Faculty Bibliography

BACKGROUND:While mass-casualty incidents (MCIs) may have competing absolute definitions, a universally accepted criterion is one that strains locally available resources. In the fall of 2017, a MCI occurred in New York and Bellevue Hospi-tal received multiple injured patients within minutes; lessons learned included the need for a formalized, efficient patient and injury tracking system. Our objective was to create an organized MCI clinical tracking form for civilian trauma centers. METHODS:After the MCI, the notes of the surgeon responsible for directing patient triage were analyzed. A suc-cinct, organized template was created that allows MCI directors to track demographics, injuries, interventions, and other important information for hmultiple patients in a real-time fashion. This tool was piloted during a subsequent MCI. RESULTS:In late 2018, the hospital received six patients following another MCI. They arrived within a 4-minute window, with 5 patients being critically injured. Two emergent surgeries and angioembolizations were performed. The tool was used by the MCI director to prioritize and expedite care. All physicians agreed that the tool assisted in organizing diagnostic and therapeutic triage. CONCLUSIONS:During MCIs, a streamlined patient tracking template assists with information recall and communica-tion between providers and may allow for expedited care.

While the incidence of geriatric trauma continues to increase, outcomes following severe blunt liver injury (BLI) are unknown. We sought to investigate independent predictors of mortality among elderly trauma patients with severe BLI. A retrospective study of the NTDB (2014-15) identified patients with isolated, high-grade BLI. Patients were stratified into two groups, non-elderly (<65 years) and elderly (≥65 years), and then two management groups: operative within 24 h of admission and non-operative. Demographics and outcomes were compared. Multivariable logistic regression was used to estimate association with mortality. A total of 1133 patients met our inclusion criteria. 107 patients required surgery and 1011 patients were managed non-operatively. Age was independently associated with mortality (AOR 1.04, p < .001). For patients <65 years, need for operative intervention was associated with a 55 times greater likelihood of death (AOR 55.1, p < .001). In patients ≥65 years, operative intervention was associated with a 122 times greater likelihood of death (AOR 122.09, p = .005). Age is independently associated with mortality in patients with high grade BLI.

BACKGROUND:While mass-casualty incidents (MCIs) may have competing absolute definitions, a universally ac-cepted criterion is one that strains locally available resources. In the fall of 2017, a MCI occurred in New York and Bellevue Hospital received multiple injured patients within minutes; lessons learned included the need for a formal-ized, efficient patient and injury tracking system. Our objective was to create an organized MCI clinical tracking form for civilian trauma centers. METHODS:After the MCI, the notes of the surgeon responsible for directing patient triage were analyzed. A suc-cinct, organized template was created that allows MCI directors to track demographics, injuries, interventions, and other important information for multiple patients in a real-time fashion. This tool was piloted during a subsequent MCI. RESULTS:In late 2018, the hospital received six patients following another MCI. They arrived within a 4-minute window, with 5 patients being critically injured. Two emergent surgeries and angioembolizations were performed. The tool was used by the MCI director to prioritize and expedite care. All physicians agreed that the tool assisted in orga-nizing diagnostic and therapeutic triage. CONCLUSIONS:During MCIs, a streamlined patient tracking template assists with information recall and communica-tion between providers and may allow for expedited care.

