Acute cardiogenic shock secondary to blunt traumatic aortic valve injury.

Background: Blunt cardiac injuries rarely result in aortic valve cusp rupture, leading to acute aortic insufficiency and cardiogenic shock. This rare clinical entity carries a high mortality rate if left undiagnosed and not managed surgically, with few patients surviving beyond 24 h. It presents a diagnostic challenge in the polytrauma patient in shock, with multiple possible and complementary etiologies. Case presentation: We present a 56-year-old male with persistent hypotension, a wide pulse pressure, and elevated serum troponin levels suggesting blunt cardiac injury after a motor vehicle accident. Transthoracic and transesophageal echocardiography revealed normal biventricular function but severe aortic insufficiency due to prolapse of the left coronary cusp.He was taken emergently to surgery, where aortic valve exploration revealed complete left coronary cusp avulsion from the aortic annulus with a mid-cusp tear, requiring aortic valve replacement with a bioprosthetic valve. Postoperative echocardiography showed normal biventricular function with a well-seated bioprosthetic aortic valve with no insufficiency. Conclusions: Traumatic aortic valve injury can lead to torn or prolapsed cusps causing acute aortic insufficiency leading to cardiogenic shock, but early recognition with appropriate and targeted diagnostic imaging is vital to prevent rapid patient deterioration and demise.

The Importance of Early Femoral Access When REBOA Catheter Must Be Removed Prior to Hemorrhage Control.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a tool for hemorrhage control. We describe a case where the REBOA Catheter needed to be removed prior to hemorrhage control. The patient is a 40-year-old man that presented following motor vehicle collision. A REBOA Catheter was placed via the right common femoral artery (CFA). CT scan demonstrated extravasation from the left inferior epigastric artery. The Interventional Radiology (IR) team would only be able to perform angioembolization via contralateral access where the REBOA Catheter was in place. Prior to removing the REBOA Catheter on the right, left CFA access was obtained in the event a new catheter needed to be deployed. Ultimately, IR performed angioembolization without a second REBOA Catheter. In gaining contralateral access prior to removing the REBOA Catheter, this case provides a strategy for expeditious replacement of REBOA Catheters in situations where the catheter interferes with hemorrhage control procedures.

A Comparison of Teleburn to In-Person Consultation of Pediatric Patients in a Children's Emergency Department.

BACKGROUND: Pediatric burn care is an essential component to emergency care and there are disparities in access to regional burn centers. Teleburn is a tool that enables providers without a certified burn center to provide photos of a burn to experts and receive recommendations. The purpose of this study is to evaluate the effectiveness of a Teleburn system to the in-person consultation regarding burn infection rate, clinic follow up rate, post-burn admission rate, and 72-hour bounce back rate. DESIGN/METHODS: Data was collected from December 2019-March 2022 through the electronic medical record. A total of 416 patient encounters that met criteria were analyzed. A non-inferiority study was designed comparing proportional outcomes of Teleburn initial visits to emergency department visits regarding burn infection rate, clinic follow up rate, post-burn admission rate, and 72-hour bounce back rate. The data were compared with a difference of greater than 10% being considered inferior. RESULTS: No differences were identified in rates of readmission - 1.67% difference (95% CI -27%< x< 23.8%) and return within 72 hours - 0.7% difference (-18.4%< x< 19.7%). Teleburn patients were 12.6% less likely to follow up (2.7%< x< 22.40%). Only one infection was identified, which was insufficient to conclude non-inferiority. CONCLUSION: While convenient, Teleburn consult could not be demonstrated to be non-inferior to in-person consultation. No differences in infection rates were identified, and difference in readmission and return were clinically insignificant. This study demonstrates that Teleburn may be effective and feasible to regional burn centers if follow up can be improved.

Vascular imaging immediately after tourniquet removal does not increase vasospasm risk.

