Fat emboli syndrome and the orthopaedic trauma surgeon: lessons learned and clinical recommendations.

PURPOSE: Fat emboli syndrome is a rare but well-described complication of long-bone fractures classically characterised by a triad of respiratory failure, mental status changes and petechial rash. In this paper, we present the case of a patient who sustained bilateral femoral fractures and subsequently developed FES. Our aim was to review and summarise the current literature regarding the pathophysiology and management of fat emboli syndrome (FES) and propose an algorithm for treating patients with bilateral femoral fractures to reduce the risk of FES. METHODS: A literature analysis was performed to determine implications in the clinical setting. RESULTS: Currently, there exists little high-quality evidence to guide the orthopaedic surgeon in identifying patients at highest risk of FES or in preventing FES in patients with multiple long-bone fractures. However, the literature does suggest that the risk is directly related to the volume of marrow displaced and inversely related to both the time to fracture stabilisation and the respiratory reserve of the patient. Based on these correlations, we propose an algorithm for treating patients with bilateral femoral fractures, taking into consideration haemodynamic and pulmonary stability. CONCLUSIONS: Our algorithm for managing bilateral femoral fractures prioritises early stabilisation with external fixation, staged intramedullary nailing and conversion to plate fixation if FES develops. This protocol is meant to be the basis of future investigations of optimal treatment strategies.

Recent developments in the assessment of the multiply injured trauma patient.

PURPOSE OF REVIEW: To provide an update on the recent developments and controversies in the assessment of the traumatically injured patient. RECENT FINDINGS: Recent literature suggests that: whole-body computed tomography (CT) is an effective strategy in more severely injured blunt trauma patients; 64-slice CT scanning now provides an effective noninvasive screening method for blunt cerebrovascular injury; the need for MRI imaging, in addition to CT, for the diagnosis of occult ligamentous injury of the cervical spine remains an unresolved controversy; point-of-care testing has made significant improvements in our ability to predict which patients will need a massive transfusion; and thromboelastography has enhanced our ability to tailor a hemostatic resuscitation more accurately. SUMMARY: The recent advances in the assessment of the multiply injured patient allow clinicians to more efficiently diagnose a patient's injuries and implement treatment in a more timely manner.

An Abdominal Seat Belt Sign is Associated With Similar Incidence of Hollow Viscus Injury but Increased In-Hospital Mortality in Older Adult Trauma Patients: A PCSA Multicenter Study.

BACKGROUND: The abdominal seat belt sign (SBS) is associated with an increased risk of hollow viscus injury (HVI). Older age is associated with worse outcomes in trauma patients. Thus, older trauma patients ≥65 years of age (OTPs) may be at an increased risk of HVI with abdominal SBS. Therefore, we hypothesized an increased incidence of HVI and mortality for OTPs vs younger trauma patients (YTPs) with abdominal SBS. STUDY DESIGN: This post hoc analysis of a multi-institutional, prospective, observational study (8/2020-10/2021) included patients >18 years old with an abdominal SBS who underwent abdominal computed tomography (CT) imaging. Older trauma patients were compared to YTPs (18-64 years old) with bivariate analyses. RESULTS: Of the 754 patients included in this study from nine level-1 trauma centers, there were 110 (14.6%) OTPs and 644 (85.4%) YTPs. Older trauma patients were older (mean 75.3 vs 35.8 years old, P < .01) and had a higher mean Injury Severity Score (10.8 vs 9.0, P = .02). However, YTPs had an increased abdominal abbreviated-injury scale score (2.01 vs 1.63, P = .02). On CT imaging, OTPs less commonly had intraabdominal free fluid (21.7% vs 11.9%, P = .02) despite a similar rate of abdominal soft tissue contusion (P > .05). Older trauma patients also had a statistically similar rate of HVI vs YTPs (5.5% vs 9.8%, P = .15). Despite this, OTPs had increased mortality (5.5% vs 1.1%, P < .01) and length of stay (LOS) (5.9 vs 4.9 days P < .01). CONCLUSION: Despite a similar rate of HVI, OTPs with an abdominal SBS had an increased rate of mortality and LOS. This suggests the need for heightened vigilance when caring for OTPs with abdominal SBS.

Thoracic irrigation for prevention of secondary intervention after thoracostomy tube drainage for hemothorax: A Western Trauma Association multi-center study.

