A retrospective, multi-agency 'target trial emulation' for the comparison of post-resuscitation epinephrine to norepinephrine.

INTRODUCTION: Epinephrine and norepinephrine are the two most commonly used prehospital vasopressors in the United States. Prior studies have suggested that use of a post-ROSC epinephrine infusion may be associated with increased rearrest and mortality in comparison to use of norepinephrine. We used target trial emulation methodology to compare the rates of rearrest and mortality between the groups of OHCA patients receiving these vasopressors in the prehospital setting. METHODS: Adult (18-80 years of age) non-traumatic OHCA patients in the 2018-2022 ESO Data Collaborative datasets with a documented post-ROSC norepinephrine or epinephrine infusion were included in this study. Logistic regression modeling was used to evaluate the association between vasopressor agent and outcome using two sets of covariables. The first set of covariables included standard Utstein factors, the dispatch to ROSC interval, the ROSC to vasopressor interval, and the follow-up interval. The second set added prehospital systolic blood pressure and SpO2 values. Kaplan-Meier time-to-event analysis was also conducted and the vasopressor groups were compared using a multivariable Cox regression model. RESULTS: Overall, 1,893 patients treated by 309 EMS agencies were eligible for analysis. 1,010 (53.4%) received an epinephrine infusion and 883 (46.7%) received a norepinephrine infusion as their initial vasopressor. Adjusted analyses did not discover an association between vasopressor agent and rearrest (aOR: 0.93 [0.72, 1.21]) or mortality (aOR: 1.00 [0.59, 1.69]). CONCLUSIONS: In this multi-agency target trial emulation, the use of a post-resuscitation epinephrine infusion was not associated with increased odds of rearrest in comparison to the use of a norepinephrine infusion.

Investigation and Validation of the TEG6s During Rotary Wing Aeromedical Flight.

INTRODUCTION: In order to improve rural and austere trauma care, hospital-based testing performed at the point of injury may shorten the time lapsed from injury to intervention. This study aimed to evaluate the use of the TEG6s® device in a rotary wing aircraft. Prior attempts suffered from limitation related to lack of vibration mitigation. METHODS: This was an investigator initiated, industry supported study. Haemonetics® provided a TEG6s® analyzer. The device underwent a standard validation. It was secured in place on the aircraft utilizing shipping foam for vibration mitigation. Donors provided 2 tubes of sample blood in one sitting. Paired studies were performed on the aircraft during level flight and in the hospital, using the Global Hemostasis with Lysis Cartridge. Both normal and presumed pathologic samples were tested in separate phases. Paired T-tests were performed. RESULTS: For normal donors, mean R (minutes) for laboratory compared to the aircraft was 6.2 vs. 7.2 (p = 0.025). Mean CRT MA (mm) was 59.3 and 55.9 ± 7.3 (p < 0.001) for lab and aircraft (p < 0.001). Among normal donors, R was within normal range for 17/18 laboratory and 18/18 aircraft tests (p > 0.99).During the testing of pathologic samples mean R time was 14.8 for lab samples and 12.6 minutes for aircraft (p = 0.02). Aircraft samples were classified as abnormal in 78% of samples, this was not significantly different than lab samples (p = 0.5). CONCLUSIONS: The use of the TEG6s® for inflight viscoelastic testing appears promising. While statistically significant differences are seen in some results, these values are not considered clinically significant. Classifying samples as normal or abnormal demonstrated a higher correlation. Future studies should focus on longer flight times to evaluate for LY30, takeoff and landing effects. Overall, this study suggests that TEG6s® can be utilized in a prehospital environment, and further study is warranted. LEVEL OF EVIDENCE: Level II, Diagnostic Tests or Criteria.

Prevalence of Burn Pit Associated Symptoms Among US Veterans Who Utilize Non-Veteran's Affairs Private Healthcare.

OBJECTIVE: Do the 3.5 million US veterans, who primarily utilize private healthcare, have similar burn pit exposure and disease compared to the VA Burn Pit registry? METHODS: This is an online volunteer survey of Gulf War and Post-9/11 veterans. RESULTS: Burn pit exposure had significantly higher odds of extremity numbness, aching pain and burning, asthma, chronic obstructive pulmonary disease, interstitial lung disease, constrictive bronchiolitis, pleuritis, and pulmonary fibrosis. Chi-square did not reveal a difference in burn pit exposure and cancer diagnoses. CONCLUSIONS: These data demonstrate increased risk of neurological symptoms associated with burn pit exposure, which are not covered in the 2022 federal Promise to Address Comprehensive Toxics Act. Additional data will allow for the continued review and consideration for future medical benefits.

