Warfarin, not direct oral anticoagulants or antiplatelet therapy, is associated with increased bleeding risk in emergency general surgery patients: Implications in this new era of novel anticoagulants: An EAST multicenter study.

INTRODUCTION: This study aimed to assess perioperative bleeding complications and in-hospital mortality in patients requiring emergency general surgery presenting with a history of antiplatelet (AP) versus direct oral anticoagulant (DOAC) versus warfarin use. METHODS: A prospective observational study across 21 centers between 2019 and 2022 was conducted. Inclusion criteria were age 18 years or older, and DOAC, warfarin, or AP use within 24 hours of an emergency general surgery procedure. Outcomes included perioperative bleeding and in-hospital mortality. The study was conducted using analysis of variance, χ 2 , and multivariable regression models. RESULTS: Of the 413 patients, 221 (53.5%) reported AP use, 152 (36.8%) DOAC use, and 40 (9.7%) warfarin use. The most common indications for surgery were obstruction (23% [AP], 45% [DOAC], and 28% [warfarin]), intestinal ischemia (13%, 17%, and 23%), and diverticulitis/peptic ulcers (7%, 7%, and 15%). Compared with DOAC use, warfarin use was associated with significantly higher perioperative bleeding complication (odds ratio [OR], 4.4 [95% confidence interval (CI), 2.0-9.9]). There was no significant difference in perioperative bleeding complication between DOAC and AP use (OR, 0.7 [95% CI, 0.4-1.1]). Compared with DOAC use, there was no significant difference in mortality between warfarin use (OR, 0.7 [95% CI, 0.2-2.5]) or AP use (OR, 0.5 [95% CI, 0.2-1.2]). After adjusting for confounders, warfarin use (OR, 6.3 [95% CI, 2.8-13.9]), medical history, and operative indication were associated with an increase in perioperative bleeding complications. However, warfarin was not independently associated with risk of mortality (OR, 1.3 [95% CI, 0.39-4.7]), whereas intraoperative vasopressor use (OR, 4.7 [95% CI, 1.7-12.8]), medical history, and postoperative bleeding (OR, 5.5 [95% CI, 2.4-12.8]) were. CONCLUSION: Despite ongoing concerns about the increase in DOAC use and lack of readily available reversal agents, this study suggests that warfarin, rather than DOACs, is associated with higher perioperative bleeding complications. However, that risk does not result in an increase in mortality, suggesting that perioperative decisions should be dictated by patient disease and comorbidities rather than type of AP or anticoagulant use. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Anticoagulation in emergency general surgery: Who bleeds more? The EAST multicenter trials ACES study.

BACKGROUND: While direct oral anticoagulant (DOAC) use is increasing in the Emergency General Surgery (EGS) patient population, our understanding of their bleeding risk in the acute setting remains limited. Therefore, the objective of this study was to determine the prevalence of perioperative bleeding complications in patients using DOACs versus warfarin and AP therapy requiring urgent/emergent EGS procedures (EGSPs). METHODS: This was a prospective observational trial, conducted between 2019 and 2022, across 21 centers. Inclusion criteria were 18 years or older, DOAC, warfarin/AP use within 24 hours of requiring an urgent/emergent EGSP. Demographics, preoperative, intraoperative, and postoperative data were collected. ANOVA, χ 2 , and multivariable regression models were used to conduct the analysis. RESULTS: Of the 413 patients enrolled in the study, 261 (63%) reported warfarin/AP use and 152 (37%) reported DOAC use. Appendicitis and cholecystitis were the most frequent indication for operative intervention in the warfarin/AP group (43.4% vs. 25%, p = 0.001). Small bowel obstruction/abdominal wall hernias were the main indication for operative intervention in the DOAC group (44.7% vs. 23.8%, p = 0.001). Intraoperative, postoperative, and perioperative bleeding complications and in-hospital mortality were similar between the two groups. After adjusting for confounders, a history of chemotherapy (odds ratio [OR], 4.3; p = 0.015) and indication for operative intervention including occlusive mesenteric ischemia (OR, 4.27; p = 0.016), nonocclusive mesenteric ischemia (OR, 3.13; p = 0.001), and diverticulitis (OR, 3.72; p = 0.019) were associated with increased perioperative bleeding complications. The need for an intraoperative transfusion (OR, 4.87; p < 0.001), and intraoperative vasopressors (OR, 4.35; p = 0.003) were associated with increased in-hospital mortality. CONCLUSION: Perioperative bleeding complications and mortality are impacted by the indication for EGSPs and patient's severity of illness rather than a history of DOAC or warfarin/AP use. Therefore, perioperative management should be guided by patient physiology and indication for surgery rather than the concern for recent antiplatelet or anticoagulant use. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level III.

