Can the 5-item Modified Frailty Index Predict Outcomes in Geriatric Trauma? A National Database Study.

BACKGROUND: Frailty results in increased vulnerability to adverse outcomes following trauma. We investigated the association between the 5-item modified frailty index (mFI-5) and outcomes in geriatric trauma patients. METHODS: The 2011-2016 Trauma Quality Improvement Program database was used to study outcomes in patients ≥ 65 years old. The mFI-5 was measured and categorized into no frailty (mFI-5 = 0), moderate frailty (mFI-5 = 0.2), and severe frailty (mFI-5 ≥ 0.4). Multivariable logistic regression analyses were performed to identify independent factors of mortality and complications. RESULTS: 26,963 cases met the inclusion criteria, of whom 25.5% were not frail, 38% were moderately frail, and 36.6% were severely frail. Mean age (± SD) was 76 ± 7 years, 61.5% were male, and 97.8% sustained blunt injuries. Median Injury Severity Score (ISS) was 17 (IQR = 10-26), and the median Glasgow Coma Scale was 15 (IQR = 12-15). Overall mortality was 30.6%. Factors independently associated with mortality were age (OR = 1.07 per year, 95%CI 1.06-1.07), blunt trauma (OR = 1.44, 95%CI 1.19 -1.75), ISS (OR = 1.04 per unit increase in ISS, 95%CI 1.03-1.04), and severe frailty (OR = 1.23, 95%CI 1.15-1.32). Interestingly, male sex and GCS appeared to be protective factors with OR of 0.88 (95%CI 0.83 - 0.93) and 0.89 per point change in GCS (95%CI 0.88-0.9), respectively. Moderate (OR = 1.27, 95%CI 1.19-1.25) and severe frailty (OR = 1.49, 95%CI 1.-1.59) were significantly associated with in-hospital complications. CONCLUSION: Moderate and severe frailty were significant predictors of complications. Only severe frailty was associated with short-term mortality. The mFI-5 can be used as an objective measure to stratify risks in geriatric trauma.

The American Association for the Surgery of Trauma (AAST) Liver Injury Grade Does Not Equally Predict Interventions in Blunt and Penetrating Trauma.

INTRODUCTION: The AAST liver injury grade has a validated association with mortality and need for operation. AAST liver injury grade is the same regardless of the mechanism of trauma. METHODS: A 5-year retrospective review of all liver injuries at an urban, level-one trauma center was performed. RESULTS: Totally, 315 patients were included (29% blunt, 71% penetrating). In blunt trauma, AAST grade was associated with need for laparotomy (0%, 7%, 5%, 33%, 29%, Grade 1-5, p = 0.01), angiography (0%, 7%, 25%, 40%, 57%, p < 0.001), embolization (0%, 7%, 15%, 33%, 43%, p = 0.01), and percutaneous drainage procedures (13% use in Grade 4, otherwise 0%, p = 0.04), but not ERCP (0% for all grades). In penetrating trauma, AAST grade was associated with need for angiography (7%, 4%, 15%, 24%, 30%, p < 0.01) and percutaneous drainage (7%, 2%, 14%, 18%, 26%, p = 0.03) and had a marginal association with embolization (0%, 4%, 11%, 13%, 22%, p = 0.06). Laparotomy, ERCP, sphincterotomy, and stenting rates increased with AAST grade, but this was not statistically significant. CONCLUSION: AAST grade is associated with the need for surgical hemostasis, angioembolization, and percutaneous drainage in both penetrating and blunt trauma. Operative, endoscopic, and percutaneous procedures are utilized more in penetrating trauma. Angioembolization was used more in blunt trauma. Mechanism should be considered when using AAST grade to guide management of liver injuries.

The American Association for the Surgery of Trauma Organ Injury Scale is Associated With Cystoscopic and Percutaneous Urologic Procedures in Renal Injuries.