BACKGROUND: Prehospital tourniquet use is now standard in trauma patients with diagnosed or suspected extremity vascular injuries. Tourniquet-related vasospasm is an understudied phenomenon that may confound management by causing erroneous arterial pressure indices (APIs) and abnormalities on computed tomography angiography (CTA) that do not reflect true arterial injuries. We hypothesized that shorter intervals between tourniquet removal and CTA imaging and longer total tourniquet times would be correlated with a higher likelihood of false positive CTA. MATERIALS AND METHODS: We performed a single-institution retrospective cohort study of patients presenting to a busy, urban Level 1 Trauma Center with prehospital tourniquets from 2019 to 2021. Patients who presented with a tourniquet disengaged upon arrival or who died prior to admission to the Trauma Unit were excluded. Tourniquet duration, time between tourniquet removal and CTA imaging (CTA interval), CTA findings, and management of extremity arterial injuries were extracted. The proportion of false positive injuries on CTA was assessed for correlation with increasing time interval from tourniquet removal to CTA imaging and correlation with increasing total tourniquet time using multivariable logistic regression. RESULTS: 251 patients were identified with prehospital tourniquets. 127 underwent CTA of the affected extremity, 96 patients had an abnormal CTA finding, and 57 (45% of total CTA patients) had false positive arterial injuries on imaging. Using multivariable logistic regression, neither the CTA interval nor the tourniquet duration was associated with false positive CTA injuries. Female sex was associated with false positive injuries on CTA (OR 2.91, 95% CI: 1.01 - 8.39). Vasospasm was cited as a possible explanation by radiologists in 40% of false positive CTA reports. CONCLUSIONS: Arterial vasospasm is a frequent finding on CTA after tourniquet use for extremity trauma, but concerns regarding tourniquet-related vasospasm should not alter trauma patient management. Neither the duration of tourniquet application nor the time interval since removal is associated with decreased CTA accuracy, and any delay in imaging does not appear to reduce the likelihood of vasospasm. These findings are important for supporting expedited care of trauma patients with severe extremity injuries.

Identifying temporal variations in burn admissions.

BACKGROUND: Variations in admission patterns have been previously identified in non-elective surgical services, but minimal data on the subject exists with respect to burn admissions. Improved understanding of the temporal pattern of burn admissions could inform resource utilization and clinical staffing. We hypothesize that burn admissions have a predictable temporal distribution with regard to the time of day, day of week, and season of year in which they present. STUDY DESIGN: A retrospective, cohort observational study of a single burn center from 7/1/2016 to 3/31/2021 was performed on all admissions to the burn surgery service. Demographics, burn characteristics, and temporal data of burn admissions were collected. Bivariate absolute and relative frequency data was captured and plotted for all patients who met inclusion criteria. Heat-maps were created to visually represent the relative admission frequency by time of day and day of week. Frequency analysis grouped by total body surface area against time of day and relative encounters against day of year was performed. RESULTS: 2213 burn patient encounters were analyzed, averaging 1.28 burns per day. The nadir of burn admissions was from 07:00 and 08:00, with progressive increase in the rate of admissions over the day. Admissions peaked in the 15:00 hour and then plateaued until midnight (p<0.001). There was no association between day of week in the burn admission distribution (p>0.05), though weekend admissions skewed slightly later (p = 0.025). No annual, cyclical trend in burn admissions was identified, suggesting that there is no predictable seasonality to burn admissions, though individual holidays were not assessed. CONCLUSION: Temporal variations in burn admissions exist, including a peak admission window late in the day. Furthermore, we did not find a predictable annual pattern to use in guiding staffing and resource allocation. This differs from findings in trauma, which identified admission peaks on the weekends and an annual cycle that peaks in spring and summer.

Multiyear experience with mobile online platform for documentation of acute care surgery fellows supervision.

BACKGROUND: There is currently no standard for documenting supervision of acute care surgery (ACS) fellows. To accomplish this goal, we developed a web-based survey that is accessible via mobile platform. We hypothesize that our mobile access survey is an effective, reproducible tool for assessing fellow clinical performance. METHODS: A retrospective review from 2016 to 2022 of all data captured in an encrypted database on all ACS fellows at our institution was performed. Supervision was defined as: Type 1 direct face-to-face, Type 2a immediately available in-house, Type 2b available after notification via phone with remote electronic medical record access, and Type 3 retrospective review. Data were collected by supervising faculty using a web-based clinical performance survey created by fellowship program leadership. Survey data collected included clinical summary, trainee, proctoring faculty, clinical service, operative/nonoperative, supervision type, Zwisch autonomy scale, time to input data, and graduate medical education milestone performance. Data were analyzed using descriptive statistics. RESULTS: A total of 883 proctoring events were identified, including the majority as Type 1 (97.4%). Trauma comprised 64% of evaluations. Fifty-two percent of the proctoring events were surgical cases. Complexity was graded as average (77%), hardest (16%), basic (7%). Guidance included supervision only, 491 of 666 (74%), with 26% requiring faculty intervention. Fellow performance was graded as average (66%), above average (31%), and below average/critical deficiency (3%). Graduate medical education performance was available for 247 of 883 interactions identifying 31 events with potential for improvement. Average evaluation completion time: 2 minutes (n = 134). CONCLUSION: A mobile web-based survey is a convenient and reliable tool for documenting ACS fellow clinical activity and was effectively used by all ACS faculty to record supervision. A combination of clinical and objective data is useful to determine ACS fellows' performance and to provide targeted education and remediation. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Acquired Tracheomalacia Requiring Urgent Tracheostomy Exchange in Patients With COVID-19.

