Comparison of military and civilian surgeon outcomes with emergent trauma laparotomy in a mature military-civilian partnership.

Introduction: Medical readiness is of paramount concern for active-duty military providers. Low volumes of complex trauma in military treatment facilities has driven the armed forces to embed surgeons in high-volume civilian centers to maintain clinical readiness. It is unclear what impact this strategy may have on patient outcomes in these centers. We sought to compare emergent trauma laparotomy (ETL) outcomes between active-duty Air Force Special Operations Surgical Team (SOST) general surgeons and civilian faculty at an American College of Surgeons verified level 1 trauma center with a well-established military-civilian partnership. Methods: Retrospective review of a prospectively maintained, single-center database of ETL from 2019 to 2022 was performed. ETL was defined as laparotomy from trauma bay within 90 min of patient arrival. The primary outcome was to assess for all-cause mortality differences at multiple time points. Results: 514 ETL were performed during the study period. 22% (113 of 514) of patients were hypotensive (systolic blood pressure ≤90 mm Hg) on arrival. Six SOST surgeons performed 43 ETL compared with 471 ETL by civilian faculty. There were no differences in median ED length of stay (27 min vs 22 min; p=0.21), but operative duration was significantly longer for SOST surgeons (129 min vs 110 min; p=0.01). There were no differences in intraoperative (5% vs 2%; p=0.30), 6-hour (3% vs 5%; p=0.64), 24-hour (5% vs 5%; p=1.0), or in-hospital mortality rates (5% vs 8%; p=0.56) between SOST and civilian surgeons. SOST surgeons did not significantly impact the odds of 24-hour mortality on multivariable analysis (OR 0.78; 95% CI 0.10, 6.09). Conclusion: Trauma-related mortality for patients undergoing ETL was not impacted by SOST surgeons when compared with their civilian counterparts. Military surgeons may benefit from the valuable clinical experience and mentorship of experienced civilian trauma surgeons at high volume trauma centers without creating a deficit in the quality of care provided. Level of evidence: Level IV, therapeutic/care management.

Balanced resuscitation and earlier mortality end points: bayesian post hoc analysis of the PROPPR trial.

Introduction: The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial failed to demonstrate a mortality difference for hemorrhaging patients receiving a balanced (1:1:1) vs a 1:1:2 resuscitation at 24 hours and 30 days. Recent guidelines recommend earlier mortality end points for hemorrhage-control trials, and the use of contemporary statistical methods. The aim of this post hoc analysis of the PROPPR trial was to evaluate the impact of a balanced resuscitation strategy at early resuscitation time points using a Bayesian analytical framework. Methods: Bayesian hierarchical models were created to assess mortality differences at the 1, 3, 6, 12, 18, and 24 hours time points between study cohorts. Posterior probabilities and Bayes factors were calculated for each time point. Results: A 1:1:1 resuscitation displayed a 96%, 99%, 94%, 92%, 96%, and 94% probability for mortality benefit at 1, 3, 6, 12, 18, and 24 hours, respectively, when compared with a 1:1:2 approach. Associated Bayes factors for each respective time period were 21.2, 142, 14.9, 11.4, 26.4, and 15.5, indicating 'strong' to 'decisive' supporting evidence in favor of balanced transfusions. Conclusion: This analysis provides evidence in support that a 1:1:1 resuscitation has a high probability of mortality benefit when compared with a 1:1:2 strategy, especially at the newly defined more proximate time points during the resuscitative period. Researchers should consider using Bayesian approaches, along with more proximate end points when assessing hemorrhage-related mortality, for the analysis of future clinical trials. Level of evidence: Level III/Therapeutic.

Intra-abdominal packing does not increase infection risk or mandate longer presumptive antibiotic therapy.