BACKGROUND: Retained hemothorax (rHTX) requiring intervention occurs in up to 20% of patients who undergo chest tube (TT) placement for a hemothorax (HTX). Thoracic irrigation at the time of TT placement decreases the need for secondary intervention in this patient group but those findings are limited because of the single center design. A multi-center study was conducted to evaluate the effectiveness of thoracic irrigation. METHODS: A multi-center, prospective, observational study was conducted between June 2018 and July 2023. Eleven sites contributed patients. Patients were included if they had a TT placed for a HTX and were excluded if: age < 18 years, TT for pneumothorax, thoracotomy or VATS performed within 6 hours of TT, TT >24 hours after injury, TT removed <24 hours, or death within 48 hours. Thoracic irrigation was performed at the discretion of the attending. Each hemithorax was considered separately if bilateral HTX. The primary outcome was secondary intervention for HTX-related complications (rHTX, effusion, or empyema). Secondary intervention was defined as: TT placement, instillation of thrombolytics, VATS, or thoracotomy. Irrigated and non-irrigated hemithoraces were compared using a propensity weighted analysis with age, sex, mechanism of injury, Abbreviated Injury Scale (AIS) chest and TT size as predictors. RESULTS: 493 patients with 462 treated hemothoraces were included, 123 (25%) had thoracic irrigation at TT placement. There were no significant demographic differences between the cohorts. Fifty-seven secondary interventions were performed, 10 (8%) and 47 (13%) in the irrigated and non-irrigated groups, respectively (p = 0.015). Propensity weighted analysis demonstrated a reduction in secondary interventions in the irrigated cohort (Odds Ratio 0.56 (0.34-0.85); p = 0.005). CONCLUSION: This Western Trauma Association multi-center study demonstrates a benefit of thoracic irrigation at the time of TT placement for a HTX. Thoracic irrigation reduces the odds of a secondary intervention for rHTX-related complications by 44%. LEVEL OF EVIDENCE: Therapeutic Study, Level II.

Prevalence and Outcomes of High versus Low Ratio Plasma to Red Blood Cell Resuscitation in a Multi-Institutional Cohort of Severely Injured Children.

BACKGROUND: The benefit of targeting high ratio fresh frozen plasma (FFP):red blood cell (RBC) transfusion in pediatric trauma resuscitation is unclear as existing studies are limited to patients who retrospectively met criteria for massive transfusion. The purpose of this study is to evaluate the use of high ratio FFP:RBC transfusion and the association with outcomes in children presenting in shock. METHODS: A post-hoc analysis of a 24-institution prospective observational study (4/2018-9/2019) of injured children <18 years with elevated age-adjusted shock index was performed. Patients transfused within 24 hours were stratified into cohorts of low (<1:2) or high (>1:2) ratio FFP:RBC. Nonparametric Kruskal-Wallis and chi-square were used to compare characteristics and mortality. Competing risks analysis was used to compare extended (≥75th percentile) ventilator, intensive care, and hospital days while accounting for early deaths. RESULTS: Of 135 children with median (IQR) age 10 (5,14) years and weight 40 (20,64) kg, 85 (63%) received low ratio transfusion and 50 (37%) high ratio despite similar activation of institutional massive transfusion protocols (MTP; low-38%, high-46%, p = .34). Most patients sustained blunt injuries (70%). Median injury severity score was greater in high ratio patients (low-25, high-33, p = .01); however, hospital mortality was similar (low-24%, high-20%, p = .65) as was the risk of extended ventilator, ICU, and hospital days (all p > .05). CONCLUSION: Despite increased injury severity, patients who received a high ratio of FFP:RBC had comparable rates of mortality. These data suggest high ratio FFP:RBC resuscitation is not associated with worst outcomes in children who present in shock. MTP activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers. LEVEL OF EVIDENCE: Prospective cohort study, Level II.

Preinjury alcohol exposure attenuates the neuroinflammatory response to traumatic brain injury.