Tracheostomy for prolonged ventilation of patients with COVID-19 was often delayed due to high viral loads and persistent high ventilatory requirements. With prolonged intubation and significant dose corticosteroid use, patients with COVID-19 are at risk for tracheomalacia, and urgent tube exchange may be required to address persistent cuff leak and to maintain adequate mechanical ventilation. We sought to describe our single center experience with COVID-19 patients requiring tracheostomy and the tracheal complications that followed. We performed a review of patients with COVID-19 who underwent tracheostomy from June 2020 to October 2021. 45 patients were identified; 82.2% survived their index hospitalization. Tracheostomy was performed after 16.4 days of mechanical ventilation. 22.2% required urgent exchange to an extended length tracheostomy tube after 7.2 days from initial tracheostomy. Placement of an extended length tracheostomy tube can reduce cuff leak in ventilated COVID-19 patients and may be considered during initial tracheostomy placement.

Prior Antibiotic Exposure Is Associated With Reoperation After Elective Non-colorectal Surgery.

BACKGROUND: Recent antibiotic exposure has previously been associated with poor outcomes following elective surgery. The purpose of this study is to evaluate the impact of prior recent antibiotic exposure in a multicenter cohort of Veterans Affairs patients undergoing elective non-colorectal surgery. METHODS: This is a retrospective cohort study of the Veterans Affairs Surgical Quality Improvement Program, including elective, non-cardiovascular, non-colorectal surgery from 2013 to 2017. Outpatient antibiotic exposure within 90 days prior to surgery was identified from the Veterans Affairs outpatient pharmacy database and matched with each case. Primary outcomes included serious complication, any complication, any infection, or surgical site infection. Secondary outcomes included 30-day mortality, length of stay, and Clostridioides difficile infection. RESULTS: Of 21,112 eligible patients, 2885 (13.7%) were exposed to antibiotics within 90 days prior to surgery with a duration of 7 (IQR: 5-10) days and prescribed 42 (IQR: 21-64) days prior to surgical intervention. Compared to non-exposed patients, exposed patients had higher unadjusted complication rates, increased length of stay, and rates of return to the operating. Exposure was independently associated with return to the operating room (OR: 1.39; 99% CI: 1.05-1.84). CONCLUSIONS: Among Veterans, recent antibiotic exposure within 90 days of elective surgery was associated with a 39% increase in the odds of return to the operating room. Further work is needed to evaluate the effects of antibiotic exposure and dysbiosis on surgical outcomes.

COVID-19 Vaccination Gap in Admitted Trauma Patients: A Critical Opportunity.

BACKGROUND: Coronavirus disease 2019 (COVID-19) vaccination is the core strategy for pandemic management. We hypothesized that a vaccination gap might exist between emergency department (ED) patients admitted for trauma and other ED patients. STUDY DESIGN: This was an observational quality improvement study using electronic health record data at an academic level-1 trauma center. Participants were all patients presenting to the adult ED with a Tennessee home address between January 1 and June 1, 2021. We measured the proportional difference in vaccination between admitted trauma patients and other ED patients over time (by week) and association via Spearman's rank correlation coefficient. Binary logistic regression facilitated covariate analysis to account for age, sex, race, home county, and ethnicity without and then with interaction between trauma admission and time. Geographic visual analysis compared county-level vaccination rates with odds of trauma admission by home county using a bivariate chloropleth map. RESULTS: The proportional difference in vaccination between trauma-admitted and other ED patients increased over time (Spearman's = 0.699). Adjusting for age, sex, race, home county, and ethnicity, there was a statistically significant vaccination difference between trauma-admitted and other ED patients (odds ratio = 0.53, 95% CI 0.43-0.65, p < 0.0001). Geographic analysis revealed increased trauma admission odds and lower vaccination rates in surrounding counties compared with Davidson County. CONCLUSIONS: We observed a widening COVID-19 vaccination gap between trauma-admitted and other ED patients. Vaccine outreach during trauma admission may provide a valuable point of contact for unvaccinated patients.

