INTRODUCTION:Readmission after trauma remains a significant challenge in the geriatric population. Few studies have looked at geriatric trauma readmission (GTR) across a mature trauma network including at level IV centers. Our objective was to determine if discharge functional status predicts GTR across all levels of trauma centers. Secondary objective was to determine incidence and reason for GTR. METHODS:Institutional trauma registries were queried for all geriatric trauma admissions across our network (2018-2023). These data were merged with all-cause network readmission data. Demographics, injury characteristics, trauma center level, frailty, discharge functional status (functional independence measure [FIM]), disposition, and payor status were compared between non-GTR and GTR patients. Univariate, followed by multivariate, logistic regression was used to identify predictors of readmission. Reason for GTR and time to GTR were examined. RESULTS:A total of 11,270 patients were admitted across the network with a median age of 81 years (interquartile range, 74-88 years) and a median Injury Severity Score of 5 (4-9), while 6.6% (n = 741) had an Injury Severity Score of >16. All-cause GTR rate was 6.2% (n = 700). On multivariate analysis, FIM score (odds ratio [OR], 0.99 [0.95-1.02]; p  = 0.60), treatment at a level IV center, and disposition were not predictors of GTR. The results were similar after adjusting for frailty, with three or more comorbidities (OR, 1.708 [1.16-2.51]; p  < 0.01) and hospital length of stay (OR, 1.05 [1.01-1.09]; p  < 0.01) representing the highest predictors of GTR. Fourteen percent (n = 101/700) of GTR patients were readmitted for a trauma complication, 11% (n = 75) for new injury, 63% (n = 439) for a medical condition, and 12% (n = 84) because of prior refusal for rehab. The median time to GTR was 14 days (interquartile range, 6-21 days). Fifty-seven percent (n = 396) had incomplete follow-up. CONCLUSION:Hospital length of stay and more than three comorbidities but not FIM score predict GTR with most GTR for a new or preexisting medical condition. These variables represent suitable targets for GTR reduction. ( J Trauma Acute Care Surg . 2026;100: 730-738. Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE:Prognositc and Epidemiologic; Level IV.

INTRODUCTION Rib fractures remain a significant source of trauma admissions. In 2020, the Pennsylvania Trauma System Foundation standards changed to allow patients with more than three rib fractures to be admitted to level IV centers. The primary aim of this study was to evaluate outcomes of patients with more than three uncomplicated rib fractures admitted to level IV trauma centers. METHODS Our network database was queried for patients with isolated uncomplicated rib fractures between 2018 and 2022. Patients were stratified based on evaluation before or after the change in standards. Patients evaluated at level IV centers were compared for demographics, injury characteristics, transfer rate, and outcomes. Finally, 1:1 propensity score matching was used to create a matched group of patients with more than three rib fractures to assess outcomes based on admission to level IV versus level I/II centers. RESULTS A total of 1,070 patients with isolated rib fractures were admitted over the study period. Level IV centers evaluated 360 patients with 132 (36.6%) and 228 (63.3%) in the pre- and poststandard change periods. There was a significant reduction in transfers for isolated rib fractures (56% vs. 21% p < 0.01). Compared with patients with three or less rib fractures, those with more than three fractures had similar hospital length of stay (median [interquartile range (IQR)], 3 [2–5] vs. 2 [1–4]; p = 0.29) and mortality (0% vs. 2.3%, p = 0.22). After propensity match, there was no difference in age (median [IQR], 71 [60–81] vs. 73 [65–85]; p = 0.24), injury characteristics, hospital length of stay (median [IQR], 2.5 [2–5] vs. 2 [1–4]; p = 0.37), and mortality (1.7% vs. 0%, p = 0.30). CONCLUSION Change in state admission standards allowed for a reduction in transfer of patients with more than three isolated rib fractures. In a group of matched patients with more than three rib fractures, level IV centers had similar outcomes to level I or II centers. LEVEL OF EVIDENCE Clinical Research, Retrospective Study; Level III.