BACKGROUND: Damage control laparotomy allows for resuscitation and reversal of coagulopathy with improved mortality. In-tra-abdominal packing is often used to limit hemorrhage. Temporary abdominal closure is associated with increased rates of subse-quent intra-abdominal infection. The effect of increased duration of antibiotics is unknown on these infection rates. We sought to determine the role of antibiotics in damage control surgery. METHODS: A retrospective analysis of all trauma patients requiring damage control laparotomy on admission to an ACS verified level one trauma center from 2011 to 2016 was performed. Demographic and clinical data including ability and time to attain primary fascial closure, as well as complication rates, were recorded. The primary outcome measure was intra-abdominal abscess formation following damage control laparotomy. RESULTS: Two-hundred and thirty-nine patients underwent DCS during the study period. A majority were packed (141/239, 59.0%). No differences existed in demographics or injury severity between groups, and infection rates were similar (30.5% vs. 38.8%, P=0.18). Patients with infection were more likely to have suffered gastric injury (23.3% vs. 6.1%, P=0.003) than those without complication. There was no significant association between gram negative and anaerobic (Odds Radio [OR] 0.96, 95% confidence interval [CI] 0.87-1.05) or antifungal therapy (OR 0.98, 95% CI 0.74-1.31) and infection rate, regardless of duration on multivariate regression CONCLUSION: Our study offers the first review of the effect of antibiotic duration on intra-abdominal complications following DCS. Gastric injury was more commonly identified in patients who developed intra-abdominal infection. Duration of antimicrobial therapy does not affect infection rate in patients who are packed following DCS.

The females have spoken: A patient-centered national survey on the administration of emergent transfusions with the potential for future fetal harm.

BACKGROUND: Traumatic hemorrhage is the leading cause of preventable death. Early in the resuscitation, only RhD-positive red blood cells are likely to be available, which poses a small risk of causing harm to a future fetus if transfused to an RhD-negative females of childbearing age (CBA), that is, 15 to 49 years old. We sought to characterize how the population, in particular females of CBA, felt about emergency blood administration vis-a-vis potential future fetal harm. METHODS: A national survey was performed using Facebook advertisements in three waves from January 2021 to January 2022. The advertisements directed users to the survey site with seven demographic questions and four questions on accepting transfusion with differing probabilities for future fetal harm (none/any/1:100/1:10,000). Acceptance of transfusion questions were scored on 3-point Likert scale (likely/neutral/unlikely). Only completed responses by females were analyzed. RESULTS: Advertisements were viewed 16,600,430 times by 2,169,805 people with 15,396 advertisement clicks and 2,873 surveys initiated. Most (2,256 of 2,873 [79%]) were fully completed. Majority (2,049 of 2,256 [90%]) of respondents were female. Eighty percent of females (1,645 of 2,049) were of CBA. Most females responded "likely" or "neutral" when asked whether they would accept a lifesaving transfusion if the following risk of fetal harm were present: no risk (99%), any risk (83%), 1:100 risk (85%), and 1:10,000 risk (92%). There were no differences between females of CBA versus non-CBA with respect to the likelihood of accepting lifesaving transfusion with any potential for future fetal harm ( p = 0.24). CONCLUSION: This national survey suggests that most females would accept lifesaving transfusion even with the potential low risk of future fetal harm. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

It is time to look in the mirror: Individual surgeon outcomes after emergent trauma laparotomy.

BACKGROUND: Multiple quality indicators are used by trauma programs to decrease variation and improve outcomes. However, little if any provider level outcomes related to surgical procedures are reviewed. Emergent trauma laparotomy (ETL) is arguably the signature case that trauma surgeons perform on a regular basis, but few data exist to facilitate benchmarking of individual surgeon outcomes. As part of our comprehensive performance improvement program, we examined outcomes by surgeon for those who routinely perform ETL. METHODS: A retrospective cohort study of patients undergoing ETL directly from the trauma bay by trauma faculty from December 2019 to February 2021 was conducted. Patients were excluded from mortality analysis if they required resuscitative thoracotomy for arrest before ETL. Surgeons were compared by rates of damage control and mortality at multiple time points. RESULTS: There were 242 ETL (7-32 ETLs per surgeon) performed by 14 faculties. Resuscitative thoracotomy was performed in 7.0% (n = 17) before ETL. Six patients without resuscitative thoracotomy died intraoperatively and damage-control laparotomy was performed on 31.9% (n = 72 of 226 patients). Mortality was 4.0% (n = 9) at 24 hours and 7.1% (n = 16) overall. Median Injury Severity Score (p = 0.21), new injury severity score (p = 0.21), and time in emergency department were similar overall among surgeons (p = 0.15), while operative time varied significantly (40-469 minutes; p = 0.005). There were significant differences between rates of individual surgeon's mortality (range [hospital mortality], 0-25%) and damage-control laparotomy (range, 14-63%) in ETL. CONCLUSION: Significant differences exist in outcomes by surgeon after ETL. Benchmarking surgeon level performance is a necessary natural progression of quality assurance programs for individual trauma centers. Additional data from multiple centers will be vital to allow for development of more granular quality metrics to foster introspective case review and quality improvement. LEVEL OF EVIDENCE: Therapeutic/care management, level III.

