI.

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https://journals.lww.com/jtrauma/Fulltext/2020/04000/Human_neural_stem_cell_transplant.2.aspx

An analysis of outcomes and predictors of intensive care unit bouncebacks in a mature trauma system

imageBACKGROUND
With the recent birth of the Pennsylvania TQIP Collaborative, statewide data identified unplanned admissions to the intensive care unit (ICU) as an overarching issue plaguing the state trauma community. To better understand the impact of this unique population, we sought to determine the effect of unplanned ICU admission/readmission on mortality to identify potential predictors of this population. We hypothesized that ICU bounceback (ICUBB) patients would experience increased mortality compared with non-ICUBB controls and would likely be associated with specific patterns of complications.
METHODS
The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2012 to 2015 for all ICU admissions. Unadjusted mortality rates were compared between ICUBB and non-ICUBB counterparts. Multilevel mixed-effects logistic regression models assessed the adjusted impact of ICUBB on mortality and the adjusted predictive impact of 8 complications on ICUBB.
RESULTS
A total of 58,013 ICU admissions were identified from 2012 to 2015. From these, 53,715 survived their ICU index admission. The ICUBB rate was determined to be 3.82% (2,054/53,715). Compared with the non-ICUBB population, ICUBB patients had a significantly higher mortality rate (12% vs. 8%; p < 0.001). In adjusted analysis, ICUBB was associated with a 70% increased odds ratio for mortality (adjusted odds ratio, 1.70; 95% confidence interval, 1.44–2.00; p < 0.001). Adjusted analysis of predictive variables revealed unplanned intubation, sepsis, and pulmonary embolism as the strongest predictors of ICUBB.
CONCLUSION
Intensive care unit bouncebacks are associated with worse outcomes and are disproportionately burdened by respiratory complications. These findings emphasize the importance of the TQIP Collaborative in identifying statewide issues in need of performance improvement within mature trauma systems.
LEVEL OF EVIDENCE
Epidemiological study, level III.

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https://journals.lww.com/jtrauma/Fulltext/2020/04000/An_analysis_of_outcomes_and_predictors_of.3.aspx

Effects of hospital-acquired pneumonia on long-term recovery and hospital resource utilization following moderate to severe traumatic brain injury

imageBACKGROUND
Individuals with traumatic brain injury (TBI) have extended inpatient hospital stays that include prolonged mechanical ventilation, increasing risk for infections, including pneumonia. Studies show the negative short-term effects of hospital-acquired pneumonia (HAP) on hospital-based outcomes; however, little is known of its long-term effects.
METHODS
A prospective cohort study was conducted. National Trauma Databank and Traumatic Brain Injury Model Systems were merged to derive a cohort of 3,717 adults with moderate-to-severe TBI. Exposure data were gathered from the National Trauma Databank, and outcomes were gathered from the Traumatic Brain Injury Model Systems. The primary outcome was the Glasgow Outcome Scale—Extended (GOS-E), which was collected at 1, 2, and 5 years postinjury. The GOS-E was categorized as favorable (>5) or unfavorable (≤5) outcomes. A generalized estimating equation model was fitted estimating the effects of HAP on GOS-E over the first 5 years post-TBI, adjusting for age, race, ventilation status, brain injury severity, injury severity score, thoracic Abbreviated Injury Scale score of 3 or greater, mechanism of injury, intraventricular hemorrhage, and subarachnoid hemorrhage.
RESULTS
Individuals with HAP had a 34% (odds ratio, 1.34; 95% confidence interval, 1.15–1.56) increased odds for unfavorable GOS-E over the first 5 years post-TBI compared with individuals without HAP, after adjustment for covariates. There was a significant interaction between HAP and follow-up, such that the effect of HAP on GOS-E declined over time. Sensitivity analyses that weighted for nonresponse bias and adjusted for differences across trauma facilities did not appreciably change the results. Individuals with HAP spent 10.1 days longer in acute care and 4.8 days longer in inpatient rehabilitation and had less efficient functional improvement during inpatient rehabilitation.
CONCLUSION
Individuals with HAP during acute hospitalization have worse long-term prognosis and greater hospital resource utilization. Preventing HAP may be cost-effective and improve long-term recovery for individuals with TBI. Future studies should compare the effectiveness of different prophylaxis methods to prevent HAP.
LEVEL OF EVIDENCE
Prospective cohort study, level III.