Background: Focused Assessment with Sonography in Trauma (FAST) examination is a point-of-care ultrasound study used to evaluate for abdominal hemorrhage, pneumothorax, or pericardial blood in trauma patients as an adjunct to their initial assessment. The quality of the image can be limited, and its diagnostic value is heavily dependent on operator skill. Our objective was to determine whether a standardized review process improved image quality and reduced incidence of nondiagnostic or insufficient imaging by 10% over a 6-month period. Study Design: Between July 1, 2021, and March 31, 2022, we evaluated 1106 trauma activations at our level II trauma center. Two exams per practitioner per month were reviewed by an emergency medicine trained traumatologist with specialized training in point-of-care ultrasound and board certification in echocardiography. Priority was given to exams on patients with known injuries identified on other studies. If there were no exams that matched these criteria, random exams were selected. Images were reviewed for image quality, diagnostic accuracy, and labeling with counseling given to the provider if indicated. Categorical variables were compared using chi squared analysis, while continuous non-normally distributed variables were compared using the Mann-Whitney U test. Results: A total of 305 FAST exams were reviewed (186 pre-intervention and 119 during intervention). Image quality improved from 46.3% (n = 31/65) to 79.0% (n = 94/119) (P < .01) with need for counseling falling from 63.1% (n = 41/65) pre-QI to 42.0% (n = 50/119) post-QI (P < .01). Incidence of detectable injury, BMI, ISS, and AIS body regions were consistent across the study period. This was seen in both the geriatric and non-geriatric cohorts despite a significant increase in ISS in the post-intervention geriatric patients.Discussion: A FAST review program is associated with improvement in image quality and decreased need for counseling of trauma providers.

BACKGROUND:Most patients who sustain a traumatic injury require outpatient follow-up. A common barrier to outpatient postadmission care is patient failure to follow-up. One of the most significant factors resulting in failure to follow-up is age more than 35 years. Recent work has shown that follow-up telephone calls reduce readmission rates. Our aim was to decrease no-show appointments by 10% in 12 months.STUDY DESIGN:The electronic medical records at our level I and II trauma centers were queried for all outpatient appointments for trauma between July 1, 2020, and June 9, 2021, and whether the patient attended their follow-up appointment. Patients with visits scheduled after August 1, 2021, received 24- and 48-hour previsit reminder calls. Patients with visits scheduled between July 1, 2020, and August 1, 2021, did not receive previsit calls. Both groups were compared using multivariable direct logistic regression models.RESULTS:A total of 1,822 follow-up opportunities were included in the study. During the pre-implementation phase, there was a no-show rate of 30.9% (329 of 1,064 visits). Postintervention, a 12.2% reduction in overall no-show rate occurred. A statistically significant 11.2% decrease (p < 0.001) was seen in elderly patients. Multivariate analysis showed standardized calls resulted in significantly decreased odds of failing to keep an appointment (adjusted odds ratio = 0.610, p < 0.001).CONCLUSIONS:Reminder calls led to a 12.2% reduction in no-show rate and were an independent predictor of a patient's likelihood of attending their appointment. Other predictors of attendance included insurance status and abdominal injury.

Background: Nationally, the volume of geriatric falls with intracranial hemorrhage (ICH) is increasing. Our institution began observing patients with ICH, a GCS ≥ 14, and no midline shift or intraventricular hemorrhage with hourly neurologic examination outside the ICU in a high observation trauma (HOT) protocol. We first excluded patients on anticoagulants/antiplatelets (HOT I), then included antiplatelets and warfarin (HOT II) and finally included direct oral anticoagulants (HOT III). Our hypothesis is that HOT protocol safely reduces ICU utilization and creates cost savings in this patient population. Study Design: Our institutional trauma registry was retrospectively queried for all patients on HOT protocol. Patients were stratified based on date of admission: HOT I (2008-2014), HOT II (2015-2018) and HOT III (2019-2021). Demographics, anticoagulant use, injury characteristics, lengths of stay (LOS), incidence of neuro-intervention, and mortality. Results: Over the study period, 2343 patients were admitted, including HOT I (n=939), HOT II (n=794), and HOT III (n=610). Of these patients, 331 (35%), 554 (70%), and 495 (81%) were admitted to the floor under HOT protocol. HOT patients required neurointervention in 3.0%, 0.5% and 0.4% of cases over HOT I, II, and III, respectively. Mortality among HOT protocol patients was found to be 0.6% in HOT I, 0.9% in HOT II and 0.2% in the HOT III cohort (p=0.33). Conclusion: Across the study period, ICU utilization decreased without an increase in neurosurgical intervention or mortality indicating the efficacy of the HOT selection criteria in identifying appropriate candidates for stepdown admission and high observation trauma protocol.

