Faculty Bibliography

Managing mangled upper extremity injuries is a challenging problem because multiple tissue components including soft tissue, muscle, tendon, bone, nerves, and vessels are involved. The complexity of these injuries has hindered the development of accurate scoring systems and treatment algorithms.

BACKGROUND: Traumatic injury is the leading cause of paediatric morbidity and mortality in the USA. We present updated national data on emergency department (ED) discharges for traumatic injury for a recent 7-year period. METHODS: We conducted a descriptive epidemiological analysis of the Nationwide Emergency Department Sample Survey, the largest and most comprehensive database in the USA, for 2006-2012. Among children and adolescents, we tracked changes in injury mechanism and severity, cost of care, injury intent and the role of trauma centres. RESULTS: There was an 8.3% (95% CI 7.7 to 8.9) decrease in the annual number of ED visits for traumatic injury in children and adolescents over the study period, from 8 557 904 (SE=5861) in 2006 to 7 846 912 (SE=5191) in 2012. The case-fatality rate was 0.04% for all injuries and 3.2% for severely injured children. Children and adolescents with high-mortality injury mechanisms were more than three times more likely to be treated at a level 1 trauma centre (OR=3.5, 95% CI 3.3 to 3.7), but were more no more likely to die (OR=0.96, 95% CI 0.93 to 1.00). Traumatic brain injury diagnoses increased 22.2% (95% CI 20.6 to 23.9) during the study period. Intentional assault accounted for 3% (SE=0.1) of all child and adolescent ED injury discharges and 7.2% (SE=0.3) of discharges among 15-19 year-olds. There was an 11.3% (95% CI 10.0 to 12.6) decline in motor vehicle injuries from 2009 to 2012. The total cost of care was $23 billion (SE=0.01), a 78% increase from 2006 to 2012. CONCLUSIONS: This analysis presents a recent portrait of paediatric trauma across the USA. These analyses indicate the important role and value of trauma centre care for injured children and adolescents, and that the most common causes and mechanisms of injury are preventable.

BACKGROUND:A federal assault weapons ban has been proposed as a way to reduce mass shootings in the U.S. (U.S). The Federal Assault Weapons Ban (A.W.B.) of 1994 made the manufacture and civilian use of a defined set of automatic and semi-automatic weapons and large capacity magazines illegal. The ban expired in 2004. The period from 1994 to 2004 serves as a single-arm pre-post observational study to assess the effectiveness of this policy intervention. METHODS:Mass shooting data for 1981 to 2017 were obtained from three well-documented, referenced, and open-source sets of data, based on media reports. We calculated the yearly rates of mass shooting fatalities as a proportion of total firearm homicide deaths and per U.S. POPULATION/METHODS:We compared the 1994-2004 federal ban period to non-ban periods, using simple linear regression models for rates and a Poison model for counts with a year variable to control for trend. The relative effects of the ban period were estimated with odds ratios. RESULTS:Assault rifles accounted for 430 or 85.8% of the total 501 mass-shooting fatalities reported (95% CI 82.8, 88.9) in 44 mass-shooting incidents. Mass shootings in the U.S. accounted for an increasing proportion of all firearm-related homicides (coefficient for year = 0.7, p = 0.0003), with increment in year alone capturing over a third of the overall variance in the data (Adjusted R-squared = 0.3). In a linear regression model controlling for yearly trend, the federal ban period was associated with a statistically significant 9 fewer mass shooting related deaths per 10,000 firearm homicides (p = 0.03). Mass-shooting fatalities were 70% less likely to occur during the federal ban period (Relative Rate = 0.30, 95% CI 0.22,0.39). CONCLUSIONS:Mass-shooting related homicides in the U.S. were reduced during the years of the federal assault weapons ban of 1994 to 2004. STUDY TYPE/METHODS:Observational LEVEL OF EVIDENCE: III/IV.

The objective of this study was to assess whether patients with comorbid psychiatric conditions admitted after traumatic injury require greater health-care resource utilization. The trauma registry of a Level 1 trauma center was used to identify all adult trauma patients presenting from 2012 to 2015. Patients with psychiatric needs, identified as having either an ICD-9 code corresponding to a psychiatric disorder or requiring inpatient psychiatric consultation, were compared with controls, using propensity score matching. Patients with psychiatric disorders were more than three times more likely to present with penetrating injuries (odds ratio [OR] 3.5, P < 0.005). They had longer length of hospital stay (median 5 [IQR 2.5-11] vs. three days [IQR 1-7], P < 0.01), were approximately 70 per cent more likely to require ICU-level care (OR 1.68, P = 0.08), and were 80 per cent less likely to be discharged home (OR 0.18, P < 0.005). Trauma patients with psychiatric illness or need consume greater health-care resources.

BACKGROUND:Firearm-related injuries cause significant morbidity and mortality in the United States (US), consuming resources and fueling political and public health discourse. Most analyses of firearm injuries are based on fatality statistics. Here, we describe the epidemiology of firearm injuries presenting to US emergency departments (EDs). METHODS:We performed a retrospective study of the Healthcare Cost and Utilization Program Nationwide Emergency Department Survey (NEDS) from 2009 to 2012. NEDS is the largest all-payer ED survey in the US containing approximately 30 million annual records. Results include survey-adjusted counts, proportions, means, and rates, and confidence intervals of age-stratified ED discharges for firearm injuries. RESULTS:There were 71,111 (se = 613) ED discharges for firearm injuries in 2009; the absolute number increased 3.9% (se = 1.2) to 75,559 (se = 610) in 2012. 18-to-44-year-olds accounted for the largest proportion of total injuries with 52,187 (se = 527) in 2009 and 56,644 (se = 528) in 2012-a 7.2% (se = 1.6) relative rate increase and an absolute increase of 3.3/100,000 (se = 0.7). Firearm injuries among children < 5-years-old increase 16%, and 19% among children 5-to-9-years-old. 136,112 (se = 761)-or 48.2%-of those injured were treated and discharged home without admission; 106,927 (se = 755) were admitted. Firearm deaths represented one-third of all trauma mortality. Three-quarters of those injured resided in neighborhoods with median incomes below $49,250. CONCLUSIONS:Firearm injuries increased from 2009 to 2012, driven by adults aged 18-to-44-years-old, and disproportionately impacting lower socioeconomic communities. Injuries also increased among young children. Firearm injuries remain a continued public health challenge, and a significant source of ED morbidity and mortality.

