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Nationwide trends in mortality following penetrating trauma: Are we up for the challenge?

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

Journal of Trauma and Acute Care Surgery: July 2018 - Volume 85 - Issue 1 - p 160–166
doi: 10.1097/TA.0000000000001907
EAST Quickshot Presentations

BACKGROUND Despite a focus on improved prehospital care, penetrating injuries contribute substantially to trauma mortality in the United States. We therefore analyzed contemporary trends in prehospital mortality from penetrating trauma in the past decade.

METHODS We identified patients in the The National Trauma Data Bank from 2007 to 2010 (“early period”) and 2011 to 2014 (“late period”) with gunshot wounds (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, prehospital mortality, and in-hospital mortality between the early and late periods. Models accounted for hospital clusters and adjusted for age, pulse, hypotension, New Injury Severity Score, Glasgow Coma Scale, and number of injured body parts.

RESULTS From 2007 to 2014, 437,398 patients experienced penetrating traumas, with equal distributions of GSW and SW. There were unadjusted differences in prehospital 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 prehospital death (GSWs: adjusted odds ratio [aOR], 4.54; 95% confidence interval [CI], 3.31–6.22; SWs: aOR, 8.98; 95% CI, 5.50–14.67) and lower odds of in-hospital death (GSWs: aOR, 0.85; 95% CI, 0.80–0.90; SWs: aOR, 0.81; 95% CI, 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.

CONCLUSION In the United States, the prevalence of penetrating traumas remains a nationwide burden. The odds of prehospital mortality has increased over fourfold for GSWs and almost ninefold for SWs. Examining violence intensity, along with improvements in hospital care and data collection, may explain these findings.

LEVEL OF EVIDENCE Prognostic and epidemiological, level IV.

From the Department of Surgery (J.V.S., R.F., A.K., E.R.H., D.T.E.), The Johns Hopkins Hospital, School of Medicine (A.M.), Johns Hopkins, Baltimore, Maryland; Department of Surgery (A.B.N.), Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Canada; and Department of Surgery (B.J.), College of Medicine Tucson, University of Arizona, Tucson, Arizona.

Submitted: November 30, 2017, Revised: January 18, 2018, Accepted: February 24, 2018, Published online: April 3, 2018.

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.

Address for reprints: Joseph V. Sakran, MD, MPH, MPA, Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins Hospital, Sheikh Zayed Tower, Suite 6107, Baltimore, MD 21287; email: jsakran1@jhmi.edu; josephsakran@gmail.com.

© 2018 Lippincott Williams & Wilkins, Inc.