Preinjury Frailty Predicts 1-Year Mortality in Older Adults With Traumatic Spine Fractures.

BACKGROUND AND OBJECTIVES: Nearly 30% of older adults presenting with isolated spine fractures will die within 1 year. Attempts to ameliorate this alarming statistic are hindered by our inability to identify relevant risk factors. The primary objective of this study was to develop a prediction model that identifies feasible targets to limit 1-year mortality. METHODS: This retrospective cohort study included 703 older adults (65 years or older) admitted to a level I trauma center with isolated spine fractures, without neural deficit, from January 2013 to January 2018. Multivariable analysis was used to select for independently significant patient demographics, frailty variables, injury metrics, and management decisions to incorporate into distinct logistic regression models predicting 1-year mortality. Variables were considered significant, if P < .05. RESULTS: Of the 703 older adults, 199 (28.3%) died after hospital discharge, but within 1 year of index trauma. Risk Analysis Index (RAI; odds ratio [OR]: 1.116; 95% CI: 1.087-1.149; P < .001) and ambulation requiring a cane (OR: 2.601; 95% CI: 1.151-5.799; P = .02) or walker (OR: 4.942; 95% CI: 2.698-9.196; P < .001), ie, frailty variables, were associated with increased odds of 1-year mortality. Spine trauma scales were not associated with 1-year mortality. Longer hospital stays (OR: 1.112; 95% CI: 1.034-1.196; P = .004) and nursing home discharge (OR: 3.881; 95% CI: 2.070-7.378; P < .001) were associated with increased odds, while discharge to rehab (OR: 0.361; 95% CI: 0.155-0.799; P = .014) decreased 1-year mortality odds. A "preinjury" regression model incorporating Risk Analysis Index and ambulation status resulted in an area under receiver operating characteristic curve (AUROCC) of 0.914 (95% CI: 0.863-0.965). A "postinjury" model incorporating Glasgow Coma Scale, hospital stay duration, and discharge disposition resulted in AUROCC of 0.746 (95% CI: 0.642-0.849). Combining elements of the preinjury and postinjury models into an "integrated model" produced an AUROCC of 0.908 (95% CI: 0.852-0.965). CONCLUSION: Preinjury frailty measures are most strongly associated with 1-year mortality outcomes in older adults with isolated spine fractures. Incorporating injury metrics or management decisions did not enhance predictive accuracy. Further work is needed to understand how targeting frailty may reduce mortality.

Testing a Novel Deliberate Practice Intervention to Improve Diagnostic Reasoning in Trauma Triage: A Pilot Randomized Clinical Trial.

Importance: Diagnostic errors made during triage at nontrauma centers contribute to preventable morbidity and mortality after injury. Objective: To test the feasibility, acceptability, and preliminary effect of a novel deliberate practice intervention to improve diagnostic reasoning in trauma triage. Design, Setting, and Participants: This pilot randomized clinical trial was conducted online in a national convenience sample of 72 emergency physicians between January 1 and March 31, 2022, without follow-up. Interventions: Participants were randomly assigned to receive either usual care (ie, passive control) or a deliberate practice intervention, consisting of 3 weekly, 30-minute, video-conferenced sessions during which physicians played a customized, theory-based video game while being observed by content experts (coaches) who provided immediate, personalized feedback on diagnostic reasoning. Main Outcomes and Measures: Using the Proctor framework of outcomes for implementation research, the feasibility, fidelity, acceptability, adoption, and appropriateness of the intervention was assessed by reviewing videos of the coaching sessions and conducting debriefing interviews with participants. A validated online simulation was used to assess the intervention's effect on behavior, and triage among control and intervention physicians was compared using mixed-effects logistic regression. Implementation outcomes were analyzed using an intention-to-treat approach, but participants who did not use the simulation were excluded from the efficacy analysis. Results: The study enrolled 72 physicians (mean [SD] age, 43.3 [9.4] years; 44 men [61%]) but limited registration of physicians in the intervention group to 30 because of the availability of the coaches. Physicians worked in 20 states; 62 (86%) were board certified in emergency medicine. The intervention was delivered with high fidelity, with 28 of 30 physicians (93%) completing 3 coaching sessions and with coaches delivering 95% of session components (642 of 674). A total of 21 of 36 physicians (58%) in the control group participated in outcome assessment; 28 of 30 physicians (93%) in the intervention group participated in semistructured interviews, and 26 of 30 physicians (87%) in the intervention group participated in outcome assessment. Most physicians in the intervention group (93% [26 of 28]) described the sessions as entertaining and valuable; most (88% [22 of 25]) affirmed the intention to adopt the principles discussed. Suggestions for refinement included providing more time with the coach and addressing contextual barriers to triage. During the simulation, the triage decisions of physicians in the intervention group were more likely to adhere to clinical practice guidelines than those in the control group (odds ratio; 13.8, 95% CI, 2.8-69.6; P = .001). Conclusions and Relevance: In this pilot randomized clinical trial, coaching was feasible and acceptable and had a large effect on simulated trauma triage decisions, setting the stage for a phase 3 trial. Trial Registration: ClinicalTrials.gov Identifier: NCT05168579.

