To Örebro University

INTRODUCTION: Hemorrhage is the leading cause of preventable deaths in trauma patients, resulting in 1.5 million deaths annually worldwide. Traditional trauma assessment follows the ABC (airway, breathing, circulation) sequence; evidence suggests the CAB (circulation, airway, breathing) approach to maintain perfusion and prevent hypotension. Damage Control Resuscitation (DCR), derived from military protocols, focuses on early hemorrhage control and volume replacement to combat the "diamond of death" (hypothermia, hypocalcemia, acidosis, coagulopathy). This study evaluates the implementation of DCR protocols in Brazilian trauma centers, hypothesizing sub-optimal resuscitation due to high costs of necessary materials and equipment.

METHODS: In 2024, an electronic survey was conducted among Brazilian Trauma Society members to assess DCR practices. The survey, completed by 121 participants, included demographic data and expertise in DCR.

RESULTS: All 27 Brazilian states were represented in the study. Of the respondents, 47.9% reported the availability of Massive Transfusion Protocol (MTP) at their hospitals, and only 18.2% utilized whole blood. Permissive hypotension was practiced by 84.3%, except in traumatic brain injury cases. The use of tranexamic acid was high (96.7%), but TEG/ROTEM was used by only 5%. For hemorrhage control, tourniquets and resuscitative thoracotomy were commonly available, but REBOA was rarely accessible (0.8%).

CONCLUSION: Among the centers represented herein, the results highlight several inconsistencies in DCR and MTP implementation across Brazilian trauma centers, primarily due to resource constraints. The findings suggest a need for improved infrastructure and adherence to updated protocols to enhance trauma care and patient outcomes.

BACKGROUND: Trauma is the leading cause of death in pediatric patients, with major vascular injuries significantly worsening outcomes. This study aimed to evaluate the mortality and complication profile of pediatric trauma patients suffering from major vascular injuries as a result of gunshot wounds (GSWs) compared with blunt mechanisms.

METHODS: We queried the American College of Surgeons Trauma Quality Improvement Program database from 2013 to 2021 for pediatric (≤12 years old) trauma patients who suffered a major vascular injury as a result of either blunt trauma or a GSW. Patients were excluded if they had a head or face Abbreviated Injury Scale ≥2 or an Abbreviated Injury Scale of 6 in any other region. These groups were examined regarding demographics, clinical characteristics, and in-hospital outcomes. In order to adjust for confounding, Poisson regression models with robust standard errors were employed.

RESULTS: After applying the inclusion and exclusion criteria 1,605 patients remained for further analysis. Of these, 18.1% patients (n = 292) suffered a GSW. GSW patients were significantly more injured than blunt trauma patients (Injury Severity Score ≥ 16: 59.6% vs. 33.6%, p < 0.001). GSW patients had significantly higher rates of major intrathoracic as well as femoral vascular injuries, whereas intraabdominal aortic and renal vascular injuries were more common in blunt trauma patients. GSW patients accordingly demonstrated significantly higher rates of in-hospital mortality (21.2% vs. 5.3%, p < 0.001) and overall complications (13.7% vs. 8.4%, p = 0.007). After adjusting for potential confounding, suffering a major vascular injury due to a GSW was associated with an 80% higher rate of mortality (p = 0.013).

CONCLUSION: The overall lethality and complication rate for major vascular injury is greater after GSWs than blunt trauma. These findings underscore the importance of firearm injury prevention and provide further insight into the new leading cause of death in children.

LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

PURPOSE: Frailty has gained recognition as a crucial determinant of patient outcomes following traumatic spinal injury (TSI), particularly due to its increasing incidence in elderly populations. The aim of the current investigation was therefore to compare the ability of several frailty scores to predict adverse outcomes in surgically managed isolated TSI patients without spinal cord injury.