The association of clinical, treatment, and demographic characteristics with rearrest in a national dataset.

INTRODUCTION: Following initial resuscitation from out-of-hospital cardiac arrest, rearrest frequently occurs and has been associated with adverse outcomes. We aimed to identify clinical, treatment, and demographic characteristics associated with prehospital rearrest at the encounter and agency levels. METHODS: Adult non-traumatic cardiac arrest patients who achieved ROSC following EMS resuscitation in the 2018-2021 ESO annual datasets were included in this study. Patients were excluded if they had a documented DNR/POLST or achieved ROSC after bystander CPR only. Rearrest was defined as post-ROSC CPR initiation, administration of ≥ 1 milligram of adrenaline, defibrillation, or a documented non-perfusing rhythm on arrival at the receiving hospital. Multivariable logistic regression modeling was used to evaluate the association between rearrest and case characteristics. Linear regression modeling was used to evaluate the association between agency-level factors (ROSC rate, scene time, and scene termination rate), and rearrest rate. RESULTS: Among the 53,027 cases included, 16,116 (30.4%) experienced rearrest. Factors including longer response intervals, longer 'low-flow' intervals, unwitnessed OHCA, and a lack of bystander CPR were associated with rearrest. Among agencies that treated ≥ 30 patients with outcome data, the agency-level rate of rearrest was inversely associated with agency-level rate of survival to discharge to home (R2 = -0.393, p < 0.001). CONCLUSIONS: This multiagency retrospective study found that factors associated with increased ischaemic burden following OHCA were associated with rearrest. Agency-level rearrest frequency was inversely associated with agency-level survival to home. Interventions that decrease the burden of ischemia sustained by OHCA patients may decrease the rate of rearrest and increase survival.

Reverse shock index multiplied by the motor component of the Glasgow Coma Scale predicts mortality and need for intervention in pediatric trauma patients.

BACKGROUND: Timely identification of high-risk pediatric trauma patients and appropriate resource mobilization may lead to improved outcomes. We hypothesized that reverse shock index times the motor component of the Glasgow Coma Scale (rSIM) would perform equivalently to reverse shock index times the total Glasgow Coma Scale (rSIG) in the prediction of mortality and the need for intervention following pediatric trauma. METHODS: The 2017-2020 National Trauma Data Bank datasets were used. We included all patients <16 years of age that had a documented prehospital and trauma bay systolic blood pressure, heart rate, and total GCS. We excluded all patients who arrived at the trauma center without vital signs and interfacility transport patients. Receiver operating characteristic (ROC) curves were used to model the performance of each metric as a classifier with respect to our primary and secondary outcomes, and the area under the ROC curve (AUC) was used for comparison. Our primary outcome was mortality prior to hospital discharge. Secondary outcomes included blood product administration or hemorrhage control intervention (surgery or angiography) < 4 hours following hospital arrival and ICU admission. RESULTS: After application of exclusion criteria, 77,996 patients were included in our analysis. rSIM and rSIG performed equivalently as predictors of mortality in the 1-2 (p = 0.05) and 3-5 (p = 0.28) year categories, but rSIM was statistically outperformed by rSIG in the 6-12 (AUC: 0.96 vs. 0.95, p = 0.04) and 13-16 (AUC: 0.96 vs. 0.95, p < 0.01) year-old age categories. rSIM and rSIG also performed similarly with respect to prediction of secondary outcomes. CONCLUSION: rSIG and rSIM are both outstanding predictors of mortality following pediatric trauma. Statistically significant differences in favor of rSIG were noted in some age groups. Because of the simplicity of calculation, rSIM may be a useful tool for pediatric trauma triage. LEVEL OF EVIDENCE: III, Diagnostic Tests or Criteria.

A Retrospective Nationwide Comparison of the iGel and King Laryngeal Tube Supraglottic Airways for Out-of-Hospital Cardiac Arrest Resuscitation.