BACKGROUND: The American Association for the Surgery of Trauma Organ Injury Scale for the kidney was created in 1989. It has been validated to various outcomes including operations. It was updated in 2018 to better predict endourologic interventions, but this change has not been validated. In addition, the AAST-OIS does not consider mechanism of trauma in its interpretation. METHODS: We analyzed 3 years of the Trauma Quality Improvement Program database including all patients with a kidney injury. We recorded rates of mortality, operation, renal operation, nephrectomy, renal embolization, cystoscopic intervention, and percutaneous urologic procedures. RESULTS: 26294 patients were included. In penetrating trauma, mortality, operation, renal-specific operation, and nephrectomy rates increased at every grade. Renal embolization and cystoscopy rates peaked in grade IV. Percutaneous interventions were rare across all grades. In blunt trauma, mortality and nephrectomy rates increased only in grades IV and V. Operation, renal operation, and renal embolization rates increased at every grade level. Cystoscopy rates peaked in grade IV. Percutaneous procedure rates only increased between grades III and IV. Penetrating injuries are more likely to require nephrectomy in grades III-V, cystoscopic procedures in grade III, and percutaneous procedures in grades I-III. DISCUSSION: Endourologic procedures are most utilized in grade IV injuries, which are in part defined by injuries with damage to the central collecting system. Despite penetrating injuries more frequently requiring nephrectomy, they also more frequently require nonsurgical procedures. Mechanism of trauma should be considered when interpreting the AAST-OIS for kidney injuries.

The American Association for the Surgery of Trauma Organ Injury Scale for Spleen Does Not Equally Predict Interventions in Penetrating and Blunt Trauma.

BACKGROUND: The American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) for the spleen (and other organs) was created in 1989. It has been validated to predict mortality, need for operation, length of stay (LOS), and intensive care unit (ICU) LOS. PURPOSE: We aimed to determine if the Spleen OIS is applied equally to blunt and penetrating trauma. RESEARCH DESIGN/STUDY SAMPLE: We analyzed the Trauma Quality Improvement Program (TQIP) database from 2017-2019, including patients with spleen injuries. DATA COLLECTION: Outcomes included the rates of mortality, operation, spleen-specific operation, splenectomy, and splenic embolization. RESULTS: 60900 patients had a spleen injury with an OIS grade. Mortality rates increased in Grades IV and V for both blunt and penetrating trauma. In blunt trauma, the odds for any operation, spleen-specific operation, and splenectomy increased, for each increase in grade. Penetrating trauma showed similar trends in grades up to grade IV, but were statistically similar between grade IV and V. Splenectomy was higher in penetrating trauma for all grades. Splenic embolization peaked at 25% of grade IV trauma before decreasing in grade V. Rates in penetrating trauma were significantly lower in all grades, peaking at 2.5% of Grade III injuries. CONCLUSIONS: The mechanism of trauma is a significant factor for all outcomes, independent of AAST-OIS. Hemostasis is predominantly surgical in penetrating trauma, achieved with angioembolization more frequently in blunt trauma. Penetrating trauma management is influenced by the potential for injury to peri-splenic organs.

Initial Assessment of a Regional Military-Civilian Partnership on Trauma Surgery Skills Sustainment.

INTRODUCTION: Trauma surgery skills sustainment and maintenance of combat readiness present a major problem for military general surgeons. The Military Health System (MHS) utilizes the knowledge, skills, and abilities (KSA) threshold score of 14,000 as a measure of annual deployment readiness. Only 9% of military surgeons meet this threshold. Most military-civilian partnerships (MCPs) utilize just-in-time training models before deployment rather than clinical experiences in trauma at regular intervals (skills sustainment model). Our aim is to evaluate an established skills sustainment MCP utilizing KSAs and established military metrics. MATERIALS AND METHODS: Three U.S. Navy active duty general surgeons were embedded into an urban level-1 trauma center taking supervised trauma call at regular intervals prior to deployment. Operative density (procedures/call), KSA scores, trauma resuscitation exposure, and combat casualty care relevant cases (CCC-RCs) were reviewed. RESULTS: During call shifts with a Navy surgeon present an average 16.4 trauma activations occurred; 32.1% were category-1, 27.6% were penetrating, 72.4% were blunt, and 33.8% were admitted to the intensive care unit. Over 24 call shifts of 24 hours in length, 3 surgeons performed 39 operative trauma cases (operative density of 1.625), generating 11,683 total KSA points. Surgeons 1, 2, and 3 generated 5109, 3167, and 3407 KSA points, respectively. The three surgeons produced a total of 11,683 KSA points, yielding an average of 3,894 KSA points/surgeon. In total, 64.1% of operations fulfilled CCC-RC criteria. CONCLUSIONS: Based on this initial evaluation, a military surgeon taking two calls/month over 12 months through our regional skills sustainment MCP can generate more than 80% of the KSA points required to meet the MHS KSA threshold for deployment readiness, with the majority being CCC-RCs. Intangible advantages of this model include exposure to multiple trauma resuscitations while possibly eliminating just-in-time training and decreasing pre-deployment requirements.

