Austin Porter

Hemodynamic variables predict outcome of emergency thoracotomy in the pediatric trauma population.

BACKGROUND Limited data exist regarding indications for resuscitative emergency thoracotomy (ETR) in the pediatric population. We attempt to define the presenting hemodynamic parameters that predict survival for pediatric patients undergoing ETR. METHODS We reviewed all pediatric patients (age <18years), entered into the National Trauma Data Bank from 2007 to 2010, who underwent ETR within one hour of ED arrival. Mechanism of injury and hemodynamics were analyzed using Chi squared and Wilcoxon tests. RESULTS 316 children (70 blunt, 240 penetrating) underwent ETR, 31% (98/316) survived to discharge. Less than 5% of patients survived when presenting SBP was ≤50mmHg or heart rate was ≤70bpm. For blunt injuries there were no survivors with a pulse ≤80bpm or SBP ≤60mmHg. When survivors were compared to nonsurvivors, blood pressure, pulse, and injury type were statistically significant when treated as independent variables and in a logistic regression model. CONCLUSIONS When ETR was performed for SBP ≤50mmHg or for heart rate ≤70bpm less than 5% of patients survived. There were no survivors of blunt trauma when SBP was ≤60mmHg or pulse was ≤80bpm. This review suggests that ETR may have limited benefit in these patients.

The effectiveness of a statewide trauma call center in reducing time to definitive care for severely injured patients.

BACKGROUND The state of Arkansas developed and implemented a comprehensive inclusive trauma system in July 2010. The Arkansas Trauma Communication Center (ATCC) is a central component in the system, designed to facilitate both scene transports and interfacility transfers within the state. The first 18 months of operations were examined to evaluate the relationship between ATCC use and emergency department (ED) length of stay (LOS) at sending facilities for patients who require urgent care. METHODS ATCC data were linked to the Arkansas Trauma Registry using unique identifiers. Patients younger than 15 years were excluded from the analysis. Patients older than 15 years with significant injury requiring interfacility transfer were the study population. Significant injury was defined as those with hypotension (systolic blood pressure < 90 mm Hg) or Glasgow Coma Scale (GCS) score less than 9 at the sending facility or Injury Severity Score (ISS) of 16 or greater at the definitive care facility. This cohort was stratified by the use of the ATCC, and ED LOS was determined. RESULTS The study population who met the inclusion criteria was 856; 632 (74%) of whom used the ATCC and 224 (26%) did not use the ATCC for interfacility transfers. There were no statistically significant differences noted between these two groups regarding ISS, systolic blood pressure, and GCS score. The ATCC was associated with a 21-minute reduction in the ED LOS at the sending facility when controlling for all other factors. (p = 0.005). CONCLUSION In the first 18 months following inception, the ATCC has been effective in expediting the transfer process and thus reducing the time to definitive care for severely injured patients. ATCC use has improved since inception and is now a contract deliverable for trauma hospitals based on these early results. LEVEL OF EVIDENCE Therapeutic study, level III.

Social services utilization and need among a community sample of persons living with HIV in the rural south

Abstract HIV prevalence has increased faster in the southern USA than in other areas, and persons living with HIV (PLWHIV) in the south are often rural, impoverished, or otherwise under-resourced. Studies of urban PLWHIV and those receiving medical care suggest that use of social services can enhance quality of life and some medical outcomes, but little is known about patterns of social service utilization and need among rural southern PLWHIV. The AIDS Alabama needs assessment survey, conducted in 2007, sampled a diverse community cohort of 476 adult PLWHIV representative of the HIV-positive population in Alabama (66% male, 76% Black, and 26% less than high school education). We developed service utilization/need (SUN) scores for each of 14 social services, and used regression models to determine demographic predictors of those most likely to need each service. We then conducted an exploratory factor analysis to determine whether certain services clustered together for the sample. Case management, assistance obtaining medical care, and financial assistance were most commonly used or needed by respondents. Black respondents were more likely to have higher SUN scores for alcohol treatment and for assistance with employment, housing, food, financial, and pharmacy needs; respondents without spousal or partner relationships had higher SUN scores for substance use treatment. Female respondents were more likely to have higher SUN scores for childcare assistance. Black respondents and unemployed respondents were more likely to have SUN scores in the highest quartile of the overall score distribution. Factor analysis yielded three main factors: basic needs, substance use treatment, and legal/medical needs. These data provide important information about rural southern PLWHIV and their needs for ancillary services. They also suggest clusters of service needs that often occur among PLWHIV, which may help case managers and other service providers work proactively to identify important gaps in care.

Pediatric Traumatic Amputations in the United States: A 5-Year Review.

Background: Pediatric traumatic amputations are devastating injuries capable of causing permanent physical and psychological sequelae. Few epidemiologic reports exist for guidance of prevention strategies. The objective of this study is to review the recent trends in pediatric traumatic amputations using a national databank. Methods: A review of all pediatric (age, 0 to 17 y) amputee patients was performed using the National Trauma Data Bank from 2007 to 2011. Data including demographics, location of amputation, and mechanism of injury were analyzed. Results: In the analysis 2238 patients were identified. The majority of amputations occurred in the youngest (0 to 5 y) and oldest (15 to 17 y) age groups with a 3:1 male to female ratio. The most common amputation locations were finger (54%) and toe (20%). A caught between mechanism (16.3%) was most common overall followed by machinery, powered lawn mowers, motor vehicle collisions, firearms, and off-road vehicles. Males were statistically more likely to have an amputation and lawnmower injuries were statistically associated with lower extremity amputations in children 5 years old and below. Motor vehicle injuries were the most common cause of adolescent amputations. Firearm-related amputations occurred predominantly in adolescents, whereas off-road vehicle amputations occurred in all ages. Conclusions: Common trends in pediatric amputations are relatively unchanged over the last decade. Young children sustain more finger amputations from a caught between objects mechanism, whereas adolescents sustain serious amputations from higher energy mechanisms such as firearms-related and motor vehicle–related injuries. Lawnmower-related amputations continue to most significantly affect younger children despite increased public awareness. Improved prevention strategies targeting age and mechanism-related trends are necessary to prevent these costly and debilitating injuries. Level of Evidence: Level IV.