INTRODUCTION: While various supraglottic airway devices are available for use during out-of-hospital cardiac arrest (OHCA) resuscitation, comparisons of patient outcomes by device are limited. In this study, we aimed to compare outcomes of OHCA patients who had airway management by emergency medical services (EMS) with the iGel or King-LT. METHODS: We used the 2018-2021 ESO Data Collaborative public use research datasets for this retrospective study. All patients with non-traumatic OHCA who had iGels or King-LTs inserted by EMS were included. Our primary outcome was survival to discharge to home, and secondary outcomes included first-pass success, return of spontaneous circulation (ROSC), and prehospital rearrest. We examined the association between airway device and each outcome using two-level mixed effects logistic regression with EMS agency as the random effect, adjusted for standard Utstein variables and failed intubation prior to supraglottic airway insertion. Average treatment effects were calculated through propensity score matching. RESULTS: A total of 286,192 OHCA patients were screened, resulting in 93,866 patients eligible for inclusion in this analysis. A total of 9,456 transported patients (59.8% iGel) had associated hospital disposition data. Use of the iGel was associated with greater survival to discharge to home (aOR:1.36 [1.06, 1.76]; ATE: 2.2%[+0.5, +3.8]; n = 7,576), first pass airway success (aOR:1.94 [1.79, 2.09]; n = 73,658), and ROSC (aOR:1.19 [1.13, 1.26]; n = 73,207) in comparison to airway management with the King-LT. iGel use was associated with lower odds of experiencing a rearrest (aOR:0.73 [0.67, 0.79]; n = 20,776). Among patients who received a supraglottic device as a primary airway, use of the iGel was not associated with significantly greater survival to discharge to home (aOR:1.26 [0.95, 1.68]). Among patients who received a supraglottic device as a rescue airway following failed intubation, use of the iGel was associated with greater odds of survival to discharge to home (aOR:2.16 [1.15, 4.04]). CONCLUSION: In this dataset, use of the iGel during adult OHCA resuscitation was associated overall with better outcomes compared to use of the King-LT. Subgroup analyses suggested that use of the iGel was associated with greater odds of achieving the primary outcome than the King-LT when used as a rescue device but not when used as the primary airway management device.

The Association of Prehospital End-Tidal Carbon Dioxide with Survival Following Out-of-Hospital Cardiac Arrest.

OBJECTIVE: End tidal carbon dioxide (ETCO2) is often used to assess ventilation and perfusion during cardiac arrest resuscitation. However, few data exist evaluating the relationship between ETCO2 values and mortality in the context of contemporary resuscitation practices. We aimed to explore the association between ETCO2 and mortality following out-of-hospital cardiac arrest (OHCA). METHODS: We used the 2018-2021 ESO annual datasets to query all non-traumatic OHCA patients with attempted resuscitation. Patients with documented DNR/POLST, EMS-witnessed arrest, ROSC after bystander CPR only, or < 2 documented ETCO2 values were excluded. The lowest and highest ETCO2 values recorded during the total prehospital interval, in addition to the pre- and post-ROSC intervals for resuscitated patients, were calculated. Multivariable logistic regression models adjusted for age, sex, initial rhythm, witnessed status, bystander CPR, etiology, OHCA location, sodium bicarbonate administration, number of milligrams of epinephrine administered, and response interval were used to evaluate the association between measures of ETCO2 and mortality. RESULTS: Hospital outcome data were available for 14,122 patients, and 2,209 (15.6%) were classified as surviving to discharge. Compared to patients with maximum prehospital ETCO2 values of 30-40 mmHg, odds of mortality were increased for patients with maximum prehospital ETCO2 values of <20 mmHg (aOR: 3.5 [2.1, 5,9]), 20-29 mmHg (aOR: 1.5 [1.1, 2.1]), and >50 mmHg (aOR: 1.5 [1.2, 1.8]). After 20 minutes of ETCO2 monitoring, <12% of patients had ETCO2 values <10 mmHg. This cutpoint was 96.7% specific and 6.9% sensitive for mortality. CONCLUSION: In this dataset, both high and low ETCO2 values were associated with increased mortality. Contemporary resuscitation practices may make low ETCO2 values uncommon, and field termination decision algorithms should not use ETCO2 values in isolation.

The Association of Combined Prehospital Hypotension and Hypoxia with Outcomes following Out-of-Hospital Cardiac Arrest Resuscitation.