"HYPER-EARLY" Tracheostomy within 48 hours has less Complications and Better Prognosis Compared to Traditional Tracheostomy.

INTRODUCTION: Tracheostomies may be performed "early" or "late." There is no agreement on the best timing for tracheostomy. This study compares tracheostomies and complications when performed within 48 hours with those performed from 48 hours to 21 days. METHODS: Patients who underwent tracheostomy in the 2017-2018 National Trauma Data Bank (NTDB) were categorized into 2 groups: early tracheostomy (≤48 hours) and late tracheostomy (>48 hours to 21 days). Primary outcome measured was mortality. Chi square models, Mann-Whitney U Test, and multivariate logistics were used for data analysis. RESULTS: 843 patients had tracheostomy performed, of which 16% underwent early tracheostomy. Majority were male in both early (84%) and late (74%) tracheostomy groups. Mortality was not statically significant in early (13%) or late (9%) (P = .151). Total duration of ventilation in early tracheostomy group was less (5 days) compared to late tracheostomy group (16 days, P < .001). Patients with late tracheostomy had almost 18% cases of ventilator-associated pneumonia (VAP) when compared to early tracheostomy patients (7%, P < .001). Early tracheostomy patients also had shorter hospital length of stay (HLOS) (13 vs 27 days) and intensive care unit (ICU) length of stay (LOS) (7 vs 20 days) than late tracheostomy patients (P<.001). Early tracheostomy patients also had shorter hospital length of stay (HLOS) (13 vs 27 days) and intensive care unit (ICU) length of stay (LOS) (7 vs 20 days) than late tracheostomy patients (P < .001). CONCLUSION: Tracheostomy performed as early as 48 hours is beneficial as it demonstrates a decrease time on ventilator, decreased HLOS, as well as lower VAP rates. Our data shows "hyper-early" tracheostomies might be more beneficial that the current national practice.

Maternal Outcomes After Trauma in Pregnancy: A National Database Study.

OBJECTIVES: Trauma is an important non-obstetric cause of mortality in pregnant females. METHODS: The National Trauma Databank (NTDB) was queried between 2017 and 2018. Pregnant women >20 weeks gestation, who underwent trauma, were included. They were categorized into different age groups from 12-18, 18-35, and 36-50 years of age. The primary outcome measure was 30-day mortality. RESULTS: 1,058 pregnant trauma patients were included. Mean age was 26.7 ± 6 years. Of those 94.5% had blunt and 3.8% had penetrating injuries. Median GCS and ISS were 15 (15, 15) and 2 (1, 5), respectively. Penetrating trauma patients required more operative intervention (57.5%) than blunt trauma patients (24.6%). Univariate analysis comparing age groups 12-18, 19-35, and >36 years revealed differences. (P < .05) in ED systolic blood pressure (110.9 ± 19.7 vs 117.3 ± 20.3 vs 129.1 ± 29.3 mmHg, P = .01) and diabetes mellitus (.0 vs 2.7% vs 6.6% P = .03). There was no difference in HLOS (P = .72), complications (P = .279), and mortality (P = .32). Multivariate logistic regression analysis revealed that compared to patients 12-18 years old, patients 19 to 35 (P = .27) or those >36 (P = 1.0) did not show a significant difference in mortality. Patients with high ISS had higher complication rates (OR 1.09; 95% CI 1.04-1.15) and prolonged HLOS (OR 1.00; 95% CI 1.07-1.15). CONCLUSION: On average pregnant women (>20 weeks gestation) who presented to trauma centers had minor injuries and maternal age or mechanism of injury did not affect mortality. Despite a low ISS, a significant number of these patients required operative procedures.

