Article 1
Emergency department versus operating room intubation of patients undergoing immediate hemorrhage control surgery. Dunton Z, Seamon MJ, Subramanian M, Jopling J, Manukyan M, Kent A, Sakra JV, Stevens K, Haut E, Byrne J. Journal of Trauma and Acute Care Surgery. 2023 Jul 1;95(1):69-77.
Uncontrolled hemorrhage remains the leading cause of potentially preventable death in trauma patients. Early interventions and stabilization are crucial to impact survival, starting in the trauma bay with a primary survey. This includes the decision as to whether to intubate a patient and if this is required, the trauma surgeon must carefully consider the safest way and safest place to do this. The objective of this study by Dunton et al was to evaluate the association between ED (versus operating room) intubation and mortality for patients undergoing urgent hemorrhage control surgery at trauma centers in the United States in Canada. They hypothesized that ED intubation is associated with increased risk of morbidity and mortality.
This retrospective cohort study examined National Trauma Data Bank (NTDB) adult trauma patients who underwent hemorrhage control surgery at level 1 or 2 trauma centers between 2017-2019. “Hemorrhage control surgery” included patients who underwent surgery within 60 minutes of arrival with purpose of hemorrhage control and received at least 1 unit of transfusion in first four hours of hospital arrival. They excluded patients who underwent ED thoracotomy, were dead on arrival or suffered prehospital arrest, with nonsurvivable injuries (AIS 6) or severe head/face/neck injuries (AIS >2), and/or with initial GCS < 9. Exposure was defined as endotracheal intubation performed in the ED. The primary outcomes was in-hospital mortality and secondary outcomes included total ED dwell time, units of blood transfused in first four hours, and major complications (cardiac arrest, AKI, ARDS, VAP, severe sepsis). Statistical analyses included 1) patient level analysis (multivariable logistic regression to estimate risk-adjusted odds ratios and negative binomial models) and 2) hospital level analysis (multilevel logistic regression model to estimate unique risk-adjusted odds ratio for ED intubation at each trauma center and analyses of proportional change in variance across the centers). The study included 9,667 patients at 253 centers. ED intubation was performed in 20% patients and 9% died. On univariate, patients who underwent ED intubation had higher ISS, higher chest and extremity AIS, with more injuries of lung, thoracic vasculature, heart, abdominal vasculature, and liver. On unadjusted risk analysis, patients intubated in the ED were significantly more likely to die (17% versus 7%, p<0.001), have longer ED dwell time, receive more blood transfusions, and have more major complications. On multivariate, this mortality difference persisted (adjusted OR 1.85, 95% CI 1.54-2.23), with persistently higher major complications (in-hospital arrest, ARDS, AKI). There was wide variation in rate of ED intubation across trauma centers, with low ED intubation hospitals being more likely to be level 1, university-affiliated, nonprofit trauma centers and hospitals with high volumes of hemorrhage control surgery deferring intubation to OR more frequently. The authors ultimately suggest that where feasible, intubation should be deferred in favor of rapid resuscitation and transport to the OR for surgical hemorrhage control.
Article 2
The final decision among the injured elderly, to stop or to continue? Predictors of withdrawal of life supporting treatment. Bhogadi SK, Magnotti LJ, Hosseinpour H, Anand T, El-Qawaqzeh K, Nelson A, Colosimo C, Spencer AL, Friese R, Joseph B. J Trauma and Acute Care Surgery. 2023 Jun 1;94(6):778-783.
Withdrawal of life supporting treatment (WLST) is a seldom studied but important factor in geriatric trauma. This study aims to evaluate predictors of WLST and the role of frailty in trauma patients. This was a retrospective study of the ACS-TQIP database from 2017-2019 of patients > 65 years old with an ISS>15. Frailty was defined as patients with a frailty index >0.27 using the 11-variable modified frailty index (mFI-11). 155,583 severely injured geriatric trauma patients were included in the study. These were grouped by whether they underwent withdrawal of life supporting treatment (WLST vs no-WLST). Patients who underwent WLST were older, male, White and had lower mean ED SBP and median ED GCS, as well as higher ISS, 24-hour and overall mortality. WLST patients were also more likely to have advance directive limiting care (ADLC). Multivariable regression analysis was then done for predictors of WLST. Age, male gender, White race, ADLC, severe TBI, frailty, need for ventilator, government insurance and treatment at higher level trauma centers were independently associated with WLST. Most impressively, every 5-year increase in age after 69 years was associated with an almost 35% increase in odds of WLST. Frailty was associated with a slightly higher rate of WLST (11.9% vs 10.5%) and a longer median time to WLST (3 vs 2 days). As might be expected, mortality was much higher in the WLST group (81% vs 5%). Limitations of this study include it is retrospective and based on a database. Additionally, it lacks details regarding how and why the decision for WLST was made.
The study provides important information regarding predictors of WLST (age, male sex, White race, frailty, ADLC, severe TBI, ventilator requirement, government insurance and management at higher level trauma centers). Additional studies should be pursued regarding how to avoid potentially futile resuscitation and how we can aid patients and families in making goal-concordant care decisions.
Article 3
Are we waiting for the sky to fall? Predictors of withdrawal of life-sustaining support in older trauma patients: A retrospective analysis. Badrinathan A, Ho VP, Tinkoff G, Houck O, Vazquez D, Gerrek M, Kessler A, Rushing A. Journal of Trauma and Acute Care Surgery. 2023 Mar 1;94(3):385-391.
Previous studies have shown that more than 80% of older ICU trauma patients die after withdrawal of life sustaining support (WLSS). This study examined the effect of advance directives limiting care (ADLC), as well as other factors, on WLSS in older trauma patients. This is a retrospective review of patients 65 years of age or older from the 2017-18 ACS-TQP database. Patients were divided based on presence or absence of ADLC on admission and then propensity matched. There was a total of 597,480 patients 65 years or older. 7.36% had an ADLC and prior to matching these patients were significantly younger, female and of White race, non-Hispanic ethnicity when compared to patients lacking an ADLC. Of note, patients with an ADLC where almost three times more likely to have dementia (32.05% vs 11.30%). Prior to propensity-matching, patients with ADLC had significantly lower ICU length of stay (LOS), hospital LOS and ventilation duration but higher rates of unplanned ICU admission. They were more likely to undergo WLSS (7.68% vs 2.48%). Propensity-matching was then done of 78,276 patients to form 39,138 pairs for analysis. Post-matching, patients with ADLC still underwent WLSS more than twice as often (8.64% vs 4.40%) and a day earlier (3 days vs 4 days) than those without ADLC. On logistic regression, multiple factors were associated with WLSS including comorbidities such as CHF, COPD, ESRD but not dementia. Additionally, higher ISS was predictive of WLSS. ADLS had an odds ratio of 2.38 for WLSS but was a weaker predictor than adverse in-hospital events such as unplanned ICU admission (OR 3.29) and in-hospital cardiac arrest (4.97).
Key findings of this study were: Older trauma patients have a low rate of ADLC and ADLC is associated with more frequent and earlier WLSS. It is suggested that while ADLC may not always provide “clear-cut” instructions for WLSS they may facilitate more open and honest communication between physicians and patients/families. Limitations of this study include its retrospective nature, database-sourcing and the types of ADLC were not defined. Ultimately, the authors recommend surgeons should avoid futile interventions through early goals-of-care discussions regardless of whether patients have ADLCs.
