16.08 Walking Under the Influence: Pedestrians Struck by Vehicles Are Commonly Intoxicated

Posted on January 18, 2018

M. Srour1, T. Li1, N. K. Dhillon1, K. Patel1, E. Gillettee1, D. R. Margulies1, E. J. Ley1, G. Barmparas1  1Cedars-Sinai Medical Center,Los Angeles, CA, USA

Introduction:  The aim of this study was to characterize alcohol intoxication among pedestrians struck by vehicles and examine whether these patients are more likely to be admitted after hours.

Methods:  The Los Angeles County TEMIS database was reviewed for all pedestrians struck by a vehicle over a 16-year period starting in 01/2000. Subjects ≥ 18 years old with available time and day of admission were selected. Patients with available blood alcohol concentration (BAC) were further analyzed and those with positive (+) BAC (> 0 gr %) were compared to those with negative (-) BAC. The primary outcome was mortality.

Results: Of 36,358 patients meeting inclusion criteria, 11,963 (33%) were tested for BAC and of those 3,846 (32%) were (+).  The proportion of (+) BAC pedestrians was low from the early morning until early evening (between 4% at 6-7 am to 8% at 5-6 pm). However, after 6 pm there was an abrupt increase in this proportion, peaking at 2-3 am (27% among all admitted pedestrians and 69% among pedestrians tested for BAC). This pattern was observed for all days of the week, but was more profound on Saturdays with the respective proportions reaching 30% and 75%.  When (+) BAC patients were compared to their (-) counterparts, they were more likely to be admitted with a Glasgow Coma Scale score ≤ 8 (10% vs. 5%, p < 0.01), with a systolic blood pressure (SBP) < 90 mmHg (3% vs. 2%, p < 0.01). Injury severity scores were similar (median 5 vs 5, p=0.66). The overall mortality was 4%, divided equally between the two cohorts. After adjusting for differences, (+) BAL pedestrians were significantly more likely to survive their injuries (AOR: 0.50, p<0.01). 

Conclusion: Pedestrians who are struck by vehicles during late hours are commonly intoxicated. These findings could have implications in developing preventative strategies to separate pedestrians from vehicles or to lower vehicle speed limit after hours in high risk areas.

16.09 How timing of surgical airway impacts in-hospital mortality in medical patients in US hospitals

Posted on January 18, 2018

I. Yi1, G. Ortega3, M. F. Nunez3, E. E. Cornwell2, M. Williams2  1Howard University College Of Medicine,Washington, DC, USA 2Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA 3Howard University College Of Medicine,Clive O. Callender, MD Howard-Harvard Outcomes Research Center,Washington, DC, USA

Introduction:

Optimal timing of surgical airways in admitted patients requiring ventilator support remains elusive. Previous studies have classified tracheostomies as “early” and “late” using cut-off dates ranging from 5 to 10 days on ventilator to assess mortality. Our study aims to investigate mortality rates based on the day of the procedure and the number of days on a ventilator using a national database.

Methods:

We performed a retrospective analysis of the National Inpatient Sample (NIS) 2005–2014. We included non-trauma adult patients who underwent a surgical airway (ICD-9 31.1) procedure within 28 days of admission. We excluded patients who underwent elective and permanent tracheostomies (ICD 31.2), transfers from another facility, and patients requiring a surgical airway for the management of another localized disease (e.g. cancer or disease of the oropharynx and upper airway). We analyzed the day(s) from admission and/or day(s) from endotracheal intubation to the day the surgical airway was performed. Descriptive statistics were obtained for patient demographics, co-morbidities, length of stay, and mortality. Unadjusted and adjusted analyses were performed where appropriate to assess mortality adjusting for age, race/ethnicity, insurance, median household income, hospital type, and co-morbidities.

Results:

A total of 88,890 patients underwent a surgical airway. Most patients were White (60.5%), male (53.1%), had a mean age of 62.3 years. Most patients presented with respiratory failure (83.1%), followed by heart diseases (56.3%), sepsis (49.0%) and pneumonia (48.8%). Over the 28-days period, the average surgical airway was performed on day 13, and patients were intubated after 10 days. Most surgical airways were performed at teaching (57.7%) and urban facilities (95.9%), with an 18.9% overall mortality rate. The mortality rate was 15.7% on day 0 and 27.8% on day 28 for day of procedure, with the lowest rate at 12.6% on day 2. The mortality rate was 20.4% and 24.8% for 0 and 28 days on ventilator respectively, the lowest rate being 12.4% after 2 days on ventilator. On adjusted analysis, we found an increase by 1.6% and 1.1% in mortality rate for each day preceding the surgical airway and for each day spent on a ventilator, respectively.

Conclusion:

As time before surgical airway and number of days on ventilator increase, so does in-hospital mortality. Earlier timing of surgical airways appears to be independently associated with a modest increase in in-hospital survival compared to later surgical airways.

16.06 Traumatic Atlanto-Occipital Dissociation: No Longer a Death Sentence

Posted on January 18, 2018

D. M. Filiberto1, J. P. Sharpe1, M. A. Croce1, T. C. Fabian1, L. J. Magnotti1  1University Of Tennessee Health Science Center,Surgery,Memphis, TN, USA

Introduction: Although rare, traumatic atlanto-occipital dissociation (AOD) injuries are considered highly unstable and are associated with a high mortality rate.  In fact, these injuries were once believed to be uniformly fatal in adults. However, with recent advances in pre-hospital care coupled with early diagnosis and stabilization, these injuries are now potentially survivable. The purpose of this study was to evaluate the effect of rapid diagnosis and treatment (stabilization) of traumatic AOD following blunt injury in one of the largest single institutional series reported in the literature.

Methods:  Patients with traumatic AOD following blunt injury treated over a 17-year period were identified from the trauma registry of a level I trauma center and stratified by age, gender, injury severity (as measured by Injury Severity Score [ISS] and admission Glasgow Coma Scale [GCS] score) and severity of shock (as measured by admission base excess [BE] and 24-hour transfusions). Time to diagnosis, time to and method of stabilization, and mortality were recorded and compared. Multivariable logistic regression (MLR) was performed to determine which risk factors were independent predictors of death following AOD.