BACKGROUND: Traumatic brain injury (TBI) initiates a neuroinflammatory response that increases the risk of TBI-related mortality. Acute alcohol intoxication at the time of TBI is associated with improved survival. Ethanol is recognized as a systemic immunomodulator that may also impart neuroprotection. The effects of alcohol on TBI-induced neuroinflammation, however, are unknown. We hypothesized that ethanol treatment prior to TBI may provide neuroprotection by diminishing the neuroinflammatory response to injury. MATERIALS AND METHODS: Mice underwent gavage with ethanol (EtOH) or water (H2O) prior to TBI. Animals were subjected to blunt TBI or sham injury (Sham). Posttraumatic rapid righting reflex (RRR) and apnea times were assessed. Cerebral and serum samples were analyzed by ELISA for inflammatory cytokine levels. Serum neuron-specific enolase (NSE), a biomarker of injury severity, was also measured. RESULTS: Neurologic recovery from TBI was more rapid in H2O-treated mice compared with EtOH-treated mice. However, EtOH/TBI mice had a 4-fold increase in RRR time compared with EtOH/Sham, whereas H2O/TBI mice had a 15-fold increase in RRR time compared with H2O/Sham. Ethanol intoxication at the time of TBI significantly increased posttraumatic apnea time. Preinjury EtOH treatment was associated with reduced levels of proinflammatory cytokines IL-6, KC, MCP-1, and MIP-1α post TBI. NSE was significantly increased post injury in the H2O/TBI group compared with H2O/Sham but was not significantly reduced by EtOH pretreatment. CONCLUSIONS: Alcohol treatment prior to TBI reduces the local neuroinflammatory response to injury. The decreased neurologic and inflammatory impact of TBI in acutely intoxicated patients may be responsible for improved clinical outcomes.

Prehospital ETCO2 is predictive of death in intubated and non-intubated patients.

BACKGROUND: Prehospital identification of shock in trauma patients lacks accurate markers. Low end tidal carbon dioxide (ETCO2) correlates with mortality in intubated patients. The predictive value of ETCO2 obtained by nasal capnography cannula (NCC) is unknown. We hypothesized that prehospital ETCO2 values obtained by NCC and in-line ventilator circuit (ILVC) would be predictive of mortality. METHODS: This was a prospective, observational, multicenter study. ETCO2 values were collected by a NCC or through ILVC. AUROCs were compared with prehospital systolic blood pressure (SBP) and shock index (SI). The Youden index defined optimal cutoffs. RESULTS: Of 550 enrolled patients, 487 (88.5%) had ETCO2 measured through an NCC. Median age was 37 (27-52) years; 76.5% were male; median ISS was 13 (5-22). Mortality was 10.4%. Minimum prehospital ETCO2 significantly predicted mortality with an AUROC of 0.76 (CI 0.69-0.84; Youden index â€‹= â€‹22 â€‹mmHg), outperforming SBP with an AUROC of 0.68; (CI 0.62-0.74, p â€‹= â€‹0.04) and shock index with an AUROC of 0.67 (CI 0.59-0.74, p â€‹= â€‹0.03). CONCLUSION: Prehospital ETCO2 measured by non-invasive NCC or ILVC may be predictive of mortality in injured patients.

A proposed clinical coagulation score for research in trauma-induced coagulopathy.

BACKGROUND: Trauma-induced coagulopathy (TIC) has been the subject of intense study for greater than a century, and it is associated with high morbidity and mortality. The Trans-Agency Consortium for Trauma-Induced Coagulopathy, funded by the National Health Heart, Lung and Blood Institute, was tasked with developing a clinical TIC score, distinguishing between injury-induced bleeding from persistent bleeding due to TIC. We hypothesized that the Trans-Agency Consortium for Trauma-Induced Coagulopathy clinical TIC score would correlate with laboratory measures of coagulation, transfusion requirements, and mortality. METHODS: Trauma activation patients requiring a surgical procedure for hemostasis were scored in the operating room (OR) and in the first ICU day by the attending trauma surgeon. Conventional and viscoelastic (thrombelastography) coagulation assays, transfusion requirements, and mortality were correlated to the coagulation scores using the Cochran-Armitage trend test or linear regression for numerical variables. RESULTS: Increased OR TIC scores were significantly associated with abnormal conventional and viscoelastic measurements, including hyperfibrinolysis incidence, as well as with higher mortality and more frequent requirement for massive transfusion ( p < 0.0001 for all trends). Patients with OR TIC score greater than 3 were more than 31 times more likely to have an ICU TIC score greater than 3 (relative risk, 31.6; 95% confidence interval, 12.7-78.3; p < 0.0001). CONCLUSION: A clinically defined TIC score obtained in the OR reflected the requirement for massive transfusion and mortality in severely injured trauma patients and also correlated with abnormal coagulation assays. The OR TIC score should be validated in multicenter studies. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Anastomotic leak rates after repair of mesenteric bucket-handle injuries: A multi-center retrospective cohort study.