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https://journals.lww.com/jtrauma/Fulltext/2020/04000/Effects_of_hospital_acquired_pneumonia_on.4.aspx

Development and validation of a revised trauma-specific quality of life instrument

imageBACKGROUND
The National Academies of Science has called for routine collection of long-term outcomes after injury. One of the main barriers for this is the lack of practical trauma-specific tools to collect such outcomes. The only trauma-specific long-term outcomes measure that applies a biopsychosocial view of patient care, the Trauma Quality-of-Life (T-QoL), has not been adopted because of its length, lack of composite scores, and unknown validity. Our objective was to develop a shorter version of the T-QoL measure that is reliable, valid, specific, and generalizable to all trauma populations.
METHODS
We used two random samples selected from a prospective registry developed to follow long-term outcomes of adult trauma survivors (Injury Severity Score ≥9) admitted to three level I trauma centers. First, we validated the original T-QoL instrument using the 12-Item Short-Form Health Survey (SF-12) version 2.0 and Breslau post-traumatic stress disorder screening (B-PTSD) tools. Second, we conducted a confirmatory factor analysis to reduce the length of the original T-QoL instrument, and using a different sample, we scored and performed internal consistency and validity assessments of the revised T-QoL (RT-QoL) components.
RESULTS
All components of the original T-QoL were significantly correlated negatively with the B-PTSD and positively with the SF-12 mental and physical composite scores. After confirmatory factor analysis, a three-component structure using 18 items (six items/component) most appropriately represented the data. Each component in the revised instrument demonstrated a high level of internal consistency (Cronbach's α ≥0.8) and correlated negatively with the B-PTSD and positively with the SF-12, demonstrating concurrent validity. In addition, each of the RT-QoL components was able to distinguish between individuals based on their work status, with those who have returned to work reporting better health.
CONCLUSION
This more practical RT-QoL measure greatly increases the ability to evaluate long-term outcomes in trauma more efficiently and meaningfully, without sacrificing the validity and psychometric properties of the original instrument.
LEVEL OF EVIDENCE
Prognostic and epidemiological, level III.

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https://journals.lww.com/jtrauma/Fulltext/2020/04000/Development_and_validation_of_a_revised.5.aspx

Detecting direct oral anticoagulants in trauma patients using liquid chromatography–mass spectrometry: A novel approach to medication reconciliation

imageBACKGROUND
Accurate medication reconciliation in trauma patients is essential but difficult. Currently, there is no established clinical method of detecting direct oral anticoagulants (DOACs) in trauma patients. We hypothesized that a liquid chromatography–mass spectrometry (LCMS)–based assay can be used to accurately detect DOACs in trauma patients upon hospital arrival.
METHODS
Plasma samples were collected from 356 patients who provided informed consent including 10 healthy controls, 19 known positive or negative controls, and 327 trauma patients older than 65 years who were evaluated at our large, urban level 1 trauma center. The assay methodology was developed in healthy and known controls to detect apixaban, rivaroxaban, and dabigatran using LCMS and then applied to 327 samples from trauma patients. Standard medication reconciliation processes in the electronic medical record documenting DOAC usage were compared with LCMS results to determine overall accuracy, sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of the assay.
RESULTS
Of 356 patients, 39 (10.96%) were on DOACs: 21 were on apixaban, 14 on rivaroxaban, and 4 on dabigatran. The overall accuracy of the assay for detecting any DOAC was 98.60%, with a sensitivity of 94.87% and specificity of 99.05% (PPV, 92.50%; NPV, 99.37%). The assay detected apixaban with a sensitivity of 90.48% and specificity of 99.10% (PPV, 86.36%; NPV 99.40%). There were three false-positive results and two false-negative LCMS results for apixaban. Dabigatran and rivaroxaban were detected with 100% sensitivity and specificity.
CONCLUSION
This LCMS-based assay was highly accurate in detecting DOACs in trauma patients. Further studies need to confirm the clinical efficacy of this LCMS assay and its value for medication reconciliation in trauma patients.
LEVEL OF EVIDENCE
Diagnostic Test, level III.

