Proximal Humerus Fractures in the Elderly: Concomitant Fractures and Management

Introduction. The purpose of this study was to identify additional injuries commonly seen with proximal humerus fractures experienced by patients 65 years or older and to evaluate discrepancies in the management of these patients with regard to provider type. Methods. A retrospective review was conducted of all patients 65 years or older who sustained a proximal humerus fracture. Patient data collected included demographics, injury details, hospital course, and discharge destination. Results. Patients with a concomitant fracture (45.5%, n = 65) had a slightly higher Injury Severity Score (ISS; 8.3 ± 3.0 vs. 6.4 ± 3.0, p < 0.001) and experienced one additional death than those with an isolated fracture (54.5%, n = 78). Slightly more patients were managed by a trauma provider (51.7%, n = 74) than by a non-trauma provider (48.3%, n = 69). Those managed by a trauma provider sustained the most pelvic fractures (12.2% vs. 2.9%, p = 0.038), were more likely to be injured in a motor vehicle collision (8.1% vs. 0%, p = 0.005), had a higher ISS (8.0 ± 3.3 vs. 6.4 ± 2.8, p = 0.003), and had more imaging performed than those treated by a non-trauma provider. There was, however, no difference in operative rates, concomitant injuries, length of stay or discharge disposition regarding provider type.  Conclusions. It is important to recognize proximal humerus fractures as a sign of fragility and to optimize hospital management of these patients

Demographics and Incident Location of Gunshot Wounds at a Single Level I Trauma Center

Introduction:  Little is known surrounding the demographic and geospatial factors of firearm-related traumas in the Midwest Region.  The purpose of this study was to describe the overall incidence of firearm-related traumas and examine any racial/ethnic disparities that may exist. Methods:  A retrospective review was conducted of all patients 14 years or older who were admitted with a gunshot wound (GSW) to a Level I trauma center between 2016 and 2017.  Results:  Forty-nine percent of patients were Caucasian, 26.5% African American, and 19.6% Hispanic/Latino.  Hispanic/Latino patients were the youngest (25.8 ± 8.8) and Caucasians were the oldest (34.3 ± 14.1, P = 0.002).  Compared to Caucasian patients, African American (42.0%) and Hispanic/Latino (54.1%) patients were more likely to be admitted to the intensive care unit (ICU) (P = 0.034) and experienced longer ICU lengths of stay (2.5 ± 6.3 and 2.4 ± 4.7, P = 0.031, respectively).  African American patients (96.0%) experienced more assaults while Caucasians were more likely to receive gunshot wounds accidentally (26.9%, P = 0.001).  More African American (86.0%) and Hispanic/Latino (89.2%) patients were injured with a handgun and Caucasians sustained the highest number of shotgun/rifle related injuries (16.1%, P = 0.012).  Most GSWs occurred in zip codes 67202, 67203, 67213, 67211, and 67214.  Geographical maps indicated that GSWs were concentrated in low-income areas and areas with high minority populations.                                                                                                                                                                                              Conclusions:  Racial differences were noted, however, unlike national trends, most of our patients were older Caucasian males

Evaluation of Outcomes and Treatment Options Among Trauma Patients with Abdominal Vascular Injuries: Abdominal Vascular Injuries

Introduction.  Abdominal vascular injuries are rare and are associated with significant morbidity and mortality. Treatment options include nonoperative management, open repair, and endovascular procedures. This study aimed to characterize patients and detail treatment modalities among those who sustained a traumatic abdominal vascular injury. Methods.  A 6-year descriptive retrospective study was conducted at an American College of Surgeons-verified level 1 trauma center and included all adult patients who sustained an abdominal vascular injury. Results.  Most vascular injuries were to the iliac artery (27.9%), abdominal aorta (25.6%), and inferior vena cava (25.6%). Twenty-seven percent of patients sustained an injury to more than one vascular structure. Thirty-four percent of patients died before treatment of the abdominal vascular injury. Among the 28 patients (65.1%) treated for their vascular injuries, 46.4% were treated with open surgery, 32.1% were treated nonoperatively and 21.4% with coil embolization. The most common vascular injuries treated were lacerations (56%) and transections (21%). Sixty-four percent of the patients who survived to discharge presented for follow-up care with a mean follow-up period of 3 ± 4.1 months. There were no vascular reinterventions after discharge for patients who followed up with our hospital.  Conclusions.  Study findings suggests that appropriately selected cases of traumatic vascular injuries may be safely managed nonoperatively, as there were no mortalities, complications, or reinterventions among these patients.