BACKGROUND: Primary aim was to assess the relative risk (RR) of anastomotic leak (AL) in intestinal bucket-handle (BH) compared to non-BH injury. METHODS: Multi-center study comparing AL in BH from blunt trauma 2010-2021 compared to non-BH intestinal injuries. RR was calculated for small bowel and colonic injury using R. RESULTS: AL occurred in 20/385 (5.2%) of BH vs. 4/225 (1.8%) of non-BH small intestine injury. AL was diagnosed 11.6 ± 5.6 days from index operation in small intestine BH and 9.7 ± 4.3 days in colonic BH. Adjusted RR for AL was 2.32 [0.77-6.95] for small intestinal and 4.83 [1.47-15.89] for colonic injuries. AL increased infections, ventilator days, ICU & total length of stay, reoperation, and readmission rates, although mortality was unchanged. CONCLUSION: BH carries a significantly higher risk of AL, particularly in the colon, than other blunt intestinal injuries.

Development and Validation of a Novel Hollow Viscus Injury Prediction Score for Abdominal Seatbelt Sign: A Pacific Coast Surgical Association Multicenter Study.

BACKGROUND: High-quality CT can exclude hollow viscus injury (HVI) in patients with abdominal seatbelt sign (SBS) but performs poorly at identifying HVI. Delay in diagnosis of HVI has significant consequences necessitating timely identification. STUDY DESIGN: This multicenter, prospective observational study conducted at 9 trauma centers between August 2020 and October 2021 included adult trauma patients with abdominal SBS who underwent abdominal CT before surgery. HVI was determined intraoperatively and physiologic, examination, laboratory, and imaging findings were collected. Least absolute shrinkage and selection operator- and probit regression-selected predictor variables and coefficients were used to assign integer points for the HVI score. Validation was performed by comparing the area under receiver operating curves (AUROC). RESULTS: Analysis included 473 in the development set and 203 in the validation set. The HVI score includes initial systolic blood pressure <110 mmHg, abdominal tenderness, guarding, and select abdominal CT findings. The derivation set has an AUROC of 0.96, and the validation set has an AUROC of 0.91. The HVI score ranges from 0 to 17 with score 0 to 5 having an HVI risk of 0.03% to 5.36%, 6 to 9 having a risk of 10.65% to 44.1%, and 10 to 17 having a risk of 58.59% to 99.72%. CONCLUSIONS: This multicenter study developed and validated a novel HVI score incorporating readily available physiologic, examination, and CT findings to risk stratify patients with an abdominal SBS. The HVI score can be used to guide decisions regarding management of a patient with an abdominal SBS and suspected HVI.

Rates and risk factors for anastomotic leak following blunt trauma-associated bucket handle intestinal injuries: a multicenter study.

Objectives: The risk factors for anastomotic leak (AL) after resection and primary anastomosis for traumatic bucket handle injury (BHI) have not been previously defined. This multicenter study was conducted to address this knowledge gap. Methods: This is a multicenter retrospective study on small intestine and colonic BHIs from blunt trauma between 2010 and 2021. Baseline patient characteristics, risk factors, presence of shock and transfusion, operative details, and clinical outcomes were compared using R. Results: Data on 395 subjects were submitted by 12 trauma centers, of whom 33 (8.1%) patients developed AL. Baseline details were similar, except for a higher proportion of patients in the AL group who had medical comorbidities such as diabetes, hypertension, and obesity (60.6% vs. 37.3%, p=0.015). AL had higher rates of surgical site infections (13.4% vs. 5.3%, p=0.004) and organ space infections (65.2% vs. 11.7%, p<0.001), along with higher readmission and reoperation rates (48.4% vs. 9.1%, p<0.001, and 39.4% vs. 11.6%, p<0.001, respectively). There was no difference in intensive care unit length of stay or mortality (p>0.05). More patients with AL were discharged with an ostomy (69.7% vs. 7.3%, p<0.001), and the mean duration until ostomy reversal was 5.85±3 months (range 2-12.4 months). The risk of AL significantly increased when the initial operation was a damage control procedure, after adjusting for age, sex, injury severity, presence of one or more comorbidities, shock, transfusion of >6 units of packed red blood cells, and site of injury (adjusted RR=2.32 (1.13, 5.17)), none of which were independent risk factors in themselves. Conclusion: Damage control surgery performed as the initial operation appears to double the risk of AL after intestinal BHI, even after controlling for other markers of injury severity. Level of evidence: III.