Testing the feasibility, acceptability, and preliminary effect of a novel deliberate practice intervention to reduce diagnostic error in trauma triage: a study protocol for a randomized pilot trial.

BACKGROUND: Non-compliance with clinical practice guidelines in trauma remains common, in part because physicians make diagnostic errors when triaging injured patients. Deliberate practice, purposeful participation in a training task under the oversight of a coach, effectively changes behavior in procedural domains of medicine but has rarely been used to improve diagnostic skill. We plan a pilot parallel randomized trial to test the feasibility, acceptability, and preliminary effect of a novel deliberate practice intervention to reduce physician diagnostic errors in trauma triage. METHODS: We will randomize a national convenience sample of physicians who work at non-trauma centers (n = 60) in a 1:1 ratio to a deliberate practice intervention or to a passive control. We will use a customized, theory-based serious video game as the basis of our training task, selected based on its behavior change techniques and game mechanics, along with a coaching manual to standardize the fidelity of the intervention delivery. The intervention consists of three 30-min sessions with content experts (coaches), conducted remotely, during which physicians (trainees) play the game and receive feedback on their diagnostic processes. We will assess (a) the fidelity with which the intervention is delivered by reviewing video recordings of the coaching sessions; (b) the acceptability of the intervention through surveys and semi-structured interviews, and (c) the effect of the intervention by comparing the performance of trainees and a control group of physicians on a validated virtual simulation. We hypothesize that trainees will make ≥ 25% fewer diagnostic errors on the simulation than control physicians, a large effect size. We additionally hypothesize that ≥ 90% of trainees will receive their intervention as planned. CONCLUSIONS: The results of the trial will inform the decision to proceed with a future hybrid effectiveness-implementation trial of the intervention. It will also provide a deeper understanding of the challenges of using deliberate practice to modify the diagnostic skill of physicians. TRIAL REGISTRATION: Clinical trials.gov ( NCT05168579 ); 23 December 2021.

Prehospital low titer group O whole blood is feasible and safe: Results of a prospective randomized pilot trial.

INTRODUCTION: Low titer group O whole blood (LTOWB) resuscitation is increasingly common in both military and civilian settings. Data regarding the safety and efficacy of prehospital LTOWB remain limited. METHODS: We performed a single-center, prospective, cluster randomized, prehospital through in-hospital whole blood pilot trial for injured air medical patients. We compared standard prehospital air medical care including red cell transfusion and crystalloids followed by in-hospital component transfusion to prehospital and in-hospital LTOWB resuscitation. Prehospital vital signs were used as inclusion criteria (systolic blood pressure ≤90 mm Hg and heart rate ≥108 beats per minute or systolic blood pressure ≤70 mm Hg for patients at risk of hemorrhage). Primary outcome was feasibility. Secondary outcomes included 28-day and 24-hour mortality, multiple organ failure, nosocomial infection, 24-hour transfusion requirements, and arrival coagulation parameters. RESULTS: Between November 2018 and October 2020, 86 injured patients were cluster randomized by helicopter base. The trial has halted early at 77% enrollment. Overall, 28-day mortality for the cohort was 26%. Injured patients randomized to prehospital LTOWB (n = 40) relative to standard care (n = 46) were similar in demographics and injury characteristics. Intent-to-treat Kaplan-Meier survival analysis demonstrated no statistical mortality benefit at 28 days (25.0% vs. 26.1%, p = 0.85). Patients randomized to prehospital LTOWB relative to standard care had lower red cell transfusion requirements at 24 hours (p < 0.01) and a lower incidence of abnormal thromboelastographic measurements. No transfusion reactions during the prehospital or in-hospital phase of care were documented. CONCLUSION: Prehospital through in-hospital LTOWB resuscitation is safe and may be associated with hemostatic benefits. A large-scale clinical trial is feasible with protocol adjustment and would allow the effects of prehospital LTOWB on survival and other pertinent clinical outcomes to be appropriately characterized. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level II.

