Fireworks are a hallmark of American celebrations, yet they generate a growing and under-recognized burden of injury. The aim of this narrative review is to integrate current United States evidence on firework-related harm, reveal clinical and economic patterns, and evaluate how policy shapes risk. Recent studies and national surveillance reports show a steady rise in emergency visits linked to consumer fireworks, with males comprising most patients. The hands and upper extremities sustain the largest share of harm, followed by the eyes and the head, face, and neck region. Although less frequent, amputations, open globe injuries and full-thickness burns produce the gravest morbidity and often require multiple operations and lengthy rehabilitation. Complex cases routinely incur hospital charges in the tens of thousands of dollars, while indirect costs such as lost productivity, long-term disability, and psychological distress are seldom captured. States that allow broad retail access to consumer fireworks report markedly higher injury rates than those enforcing permits, age limits, or brief sales periods, and time series observations show clear surges when access is relaxed and declines when it is tightened. Public education alone has shown little measurable effect. The evidence indicates that firework injuries are increasing in both frequency and severity, cluster where regulation is weakest, and impose substantial human and financial costs. National surveillance, device-specific controls, and rigorously evaluated legislation, rather than education alone, are essential if preventable harm is to be reduced while holiday traditions are preserved.

Introduction: The Fundamental Critical Care Support Course (FCCS) is a standardized multidisciplinary program designed to educate participants on the basics of identification and management of patients with critical illness. Our objective was to evaluate the effect of FCCS participation on confidence in the assessment and management of critically ill patients and attitudes towards multidisciplinary education and interprofessional care in a multidisciplinary group of participants. Methods: Participants enrolled in the FCCS course from May 2018 to November 2019 were solicited to participate in a series of surveys evaluating their course experience and confidence in critical care. Attitudes towards multidisciplinary education and interprofessional care were evaluated using the Student Perceptions of Interprofessional Clinical Education-Revised Instrument version 2 (SPICE-R2) tool. A prospective pre- and post-design with a self-report survey including retrospective pre-training assessment and a 3-month follow-up was conducted. Statistical analysis was performed using descriptive statics and non-parametric methods. Results: 321 (97.9%) of the course participants enrolled in the study and completed the confidence survey and SPICE-R2 tool pre-course. Nurses (113, 35.4%) and physicians (110, 34.4%) made up the largest groups of participants, although physician assistants and paramedics were also well represented. Confidence in recognition and management of critical illness significantly improved across all studied domains after course completion, with the mean total confidence score improving from 32.96 pre-course to 41.10 post-course, P < 0.001. Attitudes towards multidisciplinary education and interprofessional care also improved (mean score 41.37 pre-course vs 42.71 post-course, P < 0.001), although pre-course numbers were higher than expected which limited the significance to only certain domains. Discussion: In a multidisciplinary group, completion of FCCS training led to increased confidence in all aspects of critical illness measured. A modest increase in attitudes regarding multidisciplinary education and interprofessional care was also demonstrated. Further study is needed to assess whether this increased confidence translates to improvements in patient care and outcomes.

Stouffer, Joy1; Hopkinson, Dennis2; Essandoh, Meredith1; Syed, Aamer3; Hamill, Mark4; McBride, Katherine5; Asare, Roselove6; Hussein, Ehab7; Hertel, Kristie8; Diaban, Fatima9; Akuamoah-Boateng, Kwame10 Author Information

Background: The Rural Trauma Team Development Course (RTTDC) is designed to help rural hospitals better organize and manage trauma patients with limited resources. Although RTTDC is well-established, limited literature exists regarding improvement in the overall objectives for which the course was designed. The aim of this study was to analyze the goals of RTTDC, hypothesizing improvements in course objectives after course completion. Methods: This was a prospective, observational study from 2015 through 2021. All hospitals completing the RTTDC led by our Level 1, academic trauma hospital were included. Our institutional database was queried for individual patient data. Cohorts were delineated before and after RTTDC was provided to the rural hospital. Basic demographics were obtained. Outcomes of interest included: Emergency Department (ED) dwell time, decision time to transfer, number of total images/computed tomography scans obtained, and mortality. Chi square and non-parametric median test were used. Significance was set at P < .05. Results: Sixteen rural hospitals were included with a total of 472 patients transferred (240 before and 232 after). Patient demographics were similar before and after RTTDC. ED dwell time was significantly reduced by 64 min (P = .003) and decision to transfer time was cut by 62 min (P = .004) after RTTDC. Mean total radiographic images and CT scans were significantly reduced (P < .001 and P = .002, respectively) after RTTDC. Mortality was unaffected by RTTDC completion (P = .941). Conclusion: The RTTDC demonstrates decreased ED dwell time, decision time to transfer, and number of radiographic images obtained prior to transfer. More rural hospitals should be offered this course.