METHODS: All adult patients (18 years or older) who suffered an isolated TSI due to blunt trauma, and required surgical management, were extracted from the 2013-2021 Trauma Quality Improvement Program database. The ability of the Orthopedic Frailty Score (OFS), the Hospital Frailty Risk Score (HFRS), the 11-factor (11-mFI) and 5-factor (5-mFI) modified frailty index, as well as the Johns Hopkins Frailty Indicator to predict adverse outcomes was compared based on the area under the receiver-operating characteristic curve (AUC). Subgroup analyses were also performed on patients who were ≥ 65 years old and those who were injured due to a ground-level fall (GLF).

RESULTS: A total of 39,449 patients were selected from the TQIP database. The 5-mFI and 11-mFI outperformed all other frailty scores when predicting in-hospital mortality (5-mFI AUC: 0.73) (11-mFI AUC: 0.73), any complication (5-mFI AUC: 0.65) (11-mFI AUC: 0.65), and FTR (5-mFI AUC: 0.75) (11-mFI AUC: 0.75). Among the 14,257 geriatric patients, however, the OFS demonstrated the highest predictive ability for in-hospital mortality (AUC: 0.65). The OFS (AUC: 0.64) also performed on the same level as both the 5-mFI (AUC: 0.63) and the 11-mFI (AUC: 0.63) when predicting FTR in this population. Among the 9616 patients who were injured due to a GLF, the OFS performed on par with the 5-mFI and 11-mFI when predicting in-hospital mortality and FTR.

CONCLUSION: Simpler scores like the 5-factor modified Frailty Index and Orthopedic Frailty Score outperform or perform on par with more complicated frailty scores when predicting mortality, complications, and failure-to-rescue in surgically managed isolated traumatic spinal injury patients without spinal cord injury, particularly among geriatric patients and those injured in a GLF.

BACKGROUND: There are no validated and sensitive models that can guide the decision regarding amputation in patients with mangled lower extremities. We sought to describe a simple scoring model, the Mangled Lower Extremity (MangLE) score, which can predict those who are highly unlikely to need an amputation as a means to direct resources to this cohort.

METHODS: This is a retrospective study using the 2013-2021 American College of Surgeons Trauma Quality Improvement Program data set. Adult patients with a mangled lower extremity, defined as a crush injury or a fracture of the femur or tibia combined with severe soft tissue injury, arterial injury, or nerve injury, were included. Patients who suffered a traumatic lower extremity amputation, underwent amputation within 24 hours of admission, or who died within 24 hours of admission were excluded. Patients were divided into those who did/did not undergo amputation during their hospital stay. Demographics, injury mechanism, Injury Severity Score, and Abbreviated Injury Scale score, initial vital signs, and comorbid conditions were abstracted. A logistic regression model was constructed and the top five most important variables were used to create the score.

RESULTS: The study includes 107,620 patients, of whom 2,711 (2.5%) underwent amputation. The five variables with the highest predictive value for amputation were arterial injury, lower-extremity Abbreviated Injury Scale score of ≥3, crush injury, blunt mechanism, and shock index. The lowest possible MangLE score was 0, and the highest was 15. The model demonstrated an excellent predictive ability for lower extremity amputation in both the development and validation data set with an area under the receiver operating characteristic curve of 0.81 (95% confidence interval, 0.80-0.82) and 0.82 (95% confidence interval, 0.81-0.84), respectively. The negative predictive value for a score of <8 is 99%.

CONCLUSION: The MangLE score is able to identify patients who are unlikely to require amputation. Resources for limb salvage can be directed to this cohort.

LEVEL OF EVIDENCE: Prospective and Epidemiologic; Level IV.

OBJECTIVES: To compare postoperative mortality regarding 2 techniques in the treatment of trochanteric hip fractures (THFs). DESIGN: Retrospective cohort study. SETTING: National databases.

PATIENTS: All consecutive surgically treated THF cases between 2008 and 2017 were included. Pathological fractures or patients younger than 60 years were excluded.