Changes in trends during the COVID-19 lockdown: An urban, Level-1 trauma center's experience.

BACKGROUND: A community lockdown has a profound impact on its citizens. Our objective was to identify changes in trauma patient demographics, volume, and pattern of injury following the COVID-19 lockdown. METHODS: A retrospective review was conducted at a Level-1 Trauma Center from 2017 to 2020. RESULTS: A downward trend in volume is seen December-April in 2020 (R2 = 0.9907). February through April showed an upward trend in 2018 and 2019 (R2= 0.80 and R2 = 0.90 respectively), but a downward trend in 2020 (R2 = 0.97). In April 2020, there was 41.6% decrease in total volume, a 47.4% decrease in blunt injury and no decrease in penetrating injury. In contrast to previous months, in April the majority of injuries occurred in home zip codes. CONCLUSIONS: A community lockdown decreased the number of blunt trauma, however despite social distancing, did not decrease penetrating injury. Injuries were more likely to occur in home zip codes.

Severe burn injury: Body Mass Index and the Baux score.

OBJECTIVE: The revised Baux score (age total body surface area (TBSA) burned and inhalation injury)) is predictive of mortality in burn patients. Our study objective was to assess whether the addition of body mass index (BMI) to the revised Baux score would be of value. We posited that increasing BMI follows a pattern similar to age and TBSA in the revised Baux score after severe burn injury. METHODS: Patient data from the burn registry was queried for patients admitted between 1/1/2013 to 8/31/2019. Patients 12 years or older with a TBSA of 20% or greater burn were included. Inpatient outcomes were analyzed based on BMI. RESULTS: 56 of 1365 patients met inclusion criteria. Mean age of the study population was 48.25 years and 64.3% of patients were male. Median BMI was 25.8 and median TBSA was 26.5. Inhalation injury was present in 44.6% (25/56) of patients. Median hospital length of stay (LOS) and ICU LOS were 21.5 and 17 days respectively. On bivariate analysis, non-survivors had higher TBSA (41.5% vs 25.5%, p = 0.034), more inhalation injury (83.3%, 10/12 vs 34.8%, 15/43 p = 0.003) and higher complication rates (91.6%, 11/12 vs 59.1 %, 25/43, p = 0.043). Survivors also had higher BMI (28.2 vs 23, p = 0.003) and increased hospital LOS (24 vs 5.5, p = 0.003). Automatic model fit in binary logistic regression showed a negative relationship between BMI and mortality. CONCLUSION: We found a negative relationship between BMI and mortality. Pre-obesity appears to have a protective role, but BMI was not found to be a useful addition to the revised Baux score. Larger sample sizes may be of benefit a for a for a more definitive understanding of the role of BMI with regards to burn survival.

Heroes in crisis: Trauma centers should be screening for and intervening on posttraumatic stress in our emergency responders.

BACKGROUND: Emergency responders face a crisis of rising suicide rates, and many resist seeking help due to the stigma surrounding mental health. We sought to evaluate the feasibility of an urban trauma center to screen for posttraumatic stress (PTS) among emergency responders and to provide mental health services. METHODS: Paramedics, firefighters, law enforcement, and corrections officers involved with patients in the trauma unit were asked to complete the Post-Traumatic Growth Inventory (PTGI) and Post-Traumatic Checklist for Diagnostic and Statistical Manual-5 (PCL-5). Additional factors known to affect PTS were correlated: occupation, age, sex, years of service, marital status, children, and pets. Willingness and barriers to seeking interventions for PTS were evaluated. RESULTS: A total of 258 responded: 36.7% paramedics, 40.2% law enforcement officers, 18.4% corrections officers, 0.8% firefighters, and 3.5% with multiple positions. Responders had a mean of 14.5 years of service (SD, 9.9 years). Mean PTGI and PCL-5 scores were 52.1 (SD, 25.1) and 17.2 (SD, 16.5), respectively. Overall, 24.7% had diagnostic PTS disorder with no difference seen in rates between professions. Of these, 80.7% had not sought care. Barriers included that they were not concerned (46%), did not recognize symptoms (24%), and were worried about consequences (20%). Concern over career advancement or losing one's job was the greatest barrier cited for seeking care. Among law enforcement, 47.7% were concerned that they would lose their ability to carry a firearm if they sought care for PTS. The PTGI score, divorce, and 46 years to 50 years were the only factors examined that correlated with increased PCL-5 score. There were 82.5% that felt the trauma center was the right place to screen and intervene upon PTS. CONCLUSION: Trauma centers are an ideal and safe place to both screen for PTS and offer mental health assistance. Comprehensive trauma-informed care by hospital-based intervention programs must expand to include emergency responders. LEVEL OF EVIDENCE: Epidemiological study type, Level II.