Introduction: The adaptation of extracorporeal membrane oxygenation (ECMO) support for refractory hypoxic respiratory failure secondary to trauma has increased over the last several years but continues to be hampered by a paucity of qualifying criteria and outcomes in publication. Our goal was to review the use of ECMO in trauma patients at our center to augment data available to the community and stimulate interest in a multicenter, prospective study. Methods: Our Level 1 ACS trauma center’s ELSO database was reviewed from January 2017 to April 2022. All patients suffering traumatic injuries who were canulated for ECMO were included; patient demographics, indications, physiology, and outcomes were collected. No patients were excluded from the analysis. Descriptive statistics and basic linear regression were performed. Results: Twelve trauma patients received ECMO support over the study period. Mean age was 34.25 years (range 13.8-64.0) with (8/12, 66.7%) of male gender. Respiratory failure was the primary reason for cannulation (10/12, 83.3%), but cardiac support (1/12, 8.3%) and ECPR (1/12, 8.3%) were also performed. The primary mode of ECMO was veno-venous (VV) support (9/12, 75%) but veno-arterial (VA) support was also used (3/12, 25%). Excluding the ECPR cannulation, the mean time from admission to cannulation was 171.3 (SD 140.3) hours. Median oxygenation parameters (IQR) prior to cannulation, including PaO2, FiO2, PaO2/FiO2 (P/F) ratio and PEEP, were 68 (47.9-100), 1.00 (0.88-1.00), 68.3 (47.9-125) and 17.5 (11-20), respectively. ECMO support was used for a median of 171 (IQR 67.66-262.3) hours. Overall mortality was 58.3% (7/12) but was improved for VV (4/9, 44.4%) and worse for VA (3/3, 100%) ECMO. For VV support, a trend towards improved survival was noted for earlier cannulation with a mean time from admission to cannulation of 183 hours in survivors vs 198.8 hours in deaths. Conclusions: Consensus for ECMO use in patients suffering traumatic injuries is lacking, and published data is highly variable. We offer our institution’s results with this patient cohort to augment existing data as well as stimulate interest in a potential multicenter study to better delineate indications and outcomes for VV ECMO in traumatically injured patients.

Introduction: The effects of firearm sales and legislation on crime and violence are intensely debated, with multiple studies yielding differing results. We hypothesized that increased lawful firearm sales would not be associated with the rates of crime and homicide when studied using a robust statistical method.Methods: National and state rates of crime and homicide during 1999-2015 were obtained from the United States Department of Justice and the Centers for Disease Control and Prevention. National Instant Criminal Background Check System background checks were used as a surrogate for lawful firearm sales. A general multiple linear regression model using log event rates was used to assess the effect of firearm sales on crime and homicide rates. Additional modeling was then performed on a state basis using an autoregressive correlation structure with generalized estimating equation estimates for standard errors to adjust for the interdependence of variables year to year within a particular state.Results: Nationally, all crime rates except the Centers for Disease Control and Prevention-designated firearm homicides decreased as firearm sales increased over the study period. Using a naive national model, increases in firearm sales were asso-ciated with significant decreases in multiple crime categories. However, a more robust analysis using generalized estimating equation estimates on state-level data demon-strated increases in firearms sales were not associated with changes in any crime variables examined. Conclusions: Robust analysis does not identify an association between increased lawful firearm sales and rates of crime or homicide. Based on this, it is unclear if efforts to limit lawful firearm sales would have any effect on rates of crime, homicide, or injuries from violence committed with firearms.(c) 2022 Elsevier Inc. All rights reserved.

