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Nationwide Trends in Mortality Following Penetrating Trauma: Are We Up for the Challenge?

Sakran, Joseph, V., MD, MPH, MPA1; Mehta, Ambar, MPH2; Fransman, Ryan, MD1; Nathens, Avery, B., MD, PhD, MPH; Joseph, Bellal, MD4; Kent, Alistair, MD1; Haut, Elliott, R., MD, PhD1; Efron, David, T., MD1

Journal of Trauma and Acute Care Surgery: April 3, 2018 - Volume Publish Ahead of Print - Issue - p
doi: 10.1097/TA.0000000000001907
2018 EAST Quick Shots: PDF Only

Objectives Despite a focus on improved pre-hospital care, penetrating injuries contribute substantially to trauma mortality in the United States (U.S.). We therefore analyzed contemporary trends in pre-hospital mortality from penetrating trauma in the past decade.

Methods We identified patients in the The National Trauma Data Bank from 2007-2010 ("early period") and 2011-2014 ("late period") with gunshot (GSW) and stab wounds (SW), who were treated at hospitals that recorded dead-on-arrival statistics. Multivariable logistic regressions assessed differences in body locations of trauma, pre-hospital mortality, and in-hospital mortality between the early and late periods. Models accounted for hospital clusters and adjusted for age, pulse, hypotension, NISS, GCS, and number of injured body parts.

Results From 2007-2014, 437,398 patients experienced penetrating traumas, with equal distributions of GSW and SW. There were unadjusted differences in pre-hospital mortality (GSW: early 2.0% vs late 4.9%; SW: early 0.2% vs late 1.1%) and in-hospital mortality (GSW: early 13.8% vs late 9.5%; SW: early 1.8% vs late 1.0%) by both mechanisms. After adjustment, patients in the late period relative to those in the early period had significantly higher odds of pre-hospital death (GSWs: aOR 4.54 [95%-CI 3.31-6.22]; SWs: aOR 8.98 [5.50-14.67]) and lower odds of in-hospital death (GSWs: aOR 0.85 [0.80-0.90]; SWs: aOR 0.81 [0.71-0.92]). Sensitivity analyses assessing GSWs and SWs by locations of body injury found similar results. Additionally, patients in the late period were more likely to experience penetrating injuries to the face, spine, and lower extremities.

Conclusions In the U.S., the prevalence of penetrating traumas remains a nationwide burden. The odds of pre-hospital mortality has increased over 4-fold for gunshot wounds and almost 9-fold for stab wounds. Examining violence intensity, along with improvements in hospital care and data collection, may explain these findings.

Level of Evidence Level IV

Type of Study Prognostic and Epidemiological

1The Johns Hopkins Hospital, Department of Surgery. 2Johns Hopkins, School of Medicine. 3Department of Surgery, Sunnybrook Health Sciences Centre and the University of Toronto.4University of Arizona, College of Medicine Tucson, Department of Surgery.

Joseph V Sakran and Ambar Mehta Equal contribution.

Corresponding Author: Joseph V. Sakran, MD, MPH, MPA, The Johns Hopkins Hospital, Department of Surgery, Division of Acute Care Surgery, Sheikh Zayed Tower, Suite 6107, Baltimore, MD 21287. Tel: 410-955-2244. Fax: 410-955-1884.

Presentation: Quick Shot presentation at the 31st Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma, January 9-13, 2018 in Lake Buena Vista, FL.

Disclosures: Authors JVS, AM, RF, ABN, BJ, AK, CJ, DF, and DTE have no disclosures. Author ERH has the following disclosures:

Dr. Haut is the primary investigator of a grant (1R01HS024547-01) from the Agency for Healthcare Research and Quality (AHRQ) titled “Individualized Performance Feedback on Venous Thromboembolism Prevention Practice.”

Dr. Haut is a co-investigator of a grant (1R21HL129028-01A1) from the National Institutes of Health National Heart, Lung, and Blood Institute (NIH-NHLBI) titled “Analysis of the impact of missed doses of venous thromboembolism prophylaxis.”

Dr. Haut is the primary investigator of contracts with The Patient-Centered Outcomes Research Institute (PCORI) titled “Preventing Venous Thromboembolism: Empowering Patients and Enabling Patient-Centered Care via Health Information Technology” (CE-12-11-4489) and “Preventing Venous Thromboembolism (VTE): Engaging Patients to Reduce Preventable Harm from Missed/Refused Doses of VTE Prophylaxis” (DI-1603-34596).

Dr. Haut receives royalties from Lippincott, Williams & Wilkins for a book - "Avoiding Common ICU Errors."

Dr. Haut is a paid consultant and speaker for the “Preventing Avoidable Venous Thromboembolism— Every Patient, Every Time” VHA/Vizient IMPERATIV® Advantage Performance Improvement Collaborative.

Dr. Haut is a paid consultant and speaker for the Illinois Surgical Quality Improvement Collaborative "ISQIC."

Dr. Haut was the paid author of a paper commissioned by the National Academies of Medicine titled “Military Trauma Care’s Learning Health System: The Importance of Data Driven Decision Making” which was used to support the report titled “A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.”

© 2018 Lippincott Williams & Wilkins, Inc.