Demographics and Incident Location of Traumatic Injuries at a Single Level I Trauma Center: Traumatic Injury Mapping

Introduction: Traumatic injuries are preventable and understanding determinants of injury, such as socio-economic and environmental factors, is vital.  This study evaluated traumatic injuries and identified areas of high trauma incidence.                                                                                               Methods:  A retrospective review was conducted of all patients 14 years or older who were admitted with a traumatic injury to a Level I trauma center between 2016 and 2017.  Descriptive analyses were presented and maps of high injury areas were generated.                                Results:  The most frequent mechanisms of injury were falls (58.3%), motor vehicle crashes (22.3%), and motorcycle crashes (5.7%).  Fall patients were more likely to be female (59.6%) and were the oldest age group (72.1 ± 17.2) compared to motor vehicle and motorcycle crash patients.  Severe head (22.1%, P = 0.007) and extremity (35.7%, P = 0.001) injuries were most frequent among fall patients, however more motorcycle crash patients required mechanical ventilation (16.1%, P < 0.001) and experienced the longest intensive care unit length of stay (5.3 ± 6.8, P < 0.001) and mechanical ventilation days (6.6 ± 8.5, P < 0.036).  Motorcycle crash patients also had the most number of deaths (7.5%, P < 0.001).  The generated maps of all traumatic suggest that most injuries occur near our hospital and are located in several of the most population-dense zip codes.                                                                                                       Conclusions:  Falls, motor vehicle crashes, and motorcycle crashes were the most common mechanisms of injury.  The use of Geographic Information System aided in the identification of high injury incidence location.                          &nbsp

Traumatic Brain Injury in Older Adults: Characteristics, Outcomes, and Considerations. Results From the American Association for the Surgery of Trauma Geriatric Traumatic Brain Injury (GERI-TBI) Multicenter Trial.

OBJECTIVES: Describe the epidemiology of a large cohort of older adults with isolated traumatic brain injury (TBI) and identify predictors of mortality, palliative interventions, and discharge to preinjury residence in those presenting with moderate/severe TBI. DESIGN: Prospective observational study of geriatric patients with TBI enrolled across 45 trauma centers. SETTING AND PARTICIPANTS: Inclusion criteria were age ≥40 years, and computed tomography (CT)-verified TBI. Exclusion criteria were any other body region abbreviated injury scale score \u3e2 and presentation at enrolling center \u3e24 hours after injury. METHODS: The analysis was restricted to individuals aged ≥65 and stratified into 3 age groups: young-old (65-74), middle-old (75-84), and oldest-old (≥85). Demographic, clinical, and injury data were collected. Predictors of mortality, palliative interventions, and discharge to preinjury residence in the moderate/severe TBI group were identified using Classification and Regression Tree and Generalized Linear Mixed Models. RESULTS: Of the 3081 subjects enrolled in the study, 2028 were ≥65 years old. Overall, 339 (16.7%) presented with a moderate/severe TBI and experienced a 64% mortality rate. A Glasgow Coma Scale (GCS) scoremortality, CT worsening (odds ratio [OR] = 1.7, P \u3c .04), cerebral edema (OR = 2.4, P \u3c .04), GCS CONCLUSION AND IMPLICATIONS: In this prospective study of a large cohort of older adults with isolated TBI, comparisons across the older age groups with moderate/severe TBI revealed that survival and favorable discharge disposition were influenced more by severity of injury rather than age itself. Indicating that chronological age alone maybe insufficient to accurately predict outcomes, and increased representation of older adults in TBI research to develop better diagnostic and prognostic tools is warranted

Factors associated with receipt of intracranial pressure monitoring in older adults with traumatic brain injury.