Results: 52 patients were identified: 35 men (67%) and 17 women (33%) with a mean age, admission GCS and ISS of 44, 8 and 34, respectively. Mean admission BE was -7.7 with patients requiring on average 3.7 units of packed red blood cells over the first 24 hours. 30 patients (58%) underwent stabilization: 16/30 underwent fusion, 5/30 were fitted with an external orthosis and 9/30 had a combination of both. Overall mortality was 32.7%. 16 of the deaths (94%) were secondary to severe traumatic brain injury. 3 of the deaths (17.6%) were among those patients who had undergone stabilization. Of the survivors, 34 patients (97%) were discharged neurologically intact: 15 patients went home, 15 to a rehabilitation center and 4 to a skilled nursing facility. Only one patient was discharged with neurological deficits to a rehabilitation center. There were no missed or delayed diagnosis related to AOD over the study. MLR identified admission GCS (OR 0.7; 95%CI 0.552-0.877) as the only independent predictor of death in patients with AOD after adjusting for severity of shock, injury severity, and time to stabilization.

Conclusion: Traumatic AOD remains a relatively rare injury following blunt trauma. Prompt diagnosis is crucial in promoting rapid stabilization and contributing to increasing survivability. Traumatic AOD should no longer be considered a uniformly fatal injury in adults.

 

16.07 Weight-Adjusted Enoxaparin Decreases Venous Thromboembolism? Rates in Trauma Patients

Posted on January 18, 2018

P. Martinez Quinones1, A. Talukder1, R. Latremouille3, T. Robinson2, A. Newsome2, C. White1  1Medical College Of Georgia,Surgery,Augusta, GA, USA 2Medical College Of Georgia,Pharmacy,Augusta, GA, USA 3Medical College Of Georgia,Augusta, GA, USA

Introduction: ? Traumatic injury is a major risk factor for the development of venous thromboembolic events (VTE), and is associated with increased bleeding risk. VTEs increase length of stay, cost and are associated with elevated morbidity and mortality in trauma patients. Optimal VTE pharmacologic prophylaxis in trauma patients remains unknown. Recent studies suggest that standard dosing of enoxaparin (30mg SQ Q12hrs) leads to sub-therapeutic levels of anti-Factor Xa, which are associated with increased risk for the development of VTE. We aimed to determine the efficiency of standard-dose versus weight-adjusted dose of enoxaparin.?

Methods:  As a quality improvement measure for medication use evaluation we conducted a retrospective registry review and data analysis. Patients with an initial trauma admission from January-December 2016 who received standard-dose (STD) or weight-adjusted (WT) enoxaparin were included. Patients <18 years, prior/current anticoagulation, prior VTE, known malignancy, autoimmune disorder and/or severe traumatic brain injury (TBI) were excluded. The primary outcome was incidence of VTE, including pulmonary embolism (PE) and deep venous thrombosis (DVT). Secondary outcomes included bleeding complications and length of stay.?

Results: We identified 142 patients who met inclusion criteria. Both groups (STD dose and WT dose) had comparable baseline characteristics for age, gender, race/ethnicity, mean weight and tobacco use. Mild-to-moderate TBI patients were similarly distributed, STD n=17, WT n=12  (p=0.81). VTE incidence was significantly different, STD n=17 and WT n=3 (p=0.03). No difference noted in length of stay (p=0.35) or time to onset of prophylaxis (p=0.93). No bleeding complications reported.?

Conclusion: Weight-adjusted enoxaparin dose for VTE prophylaxis decreased the risk of VTE in our trauma population sample without an increase in bleeding complications or expansion of intracranial hemorrhage in traumatic brain injury patients. Our ultimate goal is to develop a protocol for VTE prophylaxis that is safe and beneficial in patients with traumatic injuries.?

 

16.04 REBOA: How Many Patients Are We Missing? Assessing the Need in a Large Urban Trauma Center

Posted on January 18, 2018

R. P. Dumas1, D. N. Holena1, B. P. Smith1, M. J. Seamon1, P. M. Reilly1, Z. Qasim2, J. W. Cannon1  1University Of Pennsylvania,Division Of Traumatology, Surgical Critical Care And Emergency Surgery,Philadelphia, PA, USA 2University Of Pennsylvania,Division Of Emergency Medicine,Philadelphia, PA, USA

Introduction:

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has shown benefit as a less invasive bridge to hemorrhage control in patients with torso trauma. The number of patients who might benefit from this procedure and the need for this intervention in an urban trauma center however, remains unclear. We sought to develop a generalizable methodology to identify the number of patients with injuries and presenting physiology amenable to REBOA, with the intention of characterizing the accuracy of our algorithm compared to traditional chart review.

Methods:

We queried the database of our Level I trauma center for all patients presenting from 2014-2015. Potential REBOA patients were included based on anatomic injuries and physiology. ICD-9 codes were used to identify REBOA-amenable injury patterns (abdominal solid organ; traumatic lower extremity amputation; major abdominal or lower extremity vascular injury; pelvic fractures) and physiology (presenting systolic pressure of ≤90 mmHg or transfusion requirement during initial trauma resuscitation). We excluded patients with injuries contraindicating REBOA (major vascular neck, thoracic, and axillary injuries). Chart review was used to confirm that our algorithm correctly identified these patients. Two reviewers experienced in REBOA then performed chart review to adjudicate algorithm-identified cases.

Results:

4818 patients were admitted from 2014-2015. 666 patients were included based on injury pattern. 186 patients received blood transfusions. 149 patients had an initial systolic blood pressure ≤90 mmHg. 309 patients had contraindications to REBOA (FIGURE 1). 64 patients (79.7% male, 67.2% African-American, 53% penetrating mechanism of injury, median ISS 18.5 [IQR 14-28]) had an injury pattern and physiology amenable to REBOA with no injury contraindications. Chart review confirmed that our algorithm correctly identified 54 (86%) of patients that had anatomic injuries amenable to REBOA with no contraindications. Review by two independent REBOA-experienced physicians revealed 29 patients (46% of those identified by algorithm) that may have benefited from REBOA. The inter-rater reliability was excellent (kappa 0.94, p<0.001). In the total cohort, 0.6% of patients may have benefited from REBOA.

Conclusion:

Our REBOA algorithm identified patients who may have benefited from early femoral arterial access but over-estimated the number of true REBOA candidates. Centers seeking to establish a REBOA program should combine an algorithm to identify potential patients with a detailed chart review to determine their center-specific REBOA candidate population. Future work should focus on revision and refinement of this algorithm for application at other institutions.
 

