Extreme Thrombocytosis in Trauma Patients: Are Antiplatelet Agents the Answer?

The purpose of this study was to review the incidence of extreme thrombocytosis (ExT) (platelet count 1,000,000/μL or greater) in trauma patients and to examine the role of antiplatelet agents in its treatment. The Los Angeles County Medical Center trauma registry was used to obtain injury demographics, medications, and daily platelet counts for injured patients 16 years of age or older admitted between July 2005 and February 2008. Of 6,985 total trauma patients admitted during the study period, 95 developed ExT (1.4%). Average age was 29 years (range, 16-63 years), 89 per cent were male, 44 per cent had penetrating trauma, and mean Injury Severity Score was 24 (range, 1-57). Of the 95 patients with ExT, 41 were treated with aspirin (43%) and 54 were not (57%). The two groups did not differ with regard to basic demographics, injury patterns, vitals on admission, or splenectomy rate (34 vs 20%, P = 0.13). After adjusting for maximum platelet counts and duration of ExT, there was no difference between the treated and untreated groups in terms of mortality, complications, and intensive care unit or hospital lengths of stay. The incidence of ExT is approximately 1.4 per cent in trauma patients. Antiplatelet therapy does not affect ExT patient outcome. Further prospective studies are warranted.

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Medication Errors in Injured Patients

The American Surgeon ◽

10.1177/000313481708300738 ◽

2017 ◽

Vol 83 (7) ◽

pp. 780-785 ◽

Cited By ~ 2

Author(s):

Scott C. Dolejs ◽

Christopher F. Janowak ◽

Ben L. Zarzaur

Keyword(s):

Medication Error ◽

Patient Outcomes ◽

Medication Errors ◽

Injury Severity ◽

Trauma Patients ◽

Lengths Of Stay ◽

Scale Scores ◽

Level I ◽

Injured Patients ◽

The Impact

Trauma patients are vulnerable to medication error given multiple handoffs throughout the hospital. The purpose of this study was to assess trends in medication errors in trauma patients and the role these errors play in patient outcomes. Injured adults admitted from 2009 to 2015 to a Level I trauma center were included. Medication errors were determined based on a nurse-driven, validated, and prospectively maintained database. Multivariable logistic regression modeling was used to control for differences between groups. Among 15,635 injured adults admitted during the study period, 132 patients experienced 243 errors. Patients who experienced errors had significantly worse injury severity, lower Glasgow Coma Scale scores and higher rates of hypotension on admission, and longer lengths of stay. Before adjustment, mortality was similar between groups but morbidity was higher in the medication error group. After risk adjustment, there were no significant differences in morbidity or mortality between the groups. Medication errors in trauma patients tend to occur in significantly injured patients with long hospital stays. Appropriate adjustment when studying the impact of medical errors on patient outcomes is important.

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Cannabis Use is Associated with Increased Mechanical Ventilation and Polysubstance Use in Trauma Patients

The American Surgeon ◽

10.1177/000313481908500234 ◽

2019 ◽

Vol 85 (2) ◽

pp. 226-229 ◽

Cited By ~ 1

Author(s):

Kian Banks ◽

Subarna Biswas ◽

Monica Wong ◽

Saskya Byerly ◽

Damon Clark ◽

...

Keyword(s):

Mechanical Ventilation ◽

Los Angeles ◽

Injury Severity ◽

Univariate Analysis ◽

Traumatic Injury ◽

Penetrating Trauma ◽

Cannabis Use ◽

Trauma Patients ◽

Icu Length Of Stay ◽

Polysubstance Use

Recent policy changes in California regarding cannabis use underscore the need to study outcomes and prevalence of this drug in trauma. Our study aims to study the prevalence of cannabis use and associations with injury types and outcomes in Los Angeles County trauma patients. Data were reviewed from 21,276 adult patients from a Los Angeles countywide database spanning five years (2012–2016), who underwent urine toxicology testing in the ED after sustaining a traumatic injury. The percentage of trauma patients using marijuana increased from 36 to 43 per cent over the five-year period. On univariate analysis, cannabis-positive patients were significantly younger and more likely male, with lower median systolic blood pressure and heart rate on arrival in the ED. A higher proportion of cannabis users had penetrating trauma, and 48 per cent of cannabis users also tested positive for amphetamines, cocaine, opioids, or Phencyclidine. On multivariate analysis, cannabis was associated with an increase in need for mechanical ventilation after adjusting for age, admission Glasgow Coma Score, gender, polysubstance use, blunt or penetrating mechanism, and Injury Severity Score, and was not associated with increases in mortality or ICU length of stay.