Defining severe traumatic brain injury readmission rates and reasons in a rural state

Background Readmissions after a traumatic brain injury (TBI) have significant impact on long-term patient outcomes through interruption of rehabilitation. This study examined readmissions in a rural population, hypothesizing that readmitted patients after TBI will be older and have more comorbidities than those not readmitted. Methods Discharge data on all patients 15 years and older who were admitted to an Arkansas-based hospital for TBI were obtained from the Arkansas Hospital Discharge Data System from 2010 to 2014. This data set includes diagnoses (principal discharge diagnosis, up to 3 external cause of injury codes, 18 diagnosis codes using the International Classification of Disease, 9th Edition, Clinical Modifications), age, gender, and inpatient costs. Hospital Cost and Utilization Project Clinical Classification and Chronic Condition Indicator were used to identify chronic disease and body systems affected in principal diagnosis. Results Of the 3114 cases of significant head trauma, more than two-thirds were attributed to fall injuries, with motor vehicle crashes accounting for 20% of the remainder. The mean length of stay was 6.5 days. 691 of these patients were admitted to an Arkansas hospital in the following year, totaling 1368 readmissions. Of the readmissions, 16.4% of patients were admitted for altered mental status, 12.9% with shortness of breath (SOB), and 9.4% with chest pain. Mental disorders (psychosis, dementia, and depression) and organic nervous symptoms (Alzheimer’s disease, encephalopathy, and epilepsy) were the primary source of readmissions. More than one-third of the patients were admitted in the following year for chronic diseases such as heart failure (8.6%), psychosis (5.2%), and cerebral artery occlusion (4.1%). Discussion This study showed that there is a significant rate of readmissions in the year after a diagnosis of TBI. Complications with existing chronic diseases are among the most reported reasons for admission in this time period, demonstrating the effect severe head trauma has on long-term treatment. Level of evidence Level IV, Retrospective epidemiological study.

Football-Related Pediatric Extremity Fractures and Dislocations: Size Matters

Football remains a popular sport in the United States despite sometimes significant injuries, such as fractures and dislocations, occurring. The objective of this study was to evaluate pediatric extremity fractures and dislocations related to football. A retrospective review was conducted at a level 1 pediatric trauma center to identify patients who were treated specifically for American football-related injuries (International Classification of Diseases, Ninth Revision, code E007.0). All patients with football-related injuries presenting to the emergency department during a 6-year period (2007-2012) were reviewed for inclusion in the study. Patients with only fractures or dislocations involving the extremities were analyzed. Exclusion criteria included patients older than 18 years, non-football-related sports-related injuries, and patients presenting to non-emergency department health care facilities. Demographic information was collected in addition to type of injury, body mass index, and type of treatment. A total of 193 patients with 96 fractures and 7 dislocations were included. More than two-thirds of all fractures occurred in the lower extremities, with tibia (17.0%) and femoral shaft (14.2%) fractures being the most common. Thirty-five percent of the fractures and dislocations required operative treatment. No statistically significant correlations were identified pertaining to age, race, and timing of the injuries in the season. Regarding body mass index, underweight patients were associated with 3.6 times greater odds of sustaining a fracture when compared with patients who were not underweight (P=.006). Underweight patients may be at a higher risk for fractures or dislocations. Identifying at-risk children may result in improved patient and coach education, potentially leading to better preventive measures and fewer injuries. [Orthopedics. 2018; 41(4):216-221.].

Treatment of subperiosteal abscesses in children: is drainage of the intramedullary canal required?

Acute osteomyelitis can be successfully treated with antibiotics alone. Surgery is utilized after failure of antibiotic treatment or if an abscess is present. Limited evidence exists with regard to whether intramedullary drainage is required in addition to the drainage of the subperiosteal abscess. We reviewed our 9-year experience of treating subperiosteal abscesses identifying 68 patients. Thirty patients underwent both intramedullary and abscess drainage, whereas 38 patients underwent drainage of the abscess alone at the initial procedure. Our analysis demonstrated a statistical significance (P=0.012) and odds ratio of 6.46 in favor of an intramedullary drainage to decrease risk for need for repeat surgical treatment.

Fatal Work-Related Injuries: Southeastern United States, 2008-2011

In 2008, the work-related injury fatality rate was 3.8 per 100,000 workers in the United States but was 5.2 per 100,000 workers for the southeast region. Work-related fatalities in the southeast were examined for the period 2008 to 2011. Median work-related injury fatality rates are reported for the southeast region, each of the 12 states, and the United States. The percentages of employees in high fatality industries and work-related fatalities by cause were calculated. Finally, the Occupational Safety and Health Administration’s database was searched for fatality reports. States with the highest rates (per 100,000 workers) included Arkansas (7.2), Louisiana (6.8), and West Virginia (6.6). Arkansas, Louisiana, Mississippi, and West Virginia each had more than 20% of their employees in high fatality industries. Forty percent of work-related injury fatalities were from transportation incidents in the southeast and the United States. Future analyses should include work-related injury fatality rates by industry and compare rates with other U.S. regions.