This study evaluated the safety of early anti-factor Xa assay-guided enoxaparin dosing for chemoprophylaxis in patients with TBI. We hypothesized that assay-guided chemoprophylaxis would be comparable in the risk of intracranial hemorrhage (ICH) progression to fixed dosing. An observational analysis of adult patients with blunt traumatic brain injury (TBI) was performed at a Level I trauma center from August 2016 to September 2017. Patients in the assay-guided group were treated with an initial enoxaparin dose of 0.5 mg/kg, with peak anti-factor Xa activity measured four hours after the third dose. Prophylactic range was defined as 0.2 to 0.5 IU/mL with a dose adjustment of ± 10 mg based on the assay result. The assay-guided group was compared with historical fixed-dose controls and to a TBI cohort from the most recent Trauma Quality Improvement Project dataset. Of 179 patients included in the study, 85 were in the assay-guided group and 94 were in the fixed-dose group. Compared with the fixed-dose group, the assay-guided group had a lower Glasgow Coma Score and higher Injury Severity Score. The proportion of severe (Abbreviated Injury Score, head ≥3) TBI, ICH progression, and venous thromboembolism rates were similar between all groups. The assay-guided and fixed-dose groups had chemoprophylaxis initiated earlier than the Trauma Quality Improvement Project group. The assay-guided group had the highest percentage of low molecular weight heparin use. Early initiation of enoxaparin anti-factor Xa assay-guided venous thromboembolism chemoprophylaxis has a comparable risk of ICH progression to fixed dosing in patients with TBI. These findings should be validated prospectively in a multicenter study.

BACKGROUND:Osteopenia is common in the elderly, increasing their risk of sustaining cervical fractures after ground level falls (GLFs). We sought to examine the incidence of blunt cerebrovascular injury (BCVI) and subsequent stroke in elderly GLF patients as compared with other higher injury mechanisms. MATERIALS AND METHODS/METHODS:The Trauma Quality Improvement Program database (2011-2016) was used to identify blunt trauma patients with isolated (other body region abbreviated injury scale <3) cervical spine (C1-C7) fractures. Patients were stratified into three groups: nonelderly patients (<65) with all mechanisms of injury, elderly patients (≥65) with GLF, and elderly patients with all other mechanism of injury. Multivariable logistic regression was used to determine predictors for BCVI, stroke, spinal cord injury, and acute kidney injury. RESULTS:Seventeen thousand six hundred twenty-eight patients with cervical spine injuries were identified. BCVI was highest in the <65 group (0.8%) and lowest in elderly patients with GLF (0.3%, P = 0.001). When controlling for other factors, elderly patients with GLF were less likely to sustain BCVI (adjusted odds ratio: 0.46, P = 0.03) but had comparable rates of stroke attributable to BCVI (18.2% versus 6.5%, P = 0.184) and comparable rate of acute kidney injury compared with elderly patients with other mechanism of injury. CONCLUSIONS:In elderly patients with isolated cervical spine fracture after GLF, BCVI occurs less frequently but is associated with a comparable rate of stroke as compared with other mechanisms. Low injury mechanism should not preclude BCVI screening in the presence of cervical spine fractures.

BACKGROUND:We sought to evaluate the role of trauma center designation in the association of race and insurance status with disposition to rehabilitation centers among elderly patients with Traumatic Brain Injury (TBI). METHODS:The National Trauma Data Bank (2014-2015) was used to identify elderly (age ≥ 65) patients with isolated moderate to severe blunt TBI who survived to discharge. Race, insurance status, and outcomes were stratified by trauma center designation and compared. RESULTS:3,292 patients met the inclusion criteria. Black patients were 1.5 times less likely (AOR 0.64, p = 0.01) and Latino patients were 1.7 times less likely (AOR 0.58, p = 0 0.007) to be discharged to rehabilitation centers as compared with White patients. Asian patients at Level I hospitals were more likely to be discharged to rehabilitation centers if they had private vs. non-private insurance (42.9% versus 12.7%, p = 0.01). CONCLUSION/CONCLUSIONS:Black and Latino patients were less likely to be discharged to rehabilitation centers compared to White patients. The etiology of these disparities deserves further study.