Crystalloid volume is associated with short-term morbidity in children with severe traumatic brain injury: An Eastern Association for the Surgery of Trauma multicenter trial post hoc analysis.

OBJECTIVE: This study examined differences in clinical and resuscitation characteristics between injured children with and without severe traumatic brain injury (sTBI) and aimed to identify resuscitation characteristics associated with improved outcomes following sTBI. METHODS: This is a post hoc analysis of a prospective observational study of injured children younger than 18 years (2018-2019) transported from the scene, with elevated shock index pediatric-adjusted on arrival and head Abbreviated Injury Scale score of ≥3. Timing and volume of resuscitation products were assessed using χ 2t test, Fisher's exact t test, Kruskal-Wallis, and multivariable logistic regression analyses. RESULTS: There were 142 patients with sTBI and 547 with non-sTBI injuries. Severe traumatic brain injury patients had lower initial hemoglobin (11.3 vs. 12.4, p < 0.001), greater initial international normalized ratio (1.4 vs. 1.1, p < 0.001), greater Injury Severity Score (25 vs. 5, p < 0.001), greater rates of ventilator (59% vs. 11%, p < 0.001) and intensive care unit (ICU) requirement (79% vs. 27%, p < 0.001), and more inpatient complications (18% vs. 3.3%, p < 0.001). Severe traumatic brain injury patients received more prehospital crystalloid (25% vs. 15%, p = 0.008), ≥1 crystalloid boluses (52% vs. 24%, p < 0.001), and blood transfusion (44% vs. 12%, p < 0.001) than non-sTBI patients. Among sTBI patients, receipt of ≥1 crystalloid bolus (n = 75) was associated with greater ICU need (92% vs. 64%, p < 0.001), longer median ICU (6 vs. 4 days, p = 0.027) and hospital stay (9 vs. 4 days, p < 0.001), and more in-hospital complications (31% vs. 7.5%, p = 0.003) than those who received <1 bolus (n = 67). These findings persisted after adjustment for Injury Severity Score (odds ratio, 3.4-4.4; all p < 0.010). CONCLUSION: Pediatric trauma patients with sTBI received more crystalloid than those without sTBI despite having a greater international normalized ratio at presentation and more frequently requiring blood products. Excessive crystalloid may be associated with worsened outcomes, including in-hospital mortality, seen among pediatric sTBI patients who received ≥1 crystalloid bolus. Further attention to a crystalloid sparing, early transfusion approach to resuscitation of children with sTBI is needed. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Simulated aeromedical evacuation does not affect systemic inflammation or organ injury in a murine model of hemorrhagic shock.

Hemorrhagic shock is a primary injury amongst combat casualties. Aeromedical evacuation (AE) of casualties exposes patients to a hypobaric, hypoxic environment. The effect of this environment on the host response to hemorrhagic shock is unknown. In the present study, we sought to determine the effect of simulated AE on systemic inflammation and organ injury using a murine model of hemorrhagic shock. Mice underwent femoral artery cannulation and were hemorrhaged for 60 minutes. Mice were then resuscitated with a 1:1 ratio of plasma:packed red blood cells. At 1 or 24 hours after resuscitation, mice were exposed to a 5-hour simulated AE or remained at ground level (control). Serum was analyzed for cytokine concentrations and organs were assessed for neutrophil accumulation and vascular permeability. Mice in the simulated AE groups demonstrated reduced arterial oxygen saturation compared to ground controls. Serum cytokine concentrations, neutrophil recruitment, and vascular permeability in the lung, ileum, and colon in the simulated AE groups were not different from the ground controls. Our results demonstrate that mice exposed to simulated AE following hemorrhagic shock do not exhibit worsened systemic inflammation or organ injury compared to controls. The data suggest that AE has no adverse effect on isolated hemorrhagic shock.

The national trauma triage protocol: how EMS perspective can inform the guideline revision.