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National temporal variation in major trauma in England, Wales and Northern Ireland

Trauma ◽

10.1177/1460408620982264 ◽

2021 ◽

pp. 146040862098226

Author(s):

Will Kieffer ◽

Daniel Michalik ◽

Jason Bernard ◽

Omar Bouamra ◽

Benedict Rogers

Keyword(s):

Northern Ireland ◽

Temporal Variation ◽

Major Trauma ◽

Injury Severity ◽

Research Network ◽

Trauma Patients ◽

Trauma Outcomes ◽

Causes Of Mortality ◽

Injured Patients ◽

Time Of Admission

Introduction Trauma is one of the leading causes of mortality worldwide, but little is known of the temporal variation in major trauma across England, Wales and Northern Ireland. Proper workforce and infrastructure planning requires identification of the caseload burden and its temporal variation. Materials and Methods The Trauma Audit Research Network (TARN) database for admissions attending Major Trauma Centres (MTCs) between 1st April 2011 and 31st March 2018 was analysed. TARN records data on all trauma patients admitted to hospital who are alive at the time of admission to hospital. Major trauma was classified as an Injury Severity Score (ISS) >15. Results A total of 158,440 cases were analysed. Case ascertainment was over 95% for 2013 onwards. There was a statistically significant variation in caseload by year (p < 0.0001), times of admissions (p < 0.0001), caseload admitted during weekends vs weekdays, 53% vs 47% (p < 0.0001), caseload by season with most patients admitted during summer (p < 0.0001). The ISS varied by time of admission with most patients admitted between 1800 and 0559 (p < 0.0001), weekend vs weekday with more severely injured patients admitted during the weekend (p < 0.0001) and by season p < 0.0001). Discussion and Conclusion: There is a significant national temporal variation in major trauma workload. The reasons are complex and there are multiple theories and confounding factors to explain it. This is the largest dataset for hospitals submitting to TARN which can help guide workforce and resource allocation to further improve trauma outcomes.

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186 Acute Kidney Injury in Skeletal Trauma Admissions to Intensive Care: An Under-Estimated Complication

British Journal of Surgery ◽

10.1093/bjs/znab134.537 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

O Brown ◽

T Crisp ◽

M Flatman ◽

C Hing

Keyword(s):

Acute Kidney Injury ◽

Intensive Care ◽

Injury Severity ◽

Penetrating Trauma ◽

Kidney Injury ◽

Long Bone ◽

Trauma Patients ◽

Skeletal Trauma ◽

Body Regions ◽

Intensive Care Stay

Abstract Introduction Acute kidney injury (AKI) is associated with prolonged admission and 3.5 times increased mortality for trauma patients requiring intensive care (ICU) treatment. Blunt trauma confers greater risk of AKI than penetrating trauma, potentially related to long bone fracture. The relationship between skeletal trauma and AKI in ICU has not previously been investigated. Method Retrospective data was analysed from 202 consecutive adult patients admitted to ICU with skeletal trauma from 01/06/2018 to 01/06/2019. AKI was defined by creatinine rise >1.5 times baseline. Results AKI was found in 70/202 (34.65%) patients aged 16-99 years, 138 males and 64 females. Mean limb Abbreviated Injury Scale (AIS) was significantly higher in AKI (AIS= 2.57 (SD 0.53) versus non-AKI AIS=2.38 (SD 0.61), p = 0.027). Other body regions and total Injury Severity Score (ISS) were non-significant. AKI was associated with a significantly worse Glasgow Outcome Score (AKI 3.28 (SD 1.52) versus 4.02 (SD 1.08) p < 0.001), increased intensive care stay (AKI 7.03 (SD 8.30) days versus non-AKI 3.8 (SD 4.1) days p < 0.001) and increased 30-day mortality (AKI 18/70 (25.71%) versus non-AKI 10/132 (7.58%) p < 0.001) Conclusions Skeletal trauma patients have a high incidence of AKI, which was significantly correlated with severity of skeletal limb trauma but not overall ISS.