Impact of Coronavirus Disease 2019 Shutdown on Neurotrauma Volume in Pennsylvania.

OBJECTIVE: The 2020 coronavirus disease 2019 (COVID-19) pandemic resulted in state-specific quarantine protocols and introduced the concept of social distancing into modern parlance. We assess the impact of the COVID-19 pandemic on neurotrauma presentations in the first 3 months after shutdown throughout Pennsylvania. METHODS: The Pennsylvania Trauma Systems Foundation was queried for registry data from the Pennsylvania Trauma Outcomes Study between March 12 and June 5 in each year from 2017 to 2020. RESULTS: After the COVID-19 shutdown, there was a 27% reduction in neurotrauma volume, from 2680 cases in 2017 to 2018 cases in 2020, and a 28.8% reduction in traumatic brain injury volume. There was no significant difference in neurotrauma phenotype incurred relative to total cases. Injury mechanism was less likely to be motor vehicle collision and more likely caused by falls, gunshot wound, and recreational vehicle accidents (P < 0.05). Location of injury was less likely on roads and public locations and more likely at indoor private locations (P < 0.05). The proportion of patients with neurotrauma with blood alcohol concentration >0.08 g/dL was reduced in 2020 (11.4% vs. 9.0%; P < 0.05). Mortality was higher during 2020 compared with pre-COVID years (7.7% vs. 6.4%; P < 0.05). CONCLUSIONS: During statewide shutdown, neurotrauma volume and alcohol-related trauma decreased and low-impact traumas and gunshot wounds increased, with a shift toward injuries occurring in private, indoor locations. These changes increased mortality. However, there was not a change in the types of injuries sustained.

Development and validation of a five-factor score for prediction of pathologic pneumatosis.

BACKGROUND: The significance of pneumatosis intestinalis (PI) remains challenging. While certain clinical scenarios are predictive of transmural ischemia, risk models to assess the presence of pathologic PI are needed. The aim of this study was to determine what patient factors at the time of radiographic diagnosis of PI predict the risk for pathologic PI. METHODS: We conducted a retrospective cohort study examining patients with PI from 2010 to 2016 at a multicenter hospital network. Multivariate logistic regression was used to develop a predictive model for pathologic PI in a derivation cohort. Using regression-coefficient-based methods, the final multivariate model was converted into a five-factor-based score. Calibration and discrimination of the score were then assessed in a validation cohort. RESULTS: Of 305 patients analyzed, 102 (33.4%) had pathologic PI. We identified five factors associated with pathologic PI at the time of radiographic diagnosis: small bowel PI, age 70 years or older, heart rate 110 bpm or greater, lactate of 2 mmol/L or greater, and neutrophil-lymphocyte ratio 10 or greater. Using this model, patients in the validation cohort were assigned risk scores ranging from 0 to 11. Low-risk patients were categorized when scores are 0 to 4; intermediate, score of 5 to 6; high, score of 7 to 8; and very high risk, 9+. In the validation cohort, very high-risk patients (n = 17; 18.1%) had predicted rates of pathologic pneumatosis of 88.9% and an observed rate of 82.4%. In contrast, patients labeled as low risk (n = 37; 39.4%) had expected rates of pathologic pneumatosis of 1.3% and an observed rate of 0%. The model showed excellent discrimination (area under the curve, 0.90) and good calibration (Hosmer-Lemeshow goodness-of-fit, p = 0.37). CONCLUSION: Our score accurately stratifies patient risk of pathologic pneumatosis. This score has the potential to target high-risk individuals for expedient operation and spare low-risk individuals invasive interventions. LEVEL OF EVIDENCE: Prognostic Study, Level III.

Tranexamic Acid During Prehospital Transport in Patients at Risk for Hemorrhage After Injury: A Double-blind, Placebo-Controlled, Randomized Clinical Trial.