OBJECTIVES: The Field Triage Guidelines (FTG) support emergency medical service (EMS) decisions regarding the most appropriate transport destination for injured patients. While the components of the algorithm are largely evidenced-based, the stepwise approach was developed with limited input from EMS providers. FTG are only useful if they can easily be applied by the field practitioner. We sought to gather end-user input on the current guidelines from a broad group of EMS stakeholders to inform the next revision of the FTG. METHODS: An expert panel composed an end-user feedback tool. Data collected included: demographics, EMS agency type, geographic area of respondents, use of the current FTG, perceived utility, and importance of each step in the algorithm (1: physiologic, 2: anatomic, 3 mechanistic, 4: special populations). The American College of Surgeons Committee on Trauma (ACS COT), in partnership with several key organizations, distributed the tool to reach as many providers as possible. RESULTS: 3958 responses were received (82% paramedics/emergency medical technicians, 9% physicians, 9% other). 94% responded directly to scene emergency calls and 4% were aeromedical providers. Steps 2 and 3 were used in 95% of local protocols, steps 1 and 4 in 90%. Step 3 was used equally in protocols across all demographics; however, step 1 was used significantly more in the air medical services than ground EMS (96% vs 88%, p<0.05). Geographic variation was demonstrated in FTG use based on the distance to a trauma center, but step 3 (not step 1) drove the majority of the decisions. This point was reinforced in the qualitative data with the comment, "I see the wreck before I see the patient." CONCLUSION: The FTG are widely used by EMS in the USA. The stepwise approach is useful; however, mechanism (not physiological criteria) drives most of the decisions and is evaluated first. Revision of the FTG should consider the experience of the end-users. LEVEL OF EVIDENCE: V.

An Unencumbered Acute Care Surgeon Improves Delivery of Emergent Surgical Care for Cholecystectomy Patients.

Introduction: Many patients utilize the Emergency Room (ER) for primary care, resulting in overburdened ERs, strained resources, and delays in care. To combat this, many centers have adopted a Trauma/Acute Care Surgery (TACS) service providing specialty surgeons whose primary work is the unencumbered surgical availability to emergency surgery patients. To evaluate our programs' efficacy, we investigated cholecystectomies as a common urgent procedure representative of services provided. We hypothesized that the adoption of a TACS service would result in improved access to care as evidence by decreased ER visits prior to cholecystectomy, improved time to cholecystectomy, and decreased hospital length of stay (LOS). Methods: All patients that underwent urgent cholecystectomy from January 1, 2018 to December 31, 2018 were reviewed. The unencumbered TACS surgeon was implemented on July 1, 2018. Prior ER visits involving biliary symptoms, time from admission to cholecystectomy, and hospital LOS were compared. Results: Of the 322 urgent cholecystectomies over the study period, 165 were performed prior and 157 following adoption of the TACS structure. The average number of ER visits for biliary symptoms prior to cholecystectomy decreased from 1.4 to 1.2 (p = 0.01). Time from admission to cholecystectomy was 28.3 hours and 27.3 hours respectively (p = 0.74). Average LOS decreased following the restructure (3.1 vs 2.5 days; p = 0.03). Conclusion: Implementation of an unencumbered TACS surgeon managing urgent surgical disease improves access to and delivery of surgical services for cholecystectomy patients in a safety net, level one trauma center. Further research is necessary to determine potential improvements in hospital cost and patient satisfaction.

Inflate and pack! Pelvic packing combined with REBOA deployment prevents hemorrhage related deaths in unstable pelvic fractures.

