"Should We Phenobarb-it-All?" A Phenobarbital-Based Protocol for Non-Intensive Care Unit Trauma Patients at High Risk of or Experiencing Alcohol Withdrawal.

BACKGROUND: Alcohol use is frequent in trauma patients and alcohol withdrawal syndrome (AWS) is associated with significant morbidity. Benzodiazepines are commonly used for AWS, but may cause neurologic and respiratory adverse events (AEs). The objective was to evaluate the effectiveness and safety of a phenobarbital-based protocol for the treatment of AWS in non-intensive care unit (ICU) trauma patients. METHODS: Adult non-ICU trauma patients at high risk of or experiencing AWS PRE and POST implementation of a phenobarbital-based protocol were included. Outcomes were AWS-related complications (AWS-RC), benzodiazepine use, adjunctive medication use, hospital length of stay (HLOS), and medication-related AEs. Subgroup analyses were performed on patients with traumatic brain injury (TBI), rib fractures, and at high risk of severe AWS. RESULTS: Overall, 110 patients were included (51 PRE, 59 POST). AWS-RC developed in 17 PRE patients compared to 10 POST patients (33% vs 17%; P = .05). PRE patients were more likely to receive benzodiazepines (88% vs 42%, P < .0001) and higher total dose (11 vs 4 mg lorazepam equivalent; P = .001). No difference noted in HLOS (8 vs 8 days, P = .27), adjunctive medication use (49% vs 54%, P = .60), or AEs (57% vs 39%, P = .06). There was no difference in AWS-RC in the TBI subgroup (P = .19), less AEs in the rib fracture POST subgroup (P = .04), and less AWS-RC in the high risk of severe AWS POST subgroup (P = .03). DISCUSSION: A phenobarbital-based protocol in trauma patients is effective in preventing AWS-RC and decreasing benzodiazepine use without increasing AEs.

Failure rates of nonoperative management of low-grade splenic injuries with active extravasation: an Eastern Association for the Surgery of Trauma multicenter study.

Objectives: There is little evidence guiding the management of grade I-II traumatic splenic injuries with contrast blush (CB). We aimed to analyze the failure rate of nonoperative management (NOM) of grade I-II splenic injuries with CB in hemodynamically stable patients. Methods: A multicenter, retrospective cohort study examining all grade I-II splenic injuries with CB was performed at 21 institutions from January 1, 2014, to October 31, 2019. Patients >18 years old with grade I or II splenic injury due to blunt trauma with CB on CT were included. The primary outcome was the failure of NOM requiring angioembolization/operation. We determined the failure rate of NOM for grade I versus grade II splenic injuries. We then performed bivariate comparisons of patients who failed NOM with those who did not. Results: A total of 145 patients were included. Median Injury Severity Score was 17. The combined rate of failure for grade I-II injuries was 20.0%. There was no statistical difference in failure of NOM between grade I and II injuries with CB (18.2% vs 21.1%, p>0.05). Patients who failed NOM had an increased median hospital length of stay (p=0.024) and increased need for blood transfusion (p=0.004) and massive transfusion (p=0.030). Five patients (3.4%) died and 96 (66.2%) were discharged home, with no differences between those who failed and those who did not fail NOM (both p>0.05). Conclusion: NOM of grade I-II splenic injuries with CB fails in 20% of patients. Level of evidence: IV.

Outcomes of Protocol-Driven Venous Thromboembolic Chemo-Prophylaxis in Trauma Patients: A Trauma Quality Improvement Project Analysis.

INTRODUCTION: Low molecular weight heparin (LMWH) is the standard for venous thromboembolic (VTE) chemo-prophylaxis in trauma patients; however, inconsistencies in the use of LMWH exist. The objective of this study was to assess VTE outcomes in response to a chemo-prophylaxis protocol guided by patient physiology (eg, creatinine clearance) and comorbidities. METHODS: ACS TQIP Benchmark Reports at a level 1 trauma center using a patient physiology and comorbidity directed VTE chemo-prophylaxis protocol were analyzed for Spring 2019 to Fall 2021. Patient demographics, VTE rates and pharmacologic VTE prophylaxis type were collected for "All Patients" and "Elderly" (TQIP: age ≥ 55 years) cohorts. RESULTS: Data was analyzed for 1919183 "All Hospitals" (AH) and 5843 patients single institution (SI) using the physiologic and comorbidity guided VTE chemo-prophylaxis protocol. Elderly subgroup had 701965 (AH) and 2939 (SI) patients. Use of non-LMWH chemo-prophylaxis was significantly higher at SI: All patients = 62.6% SI vs 22.1% (P < .01); Elderly = 68.8% SI vs 28.1% AH (P < .01). VTE, DVT, and PE rates for All Patients and Elderly subgroup were significantly reduced at SI, except Elderly PE which was statistically equivalent. CONCLUSIONS: Protocol-driven VTE chemo-prophylaxis was associated with significantly lower LMWH use accompanied by significant reductions in All VTE, DVT, PE, and Elderly VTE and DVT with no difference in Elderly PE rates. These results may imply that adherence to a physiologic and comorbidity directed chemo-prophylaxis protocol, rather than LMWH, reduces VTE events in trauma patients. Further investigation to elucidate best practice is warranted.