Temporary intravascular shunts after civilian arterial injury: A prospective multicenter Eastern Association for the Surgery of Trauma study.

INTRODUCTION: We sought to determine the impact of the indication for shunt placement on shunt-related outcomes after major arterial injuries. We hypothesized that a shunt placed for damage control indications would be associated with an increase in shunt-related complications including shunt dislodgement, thrombosis, or distal ischemia. PATIENTS & METHODS: A prospective, multicenter study (eleven level one US trauma centers) of all adult trauma patients undergoing temporary intravascular shunts (TIVS) after arterial injury was undertaken (January 2017-May 2019). Exclusion criteria included age <15years, shunt placement distal to popliteal/brachial arteries, isolated venous shunts, and death before shunt removal. Clinical variables were compared by indication and shunt-related complications. The primary endpoint was TIVS complications (thrombosis, migration, distal ischemia). RESULTS: The 66 patients who underwent TIVS were primarily young (30years [IQR 22-36]) men (85%), severely injured (ISS 17 [10-25]) by penetrating mechanisms (59%), and had their shunts placed for damage control (41%). After a median SDT of 198min [89-622], 9% experienced shunt-related complications. Compared by shunt placement indication (damage control shunts [n=27] compared to non-damage control shunts [n=39]), there were no differences in gender, mechanism, extremity AIS, MESS score, fractures, or surgeon specialty between the two groups (all p>0.05). Patients with shunts placed for damage control indications had more severe injuries (ISS 23.5 compared to 13; SBP 100 compared to 129; GCS 11 compared to 15; lactate 11.5 compared to 3.6; all p<0.05), and had more frequent shunt complication predictors, but damage control shunts did not have significantly more TIVS complications (11.1% compared to 7.7%, p=0.658). Shunt complication patients were discharged home less often (33% vs 65%; p<0.05) but all survived. CONCLUSION: Shunts placed for damage control indications were not associated with shunt complications in this prospective, multicenter study.

Removal of the Prehospital Tourniquet in the Emergency Department.

BACKGROUND: Life-threatening hemorrhage from extremity injuries can be effectively controlled in the prehospital environment through direct pressure, wound packing, and the use of tourniquets. Early tourniquet application has been prioritized for rapid control of severe extremity hemorrhage and is a cornerstone of prehospital trauma resuscitation guidelines. Emergency physicians must be knowledgeable regarding the initial assessment and appropriate management of patients who present with a prehospital tourniquet in place. DISCUSSION: An interdisciplinary group of experts including emergency physicians, trauma surgeons, and tactical and Emergency Medical Services physicians collaborated to develop a stepwise approach to the assessment and removal (discontinuation) of an extremity tourniquet in the emergency department after being placed in the prehospital setting. We have developed a best-practices guideline to serve as a resource to aid the emergency physician in how to safely remove a tourniquet. The guideline contains five steps that include: 1) Determine how long the tourniquet has been in place; 2) Evaluate for contraindications to tourniquet removal; 3) Prepare for tourniquet removal; 4) Release the tourniquet; and 5) Monitor and reassess the patient. CONCLUSION: These steps outlined will help emergency medicine clinicians appropriately evaluate and manage patients presenting with tourniquets in place. Tourniquet removal should be performed in a systematic manner with plans in place to immediately address complications.

Potentially survivable fatal vascular access hemorrhage with tourniquet use: A post-mortem analysis.

