Faculty Bibliography

Introduction: Increasing evidence suggests that disparities in outcomes exist among patients with traumatic brain injury (TBI), but much less is known about such disparities in the elderly. The objective of this study was to determine if race and insurance status are associated with mortality among elderly patients with isolated moderate and severe TBI.
Method(s): A 4-year retrospective analysis of the Trauma Quality Improvement Program database (2013-2016) was performed to identify patients aged 60 and older with isolated moderate or severe TBI. Patients were stratified by race and insurance status comparing demographic characteristics and outcomes. A logistic regression analysis was performed to determine the relationship between race, insurance status, and mortality among elderly patients with isolated moderate and severe TBI.
Result(s): A total of 27,951 patients with isolated TBI were identified. Of those, 7.8% were black with 50.2% having insurance and 79.5% were white with 45.3% having insurance. The overall mortality rate was 9.22% with no significant differences in Head AIS. Black patients with insurance were significantly older (73 vs 63, p<0.001) and had more comorbidities (1 [0,2] vs 0 [0,1], p=0.002) when compared with black patients without insurance. With the exception of age, no significant differences were found among white patients. After adjusting for confounding variables, black race was independently associated with decreased mortality (AOR 0.69, 95% CI 0.5-0.96, p= 0.016).
Conclusion(s): Black race, independent of insurance, is associated with decreased mortality among older adults with isolated moderate and severe TBI. The role of race in affecting mortality following TBI warrants further investigation.
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Introduction: Venous thromboembolism (VTE) represents a significant source of morbidity after traumatic brain injury (TBI). The safety and timing of VTE chemoprophylaxis after TBI remain a concern, given the risk of intracranial hemorrhage progression. We evaluated the safety of anti-factor Xa assay-guided dosing for chemoprophylaxis in adult TBI patients. We hypothesized that Xa assay-guided chemoprophylaxis would be safe compared with fixed-dosing.
Method(s): An observational analysis of adult TBI patients was performed at a Level I trauma center from August 2016 to September 2017. Patients in the assay-guided group received an initial enoxaparin dose of 0.5 mg/kg, with peak anti-factor Xa activity measured 4 hours after the third dose. Prophylactic range was defined as 0.2 to 0.5 IU/mL with dose adjustment of +/-10 mg based on the assay result. The assay-guided group compared with historical fixed-dose controls, and a TBI cohort from the most recent Trauma Quality Improvement Program data set.
Result(s): Of the 179 patients included in the study, 85 patients were in the assay-guided group and 94 were in the fixed-dose group. Relative to the fixed-dose group, the assay-guided group had a lower Glasgow Coma Scale score and higher Injury Severity Score (Table). The proportion of severe (Abbreviated Injury Scale head >=4) TBI, intracranial hemorrhage progression, and VTE rates were similar between groups. However, the assay-guided group had chemoprophylaxis initiated earlier and had a higher percentage of low molecular weight heparin use relative to the Trauma Quality Improvement Program sample.
Conclusion(s): Early initiation of low molecular weight heparin anti-factor Xa assay-guided VTE prophylaxis is safe in TBI patients. These findings should be validated prospectively in a multicenter study. [Figure presented]
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BACKGROUND:Injury care involves the complex interaction of patient, physician, and environment that impacts patient complications, level of harm, and failure to rescue (FTR). FTR represents the likelihood of a hospital to be unable to rescue patients from death after in-hospital complications. OBJECTIVE:This study aimed to hypothesize that error type and number of errors contribute to increased level of harm and FTR. METHODS:Patient information was abstracted from weekly trauma performance improvement (PI) records (from January 1, 2016, to July 19, 2017), where trauma surgeons determined the level of harm and identified the factors associated with complications. Level of harm was determined by definitions set forth by the Agency for Healthcare Research and Quality. Logistic regression was used to determine the impact of individual factors on FTR and level of harm, controlling for age, gender, Charlson score, injury severity score (ISS), error (in diagnosis, technique, or judgment), delay (in diagnosis or intervention), and need for surgery. RESULTS:A total of 2216 trauma patients presented during the study period. Of 2216 patients, 224 (224/2216, 10.10 %) had complications reported at PI meetings; of these, 31 patients (31/224, 13.8 %) had FTR. PI patients were more likely to be older (mean age 51.3 years, SE 1.58, vs 46.5 years, SE 0.51; P=.008) and have higher ISS (median 22 vs 8; P<.001), compared with patients without complications. Physician-attributable errors (odds ratio [OR] 2.82; P=.001), most commonly errors in technique, and nature of injury (OR 1.91; P=.01) were associated with higher levels of harm, whereas delays in diagnosis or intervention were not. Each additional factor involved increased level of harm (OR 2.09; P<.001) and nearly doubled likelihood of FTR (OR 1.95; P=.01). CONCLUSIONS:Physician-attributable errors in diagnosis, technique, or judgment are more strongly correlated with harm than delays in diagnosis and intervention. Increasing number of errors identified in patient care correlates with an increasing level of harm and FTR.

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