Trauma Care

Craniocerebral firearm injuries are associated with high mortality rates as a result of the kinetic energy deposition during the projectile–tissue interaction and its consequences, causing immediate and delayed brain damage. Ballistic factors that contribute to brain injury from bullets are related to the behavior of the projectile (whether it yaws, tumbles, mushrooms or disintegrates following skull penetration) and the creation of bone fragments from the entry site. Pressure waves generated intracranially associated with the temporary cavitation are the hallmark of bullet penetration of the head. Because of the absence of any compensatory mechanism to absorb the transient pressure loading, the largely incompressible brain tissue is subjected directly to its effects. The sudden increase in intracranial pressure and the resultant deformation of the brain during cavitation contributes to the development of brain edema and may affect the cardiac and respiratory centers of the brainstem, even if not transected by the bullet trajectory. Shotgun injuries to the head at close range cause extensive destruction of the brain, usually with catastrophic results, because the pellets enter the cranial cavity bunched together, thus acting as a single projectile of large diameter and kinetic energy. Injuries from fragments present with multiple, more or less circular wounds of various depths, depending on the kinetic energy of the fragments. This review includes a conceptual temporal organization of factors that have a prognostic significance, including those related to projectile and energy transfer characteristics and their consequences.

Background/Objectives: Opioid requirements among patients with spine trauma vary widely, yet the patient- and injury-level factors associated with high morphine milligram equivalent (MME) dosing at discharge remain unclear. This study aimed to characterize factors associated with high-dose MME at discharge. Methods: We conducted a retrospective cohort study of adult patients with spine trauma from 2019 to 2020. After excluding patients without spine trauma, 1593 patients with an opioid prescription at discharge were categorized into low-dose (below the cohort median MME) and high-dose (at or above the cohort median MME) groups. Patients in the high-dose group were propensity-score matched 1:3 to low-dose controls (with replacement) on age, sex, race, ethnicity, chronic opioid use, chronic pain syndrome, and other substance use. Within the matched cohort, a multivariable logistic regression model with cluster-robust standard errors was fitted to examine factors associated with high-dose MME (cutoff at 384). Covariates included spine trauma group (isolated vs. polytrauma, isolated as reference), injury severity score (ISS) stratum (ISS ≤ 15 as reference), head injury severity category, spine injury severity category, procedural status (non-surgical as reference), mechanical ventilation status (non-ventilated as reference), hospital length of stay, and discharge disposition (home/home health as reference, versus rehabilitation, nursing home, or other facility). Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were reported. Results: Of the 1593 patients included, 793 were in the low-dose MME group and 800 in the high-dose group. In the propensity-matched cohort, surgical procedures were associated with high-dose MME (aOR 1.52 [95% CI, 1.18–1.95]; p = 0.001). Discharge to inpatient rehabilitation (aOR 0.30 [95% CI, 0.14–0.64]; p = 0.002) and discharge to a nursing home (aOR 0.41 [95% CI, 0.30–0.56]; p < 0.001) were independently associated with lower odds of high-dose MME relative to home discharge. Spine trauma type, ISS stratum, head and spine injury severity category, mechanical ventilation, discharge to other facilities, and hospital length of stay were not associated with high-dose MME. Conclusions: This study demonstrates that discharge opioid prescribing in spine trauma is shaped more by procedural and discharge practices. These findings underscore the need for targeted opioid stewardship interventions at the points of surgical decision-making and discharge planning.

Purpose: MRI is a valuable tool in evaluating select acute spine trauma cases, offering superior assessment of soft tissue, ligament, and spinal cord injuries compared to CT and radiographs. Although the ACR Appropriateness Criteria advises MRIs be performed without gadolinium-based IV contrast, guidelines utilized by ordering physicians do not clarify the role of contrast. The downsides of IV contrast should be balanced against potential benefits. This study examined the frequency and value of contrast-enhanced MRI in acute spine trauma. Methods: An IRB-approved retrospective chart review of spine MRIs ordered for trauma between 2020 and 2022 was conducted at a level 1 trauma, academic medical center. Contrast-enhanced studies were reviewed by a neuroradiologist for clinically significant findings (fractures, ligamentous injuries, epidural hematoma, cord injury) visible only or more clearly on postcontrast imaging. Patient demographics, clinical and operative notes, ordering provider specialty, and preceding imaging were reviewed. Results: Of 729 eligible patients receiving MRIs (608 adult, 121 pediatric), 16.2% of studies were performed with contrast. Pediatric patients were more likely to have radiographs and less likely to have CTs performed before MRI. Pediatric patients were more likely to undergo contrast-enhanced MRIs than adults (32.2% vs. 13.0%). Hospitalists ordered contrast more frequently (61.5%) than surgery (14.2%), emergency medicine (12.6%), or internal medicine (21.2%) providers. No cases were identified where postcontrast imaging provided findings missed or less visible on precontrast imaging. Conclusions: The absence of added value from contrast-enhanced imaging supports ACR guidelines against routine contrast use in MRI assessment of spine trauma. Heterogeneous ordering practices highlight the need for provider education.