BACKGROUND: The US military has prioritized battlefield hemorrhage control. Researchers credit tourniquet use, and a novel trauma care training program, with saving 1000-2000 lives in Iraq and Afghanistan. The Stop the Bleed campaign translates these lessons learned to the public. This is the first analysis of the potential impact of this newfound knowledge about tourniquet use for extremity fatal vascular access hemorrhage in a civilian population. Fatal vascular access hemorrhage includes bleeding from arteriovenous fistulas and grafts used for hemodialysis and central venous catheters. METHODS: This is a retrospective study of decedent records. We selected Maryland death records from 2002-2017 using the following search terms: "graft," "shunt," "fistula," "dialysis," and "central venous catheter." The records were analyzed for potential survivability with a checklist of military criteria modified for a civilian population. Suicides were excluded. Two reviewers independently classified the deaths as either potentially survivable or non-survivable, and a third reviewer broke ties. RESULTS: There were 111 deaths included in the final analysis. Ninety-two of the 111 decedents had potentially survivable extremity fatal vascular access hemorrhage. The remaining 19 records were excluded, because they did not have extremity hemorrhage. Zero decedents had hemorrhage deemed to be non-survivable with prompt tourniquet application. CONCLUSION: This study identified 92 Maryland extremity fatal vascular access hemorrhage decedents who potentially could have survived with tourniquet use-an average of 6 per year. These results suggest the need for further epidemiology investigation, as well as exploration of the risks and benefits of teaching and equipping vascular access patients and their caregivers to use tourniquets for life-threatening bleeding.

From the battlefield to main street: Tourniquet acceptance, use, and translation from the military to civilian settings.

Throughout history, battlefield medicine has led to advancements in civilian trauma care. In the most recent conflicts of Operation Enduring Freedom in Afghanistan/Operation Iraqi Freedom, one of the most important advances is increasing use of point-of-injury hemorrhage control with tourniquets. Tourniquets are gradually gaining acceptance in the civilian medical world-in both the prehospital setting and trauma centers. An analysis of Emergency Medical Services (EMS) data shows an increase of prehospital tourniquet utilization from 0 to nearly 4,000 between 2008 and 2016. Additionally, bystander educational campaigns such as the Stop the Bleed program is expanding, now with over 125,000 trained on tourniquet placement. Because the medical community and the population at large has broader acceptance and training on the use of tourniquets, there is greater potential for saving lives from preventable hemorrhagic deaths.

Resuscitative endovascular balloon occlusion of the aorta for non-traumatic intra-abdominal hemorrhage.

BACKGROUND: Hemorrhagic shock is the second leading cause of death in blunt trauma and a significant cause of mortality in non-trauma patients. The increased use of resuscitative endovascular balloon occlusion of the aorta (REBOA) as a bridge to definitive control for massive hemorrhage has provided promising results in the trauma population. We describe an extension of this procedure to our hemodynamically unstable non-trauma patients. METHODS: This is a retrospective review of patients requiring REBOA for end stage non-traumatic abdominal hemorrhage from our tertiary care facility. After excluding patients with trauma, supradiaphragmatic bleed and thoracic/abdominal aortic aneurysms, demographics, etiology of bleed, REBOA placement specifics, complications and outcomes were reviewed. RESULTS: From August 2013 to August 2016, 11 patients were identified requiring REBOA placement for hemodynamic instability from non-traumatic abdominal hemorrhage. Average patient age was 54.9 (SD 15.2). Sixty-four percent suffered cardiac arrest prior to REBOA, with mean shock index of 1.29. Average time from diagnosis of shock (MAP ≤ 65) or signs of bleeding to placement of REBOA was 177 min. The leading etiologies of hemorrhage were ruptured visceral aneurysm and massive upper gastrointestinal bleed. REBOA was placed by both acute care and vascular surgeons. The procedure was mainly completed in the operating room in 82% of the patients and at the bedside in 18%. One patient expired before operative repair. Definitive surgical control of the source of bleeding was obtained by open surgical approach (n = 6) and combined surgical and endovascular approach (n = 4). In-hospital survival was 64%. There were no local complications related to REBOA placement. CONCLUSION: Similar to the trauma population, REBOA is an adjunctive technique for proximal control of bleeding as well as resuscitation in end stage non-traumatic intra-abdominal hemorrhage. We propose an algorithmic approach to REBOA use in this population and a larger prospective review is necessary to determine both the timing of REBOA placement and which non-traumatic patients may benefit from this technique. LEVEL OF EVIDENCE: V. STUDY TYPE: Brief report.

"Second-look" laparotomy: warranted, or contributor to excessive open abdomens?

