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1.
Introduction
Rib fractures after blunt trauma contribute substantially to morbidity and mortality in the elderly.Methods
Retrospective review of 255 patients ≥65 years old at a level 2 trauma center over 6 years, who sustained blunt trauma resulting in rib fractures. Outcomes measured include mortality, hospital length of stay(LOS), intensive care unit(ICU) admission, ICU LOS, need for MV, and MV days.Results
There were 24 deaths (9.4%), of which 7 were early (<24?h). 130 patients (51%) were admitted to ICU, and 49 (19.2%) required MV. Mean ICU and MV days were 5.9 and 6.3, respectively. ICU admission was predicted by a base deficit <-2.0, ISS>15, bilateral rib fractures, pneumothorax or hemothorax on chest x-ray (All p?<?0.001), as well as hypotension, GCS<15, and 1st rib fractures (All p?<?0.05). Mortality was predicted by a base deficit?<?-5.0, GCS score of 3(Both p?<?0.001), as well as hypotension, ISS≥25, RTS <7.0, bilateral pneumothoraces, 1st rib fractures, and >5 rib fractures (All p?<?0.05).Conclusion
Rib fractures in elderly blunt trauma patients are associated with significant mortality and morbidity, but outcomes can be predicted to improve care. 相似文献2.
Eric M. Kiskaddon Jessica H. Lee Brett D. Meeks Spencer W. Barnhill Andrew W. Froehle Anil Krishnamurthy 《The Journal of arthroplasty》2018,33(5):1337-1342
Background
Attempts to control costs associated with total joint arthroplasty have included efforts to shorten hospital length of stay (LOS). Concerns related to patient outcomes and safety with decreased LOS persist. The purpose of this study was to investigate whether discharge on postoperative day (POD) 1 after joint replacement is associated with increased rates of 90-day return to the operating room, and 30-day readmissions and emergency department (ED) visits.Methods
After chart review, 447 patients admitted between January 2, 2013 and September 16, 2016 met inclusion criteria. All patients underwent one total joint arthroplasty. Patients were either discharged on POD 1 (subgroup 1) or POD 2 or 3 (subgroup 2). Statistical evaluation was performed using Wilcoxon-Mann-Whitney tests for continuous variables, and Fisher exact tests for categorical and frequency data. Statistical significance was established at P ≤ .05.Results
Subgroup 1 had significantly fewer return trips to the operating room (P = .043) and significantly fewer 30-day readmissions (P = .033). ED visits were not significantly different between groups (P = .901).Conclusion
Early discharge after joint arthroplasty appears to be a viable practice and did not result in increased rates of reoperation within the 90-day global period, or rates of 30-day readmission and ED visits. Our results support the utilization of an early discharge protocol on POD 1, with no evidence that shorter LOS results in higher rates of short-term complications. 相似文献3.
T. Gauss E. Gayat A. Harrois M. Raux A. Follin J.-L. Daban F. Cook S. Hamada 《British journal of anaesthesia》2018,120(6):1237-1244
Background
The role of vasopressors in trauma-related haemorrhagic shock (HS) remains a matter of debate. They are part of the most recent European recommendations on the management of HS and are regularly used in France. We assessed the effect of early administration of noradrenaline in 24 h mortality of trauma patients in HS, using a propensity-score analysis.Methods
The study included patients from a multicentre prospective regional trauma registry. HS was defined as transfusion of ≥4 erythrocyte-concentrate units during the first 6 h. Patients with a Glasgow coma scale=3 and pre-hospital traumatic cardiac arrest were excluded. The main outcome measure was in-hospital mortality. The explicative and adjustment variables for the outcome and treatment allocation were predetermined by a Delphi method. The in-hospital mortality of patients with and without early administration of noradrenaline was compared in a propensity-score model, including all predetermined variables.Results
Of 7141 patients in the registry in the study period, 6353 were screened and 518 patients in HS (201 with early noradrenaline use and 317 without) were included and analysed. After propensity-score matching, 100 patients remained in each group, and the hazard-ratio mortality was 0.95 (95% confidence interval: 0.45–2.01; P=0.69).Conclusions
The results of the present study suggest that noradrenaline use in the early phase of traumatic HS does not seem to affect mortality adversely. This observation supports a rationale for equipoise in favour of a prospective trial of the use of vasopressors in HS after trauma. 相似文献4.
