An Eastern Association for the Surgery of Trauma multicenter trail examining prehospital procedures in penetrating trauma patients. Taghavi S, Maher Z, Goldberg AJ, Chang G, et al. Journal of Trauma and Acute Care Surgery. 2021 Jul 1;91(1):130-140.
Prehospital procedures (PHP), including endotracheal intubation, blood product administration, and placement of intravenous access, have been shown to have beneficial effects on mortality in patients with prolonged transport times. However, retrospective series and animal studies have demonstrated that PHP may have deleterious effects on penetrating trauma patients in urban settings by delaying transport times and exacerbating shock states via drug administration for orotracheal intubation. The authors of this study performed an EAST sponsored, multicenter, prospective observational evaluation of the impact of PHP on outcomes in penetrating trauma patients in urban settings.
The study was conducted from May 2019 to May 2020 at 25 urban trauma centers. Inclusion criteria were adults (> 18y) who sustained torso or proximal extremity penetrating trauma with or without blunt trauma. Patients with isolated injuries above the clavicle and transfers were excluded. Patients were divided into two groups: those who underwent PHP and those who did not. PHP assessed were: IV access, interosseous access, endotracheal intubation, pleural decompression, bladder decompression, fluid administration, pressure dressing application, c-spine immobilization, cricothyroidotomy, tourniquet placement, and pelvic stabilization. The primary outcome was in-hospital mortality. Secondary outcomes included in-hospital complications.
Amongst 2,284 patients included, 60.7% received PHP and 39.3% did not. Individuals who received PHP were older, had higher New Injury Severity Score (NISS), and were more likely to be injured in the abdomen or chest, and less likely to be injured by gunshot. The PHP group had lower Glasgow Coma Scale scores and lower mean systolic blood pressure. The most common PHP were IV access (87.4%) and fluid administration (48.1%). Amongst those receiving PHP, 69.1% received them on scene. On univariate analysis, receipt of any PHP was associated with 1.38x increased odds of death (p<0.001). Increasing number of PHP performed was significantly associated with increased mortality. The PHP group was more likely to undergo emergency surgery and had higher rates of in-hospital complications. Multivariable logistic regression demonstrated a 10.76x greater odds of death in patients undergoing pre-hospital endotracheal intubation (p<0.001), and 3.1x increased mortality for prehospital resuscitation with greater than 750ml of crystalloid (p<0.001).
The authors conclude that the use of most PHP, and particularly fluid resuscitation and endotracheal intubation, should be reconsidered in patients with penetrating torso or proximal extremity trauma in urban settings with prioritization of rapid transport to the trauma center. The authors further caution against the use of c-spine immobilization and pre-hospital pleural decompression, both of which were associated with worse outcomes, citing reports that indicate the futility of c-spine immobilization in penetrating trauma patients and low success rates of needle decompression of the chest in the field. Limitations include selection bias, as patients undergoing PHP were more severely injured, and unknown confounders. The study identifies a high rate of PHP in penetrating trauma patients in urban settings and suggests the need for guidelines minimizing the use of PHP in this population.
Surgical stabilization of rib fractures in octogenarians and beyond - what are the outcomes? Pierraci FM, Leasia K, Hernandez MC, Kim B, et al. Journal of Trauma and Acute Care Surgery. 2021 Jun 1;90(6):1014-1021.
Elderly trauma patients with rib fractures have higher morbidity and mortality than non-elderly patients with rib fractures. This is due to a multitude of factors, including comorbidities, use of anticoagulant/antiplatelet medications, frailty, and sensitivity to narcotics. Although studies have demonstrated the benefit of surgical stabilization of rib fractures (SSRF) in flail-type injury patterns and multiple fractures causing pulmonary derangements, they have mostly excluded elderly patients. Other studies have characterized elderly as over the age of 60-65 years but included mostly healthy patients between the ages of 60-79. This is a retrospective, multicenter cohort study comparing SSRF to nonoperative management for patients ages 80 years and older.
This study included 8 academic trauma centers and was conducted through the Chest Wall Injury Society (CWIS). Only centers who maintained a prospective SSRF database could participate. Octogenarians in the SSRF database were matched to octogenarians with rib fractures managed nonoperatively that were identified in the trauma registry between the periods Jan 2015-March 2020 on age within 3y, center, Injury Severity Score and presence of intracranial hemorrhage on admission CT. Additional inclusion criteria were Chest AIS > 3 and Head AIS < 2. Variables collected included the RibScore, Blunt Pulmonary Contusion 18 (BPC 18) score, chest wall injury pattern, other procedures performed, and pulmonary comorbidities. The primary outcome was in-hospital mortality, and secondary outcomes included pneumonia, need for mechanical ventilation and/or tracheostomy, ICU length of stay and discharge on narcotics.
Ultimately 360 SSRF patients were matched to 227 nonoperative patients, with a median age of 84 and 86 years, respectively. SSRF patients had more severe chest injuries – with a higher number of median rib fractures, a higher RibScore, more flail segments, and a greater proportion requiring chest tube insertion. On univariate analysis, there was no difference in mortality between groups. On multivariate analysis including RibScore, BPC18 score and chest tube insertion, mortality was 59% lower in the SSRF group. Rates of ICU length of stay > 3d, ventilator days > 3 and pneumonia were higher in the SSRF group. Patients undergoing SSRF were less likely to be discharged on narcotics (RR=0.66, p=0.01). Additional comparisons between patients undergoing early (< 3d) SSRF, late (>3d) SSRF and nonoperative management demonstrated lower mortality in the late SSRF group compared to nonoperative management, but higher rates of pneumonia and increased risk of ICU LOS > 3d in the early compared to late SSRF group.