BACKGROUND: The Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Traumatic Brain Injury (TBI) include intracranial pressure monitoring (ICPM), yet very little is known about ICPM in older adults. Our objectives were to characterize the utilization of ICPM in older adults and identify factors associated with ICPM in those who met the BTF guidelines. METHODS: We analyzed data from the American Association for the Surgery of Trauma Geriatric TBI Study, a registry study conducted among individuals with isolated, CT-confirmed TBI across 45 trauma centers. The analysis was restricted to those aged ≥60. Independent factors associated with ICPM for those who did and did not meet the BTF guidelines were identified using logistic regression. RESULTS: Our sample was composed of 2303 patients, of whom 66 (2.9%) underwent ICPM. Relative to Glasgow Coma Scale (GCS) score of 13 to 15, GCS score of 9 to 12 (OR 10.2; 95% CI 4.3 to 24.4) and GCS score of \u3c9 \u3e(OR 15.0; 95% CI 7.2 to 31.1), intraventricular hemorrhage (OR 2.4; 95% CI 1.2 to 4.83), skull fractures (OR 3.6; 95% CI 2.0 to 6.6), CT worsening (OR 3.3; 95% CI 1.8 to 5.9), and neurosurgical interventions (OR 3.8; 95% CI 2.1 to 7.0) were significantly associated with ICPM. Restricting to those who met the BTF guidelines, only 43 of 240 (18%) underwent ICPM. Factors independently associated with ICPM included intraparenchymal hemorrhage (OR 2.2; 95% CI 1.0 to 4.7), skull fractures (OR 3.9; 95% CI 1.9 to 8.2), and neurosurgical interventions (OR 3.5; 95% CI 1.7 to 7.2). DISCUSSION: Worsening GCS, intraparenchymal/intraventricular hemorrhage, and skull fractures were associated with ICPM among older adults with TBI, yet utilization of ICPM remains low, especially among those meeting the BTF guidelines, and potential benefits remain unclear. This study highlights the need for better understanding of factors that influence compliance with BTF guidelines and the risks versus benefits of ICPM in this population. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III

Predictors of Retained Hemothorax in Trauma: Results of an EAST Multi-Institutional Trial.

BACKGROUND: The natural history of traumatic hemothorax (HTX) remains unclear. We aimed to describe outcomes of HTX following tube thoracostomy drainage and to delineate factors that predict progression to a retained hemothorax (RH). We hypothesized that initial large volume HTX predicts the development of an RH. METHODS: We conducted a prospective, observational multi-institutional study of adult trauma patients diagnosed with a HTX identified on CT scan with volumes calculated at time of diagnosis. All patients were managed with tube thoracostomy drainage within 24 hours of presentation. RH was defined as blood-density fluid identified on follow-up CT scan or need for additional intervention after initial tube thoracostomy placement for HTX. RESULTS: 369 patients who presented with a HTX initially managed with tube thoracostomy drainage were enrolled from 17 trauma centers. RH was identified in 106 (28.7%) patients. Patients with RH had a larger median [IQR] HTX volume on initial CT compared to no RH (191 [48-431] mL vs. 88 [35-245] mL, p = 0.013) and were more likely to be older with a higher burden of thoracic injury. After controlling for significant differences between groups, RH was independently associated with a larger HTX on presentation, with a 15% increase in risk of RH for each additional 100 mL of HTX on initial CT imaging (OR 1.15, 95% CI 1.08-1.21; p \u3c 0.001). Patients with an RH also had higher rates of pneumonia and longer hospital length of stay than those with successful initial management. RH was also associated with worse functional outcomes at discharge and first outpatient follow-up. CONCLUSION: Larger initial HTX volumes are independently associated with RH and unsuccessful initial management with tube thoracostomy is associated with worse patient outcomes. Future studies should use this experience to assess a range of options for reducing the risk of unsuccessful initial management. LEVEL OF EVIDENCE: III, therapeutic/care management study

Outcomes after ultramassive transfusion in the modern era: An Eastern Association for the Surgery of Trauma multicenter study