Outcomes after ultramassive transfusion in the modern era: An Eastern Association for the Surgery of Trauma multicenter study.

BACKGROUND: Despite the widespread institution of modern massive transfusion protocols with balanced blood product ratios, survival for patients with traumatic hemorrhage receiving ultramassive transfusion (UMT) (defined as ≥20 U of packed red blood cells [RBCs]) in 24 hours) remains low and resource consumption remains high. Therefore, we aimed to identify factors associated with mortality in trauma patients receiving UMT in the modern resuscitation era. METHODS: An Eastern Association for the Surgery of Trauma multicenter retrospective study of 461 trauma patients from 17 trauma centers who received ≥20 U of RBCs in 24 hours was performed (2014-2019). Multivariable logistic regression and Classification and Regression Tree analysis were used to identify clinical characteristics associated with mortality. RESULTS: The 461 patients were young (median age, 35 years), male (82%), severely injured (median Injury Severity Score, 33), in shock (median shock index, 1.2; base excess, -9), and transfused a median of 29 U of RBCs, 22 U of fresh frozen plasma (FFP), and 24 U of platelets (PLT). Mortality was 46% at 24 hours and 65% at discharge. Transfusion of RBC/FFP ≥1.5:1 or RBC/PLT ≥1.5:1 was significantly associated with mortality, most pronounced for the 18% of patients who received both RBC/PLT and RBC/FFP ≥1.5:1 (odds ratios, 3.11 and 2.81 for mortality at 24 hours and discharge; both p < 0.01). Classification and Regression Tree identified that age older than 50 years, low initial Glasgow Coma Scale, thrombocytopenia, and resuscitative thoracotomy were associated with low likelihood of survival (14-26%), while absence of these factors was associated with the highest survival (71%). CONCLUSION: Despite modern massive transfusion protocols, one half of trauma patients receiving UMT are transfused with either RBC/FFP or RBC/PLT in unbalanced ratios ≥1.5:1, with increased associated mortality. Maintaining focus on balanced ratios during UMT is critical, and consideration of advanced age, poor initial mental status, thrombocytopenia, and resuscitative thoracotomy can aid in prognostication. LEVEL OF EVIDENCE: Prognostic, level III.

Biometric Analysis of Surgeons' Physiologic Responses During Surgery.

BACKGROUND: Much has been written from the social science perspective surrounding surgeons' stress and burn out. The literature is sparse in reference to scientific investigations of the hemodynamic effect of that stress. This prospective clinical study quantifies the physiologic impact of performing surgery upon the acute care surgeon. METHODS: Over 2.5 years, monitoring devices were affixed to surgeons prior to entering the operating room, and physiologic variables were documented every 30 minutes. Qualifying cases were projected as being greater than 2 hours with a baseline preoperative measurement obtained. Variables recorded included blood pressure (BP), heart rate (HR), rate pressure product (RPP), oxygen saturation (O2 sat), and end-tidal carbon dioxide (ET CO2). RESULTS: Statistically significant differences (P < .05) were found between baseline data to the maximum recording during the surgical operation for: BP (min 101 ± 6.6 (mmHg)-max 117 ± 5.1 (mmHg)), HR (min 70.5 ± 6.2 (bpm)-max 83.7 ± 9.0 (bpm)), O2 sat (min 97 ± 2.0 (%)-max 100 ± 0.22(%)), and ET CO2 (min 34.1 ± 1.15 mmHg-max 38 ± 1.7 mmHg) (P < .0001). The RPP ranged from 10.49 mmHg/min to 15.88 mmHg/min with a mean of 14.00 mmHg/min. DISCUSSION: The practice of surgery is considered demanding in training and lifestyle in comparison to other medical specialties. This data is among the first to demonstrate the negative physiological impact of surgery upon the metabolic demand of the surgeon. The longitudinal implications of increased physiologic demand over time may have cardiovascular and cerebrovascular consequences.

