To Örebro University

BACKGROUND: Whole blood transfusion (WBT) is associated with improved hemostasis and possibly mortality in patients with hemorrhagic shock after injury but there are no studies in patients with isolated severe traumatic brain injury (TBI). The objective of this investigation was to compare outcomes of balanced component therapy (BCT) versus WBT in patients with an isolated severe TBI.

METHODS: Adult patients (≥18 years) registered in the Trauma Quality Improvement Program (2016-2019) who suffered a blunt isolated severe TBI (head Abbreviated Injury Score ≥3 in the head and ≤1 in the remaining body regions) and who received a BCT (1-2:1 packed red blood cell (PRBC):fresh frozen plasma and 1-2:1 PRBC:platelets) or WBT were eligible for inclusion. Patients were matched, based on the transfusion received, using propensity score matching. The primary outcome of interest was in-hospital mortality.

RESULTS: A total of 217 patients received either WBT (n=82) or BCT (n=135). After propensity score matching, 50 matched pairs were analyzed. The rate of in-hospital mortality was significantly lower in the WBT compared with BCT group (43.1% vs 66.7%, p=0.025) corresponding to a relative risk (RR) reduction of 35% in in-hospital mortality (RR (CI 95%): 0.65 (0.43 to 0.97)). However, in subgroup analyses comparing those who were managed surgically and conservatively, this association only remained significant among patients who underwent neurosurgical intervention.

CONCLUSIONS: WBT in patients with severe isolated TBI is associated with better survival compared with BCT in patients who require neurosurgical intervention. Further investigation into this finding using an appropriately powered, prospective study design is warranted.

LEVEL OF EVIDENCE: Level III, therapeutic.

BACKGROUND: Atlantoaxial rotatory subluxation (AARS) is an important differential diagnosis in pediatric patients presenting with torticollis, which is caused by the subluxation of the C1 vertebra relative to the C2 vertebra. Because of the uncommon nature of this condition, there is a paucity in sufficiently sized studies describing AARS. The aim of the current investigation was therefore to characterize current clinical characteristics and management of AARS.

METHODS: The American College of Surgeons Trauma Quality Improvement Program database from 2016 to 2021 was queried for pediatric (17 years old or younger) patients who were diagnosed with AARS following blunt trauma. Patients were grouped by age in order to describe and compare demographics, clinical characteristics, and in-hospital outcomes. A subgroup analysis was also performed on patients with isolated AARS, defined as AARS without the presence of a cervical fracture and an Abbreviated Injury Scale score of ≤1 in all regions besides the spine.

RESULTS: A total of 469 cases of AARS were identified, 211 (45.0%) were isolated AARS. Of these patients, 56.3% of AARS patients and 64.5% of isolated AARS patients were 8 years old or younger. Atlantoaxial rotatory subluxation in adolescents was due to a motor vehicle collision in 60.0% of cases, while 52.5% of infants/toddlers were injured in falls. Of all patients with AARS, 87.4% were managed conservatively, with or without a brace/other immobilizing device, while surgery was only indicated in 9.3% of patients. In cases of isolated AARS, conservative treatment was even more prevalent, with 92.4% of patients managed conservatively and only 4.7% requiring surgical intervention.

CONCLUSION: Atlantoaxial rotatory subluxation is most common in children 8 years old and younger, with the majority of cases resulting from falls or motor vehicle accidents. In the Trauma Quality Improvement Program database, most cases were able to be managed conservatively without the need for surgical intervention.

LEVEL OF EVIDENCE: Care Management; Level III.

BACKGROUND: Recent studies have demonstrated improved outcomes for severely injured pediatric trauma patients treated at pediatric trauma centers (PTCs). Nonetheless, specific injury patterns requiring immediate lifesaving intervention may offset the recognized benefits of PTC over adult trauma centers (ATCs). This study aims to compare the clinical outcomes of hypotensive pediatric trauma patients with gunshot wounds (GSWs), based on trauma center type. We hypothesize that outcomes are equivalent for this clinical scenario.

METHODS: The 2013-2021 Trauma Quality Improvement Program data set was used to identify all hypotensive pediatric patients (15 years or younger) with GSWs. Hypotension was defined per Pediatric Advanced Life Support Guidelines. Patients with an Abbreviated Injury Scale score of 6 in any region and transferred patients were excluded. In order to identify the association between PTC verification status and outcomes, Poisson regression models with robust standard errors were used.

RESULTS: A total of 687 patients met the criteria for analysis, and 236 (34%) cases were treated at PTCs. Pediatric trauma center patients were slightly younger (lower quartile, 10 vs. 12 years old; p = 0.037). There was no significant difference in Injury Severity Score or crude mortality rates (68.1% vs. 70.8%, p = 0.524). After adjusting for confounders, Poisson regression showed no reduction in in-hospital mortality, complications, failure to rescue, intensive care unit admission, or mechanical ventilation rates at PTCs compared with ATCs.