INTRODUCTION: The overuse of temporary abdominal closure and second look (SL) laparotomy in emergency general surgery (EGS) cases has been questioned in the recent literature. In an effort to hopefully decrease the number of open abdomen (OA) patients, we hypothesize that reviewing our cases, many of these SL patients could be managed with single-stage operative therapy and thus decrease the number of OA patients. METHODS: This is a retrospective review of prospectively collected data from Jun 2013-Jun 2014, evaluating EGS patients managed with an OA who required bowel resection in either index or SL laparotomy. Demographics, clinical variables, complications and mortality were collected. Fisher's exact t test was used for statistical analysis. RESULTS: During this time frame, 96 patients were managed with OA and 59 patients required a bowel resection. 55 (57%) of those required one bowel resection at the index operation with 4 (4.2%) only requiring one bowel resection at the second operation. In the patients requiring bowel resections, 18 (30%) required a resection at SL. At SL laparotomy, resection was required for questionably viable bowel at the index operation 60% (11), whereas 39% (7) had normal appearing bowel. Indications for resection at SL laparotomy included evolution of existing ischemia, new onset ischemia, staple line revision, and "other". 23 patients (39%) were hemodynamically unstable, contributing to the need for temporary abdominal closure. In the multivariate analysis, preoperative shock was the only predictor of need for further resection. Complications and mortality were similar in both groups. CONCLUSION: Almost one-fifth of the patients undergoing SL laparotomy for open abdomen required bowel resections, with 6.8% of those having normal appearing bowel at index operation, therefore in select EGS patients, SL laparotomy is a reasonable strategy.

Comparison of a novel, endoscopic chest tube insertion technique versus the standard, open technique performed by novice users in a human cadaver model: a randomized, crossover, assessor-blinded study.

BACKGROUND: The technique of tube thoracostomy has been standardized for years without significant updates. Alternative procedural methods may be beneficial in certain prehospital and inpatient environments with limited resources. We sought to compare the efficacy of chest tube insertion using a novel, endoscopic device (The Reactor™) to standard, open tube thoracostomy. METHODS: Novice users were randomly assigned to pre-specified sequences of six chest tube insertions performed on a human cadaver model in a crossover design, alternating between the Reactor™ and standard technique. All subjects received standardized training in both procedures prior to randomization. Insertion site, which was randomly assigned within each cadaver's hemithorax, was marked by the investigators; study techniques began with skin incision and ended with tube insertion. Adequacy of tube placement (intrapleural, unkinked, not in fissure) and incision length were recorded by investigators blinded to procedural technique. Insertion time and user-rated difficulty were documented in an unblinded fashion. After completing the study, participants rated various aspects of use of the Reactor™ compared to the standard technique in a survey evaluation. RESULTS: Sixteen subjects were enrolled (7 medical students, 9 paramedics) and performed 92 chest tube insertions (n = 46 Reactor™, n = 46 standard). The Reactor™ was associated with less frequent appropriate tube positioning (41.3% vs. 73.9%, P = 0.0029), a faster median insertion time (47.3 s, interquartile range 38-63.1 vs. 76.9 s, interquartile range 55.3-106.9, P < 0.0001) and shorter median incision length (28 mm, interquartile range 23-30 vs. 32 mm, interquartile range 26-40, P = 0.0034) compared to the standard technique. Using a 10-point Likert scale (1-easiest, 10-hardest) participants rated the ease of use of the Reactor™ no different from the standard method (3.8 ± 1.9 vs. 4.7 ± 1.9, P = 0.024). The Reactor™ received generally favorable scores for all parameters on the post-participation survey. CONCLUSIONS: In this randomized, assessor-blinded, crossover human cadaver study, chest tube insertion using the Reactor™ device resulted in faster insertion time and shorter incision length, but less frequent appropriate tube placement compared with the standard technique. Additional studies are needed to evaluate the efficacy, safety and potential advantages of this novel device.

Assessment of Anatomical Knowledge and Core Trauma Competency Vascular Skills.

Objectives: Surgical residents express confidence in performing specific vascular exposures before training, but such self-reported confidence did not correlate with co-located evaluator ratings. This study reports residents' self-confidence evaluated before and after Advanced Surgical Skills for Exposure in Trauma (ASSET) cadaver-based training, and 12-18 mo later. We hypothesize that residents will better judge their own skill after ASSET than before when compared with evaluator ratings. Methods: Forty PGY2-7 surgical residents performed four procedures: axillary artery (AA), brachial artery (BA), femoral artery exposure and control (FA), and lower extremity fasciotomy (FAS) at the three evaluations. Using 5-point Likert scales, surgeons self-assessed their confidence in anatomical understanding and procedure performance after each procedure and evaluators rated each surgeon accordingly. Results: For all the three evaluations, residents consistently rated their anatomical understanding (p < 0.04) and surgical performance (p < 0.03) higher than evaluators for both FA and FAS. Residents rated their anatomical understanding and surgical performance higher (p < 0.005) than evaluators for BA after training and up to 18 mo later. Only for third AA evaluation were there no rating differences. Conclusions: Residents overrate their anatomical understanding and performance abilities for BA, FA, and FAS even after performing the procedures and being debriefed three times in 18 mo.