16.05 Psoas Muscle Area Index May Not Predict Outcomes in Trauma Patients

Posted on January 18, 2018

A. Santoro1, E. Otoo1, A. Salami1, R. Smith2, A. Joshi1  1Albert Einstein Medical Center,Surgery,Philadelphia, PENNSYLVANIA, USA 2Albert Einstein Medical Center,Radiology,Philadelphia, PENNSYLVANIA, USA

Introduction:  Sarcopenia is the age-related loss of skeletal muscle mass. Studies have described a correlation between sarcopenia, frailty, and poor outcomes in heterogeneous populations. We sought to determine the utility of psoas muscle area index (PAI), a new tool for the assessment of sarcopenia, in predicting poor outcomes amongst trauma patients. 

Methods:  This retrospective observational study was conducted using data from the trauma database at Albert Einstein Medical Center, a level 1 trauma center in Philadelphia, PA. All level 1 & 2 trauma activations for blunt and penetrating trauma between September 2014 and December 2015 were included. Patients without abdominal CT scans at the time of initial presentation were excluded. CT scans of the abdomen were used in estimating PAI at the level of the 3rd lumbar vertebral body using the formula [psoas muscle area(mm2)/height(m2)]. PAI was dichotomized with values < the 25th percentile representing the sarcopenic group, while ICU and hospital length of stay (LoS) were dichotomized with values > the 75th percentile representing prolonged stay. Outcomes of interest were in-hospital mortality, prolonged ICU, and Hospital LoS. Multivariable logistic regression was used in elucidating associations. 

Results: A total of 254 patients were included in this study, 73 (28.7%) were aged>65 years and 111 (43.7%) were female.  In-hospital mortality occurred in 13 patients (5.2%). Prolonged ICU and hospital LoS were observed in 22.8% and 24% of the study population, respectively. PAI was not associated with in-hospital mortality (OR: 0.5, CI: 0.12-2.49; p=0.426), prolonged ICU (OR: 0.95, CI: 0.48-1.89; p=0.894), or hospital LoS (OR: 1.3, CI: 0.68-2.46; p=0.425) on univariate analyses. This trend persisted following multivariable adjustment (p>0.05 for all). Similarly, PAI was not found to be predictive of outcomes following stratification by age (above or below 65 years) and gender. 

Conclusion: PAI does not seem to have any correlation with poor outcomes in trauma patients, irrespective of age or gender. Prospective studies with larger populations are needed to determine if PAI has any prognostic utility in the risk stratification of trauma patients. 

 

16.02 Risk of Recurrent Pneumothorax and Does it Really Matter?

Posted on January 18, 2018

A. F. Elegbede1, B. W. Carr1, B. L. Zarzaur1, S. A. Savage1  1Indiana University School Of Medicine,Indianapolis, IN, USA

Introduction:

Thoracic trauma is a significant source of mortality in multiply injured patients.  The vast majority will be managed solely with tube thoracostomy, however, and chest tube insertion remains one of the most commonly performed procedures.  A common complication related to chest tube removal is recurrent pneumothorax (R-Ptx).  R-Ptx has been linked to the need for additional procedures and may increase hospital length of stay (LOS).  Though multiple studies have focused on tube removal techniques to best reduce R-Ptx, there have been few reports regarding other factors that may predispose to R-Ptx. 

Methods:
 A retrospective chart review was performed for all patients requiring chest tubes from January to July 2016 at a single Level 1 trauma center.  Data collected included patient demographics, injury characteristics, information regarding chest tube placement and any complications related to the intervention.  Groups were compared using either χ2 or Kruskal Wallis tests as appropriate.  Multivariable logistic regression was used to compare outcomes.

Results:
106 patients were included in this study. 75% of the patients were male, 83% suffered a blunt mechanism, the mean age was 48 years (SD 20.7) and mean chest AIS was 3.1 (SD 0.89). There were no differences between groups in terms of gender, overall ISS, or chest AIS.  Patients in the R-Ptx group were significantly younger (40 years (SD 17) vs 54 years (SD 21), p=0.0004), had a significantly lower body mass index (BMI) (25.3 (SD 5.7) vs 29.4 (SD 7), p=0.0031), and a higher rate of penetrating trauma (28% vs 9.5%, p=0.0179).  With multivariable logistic regression, both age and BMI remained significantly associated with R-Ptx (Table 1).   When excluding patients with trace or small R-Ptx (<1 cm),  BMI remained associated with recurrence (Table 1).   ICU LOS was no different between groups (R-Ptx 4 days (IQR0, 16); no R-Ptx 6 days (IQR 2, 13), p=0.2807).  However, R-Ptx patients had a significantly shorter hospital LOS (10 days (IQR 7, 14)) compared to no R-Ptx patients (12 days (IQR 7, 20), p=0.0088).

Conclusion:
Recurrent pneumothorax is a complication of thoracostomy tube placement that may delay recovery and discharge.  In our study, patients with a higher BMI and older age were protected from recurrence compared to our younger patients suffering penetrating trauma.  This may in part be due increased subcutaneous tissue preventing entrainment of air during tube removal.  Counterintuitively, despite the R-Ptx, these patients actually had a significantly shorter hospital LOS.  The very factors which predispose patients to recurrence may allow faster recovery and earlier discharge.  R-Ptx may not have a significant negative impact on duration of hospital stay.
 

16.03 Aspirin Versus Low-Molecular Weight Heparin for VTE Prophylaxis After Lower Extremity Trauma

Posted on January 18, 2018

M. Mazzei1, M. Uohara2, S. Pasch2, E. Dauer1, Z. Maher1, L. L. Mason1, A. Pathak1, T. Santora1, L. O. Sjoholm1, A. J. Goldberg1, J. M. Lopez1  1Temple University Hospital,Department Of Surgery,Philadelphia, PA, USA 2Temple University,Lewis Katz School Of Medicine,Philadelphia, PA, USA

Introduction: Low-molecular-weight heparin (LMWH) is an accepted standard of care for extended venous thromboembolism (VTE) prophylaxis after lower extremity trauma based on data extrapolated from elective orthopedic procedures, but can be limited due to cost and compliance. The aim of this study was to investigate the potential noninferiority of daily aspirin compared to LMWH in preventing symptomatic VTE after lower extremity trauma.

Methods: A six-year, single-institution, retrospective analysis of patients requiring surgical intervention for lower extremity trauma at a level one urban trauma center was performed. Subjects were included if they had no prior history of VTE, did not sustain lower extremity vascular injury, did not require therapeutic anticoagulation for any reason, and followed with trauma or orthopedic care providers for at least thirty days post-discharge. Subjects receiving LMWH as outpatient VTE prophylaxis were compared with those who received aspirin due to an inability to afford LMWH. The primary endpoint was the development of symptomatic VTE diagnosed by venous duplex or CT-angiography within the first thirty days from discharge.