BACKGROUND:While the incidence of geriatric trauma continues to increase, the management of high-grade blunt splenic injury (BSI) in the elderly remains controversial. Among this population, data evaluating survival rates following non-operative and operative management are inconsistent. We analyzed mortality risk in geriatric patients with high-grade BSI based on operative vs. non-operative management. METHODS:A retrospective analysis of the National Trauma Database identified patients with isolated, high-grade (AIS ≥ 3) BSI from 2014 to 2015. Patients were stratified into three groups: non-elderly (<65 years), elderly (65-79 years), and advanced age (80 years and older). Each age group was stratified into three management groups: non-operative (including embolization), initial operative management (OR within 24 h), and failed non-operative management. Patient characteristics and outcomes were compared. Multivariable logistic regression estimated association with mortality. RESULTS:5560 patients with isolated, high-grade BSI were identified. In the group that failed NOM, mortality was 2% in non-elderly patients, versus 22.2% in elderly patients and 50% in patients of advanced age (p < .01). In this group, patients over 80 years old spent an average of 6.5 days longer in the ICU vs. non-elderly patients (median 10.5 days, IQR [6.75, 19.5] vs. 4 days, IQR [3,6], p = 0.02). In patients with isolated, high grade BSI, age was independently associated with mortality (AOR 1.02; p < 0.01). Elderly patients who required surgery were over three times more likely to die (AOR 3.39; p < 0.01). Advanced age patients who required surgery were over eight times more likely to die (AOR 8.1; p < 0.01). CONCLUSIONS:For patients with BSI, age is independently associated with death in both operative and non-operative cases.

BACKGROUND:Powered, two-wheeled transportation devices like electric bicycles (E-bikes) and scooters are increasingly popular, but little is known about their relative injury risk compared to pedal operated bicycles. METHODS:Descriptive and comparative analysis of injury patterns and trends associated with E-bikes, powered scooters and pedal bicycles from 2000 to 2017 using the US National Electronic Injury Surveillance System. RESULTS:While persons injured using E-bikes were more likely to suffer internal injuries (17.1%; 95% CI 5.6 to 28.6) and require hospital admission (OR=2.8, 95% CI 1.3 to 6.1), powered scooter injuries were nearly three times more likely to result in a diagnosis of concussion (3% of scooter injuries vs 0.5% of E-bike injuries). E-bike-related injuries were also more than three times more likely to involve a collision with a pedestrian than either pedal bicycles (OR=3.3, 95% CI 0.5 to 23.6) or powered scooters (OR=3.3, 95% CI 0.3 to 32.9), but there was no evidence that powered scooters were more likely than bicycles to be involved in a collision with a pedestrian (OR=1.0, 95% CI 0.3 to 3.1). While population-based rates of pedal bicycle-related injuries have been decreasing, particularly among children, reported E-bike injuries have been increasing dramatically particularly among older persons. CONCLUSIONS:E-bike and powered scooter use and injury patterns differ from more traditional pedal operated bicycles. Efforts to address injury prevention and control are warranted, and further studies examining demographics and hospital resource utilisation are necessary.

BACKGROUND:Elderly patients with Traumatic Brain Injury (TBI) are frequently transferred to designated Trauma Centers (TC). We hypothesized that TC transfer is associated with improved outcomes. METHODS:Retrospective study utilizing the National Trauma Databank. Demographics, injury and outcomes data were abstracted. Patients were dichotomized by transfer to a designated level I/II TC vs. not. Multivariate regression was used to derive the adjusted primary outcome, mortality, and secondary outcomes, complications and discharge disposition. RESULTS:19,664 patients were included, with a mean age of 78.1 years. 70% were transferred to a level I/II TC. Transferred patients had a higher ISS (12 vs. 10, p < 0.001). Mortality was significantly lower in patients transferred to level I/II TCs (5.6% vs. 6.2%, Adjusted Odds Ratio (AOR) 0.84, p = 0.011), as was the likelihood of discharge to skilled nursing facilities (26.4% vs. 30.2%, AOR 0.80, p < 0.001). CONCLUSIONS:Elderly patients with mild TBI transferred to level I/II TCs have improved outcomes. Which patients with mild TBI require level I/II TC care should be examined prospectively.