Resuscitative Endovascular Balloon Occlusion of the Aorta: A Bridge to Flight Survival.

Trauma endures as the leading cause of death worldwide, and most deaths occur in the first 24 hours after initial injury as a result of hemorrhage. Historically, about 90% of battlefield deaths occur before the injured person arrives at a theater hospital, and most are due to noncompressible hemorrhage of the torso. Resuscitative endovascular balloon occlusion of the aorta is an evolving technique to quickly place a balloon into the thoracic or abdominal aorta to efficiently block blood flow to distal circulation. Maneuvers, such as resuscitative endovascular balloon occlusion of the aorta, to control endovascular hemorrhage offer a potential intervention to control noncompressible hemorrhage. This technique can be performed percutaneously or open in prehospital environments to restore hemodynamic functions and serve as a survival bridge until the patient is delivered to a treatment facility for definitive surgical hemostasis. This article describes the indications, complications, and application of resuscitative endovascular balloon occlusion of the aorta to military and civilian aeromedical transport.

Bringing Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Closer to the Point of Injury.

BACKGROUND: The management of noncompressible torso hemorrhage remains a significant issue at the point of injury. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used in the hospital to control bleeding and bridge patients to definitive surgery. Smaller delivery systems and wirefree devices may be used more easily at the point of injury by nonphysician providers. We investigated whether independent duty military medical technicians (IDMTs) could learn and perform REBOA correctly and rapidly as assessed by simulation. METHODS: US Air Force IDMTs without prior endovascular experience were included. All participants received didactic instruction and evaluation of technical skills. Procedural times and pretest/posttest examinations were administered after completion of all trials. The Likert scale was used to subjectively assess confidence before and after instruction. RESULTS: Eleven IDMTs were enrolled. There was a significant decrease in procedural times from trials 1 to 6. Overall procedural time (± standard deviation) decreased from 147.7 ± 27.4 seconds to 64 ± 8.9 seconds (ρ < .001). There was a mean improvement of 83.7 ± 24.6 seconds from the first to sixth trial (ρ < .001). All participants demonstrated correct placement of the sheath, measurement and placement of the catheter, and inflation of the balloon throughout all trials (100%). There was significant improvement in comprehension and knowledge between the pretest and posttest; average performance improved significantly from 36.4.6% ± 12.3% to 71.1% ± 8.5% (ρ < .001). Subjectively, all 11 participants noted significant improvement in confidence from 1.2 to 4.1 out of 5 on the Likert scale (ρ < .001). CONCLUSION: Technology for aortic occlusion has advanced to provide smaller, wirefree devices, making field deployment more feasible. IDMTs can learn the steps required for REBOA and perform the procedure accurately and rapidly, as assessed by simulation. Arterial access is a challenge in the ability to perform REBOA and should be a focus of further training to promote this procedure closer to the point of injury.

Stop the Bleed: Does the Training Work One Month Out?

The Stop the Bleed initiative empowers and trains citizens as immediate responders, to recognize and control severe hemorrhage. We sought to determine the retention of short-term knowledge and ability to apply a Combat Application Tourniquet (CAT) in 10 nonmedical personnel. A standard "Stop the Bleed" (Bleeding Control) course was taught including CAT application. Posttraining performance was assessed at 30 days using a standardized mannequin with a traumatic below-knee amputation. Technique, time, pitfalls, and feedback were all recorded. No participant had placed a CAT before the initial class. After the initial class, self-report by a Likert scale survey revealed an increased confidence in tourniquet application from 2.4 pretraining to 4.7 posttraining. At 30 days, confidence decreased to 3.4 before testing. Six of 10 were successful at tourniquet placement. Completion time was 77.75 seconds (43-157 seconds). Successful participants reported a confidence level of 4.7 versus those unsuccessful at 3.3. The "Stop the Bleed" initiative teaches lifesaving skills to the public through a short training course. This information regarding the training of nonmedical personnel may assist in strengthening training efforts for the public. Further investigations are needed to characterize skill degradation and retention over time.

Use of Resuscitative Endovascular Balloon Occlusion of the Aorta for Proximal Aortic Control in Patients With Severe Hemorrhage and Arrest.