Results: Of the 1099 patients initially identified, 712 met inclusion criteria and comprised the study population. Patients receiving aspirin (n=187) rather than LMWH (n = 525) were younger (38.99 vs. 42.88 years old, p = 0.012), more likely to be male (78.61% vs. 63.62%, p < 0.0001), and spent less time in the hospital (5.8 days vs. 7.6 days, p = 0.001). Otherwise, groups were comparable in terms of most comorbidities, mechanism of injury, presenting vitals, lower extremity injury severity score, and rates of in-hospital complications. 1.59% (3) of the patients receiving aspirin developed a symptomatic VTE during the first thirty days following discharge, compared with 1.52% (8) who developed symptomatic VTE (p = 0.93) while receiving LMWH.

Conclusion: In this retrospective review, aspirin was found to be noninferior to LMWH for preventing symptomatic VTE in patients requiring surgical intervention for lower extremity trauma. Future research should be conducted to evaluate aspirin’s potential role as a safe, effective, and affordable alterative to LMWH for extended VTE prophylaxis.

 

15.20 The Utility of Shock Index In Trauma To Predict the Need for Massive Blood Transfusion Protocol

Posted on January 18, 2018

R. Latifi1, E. Tilley1, D. Samson1, A. A. El-Menyar1  1Westchester Medical Center,Surgery,Valhalla, NY, USA

Introduction: Post-traumatic significant bleeding represents a major challenge and needs immediate detection and treatment. Predicting which patients will require massive blood transfusion protocol (MTP) is still an art, more then a science. Shock index (SI) is a simple quick mathematic equation (heart rate/systolic blood pressure) that has shown a prognostic implication in trauma patients at certain cutoffs that differ from one study to another. In these studies, higher SI was associated with unfavorable outcomes. We aimed to evaluate the value of SI in predicting the need for MTP in trauma patient a Level 1 Trauma center

Methods: We conducted a retrospective analysis for trauma patients who received blood transfusion in the trauma room between 2012 and 2016.  Data included patient demographics, heart rate, systolic and diastolic blood pressures , pulse pressure (PP) , mechanism of injury, Injury Severity Score (ISS), New Injury Severity Score (NISS) , Trauma and Injury Severity Score (TRISS), need for blood transfusion, MTP, hospital length of stay (HLOS) and mortality.  Patients < 14 years old or with incomplete clinical data were excluded. Patients were classified into group I (SI<0.8) and group II
( SI ≥0.8). Comparisons were performed by Chi Square, and Student T test, whenever applicable.  Correlation coefficient r measured the strength and direction of a linear relationship between the variables. 

Results:There were 2808 patients eligible for the study, of them 531 (19%) had SI ≥ 0.8 and 273 (9.5%) who received blood transfusion. Of those who were transfused, 14.6% received MTP. In comparison to lower SI, patients with SI≥0.8 were 11 year younger (42±20 vs 53±23), sustained more penetrating injury (9.4% vs 6.7%), had greater ISS (15±12 vs 10.5±8), higher NISS (19±15 vs 14±11), lower TRISS (0.90±0.20 vs 0.96±0.10) and received more blood transfusion (21.2% vs 7.1%) and MTP (10.2% vs 1%),p=0.001 for all. Patients with high SI also had longer HLOS (10.6 vs 6.7 days, p=0.001) and higher mortality (6.2% vs 3.4%, p=0.004). There were correlations between SI and PP(r=-0.53), HLOS(r=0.15), ISS(r=0.21), NISS(r=0.20), and TRISS(r=-0.20), p=0.001 for all.

Conclusion:Shock index can be used early to predict the need of blood transfusion and correlates with PP, HLOS, ISS, NISS, and TRISS.  However, its cutoff values for risk stratification and prognostication needs further evaluation in trauma patients.
 

16.01 Trauma Center Transfer of Elderly Patients with Mild Traumatic Brain Injury Improves Outcomes

Posted on January 18, 2018

A. M. Velez1, S. G. Frangos2, C. J. DiMaggio2,3, C. D. Berry2, M. Bukur2  1New York University School Of Medicine,Department Of Surgery,New York, NY, USA 2New York University School Of Medicine,Department Of Surgery, Division Of Trauma And Acute Care Surgery,New York, NY, USA 3New York University School Of Medicine,Department Of Population Health,New York, NY, USA

Introduction:  Accidents causing Traumatic Brain Injury (TBI) are common in the elderly. Hospitals frequently transfer these patients to designated Trauma Centers (TC) for management. Recent studies have suggested some of these injuries may be safely observed or even discharged from the Emergency Department, an issue that has not been evaluated on a national level. The objective of this study was to examine whether TC transfer of elderly patients with mild TBI is associated with improved outcomes.

Methods:  This was a retrospective study utilizing the National Trauma Databank 2015 dataset. Patients over 65 years of age who suffered injuries resulting in mild TBI (positive Head CT and GCS ≥13) were included. Demographic, injury, and outcomes data were abstracted. Patients were dichotomized by transfer to a designated Level I/II TC vs. not. Multivariate regression was used to derive adjusted outcomes for our primary outcome of mortality. Secondary outcomes assessed were complications and discharge disposition.

Results: 19,664 patients met inclusion criteria with a mean age of 78.1 years. 70% of patients were transferred to a Level I/II TC with the remainder treated at lower tier or non-designated centers. Only 4.2% of transfers came from centers without neurosurgeons, while 80% of transferring centers had > 3 neurosurgeons. Patients transferred to Level I/II TCs were more likely to be Caucasian and have Medicare funding. Falls were the predominant cause of injury with Median Head AIS (4) and GCS (15) being similar between groups. Patients transferred to Level I/II TCs had a higher ISS (12 vs. 10, p <0.001). No neurosurgical interventions were required in any of the patients. Mortality was significantly lower in patients transferred to Level I/II TCs (5.6% vs. 6.2%, Adjusted Odds Ratio (AOR) 0.84, p=0.011). Patients treated at Level I/II TCs were also less likely to be discharged to Skilled Nursing Facilities (26.4% vs. 30.2%, AOR 0.80, p <0.001).

Conclusion: In a large, multi-center sample we demonstrate improved outcomes when elderly patients with mild TBI are transferred to Level I/II TCs. These findings suggest elderly patients with mild TBI are a heterogeneous group that warrants appropriate trauma triage. Which patients with mild TBI require Level I/II TC care should be examined prospectively.