Roshan Givergis Swapna Munnangi Katayoun Fayaz M Fomani Anthony Boutin Luis Carlos Zapat LD George Angus 《中华创伤杂志(英文版)》2018,21(5):261-266
Purpose
To evaluate massive transfusion protocol practices by trauma type at a level I trauma center.Methods
A retrospective analysis was performed on a sample of 76 trauma patients with MTP activation between March 2010 and January 2015 at a regional trauma center. Patient demographics, transfusion practices, and clinical outcomes were compared by type of trauma sustained.Results
Penetrating trauma patients who required MTP activation were significantly younger, had lower injury severity score (ISS), higher probability of survival (POS), decreased mortality, and higher Glasgow Coma scale (GCS) compared to blunt trauma patients. Overall, the mortality rate was 38.16%. The most common injury sustained among blunt trauma patients was head injury (36.21%), whereas the majority of the penetrating trauma patients sustained abdominal injuries (55.56%). Although the admission coagulation parameters and timing of coagulopathy were not significantly different between the two groups of patients, a significantly higher proportion of penetrating trauma patients received high plasma content therapy relative to blunt trauma patients (p < 0.01).Conclusion
Despite the use of the same MTP for all injured patients requiring massive transfusion, significant differences existed between blunt trauma patients and penetrating trauma patients. These differences in transfusion characteristics and outcomes following MTP activation underscore the complexity of implementing MTPs and warrant vigilant transfusion practices to improve outcomes in trauma patients. 相似文献5.
Hee Soo Jung Charles Warner-Hillard Ryan Thompson Krista Haines Brooke Moungey Anne LeGare David Williamson Shaffer Carla Pugh Suresh Agarwal Sarah Sullivan 《American journal of surgery》2018,215(2):250-254
Background
We hypothesized that team communication with unmatched grammatical form and communicative intent (mixed mode communication) would correlate with worse trauma teamwork.Methods
Interdisciplinary trauma simulations were conducted. Team performance was rated using the TEAM tool. Team communication was coded for grammatical form and communicative intent. The rate of mixed mode communication (MMC) was calculated. MMC rates were compared to overall TEAM scores. Statements with advisement intent (attempts to guide behavior) and edification intent (objective information) were specifically examined. The rates of MMC with advisement intent (aMMC) and edification intent (eMMC) were also compared to TEAM scores.Results
TEAM scores did not correlate with MMC or eMMC. However, aMMC rates negatively correlated with total TEAM scores (r = ?0.556, p = 0.025) and with the TEAM task management component scores (r = ?0.513, p = 0.042).Conclusions
Trauma teams with lower rates of mixed mode communication with advisement intent had better non-technical skills as measured by TEAM. 相似文献6.
Zhamak Khorgami William J. Fleischer Yuen-Jing A. Chen Nasir Mushtaq Michael S. Charles C. Anthony Howard 《American journal of surgery》2018,215(4):727-734
Background
The Oklahoma Trauma Registry (OTR) collects data from all state-licensed acute care hospitals. This study investigates trends and outcomes of trauma in Oklahoma using OTR.Methods
107,549 patients (2005–2014) with major severity and one of the following criteria were included: length of hospital stay ≥48?h, dead on arrival or death in the hospital, hospital transfer, ICU admission, or surgery on the head, chest, abdomen, or vascular system. Patient characteristics, mechanisms of injury, and outcomes of trauma were analyzed.Results
Hospital admissions due to falls increased with an annual percent change of 4.0% (95%CI: 3.1%–4.9%) while hospital admissions due to motor vehicle crashes decreased. The number of overall deaths per year remained stable except for the fall-related deaths, which increased proportionate to the increase in the incidence of fall. Fall-related mortality was 4.2% and intracranial bleeding was present in 60% in these patients.Conclusion
Falls are significantly increasing as a mechanism of trauma admissions and trauma-related deaths in Oklahoma. Analysis of state-based trauma registries can identify trends in etiologies of injuries and may indicate a reference point to prioritize preventive plans. 相似文献7.