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https://journals.lww.com/jtrauma/Fulltext/2020/04000/Detecting_direct_oral_anticoagulants_in_trauma.6.aspx

Impact of an early mobilization protocol on outcomes in trauma patients admitted to the intensive care unit: A retrospective pre-post study

imageBACKGROUND
Prolonged immobility has detrimental consequences for critically ill patients admitted to the intensive care unit (ICU). Previous work has shown that early mobilization of ICU patients is a safe, feasible and effective strategy to improve outcomes; however, few of these studies focused on trauma ICU patients. Our objective was to assess the impact of implementing an ICU early mobilization protocol (EMP) on trauma outcomes.
METHODS
We conducted a retrospective pre-post study of adult trauma patients (>18 years old) admitted to ICU at a Level I trauma center over a 2-year period prior to and following EMP implementation, allowing for a 1-year transition period. Data were collected from the Nova Scotia Trauma Registry. We compared outcomes (mortality, length of stay [LOS], ventilator-free days) between patients admitted during pre-EMP and post-EMP periods, and assessed for factors associated with outcomes using binary logistic regression and generalized linear models.
RESULTS
Overall, 526 patients were included in the analysis (292 pre-EMP, 234 post-EMP). Ages ranged from 18 years to 92 years (mean, 49.0 ± 20.4 years) and 74.3% were men. The post-EMP group had lower ICU mortality (21.6% vs. 12.8%; p = 0.009) and in-hospital mortality (25.3% vs. 17.5%; p = 0.031). After controlling for confounders, patients in the post-EMP group were less likely to die in the ICU (odds ratio, 0.43; 95% confidence interval, 0.24–0.79; p = 0.006) or in-hospital (odds ratio, 0.55; 95% confidence interval; 0.32–0.94; p = 0.03). In-hospital LOS, ICU LOS, ICU-free days, and number of ventilator-free days were similar between the two groups.
CONCLUSION
Trauma patients admitted to ICU during the post-EMP period had decreased odds of ICU mortality and in-hospital mortality. This is the first study to demonstrate a significant reduction in trauma mortality following implementation of an ICU mobility protocol.
LEVEL OF EVIDENCE
Therapeutic, level III.

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https://journals.lww.com/jtrauma/Fulltext/2020/04000/Impact_of_an_early_mobilization_protocol_on.7.aspx

Venous thromboembolism chemoprophylaxis regimens in trauma and surgery patients with obesity: A systematic review

imageBACKGROUND
Venous thromboembolism (VTE) continues to be a devastating source of morbidity and mortality in obese patients who suffer traumatic injuries or obese surgery patients. High incidence rates in VTE despite adherence to prevention protocols have stirred interest in new dosing regimens. The purpose of this study was to systematically review the literature and present the existing VTE chemoprophylaxis regimens for obese trauma and surgical patients in terms of efficacy and safety as measured by the incidence of VTE, anti-factor Xa levels, and the occurrence of bleeding events.
METHODS
An online search of seven literature databases including PubMed, Excerpta Medica Database, GoogleScholar, JAMA Network, CINAHL, Cochrane, and SAGE Journals was performed for original studies evaluating the safety and efficacy of VTE chemoprophylaxis dosing regimens according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. The risk of bias was assessed using the Cochrane Risk of Bias Tool and the quality of evidence was determined using the GRADE Working Group criteria.
RESULTS
Of the 5,083 citations identified, 45 studies with 27,717 patients met inclusion criteria. In this group, six studies evaluated weight-based dosing regimens, four used a weight-stratified or weight-tiered strategy, five used a body mass index–stratified approach, 29 assessed fixed-dose regimens, and two used continuous infusions. The majority of the studies evaluated anti-factor Xa levels as their primary outcome rather than reduction in VTE.
CONCLUSION
Weight-based and high fixed-dose chemoprophylaxis regimens achieved target anti-Xa concentrations more frequently than standard fixed-dose regimens but were not associated with a reduction in VTE. Additionally, high fixed-dose approaches are associated with increased bleeding complications. Further evaluation with large randomized trials is warranted in trauma and surgery patients with obesity.
LEVEL OF EVIDENCE
Systematic review, level III.