 

15.19 Needs Assessment Of Bleeding Control Training In Law Enforcement

Posted on January 18, 2018

J. Bailey1, M. Iwanicki1, D. H. Livingston1, A. Fox1  1New Jersey Medical School,Newark, NJ, USA

Introduction:  The Hartford Consensus identifies law enforcement officers (LEO) as critical first responders who work in hostile environments and should be trained in bleeding control (BC). There is great emphasis to expand BC to the public, who could act as immediate responders. While universal education of BC is a laudable goal, identifying individuals who have the greatest likelihood of utilizing BC maneuvers is the optimal use of scarce resources. We postulate that LEO have little training in BC. With increasing numbers of mass casualties, we believe that the LEO community is the ideal group for BC efforts to be focused. The goal of this study was perform a needs assessment and to identify gaps in knowledge in LEO. 

Methods:  Over 6 months, 7 Bleeding Control Basics classes were conducted in New York and New Jersey for multiple law enforcement agencies. In addition, 2 civilian classes were conducted. Anonymous, voluntary surveys were collected from all participants following the classes. Responses were tabulated and analyzed using SPSS.

Results: 190 participants were taught and completed evaluations (100% response rate). 51% had prior experience utilizing bleeding control techniques, with 47% trained on direct pressure, 40% on tourniquet use, and 20% on hemostatic agents. 71% of those with experience had previous military training; of those with military training, 96% had received BC training. Military experience did not differ between LEO and civilians. Of participants, just 14% carried bleeding control kits on their person, and 6% had ever utilized a tourniquet in an emergency setting. 

Conclusion: Prior military experience conferred BC experience. LEO without military experience had no more knowledge than civilians. Despite knowledge, only a handful of LEO carry BC kits and would be ill-prepared to treat bleeding patients following trauma or mass casualty events. All class participants rated the education highly. This study clearly identified training gaps and illustrates the necessity of BC training in the LEO population. We strongly believe that BC Basics should be a mandatory component of the LEO curriculum nationwide.

 

15.16 PECARN Head Clinical Prediction Rules Show Potential of Decreasing Head CT at a Single Institution

Posted on January 18, 2018

I. Abd El-shafy1,2, N. L. Denning1, M. L. Reppucci,1, J. T. Avarello1, M. Mittler1, N. A. Christopherson1, J. M. Prince1  1North Shore University And Long Island Jewish Medical Center,Pediatric Surgery,Manhasset, NY, USA 2Maimonides Medical Center,Surgery,Brooklyn, NY, USA

Early identification of clinically-important traumatic brain injury (ciTBI) is essential for providing acute intervention for pediatric patients with head trauma. Approximately 50% of children in North American emergency departments receive a CT following head trauma, highlighting the need to limit radiation exposure. The use of the PECARN head injury clinical prediction rules have been shown to reduce the number of head CTs completed without an increase in missed injuries.  We sought to define the potential impact of strict adherence to PECARN guidelines at a newly designated level I ACS-verified pediatric trauma center.

Methods

A retrospective chart review was conducted of all pediatric head trauma patients with GCS of 14 or greater who underwent a head CT, at a level 1 ACS-verified pediatric trauma center in 2015.  Patients with coagulative disorders, neurological comorbidities, or whose mechanism of injury is related to suspected child abuse were excluded. Children transferred from an outside hospital specifically for head CT were also excluded. Data collected included basic demographics, the severity of the injury, loss of consciousness, components of clinical presentation used in the PECARN algorithm, CT scan findings, and the presence of clinically important traumatic brain injury (ciTBI). We used clinical events used by PECARN to define ciTBI. Descriptive statistics were used to describe the sample and determine the percent of subjects classified by the PECARN algorithm; namely, CT recommended vs. CT not recommended. All analysis was conducted in SAS version 9.4 (SAS Institute, Inc., Cary, NC).

 

Results

A total of 381 pediatric subjects presented to the ED with head trauma that received a head CT. 16 subjects were removed because their head CT was canceled and never performed. Patients had an average age of 8.33 ± 6.01 years with a male predominance of 63.76%. The PECARN algorithm classified 331 (86.88%) as no CT recommended, 38 (9.97%) as CT recommended and 12 (3.15%) could not be classified due to missing data points. Among all subjects with a definitive PECARN classification, either recommending head CT or not, there were no injuries or positive CT finding.

Discussion

In patients with minor head trauma discharged from the emergency room, who underwent a head CT there may have been an over utilization of head CT with 90% receiving a non-indicated head CT based on PECARN head injury clinical prediction rules at a single institution. This has led our institution to embark on the further incorporation of PECARN head injury clinical prediction rules in evaluating pediatric head trauma. 

 

15.17 Outcomes After Massive Transfusion In Trauma Patients: Variability Among Trauma Centers

Posted on January 18, 2018

M. Hamidi1, M. Zeeshan1, A. Tang1, E. Zakaria1, L. Gries1, T. O’Keeffe1, N. Kulvatunyou1, A. Jain1, B. Joseph1  1University Of Arizona,Tucson, AZ, USA

Introduction:
Exsanguinating trauma patients often require massive blood transfusion (defined as transfusion of 10 or more pRBC units within first 24 hours). The outcomes of patients requiring massive transfusion remains unclear. The aim of our study is to assess the outcomes of trauma patients receiving massive transfusion at different trauma centers. 

Methods:
We performed two years (2013-2014) retrospective analysis of the Trauma Quality Improvement program (TQIP) and included all adult trauma patients who received massive blood transfusion (MBT). We analyzed blood products given within the first 24 hours. Outcome measures were blood products received, overall mortality, mortality in the first 24 hours, complications and massive blood transfusion relationship with trauma center’s level. 

 

Results:
A total of 416,957 patients were analyzed of which 4236 received MBT and were included in our study. Mean age was 40.6+20 years, 78.2% (n=35315) were males. Median ISS was 32 [16-40], median [IQR] GCS 8[3-15]. Mean Blood transfusion in the first 24 hours was 20+13 units, mean plasma transfusion was 13+11 units, while 4+6 units platelets and 2+6 units of cryoprecipitate were transfused in the first 24 hours. Overall mortality was 43.5%(n=1976) while 12.2%(n=556) were discharged home and 7%(n=320) were discharged to a skilled nursing facility (SNIF). Out of the 25% which died, 64% (n=1265) died on the first day, while 8.8 (n=173) died on the second day. 51.4% (n=2184) received MBT in level I while 14% (n=592) received MBT in level II trauma centers. On regression analysis after controlling for demographics and injury severity patients who were treated at Level I trauma center had lower adjusted odds of mortality (OR 0.75; 95%CI [0.3-0.8], p=0.02) compare to level II center.  In addition, there was no difference in the adjusted odds of mortality based on teaching status of the hospital (p=0.61)(Community and non-teaching hospitals vs. University Hospitals). 