The COVID-19 pandemic has had profound effects on the everyday behaviors of all patients. At the same time, the United States population is aging, and an increasing portion of traumatically injured patients are geriatric. Our study aims to examine the effects of the COVID-19 pandemic on the geriatric trauma population. We performed a retrospective review of the trauma database from our single institution level I trauma center examining pandemics impact on geriatric trauma demographics, mechanism of injury, injury severity, hospitalization characteristics, and alcohol use. Data during the pandemic was compared to the prior 3 years and controlled for seasonality. Statistical analysis demonstrated an increase in duration of mechanical ventilation and alcohol use during the pandemic while other factors remained stable. This shows the need for targeted alcohol assessment in the geriatric trauma population during periods of social isolation and additional research into the effects of the COVID-19 on trauma patients.

ABSTRACT Importance Reported coronavirus disease 2019 (COVID‐19) pandemic effects on pediatric trauma have been variable. Objective We investigated the characteristics of pediatric trauma including alcohol use during the pandemic at our urban trauma center. Methods The trauma database of our adult level 1 trauma center was queried for all pediatric (age ≤ 18 years) patients presenting between March 1, 2020, and October 30, 2020. Data from 2017 to 2019 served as a control. Variables analyzed included demographics, mechanisms, injury severity, hospitalization characteristics, and positive blood alcohol. Results Pandemic pediatric trauma volumes increased by 67.5% (330/year vs. 197/year). Pandemic patients were younger (median age 13 vs. 14 years, P = 0.011), but similar in gender, ethnicity, severity, hospital length of stay, mortality, and rates of penetrating injury. Falls doubled (79/year vs. 34/year) and shifted away from high falls >6 meters (0% vs. 7.9%) to moderate falls 1–6 meters (58.2% vs. 51.5%) (P = 0.028). Transportation injury rates were similar however mechanisms shifted from motor vehicle crashes (−13.5%) towards recreational vehicles including motorcycles (+2.1%), all‐terrain vehicles (+8.6%), and bicycles (+3.8%) (P = 0.018). Pediatric‐positive blood alcohol was significantly higher (11.2% vs. 5.1%, P < 0.001), especially for ages 14–18 years (21.7% vs. 9.5%, P < 0.001). Interpretation Pediatric trauma volumes during the COVID‐19 pandemic increased. Pandemic patients had more recreational vehicle injuries and higher rates of positive blood alcohol. This suggests an increased need for alcohol assessment and targeted interventions in the pediatric population during pandemics or periods of school closures.

Background Critically ill patients experience interruptions in enteral nutrition (EN). For ventilated patients who undergo percutaneous endoscopic gastrostomy (PEG) tube placement, postprocedure fasting times vary from 1 to 24 h depending on the surgeon's preference. There is no evidence to support delayed feeding (DF) after PEG placement. This study's purpose was to determine if there is an increased complication rate associated with early feeding (EF) after PEG. Methods 150 adult ventilated patients in the trauma and surgical intensive care unit (TSICU) at a level I trauma center underwent PEG placement in March 2015 through May 2018 by one of six surgical intensivists. Retrospective review revealed variable post-PEG fasting practices: one started EN at 1 h, two started at 4 h, two started at 6 h, and one started at 24 h. Time to initiation of EN and complication rates were assessed. Patients were divided into EF (<4) and DF (>= 4 h) groups. Results Median postprocedure fasting time was 5.5 h. The overall complication rate was 3.3%, with a feeding intolerance rate of 0.7% and aspiration rate of 0%. There was no difference in complication rate for EF (3.1%) as compared with DF (3.4%) (odds ratio, 0.92; 95% CI, 0.10-8.52; P = 0.7). Conclusion Complication rates following PEG placement in ventilated TSICU patients are low and do not change with EF compared with DF. EF is probably safe.

