A. Farah1, A. Tatakis1, J. Gellings1, C. Caswell1, D.J. Wilson1, W. Butak1, D. Milia1, D. Holena1 1Medical College Of Wisconsin, Trauma And Acute Care Surgery, Milwaukee, WI, USA
Introduction: The American College of Surgeons conditionally recommends that patients with penetrating thoracoabdominal trauma be transported directly to a Level I trauma center. However, these patients may be taken to the nearest hospital for initial stabilization if immediate life-saving interventions are required. This study aimed to compare outcomes between patients directly transported(DT) to a Level I trauma center and those who underwent interhospital transfer(IHT).
Methods: We retrospectively observed patients with Penetrating Thoracoabdominal Injuries(PTAI) who presented to one Level I trauma center in Milwaukee from 2018-2022. We compared baseline demographic, injury, and physiological characteristics between DT and IHT patients, with a specific focus on the proportion of IHT patients who were hypotensive (systolic blood pressure [SBP]<90mmHg) at various stages of their transfer. Variables associated with mortality with p≤0.2 in univariate logistic regression models were considered for inclusion in multivariable models, with transfer status as the primary exposure of interest. Stata v17 was used for statistical analyses.
Results: A total of 1232 patients met the inclusion criteria, with 809(65.7%) in the DT group and 423(34.3%) in the IHT group. Both groups were predominantly male(86% DT vs 84% IHT, p=0.25) and had similar rates of gunshot wounds as the mechanism of injury(72.6% in DT vs 75.4% in IHT, p=0.23). IHT patients were slightly younger(median age 29 [IQR 23-37]vs 31 [IQR 24-31],p=0.001). In the IHT group, rates of hypotension at the transferring hospital, during interhospital transfer, and at the receiving hospital were 6.8%, 5.3%, and 3.1%, respectively. Patterns of hypotension across the 3 time points in the IHT group can be seen in the Figure. Rates of hypotension in the prehospital setting and upon emergency department arrival were 25% and 15%, respectively. In univariate modeling for mortality, age, Injury Severity Score, trauma center SBP, trauma center Glasgow Coma Scale, and gunshot wounds as the mechanism were associated with mortality (p<0.2). In multivariable modeling with transfer status as the primary exposure of interest, IHT remained strongly associated with lower odds of mortality(OR 0.32, 95% CI 0.12-0.89).
Conclusion: Patients with PTAI initially stabilized at a non-trauma center and transferred to definitive care had lower injury severity and hypotension rates than those directly transported. However, even after adjusting for these factors, IHT was still associated with decreased mortality risk. Trauma registries do not include deaths at referring centers, which may result in inclusion bias as only living patients are transferred. Future studies should include outcomes at referring centers.