Perception of risk in massive transfusion as it relates to fetal outcomes: A survey of surgeons and nurses at one American trauma center.

BACKGROUND: The use of blood products early in the resuscitation of bleeding trauma patients is widely accepted, but made difficult by limited supplies of D- red blood cell (RBC)-containing products. Use of D+ RBC-containing products would alleviate this issue, but could lead to alloimmunization. Risk associated with transfusing D+ RBC in emergency bleeding situations is being reconsidered. The level of concern surrounding emergency transfusion as it relates to future fetal harm was surveyed among surgeons and nurses. METHODS: Faculty and staff in the Departments of Surgery and Nursing were surveyed on the risks of receiving an emergency RBC transfusion and the subsequent potential for fetal harm. Answers were grouped as likely to accept (likely/very likely) or refuse transfusion (unlikely/very unlikely). Participants were compared by sex, and women by child-bearing age, ([15-50 years] vs. [>50 years]). RESULTS: Ninety surveys were initiated with 76 fully completed. Male (n = 39) and female (n = 37) respondents were comparable. Most female respondents (30/37, 81%) were of childbearing age. Overall, both males (38/39, 95%) and females (33/37, 89%; p = .19) were likely to accept a transfusion in an emergency. There was no difference in transfusion acceptance if the risk of fetal harm was presented as 1% (p = .73) or 0.1% (p = .51). Most females (34/37, 92%) were not opposed to transfusion even if there was an unspecified risk of future fetal harm. CONCLUSION: Most of the surgeons and nurses who responded would accept a transfusion in an emergency situation even if it might lead to harming a future fetus.

Use of continuous intercostal nerve blockade is associated with improved outcomes in patients with multiple rib fractures.

BACKGROUND: Rib fractures are common among trauma patients and may result in significant morbidity and mortality. There are numerous treatment options, but ideal management is unclear. Delivery of local anesthetic via an analgesia catheter for continuous intercostal nerve blockade offers an attractive potential option for management of patients with rib fractures. METHODS: We performed a single-center, retrospective case-control analysis of trauma patients with multiple rib fractures from 2016 to 2018, comparing patients managed with continuous intercostal nerve blockade with standard care. Matching was performed in a 2:1 ratio by Injury Severity Score, age, and gender. Respiratory morbidity potentially secondary to rib fractures, including unplanned intubation, failure of extubation, need for tracheostomy, pneumonia, or mortality, were all identified and included. Potential complications due to catheter insertion were identified to be recorded. The primary outcome of interest was 30-day hospital-free days. RESULTS: Nine hundred and thirty-three patients were eligible for analysis, with 48 managed using intercostal blockade compared with 96 matching controls. No complications of intercostal blockade were identified during the study period. Controls demonstrated fewer rib fractures (6.60±4.11 vs. 9.3±3.73, p=0.001) and fewer flail segments (0.8±1.76 vs. 2.0±2.94, p=0.02). Those managed with intercostal blockade demonstrated significantly more 30-day hospital-free days (15.9±6.43 vs. 13.2±9.94, p=0.048), less incidence of pneumonia (4.2% vs. 16.7%, p=0.03), and lower hospital mortality (2.1% vs. 13.5%, p=0.03). When adjusting for number of rib fractures and number of flail segments, use of continuous intercostal nerve blockade was significantly associated with lower hospital mortality (OR 0.10; 95% CI 0.01 to 0.91), pneumonia (OR 0.15; 95% CI 0.03 to 0.76), or need for tracheostomy (OR 0.23; 95% CI 0.06 to 0.83). DISCUSSION: The addition of continuous intercostal nerve blockade may help to improve outcomes in patients with multiple rib fractures compared with standard care alone. LEVEL OF EVIDENCE: Therapeutic/care management; level IV.

Early comprehensive testing for COVID-19 is essential to protect trauma centers.