IMPORTANCE: In-hospital administration of tranexamic acid after injury improves outcomes in patients at risk for hemorrhage. Data demonstrating the benefit and safety of the pragmatic use of tranexamic acid in the prehospital phase of care are lacking for these patients. OBJECTIVE: To assess the effectiveness and safety of tranexamic acid administered before hospitalization compared with placebo in injured patients at risk for hemorrhage. DESIGN, SETTING, AND PARTICIPANTS: This pragmatic, phase 3, multicenter, double-blind, placebo-controlled, superiority randomized clinical trial included injured patients with prehospital hypotension (systolic blood pressure ≤90 mm Hg) or tachycardia (heart rate ≥110/min) before arrival at 1 of 4 US level 1 trauma centers, within an estimated 2 hours of injury, from May 1, 2015, through October 31, 2019. INTERVENTIONS: Patients received 1 g of tranexamic acid before hospitalization (447 patients) or placebo (456 patients) infused for 10 minutes in 100 mL of saline. The randomization scheme used prehospital and in-hospital phase assignments, and patients administered tranexamic acid were allocated to abbreviated, standard, and repeat bolus dosing regimens on trauma center arrival. MAIN OUTCOMES AND MEASURES: The primary outcome was 30-day all-cause mortality. RESULTS: In all, 927 patients (mean [SD] age, 42 [18] years; 686 [74.0%] male) were eligible for prehospital enrollment (460 randomized to tranexamic acid intervention; 467 to placebo intervention). After exclusions, the intention-to-treat study cohort comprised 903 patients: 447 in the tranexamic acid arm and 456 in the placebo arm. Mortality at 30 days was 8.1% in patients receiving tranexamic acid compared with 9.9% in patients receiving placebo (difference, -1.8%; 95% CI, -5.6% to 1.9%; P = .17). Results of Cox proportional hazards regression analysis, accounting for site, verified that randomization to tranexamic acid was not associated with a significant reduction in 30-day mortality (hazard ratio, 0.81; 95% CI, 0.59-1.11, P = .18). Prespecified dosing regimens and post-hoc subgroup analyses found that prehospital tranexamic acid were associated with significantly lower 30-day mortality. When comparing tranexamic acid effect stratified by time to treatment and qualifying shock severity in a post hoc comparison, 30-day mortality was lower when tranexamic acid was administered within 1 hour of injury (4.6% vs 7.6%; difference, -3.0%; 95% CI, -5.7% to -0.3%; P < .002). Patients with severe shock (systolic blood pressure ≤70 mm Hg) who received tranexamic acid demonstrated lower 30-day mortality compared with placebo (18.5% vs 35.5%; difference, -17%; 95% CI, -25.8% to -8.1%; P < .003). CONCLUSIONS AND RELEVANCE: In injured patients at risk for hemorrhage, tranexamic acid administered before hospitalization did not result in significantly lower 30-day mortality. The prehospital administration of tranexamic acid after injury did not result in a higher incidence of thrombotic complications or adverse events. Tranexamic acid given to injured patients at risk for hemorrhage in the prehospital setting is safe and associated with survival benefit in specific subgroups of patients. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02086500.

Predisposed to failure? The challenge of rescue in the medical intensive care unit.

BACKGROUND: Medical intensive care unit (MICU) patients develop acute surgical processes that require operative intervention. There are limited data addressing outcomes of emergency general surgery (EGS) in this population. The aim of our study was to characterize the breadth of surgical consults from the MICU and assess mortality after abdominal EGS cases. METHODS: All MICU patients with an EGS consult in an academic medical center between January 2010 and 2016 were identified from an electronic medical record-based registry. Charts were reviewed to determine reason for consult, procedures performed, and to obtain additional clinical data. A multivariate logistic regression was used to determine patient factors associated with patient mortality. RESULTS: Of 911 MICU patients seen by our service, 411(45%) required operative intervention, with 186 patients undergoing an abdominal operation. The postoperative mortality rate after abdominal operations was 37% (69/186), significantly higher than the mortality of 16% (1833/11192) for all patients admitted to the MICU over the same period (p < 0.05). Damage-control procedures were performed in 64 (34%) patients, with 46% mortality in this group. The most common procedures were bowel resections, with mortality of 42% (28/66) and procedures for severe clostridium difficile, mortality of 38% (9/24). Twenty-seven patients met our definition of surgical rescue, requiring intervention for complications of prior procedures, with mortality of 48%. Need for surgical rescue was associated with increased admission mortality (odds ratio, 13.07; 95% confidence interval, 2.86-59.77). Twenty-six patients had pathology amenable to surgical intervention but did not undergo operation, with 100% mortality. In patients with abdominal pathology at the time of operation, in-hospital delay was associated with increased mortality (odds ratio, 5.13; 95% confidence interval, 1.11-23.77). CONCLUSION: Twenty percent of EGS consults from the MICU had an abdominal process requiring an operative intervention. While the MICU population as a whole has a high baseline mortality, patients requiring abdominal surgical intervention are an even higher risk. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

Design and implementation of the Western Pennsylvania regional Stop the Bleed initiative.