Background Appendectomy remains one of the most common emergency operations. Recent research supports the treatment of uncomplicated appendicitis with antibiotics alone. While nonoperative management of appendicitis may be safe in some patients, it may result in missed neoplasms. We present a case of acute appendicitis where the final pathology resulted in a diagnosis of a Burkitt-type lymphoma. Case presentation An 18-year-old male presented to the emergency department with 24 h of right lower quadrant pain with associated urinary retention, anorexia, and malaise. Past medical history was significant for intermittent diarrhea and anal fissure. He exhibited focal right lower quadrant tenderness. Workup revealed leukocytosis and CT uncovered acute appendicitis with periappendiceal abscess and no appendicolith. Laparoscopic appendectomy was performed and found acute appendicitis with associated abscess abutting the rectum and bladder. Pathology of the resected appendix reported acute appendicitis with evidence of Burkitt-type lymphoma. A PET scan did not reveal any residual disease. Hematology/oncology was consulted and chemotherapy was initiated with an excellent response. Conclusions Appendiceal lymphomas constitute less than 0.1% of gastrointestinal lymphomas. Primary appendix neoplasms are found in 0.5-1.0% of appendectomy specimens following acute appendicitis. In this case, appendectomy allowed for prompt identification and treatment of an aggressive, rapidly fatal lymphoma resulting in complete remission.

Objectives: Identify 5-year mortality rates in trauma patients greater than 18 years old who undergo tracheostomy and/or gastrostomy tube placement. Design: Retrospective convenience sample with two cohorts. Setting: Academic level 1 trauma center. Patients: Hospitalized patients admitted to the trauma service from July 2008 to December 2012 who underwent tracheostomy and/or gastrostomy tube placement. Interventions: Patients were placed into two cohorts: adult 18–64 and geriatric greater than or equal to 65; mortality data were obtained from the National Death Index. Measurements and Main Results: The primary outcome was 5-year mortality of both cohorts as well as those admitted who did not receive tracheostomy or gastrostomy. Univariate analysis was performed using Fisher exact and Wilcoxon signed-rank tests. Kaplan-Meier curves were plotted to examine mortality up to 5 years after discharge. Conclusions: Five-year postdischarge mortality is significantly higher in geriatric patients undergoing tracheostomy and/or gastrostomy after traumatic injury. Fifty percent die within the first 28 weeks following discharge and 93% die within 2 years.

BACKGROUND:Approximately one-third of additional imaging for trauma consults results in the discovery of new injuries. No studies have addressed the perception of these findings in non-health care providers. Our hypothesis was that significant differences in perception of the importance of injuries would exist between health care providers (HCPs) and the general population.METHODS:Six standardized scenarios were developed detailing common new injury findings on additional imaging in trauma consults. Demographics as well as information regarding the significance of findings, potential for change in care, and the importance of patient notification were collected. Surveys were electronically distributed to HCPs in our system and the public. Data analysis was performed with generalized linear modeling.RESULTS:A total of 339 public and 129 HCP surveys were returned. HCPs included attending staff, residents, and advanced care providers from a variety of specialties. Significant differences in perception were found in traumatic brain injury, spine fractures, and rib fractures, with HCPs rating most findings as less clinically important than the general population, while rating patient notification as more important. Perceived importance decreased with increased age in the general population. Increasing HCP age or length in practice did not significantly affect perception of clinical importance, except for rib fractures.DISCUSSION:Differences in perception exist regarding the significance of additional injuries between HCPs and the general population. Perceptions of the general population also change with age. Decisions to pursue additional imaging in trauma patients should include consideration of these differences in perception to help support quality patient-centered care.

Shahmanyan, Davit1; Lollar, Daniel2; Hamill, Mark2; Faulks, Emily2; Collier, Bryan2; Bower, Katie Love2 Author Information