Benjamin C. Jordan Joseph Brungardt Jared Reyes Stephen D. Helmer James M. Haan 《American journal of surgery》2018,215(1):48-52
Background
The specific contribution of dementia towards mortality in trauma patients is not well defined. The purpose of the study was to evaluate dementia as a predictor of mortality in trauma patients when compared to case-matched controls.Methods
A 5-year retrospective review was conducted of adult trauma patients with a diagnosis of dementia at an American College of Surgeons-verified level I trauma center. Patients with dementia were matched with non-dementia patients and compared on mortality, ICU length of stay, and hospital length of stay.Results
A total of 195 patients with dementia were matched to non-dementia controls. Comorbidities and complications (11.8% vs 12.4%) were comparable between both groups. Dementia patients spent fewer days on the ventilator (1 vs 4.5, P = 0.031). The length of ICU stay (2 days), hospital length of stay (3 days), and mortality (5.1%) were the same for both groups (P > 0.05).Conclusions
Dementia does not appear to increase the risk of mortality in trauma patients. Further studies should examine post-discharge outcomes in dementia patients. 相似文献8.
Avinash Bhakta Owen Glotzer Ashar Ata Marcel Tafen Steven C. Stain Paul T. Singh 《American journal of surgery》2018,215(4):643-646
Background
Postoperative pain management is a major contributor to recovery and discharge in bariatric surgery. Local anesthetic agents are of particular interest: they're non-sedating and may reduce postoperative pain and hospital length of stay (LOS).Design
Researchers queried the Bariatric Surgery Service Database for patients undergoing laparoscopic weight loss surgery from January 2012–December 2014. Patients were divided between those who did and did not receive liposomal bupivacaine intra-operatively. Measures included demographics, narcotic use, LOS, antiemetic use, and pain scales.Results
The liposomal group consisted of 233 patients and the PCA group consisted of 243 patients. The liposomal group had significantly less narcotic use than the PCA group in terms of IV morphine equivalents. This did not translate into a reduction in LOS in the liposomal group.Conclusions
TAP block using liposomal bupivacaine provides effective analgesia comparable to PCA. 相似文献9.
James W. Davis Rachel C. Dirks Krista L. Kaups Phu Tran 《American journal of surgery》2018,215(4):682-685
Background
Base Deficit (BD) and lactate have been used as indicators of shock and resuscitation. This study was done to determine the association of BD and lactate and to determine if one is superior.Methods
A retrospective review from 3/2014–12/2016 was performed. Data included demographics, systolic BP, ISS, BD, lactate, blood transfusion, and outcomes. BD and lactate were modeled continuously and categorically and compared.Results
1191 patients were included. BD and lactate correlated strongly (r?=?-0.76 p?<?0.001). Higher lactate and more negative BD were associated with transfusion and mortality. On multivariate regression, only BD was associated with transfusion (OR?=?0.8, p?<?0.001). As a categorical variable, worsening BD was associated with decreased BP, higher ISS, increased transfusions and worse outcomes.Conclusions
BD and lactate are strongly related. BD was superior to lactate in assessing the need for transfusion. The BD categories discriminate high risk trauma patients better than lactate. 相似文献10.
Introduction
Cycling has seen a large increase in popularity worldwide over the last number of years. This has been linked to an increase in the number of road traffic accidents involving cyclists. Participation in cycling as part of competitive sport and endurance events has seen particular growth.Aim
To examine patients referred with spinal trauma related to cycling and to assess whether the growing popularity of cycling and particularly competitive cycling is linked to an increase in spinal trauma.Methods
A retrospective analysis was carried out of a prospectively maintained database of referrals to a national referral centre for spinal trauma over a 4-year period (2010–2013). Data were further analysed for years 2012–2013, as there were incomplete data for years 2010–2011.Results
Spinal injuries involving cyclists increased by 200% from 2010 to 2013. In comparison those involving cars only increased by 29% and motorcycles reduced by 68%. From 2012 to 2013 there were 24 cyclist trauma referrals. The most common level injured was cervical spine (71%). Five patients (20.8%) had neurological deficit with 12.5% complete paralysis ASIA A disability score. The spinal fixation rate was 29.1%, 16.6% were managed with a HALO device. In total, 25% of patients were injured whilst training on a racer style bicycle, including all of the patients with complete spinal cord injury.Conclusion
There has been a significant increase in spinal trauma due to cycling accidents over this four year period. Competitive cycling has been a factor in the most severely injured patients. Increased public awareness campaigns for those participating in cycling for sport may be warranted. 相似文献11.