BACKGROUND: Prehospital post-resuscitation hypotension and hypoxia have been associated with adverse outcomes in the context of out-of-hospital cardiac arrest (OHCA). We aimed to investigate the association between clinical outcomes and post-resuscitation hypoxia alone, hypotension alone, and combined hypoxia and hypotension. METHODS: We used the 2018-2021 ESO annual datasets to conduct this study. All EMS-treated non-traumatic OHCA patients who had a documented prehospital return of spontaneous circulation (ROSC) and two or more SpO2 readings and systolic blood pressures recorded were evaluated for inclusion. Patients who were less than 18 years of age, pregnant, had a do-not-resuscitate order or similar, achieved ROSC after bystander CPR only, or had an EMS-witnessed cardiac arrest were excluded. Multivariable logistic regression adjusted for standard Utstein factors and highest prehospital Glasgow Coma Scale (GCS) score was used to investigate the association between hypoxia, hypotension, and outcomes. RESULTS: We analyzed data for 17,943 patients, of whom 3,979 had hospital disposition data. Hypotension and hypoxia were not documented in 1,343 (33.8%) patients, 1,144 (28.8%) had only hypoxia documented, 507 (12.7%) had only hypotension documented, and 985 (24.8%) had both hypoxia and hypotension documented. In comparison to patients who did not have documented hypotension or hypoxia, patients who had documented hypoxia (aOR: 1.76 [1.38, 2.24]), documented hypotension (aOR: 3.00 [2.15, 4.18]), and documented hypoxia and hypotension combined (aOR: 4.87 [3.63, 6.53]) had significantly increased mortality. The relationship between mortality and vital sign abnormalities (hypoxia and hypotension > hypotension > hypoxia) was observed in every evaluated subgroup. CONCLUSIONS: In this large dataset, hypotension and hypoxia were independently associated with mortality both alone and in combination. Compared to patients without documented hypotension and hypoxia, patients with documented hypotension and hypoxia had nearly five-fold greater odds of mortality.

Chest X-Ray Remains a Vital Component Prior to Tube Thoracostomy.

INTRODUCTION: The identification and treatment of traumatic pneumothorax (PTX) has long been a focus of bedside imaging in the trauma patient. While the emergence of bedside ultrasound (BUS) provides an opportunity for earlier detection, the need for tube thoracostomy (TT) based on bedside imaging, including BUS and supine AP chest X-ray (CXR) is less established in the medical literature. METHODS: Retrospective data from 2017 to 2020 were collected of all adult trauma activations at a level 1 rural trauma facility. Every adult patient included in this study received a CXR and BUS (eFast) upon arrival. The need for TT was determined by the emergency medicine attending or the trauma surgery attending evaluating the patient. McNemar's chi-squared test and conditional logistic regression analysis were performed comparing BUS, CXR, and the combination of BUS and CXR findings for the need for TT. Subgroup analyses were performed comparing BUS, CXR, and the combination of BUS and CXR for the detection of PTX compared to CT scan. RESULTS: Of the 12,244 patients who underwent trauma activation during this timeframe, 602 were included in the study. 74.9% were males with an age range of 36-63 years. Of the 602 patients, 210 received TT. Positive PTX was recorded with BUS in 128 (21%) patients with 16 false negatives (FNs) and 98 false positives (FPs), 100 (17%) PTX were identified with CXR with 114 FNs and 4 FPs, and 72 (11.9%) were noted on both CXR and BUS with 140 FNs and 2 FPs. The odds ratio of TT placement was 22 times with positive BUS alone (P < .0001, 95% CI: 10.9-43.47), 47 times with positive CXR alone (P < .0001, 95% CI: 16.99-127.5), and 70 times with both positive CXR and BUS (P < .0001, 95% CI: 17.08-288.4). CONCLUSION: A positive finding of PTX on BUS combined with CXR is more indicative of the need for TT in the trauma patient when compared with BUS or CXR alone.

Opioid-related polysubstance use and its effect on mortality and health resource utilization among trauma patients.