INTRODUCTION: Venous thromboembolism (VTE) is a common morbidity in trauma patients. Standard chemical VTE prophylaxis is often inadequate. We hypothesized that using weight-based dosing would result in appropriate prophylaxis more frequently than fixed dosing.
METHOD(S): All patients admitted to a Level I trauma service during a 6-month period were included unless contraindications for VTE prophylaxis existed. A prospective weight-based enoxa-parin dosing group was compared with a retrospective uniform-dosing group. The weight-based dosage was 0.5 mg/kg subcutaneous q12 hours rounded to the nearest 10 mg. Peak anti-factor Xa activity was measured and patients who fell outside of the prophylactic range had their dose adjusted by +/- 10 mg q12 hours. The uniform dosing group received 30 mg subcutaneous q12 hours, and did not receive dose adjustments. Data were analyzed using Pearson's correlation and Fisher's exact test, as appropriate.
RESULT(S): Eighty-three patients were included in the study. Significantly more patients in the uniform-dosing group were sub-therapeutically anti-coagulated vs the weight-based group. In the uniform dosing group, anti-Xa level correlated with body surface area (BSA) (1C = 0.24, p = 0.0010) and weight. Weight-based dosing both pre-and post-readjustment normalized the correlation of anti-Xa with BSA (ic=0.049, p = 0.18) and weight (Figure).
CONCLUSION(S): Weight-based VTE prophylaxis with anti-Xa-based dose adjustment improves the rate of appropriate prophylaxis relative to uniform dosing and eliminates variances secondary to BSA and weight in trauma patients

BACKGROUND:Between 1990 and 2003, there were 668 subway-related fatalities in New York City. However, subway-related trauma remains an understudied area of injury-related morbidity and mortality. OBJECTIVE:The objective of this study was to characterize the injuries and events leading up to the injuries of all patients admitted after subway-related trauma. METHODS:We conducted a retrospective case series of subway-related trauma at a Level I trauma center from 2001 to 2016. Descriptive epidemiology of patient demographics, incident details, injuries, and outcomes were analyzed. RESULTS:Over 15 years, 254 patients were admitted for subway-related trauma. The mean (standard error of the mean) age was 41 (1.0) years, 80% were male (95% confidence interval [CI] 74-84%) and median Injury Severity Score was 14 (interquartile range [IQR] 5-24). The overall case-fatality rate was 10% (95% CI 7-15%). The most common injuries were long-bone fractures, intracranial hemorrhage, and traumatic amputations. Median length of stay was 6 days (IQR 1-18 days). Thirty-seven percent of patients required surgical intervention. At the time of injury, 55% of patients (95% CI 49-61%) had a positive urine drug or alcohol screen, 16% (95% CI 12-21%) were attempting suicide, and 39% (95% CI 33-45%) had a history of psychiatric illness. CONCLUSIONS:Subway-related trauma is associated with a high case-fatality rate. Alcohol or drug intoxication and psychiatric illness can increase the risk of this type of injury.

BACKGROUND: This study provides important updates to the epidemiology of pediatric trauma in the United States. METHODS: Age-specific epidemiologic analysis of the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample, representing 2.4 million pediatric traumatic injury discharges in the US from 2000 to 2011. We present yearly data with overlying loess smoothing lines, proportions of common injuries and surgical procedures, and survey-adjusted logistic regression analysis. RESULTS: From 2000 to 2011 there was a 21.7% decline in US pediatric trauma injury inpatient discharges from 273.2 to 213.7 admissions per 100,000. Inpatient case-fatality decreased 5.5% from 1.26% (95% CI 1.05-1.47) to 1.19% (95% CI 1.01-1.38). Severe injuries accounted for 26.5% (se=0.11) of all discharges in 2000 increasing to 31.3% (se=0.13) in 2011. The most common injury mechanism across all age groups was motor vehicle crashes (MVCs), followed by assaults (15-19years), sports (10-14), falls (5-9) and burns (<5). The total injury-related, inflation-adjusted cost was $21.7 billion, increasing 56% during the study period. CONCLUSIONS: The overall rate of inpatient pediatric injury discharges across the United States has been declining. While injury severity is increasing in hospitalized patients, case-fatality rates are decreasing. MVCs remain a common source of all pediatric trauma. LEVELS OF EVIDENCE: Level III.

Sport Concussion Assessment Tool version 3 (SCAT-3) is one of the most widely researched concussion assessment tools in athletes. Here normative data for SCAT3 in nonathletes are presented. The SCAT3 was administered to 98 nonathlete healthy controls, as well as 118 participants with head-injury and 46 participants with other body trauma (OI) presenting to the ED. Reference values were derived and classifier functions were built to assess the accuracy of SCAT3. The control population had a mean of 2.30 (SD = 3.62) symptoms, 4.38 (SD = 8.73) symptom severity score (SSS), and 26.02 (SD = 2.52) standardized assessment of concussion score (SAC). Participants were more likely to be diagnosed with a concussion (from among healthy controls) if the SSS > 7; or SSS 7 and headache or pressure in head present, or SSS 7 and headache or pressure in head, or SSS