Philip Dawe Andrew Kirkpatrick Max Talbot Andrew Beckett Naisan Garraway Heather Wong Syed Morad Hameed 《American journal of surgery》2018,215(5):927-929
Background
Damage-control and emergency surgical procedures in trauma have the potential to save lives. They may occasionally not be performed due to clinician inexperience or lack of comfort and knowledge.Methods
Canadian Armed Forces (CAF) non-surgeon Medical Officers (MOs) participated in a live tissue training exercise. They received tele-mentoring assistance using a secure video-conferencing application on a smartphone/tablet platform. Feasibility of tele-mentored surgery was studied by measuring their effectiveness at completing a set series of tasks in this pilot study. Additionally, their comfort and willingness to perform studied procedures was gauged using pre- and post-study surveys.Results
With no pre-procedural teaching, participants were able to complete surgical airway, chest tube insertion and resuscitative thoracotomy with 100% effectiveness with no noted complications. Comfort level and willingness to perform these procedures were improved with tele-mentoring. Participants felt that tele-mentored surgery would benefit their performance of resuscitative thoracotomy most.Conclusion
The use of tele-mentored surgery to assist non-surgeon clinicians in the performance of damage-control and emergency surgical procedures is feasible. More study is required to validate its effectiveness. 相似文献12.
Yaakov Daskal Ricardo Alfici Adi Givon Kobi Peleg Oded Olsh Boris Kessel 《中华创伤杂志(英文版)》2018,21(5):273-276
Purpose: Investigation of injury patterns epidemiology among car occupants may help to develop different therapeutic approach according to the seat position. The aim of the study was to evaluate and compare differences in the incidence of serious injuries, between occupants in different locations in private cars.
Methods: A retrospective study including trauma patients who were involved in motor vehicle accidents and admitted alive to 20 hospitals (6 level Ⅰ trauma centers and 14 level Ⅱ trauma centers). We examined the incidence of injures with abbreviated injury score 3 and more, and compared their occurrence between seat locations.
Results: The study included 28,653 trauma patients, drivers account for 60.8% (17,417). Front passenger mortality was 0.47% higher than in drivers. Rear seat passengers were at greater risk (10.26%) for traumatic brain injuries than front seat passengers (7.48%) and drivers (7.01%). Drivers are less likely to suffer from serious abdominal injuries (3.84%) compared to the passengers (front passengers - 5.91%, rear passengers - 5.46%).
Conclusion: Out of victims who arrived alive to the hospital, highest mortality was found in front seat passengers. The rate of serious chest injuries was higher as well. Rear seat passengers are at greater risk for serious traumatic brain injuries. All passengers have a greater incidence of abdominal injuries. These findings need to be addressed in order to develop “customized” therapeutic policy in trauma victims. 相似文献
13.
Background
The primary objective of this study was to determine rates of reoperation, ED visits, and hospital readmission after thyroid and parathyroid surgery at a tertiary hospital. A secondary objective was to determine if scores from the American College of Surgeons Surgical Risk Calculator (ACS SRC) predicted these events.Methods
We retrospectively reviewed the records of patients undergoing parathyroid and thyroid surgery between 2011 and 2014. Patients who underwent an unplanned reoperation, returned to the ED, or were readmitted to hospital were evaluated using the ACS SRC.Results
436 patients underwent thyroid and parathyroid operations. Rates of re-operations, ED visits and hospital readmissions after thyroid and parathyroid surgery were: 3.4%, 0.6% and 3.0% and 2.2%, 0% and 1.4%, respectively. 71% of patients who experienced post-operative complications scored below average on the ACS SRC, 17% scored above average and 12% scored average risk.Conclusions
The SRC did not predict re-operation, ED visits, or hospital readmission after thyroid or parathyroid operations. 相似文献14.