Conclusion:
Hemorrhage continues to remain one of the most common cause of death after trauma. Almost half of the patients who receive massive transfusion died. Patients who receive massive blood transfusion in a Level I trauma centers are more likely to survive compared to level II trauma centers. Further studies are required to explore the differences in management of trauma centers to improve outcomes.

15.18 Less Than Stringent Glycemic Control Is Associated with Worse Outcomes in Trauma Patients

Posted on January 18, 2018

M. Rajaei1, P. Bosarge1, R. Griffin2, G. McGwin2, J. Jansen1, J. Kerby1  1UAB,Division Of Acute Care Surgery, Department Of Surgery, School Of Medicine,Birmingham, ALABAMA, USA 2UAB,Department Of Epidemiology, School Of Public Health,Birmingham, ALABAMA, USA 3UAB,Division Of Acute Care Surgery, Department Of Surgery, School Of Medicine,Birmingham, ALABAMA, USA 4UAB,Department Of Epidemiology, School Of Public Health,Birmingham, ALABAMA, USA

Introduction: Previous studies have identified hyperglycemia as an independent risk factor for poor outcomes in patients following traumatic injury. However, they have utilized serum glucose of ≥200 mg/dl to define the study population. The purpose of this study was to evaluate the effects of elevated admission glycosylated hemoglobin (HbA1C) on morbidity and mortality of trauma patients.

Methods: HbA1C on admission was obtained on all trauma patients presenting to an academic trauma service between January 2013 and June 2017. A HbA1C < 6.5 is defined by the American Diabetes Association as a more stringent A1C goal. Therefore, a HbA1C ≥ 6.5 was used to define our study population. A Cox proportional hazards model assuming equal time at risk and adjusted for age, sex, Injury Severity Score (ISS) and injury mechanism was used to estimate risk ratios (RRs) and associated 95% confidence intervals (CIs) for the association between HbA1C and specific outcomes of interest.

Results: Total of 10,586 patients were admitted to the trauma service during the period of study. Of these, 9,230 patients had admission HbA1C available and were included in the study. A total of 871 patients had a HbA1C ≥6.5 at admission. These patients were more likely to be Caucasian (74% vs. 66%, p<0.001) and were older (mean 59 vs. 42 years, p<0.001) compared to those with normal HbA1C. Individuals with HbA1C ≥6.5 had a longer hospital length of stay (mean 12 vs. 9 days, p<0.0001), ICU days (mean 13 vs. 10, p<0.001), and required longer ventilator assistance (mean 13 vs. 10, p=0.001). Despite having less severe injuries, patients with  HbA1C ≥6.5 had a 43% increased risk of developing pneumonia (RR 1.43, 95% CI 1.09-1.88), a 46% increased risk of death (RR 1.46, 95% CI 1.14-1.87), and a 2.2 fold increased risk of renal failure(RR 2.25, 95% CI 1.58-3.19).

Conclusion: Trauma patients with less than stringent glycemic control on admission are at increased risk of morbidity and mortality. These results can help identify patients at increased risk on admission following traumatic injury and help inform future trials evaluating glycemic control in trauma.

15.15 Outcomes of Trauma in Patients with Mental Illness: A Survey of the National Trauma Data Bank

Posted on January 18, 2018

R. E. Plevin1, A. Conroy1, C. Juillard1, M. M. Knudson1, R. A. Callcut1  1San Francisco General Hospital And The University Of California, San Francisco,Department Of Surgery,San Francisco, CALIFORNIA, USA

Introduction:

Mental illness is a significant public health concern in the United States, where 20% of adults carry a mental health diagnosis and 5% have been diagnosed with severe mental illness. Those with mental illness are predisposed to sustaining both intentional and unintentional injuries, but the impact of mental illness on trauma outcomes is largely unknown.  In 2012, the National Trauma Data Bank (NTDB) introduced a comorbidity of ‘Major Psychiatric Illness.’ We hypothesize that this vulnerable population is at greater risk of post-traumatic complications and consume more hospital resources compared to injured patients without mental illness.

Methods:
This is a retrospective cohort study of data from the 2012 National Sample Program (NSP) of the NTDB. Trauma patients were stratified into those with and without a diagnosed mental illness. Patients with self-inflicted injuries, those who died in the emergency room (ER), and those who were discharged or transferred directly from the ER to another facility were excluded. Patients were analyzed with respect to demographics, mechanism of injury, discharge disposition, length of stay, complications, and mortality. Multivariable regression analysis was performed to examine predictors of prolonged length of stay (LOS) and the impact of mental illness on complications.

Results:
In 2012, 146,069 patients who met the inclusion criteria were recorded in the NSP representing 633,007 injuries nationally after sample weighting. Approximately 6.9% of patients had a mental illness. Patients with mental illness were older and had more medical comorbidities. They were also more likely to be admitted to the hospital after a fall (51% vs. 41%, p < 0.01) and less likely to sustain trauma related to motor vehicles (37% vs. 29%, p < 0.01). Despite having lower injury severity scores (ISS, 10.8 vs. 11.7 p < 0.01) and mortality (1.8% vs. 2.7%, p < 0.01), patients with mental illness underwent more procedures (6.2 vs. 5.3, p < 0.05), had a longer LOS (6.9 days vs. 5.9 days, p < 0.05), and were more often discharged to a skilled nursing facility (SNF) or other inpatient facility (34% vs. 25%, p < 0.05). On logistic regression analysis, mental illness was an independent predictor for the development of pneumonia (p < 0.05), acute respiratory distress syndrome (ARDS, p < 0.05), urinary tract infection (UTI, p < 0.05), and acute renal failure (ARF, p < 0.05). 

Conclusion:
Compared to patients without such illness, the injured mentally ill are at greater risk of developing post-traumatic complications, have longer hospital stays, and are more likely to be discharged to a SNF or other inpatient facility despite lower injury severity. Future investigations are needed to better understand the etiology of these complications while primary injury prevention efforts should be directed toward methods that are effective in this vulnerable population. 