BACKGROUND: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic presents a threat to health care systems worldwide. Trauma centers may be uniquely impacted, given the need for rapid invasive interventions in severely injured and the growing incidence of community infection. We discuss the impact that SARS-CoV-2 has had in our trauma center and our steps to limit the potential exposures. METHODS: We performed a retrospective evaluation of the trauma service, from March 16 to 30, following the appearance of SARS-CoV-2 in our state. We recorded the daily number of trauma patients diagnosed with SARS-CoV-2 infection, the presence of clinical symptoms or radiological signs of COVID-19, and the results of verbal symptom screen (for new admissions). The number of trauma activations, admissions, and census, as well as staff exposures and infections, was recorded daily. RESULTS: Over the 14-day evaluation period, we tested 85 trauma patients for SARS-CoV-2 infection, and 21 (25%) were found to be positive. Sixty percent of the patients in the trauma/burn intensive care unit were infected with SARS-CoV-2. Positive verbal screen results, presence of ground glass opacities on admission chest CT, and presence of clinical symptoms were not significantly different in patients with or without SARS-CoV-2 infection (p > 0.05). Many infected patients were without clinical symptoms (9/21, 43%) or radiological signs on admission (18/21, 86%) of COVID-19. CONCLUSION: Forty-five percent of trauma patients are asymptomatic at the time of SARS-CoV-2 diagnosis. Respiratory symptoms, as well as verbal screening (recent fevers, shortness of breath, cough, international travel, and close contact with known SARS-CoV-2 carriers), are inaccurate in the trauma population. These findings demonstrate the need for comprehensive rapid testing of all trauma patients upon presentation to the trauma bay. LEVEL OF EVIDENCE: Diagnostic tests or criteria, level III, Therapeutic/care management, level IV.

Outcomes in patients with gunshot wounds to the brain.

INTRODUCTION: Gunshot wounds to the brain (GSWB) confer high lethality and uncertain recovery. It is unclear which patients benefit from aggressive resuscitation, and furthermore whether patients with GSWB undergoing cardiopulmonary resuscitation (CPR) have potential for survival or organ donation. Therefore, we sought to determine the rates of survival and organ donation, as well as identify factors associated with both outcomes in patients with GSWB undergoing CPR. METHODS: We performed a retrospective, multicenter study at 25 US trauma centers including dates between June 1, 2011 and December 31, 2017. Patients were included if they suffered isolated GSWB and required CPR at a referring hospital, in the field, or in the trauma resuscitation room. Patients were excluded for significant torso or extremity injuries, or if pregnant. Binomial regression models were used to determine predictors of survival/organ donation. RESULTS: 825 patients met study criteria; the majority were male (87.6%) with a mean age of 36.5 years. Most (67%) underwent CPR in the field and 2.1% (n=17) survived to discharge. Of the non-survivors, 17.5% (n=141) were considered eligible donors, with a donation rate of 58.9% (n=83) in this group. Regression models found several predictors of survival. Hormone replacement was predictive of both survival and organ donation. CONCLUSION: We found that GSWB requiring CPR during trauma resuscitation was associated with a 2.1% survival rate and overall organ donation rate of 10.3%. Several factors appear to be favorably associated with survival, although predictions are uncertain due to the low number of survivors in this patient population. Hormone replacement was predictive of both survival and organ donation. These results are a starting point for determining appropriate treatment algorithms for this devastating clinical condition. LEVEL OF EVIDENCE: Level II.

Diagnosis of diaphragm injuries using modern 256-slice CT scanners: too early to abandon operative exploration.

BACKGROUND: Missed injury of the diaphragm may result in hernia formation, enteric strangulation, and death. Compounding the problem, diaphragmatic injuries are rare and difficult to diagnose with standard imaging. As such, for patients with high suspicion of injury, operative exploration remains the gold standard for diagnosis. As no current data currently exist, we sought to perform a pragmatic evaluation of the diagnostic ability of 256-slice multidetector CT scanners for diagnosing diaphragmatic injuries after trauma. METHODS: A retrospective review of trauma patients from 2011 to 2018 was performed at an American College of Surgeons-verified level 1 trauma center to identify the diagnostic accuracy of CT scan for acute diaphragm injury. All patients undergoing abdominal operation were eligible for inclusion. Two separate levels of CT scan technology, 64-slice and 256-slice, were used during this time period. The prospective imaging reports were reviewed for the diagnosis of diaphragm injury and the results confirmed with the operative record. Injuries were graded using operative description per the American Association for the Surgery of Trauma guidelines. RESULTS: One thousand and sixty-eight patients underwent operation after preoperative CT scan. Acute diaphragm injury was identified intraoperatively in 14.7%. Most with diaphragmatic injury underwent 64-slice CT (134 of 157, 85.4%). Comparing patients receiving 64-slice or 256-slice CT scan, there was no difference in the side of injury (left side 57.5% vs. 69.6%, p=0.43) or median injury grade (3 (3, 3) vs. 3 (2, 3), p=0.65). Overall sensitivity, specificity, and diagnostic accuracy of the 256-slice CT were similar to the 64-slice CT (56.5% vs. 45.5%, 93.7% vs. 98.1%, and 89.0% vs. 90.2%). DISCUSSION: The new 256-slice multidetector CT scanner fails to sufficiently improve diagnostic accuracy over the previous technology. Patients with suspicion of diaphragm injury should undergo operative intervention. LEVEL OF EVIDENCE: I, diagnostic test or criteria.