BACKGROUND: Despite the widespread institution of modern massive transfusion protocols with balanced blood product ratios, survival for patients with traumatic hemorrhage receiving ultramassive transfusion (UMT) (defined as ≥20 U of packed red blood cells [RBCs]) in 24 hours) remains low and resource consumption remains high. Therefore, we aimed to identify factors associated with mortality in trauma patients receiving UMT in the modern resuscitation era. METHODS: An Eastern Association for the Surgery of Trauma multicenter retrospective study of 461 trauma patients from 17 trauma centers who received ≥20 U of RBCs in 24 hours was performed (2014-2019). Multivariable logistic regression and Classification and Regression Tree analysis were used to identify clinical characteristics associated with mortality. RESULTS: The 461 patients were young (median age, 35 years), male (82%), severely injured (median Injury Severity Score, 33), in shock (median shock index, 1.2; base excess, -9), and transfused a median of 29 U of RBCs, 22 U of fresh frozen plasma (FFP), and 24 U of platelets (PLT). Mortality was 46% at 24 hours and 65% at discharge. Transfusion of RBC/FFP ≥1.5:1 or RBC/PLT ≥1.5:1 was significantly associated with mortality, most pronounced for the 18% of patients who received both RBC/PLT and RBC/FFP ≥1.5:1 (odds ratios, 3.11 and 2.81 for mortality at 24 hours and discharge; both p < 0.01). Classification and Regression Tree identified that age older than 50 years, low initial Glasgow Coma Scale, thrombocytopenia, and resuscitative thoracotomy were associated with low likelihood of survival (14-26%), while absence of these factors was associated with the highest survival (71%). CONCLUSION: Despite modern massive transfusion protocols, one half of trauma patients receiving UMT are transfused with either RBC/FFP or RBC/PLT in unbalanced ratios ≥1.5:1, with increased associated mortality. Maintaining focus on balanced ratios during UMT is critical, and consideration of advanced age, poor initial mental status, thrombocytopenia, and resuscitative thoracotomy can aid in prognostication. LEVEL OF EVIDENCE: Prognostic, level III

“The Why &amp; How Our Trauma Patients Die

BackgroundHistorically, hemorrhage has been attributed as the leading cause (40%) of early death. However, a rigorous, real-time classification of the cause of death (COD) has not been performed. This study sought to prospectively adjudicate and classify COD to determine the epidemiology of trauma mortality.MethodsEighteen trauma centers prospectively enrolled all adult trauma patients at the time of death during December 2015 to August 2017. Immediately following death, attending providers adjudicated the primary and contributing secondary COD using standardized definitions. Data were confirmed by autopsies, if performed.ResultsOne thousand five hundred thirty-six patients were enrolled with a median age of 55 years (interquartile range, 32-75 years), 74.5% were male. Penetrating mechanism (n = 412) patients were younger (32 vs. 64, p &lt; 0.0001) and more likely to be male (86.7% vs. 69.9%, p &lt; 0.0001). Falls were the most common mechanism of injury (26.6%), with gunshot wounds second (24.3%). The most common overall primary COD was traumatic brain injury (TBI) (45%), followed by exsanguination (23%). Traumatic brain injury was nonsurvivable in 82.2% of cases. Blunt patients were more likely to have TBI (47.8% vs. 37.4%, p &lt; 0.0001) and penetrating patients exsanguination (51.7% vs. 12.5%, p &lt; 0.0001) as the primary COD. Exsanguination was the predominant prehospital (44.7%) and early COD (39.1%) with TBI as the most common later. Penetrating mechanism patients died earlier with 80.1% on day 0 (vs. 38.5%, p &lt; 0.0001). Most deaths were deemed disease-related (69.3%), rather than by limitation of further aggressive care (30.7%). Hemorrhage was a contributing cause to 38.8% of deaths that occurred due to withdrawal of care.ConclusionExsanguination remains the predominant early primary COD with TBI accounting for most deaths at later time points. Timing and primary COD vary significantly by mechanism. Contemporaneous adjudication of COD is essential to elucidate the true understanding of patient outcome, center performance, and future research.Level of evidenceEpidemiologic, level II