American College of Surgeons Committee on Trauma "Stop the Bleed Program": Quantifying the Impact of Training Upon Public School Educators Readiness.

BACKGROUND: School violence continues to afflict our educational institutions. In response, an institutional initiative was launched to train educators and school support staff in life-saving skills aimed at hemorrhage control. METHODS: The American College of Surgeons Committee on Trauma "Stop the Bleed" (STB) Program was promoted as a quality improvement initiative to schools within the geographic catchment area of this Level I Trauma Center. Participants were given the opportunity to take precourse, and postcourse confidence inventories using a Likert Scale. Statistical analysis of the 324 precourse to postcourse evaluations measuring change in confidence was used to evaluate improvement in readiness of school systems to respond in mass casualty incidents. RESULTS: Students enrolled in the STB Program were offered the opportunity to assess their confidence precourse and postcourse in reference to 7 questions. Precourse and postcourse Likert Scale inventories were compared and analyzed to assess the strength of the improvement in confidence using Student's t-test, where P < .05 is statistically significant. Students demonstrated improvement (P < .006) that was statistically significant across all 7-question relating to enhance confidence postcourse compared with the precourse. DISCUSSION: This STB quality initiative has demonstrated a statistically significant improvement in the confidence of teachers and school personnel to render lifesaving care in the event of a mass casualty or isolated incident of life-threatening hemorrhage. These results support the validity of the training in making a difference in this subpopulation of responders.

'Step Up' approach to the application of REBOA technology in a rural trauma system.

Our group has developed a 'Step Up' approach to the application of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in a rural trauma system. This incorporates viewing REBOA as a spectrum of technology. Examples of REBOA technology use to improve outcomes and provision of our system's clinical practice guideline for the Step-Up application of REBOA technology in the care of trauma patients are presented.

Moose-Motor Vehicle Collision: A Continuing Hazard in Northern New England.

BACKGROUND: Moose-motor vehicle collisions (MMVC) are especially dangerous to vehicle occupants because of the height and mass of the animal, which often collapses the roof and has a direct impact into the passenger compartment. STUDY DESIGN: Public data on MMVC were obtained from the states of New England (NE), and trauma registry data from centers in NH and ME. RESULTS: For all of NE, the annual incidence of reported MMVC has declined from a peak of >1,200 in 1998, but has still averaged >500 over the last 5 years, predominantly in ME, NH, and VT. Public education may have contributed to the decline, but the moose population has also apparently decreased due to environmental changes. In NE, MMVCs are most frequent in the summer months and evening hours. Maine data on crashes involving wild ungulates from 2003 to 2017 document 50,281 collisions with deer and 7,061 collisions with moose; 26 of the latter (0.37%) resulted in a human fatality. Logistic regression models demonstrate that vehicle occupant mortality, after controlling for multiple factors related to vehicle speed, is greatly increased when striking a moose rather than a deer (odds ratio [OR] 13.4, 95% CI 6.3, 28.7). In these data, there were no fatalities among occupants of Swedish cars, which are specifically engineered to tolerate MMVC. Three NH/ME trauma centers registered 124 cases of MMVC: median Injury Severity Score was 9; 5 patients died (4%); and 76 patients (61%) had injuries of the head, face, and/or cervical spine. CONCLUSIONS: Moose-motor vehicle collisions remain a frequent and serious hazard to motor vehicle occupants in northern NE. Trauma services should recognize characteristic injury patterns. Continuing public education, cautious driving, and moose herd management are warranted.

Increasing Referrals to a Community Paramedicine Fall Prevention Program Through Implementation of a Daily Management System.

This quality improvement project was undertaken to improve trauma service referral compliance to an existing home-based elderly fall prevention program through the implementation of a daily management system (DMS). Operational excellence, a hospital-wide initiative, provided the foundation for improvement efforts. This initiative went through a series of 5 plan, do, study, and act (PDSA) cycles and demonstrated significant improvement in referrals from 0% to 100%. Compliance with referrals after the retirement of the key performance indicator remained high at 95.5%. Results from this project provided support for the framework set forth in DMS and PDSA improvement methodologies as a feasible option to implement quality and process improvement projects. Further study in this area is warranted.