BACKGROUND: Pre-injury opioid use is common, but the effects of opioid-related polysubstance use on mortality and health resources utilization (HRU) have not been investigated yet. The objective of this study was to investigate the effects of opioid-related polysubstance use on mortality and HRU among patients in trauma centres in the US. METHODS: We conducted a retrospective cross-sectional study using the US National Trauma Databank from the year 2017 to 2019. Patients (≥ 18 years of age) who tested positive for opioids were included. Patients were analysed based on the number of substances used (i.e., opioids only, two substances (opioids + 1 substance), and three or more than three substances (opioids + ≥ 2 substances)), and polysubstance by type (i.e., opioids only, opioids and alcohol, opioids and stimulants, opioids and benzodiazepine, and other combinations). Multivariate logistic regression was used to determine the association between polysubstance use, mortality and HRU (i.e., need for hospital admission, ICU, and mechanical ventilation). RESULTS: Both polysubstance by number and type analyses showed that opioid-related polysubstance use was not significantly associated with mortality compared to opioids only. The odds of hospital admission were higher among the opioids and benzodiazepines group (OR 1.15, 95% CI 1.06-1.24, p < 0.01). The need for ICU was magnified using benzodiazepines and stimulants with opioids (OR 1.44, 95% CI 1.27-1.63, p < 0.01) when compared to the opioids only group. CONCLUSION: Opioid-related pre-injury polysubstance use was associated with higher HRU in trauma patients. The evidence can be used by policymakers and practitioners to improve patient outcomes in trauma centers.

Stay and play or load and go? The association of on-scene advanced life support interventions with return of spontaneous circulation following traumatic cardiac arrest.

INTRODUCTION: Traumatic out-of-hospital cardiac arrest (tOHCA) has a mortality rate over 95%. Many current protocols dictate rapid intra-arrest transport of these patients. We hypothesized that on-scene advanced life support (ALS) would increase the odds of arriving at the emergency department with ROSC (ROSC at ED) in comparison to performance of no ALS or ALS en route. METHODS: We utilized the 2018-2021 ESO Research Collaborative public use datasets for this study, which contain patient care records from ~2000 EMS agencies across the US. All OHCA patients with an etiology of "trauma" or "exsanguination" were screened (n=15,691). The time of advanced airway management, vascular access, and chest decompression was determined for each patient. Logistic regression modeling was used to evaluate the association of ALS intervention timing with ROSC at ED. RESULTS: 4942 patients met inclusion criteria. 14.6% of patients had ROSC at ED. In comparison to no vascular access, on-scene (aOR: 2.14 [1.31, 3.49]) but not en route vascular access was associated with increased odds of having ROSC at ED arrival. In comparison to no chest decompression, neither en route nor on-scene chest decompression were associated with ROSC at ED arrival. Similarly, in comparison to no advanced airway management, neither en route nor on-scene advanced airway management were associated with ROSC at ED arrival. The odds of ROSC at ED decreased by 3% (aOR: 0.97 [0.94, 0.99]) for every 1-minute increase in time to vascular access and decreased by 5% (aOR: 0.95 [0.94, 0.99]) for every 1-minute increase in time to epinephrine. CONCLUSION: On-scene ALS interventions were associated with increased ROSC at ED in our study. These data suggest that initiating ALS prior to rapid transport to definitive care in the setting of tOHCA may increase the number of patients with a palpable pulse at ED arrival.

Low Molecular Weight Heparin Is Superior for Venous Thromboembolism Prophylaxis in High-Risk Geriatric Patients.

INTRODUCTION: Venous thromboembolism (VTE) is a source of preventable morbidity and mortality in critically ill trauma patients. Age is one independent risk factor. Geriatric patients embody a population at high thromboembolic and hemorrhagic risk. Currently, there is little guidance between low molecular weight heparin (LMWH) and unfractionated heparin (UFH) for anticoagulant prophylaxis in the geriatric trauma patient. METHODS: A retrospective review was conducted at an ACS verified, Level I Trauma center from 2014 to 2018. All patients 65 years or older, with high-risk injuries and admitted to the trauma service were included. Choice of agent was at provider discretion. Patients in renal failure, or those that received no chemoprophylaxis, were excluded. The primary outcomes were the diagnosis of deep vein thrombosis or pulmonary embolism and bleeding associated complications (gastrointestinal bleed, TBI expansion, hematoma development). RESULTS: This study evaluated 375 subjects, 245 (65%) received enoxaparin and 130 (35%) received heparin. DVT developed in 6.9% of UFH patients, compared to 3.3% with LMWH (P = .1). PE was present in 3.8% of UFH group, but only .4% in the LMWH group (P = .01). Combined rate of DVT/PE was significantly lower (P = .006) with LMWH (3.7%) compared to UFH (10.8%). 10 patients had documented bleeding events, and there was no significant association between bleeding and the use of LMWH or UFH. CONCLUSIONS: VTE events are more common in geriatric patients treated with UFH compared to LMWH. There was no associated increase in bleeding complications when LMWH was utilized. LMWH should be considered the chemoprophylatic agent of choice in high risk geriatric trauma patients.