The choices we make: Ethical challenges in trauma surgery.

BACKGROUND: Ethical issues in trauma surgery are commonplace but scarcely studied. We aim to characterize the ethical dilemmas trauma surgeons encounter in clinical practice and describe perceptions about the ability to manage these dilemmas and strategies they use to address them. METHODS: Members of a U.S. trauma society were electronically surveyed on handling ethically challenging scenarios. The survey instrument was developed using published ethics literature and iterative cognitive interviews. Domains included perceived frequency of encountering and self-efficacy of managing ethical situations in trauma surgery. Common situations were defined as those encountered monthly or weekly. Ethical problems were categorized within 7 larger categories: general ethics, autonomy, communication, justice, end-of-life, conflict, and other. Descriptive analyses were performed; group comparisons were analyzed using analysis of variance. RESULTS: Of 1,748 surveyed, 548 responded (30.6%) and 154 (28%) were female. Most were White, under 55 years age, had completed fellowship training, and were practicing at a level I or II trauma center. The most encountered ethical categories were generic ethics and communication (79%). Issues involving conflict were least frequent (21%). Respondents felt most uncomfortable with autonomy topics. Respondents with high self-efficacy in handling ethical situations were older, in practice ≥15 years, served on an ethics committee, and/or frequently experienced ethical challenges. CONCLUSION: Most trauma surgeons regularly encounter ethical challenges, especially those related to communication. Trauma surgeons encounter ethical issues involving conflict least often, and lowest self-efficacy scores with issues involving autonomy. Experienced trauma surgeons reported higher self-efficacy scores in managing ethical issues. Future work should examine how self-efficacy translates to observed behavior, and how trauma surgeons build and enhance their ethical skillsets in the care of the injured patient.

Evaluating Discrepancies in Percent Total Body Surface Area Burn Assessments Between Prehospital Providers and Burn Center Physicians.

Burns are routinely assessed at the scene of the incident by prehospital or emergency medical services providers. The initial management of burns is based on the calculation of the extent of the injury, reported as percent total body surface area (TBSA). This study evaluates discrepancies in the estimation of TBSA between prehospital providers and burn team physicians over a 3-year period at an academic, university medical center serving as the regional burn center. A total of 120 adult and 27 pediatric patients (younger than age 16 years) were included in this study; 95 (65%) patients were male, 67 (46%) patients were Caucasian, 62 (42%) patients had no healthcare insurance, and the median age was 35 years (interquartile range [IQR] 27). The most common etiology of burns was hot liquid, 39 (26.5%). Median [IQR] and mean (SD) estimated TBSA (%) were 4 [1-10] and 8.6 (12.8) for prehospital providers and 2 [1-6] and 5.9 (9.9) for burn team physicians. Bland-Altman plots evaluating second- and third-degree burns separately and combined demonstrated that, as burns involved more surface area, agreement decreased between emergency medical service providers and burn physicians. Agreement between prehospital providers and burn physicians decreased as TBSA of burns increased. This finding reaffirms the need for more standardized education and training for all medical personnel.

Current Management of Gynecologic Trauma.

INTRODUCTION: To date, there are few reports describing the management of traumatic gynecologic injuries leaving physicians with little guidance. OBJECTIVE: Describe the injury patterns and the preferred management of these injuries. METHODS: A retrospective cohort study was performed using the National Trauma Data Bank (NTDB) from years 2011 to 2013. Female patients age 16 years and older with internal gynecologic injuries were identified based on diagnosis codes. Demographics, associated diagnoses and procedure codes were compiled for the cohort. RESULTS: 313 patients met inclusion criteria. The mechanism of injury was blunt in 236 (75%) patients, penetrating in 68 (21%), and other in 9 (4%). The mean Injury Severity Score was 16.6 ± 14.6. Mean age was 34 ± 21 years old. 226 (74.8%) patients had an ovarian and/or fallopian tube injury, 71 (25.2%) had a uterine injury, 8 (3%) had both, and 8 (3%) had injury to the ovarian or uterine vessels only. Of the 226 patients with ovarian and/or fallopian tube injury, 11(5%) underwent repair and 10 (4%) underwent salpingo-oophorectomy. Of the 71 uterine injuries, 15 (21%) underwent repair and 5 (7%) required a hysterectomy. CONCLUSIONS: Most traumatic internal gynecologic injuries result from blunt mechanism. Currently, these injuries are largely managed non-operatively. When surgery was performed, ovarian and uterine repair was more common than salpingo-oophorectomy and hysterectomy. Prospective large-scale studies are needed to establish a standard of treatment for the management of gynecologic trauma and to assess both short and long term outcomes and fertility rates.

