Outcomes in patients with gunshot wounds to the brain.

Introduction:Gunshot wounds to the brain (GSWB) confer high lethality and uncertain recovery. It is unclear which patients benefit from aggressive resuscitation, and furthermore whether patients with GSWB undergoing cardiopulmonary resuscitation (CPR) have potential for survival or organ donation. Therefore, we sought to determine the rates of survival and organ donation, as well as identify factors associated with both outcomes in patients with GSWB undergoing CPR. Methods:We performed a retrospective, multicenter study at 25 US trauma centers including dates between June 1, 2011 and December 31, 2017. Patients were included if they suffered isolated GSWB and required CPR at a referring hospital, in the field, or in the trauma resuscitation room. Patients were excluded for significant torso or extremity injuries, or if pregnant. Binomial regression models were used to determine predictors of survival/organ donation. Results:825 patients met study criteria; the majority were male (87.6%) with a mean age of 36.5 years. Most (67%) underwent CPR in the field and 2.1% (n=17) survived to discharge. Of the non-survivors, 17.5% (n=141) were considered eligible donors, with a donation rate of 58.9% (n=83) in this group. Regression models found several predictors of survival. Hormone replacement was predictive of both survival and organ donation. Conclusion:We found that GSWB requiring CPR during trauma resuscitation was associated with a 2.1% survival rate and overall organ donation rate of 10.3%. Several factors appear to be favorably associated with survival, although predictions are uncertain due to the low number of survivors in this patient population. Hormone replacement was predictive of both survival and organ donation. These results are a starting point for determining appropriate treatment algorithms for this devastating clinical condition. Level of evidence:Level II

Impact of trauma center volume on major vascular injury: An analysis of the National Trauma Data Bank (NTDB)

BACKGROUND: The association of procedure volume and improved outcomes has been established with infrequently performed elective operations. However, effect of trauma center volume on outcomes in emergency surgery has not been defined. We hypothesized that high volume centers (HVC) would provide better outcomes for operative major vascular injuries (MVI) than low volume centers (LVC). METHODS: The NTDB was queried from 2010 to 2014. Patients with MVI were identified and HVC were compared to LVC. HVC were defined as \u3e480 patients per year with ISS≥15. RESULTS: There were 37,125 patients with MVI, with 16,461 (44.3%) managed operatively. Of these, 15,965 (97%) underwent surgery at HVC and 496 (3%) at LVC. There was no difference in shunt utilization, however, HVC were more likely to utilize endovascular repair (31.0% vs. 21.9%, p \u3c 0.001). Rates of death, amputation, and compartment syndrome were similar. HVC were more likely to develop pneumonia or sepsis. On logistic regression, HVC was not associated with survival (OR: 0.90, 95%CI: 0.60-1.34, p = 0.60). Variables associated with mortality for HVC and LVC included thoracic arterial injury (OR: 1.57, 95%CI: 1.27-1.94, p \u3c 0.001), penetrating mechanism (OR:1.84, 95%CI: 1.57-2.15, p \u3c 0.001), and open repair (OR: 1.95, 95%CI: 1.69-2.26, p \u3c 0.001). Lower ISS (OR: 0.29, 95%CI: 0.24-0.34, p \u3c 0.001) and higher presenting blood pressure (OR: 0.99, 95%CI: 0.99-1.00, p \u3c 0.001) were associated with survival. CONCLUSIONS: Although LVC may have less proficiency with endovascular techniques, trauma center volume does not influence survival in emergency surgery for MVI

Language and trauma: Is care equivalent for those who do not speak English?