Alexander, Roslyn M. DO; Hamlin, Sean MD, MBBCh; Szoke, Annmarie DNP; Ramirez, Christine L. MD, FACS; Wilde-Onia, Rebecca MSN, RN; Thomas, Peter DO, FACS; Cipolla, James MD, FACS; Castillo, Roberto C. DO, FACS; Braverman, Maxwell A. DO Author Information

INTRODUCTION:Despite its shortcomings, trauma-related injury severity score (TRISS) correlates well with mortality in large trauma datasets. The aim of this study was to determine if TRISS correlates with morbidity and hospital lengths of stay using data from an institutional registry at a Level I Trauma Center. We hypothesized that higher TRISS correlates with increased complications and longer hospital stays. METHODS:A retrospective review of our institutional registry was performed, examining all trauma admissions between January 1999 and June 30, 2015. Out of a total of 32,026 patient records, TRISS data were available in 23,205 cases. Abstracted data included patient age, gender, ISS, TRISS, presence of complication, Glasgow Coma Scale (GCS), hospital length of stay, intensive care unit LOS, step-down unit LOS, functional independence measure, and 30-day mortality. RESULTS:TRISS was highly predictive of mortality, with the AUC value of 0.95 (95% confidence interval 0.936-0.954, P < 0.01) compared to ISS (AUC 0.794), GCS (AUC 0.827), and age (AUC 0.650). TRISS also performed better than the other variables in terms of the ability to predict morbidity events (AUC 0.813). TRISS was comparable to ISS in terms of prediction of ICU admission (AUC 0.801 versus 0.811, respectively). After correcting for patient age and gender, higher TRISS significantly correlated with longer hospital stays . CONCLUSIONS:Despite previous criticisms, we found that TRISS is superior to ISS for mortality and morbidity prediction. TRISS correlated significantly with a hospital, step down, and ICU lengths of stay using a large administrative dataset.

Gifford, Amanda L. MD; Castillo, Roberto C. DO; Stewart, Nakosi J. MD; Thomas, Peter G. DO FACS; Cipolla, James MD, FACS; Stawicki, Stanislaw P. MD, FACS Author Information

Enmeshment of emergency trauma providers (ETPs) into the United States health-care fabric resulted in the establishment of a formalized surgical critical care fellowship and certification for emergency medicine trainees. The aim of this study was to compare trauma outcomes for surgery-trained providers (STPs) and ETPs at our institution, hypothesizing patient outcome equivalency. We performed an institutional review board–exempt institutional registry review (January 1, 2004 to August 1, 2018), comparing 74 STPs and 6 ETPs. Comparator variables included all-cause mortality, all-cause morbidity, CTimaging studies per provider, time in ED (min), hospital/ICU lengths of stay, ICU admissions, and functional outcomes on discharge. Statistical comparisons included chi-square test for categorical data and analysis of covariance for continuous data (adjustments made for patient age, Injury Severity Score, and trauma mechanism; all P < 0.20). Statistical significance was set at P < 0.05, with an equivalence study design. A total of 33,577 trauma resuscitations were reviewed (32,299 STP-led and 1,278 ETP-led). Except for patient age (STP 50.2 ± 25.9 vs ETP 54.9 ± 25.3 years), Injury Severity Score (8.47 ± 8.14 vs 9.22 ± 8.40), and ICU admissions (16.1% vs 18.8%), we noted no significant intergroup differences. ETPs’ performance was equivalent to that of STPs for all primary comparator variables (mortality, morbidity, CT utilization, time in the ED, lengths of stay, and functional outcomes). Incorporation of ETPs into our trauma center resulted in outcome parity between ETPs and STPs, while simultaneously expanding the expertise and experiential diversity within our multidisciplinary team. This study provides support for further incorporation of ETPs as equal partners across the growing network of United States regional trauma centers.

The relationship between trauma volumes and patient outcomes continues to be controversial, with limited data available regarding the effect of month-to-month trauma volume variability on clinical results. This study examines the relationship between monthly trauma volume variations and patient mortality at seven Level I Trauma Centers located in the Eastern United States. We hypothesized that higher monthly trauma volumes may be associated with lower corresponding mortality.