Comparison of American Association for the Surgery of Trauma grading scale with modified Hinchey classification in acute colonic diverticulitis: A pilot study.

BACKGROUND: The American Association for the Surgery of Trauma (AAST) developed a severity scale for surgical conditions, including diverticulitis. The Hinchey classification requires operative intervention yet remains the established scoring system for acute diverticulitis. This is a pilot study to compare the AAST grading scale for acute colonic diverticulitis with the traditional Hinchey classification. We hypothesize that the AAST classification scale is equivalent to the Hinchey in predicting outcomes. METHODS: This is a retrospective cohort study at an academic medical center. A consecutive sample of patients with acute diverticulitis and computed tomography imaging was reviewed. Chart review identified demographic and physiologic data with interventional and clinical outcomes. Each computed tomography scan was assigned AAST and modified Hinchey classification scores by a radiologist. Multivariate regression and receiver operating characteristic curve analysis compared six outcomes: need for procedure, complication, intensive care unit (ICU) admission, length of stay, 30-day readmission, and mortality. RESULTS: One hundred twenty-nine patients were included. Of the total patients, 42.6% required procedural intervention, 21.7% required ICU admission, 18.6% were readmitted, and 6.2% died. Both AAST and Hinchey predicted the need for operation (AAST odds ratios, 1.55, 12.7, 18.09, and 77.24 for stages 2-5; Hinchey odds ratios, 8.85, 11.49, and 22.9 for stages 1b-3, stage 4 predicted perfectly). The need for operation c-statistics (area under the curve) for AAST and Hinchey was 0.80 and 0.83 for Hinchey and AAST, respectively (p = 0.35). The complication c-statistics curve for AAST and Hinchey was 0.83 and 0.80, respectively (p = 0.33). The AAST and Hinchey scores were less predictive for ICU admission, readmission, and mortality with c-statistics of less than 0.80. CONCLUSION: The AAST grading of acute diverticulitis is equivalent to the modified Hinchey classification in predicting procedural intervention and complications. The AAST system may be preferable to Hinchey because it can be applied preoperatively. Although this pilot study demonstrated that the AAST score predicts surgical need, a larger study is required to evaluate the AAST score for other outcomes. LEVEL OF EVIDENCE: Prognostic and epidemiological study, level III.

Antimotility agents for the treatment of acute noninfectious diarrhea in critically ill patients: A practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Acute noninfectious diarrhea is a common phenomenon in intensive care unit patients. Multiple treatments are suggested but the most effective management is unknown. A working group of the Eastern Association for the Surgery of Trauma, aimed to evaluate the effectiveness of loperamide, diphenoxylate/atropine, and elemental diet on acute noninfectious diarrhea in critically ill adults and to develop recommendations applicable to daily clinical practice. METHODS: The literature search identified 11 randomized controlled trials (RCT) appropriate for inclusion. The Grading of Recommendations Assessment, Development, and Evaluation methodology was applied to evaluate the effect of loperamide, diphenoxylate/atropine, and elemental diet on the resolution of noninfectious diarrhea in critically ill adults based on selected outcomes: improvement in clinical diarrhea, fecal frequency, time to the diarrhea resolution, and hospital length of stay. RESULTS: The level of evidence was assessed as very low. Analyses of 10 RCTs showed that loperamide facilitates resolution of diarrhea. Diphenoxylate/atropine was evaluated in three RCTs and was as effective as loperamide and more effective than placebo. No studies evaluating elemental diet as an intervention in patients with diarrhea were found. CONCLUSION: Loperamide and diphenoxylate/atropine are conditionally recommended to be used in critically ill patients with acute noninfectious diarrhea. LEVEL OF EVIDENCE: Systematic Review/Guidelines, level III.

