Srinivas H. Reddy

Factors associated with trauma clinic follow-up compliance after discharge: experience at an urban Level I trauma center.

BACKGROUND Disparities in access to postdischarge services for trauma patients exist, and clinic follow-up remains an important avenue to ensure initial and continued access to postdischarge services. In addition, follow-up is vital to rigorous long-term trauma outcomes research. However, there is a relative paucity of literature specifically addressing clinic follow-up. The purposes of this study were to elucidate factors associated with clinic follow-up compliance and noncompliance after discharge from an urban Level I trauma center and to confirm the prevailing notion that follow-up in trauma clinic is poor. METHODS Our trauma registry was queried for all trauma service discharges of patients 18 years and older for a 2-year period. Patients with incomplete information were excluded. Demographic data such as race/ethnicity and insurance status were collected on all patients. Primary outcome was defined as trauma clinic follow-up within 4 weeks after discharge. Patients compliant with follow-up were compared with noncompliant patients. RESULTS After exclusion criteria were applied, there were 1,818 discharges included in the analysis, with 564 (31%) complying with follow-up (p < 0.001). Factors significantly associated with follow-up noncompliance included patients older than 35 years, white race, Medicaid/Medicare payers, blunt mechanism, extended hospital length of stay, and discharge to rehabilitation facilities. No insurance, penetrating mechanism, short hospital stay, discharge to home, and weekend discharge were all significantly associated with follow-up compliance. Discharge on weekends and to home were independent predictors of compliance, whereas, Medicaid/Medicare insurance status and operative intervention were independent predictors of noncompliance. CONCLUSION This study indentifies factors associated with trauma clinic follow-up compliance and confirms the notion that trauma clinic follow-up compliance at an urban Level I trauma center is alarmingly low. These findings may serve as targets to improve follow-up, thereby improving trauma outcomes research and long-term outcomes. Consequently, clinic follow-up compliance warrants further study and consideration as an essential trauma registry datum. LEVEL OF EVIDENCE Prognostic study, level III.

Utility of the Military Acute Concussion Evaluation as a screening tool for mild traumatic brain injury in a civilian trauma population.

BACKGROUND Mild traumatic brain injury (mTBI) constitutes 75% of more than 1.5 million traumatic brain injuries annually. There exists no consensus on point-of-care screening for mTBI. The Military Acute Concussion Evaluation (MACE) is a quick and easy test used by the US Army to screen for mTBI; however, its utility in civilian trauma is unclear. It has two parts: a history section and the Standardized Assessment of Concussion (SAC) score (0–30) previously validated in sports injury. As a performance improvement project, our institution sought to evaluate the MACE as a concussion screening tool that could be used by housestaff in a general civilian trauma population. METHODS From June 2013 to May 2014, patients 18 years to 65 years old with suspected concussion were given the MACE within 72 hours of admission to our urban Level I trauma center. Patients with a positive head computed tomography were excluded. Demographic data and MACE scores were recorded in prospect. Concussion was defined as loss of consciousness and/or posttraumatic amnesia; concussed patients were compared with those nonconcussed. Sensitivity and specificity for each respective MACE score were used to plot a receiver operating characteristic (ROC) curve. An ROC curve area of 0.8 was set as the benchmark for a good screening test to distinguish concussion from nonconcussion. RESULTS There were 84 concussions and 30 nonconcussed patients. Both groups were similar; however, the concussion group had a lower mean MACE score than the nonconcussed patients. Data analysis demonstrated the sensitivity and specificity of a range of MACE scores used to generate an ROC curve area of only 0.65. CONCLUSION The MACE showed a lower mean score for individuals with concussion, defined by loss of consciousness and/or posttraumatic amnesia. However, the ROC curve area of 0.65 highly suggests that MACE alone would be a poor screening test for mTBI in a general civilian trauma population. LEVEL OF EVIDENCE Diagnostic study, level II.

End-tidal CO2 on admission is associated with hemorrhagic shock and predicts the need for massive transfusion as defined by the critical administration threshold: A pilot study