The authors conclude that amongst octogenarians, SSRF is independently associated with lower mortality than nonoperative management of rib fractures. Worse secondary outcomes in the SSRF group could be related to effects of surgery, the inability to control for several confounders as well as survival bias in the SSRF group. The authors note that several factors, including patients’ wishes regarding goals of care, remain unknown and may have skewed the nonoperative group towards a higher mortality. The study suggests that SSRF in octogenarians with severe chest wall trauma may confer a mortality benefit.
Outcomes after ultramassive transfusion in the modern era: An Eastern Association for the Surgery of Trauma multicenter study. Matthay ZA, Hellmann ZJ, Callcut RA, et al. J Trauma Acute Care Surg. 2021 Jul 1;91(1):24-33.
In 2017 EAST published a Practice Management Guideline addressing the principles of damage control resuscitation (DCR) in an evidence-based systematic review. The authors recommend targeting a high ratio of both plasma and platelets for resuscitating severely injured bleeding trauma patients. Despite this PMG, it remains largely unknown how well trauma centers adhere to these principles especially in patients that undergo large-volume resuscitations.
In this EAST Multicenter trial by Matthay et al, the authors identify risk factors associated with mortality for patients undergoing ultramassive transfusion (UMT) (defined as ≥20 units pRBCs in 24 hours). This study is particularly relevant and needed because the majority of the patients studied in both the PROMMTT and PROPPR trials did not undergo UMT and were transfused less than 10 units of colloid. Perhaps more importantly, it is imperative to study UMT as these patients inherently have the potential to significantly stress a healthcare system and require significant and often ongoing, resources.
In this retrospective multicenter trial, 461 patients across 17 trauma centers underwent UMT during the five-year study period. As expected, patients were young, severely injured (median ISS 33) males in hemorrhagic shock. Nearly 50% of patients died within 24 hours. The median number of pRBCS, FFP and platelets transfused was 29, 22 and 24 units respectively. Almost two-thirds of the patients died by the time of discharge (65%). The use of viscoelastic testing was relatively low (41%) and the administration of cryoprecipitate only 71%. The majority of the cohort (52%) had a RBC/PLT or RBC/FFP ratio ≥ 1.5 and nearly 20% of the cohort had both a RBC/PLT and RBC/FFP ratio ≥ 1.5. Transfusion ratio was significantly associated with mortality in every group (RBC/PLT, RBC/FFP) but most pronounced in the patients that had both RBC/PLT and RBC/FFP ratio ≥ 1.5 (odds ratio 3.11 for mortality at 24 hours). Cryoprecipitate and tranexamic acid administration both trended towards decrease mortality at 24 hours but did not reach statistical significance, and neither was associated with increased venous thromboembolism rates. On regression analysis, patients that underwent resuscitative thoracotomy, presented with a low GCS, thrombocytopenia and advanced age (>50), did poorly (mortality 71%).
Despite being a robust study of large, level 1 and level 2 trauma centers with transfusion protocols in place, the authors identified significant deviations from established DCR principles in patients undergoing UMT. These deviations are noteworthy, as the UMT patient population is a group that may potentially stand to gain the most from a balanced resuscitation.
Association of Rideshare Use With Alcohol-Associated Motor Vehicle Crash Trauma. Conner CR, Ray HM, McCormack RM, et al. JAMA Surg. 2021 June 9;e212227.
The use of application-based rideshare services has dramatically increased over the past decade, transforming the transportation industry. Cities have had to adapt and balance both rider and driver safety. Media reports of the impact of these services on impaired driving arrests have been conflicting Similarly, the medical literature is inconsistent. This large Houston-based multicenter cohort study is a robust analysis into the association of rideshare use with alcohol-related motor vehicle trauma. Using multiple data sources, the investigators were able to control for population growth, alcohol consumption, geography and driving patterns to analyze the impact that the deployment of Uber in the city of Houston in 2014 had on motor vehicle collision (MVC) traumas.
The authors utilized multiple data sources to carry out the analysis. More than a decade of MVC data from Houston’s two level 1-trauma centers (nearly twenty-five thousand MVCs), rideshare data directly from Uber for five years (more than 24 million rides), and more than ten years of arrest data from a Texas Public Information Act data request for arrests for driving under the influence or while intoxicated were analyzed. Using governmental databases, the authors additionally analyzed vehicle-miles traveled county data for the city of Houston to control for vehicle usage, and alcohol consumption data to control for alcohol consumption.
Pre and post rideshare deployment revealed a decrease in MVC trauma by nearly 25% during the peak hours of Friday and Saturday nights. Furthermore, in their analysis the authors demonstrated that after the deployment of Uber, patients younger than 30 years of age (those most likely to use ridesharing services) had a decreased incidence of MVC traumas by nearly 40%. The authors also found that the Injury Severity Score significantly decreased following the introduction of rideshare services during the study period. To study the impact of rideshare services on alcohol-associated motor vehicle traumas, the investigators analyzed nearly a quarter of a million arrests for impaired driving. They found that after the implementation of rideshare services, the impaired driving conviction rates decreased from 22.5 per day (pre-rideshare) to 19.0 per day (post-rideshare). The strongest decrease was seen for arrests made over the weekend. Using geographic analysis the investigators interestingly determined that the location of the convictions changed from predominately in the city core (where rideshare volume is the greatest) to outside of the city. The authors also identified three peak months (March, May and June) during which MVC trauma increased, this increase corresponded with an increase in alcohol consumption.