Looking at 140 patients retrospectively who had abdominal gunshot wounds with associated fractures, prophylactic antibiotics longer than three days did not offer any benefit in preventing fracture infection. Only two patients experienced fracture related infections and 65 total experienced any infection related complications.
From and ED standpoint, it appears reasonable to give a dose of antibiotics in this very rare subset of gunshot wound patients.
A retrospective, single Australian center review of 300 patients who had blunt cerebral vascular injuries found:
-9.8% had an inpatient CVA
-Most occurred in first 72 hours
-Those receiving no anti coagulation or antiplatelets had 28% CVA incidence.
-Those treated had a 3.6% CVA incidence (anti platelets were better than anti coagulation)
-Carotid artery injury was less common than vertebral artery but had higher frequency of CVA
-associated factors: low GCS, rib fractures, severe trauma
Take away: non-treatment of blunt cerebral vascular injuries had higher inpatient stroke risk. Antiplatelet agents such as aspirin and Clopidogrel performed better than anticoagulants
This paper looked at the literature regarding missed injuries in trauma patients. Missed injuries was defined as an injury discovered after the patient was discharged. Most of the missed injuries and causes are not novel but are worthy of remembering.
They suggest a Trauma Tertiary Survey helps prevent missed injury. “Tertiary Survey (TTS), which includes a thorough in-hospital re-examination and a review of diagnostic investigations within the first 24 h, has been shown to significantly reduce the occurrence of missed injuries (1–9 %) in severe trauma patients found after a primary and secondary survey.” This concept is similar to a discharge time out in emergency medicine where all data is reviewed, viral signals are confirmed normal and a team discharge is performed.
The paper offers these suggestions to avoid missed injuries:
1.
Standardize Tertiary Trauma Surveys (TTS).
2.
Be Cognizant of Cognitive Biases (e.g., Anchoring Bias).
3.
Repeat Imaging When Clinically Indicated.
4.
Use Protocolized Imaging Techniques (CT/MRI).
5.
Ensure Radiology-Trauma Communication.
6.
Prioritize High-Risk Populations.
7.
Implement Peer Review or Double-Check Systems.
8.
Encourage a Culture of Collaboration and Humility.
9.
Limit Provider Fatigue and Overload.
10.
Create Tailored Checklists for Subtle Injuries.
Outcomes in traumatic brain injury are improved when physiologic homeostasis is achieved as soon as possible after injury. Here are the American College of Surgeons’ recommendations. Note SBP over 110 and a hemoglobin over 7. A study looking at a more liberal transfusion target showed worse ARDS and no mortality benefit.
This study from Great Britain compared fatalities for pedestrians and cyclist struck by motor vehicles based on vehicle body type. They found :
“We conclude that in Great Britain, being hit by an SUV as opposed to a passenger car increases injury severity among pedestrians and cyclists, with the strongest effect in children.“
These authors looked at 5958 trauma patients arriving at their trauma center with a systolic blood pressure greater than 90. They calculated shock index (heart rate /sbp) for all of these and then looked at who received a blood transfusion within one hour of arrival. 211 patients received blood in that time frame. “Patients were stratified by SI using the following thresholds: ? 0.7, > 0.7 to 0.9, > 0.9 to 1.1, > 1.1 to 1.3, and > 1.3.”
“A main effect was observed for shock index with increased risk for required transfusion for patients with admission shock index >0.7 (P < 0.001). In comparison to shock index of ? 0.7, odds ratios were 2.5(1.7 - 3.8), 8.2(5.4 - 12.2), 24.9(15.1 - 41.1), 59.0(32.0 - 108.6) for each categorical increase in SI.”
Based on a review of 511 patients transferred to a level one trauma center for evaluation of facial fractures, this group developed the Facial Fracture Transfer Guidelines. they found that over half of the patients transferred to them did not require intervention and were discharged within 6 hours. These guidelines are meant to decrease unneeded transfers yet provide appropriate care to those with traumatic facial injuries.
Most common facial fracture is the nasal fracture followed by the zygomatic arch fractures.
Le Fort Classification of facial fractures/facial stability. The higher the number, the more unstable.
Orbital blow out fractures may entrap the ocular muscles leading to eye immobility in various directions.
Brain injury guidelines were designed to decrease transfers and neurosurgical consults for adults with head injuries.
A new retrospective study suggests that modified guidelines may be feasible in the pediatric population as well. More data is needed but this is an important step in assuring safe resource utilization in pediatric head injury patients.
In this Israeli study comparing mortality for trauma patients intubated in the emergency department vs the operating room, in hospital mortality was higher for the ED group before controlling for injury severity score and shock. After controlling for injury severity and shock, there was no difference in In hospital mortality. Coupled with previous research, if intubation can wait until after resuscitation and in the OR, that is ideal. And sometimes it just has to happen in the ED and we should be prepared for rapid resuscitation.
Another case series of 3 resuscitative hysterotomies, all performed by obstetricians, reported 33% maternal and 67% neonate survival.(1).
The mechanics of the procedure are:
(3)
A literature search revealed very little evidence, however in 66 women and 68 neonates who underwent resuscitative hysterotomy for out of hospital cardiac arrest 4.5% of women and 45% of neonates survived to discharge. The longest down time was 29 minutes and 47 minutes for women and neonates respectively. While more evidence is needed, it appears this procedure should be performed as early as possible and may lead to some survival benefit.
The National Association of Emergency Medical Service Physicians reminds us that femur fractures rarely cause enough blood loss to cause hemodynamic instability (look for other sources), often have concomitant injuries in the pelvis or distal extremity, and can be effectively splinted either static or with traction (which has contraindications, complications, and technical hurdles).
An Australian retrospective study of 158 patients treated for nail gun injuries found those treated with operative debridement or with prophylactic antibiotics had no different 30 day infection rates compared to patients receiving no antibiotics.
This literature search from 1946-2023 looking at comparing selective use of CT scans vs whole body scans in geriatric trauma found no benefit of whole body CT in mortality, hospital length of stay or ED discharge. This study only included 15,000 pts over that very long time line. More robust, current work needs to be done on this important topic.
Looking at a year’s worth of data from the National Trauma Databank, the authors found incarcerated trauma patients were more likely to be stabbed, male, persons of color and have a higher adjusted mortality rate.
This study looked at exposure to gun violence and found increased use of mental health resources, depression and suicide risk even with a single exposure. Repetitive exposure increased suicide risk as well as mental health service utilization, depression and overall health service utilization. While further work is needed, screening our patients for gun violence exposure could undercover mental health needs.
This study looking at the type of facility that cared for rural injured patients reminds us that the majority of trauma care for rural patients occurs in non-trauma centers. This included some of the most severely injured and for many definitive care was received at these centers.
This may lead to lack of inclusion in trauma registries and under valuing the care being delivered by non-trauma centers. Protocols to facilitate transfers, air medical protocols and availability along with tele-health all are important in rural trauma care. Non-trauma designated centers are a critical part of the trauma network for rural residents and their value can not be ignored.
This study looked at pre-trauma mental health diagnosis (from medical records) and post-trauma mental health symptoms as assessed by survey. The majority of patients suffered blunt trauma and mean age was 67. Having pre/traumatic mental health diagnosis and particularly post-traumatic symptoms lead to worse health outcomes and financial conditions. Further work needs to be done to assess how to improve mental health symptoms post-traumatic injury.
The American Society of Anesthesia score was an independent predictor of 90-day mortality as
well as low functional status at one year in 720 patients presenting to a single center with
moderate to severe brain injury. When used in conjunction with other prognosticating tools such
as the Trauma and Injury Severity Score, it increased the prognostic value of these scales.