Impact of initial temporary abdominal closure in damage control surgery: a retrospective analysis.

Background: Damage control surgery has revolutionized trauma surgery. Use of damage control surgery allows for resuscitation and reversal of coagulopathy at the risk of loss of abdominal domain and intra-abdominal complications. Temporary abdominal closure is possible with multiple techniques, the choice of which may affect ability to achieve primary fascial closure and further complication. Methods: A retrospective analysis of all trauma patients requiring damage control laparotomy upon admission to an ACS-verified level one trauma center from 2011 to 2016 was performed. Demographic and clinical data including ability and time to attain primary fascial closure, as well as complication rates, were recorded. The primary outcome measure was ability to achieve primary fascial closure during initial hospitalization. Results: Two hundred and thirty-nine patients met criteria for inclusion. Primary skin closure (57.7%), ABThera™ VAC system (ABT) (15.1%), Bogota bag (BB) (25.1%), or a modified Barker's vacuum-packing (BVP) (2.1%) were used in the initial laparotomy. Patients receiving skin-only closure had significantly higher rates of primary fascial closure and lower hospital mortality, but also significantly lower mean lactate, base deficit, and requirement for massive transfusion. Between ABT or BB, use of ABT was associated with increased rates of fascial closure. Multivariate regression revealed primary skin closure to be significantly associated with primary fascial closure while BB was associated with failure to achieve fascial closure. Conclusions: Primary skin closure is a viable option in the initial management of the open abdomen, although these patients demonstrated less injury burden in our study. Use of vacuum-assisted dressings continues to be the preferred method for temporary abdominal closure in damage control surgery for trauma.

Novel microRNA correlations in the severely injured.

PURPOSE: Severe injury initiates an inflammatory response that can perpetuate immunological dysfunction, uncontrolled inflammation, and subsequent multisystem organ failure. MicroRNAs (miRNAs) have recently been identified as regulators of this inflammatory response. Our study sought to identify the differential expression of unique miRNAs and their correlations with genes of the Toll-like receptor (TLR) pathways, and clinical parameters in the severely injured. METHODS: Fourteen trauma patients requiring transfusion were prospectively enrolled in this institutional review board-approved study. Inclusion criteria consisted of adult patients deemed clinically to be in hemorrhagic shock necessitating transfusion in the acute phase of their injury care. Peripheral blood samples were obtained after admission to the surgical intensive care unit. Expression of circulating mature miRNA from each patient, as well as from 10 healthy, age-matched controls, was determined and compared using the HiSeq 2500 sequencing system and the R software system. Gene expression of TLR signaling pathways for each patient was examined using custom gene expression polymerase chain reaction arrays. Statistical analyses were performed using general linear models and empirical Bayes methods to determine differential expression and Spearman's nonparametric correlation analysis. RESULTS: Subjects were 21-77 years old (mean, 42), 80% male, Injury Severity Score 11-43 (mean, 26), with 11 blunt and 3 penetrating injuries. Three were intubated and 5 received blood products before arrival. Base deficit upon hospital admission was 3 to 20 (mean, 9). All patients required blood transfusion secondary to blood loss sustained during injury. Survival to discharge was 93%. Controls were 27-64 years old (mean, 40) and 60% male. Sequencing analysis revealed 69 differentially expressed miRNAs (P < .05) in the severely injured. Within the differentially expressed miRNAs, there were 12 direct and 6 indirect correlations with multiple genes involved in the TLR3 and TLR4 signaling pathways. The relationships between these same miRNAs and clinical parameters were also analyzed. We discovered 4 direct correlations with base deficit and HCO3, and 7 indirect correlations involving total fresh frozen plasma transfused, base deficit, HCO3, and PaCO2 levels. CONCLUSION: Differential expression and correlations between miRNAs, genes of the TLR pathways, and clinical parameters are unique findings in the severely injured and may lead to a greater understanding of the regulation of sterile inflammation after severe injury.