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A retrospective cohort study of 27,049 polytraumatized patients age 60 and above: identifying changes over 16 years

European Geriatric Medicine ◽

10.1007/s41999-021-00546-9 ◽

2021 ◽

Author(s):

Y. Kalbas ◽

M. Lempert ◽

F. Ziegenhain ◽

J. Scherer ◽

V. Neuhaus ◽

...

Keyword(s):

Length Of Stay ◽

Injury Severity ◽

Descriptive Analysis ◽

Patient Characteristics ◽

Severe Trauma ◽

Diagnostic Tools ◽

Trauma Patients ◽

Treatment Algorithms ◽

Injured Patients ◽

Over Time

Abstract Purpose The number of severely injured patients exceeding the age of 60 has shown a steep increase within the last decades. These patients present with numerous co-morbidities, polypharmacy, and increased frailty requiring an adjusted treatment approach. In this study, we establish an overview of changes we observed in demographics of older severe trauma patients from 2002 to 2017. Methods A descriptive analysis of the data from the TraumaRegister DGU® (TR-DGU) was performed. Patients admitted to a level one trauma center in Germany, Austria and Switzerland between 2002 and 2017, aged 60 years or older and with an injury severity score (ISS) over 15 were included. Patients were stratified into subgroups based on the admission: 2002–2005 (1), 2006–2009 (2), 2010–2013 (3) and 2014–2017 (4). Trauma and patient characteristics, diagnostics, treatment and outcome were compared. Results In total 27,049 patients with an average age of 73.9 years met the inclusion criteria. The majority were males (64%), and the mean ISS was 27.4. The proportion of patients 60 years or older [(23% (1) to 40% (4)] rose considerably over time. Trauma mechanisms changed over time and more specifically low falls (< 3 m) rose from 17.6% (1) to 40.1% (4). Altered injury patterns were also identified. Length-of-stay decreased from 28.9 (1) to 19.5 days (4) and the length-of-stay on ICU decreased from 17.1 (1) to 12.7 days (4). Mortality decreased from 40.5% (1) to 31.8% (4). Conclusion Length of stay and mortality decreased despite an increase in patient age. We ascribe this observation mainly to increased use of diagnostic tools, improved treatment algorithms, and the implementation of specialized trauma centers for older patients allowing interdisciplinary care.

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Pulmonary Hypertension Roundtable: The Role of Exercise in Clinical Practice and Clinical Trials

Advances in Pulmonary Hypertension ◽

10.21693/1933-088x-18.2.63 ◽

2019 ◽

Vol 18 (2) ◽

pp. 63-67

Keyword(s):

Clinical Trials ◽

Pulmonary Hypertension ◽

Heart Disease ◽

Clinical Practice ◽

Los Angeles ◽

Guest Editor ◽

Harvard Medical School ◽

Medical Center ◽

Professor Emeritus

On May 20, 2019, Guest Editor Ronald Oudiz, MD, Director of the Pulmonary Hypertension Program at Harbor-UCLA Medical Center in Los Angeles, California, led a discussion with Aaron Waxman, MD, PhD, Director of the Center for Pulmonary Heart Disease at Brigham and Women's Hospital and Harvard Medical School in Boston, Massachusetts, and Robert Naeije, MD, Professor Emeritus at the Free University of Brussels, Belgium.

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Pre-hospital CPR and early REBOA in trauma patients - Results from the ABOTrauma Registry.

