Burn and Trauma Burden and Screening for Interpersonal Violence During the COVID-19 Pandemic.

INTRODUCTION: Nationwide shelter-in-place (SIP) orders during the pandemic have had long-lasting effects, including increased rates of domestic violence and interpersonal violence. Screening for violence varies by institution, which tool is used, and when. Given increases in burn and trauma admissions over the course of the pandemic, we sought to examine trends at our institution during this time period to better guide care and anticipate system-level effects. METHODS: We performed a retrospective cohort study of pediatric burn and adult burn and trauma patients at our level 1 trauma/burn center between March-May 2019 and March-May 2020. Home safety screening was performed by nursing staff using a 1-part screening questionnaire. Patients presenting before March 15, 2020, were defined as "pre-SIP; " between March 16-May 19, 2020, were "during SIP; " and those after May 19, 2020, were designated as "post-SIP." Descriptive and chi-square statistics were used. Demographic, injury patterns, and screening information were collected. RESULTS: Blunt trauma comprised 60% of injuries, followed by burns (30%) then penetrating injury (7%). Over the entire time period analyzed, 1822 patients had documented home safety screening; ∼2% of patients screened reported a safety concern pre-SIP, compared to 3% of patients during SIP. There were higher rates of burns and penetrating injury during SIP compared to other periods (P ≤ 0.0001). Home safety screening rates were 94%-95% pre- and during SIP, but dropped to 85% post-SIP (P < 0.0001). Home safety concerns were reported almost 2% of the time pre-SIP and 3% during SIP (P = 0.016). CONCLUSIONS: We noted an increase in trauma and burns during and after SIP orders, consistent with the experiences of other institutions. Implementation of a nurse-driven screening process demonstrated high compliance with appropriate referrals. The burden of burn and traumatic injury remains significant, highlighting a need for continued psychosocial screening and the provision of psychosocial support resources in the acute trauma setting.

ECMO simulation: How much, who to train, and a review of cost, fidelity and performance.

BACKGROUND: Extracorporeal Membrane Oxygenation (ECMO) is a high-risk, low-volume procedure requiring repetition, skill and multiple disciplines with fidelity of communication. Yet many barriers exist to maintain proficiency and skills with variable cost and fidelity. We designed and implemented a low-cost monthly ECMO simulation and hypothesized providers would have increased familiarity and improved teamwork. We also review some key elements of cost, fidelity and evaluation of effectiveness. METHODS: A structured, 1-hour ECMO simulation was performed on a customized mannikin on a monthly basis in 2022. Qualitative surveys were administered to each member post-simulation. Answers were categorized by theme, including satisfaction of patient care, evaluation of self and team dynamics, and areas for improvement. RESULTS: Most participants were satisfied with their ability to take care of the patient, with common themes of communication and coordination of roles. Identified areas of improvement were mostly limited to technical skills, and soft skills such as communication and teamwork. CONCLUSIONS: We designed and implemented a low-cost, monthly and multi-disciplinary ECMO simulation program with overall positive feedback and identified areas for improvement. There remains variability in cost, fidelity and evaluation of performance and retention. There may be a need to create guidelines for ECMO simulation training that can be applied at all institutions utilizing ECMO for patient care.

Early administration of high dose enoxaparin after traumatic brain injury.

BACKGROUND: Early enoxaparin 30 mg BID administration at 24 h post-injury has been demonstrated in patients with traumatic brain injury (TBI). However this dose can also yield subtherapeutic anti-Xa levels in 30-50% of trauma patients, suggesting that larger doses may be required for adequate prophylaxis against venous thromboembolism (VTE). The safety of enoxaparin 40 mg BID in trauma patients has previously been shown - however, these studies have largely excluded TBI patients. Therefore, we sought to demonstrate the safety of early enoxaparin 40 mg BID in a low-risk group of TBI patients. METHODS: A retrospective review of TBI patients at a Level 1 trauma center was performed. Patients with stable computed tomography (CT) of the head at 6 to 24 h post-injury who received enoxaparin 40 mg BID were included and serial GCS evaluations to identify possible clinical complications. To evaluate the safety of this dosing regimen, data was then compared to patients from our institution with similar TBI profiles who had received 5,000 units (U) of subcutaneous heparin (SQH) prophylaxis. RESULTS: 199 TBI patients were identified over a nine month period, 40/199 (19.7%) received DVT prophylaxis after traumatic injury. Of these 40, 19 (47.5%) received enoxaparin 40 mg BID and 21 (52.5%) received 5,000U of SQH. Low risk TBI patients who were either given enoxaparin (n = 7) or SQH (n = 4), demonstrated no clinical decline in mental status during their inpatient stay. CONCLUSION: Prior studies have demonstrated that enoxaparin 40 mg BID dosing is superior to traditional VTE prophylaxis in trauma patients. However, TBI patients are often excluded from this dosing due to concern for progression. Our study showed no clinical decline in mental status in a small cohort of low-risk TBI patients who received enoxaparin 40 mg BID.