15.13 Persistent Lactic Acidemia at 12 Hours: Greater Mortality and Length of Stay in Pediatric Trauma

Posted on January 18, 2018

O. M. Kassar1, J. S. Young1  1University Of Virginia,Division Of Acute Care & Trauma Surgery,Charlottesville, VA, USA

Introduction:  Prior studies have demonstrated that persistent lactic acidemia at 24 hours is correlated with poor clinical outcomes and longer hospital stays in adult trauma patients. This study was intended to investigate this observation in the pediatric trauma population.

Methods:  This retrospective analysis included 1037 pediatric patients (0-17 years old) admitted to a level I trauma center between 1995 and 2015. Criteria for inclusion were length of stay greater than one day, initial lactate drawn, and more than one lactate drawn if initial lactate was elevated. Elevated lactate was defined as lactate greater than or equal to 2.5mmol/L. Time to lactate clearance, defined as return of lactic acid level less than 2.5mmol/L, was recorded in hours. Primary outcomes included mortality and length of stay. Statistical analyses were performed using SPSS statistical software (IBM Corp.) and Microsoft Excel (Microsoft Corp). For all statistical tests, a p value less than 0.05 was considered statistically significant.

Results: The majority of pediatric trauma admissions resulted from MVC (68.6%) followed by falls (14.9%). Mean injury severity score was 12 and mean length of stay was six days among all patients. Of 1037 patients, only 17 died. Patients were divided into five cohorts based on time to lactate clearance. Increased mortality correlated with longer time to lactate clearance and trended toward significance. Statistically significant differences in both mortality (0.62% vs 14.5%) and length of stay (five vs nine days) were observed between patients with and without lactate clearance within 12 hours, respectively.

Conclusion: Contrary to observations in adult trauma populations, pediatric patients experience significantly increased mortality after only 12 hours of persistent lactic acidemia. Lactate clearance before 12 hours in pediatric trauma patients is associated with both improved outcomes and shorter length of stay.

 

 

 

15.14 Intravenous+Inhaled Colistin Vs. Intravenous Monotherapy For Multi-Resistant Gram-Negative Pneumonia

Posted on January 18, 2018

W. Terzian3, S. P. Stawicki3, L. E. Bratis2, M. Turki2, N. D. Civic1, C. V. Murphy4  1St. Luke’s University Health Network,Department Of Pharmacy,Bethlehem, PA, USA 2St. Luke’s University Health Network,Center For Critical Care,Bethlehem, PA, USA 3St. Luke’s University Health Network,Department Of Surgery,Bethlehem, PA, USA 4Ohio State University,Department Of Pharmacy,Columbus, OH, USA

Introduction: Continued increase of multi-drug resistant (MDR) gram-negative (GN) infections, including Pseudomonas spp and Acinetobacter spp, prompted re-examination of  Colistin – an antibiotic abandoned in the 1970s due to nephro- and neurotoxicity – as an alternative for recalcitrant MDR-GN pneumonia. Colistin may be administered intravenously or as an inhaled-intravenous combination. Effectiveness of combination therapy has been examined previously; however, no definitive evidence exists to either support or refute this approach. The current meta-analysis examines potential benefits of combination intravenous-inhaled colistin (IVIC) regimen compared to intravenous colistin monotherapy (ICM) in patients with MDR-GN pneumonia.

Methods: An exhaustive English-language literature review was performed using Google™ Scholar, PubMed, and EBSCO Internet repositories. Out of 119 potential candidate studies, 6 retrospective reports met the inclusion criteria of: (a) directly comparing the two therapy groups (IVIC versus ICM); (b) sufficient scientific quality, including detailed descriptions of comparator groups and corresponding outcomes; and (c) describing similar microbiologic pathogen mix. Meta-analytic techniques were utilized to pool clinical results from the six studies, with selected clinical outcomes of mortality (6 studies), microbiologic cure (4 studies), and clinical cure (4 studies) being reported.

Results: The overall quality of data reporting for all three studies included was low. Combined data on microbiologic cure demonstrated no differences between IVIC and ICM regimens (OR 2.076, 95%CI 0.453-1.929, p=0.165). For clinical cure and mortality, pooled analyses demonstrate potential benefit to combined (IVIC) therapy. More specifically, IVIC colistin use is associated with both increased clinical cure (OR 2.857, 95%CI 1.385-5.890, p=0.004) and lower mortality (OR 0.603, 95%CI 0.384-0.949, p=0.029). Key study results are summarized in Table 1.

Conclusion: Addition of aerosolized Colistin to intravenous Colistin may improve clinical cure and mortality for patients with MDR-GN pneumonia. In terms of microbiologic cure, current results show a trend toward improved outcomes with the IVIC approach. Results of this exploratory meta-analysis support the use of IVIC as the primary therapeutic approach. Large, sufficiently powered prospective trials are needed to confirm the benefit of combination IVIC therapy for MDR-GN pneumonia, especially with regard to microbiologic cure.

15.11 Obesity is Associated with Increased Lower Extremity Injuries in Frontal Motor Vehicle Collisions

Posted on January 18, 2018

K. He1, N. Wang2, P. Zhang1,2, S. Holcombe1,2, S. Wang1,2  2International Center For Automotive Medicine,Ann Arbor, MI, USA 1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction:  Obesity has become a disease of epidemic proportions nationally and internationally, leading to significant changes in patient morphomic variability. Obese body habitus has been associated with changing motor vehicle collision (MVC) injury patterns due to greater kinetic energy and thicker subcutaneous tissue. In particular, excess posterior subcutaneous adipose tissue (e.g. buttock fat) has been shown in cadaver tests to allow increased forward excursion of the femur and lower extremity, which is hypothesized to result in increased lower extremity (LE) injuries in obese patients. While the clinical significance of LE injuries has been underestimated on injury severity scales due their low mortality risk, LE injuries have been shown to have considerable societal burden approaching that of fatality. Moreover, compared to their normal weight counterparts, overweight patients are at risk for prolonged disability and increased healthcare utilization in the rehabilitation period. In this study, we hypothesize that obese occupants experience greater risk of lower extremity injuries in frontal MVCs. 

Methods:  Vehicle and demographics data from 1996-2015 were extracted from the University of Michigan International Center for Automotive Medicine crash database. Morphomics data were processed from Computed Tomography scans obtained from the initial trauma evaluation. We fitted logistic regression models using crash, demographic, and morphomic variables for occupants with and without maximum abbreviated injury scale greater than 2 (MAIS2+) LE injuries. The performance of logistic regression models was assessed using the Akaike Information Criterion (AIC), and the area under the receiver operating characteristic curve (AUC). The top 100 models were selected by AIC, and the importance of each variable was calculated using weighted frequencies. Odds ratios and confidence intervals (CI) for obesity-related morphomic factors and lower extremity injury were calculated for a belted male in a 25 miles-per-hour frontal crash.