A retrospective comparison of the King Laryngeal Tube and iGel supraglottic airway devices: A study for the CARES surveillance group.

OBJECTIVE: Supraglottic airway devices are increasingly used during the resuscitation of out-of-hospital cardiac arrest (OHCA) patients in the United States and worldwide. In this study, we aimed to compare the neurologic outcomes of OHCA patients managed with the King Laryngeal Tube (King LT) to the neurologic outcomes of patients managed with the iGel. METHODS: We used the Cardiac Arrest Registry to Enhance Survival (CARES) public use research dataset for our analysis. Non-traumatic OHCA cases with attempted EMS resuscitation enrolled from 2013-2021 were included. We used two-level mixed effects multivariable logistic regression analyses with treating EMS agency as the random effect to determine the association between supraglottic airway device and outcome. The primary outcome was survival with a Cerebral Performance Category (CPC) score of 1 or 2 at discharge. Secondary outcomes included survival to hospital admission and survival to hospital discharge. Age, sex, calendar year of OHCA, initial ECG rhythm, witnessed status (unwitnessed, bystander witnessed, 9-1-1 responder witnessed), bystander CPR, response interval, and OHCA location (private/home, public, institutional) were used as covariables. RESULTS: In comparison to use of the King LT, use of the iGel was associated with greater neurologically favorable survival (aOR: 1.45 [1.33, 1.58]). In addition, use of the iGel was associated with greater survival to hospital admission (1.07 [1.02, 1.12]) and survival to hospital discharge (1.35 [1.26, 1.46]). CONCLUSIONS: This study adds to the body of literature suggesting that use of the iGel during OHCA resuscitation is associated with better outcomes than use of the King LT.

Prehospital shock index predicts outcomes after prolonged transport: A multicenter rural study.

BACKGROUND: Shock index (SI) predicts outcomes after trauma. Prior single-center work demonstrated that emergency medical services (EMSs) initial SI was the most accurate predictor of hospital outcomes in a rural environment. This study aimed to evaluate the predictive ability of SI in multiple rural trauma systems with prolonged transport times to a definitive care facility. METHODS: This retrospective review was performed at four American College of Surgeons-verified level 1 trauma centers with large rural catchment basins. Adult trauma patients who were transferred and arrived >60 minutes from scene during 2018 were included. Patients who sustained blunt chest or abdominal trauma were analyzed. Subjects with missing data or severe head trauma (Abbreviated Injury Scale score, >2) were excluded. Poisson and binomial logistic regression were used to study the effect of SI and delta shock index (∆SI) on outcomes. RESULTS: After applying the criteria, 789 patients were considered for analysis (502 scene patients and 287 transfers). The mean Injury Severity Score was 8 (interquartile range, 6) for scene and 8.9 (interquartile range, 5) for transfers. Initial EMSs SI was a significant predictor of the need for blood transfusion and intensive care unit care in both scene and transferred patients. An increase in ∆SI was predictive of the need for operative intervention ( p < 0.05). There were increased odds for mortality for every 0.1 change in EMSs SI; those changes were not deemed significant among both scene and transfer patients ( p < 0.1). CONCLUSION: Providers must maintain a high level of clinical suspicion for patients who had an initially elevated SI. Emergency medical services SI is a significant predictor for use of blood and intensive care unit care, as well as mortality for scene patients. This highlights the importance of SI and ∆SI in rural trauma care. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Substance use in rural trauma patients admitted for motor vehicle injuries before and during the COVID-19 pandemic.

BACKGROUND: Urban trauma centers reported increased substance use among individuals injured in motor vehicle collisions (MVC) after the start of the COVID-19 pandemic. Little is known about individuals admitted to rural trauma centers during this time. This study's purpose was to describe substance use trends before and during the pandemic among individuals injured in MVC and treated at a rural Level-1 trauma center in West Virginia. METHODS: A cross-sectional analysis was performed using patients' medical records. The study population included individuals ≥ 18 years of age who received treatment for a motor vehicle-related injury between September 1, 2018, and September 30, 2021, and were tested for drugs and alcohol upon admittance. The pre-COVID-19 period was defined as September 1, 2018-March 15, 2020. The COVID-19 period was March 16, 2020-September 30, 2021. The primary dependent variable was the patients' drug test results. The primary independent variable was the time period. The data were analyzed using Chi-square tests, logistic regression, and proportional odds models. RESULTS: During this time, 1465 patients received treatment. On average, patients were 45 years ± 20 of age and male (57%). During COVID-19, 17% of patients tested positive for alcohol and 58% tested positive for non-alcohol drugs. After adjusting for patients' sex and age, the number of drugs that patients tested positive for was 31% higher during COVID-19 (aOR 1.31; 95% CI 1.08, 1.58). The proportion of patients testing positive for cannabinoids (p = 0.05), opioids (p = 0.001), and stimulants (p = 0.010) increased from pre-COVID-19 to COVID-19 periods. CONCLUSIONS: Drug and alcohol use increased among trauma patients admitted to a rural trauma center during COVID-19. Significant increases were seen in the number of drugs and for cannabinoids, opioids, and stimulants.