The scales of recovery: Balancing posttraumatic stress with resilience in the violently injured.

BACKGROUND: Community violence remains a clinical concern for urban hospitals nationwide; however, research on resilience and posttraumatic growth (PTG) among survivors of violent injury is lacking. This study intends to assess survivors of violent injury for resilience and PTG to better inform mental health interventions. METHODS: Adults who presented with nonaccidental penetrating trauma to an urban level 1 trauma center and were at least 1 month, but no more than 12 months, from treatment were eligible. Participants completed the Connor-Davidson Resiliency Scale, Posttraumatic Growth Inventory (PTGI), Primary Care Posttraumatic Stress Disorder screen, and a community violence exposure screen. Additional demographic, injury, and treatment factors were collected from medical record. RESULTS: A total of 88 patients participated. The mean resiliency score was 83.2, with 71.1% scoring higher than the general population and 96.4% scoring higher than the reported scores of those seeking treatment for posttraumatic stress disorder (PTSD). Participants demonstrated a mean PTGI score of 78 (SD, 20.4) with 92.4% scoring above the significant growth threshold of 45. In addition, 60.5% of patients screened positive for significant PTSD symptoms, approximately eight times higher than general population. Exposure to other traumatic events was high; an overwhelming 94% of participants stated that they have had a family member or a close friend killed, and 42% had personally witnessed a homicide. Higher resilience scores correlated with PTGI scores (p < 0.001) and lower PTSD screen (p = 0.02). CONCLUSION: Victims of violent injury experience a myriad of traumatic events yet are highly resilient and exhibit traits of growth across multiple domains. Resiliency can coexist with posttraumatic stress symptoms. Practitioners should assess for resiliency and PTG in addition to PTSD. Further investigation is needed to clarify the relational balance between resilience and posttraumatic stress. LEVEL OF EVIDENCE: Epidemiological study type, Level II.

CT should replace three-view radiographs as the initial screening test in patients at high, moderate, and low risk for blunt cervical spine injury: a prospective comparison.

BACKGROUND: An estimated 10,000 Americans suffer cervical spine injuries each year. More than 800,000 cervical spine radiographs (CSR) are ordered annually. The human and healthcare costs associated with these injuries are enormous especially when diagnosis is delayed. Controversy exists in the literature concerning the diagnostic accuracy of CSR, with reported sensitivity ranging from 32% to 89%. We sought to compare prospectively the sensitivity of cervical CT (CCT) to CSR in the initial diagnosis of blunt cervical spine injury for patients meeting one or more of the NEXUS criteria. METHODS: The study prospectively compared the diagnostic accuracy of CSR to CCT in consecutive patients evaluated for blunt trauma during 23 months at an urban, public teaching hospital and Level I Trauma Center. Inclusion criteria were adult patient, evaluated for blunt cervical spine injury, meeting one or more of the NEXUS criteria. All patients received both three-view CSR and CCT as part of a standard diagnostic protocol. Each CSR and CCT study was interpreted independently by a different radiology attending who was blinded to the results of the other study. Clinically significant injuries were defined as those requiring one or more of the following interventions: operative procedure, halo application, and/or rigid cervical collar. RESULTS: Of 1,583 consecutive patients evaluated for blunt cervical spine trauma, 78 (4.9%) patients received only CCT or CSR and were excluded from the study. Of the remaining 1,505 patients, 78 (4.9%) had evidence of a radiographic injury by CSR or CCT. Of these 78 patients with radiographic injury, 50 (3.3%) patients had clinically significant injuries. CCT detected all patients with clinically significant injuries (100% sensitive), whereas CSR detected only 18 (36% sensitive). Of the 50 patients, 15 were at high risk, 19 at moderate risk, and 16 at low risk for cervical spine injury according to previously published risk stratification. CSR detected clinically significant injury in 7 high risk (46% sensitive), 7 moderate risk (37% sensitive), and 4 low risk patients (25% sensitive). CONCLUSION: Our results demonstrate the superiority of CCT compared with CSR for the detection of clinically significant cervical spine injury. The improved ability to exclude injury rapidly provides further evidence that CCT should replace CSR for the initial evaluation of blunt cervical spine injury in patients at any risk for injury.