Aim: Few studies examine the relationship of language and surgical outcomes. Language is not included as a variable in many databases. The aim of this study was to examine the association of language and outcomes in trauma. Materials and methods: A 5-year retrospective review was performed at a level I trauma center. All adult trauma patients with a non-English primary language were matched to an English-speaking cohort by age, gender, injury mechanism, initial Glasgow coma scale (GCS), and injury severity score (ISS). Analysis included an unpaired two-tailed Student\u27s t test for continuous variables and a Fisher\u27s exact test for categorical variables. Results: Three hundred ninety-five non-English-speaking patients were identified. There was no difference in mortality, intubation rate, number of ventilator days, average hospital length of stay, readmission rates, or rates of nine complications, even when stratified for high (≥15) vs low (≤14) ISS. Non-English-speaking patients had a shorter average length of intensive care unit (ICU) stay (5.4 vs 6.9 days, p = 0.03), were mostly self-pay (236, 59.7% vs 127, 32.2%, p \u3c 0.01), and were more likely to be discharged home (340, 86.1% vs 309, 78.2%, p = 0.01). Conclusion: Despite similar outcomes, non-English-speaking trauma patients left the ICU more quickly, were more likely self-pay, and more likely to be discharged home. Clinical significance: These findings raise concerns about possible disparities in trauma care for non-English speaking patients and highlight the importance of inclusion of language as a variable in patient registries and national databases. Future studies should investigate additional potentially significant socioeconomic factors

Language and Trauma: Is Care Equivalent for Those Who do not Speak English?

Aim: Few studies examine the relationship of language and surgical outcomes. Language is not included as a variable in many databases. The aim of this study was to examine the association of language and outcomes in trauma. Materials and methods: A 5-year retrospective review was performed at a level I trauma center. All adult trauma patients with a non-English primary language were matched to an English-speaking cohort by age, gender, injury mechanism, initial Glasgow coma scale (GCS), and injury severity score (ISS). Analysis included an unpaired two-tailed Student\u27s t test for continuous variables and a Fisher\u27s exact test for categorical variables. Results: Three hundred ninety-five non-English-speaking patients were identified. There was no difference in mortality, intubation rate, number of ventilator days, average hospital length of stay, readmission rates, or rates of nine complications, even when stratified for high (≥15) vs low (≤14) ISS. Non-English-speaking patients had a shorter average length of intensive care unit (ICU) stay (5.4 vs 6.9 days, p = 0.03), were mostly self-pay (236, 59.7% vs 127, 32.2%, p \u3c 0.01), and were more likely to be discharged home (340, 86.1% vs 309, 78.2%, p = 0.01). Conclusion: Despite similar outcomes, non-English-speaking trauma patients left the ICU more quickly, were more likely self-pay, and more likely to be discharged home. Clinical significance: These findings raise concerns about possible disparities in trauma care for non-English speaking patients and highlight the importance of inclusion of language as a variable in patient registries and national databases. Future studies should investigate additional potentially significant socioeconomic factors

Outcomes in patients with gunshot wounds to the brain.

INTRODUCTION: Gunshot wounds to the brain (GSWB) confer high lethality and uncertain recovery. It is unclear which patients benefit from aggressive resuscitation, and furthermore whether patients with GSWB undergoing cardiopulmonary resuscitation (CPR) have potential for survival or organ donation. Therefore, we sought to determine the rates of survival and organ donation, as well as identify factors associated with both outcomes in patients with GSWB undergoing CPR. METHODS: We performed a retrospective, multicenter study at 25 US trauma centers including dates between June 1, 2011 and December 31, 2017. Patients were included if they suffered isolated GSWB and required CPR at a referring hospital, in the field, or in the trauma resuscitation room. Patients were excluded for significant torso or extremity injuries, or if pregnant. Binomial regression models were used to determine predictors of survival/organ donation. RESULTS: 825 patients met study criteria; the majority were male (87.6%) with a mean age of 36.5 years. Most (67%) underwent CPR in the field and 2.1% (n=17) survived to discharge. Of the non-survivors, 17.5% (n=141) were considered eligible donors, with a donation rate of 58.9% (n=83) in this group. Regression models found several predictors of survival. Hormone replacement was predictive of both survival and organ donation. CONCLUSION: We found that GSWB requiring CPR during trauma resuscitation was associated with a 2.1% survival rate and overall organ donation rate of 10.3%. Several factors appear to be favorably associated with survival, although predictions are uncertain due to the low number of survivors in this patient population. Hormone replacement was predictive of both survival and organ donation. These results are a starting point for determining appropriate treatment algorithms for this devastating clinical condition. LEVEL OF EVIDENCE: Level II