A Comprehensive Spinal Cord Injury Treatment Protocol Improves Outcomes and Decreases Complications.

BACKGROUND: Spinal cord injury (SCI) is a devastating event with a complicated recovery. Through the use of an interdisciplinary team a comprehensive care plan was developed, utilizing all available best practices, to prevent secondary complications. Previous work has shown the benefit of single system protocols or interventions. This study aimed to assess changes in outcomes after implementation of a comprehensive protocol. MATERIAL AND METHODS: This was a retrospective cohort study performed at an ACS Level I trauma center. It was based on data abstract from the institutions trauma registry over a 10 year period. Patients with quadriplegia after a traumatic injury were included. Data on hospital outcomes and complications was collected and compared before and after the use of the Spinal cord injury protocol. RESULTS: 58 patients were evaluated. Overall, there was a reduction in complications after the implementation, with significant reductions in pneumonia (47% vs 16%; P = .02) and decubitus ulcers (47% to 11%; P = .005). ICU length of stay decreased by 7 days and hospital length of stay decreased 13 days. There was no difference in mortality. Hospital costs also decreased a mean of $42,000. CONCLUSIONS: A comprehensive SCI protocol can reduce secondary complications in quadriplegic patients. This study found significant decreases in pneumonia and decubitus ulcer rates after implementation of the protocol. Lengths of stay and cost were also significantly reduced. Future research using comprehensive SCI protocols is needed to further assess its effects on outcomes for this specific patient population. Similar centers should consider adoption of comprehensive SCI protocols.

Cost Effective Virtual Intensive Care Unit Expanding Capabilities in Critical Access Hospitals.

BACKGROUND: Tele-consults provide access to specialized care for a specific question and single point in time. eICU models utilize remote monitoring and ordering but have significant financial burden. We developed a virtual intensive care unit (VICU) for daily input of an intensivist working with local physicians. The purpose was to expand the acute care ability of the critical access hospital (CAH). The study evaluates the impact on the CAH and system. METHODS: The CAH developed an ICU team, led by a hospitalist, who staffed the intensive care unit (ICU). The CAH ICU team rounds daily via a secure video link to provide care in consultation with intensivists based at a university, tertiary care center (TC). A retrospective analysis was conducted 6 months before and after implementation (4/2018-3/2019). Fisher's exact test was used to compare pre- and post-intervention with significance at P < .04. RESULTS: After VICU implementation, there were 265 initial daily and 35 follow-up consults. Monthly transfers to a higher level of care decreased from 63 to 57 (P = .03). Transfers to TC increased from 49.6 to 62.0% (P = .001). Critical access hospital average monthly census and average monthly inpatient days increased (69 to 130 (P < .0001) and 158 to 319 (P < .0001), respectively). Critical access hospital physicians report increased comfort to admit ICU and non-ICU patients due to the program. The total startup cost was $5180. CAH hired 11 providers. There were no unanticipated deaths. DISCUSSION: VICU implementation resulted in new CAH jobs. The CAH experienced increased inpatient census and revenues (ICU and non-ICU) while decreasing patients transferred out of the system.

Prehospital Tourniquet Use Should be a Trauma Team Activation Criterion.