Importance: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a percutaneous transfemoral balloon technique used in select centers for resuscitation and temporary hemostasis, often instead of emergency department thoracotomy. The ability to perform aortic occlusion (AO) with an intravascular device allows focused occlusion at the most distal level to perfuse proximal regions while slowing hemorrhage to injured areas. Objective: To describe what is to date the largest single-institution experience with REBOA in the United States. Design, Setting, and Participants: Use of REBOA at an urban tertiary care facility for severe traumatic hemorrhage, traumatic arrest (AR), or nontraumatic hemorrhage (NTH) was investigated from February 1, 2013, to January 31, 2017, among 90 patients who were not responsive or were transiently responsive to resuscitation measures, or were in arrest, from presumed hemorrhage below the diaphragm. Possible causes were trauma or nontrauma-related hemorrhage. Patients with ruptured aortic aneurysms were excluded. Main Outcomes and Measures: In-hospital mortality. Results: Of the 90 patients in the study (15 women and 75 men; mean [SD] age, 41.5 [17.4] years), 29 underwent REBOA for severe traumatic hemorrhage, 50 for AR, and 11 for NTH. For the patients with severe traumatic hemorrhage and AR, the median age was 36.2 years (interquartile range, 25.3-55.5 years), mean (SD) admission Glasgow Coma Scale score was 6 (5), and median Injury Severity Score was 39 (interquartile range, 10-75). The distal thoracic aorta was occluded in 73 patients (81%), and in all patients with AR. A total of 17 patients (19%) had distal abdominal AO. Mean (SD) systolic blood pressure improved in patients with severe traumatic hemorrhage, from 68 (28) mm Hg prior to AO, to 131 (12) mm Hg after AO (P < .001). Percutaneous access was used in 30 patients (33%), including 13 patients with AR (26%), and groin cutdown in 60 patients (67%), including 37 patients with AR (74%). Overall 30-day mortality was 62% (n = 56): 11 (39%) in patients with severe traumatic hemorrhage and 45 (90%) in patients with AR. Of the patients with AR, 29 (58%) had return of spontaneous circulation and 11 of those patients (38%) survived to the operating room. All patients who survived AR gained full neurologic recovery. No aortoiliac injury or limb loss occurred from REBOA use. Eleven patients underwent REBOA for NTH; 7 (64%) were in arrest. Overall in-hospital mortality for patients with NTH was 36% (n = 4). No procedural complications occurred in this group. Conclusions and Relevance: REBOA is a minimally invasive alternative to emergency department thoracotomy with aortic cross-clamp to temporize noncompressible torso hemorrhage and obtain proximal control in both traumatic and nontraumatic causes of hemorrhage. REBOA can also be used for more targeted AO in the distal aorta for pelvic, junctional, or extremity hemorrhage.

Time to aortic occlusion: It's all about access.

INTRODUCTION: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a less invasive method of proximal aortic occlusion compared with resuscitative thoracotomy with aortic cross-clamping (RTACC). This study compared time to aortic occlusion with REBOA and RTACC, both including and excluding time required for common femoral artery (CFA) cannulation. METHODS: This was a retrospective, single-institution review of REBOA or RTACC performed between February 2013 and January 2016. Time of skin incision to aortic cross-clamp for RTACC, time required for CFA cannulation by percutaneous and open methods, and time from guide-wire insertion to balloon inflation at Zone 1 for REBOA, were obtained from videographic recordings. RESULTS: Eighteen RTACC and 21 REBOAs were performed. Median (Q1, Q3) time from skin incision to aortic cross-clamping was 317 seconds (227, 551 seconds). Median (Q1, Q3) time from start of arterial access to Zone 1 balloon occlusion was 474 seconds (431, 572 seconds) (vs. RTACC, p = 0.01). All REBOA procedures were performed with the same device. The median time to complete CFA cannulation was 247 seconds (range, 164-343 seconds), with no difference between percutaneous or open procedures (p = 0.07). The median (Q1, Q3) time to aortic occlusion in REBOA once arterial access had been established was 245 seconds (179, 295.5 seconds), which was significantly shorter than RTACC (p = 0.003). CONCLUSIONS: Once CFA access is achieved, time to aortic occlusion is faster with REBOA. Time to aortic occlusion is less than the time required to cannulate the CFA either by percutaneous or open approaches, emphasizing the importance of accurate and expedient CFA access. Resuscitative endovascular balloon occlusion of the aorta may represent a feasible alternative to thoracotomy for aortic occlusion. Time to aortic occlusion will likely decrease with the advent of newer REBOA technology. The rate-limiting portion of REBOA continues to be obtaining CFA access. LEVEL OF EVIDENCE: Therapeutic, level V.