10.21203/rs.2.19571/v2 ◽

2020 ◽

Author(s):

Peter Hilbert-Carius ◽

David T McGreevy ◽

Fikri M. Abu-Zidan ◽

Tal M. Hörer

Keyword(s):

Survival Rate ◽

Hospital Admission ◽

Injury Severity ◽

Balloon Occlusion ◽

Trauma Patients ◽

Probability Of Survival ◽

Traumatic Cardiac Arrest ◽

Predicted Probability ◽

Using Data

Abstract Background: Severely injured trauma patients suffering from traumatic cardiac arrest (TCA) and requiring cardiopulmonary resuscitation (CPR) rarely survive. The role of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) performed early after hospital admission in patients with TCA is not well-defined. As the use of REBOA increases, there is great interest in knowing if there is a survival benefit related to the early use of REBOA after TCA. Using data from the ABOTrauma Registry, we aimed to study the role of REBOA used early after hospital admission in trauma patients who required pre-hospital CPR. Methods: Retrospective and prospective data on the use of REBOA were collected from the ABOTrauma Registry from 11 centers in seven countries globally between 2014 and 2019. In all patients with pre-hospital TCA, the predicted probability of survival, calculated with the Revised Injury Severity Classification II (RISC II), was compared with the observed survival rate. Results: Of 213 patients in the ABOTrauma Registry, 26 patients (12.2%) who had received pre-hospital CPR were identified. The median (range) Injury Severity Score (ISS) was 45.5 (25-75). Fourteen patients (54%) had been admitted to hospital with ongoing CPR. Nine patients (35%) died within the first 24 hours, while seventeen patients (65%) survived post 24 hours. The survival rate to hospital discharge was 27% (n=7). The predicted mortality using the RISC II was 0.977 (25 out of 26). The observed mortality (19 out of 26) was significantly lower than the predicted mortality (p=0.049). Patients not responding to REBOA were more likely to die. Only one (10%) out of 10 non-responders survived. Survival rate in the 16 patients responding to REBOA was 37.5% (n=6). REBOA with a median (range) duration of 45 (8-70) minutes significantly increases blood pressure from median (range) 56.5 (0-147) to 90 (0-200) mmHg. Conclusions: Mortality in patients suffering from TCA and receiving REBOA early after hospital admission is significantly lower than predicted by the RISC II. REBOA may improve survival after TCA. The use of REBOA in these patients should be further investigated.

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Trauma in pregnancy: A review of the Pennsylvania Trauma Systems Foundation database

Trauma ◽

10.1177/1460408617703677 ◽

2017 ◽

Vol 20 (1) ◽

pp. 30-37 ◽

Cited By ~ 3

Author(s):

Meike Schuster ◽

Natasha Becker ◽

Amanda Young ◽

Michael J Paglia ◽

A Dhanya Mackeen

Keyword(s):

Blunt Trauma ◽

Motor Vehicle ◽

Penetrating Trauma ◽

Blunt Injury ◽

Trauma Patients ◽

Severely Injured ◽

Trauma Systems ◽

Severely Injured Patients ◽

Vaginal Deliveries ◽

Injured Patients

Objective The goal of this study is to determine if injury severity score (ISS) of ≥9 and systolic blood pressure (SBP) predict poor maternal/pregnancy outcomes in blunt and penetrating trauma, respectively. Methods The Pennsylvania Trauma Systems Foundation database was used to identify pregnant trauma patients. Blunt trauma patients were analyzed with regard to ISS, while penetrating trauma patients were analyzed to determine whether SBP < 90 mmHg was predictive of poor maternal outcome. Results Patients with severe blunt injury (ISS ≥ 9) due to motor vehicle accident were less likely to wear seatbelts (51% vs. 63%, p = 0.005), and delivery was required in 17% of these patients as compared to 6% of the less severely injured, and only 6% of those were vaginal deliveries. Severely injured patients were discharged home 68% of the time and 6% died compared to less severely injured patients of which 83% were discharged home and <1% died; all other patients required discharge to a rehabilitation facility. Patients with penetrating trauma and SBP < 90 mmHg on arrival were more likely to require delivery (35% vs. 5%, p < 0.001) and were 14 times more likely to die (58% vs. 4%, p < 0.001) when compared to the normotensive group. Conclusion ISS ≥ 9 and SBP < 90 mmHg are predictors for poor outcomes after trauma during pregnancy. Severely injured blunt trauma patients often require surgery and delivery. Patients who present with SBP < 90 after penetrating trauma are more likely to deliver and are 14 times more likely to die.