BACKGROUND Critical administration threshold (≥3 units of packed red blood cells/h or CAT+) has been proposed as a new definition for massive transfusion (MT) that includes volume and rate of blood transfusion. CAT+ has been shown to eliminate survivor bias and be a better predictor of mortality than the traditional MT (>10 units/24h). End-tidal CO2 (ET CO2) negatively correlates with lactate and is an early predictor of shock in trauma patients. We conducted a pilot study to test the hypothesis that low ET CO2 on admission predicts CAT+. METHODS ET CO2 via capnography and serum lactate were prospectively collected on admission for 131 patients requiring trauma team activation. Demographic data were obtained from patient charts. Excluded were patients with isolated head injuries, traumatic arrests, or pre-hospital intubations. CAT± status was determined for each hour up to 6h from admission as described; likewise, MT± status was determined up to 24h from admission. RESULTS After exclusion criteria, 67 patients were analyzed. Mean age was 41.2 (SD 18.5). Thirty-three patients had a blunt mechanism of injury (49%), median ISS was 9 (interquartile range 4-19), and there were 6 deaths (9%). ET CO2 and lactate were negatively correlated by Spearman rank-based correlation (rho=-0.41, p=0.0006). Twenty-one (31%) and 8 (12%) patients were CAT+ and traditional MT+, respectively. There were a significantly greater proportion of patients with ISS>15, ET CO2 <35, or who died found to be CAT+. A binomial logistic regression model adjusting for age, SBP <90, HR, and ISS >15 revealed ET CO2 < 35 to be independently predictive of CAT+ (OR 9.24, 95% CI 1.51-56.57, p=0.016). CONCLUSIONS This pilot study demonstrated that low ET CO2 had strong association with standard indicators for shock and was predictive of patients meeting CAT+ criteria in the first 6h after admission. Further study to verify these results and to elucidate CAT criterias association with mortality will require a larger sample size.

Penetrating neck trauma in children: an uncommon entity described using the National Trauma Data Bank

BACKGROUND Penetrating neck trauma is uncommon in children; consequently, data describing epidemiology, injury pattern, and management are sparse. The aim of this study was to use the National Trauma Data Bank (NTDB) to describe pediatric penetrating neck trauma (PPNT). METHODS The NTDB was queried for children (defined as <15 years old) with PPNT between years 2008 and 2012. Descriptive analysis was used to describe age groups (0–5, 6–10, and 11–14 years) and injury type categorized as aerodigestive, vascular, cervical spine, and nerve. RESULTS A total of 1,238 patients with penetrating neck trauma were identified among 434,788 children in the NTDB (0.28%). Mean age was 7.9 years, and 70.6% of patients were male. The most common mechanisms of injury were stabbing (44%) and gunshot/firearm (24%). Most patients were treated at a pediatric trauma center (65.8%). Computed tomographic scan was the most frequent (42.2%) diagnostic study performed, followed by laryngoscopy (27.0%) and esophagoscopy (27.4%). Almost a quarter of patients (23.7%) went directly to the operating room from the emergency department (ED). Aerodigestive injuries were most common and occurred more frequently in the youngest age group (p < 0.001). Operative procedures for aerodigestive type injuries were most common (82.7%). There were 69 deaths, yielding a mortality rate of 5.6%. When adjusting for age, admission to a pediatric trauma center, and injury type, only vascular injury (odds ratio, 3.92; 95% confidence interval, 2.19–7.24; p < 0.0001) and ED hypotension (odds ratio, 27.12; 95% confidence interval, 15.11–48.67; p < 0.0001) were found to be independently associated with death. CONCLUSION PPNT is extremely rare—0.28% reported NTDB incidence. Age seems to influence injury type but does not affect mortality. Computed tomographic scan is the dominant diagnostic study used for selective management. Vascular injury type and hypotension on presentation to the ED were independently associated with mortality. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

Risk factors associated with bladder and urethral injuries in female children with pelvic fractures: An analysis of the National Trauma Data Bank.

BACKGROUND Bladder and/or urethral injuries (BUIs) secondary to pelvic fractures are rare in children and are associated with a high morbidity. These injuries are much less likely to occur in females and are often missed in the emergency department. To help clinicians detect these injuries in female children, larger studies are needed to identify risk factors specific to this patient population. This study aimed to identify risk factors associated with BUI in female children with a pelvic fracture. METHODS We reviewed the National Trauma Data Bank for females younger than 16 years who sustained a pelvic fracture from 2010 to 2012. Patients with penetrating injuries were excluded. Variables including patient characteristics, mechanism of injury, and type of pelvic fracture were selected for bivariate analysis. Variables with an association of p < 0.05 were then tested using binary logistic regression. RESULTS Of the 149,091 females younger than 16 years in the National Trauma Data Bank, 2,639 patients (2%) with pelvic fractures were identified. The median patient age was 12 years (interquartile range [IQR], 7–14 years). BUI was identified in 81 patients (3%). Patients with BUI had a significantly higher median Injury Severity Score (ISS) (25 [IQR, 17–34] vs. 13 [IQR, 6–22], p < 0.001). Four variables were found to be independently associated with BUI in the logistic regression model: vaginal laceration (adjusted odds ratio [OR], 9.1; 95% confidence interval [CI], 4.4–18.7), disruption of the pelvic circle (adjusted OR, 3.0; 95% CI, 1.6–5.6), multiple pelvic fractures (adjusted OR, 2.3; 95% CI, 1.3–3.9), and sacral spine injury (adjusted OR, 1.6; 95% CI, 1.0–2.6). In total, 62 patients (77%; 95% CI, 67–86%) with BUI had at least one of these findings. CONCLUSION Female children who sustained a pelvic fracture and have a vaginal laceration, disruption of the pelvic circle, multiple pelvic fractures, or a sacral spine injury seem to be at highest risk for BUI. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