Missing expectations: Windlass tourniquet use without formal training yields poor results.

BACKGROUND: Despite significant attempts to educate civilians in hemorrhage control, the majority remain untrained. We sought to determine if laypersons can successfully apply one of three commercially available tourniquets; including those endorsed by the United States Military and the American College of Surgeons. METHODS: Preclinical graduate health science students were randomly assigned a commercially available windless tourniquet: SAM XT, Combat Application Tourniquet (CAT), or Special Operation Forces Tactical Tourniquet (SOFT-T). Each was given up to 1 minute to read package instructions and asked to apply it to the HapMed Leg Tourniquet Trainer. Estimated blood loss was measured until successful hemostatic pressure was achieved or simulated death occurred from exsanguination. Simulation survival, time to read instructions and stop bleeding, tourniquet pressure, and blood loss were analyzed. RESULTS: Of the 150 students recruited, 55, 46, and 49 were randomized to the SAM XT, CAT, SOFT-T, respectively. Mean overall simulation survival was less than 66% (65%, 72%, 61%; p = 0.55). Of survivors, all three tourniquets performed similarly in median pressure applied (319, 315, and 329 mm Hg; p = 0.54) and median time to stop bleeding (91, 70, 77 seconds; p = 0.28). There was a statistical difference in median blood loss volume favoring SOFT-T (SAM XT, 686 mL; CAT, 624 mL; SOFT-T, 433 mL; p = 0.03). All 16 participants with previous experience were able to successfully place the tourniquet compared with 81 (62%) of 131 first-time users (p = 0.008). CONCLUSION: No one should die of extremity hemorrhage, and civilians are our first line of defense. We demonstrate that when an untrained layperson is handed a commonly accepted tourniquet, failure is unacceptably high. Current devices are not intuitive and require training beyond the enclosed instructions. Plans to further evaluate this cohort after formal "Stop the Bleed" training are underway.

Right hospital, right patients: Penetrating injury patients treated at high-volume penetrating trauma centers have lower mortality.

BACKGROUND: The recognition of the relationship between volume and outcomes led to the regionalization of trauma care. The relationship between trauma mechanism-subtype and outcomes has yet to be explored. We hypothesized that trauma centers with a high volume of penetrating trauma patients might be associated with a higher survival rate for penetrating trauma patients. METHODS: A retrospective cohort analysis of penetrating trauma patients presenting between 2011 and 2015 was conducted using the National Trauma Database and the trauma registry at the Stroger Cook County Hospital. Linear regression was used to determine the relationship between mortality and the annual volume of penetrating trauma seen by the treating hospital. RESULTS: Nationally, penetrating injuries account for 9.5% of the trauma cases treated. Patients treated within the top quartile penetrating-volume hospitals (≥167 penetrating cases per annum) are more severely injured (Injury Severity Score: 8.9 vs. 7.7) than those treated at the lowest quartile penetrating volume centers (<36.6 patients per annum). There was a lower mortality rate at institutions that treated high numbers of penetrating trauma patients per annum. A penetrating trauma mortality risk adjustment model showed that the volume of penetrating trauma patients was an independent factor associated with survival rate. CONCLUSION: Trauma centers with high penetrating trauma patient volumes are associated with improved survival of these patients. This association with improved survival does not hold true for the total trauma volume at a center but is specific to the volume of the penetrating trauma subtype. LEVEL OF EVIDENCE: Prognostic/Epidemiology Study, Level-III; Therapeutic/Care Management, Level IV.

Taser X26 discharges in swine: ventricular rhythm capture is dependent on discharge vector.