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Delays in Transfer of Elderly Less-injured Trauma Patients Can Have Deadly Consequences

The American Surgeon ◽

10.1177/000313481408001130 ◽

2014 ◽

Vol 80 (11) ◽

pp. 1132-1135 ◽

Cited By ~ 4

Author(s):

Peter E. Fischer ◽

Paul D. Colavita ◽

Gregory P. Fleming ◽

Toan T. Huynh ◽

A. Britton Christmas ◽

...

Keyword(s):

Trauma Center ◽

Injury Severity ◽

Trauma Patients ◽

Severely Injured ◽

Severely Injured Patients ◽

Local Trauma ◽

Level 1 ◽

Poor Outcomes ◽

Injured Patients ◽

Level 1 Trauma Center

Transfer of severely injured patients to regional trauma centers is often expedited; however, transfer of less-injured, older patients may not evoke the same urgency. We examined referring hospitals’ length of stay (LOS) and compared the subsequent outcomes in less-injured transfer patients (TP) with patients presenting directly (DP) to the trauma center. We reviewed the medical records of less-injured (Injury Severity Score [ISS] 9 or less), older (age older than 60 years) patients transferred to a regional Level 1 trauma center to determine the referring facility LOS, demographics, and injury information. Outcomes of the TP were then compared with similarly injured DP using local trauma registry data. In 2011, there were 1657 transfers; the referring facility LOS averaged greater than 3 hours. In the less-injured patients (ISS 9 or less), the average referring facility LOS was 3 hours 20 minutes compared with 2 hours 24 minutes in more severely injured patients (ISS 25 or greater, P < 0.05). The mortality was significantly lower in the DP patients (5.8% TP vs 2.6% DP, P = 0.035). Delays in transfer of less-injured, older trauma patients can result in poor outcomes including increased mortality. Geographic challenges do not allow for every patient to be transported directly to a trauma center. As a result, we propose further outreach efforts to identify potential causes for delay and to promote compliance with regional referral guidelines.

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The Impact of In-house Attending Surgeon Supervision on the Rates of Preventable and Potentially Preventable Complications and Death at the Start of the New Academic Year

The American Surgeon ◽

10.1177/000313481307901113 ◽

2013 ◽

Vol 79 (11) ◽

pp. 1134-1139 ◽

Cited By ~ 4

Author(s):

Kenji Inaba ◽

Adam Hauch ◽

Bernardino C. Branco ◽

Stephen Cohn ◽

Pedro G. R. Teixeira ◽

...

Keyword(s):

Los Angeles ◽

Trauma Center ◽

Medical Center ◽

Trauma Patients ◽

University Of Southern California ◽

Academic Level ◽

Significant Difference ◽

Level I ◽

The Impact ◽

Academic Year

The purpose of this study was to examine the impact of in-house attending surgeon supervision on the rate of preventable deaths (PD) and complications (PC) at the beginning of the academic year. All trauma patients admitted to the Los Angeles County 1 University of Southern California Medical Center over an 8-year period ending in December 2009 were reviewed. Morbidity and mortality reports were used to extract all PD/PC. Patients admitted in the first 2 months (July/ August) of the academic year were compared with those admitted at the end of the year (May/June) for two distinct time periods: 2002 to 2006 (before in-house attending surgeon supervision) and 2007 to 2009 (after 24-hour/day in-house attending surgeon supervision). During 2002 to 2006, patients admitted at the beginning of the year had significantly higher rates of PC (1.1% for July/ August vs 0.6% for May/June; adjusted odds ratio [OR], 1.9; 95% confidence interval [CI], 1.1 to 3.2; P < 0.001). There was no significant difference in mortality (6.5% for July/August vs 4.6% for May/ June; adjusted OR, 1.1; 95% CI,0.8 to 1.5; P = 0.179). During 2007 to 2009, after institution of 24-hour/day in-house attending surgeon supervision of fellows and housestaff, there was no significant difference in the rates of PC (0.7% for July/August vs 0.6% for May/June; OR, 1.1; 95% CI, 0.8 to 1.3; P = 0.870) or PD (4.6% for July/August vs 3.7% for May/June; OR, 1.3; 95% CI, 0.9 to 1.7; P = 0.250) seen at the beginning of the academic year. At an academic Level I trauma center, the institution of 24-hour/day in-house attending surgeon supervision significantly reduced the spike of preventable complications previously seen at the beginning of the academic year.

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