Head-camera video recordings of trauma core competency procedures can evaluate surgical resident's technical performance as well as colocated evaluators.

BACKGROUND: Unbiased evaluation of trauma core competency procedures is necessary to determine if residency and predeployment training courses are useful. We tested whether a previously validated individual procedure score (IPS) for individual procedure vascular exposure and fasciotomy (FAS) performance skills could discriminate training status by comparing IPS of evaluators colocated with surgeons to blind video evaluations. METHODS: Performance of axillary artery (AA), brachial artery (BA), and femoral artery (FA) vascular exposures and lower extremity FAS on fresh cadavers by 40 PGY-2 to PGY-6 residents was video-recorded from head-mounted cameras. Two colocated trained evaluators assessed IPS before and after training. One surgeon in each pretraining tertile of IPS for each procedure was randomly identified for blind video review. The same 12 surgeons were video-recorded repeating the procedures less than 4 weeks after training. Five evaluators independently reviewed all 96 randomly arranged deidentified videos. Inter-rater reliability/consistency, intraclass correlation coefficients were compared by colocated versus video review of IPS, and errors. Study methodology and bias were judged by Medical Education Research Study Quality Instrument and the Quality Assessment of Diagnostic Accuracy Studies criteria. RESULTS: There were no differences (p ≥ 0.5) in IPS for AA, FA, FAS, whether evaluators were colocated or reviewed video recordings. Evaluator consistency was 0.29 (BA) - 0.77 (FA). Video and colocated evaluators were in total agreement (p = 1.0) for error recognition. Intraclass correlation coefficient was 0.73 to 0.92, dependent on procedure. Correlations video versus colocated evaluations were 0.5 to 0.9. Except for BA, blinded video evaluators discriminated (p < 0.002) whether procedures were performed before training versus after training. Study methodology by Medical Education Research Study Quality Instrument criteria scored 15.5/19, Quality Assessment of Diagnostic Accuracy Studies 2 showed low bias risk. CONCLUSION: Video evaluations of AA, FA, and FAS procedures with IPS are unbiased, valid, and have potential for formative assessments of competency. LEVEL OF EVIDENCE: Prognostic study, level II.

Resuscitative Endovascular Balloon Occlusion of the Aorta: Pushing Care Forward.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA), used to temporize noncompressible and junctional hemorrhage, may be deployable to the forward environment. Our hypothesis was that nonsurgeon physicians and high-level military medical technicians would be able to learn the theory and insertion of REBOA. METHODS: US Army Special Operations Command medical personnel without prior endovascular experience were included. All participants received didactic instruction of the Basic Endovascular Skills for Trauma Course™ together, with individual evaluation of technical skills. A pretest and a posttest were administered to assess comprehension. RESULTS: Four members of US Army Special Operations Command-two nonsurgeon physicians, one physician assistant, and one Special Operations Combat Medic-were included. REBOA procedural times moving from trial 1 to trial 6 decreased significantly from 186 ± 18.7 seconds to 83 ± 10.3 seconds (ρ < .0001). All participants demonstrated safe REBOA insertion and verbalized the indications for REBOA insertion and removal through all trials. All five procedural tasks were performed correctly by each participant. Comprehension and knowledge between the pretest and posttest improved significantly from 67.6 ± 7.3% to 81.3 ± 8.1% (ρ = .039). CONCLUSION: This study demonstrates that nonsurgeon and nonphysician providers can learn the steps required for REBOA after arterial access is established. Although insertion is relatively straightforward, the inability to gain arterial access percutaneously is prohibitive in providers without a surgical skillset and should be the focus of further training.

Pneumatosis Intestinalis Predictive Evaluation Study: A multicenter epidemiologic study of the American Association for the Surgery of Trauma.