BACKGROUND: Hemorrhage is the leading cause of preventable death in trauma, and nearly 40% of prehospital deaths can be attributed to blood loss. The Stop the Bleed program provides a structured curriculum for teaching hemorrhage control and the use of bleeding control kits. To overcome implementation barriers and to achieve the goal of making education on bleeding control as common as cardiopulmonary resuscitation, widespread implementation with outreach to the public and law enforcement is necessary. METHODS: We provide a description and analysis of the implementation of a regional Stop the Bleed program, which includes a step-by-step guide to the design of this program provided as a template to guide attempts at large-scale Stop the Bleed program development. RESULTS: Combining the efforts of regional trauma and nontrauma centers as a hub-and-spoke design, a region covering four states, 72 counties, and 30,000 square miles was targeted. A total of 27,291 individuals were trained in a 21-month period including 3,172 trainers, 19,310 lay public, and 4,809 law enforcement officers. A total of 436 bleeding control kits were distributed to 102 public schools, and tourniquets were provided to 4,809 law enforcement officers. Program development and community outreach resulted in official recognition of the program by the Pennsylvania State Senate. CONCLUSIONS: With the use of a multicenter outreach program design with emphasis on law enforcement and public education while developing a train-the-trainer program, widespread and rapid dissemination of Stop the Bleed teaching is feasible. The general steps described in this manuscript may serve as a template for new or developing programs in other areas to increase the national exposure to Stop the Bleed. LEVEL OF EVIDENCE: Economic/Decision study, level IV.

Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock.

BACKGROUND: After a person has been injured, prehospital administration of plasma in addition to the initiation of standard resuscitation procedures in the prehospital environment may reduce the risk of downstream complications from hemorrhage and shock. Data from large clinical trials are lacking to show either the efficacy or the risks associated with plasma transfusion in the prehospital setting. METHODS: To determine the efficacy and safety of prehospital administration of thawed plasma in injured patients who are at risk for hemorrhagic shock, we conducted a pragmatic, multicenter, cluster-randomized, phase 3 superiority trial that compared the administration of thawed plasma with standard-care resuscitation during air medical transport. The primary outcome was mortality at 30 days. RESULTS: A total of 501 patients were evaluated: 230 patients received plasma (plasma group) and 271 received standard-care resuscitation (standard-care group). Mortality at 30 days was significantly lower in the plasma group than in the standard-care group (23.2% vs. 33.0%; difference, -9.8 percentage points; 95% confidence interval, -18.6 to -1.0%; P=0.03). A similar treatment effect was observed across nine prespecified subgroups (heterogeneity chi-square test, 12.21; P=0.79). Kaplan-Meier curves showed an early separation of the two treatment groups that began 3 hours after randomization and persisted until 30 days after randomization (log-rank chi-square test, 5.70; P=0.02). The median prothrombin-time ratio was lower in the plasma group than in the standard-care group (1.2 [interquartile range, 1.1 to 1.4] vs. 1.3 [interquartile range, 1.1 to 1.6], P<0.001) after the patients' arrival at the trauma center. No significant differences between the two groups were noted with respect to multiorgan failure, acute lung injury-acute respiratory distress syndrome, nosocomial infections, or allergic or transfusion-related reactions. CONCLUSIONS: In injured patients at risk for hemorrhagic shock, the prehospital administration of thawed plasma was safe and resulted in lower 30-day mortality and a lower median prothrombin-time ratio than standard-care resuscitation. (Funded by the U.S. Army Medical Research and Materiel Command; PAMPer ClinicalTrials.gov number, NCT01818427 .).

Development of the emergency preservation and resuscitation for cardiac arrest from trauma clinical trial.

BACKGROUND: Patients who suffer a cardiac arrest from trauma rarely survive, even with aggressive resuscitation attempts, including an emergency department thoracotomy. Emergency Preservation and Resuscitation (EPR) was developed to utilize hypothermia to buy time to obtain hemostasis before irreversible organ damage occurs. Large animal studies have demonstrated that cooling to tympanic membrane temperature 10°C during exsanguination cardiac arrest can allow up to 2 hours of circulatory arrest and repair of simulated injuries with normal neurologic recovery. STUDY DESIGN: The Emergency Preservation and Resuscitation for Cardiac Arrest from Trauma trial has been developed to test the feasibility and safety of initiating EPR. Select surgeons will be trained in the EPR technique. If a trained surgeon is available, the subject will undergo EPR. If not, the subject will be followed as a control subject. For this feasibility study, 10 EPR and 10 control subjects will be enrolled. STUDY PARTICIPANTS: Study participants will be those with penetrating trauma who remain pulseless despite an emergency department thoracotomy. INTERVENTIONS: Emergency Preservation and Resuscitation will be initiated via an intra-aortic flush of a large volume of ice-cold saline solution. Following surgical hemostasis, delayed resuscitation will be accomplished with cardiopulmonary bypass. OUTCOME MEASURES: The primary outcome will be survival to hospital discharge without significant neurologic deficits. Secondary outcomes include long-term survival and functional outcome. IMPLICATIONS: Once data from these 20 subjects are reviewed, revisions to the inclusion criteria and/or the EPR technique may then be tested in a second set of EPR and control subjects.