CONCLUSION: Gunshot wounds in children pose unique clinical challenges. Majority of cases are cared for at ATCs. Analysis of best available data did not demonstrate a benefit to managing these patients at a PTC. Conversely, ATCs were not superior, despite managing this scenario in both adults and children more often. These findings underscore the importance of ATCs in the care of this particular injury pattern and call attention to the recent pediatric readiness requirements for American College of Surgeons (ACS)-verified trauma centers to treat pediatric firearm injuries at both PTCs and ATC.

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

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: Rib fractures, common in blunt chest trauma, affect 10% of trauma patients and are linked to increased pulmonary morbidity and mortality. This study applies machine learning to identify predictors of complications in conservatively managed rib fracture patients.

METHODS: Data from the 2013-2021 American College of Surgeons' Trauma Quality Improvement Program included adults (≥ 18 years) with isolated thoracic injury from blunt trauma and conservatively managed rib fractures. Variables included demographics, comorbidities, injury severity, injury patterns, admission vitals, and complications. The permutation importance method identified top predictors of in-hospital complications.

RESULTS: Of 321,355 rib fracture patients, 183,303 (57.0%) had isolated rib fractures. The five primary predictors of complications in all rib fracture patients were age, Glasgow Coma Scale (GCS) on admission, Revised Cardiac Risk Index (RCRI), chronic obstructive pulmonary disease (COPD), and alcohol use disorder. For isolated rib fracture patients, the same predictors applied but in the order: age, RCRI, GCS, COPD, and alcohol use disorder. A logistic regression model using these predictors showed acceptable discriminative capacity for complications in the full cohort [AUC (95% CI): 0.72 (0.71-0.72)] and isolated rib fracture patients [AUC (95% CI): 0.72 (0.71-0.73)].

CONCLUSION: Cardiovascular risk, age, and level of consciousness on admission are key predictors of complications in conservatively managed rib fracture patients. Though complication rates remain low overall, elderly patients with multiple cardiovascular risk factors face a heightened risk of deterioration.

Background: Severe lower extremity injuries in pediatric patients present significant challenges for surgeons deciding between repair and amputation. A novel scoring system, the MangLE score, has been developed to identify adult patients who are unlikely to require amputation after severe lower extremity injury. This study sought to evaluate the predictive ability of the MangLE score in pediatric patients.

Methods: A retrospective analysis was conducted using the 2013-2021 American College of Surgeons Trauma Quality Improvement Program (TQIP) database. Pediatric patients (≤17 years) with mangled lower extremities were included. Patients were stratified into age groups (0-3, 4-9, 10-13, and 14-17 years), and the predictive ability of the MangLE score for lower extremity amputation was assessed based on the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity.

Results: A total of 7959 patients met the inclusion criteria. The MangLE score demonstrated an excellent predictive capability in patients aged 10-13 (AUC (95% CI): 0.87 (0.79-0.94)) and 14-17 (AUC (95% CI): 0.83 (0.79-0.86)). At the cutoff of ≥8, this resulted in an NPV of 99.7% for 10-13-year-olds and 99.4% for 14-17-year-olds. However, the MangLE score was ineffective in discriminating between those who did and did not require a lower extremity amputation in patients between 0 and 9 years old.

Discussion: The MangLE score maintains an excellent predictive ability for identifying those unlikely to require lower extremity amputation in pediatric mangled extremity patients aged 10-17; however, it fails to accurately predict this outcome in younger patients. Level of Evidence Level IV.

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: Surgical stabilization of rib fractures (SSRF) remains controversial as studies search for the patient population who would benefit most from SSRF. This study aimed to identify the predictive risk factors in patients with chest wall injuries who underwent SSRF and sustained in-hospital complications.

Methods: This study is a retrospective review of the 2016-2019 Trauma Quality Improvement Program database. Data included age, sex, comorbidities, Abbreviated Injury Score (AIS), injury pattern, interventions, and complications. All adult patients who suffered ≥1 rib fracture following an isolated thoracic injury (AIS ≥2 but < 6 and AIS ≤ 1 in all other regions) and underwent SSRF were eligible for inclusion.

Results: A total of 1823 patients were included in this study of whom 4.8% (N = 87) of patients suffered an in-hospital complication. Patients who suffered a complication were generally older, male, had a higher cardiac risk, were more severely injured, and tended to have a longer time to SSRF (3.8 vs 2.5 days, P < 0.001). The top 5 predictors of in-hospital complications were RCRI, thorax AIS, time to SSRF, age, and sex. These variables were sufficient for achieving an acceptable discriminative ability for complications (AUC (95% CI): 0.78 (0.73-0.83)).

Discussion: Cardiovascular risk, thoracic injury severity, and delayed SSRF were correlated with elevated risk of complications. As time to surgery constitutes the sole changeable factor, prompt intervention may substantially diminish postoperative morbidity. These findings can enhance risk classification and assist therapeutic decision making for SSRF.

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.