The most severely injured patients who arrive to emergency departments (EDs) in extremis present the most difficult challenge to traumatologists. For decades, unacceptably high mortality rates in this subset of patients evaded even the most extreme and invasive life‐saving intervention – the ED thoracotomy (EDT).[1‐3] The physiological premise behind the EDT is to perform three essential maneuvers: to relieve cardiac tamponade, to control hemorrhage, and to achieve temporary aortic occlusion.[4] Aortic cross‐clamping during EDT increases coronary blood flow, cardiac output, mean arterial pressure, carotid blood flow, and brain perfusion/ oxygenation.[5] The success of this procedure is varied depending on the cause of traumatic cardiac arrest, but a review of 868 patients from a single center showed an approximate 5% survival rate.[6] According to literature compilation by Pust and Namias, average survival for blunt traumatic EDT was 1.6%, with corresponding figure being approximately 10 times higher (16.8%) for penetrating traumatic EDT.[7] It has been postulated that significant contribution to morbidity and mortality within the EDT population may be associated with the thoracotomy itself,[8] suggesting that the performance of EDT should be restricted to a subset of patients who – based on best available scientific evidence – have the most reasonable chance of survival. By any measure, the performance of EDT simply to ensure “procedural skills maintenance” is ethically questionable, and there are increasing doubts about the benefit of entering an uninjured body cavity to address an injury elsewhere.

Each year, thousands of people worldwide succumb to end-organ failure while awaiting life-saving transplantation procedures. The shortage of organs continues with no signs of easing in the foreseeable future. The availability of organs from living donors continues to be constrained. At the same time, the cumulative knowledge of organ preservation is advancing steadily resulting in an enhanced ability to utilize a growing number of previously unsuitable tissue and organ gifts. Our ability to procure and preserve more organs is accompanied by the increasing use of so-called "expanded criteria" donors, or those whose organs may not have been suitable without modern advances in organ preservation science. Within the overall context of organ donation from non-living donors, the importance of physiologic and end-organ optimization cannot be understated. This chapter discusses our current state of understanding of optimized organ procurement approaches derived from practical experiences and "lessons learned" at a high-performing, community-based tertiary referral hospital.

Organ procurement (OP) from donors after brain death and circulatory death represents the primary source of transplanted organs. Despite favorable laws and regulations, OP continues to face challenges for a number of reasons, including institutional, personal, and societal barriers. This focused review presents some of the key components of a successful OP program at a large, high-performing regional health network. This review focuses on effective team approaches, aggressive resuscitative strategies, optimal communication, family support, and community outreach efforts.

INTRODUCTION:Advanced age has been traditionally associated with worse traumatic brain injury (TBI) outcomes. Although prompt neurosurgical intervention (NSI, craniotomy or craniectomy) may be life-saving in the older trauma patient, it does not guarantee survival and/or return to preinjury functional status. The aim of this study was to determine whether a simple score, based entirely on the initial cranial computed tomography (CCT) is predictive of the need for NSI and key outcome measures (e.g., morbidity and mortality) in the older (age 45+ years) TBI patient subset. We hypothesized that increasing number of categorical CCT findings is independently associated with NSI, morbidity, and mortality in older patients with severe TBI. METHODS:After IRB approval, a retrospective study of patients 45 years and older was performed using our Regional Level 1 Trauma Center registry data between June 2003 and December 2013. Collected variables included patient demographics, Injury Severity Score (ISS), Abbreviated Injury Scale Head (AISh), brain injury characteristics on CCT, Glasgow Coma Scale (GCS), Intensive Care Unit (ICU) and hospital length of stay (LOS), all-cause morbidity and mortality, functional independence scores, as well as discharge disposition. A novel CCT scoring tool (CCTST, scored from 1 to 8+) was devised, with one point given for each of the following findings: subdural hematoma, epidural hematoma, subarachnoid blood, intraventricular blood, cerebral contusion/intraparenchymal blood, skull fracture, pneumocephalus, brain edema/herniation, midline shift, and external (skin/face) trauma. Descriptive statistics and univariate analyses were conducted with 30-day mortality, in-hospital morbidity, and need for NSI as primary end-points. Secondary end-points included the length of stay in the ICU (ICULOS), step-down unit (SDLOS), and the hospital (HLOS) as well as patient functional outcomes, and postdischarge destination. Factors associated with the need for NSI were determined using matched NSI (n = 310) and non-NSI (n = 310) groups. All other analyses examined the combined patient sample (n = 620). Variables achieving a significance level of P < 0.20 were included in the logistic regression. Receiver operating characteristic curves, with corresponding area under the curve (AUC) determinations, were also analyzed. Statistical significance was set at α = 0.05. Data are presented as percentages, mean ± standard deviation, or adjusted odds ratios (AORs) with 95% confidence intervals (95% CIs). RESULTS:A total of 620 patients were analyzed, including 310 patients who underwent NSI and 310 age- and ISS-matched non-NSI controls. Average patient age was 72.8 ± 13.4 years (64.1% male, 99% blunt trauma, mean ISS 25.1 ± 8.68, and mean AISh/GCS of 4.63/10.9). CCTST was the only variable independently associated with NSI (AOR 1.23, 95% CI 1.06-1.42) and was inversely proportional to initial GCS and functional outcome scores on discharge. Increasing CCTST was associated with greater mortality, morbidity, HLOS, SDLOS, ICULOS, and ventilator days. On multivariate analysis, factors independently associated with mortality included AISh (AOR 2.70, 95% CI 1.21-6.00), initial GCS (AOR 1.14, 1.07-1.22), and CCTST (AOR 1.31, 1.09-1.58). Variables independently associated with in-hospital morbidity included CCTST (AOR 1.16, 1.02-1.34), GCS (AOR 1.05, 1.01-1.09), and NSI (AOR 2.62, 1.69-4.06). Multivariate models incorporating factors independently associated with each respective outcome displayed good overall predictive characteristics for mortality (AUC 0.787) and in-hospital morbidity (AUC 0.651). Finally, modified CCTST demonstrated good overall predictive ability for NSI (AUC 0.755). CONCLUSION:This study found that the number of discrete findings on CCT is independently associated with major TBI outcome measures, including 30-day mortality, in-hospital morbidity, and NSI. Of note, multivariate models with best predictive characteristics incorporate both CCTST and GCS. CCTST is easy to calculate, and this preliminary investigation of its predictive utility in older patients with TBI warrants further validation, focusing on exploring prognostic synergies between CCTST, GCS, and AISh. If independently confirmed to be predictive of clinical outcomes and the need for NSI, the approach described herein could lead to a shift in both operative and nonoperative management of patients with TBI.