External validation of the Air Medical Prehospital Triage score for identifying trauma patients likely to benefit from scene helicopter transport.

BACKGROUND: The Air Medical Prehospital Triage (AMPT) score was developed to identify injured patients who may benefit from scene helicopter emergency medical services (HEMS) transport. External validation using a different data set is essential to ensure reliable performance. The study objective was to validate the effectiveness of the AMPT score to identify patients with a survival benefit from HEMS using the Pennsylvania Trauma Outcomes Study registry. METHODS: Patients 16 years or older undergoing scene HEMS or ground EMS (GEMS) transport in the Pennsylvania Trauma Outcomes Study registry 2000-2013 were included. Patients with 2 or higher AMPT score points were triaged to HEMS, while those with less than 2 points were triaged to GEMS. Multilevel Poisson regression determined the association of survival with actual transport mode across AMPT score triage assignments, adjusting for demographics, mechanism, vital signs, interventions, and injury severity. Successful validation was defined as no survival benefit for actual HEMS transport in patients triaged to GEMS by the AMPT score, with a survival benefit for actual HEMS transport in patients triaged to HEMS by the AMPT score. Subgroup analyses were performed in patients treated by advanced life support providers and patients with transport times longer than 10 minutes. RESULTS: There were 222,827 patients included. For patients triaged to GEMS by the AMPT score, actual transport mode was not associated with survival (adjusted relative risk, 1.004; 95% confidence interval, 0.999-1.009; p = 0.08). For patients triaged to HEMS by the AMPT score, actual HEMS transport was associated with a 6.7% increase in the relative probability of survival (adjusted relative risk, 1.067; 95% confidence interval, 1.040-1.083, p < 0.001). Similar results were seen in all subgroups. CONCLUSIONS: This study is the first to externally validate the AMPT score, demonstrating the ability of this tool to reliably identify trauma patients most likely to benefit from HEMS transport. The AMPT score should be considered when protocols for HEMS scene transport are developed and reviewed. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III; therapeutic/care management study, level IV.

Surgical rescue: The next pillar of acute care surgery.

BACKGROUND: The evolving field of acute care surgery (ACS) traditionally includes trauma, emergency general surgery, and critical care. However, the critical role of ACS in the rescue of patients with a surgical complication has not been explored. We here describe the role of "surgical rescue" in the practice of ACS. METHODS: A prospective, electronic medical record-based ACS registry spanning January 2013 to May 2014 at a large urban academic medical center was screened by ICD-9 codes for acute surgical complications of an operative or interventional procedure. Long-term outcomes were derived from the Social Security Death Index. RESULTS: Of 2,410 ACS patients, 320 (13%) required "surgical rescue": most commonly, from wound complications (32%), uncontrolled sepsis (19%), and acute obstruction (15%). The majority of complications (85%) were related to an operation; 15% were related to interventional procedures. The most common rescue interventions required were bowel resection (23%), wound debridement (18%), and source control of infection (17%); 63% of patients required operative intervention, and 22% required surgical critical care. Thirty-six percent of complications occurred in ACS primary patients ("local"), whereas 38% were referred from another surgical service ("institutional") and 26% referred from another institution ("regional"). Hospital length of stay was longer, and in-hospital and 1-year mortalities were higher in rescue patients compared with those without a complication. Outcomes were equivalent between "local" and "institutional" patients, but hospital length of stay and discharge to home were significantly worse in "institutional" referrals. CONCLUSION: We here describe the distinct role of the acute care surgeon in the surgical management of complications; this is an additional pillar of ACS. In this vital role, the acute care surgeon provides crucial support to other providers as well as direct patient care in the "surgical rescue" of surgical and procedural complications. LEVEL OF EVIDENCE: Epidemiological study, level III; therapeutic/care management study, level IV.

Perceived performance and impact of a non-physician-led interprofessional team in a trauma clinic setting.