Association of Whole-Body Computed Tomography With Mortality Risk in Children With Blunt Trauma

Importance Although several studies have demonstrated an improvement in mortality for injured adults who receive whole-body computed tomography (WBCT), it is unclear whether children experience the same benefit. Objective To determine whether emergent WBCT is associated with lower mortality among children with blunt trauma compared with a selective CT approach. Design, Setting, and Participants A retrospective, multicenter cohort study was conducted from January 1, 2010, to December 31, 2014, using data from the National Trauma Data Bank on children aged 6 months to 14 years with blunt trauma who received an emergent CT scan in the first 2 hours after emergency department arrival. Data analysis was conducted from February 2 to December 29, 2017. Exposures Patients were classified as having WBCT if they received CT head, CT chest, and CT abdomen/pelvis scans in the first 2 hours and as having a selective CT if they did not receive all 3 scans. Main Outcomes and Measures The primary outcome was in-hospital mortality in the 7 days after ED arrival. To adjust for potential confounding, propensity score weighting was used. Subgroup analyses were performed for those with the highest mortality risk (ie, occupants and pedestrians involved in motor vehicle crashes, children with a Glasgow Coma Scale score lower than 9, children with hypotension, and those admitted to the intensive care unit). Results Of the 42 912 children included in the study (median age [interquartile range], 9 [5-12] years; 27 861 [64.9%] boys), 8757 (20.4%) received a WBCT. Overall, 405 (0.9%) children died within 7 days. After adjusting for the propensity score, children who received WBCT had no significant difference in mortality compared with those who received selective CT (absolute risk difference, −0.2%; 95% CI, −0.6% to 0.1%). All subgroup analyses similarly showed no significant association between WBCT and mortality. Conclusions and Relevance Among children with blunt trauma, WBCT, compared with a selective CT approach, was not associated with lower mortality. These findings do not support the routine use of WBCT for children with blunt trauma.

Geriatric nursing home falls: A single institution cross-sectional study.

BACKGROUND Falls are the leading cause of fatal injury in geriatric patients. Nursing home falls occur at twice the rate of community falls, yet few studies have compared these groups. We hypothesized that nursing home residents admitted for fall would be sicker than their community counterparts on presentation and have worse outcomes. METHODS Records of 1708 patients, age 65 years and older with a documented nursing home status, admitted to our center between 2008 and 2012 were reviewed. Clinical data including injury severity score (ISS), admission Glasgow coma scale (GCS), in-hospital complications, length of stay (LOS), and in-hospital mortality were collected. Continuous data were analyzed using Mann-Whitney tests and categorical data using Fisher exact tests. Variables in the univariate tests were analyzed in a multivariate logistic regression. RESULTS Nursing home patients were older than community patients, presented with lower GCS, lower hemoglobin, higher international normalized ratio (INR) and a higher percentage of patients with body mass index (BMI)<18.5. LOS for nursing home patients was longer, and they suffered higher rates of in-hospital complications. ISS, rates of traumatic brain injury, operative intervention and mortality were not significantly different. In a multivariate logistic regression, ISS, GCS and age, but not nursing home status, were significant predictors of in-hospital mortality. CONCLUSIONS In comparison to their community counterparts, nursing home patients presenting after fall are more debilitated and have increased morbidity as evidenced by more in-house complications and increased LOS. However, nursing home residency was not a significant predictor of mortality.

Pelvic Fracture Urethral Injuries in Children: A Case Report and Appraisal of Their Emergency Management.

Abstract Pelvic fracture urethral injuries are uncommon injuries that are frequently overlooked in the emergency department. We present a case of a 2-year-old girl whose urethral trauma was initially missed and potentially worsened by the placement of a urinary catheter. The clinical and diagnostic features of these rare injuries are discussed along with the controversies surrounding urinary catheter placement and retrograde urethrography.

1133: Weaning Directly From Airway Pressure Release Ventilation With Spontaneous Breathing Trials

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) D3, omega 3-fatty acids, glutamine, and progesterone) improves recovery and lowers mortality rate better than two drug therapy with vitamin D3 and progesterone alone (Bahram Aminmansour study). Methods: This study with 183 patients TBI patients was a prospective comparison study done at Grady Memorial Hospital, a Level I trauma center in Atlanta, Georgia from August 2009 through February 2012 versus the Bahram study. Mean vitamin D3 level was 18.76 ng/ml ± 10.1. Mean ICU length of stay was 8.43 days ± 13.77. Results: There were 18 deaths (six were excluded due to withdrawal of care/ support). Mortality rate after exclusion criteria was 6.6% which is 34.4% lower than the 10% mortality rate in the Aminmansour Bahran study. Our recovery to a GCS of 10 was 90% versus 60% in the Bahran study. Conclusions: Our study potentially shows that our 4 drug combination therapy is more effective, offers better recovery, and offers more neuroprotection than 2 drug therapy in the Bahran study. Further studies are needed to examine our 4 drug combination treatment in TBI patients.