INTRODUCTION: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is advocated for hemorrhage control in pelvic fracture patients in shock. We evaluated REBOA in patients undergoing preperitoneal pelvic packing (PPP) for pelvic fracture-related hemorrhage. METHODS: Retrospective, single-institution study of unstable pelvic fractures (hemodynamic instability despite 2 units of red blood cells (RBCs) and fracture identified on x-ray). Management included the placement of a Zone III REBOA in the emergency department (ED) for systolic blood pressure <80 mmHg. All PPP patients were included and analyzed for injury characteristics, transfusion requirements, outcomes and complications. Additionally, patients who received REBOA (REBOA+) were compared to those that did not (REBOA-). RESULTS: During the study period (January 2015 - January 2019), 652 pelvic fracture patients were admitted; 78 consecutive patients underwent PPP. Median RBCs at PPP completion compared to 24 h post-packing were 11 versus 3 units (p<0.05). Median time to operation was 45 min. After PPP, 7 (9%) patients underwent angioembolization. Mortality was 14%. No mortalities were due to ongoing pelvic fracture hemorrhage or physiologic exhaustion; all were a withdrawal of life sustaining support, most commonly due to neurologic insults (TBI/fat emboli = 6, stroke/spinal cord injury = 3). REBOA+ patients (n = 31) had a significantly higher injury severity score (45 vs 38, p<0.01) and higher heart rate (130 vs 118 beats per minute, p = 0.04) than REBOA-. The systolic blood pressure, base deficit, and number of RBCs transfused in the ED, and time spent in the ED were similar between groups. REBOA+ had a higher median transfusion of RBCs at PPP completion (11 units vs 5 units, p<0.01) but similar RBC transfusion in the 24 h after PPP (2 vs 1 units, p = 0.27). Mortality, pelvic infection, and ICU length of stay was not different between these cohorts. CONCLUSION: PPP with REBOA was utilized in more severely injured patients with greater physiologic derangements. Although REBOA patients required greater transfusion requirements, there were no deaths due to acute pelvic hemorrhage. This suggests the combination of REBOA with PPP provides life-saving hemorrhage control in otherwise devastating injuries.

Excluding Hollow Viscus Injury for Abdominal Seat Belt Sign Using Computed Tomography.

Importance: Abdominal seat belt sign (SBS) has historically entailed admission and observation because of the diagnostic limitations of computed tomography (CT) imaging and high rates of hollow viscus injury (HVI). Recent single-institution, observational studies have questioned the utility of this practice. Objective: To evaluate whether a negative CT scan can safely predict the absence of HVI in the setting of an abdominal SBS. Design, Setting, and Participants: This prospective, observational cohort study was conducted in 9 level I trauma centers between August 2020 and October 2021 and included adult trauma patients with abdominal SBS. Exposures: Inclusion in the study required abdominal CT as part of the initial trauma evaluation and before any surgical intervention, if performed. Results of CT scans were considered positive if they revealed any of the following: abdominal wall soft tissue contusion, free fluid, bowel wall thickening, mesenteric stranding, mesenteric hematoma, bowel dilation, pneumatosis, or pneumoperitoneum. Main Outcomes and Measures: Presence of HVI diagnosed at the time of operative intervention. Results: A total of 754 patients with abdominal SBS had an HVI prevalence of 9.2% (n = 69), with only 1 patient with HVI (0.1%) having a negative CT (ie, none of the 8 a priori CT findings). On bivariate analysis comparing patients with and without HVI, there were significant associations between each of the individual CT scan findings and the presence of HVI. The strongest association was found with the presence of free fluid, with a more than 40-fold increase in the likelihood of HVI (odds ratio [OR], 42.68; 95% CI, 20.48-88.94; P < .001). The presence of free fluid also served as the most effective binary classifier for presence of HVI (area under the receiver operator characteristic curve [AUC], 0.87; 95% CI, 0.83-0.91). There was also an association between a negative CT scan and the absence of HVI (OR, 41.09; 95% CI, 9.01-727.69; P < .001; AUC, 0.68; 95% CI, 0.66-0.70). Conclusions and Relevance: The prevalence of HVI among patients with an abdominal SBS and negative findings on CT is extremely low, if not zero. The practice of admitting and observing all patients with abdominal SBS should be reconsidered when a high-quality CT scan is negative, which may lead to significant resource and cost savings.

Patient characteristics and diagnostic tests associated with syncopal falls: A Southwestern surgical congress multicenter study.

BACKGROUND: Patients suspected of syncope frequently undergo laboratory and imaging studies to determine the etiology of the syncope. Variability exists in these workups across institutions. The purpose of this study was to evaluate the utilization and diagnostic yield of these workups and the patient characteristics associated with syncopal falls. METHODS: A multi-institutional retrospective review was performed on adult patients admitted after a fall between 1/2017-12/2018. Syncopal falls were compared to non-syncopal falls. RESULTS: 4478 patients were included. There were 795 (18%) patients with a syncopal fall. Electrocardiogram, troponin, echocardiogram, CT angiography (CTA), and carotid ultrasound were more frequently tested in syncope patients compared to non-syncope patients. Syncope patients had higher rates of positive telemetry/Holter monitoring, CTAs, and electroencephalograms. CONCLUSION: Patients who sustain syncopal falls frequently undergo diagnostic testing without a higher yield to determine the etiology of syncope.