BACKGROUND: Data from our previous studies indicate that Taser X26 stun devices can acutely alter cardiac function in swine. We hypothesized that most transcardiac discharge vectors would capture ventricular rhythm, but that other vectors, not traversing the heart, would fail to capture the ventricular rhythm. METHODS: Using an Institutional Animal Care and Use Committee (IACUC) approved protocol, four Yorkshire pigs (25-36 kg) were anesthetized, paralyzed with succinylcholine (2 mg/kg), and then exposed to 10 second discharges from a police-issue Taser X26. For most discharges, the barbed darts were pushed manually into the skin to their full depth (12 mm) and were arranged in either transcardiac (such that a straight line connecting the darts would cross the region of the heart) or non-transcardiac vectors. A total of 11 different vectors and 22 discharge conditions were studied. For each vector, by simply rotating the cartridge 180-degrees in the gun, the primary current-emitting dart was changed and the direction of current flow during the discharge was reversed without physically moving the darts. Echocardiography and electrocardiograms (ECGs) were performed before, during, and after all discharges. p values < 0.05 were considered significant. RESULTS: ECGs were unreadable during the discharges because of electrical interference, but echocardiography images clearly demonstrated that ventricular rhythm was captured immediately in 52.5% (31 of 59) of the discharges on the ventral surface of the animal. In each of these cases, capture of the ventricular rhythm with rapid ventricular contractions consistent with ventricular tachycardia (VT) or flutter was seen throughout the discharge. A total of 27 discharges were administered with transcardiac vectors and ventricular capture occurred in 23 of these discharges (85.2% capture rate). A total of 32 non-transcardiac discharges were administered ventrally and capture was seen in only eight of these (25% capture rate). Ventricular fibrillation (VF) was seen with two vectors, both of which were transcardiac. In the remaining animals, VT occurred postdischarge until sinus rhythm was regained spontaneously. CONCLUSIONS: For most transcardiac vectors, Taser X26 caused immediate ventricular rhythm capture. This usually reverted spontaneously to sinus rhythm but potentially fatal VF was seen with two vectors. For some non-transcardiac vectors, capture was also seen but with a significantly (p < 0.0001) decreased incidence.

Placenta to the Rescue: Limb Salvage Using Dehydrated Human Amnion/Chorion Membrane.

Reconstruction of skin and soft tissue wounds can pose a unique surgical challenge. This is especially true for cases of exposed bone and tendon where soft tissue loss is extensive and opportunities for tissue advancement or rotation are limited. A clinical case is presented describing an experience with dehydrated human amnion/chorion membrane (dHACM, EpiFix®/AmnioFix®, MiMedx Group, Marietta, GA) graft to obtain granulation over an open fracture with desiccated bone. The 22-year-old female trauma patient presented with high-grade bilateral lower extremity soft tissue loss after being run over and dragged by a semitruck. Despite several weeks of serial debridemonts, the right distal fibula and left medial femur remained desiccated and infected. Both extremities had cavernous tissue landscapes with minimal granulation tissue and neither was hospitable for split thickness skin grafting. Four separate applications of dHACM (combination of EpiFix® and AmnioFix®) to the affected areas of exposed bone were successful at stimulating a robust granulation bed. On hospital days 44 and 61, the wounds were successfully skin grafted. The authors suspect that the dHACM applications contributed to successful granulation coverage to the affected bones that were otherwise not amendable to other coverage options. This contributed to limb salvage and a successful outcome.

Does Pain Have a Role When It Comes to Tourniquet Training?