Promotility agents for the treatment of ileus in adult surgical patients: A practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Ileus is a common challenge in adult surgical patients with estimated incidence to be 17% to 80%. The main mechanisms of the postoperative ileus pathophysiology are fluid overload, exogenous opioids, neurohormonal dysfunction, gastrointestinal stretch, and inflammation. Management includes addressing the underlying cause and supportive care. Multiple medical interventions have been proposed, but effectiveness is uncertain. A working group of the Eastern Association for the Surgery of Trauma aimed to evaluate the effectiveness of metoclopramide, erythromycin, and early enteral nutrition (EEN) on ileus in adult surgical patients and to develop recommendations applicable in a daily clinical practice. METHODS: Literature search identified 45 articles appropriate for inclusion. The Grading of Recommendations Assessment, Development and Evaluation methodology was applied to evaluate the effect of metoclopramide, erythromycin, and EEN on the resolution of ileus in adult surgical patients based on selected outcomes: return of normal bowel function, attainment of enteral feeding goal, and hospital length of stay. The recommendations were made based on the results of a systematic review, a meta-analysis, and evaluation of levels of evidence. RESULTS: The level of evidence for all PICOs was assessed as low. Neither metoclopramide nor erythromycin were effective in expediting the resolution of ileus. Analyses of 32 randomized controlled trials showed that EEN facilitates return of normal bowel function, achieving enteral nutrition goals, and reducing hospital length of stay. CONCLUSION: In patients who have undergone abdominal surgery, we strongly recommend EEN to expedite resolution of Ileus, but we cannot recommend for or against the use of either metoclopramide or erythromycin to hasten the resolution of ileus in these patients. LEVEL OF EVIDENCE: Type of Study Therapeutic, level II.

Incidence and Cause of Potentially Preventable Death after Civilian Public Mass Shooting in the US.

BACKGROUND: The incidence and severity of civilian public mass shooting (CPMS) events continue to rise. Understanding the wounding pattern and incidence of potentially preventable death (PPD) after CPMS is key to updating prehospital response strategy. METHODS: A retrospective study of autopsy reports after CPMS events identified via the Federal Bureau of Investigation CPMS database from December 1999 to December 31, 2017 was performed. Sites of injury, fatal injury, and incidence of PPD were determined independently by a multidisciplinary panel composed of trauma surgery, emergency medicine, critical care paramedicine, and forensic pathology. RESULTS: Nineteen events including 213 victims were reviewed. Mean number of gunshot wounds per victim was 4.1. Sixty-four percent of gunshots were to the head and torso. The most common cause of death was brain injury (52%). Only 12% (26 victims) were transported to the hospital and the PPD rate was 15% (32 victims). The most commonly injured organs in those with PPD were the lung (59%) and spinal cord (24%). Only 6% of PPD victims had a gunshot to a vascular structure in an extremity. CONCLUSIONS: The PPD rate after CPMS is high and is due mostly to non-hemorrhaging chest wounds. Prehospital care strategy should focus on immediate point of wounding care by both laypersons and medical personnel, as well as rapid extrication of victims to definitive medical care.

Wounding Patterns Based on Firearm Type in Civilian Public Mass Shootings in the United States.

BACKGROUND: There are no studies correlating wounding pattern or probability of death based on firearm type used in civilian public mass shooting (CPMS) events. Previous studies on non-CPMS events found that handguns are more lethal than rifles. We hypothesized that CPMS events associated with a handgun are also more lethal than those associated with a rifle. STUDY DESIGN: A retrospective study of autopsy reports from CPMS events was performed; CPMS was defined using the FBI and the Congressional Research Service definition. Site(s) of injury, site(s) of fatal injury, and presence of potentially preventable death (PPD) were determined independently by each author and cross-referenced to firearm type used. RESULTS: Autopsy reports of 232 victims from 23 events were reviewed. Seventy-three victims (31%) were shot by handguns, 105 (45%) by rifles, 22 (9%) by shotguns, and 32 (14%) by multiple firearms. Events using a handgun were associated with a higher percentage killed, and events using a rifle were associated with more people shot, although neither difference reached statistical significance. Victims shot by handguns had the highest percentage of having more than 1 fatal wound (26%); those shot by rifle had the lowest percentage (2%) (p = 0.003). Thirty-eight victims (16%) were judged to have had a PPD. The probability of having a PPD was lowest for events involving a handgun (4%) and highest for events involving a rifle (23%) (p = 0.002). Wounding with a handgun was significantly associated with brain (p = 0.007) and cardiac injury (p = 0.03). CONCLUSIONS: Civilian public mass shooting events with a handgun are more lethal than those associated with use of a rifle.