Prehospital end-tidal carbon dioxide is predictive of death and massive transfusion in injured patients: An Eastern Association for Surgery of Trauma multicenter trial.

BACKGROUND: Prehospital identification of the injured patient likely to require emergent care remains a challenge. End-tidal carbon dioxide (ETCO2) has been used in the prehospital setting to monitor respiratory physiology and confirmation of endotracheal tube placement. Low levels of ETCO2 have been demonstrated to correlate with injury severity and mortality in a number of in-hospital studies. We hypothesized that prehospital ETCO2 values would be predictive of mortality and need for massive transfusion (MT) in intubated patients. METHODS: This was a retrospective multicenter trial with 24 participating centers. Prehospital, emergency department, and hospital values were collected. Receiver operating characteristic curves were created and compared. Massive transfusion defined as >10 U of blood in 6 hours or death in 6 hours with at least 1 U of blood transfused. RESULTS: A total of 1,324 patients were enrolled. ETCO2 (area under the receiver operating characteristic curve [AUROC], 0.67; confidence interval [CI], 0.63-0.71) was better in predicting mortality than shock index (SI) (AUROC, 0.55; CI, 0.50-0.60) and systolic blood pressure (SBP) (AUROC, 0.58; CI, 0.53-0.62) (p < 0.0005). Prehospital lowest ETCO2 (AUROC, 0.69; CI, 0.64-0.75), SBP (AUROC, 0.75; CI, 0.70-0.81), and SI (AUROC, 0.74; CI, 0.68-0.79) were all predictive of MT. Analysis of patients with normotension demonstrated lowest prehospital ETCO2 (AUROC, 0.66; CI, 0.61-0.71), which was more predictive of mortality than SBP (AUROC, 0.52; CI, 0.47-0.58) or SI (AUROC, 0.56; CI, 0.50-0.62) (p < 0.001). Lowest prehospital ETCO2 (AUROC, 0.75; CI, 0.65-0.84), SBP (AUROC, 0.63; CI, 0.54-0.74), and SI (AUROC, 0.64; CI, 0.54-0.75) were predictive of MT in normotensive patients. ETCO2 cutoff for MT was 26 mm Hg. The positive predictive value was 16.1%, and negative predictive value was high at 98.1%. CONCLUSION: Prehospital ETCO2 is predictive of mortality and MT. ETCO2 outperformed traditional measures such as SBP and SI in the prediction of mortality. ETCO2 may outperform traditional measures in predicting need for transfusion in occult shock. LEVEL OF EVIDENCE: Diagnostic test, level III.

Finding the elusive trauma denominator: Feasibility of combining data sets to quantify the true burden of firearm trauma.

BACKGROUND: Evidence guiding firearm injury prevention is limited by current data collection infrastructure. Trauma registries (TR) omit prehospital deaths and underestimate the burden of injury. In contrast, the National Violent Death Reporting System (NVDRS) tracks all firearm deaths including prehospital fatalities, excluding survivors. This is a feasibility study to link these data sets through collaboration with our state public health department, aiming to better estimate the burden of firearm injury and assess comparability of data. METHODS: We reviewed all firearm injuries in our Level I TR from 2011 to 2017. We provided the public health department with in-hospital deaths, which they linked to NVDRS using patient identifiers and time of injury/death. The NVDRS collates information about circumstances, incident type, and wounding patterns from multiple sources including death certificates, autopsy records, and legal proceedings. We considered only subjects with injury location in a single urban county to best estimate in-hospital and prehospital mortality. RESULTS: Of 168 TR deaths, 166 (99%) matched to NVDRS records. Based on data linkages, we estimate 320 prehospital deaths, 184 in-hospital deaths, and 453 survivors for a total of 957 firearm injuries. For the matched patients, there was near-complete agreement regarding simple demographic variables (e.g., age and sex) and good concordance between incident types (suicide, homicide, etc.). However, agreement in wounding patterns between NVDRS and TR varied. CONCLUSION: We demonstrate the feasibility of linking TR and NVDRS data with good concordance for many variables, allowing for good estimation of the trauma denominator. Standardized data collection methods in one data set could improve methods used by the other, for example, training NVDRS abstractors to utilize Abbreviated Injury Scale designations for injury patterns. Such data integration holds immediate promise for guiding prevention strategies. LEVEL OF EVIDENCE: Epidemiological study, level IV.