Faced with the challenge of meeting the wide degree of post-discharge needs in their trauma population, the University of Pittsburgh Medical Center (UPMC) developed a non-physician-led interprofessional team to provide follow-up care at its UPMC Falk Trauma Clinic. We assessed this model of care using a survey to gauge team member perceptions of this model, and used clinic visit documentation to apply a novel approach to assessing how this model improves the care received by clinic patients. The high level of perceived team performance and cohesion suggests that this model has been successful thus far from a provider perspective. Patients are seen most frequently by audiologists, while approximately half of physical therapy and speech language therapy consults generate a new therapy referral, which is interpreted as a potential change in the patient's care trajectory. The broader message of this analysis is that a collaborative, non-hierarchical team model incorporating rehabilitative specialists, who often operate independently of one another, can be successful in this setting, where patients appear to have a strong and previously under-attended need for rehabilitative intervention.

Not all prehospital time is equal: Influence of scene time on mortality.

BACKGROUND: Trauma is time sensitive, and minimizing prehospital (PH) time is appealing. However, most studies have not linked increasing PH time with worse outcomes because raw PH times are highly variable. It is unclear whether specific PH time patterns affect outcomes. Our objective was to evaluate the association of PH time interval distribution with mortality. METHODS: Patients transported by emergency medical services in the Pennsylvania trauma registry from 2000 to 2013 with a total PH time (TPT) of 20 minutes or longer were included. TPT was divided into three PH time intervals: response, scene, and transport time. The number of minutes in each PH time interval was divided by TPT to determine the relative proportion each interval contributed to TPT. A prolonged interval was defined as any one PH interval contributing equal to or greater than 50% of TPT. Patients were classified by prolonged PH interval or no prolonged PH interval (all intervals < 50% of TPT). Patients were matched for TPT, and conditional logistic regression determined the association of mortality with PH time pattern, controlling for confounders. PH interventions were explored as potential mediators, and PH triage criteria used identify patients with time-sensitive injuries. RESULTS: There were 164,471 patients included. Patients with prolonged scene time had increased odds of mortality (odds ratio, 1.21; 95% confidence interval, 1.02-1.44; p = 0.03). Prolonged response, transport, and no prolonged interval were not associated with mortality. When adjusting for mediators including extrication and PH intubation, prolonged scene time was no longer associated with mortality (odds ratio, 1.06; 95% confidence interval, 0.90-1.25; p = 0.50). Together, these factors mediated 61% of the effect between prolonged scene time and mortality. Mortality remained associated with prolonged scene time in patients with hypotension, penetrating injury, and flail chest. CONCLUSION: Prolonged scene time is associated with increased mortality. PH interventions partially mediate this association. Further study should evaluate whether these interventions drive increased mortality because they prolong scene time or by another mechanism, as reducing scene time may be a target for intervention. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Development and Validation of the Air Medical Prehospital Triage Score for Helicopter Transport of Trauma Patients.

OBJECTIVE: The aim of this study was to develop and internally validate a triage score that can identify trauma patients at the scene who would potentially benefit from helicopter emergency medical services (HEMS). SUMMARY BACKGROUND DATA: Although survival benefits have been shown at the population level, identification of patients most likely to benefit from HEMS transport is imperative to justify the risks and cost of this intervention. METHODS: Retrospective cohort study of subjects undergoing scene HEMS or ground emergency medical services (GEMS) in the National Trauma Databank (2007-2012). Data were split into training and validation sets. Subjects were grouped by triage criteria in the training set and regression used to determine which criteria had a survival benefit associated with HEMS. Points were assigned to these criteria to develop the Air Medical Prehospital Triage (AMPT) score. The score was applied in the validation set to determine whether subjects triaged to HEMS had a survival benefit when actually transported by helicopter. RESULTS: There were 2,086,137 subjects included. Criteria identified for inclusion in the AMPT score included GCS <14, respiratory rate <10 or >29, flail chest, hemo/pneumothorax, paralysis, and multisystem trauma. The optimal cutoff for triage to HEMS was ≥2 points. In subjects triaged to HEMS, actual transport by HEMS was associated with an increased odds of survival (AOR 1.28; 95% confidence interval [CI] 1.21-1.36, P < 0.01). In subjects triaged to GEMS, actual transport mode was not associated with survival (AOR 1.04; 95% CI 0.97-1.11, P = 0.20). CONCLUSIONS: The AMPT score identifies patients with improved survival following HEMS transport and should be considered in air medical triage protocols.

Helicopter transport improves survival following injury in the absence of a time-saving advantage.