BACKGROUND: One of the greatest conundrums with tourniquet (TQ) education is the use of an appropriate surrogate of hemorrhage in the training setting to determine whether a TQ has been successfully used. At our facility, we currently use loss of audible Doppler signal or loss of palpable pulse to represent adequate occlusion of vasculature and thus successful TQ application. We set out to determine whether pain can be used to indicate successful TQ application in the training setting. METHODS: Three tourniquet systems (a pneumatic tourniquet, Combat Application Tourniquet® [C-A-T], and Stretch Wrap and Tuck Tourniquet™ [SWAT-T]) were used to occlude the arterial vasculature of the left upper arm (LUA), right upper arm (RUA), left forearm (LFA), right forearm (RFA), right thigh (RTH), and right calf (RCA) of 41 volunteers. A 4MHz, handheld Doppler ultrasound was used to confirm loss of Doppler signal (LOS) at the radial or posterior tibial artery to denote successful TQ application. Once successful placement of the TQ was noted, subjects rated their pain from 0 to 10 on the visual analog scale. In addition, the circumference of each limb, the pressure with the pneumatic TQ, number of twists with the C-A-T, and length of TQ used for the SWAT-T to obtain LOS was recorded. RESULTS: All 41 subjects had measurements at all anatomic sites with the pneumatic TQ, except one participant who was unable to complete the LUA. In total, pain was rated as 1 or less by 61% of subjects for LUA, 50% for LFA, 57.5% for RUA, 52.5% RFA, 15% for RTH, and 25% for RCA. Pain was rated 3 or 4 by 45% of subjects for RTH. For the C-A-T, data were collected from 40 participants. In total, pain was rated as 1 or less by 57.5% for the LUA, 70% for the LFA, 62.5% for the RUA, 75% for the RFA, 15% for the RTH, and 40% for the RCA. Pain was rated 3 or 4 by 42.5%. The SWAT-T group consisted of 37 participants for all anatomic locations. In total, pain was rated as 1 or less by 27% for LUA, 40.5% for the LFA, 27.0% for the RUA, 43.2 for the RFA, 18.9% for the RTH, and 16.2% for the RCA. Pain was rated 5 by 21.6% for RTH application, and 3 or 4 by 35%. CONCLUSION: The unexpected low pain values recorded when loss of signal was reached make the use of pain too sensitive as an indicator to confirm adequate occlusion of vasculature and, thus, successful TQ application.

The "TRAUMA LIFE" initiative: The impact of a multidisciplinary checklist process on outcomes and communication in a Trauma Intensive Care Unit.

BACKGROUND: Checklists have been advocated to improve quality outcomes/communication in the critical care setting, but results have been mixed. A new checklist process, "TRAUMA LIFE", was implemented in our Trauma Intensive Care Unit (TICU) to replace prior checklists. The purpose of this study was to evaluate the impact of the "TRAUMA LIFE" process implementation on quality metrics and on patient/family communication in the TICU. METHODS: "TRAUMA LIFE" was considered maturely implemented by 2016. Multiple quality metrics, including restraint order compliance, were compared between 2013 and 2016 (pre- and post-implementation). Compliance with the "Family Message" (FM), a part of the "TRAUMA LIFE" communication process, was analyzed in 2016. RESULTS: Improvement was seen in CAUTI, VAE, and IUCU; CLABSI rates increased. Restraint order compliance increased significantly. FM delivery compliance was inconsistent; improvement was noted in concordance between update content and FM documented in Electronic Medical Record. CONCLUSION: Implementation of "TRAUMA LIFE" was well integrated into the rounding process and was associated with some improvement in quality metrics and communication. Additional evaluation is required to assess sustainability.

Management of adult pancreatic injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Traumatic injury to the pancreas is rare but is associated with significant morbidity and mortality, including fistula, sepsis, and death. There are currently no practice management guidelines for the medical and surgical management of traumatic pancreatic injuries. The overall objective of this article is to provide evidence-based recommendations for the physician who is presented with traumatic injury to the pancreas. METHODS: The MEDLINE database using PubMed was searched to identify English language articles published from January 1965 to December 2014 regarding adult patients with pancreatic injuries. A systematic review of the literature was performed, and the Grading of Recommendations Assessment, Development and Evaluation framework was used to formulate evidence-based recommendations. RESULTS: Three hundred nineteen articles were identified. Of these, 52 articles underwent full text review, and 37 were selected for guideline construction. CONCLUSION: Patients with grade I/II injuries tend to have fewer complications; for these, we conditionally recommend nonoperative or nonresectional management. For grade III/IV injuries identified on computed tomography or at operation, we conditionally recommend pancreatic resection. We conditionally recommend against the routine use of octreotide for postoperative pancreatic fistula prophylaxis. No recommendations could be made regarding the following two topics: optimal surgical management of grade V injuries, and the need for routine splenectomy with distal pancreatectomy. LEVEL OF EVIDENCE: Systematic review, level III.