Ji Wan Kim Yongkoo Lee Joonho Seo Jai Hyung Park Yong Min Seo Sung Soo Kim Hyun Chul Shon 《Journal of orthopaedic science》2018,23(2):383-388
Background
To report our experiences with the use of three-dimensional (3D) printing in the field of orthopedic trauma.Methods
This retrospective study enrolled 24 patients from three university teaching hospitals in whom 3D printing technique was applied: 14 patients with acetabular fractures and 10 patients with clavicular shaft fractures. We summarized our experiences with 3D printed bone models.Results
Three-dimensional printed acetabular models improved understanding of complex acetabular anatomy and fracture pattern to plan the optimal positioning of a reduction clamp and the trajectory of screws. Pre-bending of a reconstruction plate could reduce operative time. We also recorded fluoroscopic images of a simulated surgery for percutaneous screw fixation of the acetabular posterior column, with the optimal positioning of the guide wire determined during the simulation used as a reference during the actual operation. This surgical simulation was performed by a resident and served as a helpful training method. For fractures of the clavicle, we identified the optimal position of anatomical plates using 3D printed clavicle models.Conclusion
In our experience, 3D printing technique provided surgeons with improved understanding of the fracture pattern and anatomy and was effectively used for preoperative planning, education of surgical trainees, and performing simulations to improve intra-operative technical outcomes. 相似文献15.
Aravind K. Bommiasamy Christopher Connelly Alexi Moren Chris Dodgion Kelsey Bestall Anthony Cline Robert G. Martindale Martin A. Schreiber Laszlo N. Kiraly 《American journal of surgery》2018,215(5):825-830
Background
Clostridium difficile infection (CDI) is a common cause of healthcare associated infections contributing to morbidity and mortality. Our objective was to evaluate the impact of the implementation of a CDI bundle along with probiotic utilization.Methods
A retrospective review of trauma admissions from 2008 to 2014 was performed. The CDI bundle was implemented in stages from 2009 through 2014 with probiotics initiated in 2010. The bundle included changes in cleaning practices, education, screening, and contact precautions.Results
4632 (49%) patients received antibiotics with 21% receiving probiotics. Probiotic use was associated with increased age, male sex, more severely injured, and antibiotic use. CDI incidence decreased from 11.2 to 4.8 per 1000 admissions, p?=?.03. Among patients who received antibiotics CDI incidence decreased from 2.2% to 0.7%, p?=?.01.Conclusions
We report the largest series of a CDI bundle implementation including probiotics. During the period of adoption of these interventions, the incidence of CDI decreased significantly. 相似文献16.
Background
As the leading cause of mortality in the United States, trauma management have improved drastically over the past few decades with improved resuscitation and hemorrhage control. Stem cells are being used in an attempt to augment healing from trauma.Data sources
PubMed and ClinicalTrials.gov were searched for published and registered pre-clinical and clinical trials for the application of stem cells to AKI, ARDS, shock, infection, TBI, wound healing, and bone healing.Conclusions
Stem cell therapy for augmentation of healing traumatic injuries appears safe, as demonstrated by completed phase I/II trials. Further large scale studies are needed to assess the clinical efficacy. 相似文献17.