BACKGROUND: Although survival benefits have been shown at the population level, it remains unclear what drives the outcome benefits for helicopter emergency medical services (HEMS) in trauma. Although speed is often cited as the vital factor of HEMS, we hypothesized a survival benefit would exist in the absence of a time savings over ground emergency medical services (GEMS). The objective was to examine the association of survival with HEMS compared with GEMS transport across similar prehospital transport times. METHODS: We used a retrospective cohort of scene HEMS and GEMS transports in the National Trauma Databank (2007-2012). Propensity score matching was used to match HEMS and GEMS subjects on the likelihood of HEMS transport. Subjects were stratified by prehospital transport times in 5-minute increments. Conditional logistic regression determined the association of HEMS with survival across prehospital transport times strata controlling for confounders. Transport distance was estimated from prehospital transport times and average HEMS/GEMS transport speeds. RESULTS: There were 155,691 HEMS/GEMS pairs matched. HEMS had a survival benefit over GEMS for prehospital transport times between 6 and 30 minutes. This benefit ranged from a 46% increase in odds of survival between 26 and 30 minutes (adjusted odds ratio [AOR], 1.46; 95% CI, 1.11-1.93; P < .01) to an 80% increase in odds of survival between 16 and 20 minutes (AOR, 1.80; 95% CI, 1.51-2.14; P < .01). This prehospital transport times window corresponds to estimated transport distance between 14.3 and 71.3 miles for HEMS and 3.3 and 16.6 miles for GEMS. CONCLUSION: When stratified by prehospital transport times, HEMS had a survival benefit concentrated in a window between 6 and 30 minutes. Because there was no time-savings advantage for HEMS, these findings may reflect care delivered by HEMS providers.

Geographic Variation in Outcome Benefits of Helicopter Transport for Trauma in the United States: A Retrospective Cohort Study.

OBJECTIVE: Evaluate the effect of US geographic region on outcomes of helicopter transport (HT) for trauma. BACKGROUND: HT is an integral component of trauma systems. Evidence suggests that HT is associated with improved outcomes; however, no studies examine the impact of geographic variation on outcomes for HT. METHODS: Retrospective cohort study of patients undergoing scene HT or ground transport in the National Trauma Databank (2009-2012). Subjects were divided by US census region. HT and ground transport subjects were propensity-score matched based on prehospital physiology and injury severity. Conditional logistic regression was used to evaluate the effect of HT on survival and discharge to home in each region. Region-level characteristics were assessed as potential explanatory factors. RESULTS: A total of 193,629 pairs were matched. HT was associated with increased odds of survival and discharge to home; however, the magnitude of these effects varied significantly across regions (P < 0.01). The South had the greatest survival benefit (odds ratio: 1.44; 95% confidence interval: 1.39-1.49, P < 0.01) and the Northeast had the greatest discharge to home benefit (odds ratio: 1.29; 95% confidence interval: 1.18-1.41, P < 0.01). A subset of region-level characteristics influenced the effect of HT on each outcome, including helicopter utilization, injury severity, trauma center and helicopter distribution, trauma center access, traffic congestion, and urbanicity (P < 0.05). CONCLUSIONS: Geographic region impacts the benefits of HT in trauma. Variations in resource allocation partially account for outcome differences. Policy makers should consider regional factors to better assess and allocate resources within trauma systems to optimize the role of HT.

Emergency preservation and resuscitation for cardiac arrest from trauma.

The advent of cardiopulmonary resuscitation (CPR) revolutionized the care of patients with cardiac arrest, now allowing survival of up to 30% after out-of-hospital arrest due to arrhythmia; however, outcomes for cardiac arrest after trauma remain dismal, with less than 10% survival despite the most aggressive modern resuscitation techniques. The short time interval between cardiac arrest and brain ischemia, the reduced efficacy of CPR in the patient with profound hypovolemia due to hemorrhage, and the speed of exsanguination from major vascular injury all conspire to limit the effectiveness of standard CPR in the critically injured patient. Beginning in the 1980s, researchers began to harness the effects of profound hypothermia in order to extend the window of survivability after traumatic arrest, allowing the critical time needed to obtain surgical hemostasis in otherwise lethal exsanguinating injuries. These studies have culminated in the emergency preservation and resuscitation (EPR) of the trauma patient. Rapid central arterial access is obtained and profound (<10 °C) hypothermia induced with aortic infusion of cold saline. During this window of up to 1 h, damage control surgical techniques are applied to control hemorrhage and repair injuries, followed by controlled rewarming and reperfusion using cardiopulmonary bypass. In this review, we trace these techniques from their early theoretical development, through refinement in clinically relevant animal models, and into their present application in a currently-enrolling human clinical trial of EPR for cardiac arrest from trauma (EPR-CAT), as well as examine current topics, ongoing challenges, and future directions for emergency preservation and resuscitation research.