INTERVENTION: Patients were grouped based on the surgical technique: sliding hip screw (SHS) or intramedullary (IM) nail. This data set was cross-referenced with a National Board of Health and Welfare's patient registry and a Cause of Death registry.

MAIN OUTCOME MEASUREMENTS: Mortality, comorbidities, and length of stay (LOS).

RESULTS: Forty-six thousand one hundred twenty-one cases were included. Twenty-five thousand eight hundred seventy-seven patients received a SHS, and 20,244 received an IM nail. Patients in the IM group were more often female (71.8% vs. 69.2%, P < 0.001), slightly less fit for surgery (American Society of Anesthesiologists score ≥3: 61.2% vs. 60.1%, P = 0.003), and more frail (Orthopedic Frailty Score ≥2: 54.2% vs. 52.8%, P = 0.005). Multifragment fractures were more prevalent in the IM nail group (66.6% vs. 32.0%, P < 0.001), which suffered from a higher comorbidity burden. After adjusting for potential confounders, no clinically significant differences in 7-day, 30-day, 90-day, or 1-year postoperative mortality were observed. Subgroup analyses focusing on 2-fragment and multifragment fractures could not detect any difference in mortality. LOS was 1 day shorter for the IM nail group as a whole.

CONCLUSIONS: Based on 10 years of data including 46,121 patients with THF managed with SHS or IM nail, no difference was observed in mortality up to 1 year postoperatively, when comparing surgical technique. LOS was shorter for the IM nail group.

BACKGROUND: Dense inflammation obscuring the hepatocystic anatomy can hinder the ability to perform a safe standard laparoscopic cholecystectomy in severe cholecystitis, requiring use of a bailout procedure. We compared clinical outcomes of laparoscopic and open subtotal cholecystectomy against the traditional standard of open total cholecystectomy to identify the optimal bailout strategy for the difficult gallbladder.

METHODS: A multicenter, multinational retrospective cohort study of patients who underwent bailout procedures for severe cholecystitis. Procedures were compared using one-way analysis of variance/Kruskal-Wallis tests and χ2 tests with multiple pairwise comparisons, maintaining a family-wise error rate at 0.05. Multiple multivariate linear/logistical regression models were created.

RESULTS: In 11 centers, 727 bailout procedures were conducted: 317 laparoscopic subtotal cholecystectomies, 172 open subtotal cholecystectomies, and 238 open cholecystectomies. Baseline characteristics were similar among subgroups. Bile leak was common in laparoscopic and open fenestrating subtotal cholecystectomies, with increased intraoperative drain placements and postoperative endoscopic retrograde cholangiopancreatography(P < .05). In contrast, intraoperative bleeding (odds ratio = 3.71 [1.9, 7.22]), surgical site infection (odds ratio = 2.41 [1.09, 5.3]), intensive care unit admission (odds ratio = 2.65 [1.51, 4.63]), and length of stay (Δ = 2 days, P < .001) were higher in open procedures. Reoperation rates were higher for open reconstituting subtotal cholecystectomies (odds ratio = 3.43 [1.03, 11.44]) than other subtypes. The overall rate of bile duct injury was 1.1% and was not statistically different between groups. Laparoscopic subtotal cholecystectomy had a bile duct injury rate of 0.63%.

CONCLUSION: Laparoscopic subtotal cholecystectomy is a feasible surgical bailout procedure in cases of severe cholecystitis where standard laparoscopic cholecystectomy may carry undue risk of bile duct injury. Open cholecystectomy remains a reasonable option.