Terzian, Hillman WT MD; Hoey, Brian A. MD, FACS; Hoff, William S. MD, FACS; Thomas, Peter DO; Wojda, Thomas R. MD; Cipolla, James MD, FACS; Stawicki, Stanislaw P. MD, FACS Author Information

Foreign intravascular object embolization (FIOE) is an important, yet underreported occurrence that has been described in a variety of settings, from penetrating trauma to intravascular procedures. In this chapter, the authors will review the most common types of FIOEs, including bullet or "projectile" embolism (BPE), followed by intravascular catheter or wire embolization (ICWE), and conclude with intravascular noncatheter object (e.g., coil, gelatin, stent, and venous filter) migration (INCOM). In addition to detailed topic-based summaries, tables highlighting selected references and case scenarios are also presented to provide the reader with a resource for future research in this clinical area.

Severe respiratory failure may develop in the trauma patient as a consequence of direct lung injury, in response to trauma‐associated systemic inflammatory response syndrome (SIRS), as a result of infection, or at times as an unintended consequence of the life‐saving management of the acute traumatic injury. Approximately 0.5% of all adult trauma patients develop some form of pulmonary dysfunction along the acute lung injury (ALI) – acute respiratory distress (ARDS) spectrum, with the incidence of severe respiratory failure reaching 10–20% in multisystem trauma victims. Of concern, mortality in patients with acute respiratory failure who go on to develop severe pulmonary dysfunction can be as high as 37–50% with the use of conventional therapeutic modalities. Extracorporeal membrane oxygenation (ECMO) has been proposed as a rescue strategy when less invasive primary or adjunctive attempts fail. Numerous case reports and single‐center studies demonstrate potential benefits of early implementation of veno‐venous (VV)‐ECMO for the treatment of severe respiratory failure associated with trauma or sequelae of trauma. In this clinical context, VV‐ECMO can be employed to correct for both ventilatory and oxygenation failure while allowing the treating physician to provide much needed rest to the patient's lungs and permit healing to take place. The use of ECMO (mainly veno‐venous, with limited use of veno‐arterial circuits for cardiac indications) has been described in patients with severe chest injuries, traumatic pneumonectomy, bronchopleural fistulas, and various forms of respiratory failure refractory to conventional therapies.

Blunt trauma to the chest resulting in coronary thrombosis and ST elevation myocardial infarction (STEMI) is a rare but well-described occurrence in adults. Angiography in such cases has generally disclosed complete epicardial coronary occlusion with thrombus, indistinguishable from the findings commonly found in spontaneous plaque rupture due to atherosclerotic disease. In all previously reported cases in which coronary interrogation with intravascular ultrasound (IVUS) was performed in association with acute revascularization, coronary artery dissection was implicated as the etiology of coronary thrombosis. We present the first case report of blunt trauma-associated coronary thrombosis without underlying atherosclerosis or coronary dissection, as documented by IVUS imaging.