BACKGROUND: Our group has previously published a retrospective review defining variables predictive of transmural bowel ischemia in the setting of pneumatosis intestinalis (PI). We hypothesize this prospective study will confirm the findings of the retrospective review, enhancing legitimacy to the predictive factors for pathologic PI previously highlighted. METHODS: Data were collected using the Research Electronic Data Capture. Forward logistic regression was utilized to identify independent predictors for pathologic PI. Statistical significance was defined as p ≤ 0.05. RESULTS: During the 3-year study period, 127 patients with PI were identified. Of these, 79 had benign disease, and 49 pathologic PI defined by the presence of transmural ischemia during surgical exploration or autopsy. Laboratory values such as elevated international normalized ratio (INR), decreased hemoglobin, and a lactate value of greater than 2.0 mmol/L were predictive of pathologic PI, as well as clinical factors including adynamic ileus, peritoneal signs on physical examination, sepsis, and hypotension. The location was also a significant factor, as patients with small bowel PI had a higher incidence of transmural ischemia than colonic PI. On multiple logistic regression, lactate value of greater than 2.0 mmol/L (odds ratio, 5.1, 1.3-19.5; p = 0.018), elevated INR (odds ratio, 3.2, 1.1-9.6; p = 0.031), peritonitis (15.0, 2.9-78; p = 0.001), and decreased hemoglobin (0.70, 0.50-0.97, 0.031) remained significant predictors of transmural ischemia (area under the curve, 0.90; 0.83-0.97). A lactate value of 2.0 mmol/L or greater and peritonitis are common factors between the retrospective review and this prospective study. CONCLUSIONS: We recommend surgical exploration to be strongly considered for those PI patients presenting also with a lactate greater than 2 mmol/L and/or peritonitis. We suggest strong suspicion for necrosis in those patient with PI and small bowel involvement, ascites on computed tomography scan, adynamic ileus, anemia, and a high INR. LEVEL OF EVIDENCE: Prognostic study, level II; therapeutic study, level II.

Hydrophobically modified chitosan gauze: a novel topical hemostat.

BACKGROUND: Currently, the standard of care for treating severe hemorrhage in a military setting is Combat Gauze (CG). Previous work has shown that hydrophobically modified chitosan (hm-C) has significant hemostatic capability relative to its native chitosan counterpart. This work aims to evaluate gauze coated in hm-C relative to CG as well as ChitoGauze (ChG) in a lethal in vivo hemorrhage model. METHODS: Twelve Yorkshire swine were randomized to receive either hm-C gauze (n = 4), ChG (n = 4), or CG (n = 4). A standard hemorrhage model was used in which animals underwent a splenectomy before a 6-mm punch arterial puncture of the femoral artery. Thirty seconds of free bleeding was allowed before dressings were applied and compressed for 3 min. Baseline mean arterial pressure was preserved via fluid resuscitation. Experiments were conducted for 3 h after which any surviving animal was euthanized. RESULTS: hm-C gauze was found to be at least equivalent to both CG and ChG in terms of overall survival (100% versus 75%), number of dressing used (6 versus 7), and duration of hemostasis (3 h versus 2.25 h). Total post-treatment blood loss was lower in the hm-C gauze treatment group (4.7 mL/kg) when compared to CG (13.4 mL/kg) and ChG (12.1 mL/kg) groups. CONCLUSIONS: hm-C gauze outperformed both CG and ChG in a lethal hemorrhage model but without statistical significance for key endpoints. Future comparison of hm-C gauze to CG and ChG will be performed on a hypothermic, coagulopathic model that should allow for outcome significance to be differentiated under small treatment groups.

Stratification of risk to the surgical team in removal of small arms ammunition implanted in the craniofacial region: case report.

In cases of penetrating injury with implantation of small arms ammunition, it can often be difficult to tell the difference between simple ballistics and ballistics associated with unexploded ordnances (UXOs). In the operative environment, where highly flammable substances are often close to the surgical site, detonation of UXOs could have catastrophic consequences for both the patient and surgical team. There is a paucity of information in the literature regarding how to evaluate whether an implanted munition contains explosive material. This report describes a patient who presented during Operation Enduring Freedom with an implanted munition suspicious for a UXO and the subsequent workup organized by Explosive Ordnance Disposal (EOD) Company prior to surgical removal. Clinical risk factors for UXOs include assassination attempts and/or wartime settings. Specific radiological features suggestive of a UXO include projectile size greater than 7.62-mm caliber, alterations in density of the tip, as well as radiological evidence of a hollowed-out core. If an implanted UXO is suspected, risks to the surgical and anesthesia teams can be minimized by notifying the nearest military installation with EOD capabilities and following clinical practice guidelines set forth by the Joint Theater Trauma System.