Results: 243 occupants were included in our logistic regression. We used four vehicle variables, three demographic variables, and six morphomic variables, which resulted in over 8,000 models. The final model predicting MAIS2+ included crash, demographic, and morphomics variables and resulted in an AUC of 0.807. BMI was the most important variable in our final model. The odds ratios for lower extremity injury between posterior top of spine to back skin distance (buttock fat) percentiles were (N=250): Q25 (25th percentile) and Q75: 1.7 (95% CI 1.2, 2.6); Q10 and Q90: 2.8 (95% CI 1.4, 5.9); Q5 and Q95: 4.1 (95% CI 1.5, 11); Q1 and Q99: 6.5 (95% CI 1.7, 25).

Conclusion: Overweight and obese patients are at higher risk for lower extremity injuries in frontal MVCs. Body fat morphomic variables such as the thickness of buttock fat are biomechanically significant and can be used to predict risk for lower extremity injury in frontal MVCs.

 

15.12 Penetrating Cardiac Trauma: A Ten-Year Experience at a Regional Trauma Center

Posted on January 18, 2018

J. A. Enriquez3, R. M. Clark1, B. B. Coffman2, S. W. Lu1, S. D. West1, M. Wang1, T. R. Howdieshell1  1University Of New Mexico HSC,Department Of Surgery,Albuquerque, NM, USA 2University Of New Mexico HSC,Department Of Pathology,Albuquerque, NM, USA 3University Of New Mexico HSC,School Of Medicine,Albuquerque, NM, USA

Introduction:
Penetrating cardiac trauma is a devastating injury associated with high morbidity and mortality. Modern imaging techniques such as ultrasound (Focused Assessment with Sonography for Trauma, FAST) and computed tomography (CT) have changed the way penetrating cardiac trauma patients are evaluated while operative methods have remained relatively unchanged. Rural trauma centers are uniquely poised to explore the natural history of these injuries including the likelihood of survival after prolonged prehospital transfer. 

Methods:
A retrospective review of a prospectively maintained comprehensive trauma database was conducted of all penetrating cardiac injuries treated at our center spanning a 10-year period. Medical records were abstracted to gather patient demographics, medical comorbidities, presentation, type and anatomic location of injury, trauma bay resuscitation, operative intervention and outcomes including survival and complications. Data were compiled using RedCap database software and descriptive statistics were generated. Comparisons were evaluated using either Chi square or Students t test analysis. 

Results:
During the study period, our center treated a total of 102 patients with penetrating cardiac injuries. Twenty-four percent of subjects were transferred from rural locations within the region with 95% of rural patients surviving to hospital discharge. Stab wounds accounted for 63% of injury mechanisms while 33% of patients had gunshot wounds (GSW). The majority of cardiac injuries resulted from wounding within the anatomic cardiac box (89%) with axillary (17%) and periclavicular (8%) wounds being less common. Fifty-two percent of patients underwent real-time FAST examination in the trauma resuscitation area with 49% of FAST scans demonstrating pericardial effusion and 24% of exams deemed negative for abnormality (false negative). CT was used in 21% of cases with cardiac injury (61%), hemothorax (39%) and mediastinal hemorrhage (22%) accounting for the most common radiographic findings. The majority (79%) of patients underwent operative intervention shortly after arrival to the trauma center including 11 emergency resuscitative thoracotomies (11%). Ultimately, 56% of subjects survived to hospital discharge. The vast majority of deaths occurred in the emergency department shortly after arrival. 

Conclusion:
The unique geographic arrangement of New Mexico provides an opportunity to understand the natural history of penetrating cardiac trauma and the effects of prehospital management on survival.  These data suggest that survival to presentation to a trauma center portends a high likelihood of survival to discharge for injured rural patients. Modern diagnostic techniques include ultrasound examination as well as advanced cross sectional modalities. These procedures demonstrated surprisingly low sensitivity for cardiac injury in our series.  
 

15.10 End of Life Decision Making for Geriatric Trauma Intensive Care Patients

Posted on January 18, 2018

M. Wooster4, A. Stassi5, J. Kurtz3, J. Hill2, M. Bonta6, M. C. Spalding2  2Grant Medical Center,Trauma And Acute Care Surgery,Columbus, OH, USA 3Doctor’s Hospital,General Surgery,Columbus, OH, USA 4Indiana University School Of Medicine,Trauma And Acute Care Surgery,Indianapolis, IN, USA 5University Of South Carolina, Palmetto Health-Richland,Trauma And Acute Care Surgery,Columbia, SC, USA 6Riverside Methodist Hospital,Trauma And Acute Care Surgery,Columbus, OH, USA

Introduction:  The geriatric trauma population is growing and fraught with poor physiological response to injury and high mortality rates. We investigated end of life (EOL) decision making of geriatric trauma patients. We hypothesize that age, religion, injury severity score (ISS), decision maker, pre-existing medical conditions, living wills/advanced directives/do not resuscitate status, and in-hospital complications will affect decision making regarding continued life support (CLS) versus withdrawal of care (WOC). 

Methods:  We performed a retrospective review of geriatric trauma patients at a level I and level II trauma center from January 1, 2007 to December 31, 2014. 274 patients met inclusion criteria with 144 patients undergoing CLS and 130 WOC.

Results: 35,747 geriatric trauma patients were admitted. Age, Catholicism, insurance type, massive transfusion protocol, antithrombotic therapy, ventilator days, ICU length of stay (LOS), and overall LOS were found to be statistically significant (p<0.05) predictors of WOC. After logistic regression, insurance type and Injury Severity Score were found to be significant (p=0.013/0.045). WOC patients had shorter time to palliative consultation. Patients with geriatrics consultation were 16.1 times more likely to undergo CLS (p=0.026). There was no difference in outcomes relative to patients advanced directives/living will/do not resuscitate status prior to hospital admission. However, 16% (44/274) of patients who underwent CLS or WOC had an advanced directive/living will/do not resuscitate status prior to hospital admission eventually progressed to WOC.

Conclusion: Our study examined the complex nature of EOL decisions and revealed difficulty in discerning progression to WOC versus CLS based on demographics, pre-hospital, and in-hospital factors. We also observed an apparent disconnect between the patient's wishes via living wills/advanced directives/do not resuscitate orders and fulfillment during EOL decision-making. Both geriatric and palliative care consultations are encouraged and may influence end of life decision making in geriatric trauma patients.

 

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