PURPOSE: Prehospital tourniquet application is not a standard trauma team activation (TTA) criterion recommended by the ACS COT. Tourniquet use has seen a resurgence recently with associated risks and benefits of more liberal usage. Our institution added tourniquet application as TTA criterion in January 2019. This study aimed to evaluate the effect this would have on patient care and overtriage. METHODS: A prospective analysis was conducted for all TTA associated with tourniquets placed during 2019. An overtriage analysis was conducted utilizing a modified Cribari method as described in Resources for the Optimal Care of the Injured Patient, comparing patients that met standard TTA criteria (TTA-S), to those who met criteria due to tourniquet placement (TTA-T). RESULTS: During the study, there were 46 TTA with tourniquets. Mean prehospital tourniquet time was 80 minutes. Median ISS was 10, 8 (17%) had an ISS >15. Urgent operative intervention was needed in 74%, with 23% and 21% requiring orthopedic and vascular procedures, respectively. Tourniquets were correctly placed in 80% and clinically appropriate in 57%. Of these subjects, 25 (54%) were TTA-S and 21 TTA-T. Overtriage analysis was performed. Overtriage for TTA-T was 33.3%. Overtriage among TTA-S was 4%. CONCLUSION: Patients with prehospital tourniquets are frequently severely injured. The immediate presence of a trauma surgeon can have significant impacts in these cases. This is particularly important in a rural environment with long tourniquet times. Prehospital tourniquet application as a TTA criteria does not result in excessive overtriage.

A multicenter evaluation on the impact of non-therapeutic transfer in rural trauma.

INTRODUCTION: Trauma transfers are a common occurrence in rural areas, where critical access and lower-level trauma centers routinely transfer to tertiary care centers for specialized care. Transfers are non-therapeutic (NTT) when no specialist intervention occurs, leading to transfer that were futile (FT) or secondary overtriage (SOT). This study aimed to evaluate the prevalence of NTT among four trauma centers providing care to rural Appalachia. METHODS: This retrospective review was performed at four, ACS verified, Level 1 trauma centers. All adult trauma patients, transferred during 2018 were included for analysis. Transfers were considered futile if in <48 h the patient died or was discharged to hospice, without operative intervention. SOT transfers were discharged in <48 h, without major intervention, with an ISS< 15. Cost analysis was performed to describe the impact of NTT on EMS use. RESULTS: 4,189 patients were analyzed during the study period. 105 (2.5%) met criteria for futility. Futile patients had a median ISS of 25 (IQR 9-26), and 48% had an AIS head ≥4. These were significantly greater (p<0.001) than non-futile transfers, median ISS 5 (IQR 2-9), 3% severe head injury. SOT occurred in 1371 (33%), median ISS of 5, and lower AIS scores by region. Isolated facial injuries resulted in 165 transfers. 13% of FT+SOT were admitted to the ICU. Only 22% of FT+SOT came from a trauma center. 68% were transported by ALS and 13% transported by air transport. FT+SOT traveled on average 70 miles from their home to receive care. CONCLUSIONS: Non-therapeutic transfers account for more than 1/3 of transfers in this rural environment. There was a significant use of advanced life support and aeromedical transport. The utility of these transfers should be questioned. With the recent increases in telehealth there is an opportunity for trauma systems to improve regional care and decrease transfers for futile cases.

The Use of Whole Blood in Rural Trauma Leads to Decreased Resource Utilization.

BACKGROUND: Nearly 40% of trauma deaths result from uncontrolled hemorrhage. Most of these deaths occur within 24 hours, highlighting the importance of early resuscitation. Balanced component resuscitation has been shown to improve outcomes in hemorrhagic shock. However, hemostatic properties may then be decreased, leading to inadequate coagulopathy treatment or higher transfusion requirements. Data comparing the efficacy of component vs. whole blood (WB) resuscitation in early trauma is poor, particularly in the rural population. This study investigates WB use and resource utilization at a rural Level 1 trauma center. METHODS: A prospective cohort study with historical controls (HC) was performed using patients over age 17 presenting as the highest priority trauma. Two units of WB were available to patients with signs of hemorrhagic shock, with subsequent transfusions via massive transfusion protocol or thromboelastography guidance. Component utilization, time to hemorrhage control, complications, and transfer times were examined. RESULTS: Forty patients received WB vs. 153 HC. WB patients had lower complication rates (35% vs. 55.6%; P = .02), and a significant reduction in pRBC utilization in the emergency department (0 vs. 2; P < .0001) and throughout admission (2.0 vs. 4.0; P = .0003). All patients had prolonged transport times given the rural setting (1.42 hours HC vs. 2.03 hours WB; P = .002). DISCUSSION: Unlike most urban WB studies, this study occurred in a rural area with extended transportation times, when WB is inaccessible for patients. Despite this delay, WB patients demonstrated lower component utilization and complication rates. Further research is needed to characterize the impact of early WB access.