Cassie A. Barton Marissa Hom Nathan B. Johnson Jon Case Ran Ran Martin Schreiber 《American journal of surgery》2018,215(5):775-779
Introduction
Life-threatening bleeding can complicate warfarin therapy. Rapid anticoagulant reversal via replacement of vitamin-K dependent clotting factors is essential for hemostasis. We compare two methods of rapid factor replacement for warfarin reversal.Methods
A retrospective cohort study of warfarin-treated patients experiencing life-threatening bleeding who received a reversal protocol comprised of 4F PCC or 3F PCC and rFVIIa was performed. Demographic, clinical and anticoagulant reversal information, and all adverse events attributed to warfarin reversal were recorded.Results
195 patients were included in final analysis. While baseline demographics were similar between groups, the 3F-PCC group had a longer ICU LOS and higher in-hospital mortality (p?<?.01, .01).Pre-reversal INR was similar between both groups, but post-reversal INR was significantly lower in the 3F-PCC group, 0.8 versus 1.3 (p?<?.01). Significantly more patients experienced thromboembolic complications in the 3F-PCC group than the 4F-PCC group (p?<?.01). Receipt of rFVIIa was significantly associated with thromboembolic complications.Discussion
A 4F PCC reversal strategy is efficacious in INR reversal and provides lower thromboembolic risk as compared to 3F PCC with rFVIIa. 相似文献18.
Jarrett Williams Benjamin S. Kester Joseph A. Bosco James D. Slover Richard Iorio Ran Schwarzkopf 《The Journal of arthroplasty》2017,32(3):714-718
Background
To curb the unsustainable rise in health care expenses, health care payers are developing programs to incentivize hospitals and physicians to improve the value of care delivered to patients. Payers are utilizing various metrics, such as length of stay (LOS) and unplanned readmissions, to track progression of quality metrics. Relevant to orthopedic surgeons, the Centers for Medicare and Medicaid Services announced in 2015 the Comprehensive Care for Joint Replacement Payment Model—a program aimed at improving the quality of health care delivered to patients by shifting more of the financial risk of patient care onto providers.Methods
We analyzed the medical records of 1329 consecutive lower extremity total joint patients enrolled in Centers for Medicare and Medicaid Services' Bundled Program for Care Improvement treated over a 21-month period. The goal of this study was to ascertain if hospital LOS is associated with unplanned readmissions within 90 days of admission for a total hip or knee arthroplasty.Results
After controlling for multiple demographic variables including sex, age, comorbidities and discharge location, we found that hospital LOS greater than 4 days is a significant risk factor for unplanned readmission within 90 days (odd ratio = 1.928, P = .010). Total knee arthroplasty (TKA) and discharge to a location other than home are also independent risk factors for 90-day readmission.Conclusion
Our results demonstrate that increased LOS is a significant risk factor for readmission within 90 days of admission for a hip or knee arthroplasty in the Medicare population. 相似文献19.
Omar A. Behery Shalen Kouk Kevin K. Chen Kathleen A. Mullaly Joseph A. Bosco James D. Slover Richard Iorio Ran Schwarzkopf 《The Journal of arthroplasty》2018,33(3):639-642
Background
The Bundled Payments for Care Improvement initiative was developed to reduce costs associated with total joint arthroplasty through a single payment for all patient care from index admission through a 90-day post-discharge period, including care at skilled nursing facilities (SNFs). The aim of this study is to investigate whether forming partnerships between hospitals and SNFs could lower the post-discharge costs. We hypothesize that institutionally aligned SNFs have lower post-discharge costs than non-aligned SNFs.Methods
A cohort of 615 elective, primary total hip and knee arthroplasty subjects discharged to an SNF under the Bundled Payments for Care Improvement from 2014 to 2016 were included in our analysis. Patients were grouped into one of the 3 categories of SNF alignment: group 1: non-partners; group 2: agreement-based partners; group 3: institution-owned partners. Demographics, comorbidities, length of stay (LOS) at SNF, and associated costs during the 90-day post-operative period were compared between the 3 groups.Results
Mean index hospital LOS was statistically shortest in group 3 (mean 2.7 days vs 3.5 for groups 1 and 2, P = .001). SNF LOS was also shortest in group 3 (mean 11 days vs 19 and 21 days in groups 2 and 1 respectively, P < .001). Total SNF costs and total 90-day costs were both significantly lower in group 3 compared with groups 1 and 2 (P < .001 for all), even after controlling for medical comorbidities.Conclusion
Institution-owned partner SNFs demonstrated the shortest patient LOS, and the lowest SNF and total 90-day costs, without increased risk of readmissions, compared with other SNFs. 相似文献20.