Trauma recidivists are a high-risk patient population. The effects of recidivism on Geriatric trauma mortality have not been investigated. Our hypothesis is that trauma recidivism is associated with high postdischarge mortality after the initial index admission in both the geriatric and adult trauma populations. The trauma registry of our Level I trauma center was queried for patients evaluated between 2008 and 2012. Patients were stratified adult (18–64) and geriatric (≥65) groups and matched with mortality data from the National Death Index. Unique patients were identified and recidivists flagged. Statistical analysis was performed based on characteristics from the index admission using nonparametric tests, and Kaplan–Meier curves were plotted to examine postdischarge mortality after index admission for recidivists. A total of 8716 records met inclusion criteria; 800 recidivist records were identified representing 369 unique patients. Recidivists presented between 2 and 7 times. Recidivists were more likely to be male, required ICU admission and mechanical ventilation, had a longer median length of stay, were less likely to discharge home, and had a higher postdischarge mortality. Stratifying into adult and geriatric groups demonstrated significant differences in injury severity, injury patterns, length of stay, race, gender, mechanism, and postdischarge mortality. Recidivists demonstrated a higher postdischarge mortality in both groups with the geriatric group approaching 46 per cent. Trauma recidivists represent an at-risk group with significantly higher postdischarge mortality. Group characteristics differ significantly between the adult and geriatric recidivist populations. Further research is needed to identify modifiable risk factors in these populations to minimize risks of morbidity and mortality.

Background: Intentional self-inflicted injuries present unique challenges in treatment and prevention. We hypothesized intentional self-inflicted injuries would have higher in-hospital and postdischarge mortality than nonintentional self-inflicted injuries trauma. Methods: Adult patients evaluated 2008 to 2012 were identified in our trauma registry and matched with mortality data from the National Death Index. Intentional self-inflicted injuries were identified using E-Codes. Readmissions were identified and analyzed. Intentional self-inflicted injuries patients who died inhospital were compared with those surviving to discharge. Univariate analysis was performed using nonparametric tests. Kaplan-Meier curves were plotted to compare mortality <= 5 years postdischarge between intentional self-inflicted injuries and non-intentional self-inflicted injuries patients. Results: In the study, 8,716 patient records were evaluated with 245 (2.8%) classified as intentional self-inflicted injuries. Eighteen (7.8%) patients with intentional self-inflicted injuries had multiple admissions, compared with 352 (4.4%) patients with nonintentional self-inflicted injuries with readmissions (P = .0210). In-hospital mortality was higher for intentional self-inflicted injuries compared with patients with non-intentional self-inflicted injuries (18.7% vs 4.9%, P < .0001). Survival analysis demonstrated that patients with intentional self-inflicted injuries had significantly lower postdischarge mortality at multiple time points. Conclusion: Patients with intentional self-inflicted injuries trauma have high in-hospital mortality, but low postdischarge mortality. We attribute this to high lethality mechanisms but appropriate psychiatric treatment and rehabilitation. However, the high intentional self-inflicted injuries readmission rate indicates further study of intentional self-inflicted injuries follow-up is warranted. Better prevention strategies are needed to identify and intervene in patients at-risk for intentional self-inflicted injuries. (C) 2019 Elsevier Inc. All rights reserved.

BACKGROUND: Over the last 30 years, public opinion and state level legislation regarding the concealed-carry of firearms have shifted dramatically. Previous studies of potential effects have yielded mixed results, making policy recommendations difficult. We investigated whether liberalization of state level concealed-carry legislation was associated with a change in the rates of homicide or other violent crime. STUDY DESIGN: Data on violent crime and homicide rates were collected from the US Department of Justice Uniform Crime Reporting Program (UCR) and the Centers for Disease Control and Prevention (CDC) over 30 years, from 1986 to 2015. State level concealed-carry legislation was evaluated each study year on a scale including "no carry," "may issue," "shall issue," and "unrestricted carry." Data were analyzed using general multiple linear regression models with the log event rate as the dependent variable, and an autoregressive correlation structure was assumed with generalized estimating equation (GEE) estimates for standard errors. RESULTS: During the study period, all states moved to adopt some form of concealed-carry legislation, with a trend toward less restrictive legislation. After adjusting for state and year, there was no significant association between shifts from restrictive to nonrestrictive carry legislation on violent crime and public health indicators. Adjusting further for poverty and unemployment did not significantly influence the results. CONCLUSIONS: This study demonstrated no statistically significant association between the liberalization of state level firearm carry legislation over the last 30 years and the rates of homicides or other violent crime. Policy efforts aimed at injury prevention and the reduction of firearm-related violence should likely investigate other targets for potential intervention. ((C) 2018 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.)