Ketamine in the Prehospital Environment: A National Survey of Paramedics in the United States.

BACKGROUND: Use of ketamine in the prehospital setting may be advantageous due to its potent analgesic and sedative properties and favorable risk profile. Use in the military setting has demonstrated both efficacy and safety for pain relief. The purpose of this study was to assess ketamine training, use, and perceptions in the civilian setting among nationally certified paramedics (NRPs) in the United States. METHODS: A cross-sectional survey of NRPs was performed. The electronic questionnaire assessed paramedic training, authorization, use, and perceptions of ketamine. Included in the analysis were completed surveys of paramedics who held one or more state paramedic credentials, indicated "patient care provider" as their primary role, and worked in non-military settings. Descriptive statistics were calculated. RESULTS: A total of 14,739 responses were obtained (response rate=23%), of which 10,737 (73%) met inclusion criteria and constituted the study cohort. Over one-half (53%) of paramedics reported learning about ketamine during their initial paramedic training. Meanwhile, 42% reported seeking ketamine-related education on their own. Of all respondents, only 33% (3,421/10,737) were authorized by protocol to use ketamine. Most commonly authorized uses included pain management (55%), rapid sequence intubation (RSI; 72%), and chemical restraint/sedation (72%). One-third of authorized providers (1,107/3,350) had never administered ketamine, with another 32% (1,070/3,350) having administered ketamine less than five times in their career. Ketamine was perceived to be safe and effective as the vast majority reported that they were comfortable with the use of ketamine (94%) and would, in similar situations (95%), use it again. CONCLUSION: This was the first large, national survey to assess ketamine training, use, and perceptions among paramedics in the civilian prehospital setting. While training related to ketamine use was commonly reported among paramedics, few were authorized to administer the drug by their agency's protocols. Of those authorized to use ketamine, most paramedics had limited experience administering the drug. Future research is needed to determine why the prevalence of ketamine use is low and to assess the safety and efficacy of ketamine use in the prehospital setting. Buckland DM , Crowe RP , Cash RE , Gondek S , Maluso P , Sirajuddin S , Smith ER , Dangerfield P , Shapiro G , Wanka C , Panchal AR , Sarani B . Ketamine in the prehospital environment: a national survey of paramedics in the United States. Prehosp Disaster Med. 2018;33(1):23-28.

Creation and Efficacy of a Cadaver-Based Prosection Anatomical Course for Critical Care Advanced Practice Providers.

OBJECTIVE: Intensive care units (ICUs) increasingly rely on advanced practice providers (APPs) to care for critically ill patients. Our institutional APPs perceived functional anatomical knowledge deficits. To meet this need, a cadaver-based prosection course was developed. The purpose of our study was to describe and evaluate the learner-perceived course efficacy. DESIGN: A precourse survey collected participant demographics. Precourse and postcourse surveys assessed perceived confidence in 13 anatomical areas. The postcourse survey also evaluated preparedness to perform ICU procedures and to care for postoperative patients, and additionally, gauged participant satisfaction and opinions. Summary statistics and pre-post survey comparisons were performed using Stata 14.0. PARTICIPANTS: Twenty-five APPs, all Advanced Practice Registered Nurse certified and working within our tertiary care ICUs, completed the course. Participants practiced in a variety of ICUs, inclusive of neurologic/neurosurgical (4.0%), burn (8.0%), medical (12.0%), trauma (28.0%) and surgical (48.0%), and typically held a Masters of Science in Nursing as his/her highest attained degree. Experience levels ranged from 0 to 8 years. RESULTS: Precourse survey results confirmed perceived anatomical knowledge deficits, noting median APP scores 3.00 or less, correlating to neutral to very little confidence, in all 13 queried anatomical areas. Wilcoxon signed-rank statistical analysis revealed significantly improved confidence level in anatomic knowledge following course completion in all 13 anatomical areas. Aligning with the improved confidence, most participants felt they were better prepared to perform ICU procedures and care for patients following operative intervention. CONCLUSION: Cadaver-based anatomical training has significant benefit to ICU APPs perceived knowledge and performance.