A. Grigorian1, J. Nahmias1, T. Chin1, E. Kuncir1, M. Dolich1, V. Joe1, M. Lekawa1 1University of California, Irvine,Surgery,Orange, CA, USA
Introduction: The care provided and resulting outcomes may differ in patients with a gunshot-wound (GSW) treated at an American College of Surgeon’s Level-I trauma center compared to a Level-II center. In addition, there has recently been an increase in the non-operative management (NOM) of GSWs in the right upper quadrant or those with a tangential trajectory. Previous studies have had conflicting results when comparing risk of mortality in patients with GSWs treated at Level-I and II centers. However, the populations studied were restricted geographically. We hypothesized that patients presenting after a GSW to the torso at a Level-I center would have a shorter time to surgical intervention (exploratory laparotomy or thoracotomy), compared to a Level-II in a national database. We also hypothesized that patients with GSWs managed operatively at a Level-I center would have a lower risk of mortality.
Methods: The Trauma Quality Improvement Program (2010-2016) was queried for patients presenting to a Level-I or II trauma center after a GSW. Patients with grade>1 for abbreviated injury scale of the head, neck and extremities were excluded to select for patients with injuries to the torso. A multivariable logistic regression analysis was performed.
Results: From 17,965 patients with GSWs, 13,812 (76.8%) were treated at a Level-I center and 4,153 (23.2%) at a Level-II center. There was no difference in the median injury severity score (ISS) (14, p=0.55). The Level-I cohort had a higher rate of laparotomy (38.9% vs. 36.5%, p<0.001) with a shorter median time to laparotomy (49 vs. 55 minutes, p<0.001) but no difference in rate (p=0.14) and time to thoracotomy (p=0.62). GSW patients at a Level-I center managed with laparotomy (11.5% vs. 13.8%, p=0.02) or thoracotomy (50.8% vs. 61.5%, p=0.01) and those with NOM (12.8% vs. 14.0%, p=0.04) had a lower rate of mortality. After adjusting for covariates, only patients undergoing thoracotomy (OR=0.67, CI=0.47-0.95, p=0.02) or those with NOM (OR=0.85, CI=0.74-0.98, p=0.03) at a Level-I center had lower risk for death, compared to Level-II.
Conclusion: Despite having a similar ISS, patients presenting after GSWs to the torso at a Level-I center undergo laparotomy in a shorter time compared to those treated at a Level-II center and although they had a trend towards a lower mortality risk, this was not statistically significant. Patients with GSWs managed with thoracotomy or with NOM at a Level-I center have a lower risk of mortality, compared to a Level-II. Future prospective studies examining variations in practice, resources available and surgeon experience to account for these differences are warranted and to determine optimal pre-hospital trauma designation for this population.