Hip dysplasia in young adults is underdiagnosed and can cause pain and discomfort. Progression to osteoarthritis (OA) is common, necessitating total hip arthroplasty at an early age. When discovered early, symptomatic patients can be offered physiotherapy and/or hip-preserving surgery to alleviate pain and decrease the risk of early OA. A pilot project to screen radiograms for hip dysplasia was started across the Swedish region of orebro Lan in January 2019, comparing the incidence of dysplasia before and after initiation of the screening program. All elective conventional radiograms of the hip (age 12-44 years), requested by primary care physicians, were analyzed by consultant radiologists according to a pre-established algorithm to identify hip abnormalities. If the hip radiograms showed dysplastic changes, or other pathological signs, the radiologist advised referral to a specialized Youth Hip Clinic for further work-up and treatment. A total of 1056 radiograms were requested by clinicians during the study periods (601 and 455 during 2018 and 2020, respectively). A total of 457 trauma-related cases were excluded, resulting in 599 available for analysis (348 and 251 during 2018 and 2020, respectively). During 2018, 17 patients (4.9%) received the radiologic diagnosis of dysplasia, compared with 44 patients (17.5%) during 2020 (P < 0. 001). A three-fold increase of patients diagnosed with hip dysplasia was detected as a result of the implementation of the screening program. The advantage of screening is early referral to an orthopedic department for evaluation and consideration for physiotherapy and/or surgical intervention.

INTRODUCTION: As the incidence of traumatic spine injuries has been steadily increasing, especially in the elderly, the ability to categorize patients based on their underlying risk for the adverse outcomes could be of great value in clinical decision making. This study aimed to investigate the association between the Revised Cardiac Risk Index (RCRI) and adverse outcomes in patients who have undergone surgery for traumatic spine injuries.

METHODS: All adult patients (18 years or older) in the 2013-2019 TQIP database with isolated spine injuries resulting from blunt force trauma, who underwent spinal surgery, were eligible for inclusion in the study. The association between the RCRI and in-hospital mortality, cardiopulmonary complications, and failure-to-rescue (FTR) was determined using Poisson regression models with robust standard errors to adjust for potential confounding.

RESULTS: A total of 39,391 patients were included for further analysis. In the regression model, an RCRI ≥ 3 was associated with a threefold risk of in-hospital mortality [adjusted IRR (95% CI): 3.19 (2.30-4.43), p < 0.001] and cardiopulmonary complications [adjusted IRR (95% CI): 3.27 (2.46-4.34), p < 0.001], as well as a fourfold risk of FTR [adjusted IRR (95% CI): 4.27 (2.59-7.02), p < 0.001], compared to RCRI 0. The risk of all adverse outcomes increased stepwise along with each RCRI score.

CONCLUSION: The RCRI may be a useful tool for identifying patients with traumatic spine injuries who are at an increased risk of in-hospital mortality, cardiopulmonary complications, and failure-to-rescue after surgery.

The aim of the current investigation was to compare the ability of several frailty scores to predict adverse outcomes in hip fracture patients. All adult patients (18 years or older) who suffered a hip fracture due to a fall and underwent surgical fixation were extracted from the 2019 National Inpatient Sample (NIS) Database. A combination of logistic regression and bootstrapping was used to compare the predictive ability of the Orthopedic Frailty Score (OFS), the Nottingham Hip Fracture Score (NHFS), the 11-factor modified Frailty Index (11-mFI) and 5-factor (5-mFI) modified Frailty Index, as well as the Johns Hopkins Frailty Indicator. A total of 227,850 patients were extracted from the NIS. In the prediction of in-hospital mortality and failure-to-rescue (FTR), the OFS surpassed all other frailty measures, approaching an acceptable predictive ability for mortality [AUC (95% CI): 0.69 (0.67-0.72)] and achieving an acceptable predictive ability for FTR [AUC (95% CI): 0.70 (0.67-0.72)]. The NHFS demonstrated the highest predictive ability for predicting any complication [AUC (95% CI): 0.62 (0.62-0.63)]. The 11-mFI exhibited the highest predictive ability for cardiovascular complications [AUC (95% CI): 0.66 (0.64-0.67)] and the NHFS achieved the highest predictive ability for delirium [AUC (95% CI): 0.69 (0.68-0.70)]. No score succeeded in effectively predicting venous thromboembolism or infections. In summary, the investigated frailty scores were most effective in predicting in-hospital mortality and failure-to-rescue; however, they struggled to predict complications.