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https://journals.lww.com/jtrauma/Fulltext/2020/04000/Venous_thromboembolism_chemoprophylaxis_regimens.8.aspx

The effect of cirrhosis on trauma outcomes: A systematic review and meta-analysis

imageBACKGROUND
The negative effect of cirrhosis on mortality following traumatic injury has been quantified in multiple observational studies. However, to our knowledge, the information contained in these studies has never been synthesized. The aims of this study were: (1) to determine the magnitude of the effect of liver cirrhosis on mortality, morbidity, and hospital course among trauma patients and (2) to analyze sources of study heterogeneity that may lead to differing estimates in the observed mortality rate among patients with cirrhosis.
METHODS
A systematic search of EMBASE and PubMed was conducted. Data were extracted from eligible studies and analyzed using a random-effects model to compare trauma outcomes in cirrhotic and noncirrhotic patients (PROSPERO Registration CRD42018088464). Mortality was the primary outcome. Secondary outcomes included complication rate, length of hospital stay, length of intensive care unit stay, and mechanical ventilation days.
RESULTS
Title and abstract review of 15,958 articles led to the identification of 31 relevant articles. Ultimately, 18 observational studies were included in this meta-analysis. The pooled effect sizes for mortality (odds ratio [OR], 4.52; 95% confidence interval [CI], 3.13–6.54) and complication rate (OR, 1.92; 95% CI, 1.30–2.85) were higher in the cirrhotic group than the noncirrhotic group. Trauma patients with cirrhosis also incurred longer hospital stays (mean difference, 3.81 days; 95% CI, 1.22–6.41) and longer ICU stays (mean difference, 2.40 days; 95% CI, 0.65–4.15). There was no difference in days spent on mechanical ventilation.
CONCLUSION
Preexisting liver cirrhosis is associated with increased mortality rate, complication rate, and length of hospitalization among trauma patients, even after adjusting for confounding factors and potential sources of between-study heterogeneity. Trauma patients with cirrhosis would benefit from heightened surveillance and injury prevention interventions.
LEVEL OF EVIDENCE
Systematic review and meta-analysis, level III.

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https://journals.lww.com/jtrauma/Fulltext/2020/04000/The_effect_of_cirrhosis_on_trauma_outcomes__A.9.aspx

The impact of frailty on posttraumatic outcomes in older trauma patients: A systematic review and meta-analysis

imageBACKGROUND
Frailty is a risk factor for mortality among the elderly. However, evidence from longitudinal studies linking trauma and frailty is fragmented, and a comprehensive analysis of the relationship between frailty and adverse outcomes is lacking. Therefore, we conducted a systematic review and meta-analysis to examine whether frailty is predictive of posttraumatic results including mortality, adverse discharge, complications, and readmission in trauma patients.
METHODS
This systematic review was registered with the PROSPERO international prospective register of systematic reviews. Articles in PubMed, Embase, and Web of Science databases from January 1, 1990, to October 31, 2019, were systematically searched. Articles in McDonald et al.'s study (J Trauma Acute Care Surg. 2016;80(5):824-834) and Cubitt et al.'s study (Injury 2019;50(11):1795-1808) were included for studies evaluating the association between frailty and outcomes in trauma patients. Cohort studies, both retrospective and prospective, were included. Study population was patients suffering trauma injuries with an average age of 50 years and older. Multivariate adjusted odds ratios (ORs) were calculated through a random-effects model, and the Newcastle-Ottawa Quality Assessment Scale was used to assess studies.
RESULTS
We retrieved 11,313 entries. Thirteen studies including seven prospective and six retrospective cohort studies involving 50,348 patients were included in the meta-analysis. Frailty was a significant predictor of greater than 30-day mortality (OR, 2.41; 95% confidence interval [CI], 1.17–4.95; I2 = 88.1%), in-hospital and 30-day mortality (OR, 4.05; 95% CI, 2.02–8.11; I2 = 0%), postoperative complications (OR, 2.23; 95% CI, 1.34–3.73; I2 = 78.2%), Clavien-Dindo IV complications (OR, 4.16; 95% CI, 1.70–10.17; I2 = 0%), adverse discharge (OR, 1.80; 95% CI, 1.15–2.84; I2 = 78.6%), and readmission (OR, 2.16; 95% CI, 1.19–3.91; I2 = 21.5%) in elderly trauma patients. Subgroup analysis showed that prospective studies (OR, 3.06; 95% CI, 1.43–6.56) demonstrated a greater correlation between frailty and postoperative complications.
CONCLUSION
Frailty has significant adverse impacts on the occurrence of posttraumatic outcomes. Further studies should focus on interventions for patients with frailty. Given the number of vulnerable elderly trauma patients grows, further studies are needed to determine the accuracy of these measures in terms of trauma outcomes.
LEVEL OF EVIDENCE
Systematic review and meta-analysis, level IV.

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https://journals.lww.com/jtrauma/Fulltext/2020/04000/The_impact_of_frailty_on_posttraumatic_outcomes_in.10.aspx

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