Nutritional Considerations for Patients With Renal Failure Undergoing Sleeve Gastrectomy.

Obesity is highly prevalent in patients with renal disease, as it contributes to or accelerates the progression of kidney disease and is frequently a barrier to kidney transplantation. Patients with renal disease have unique dietary needs due to various metabolic disturbances resulting from altered processing and clearance of nutrients. They also frequently present with physical disability, resulting in difficulty achieving adequate weight loss through lifestyle modifications. Therefore, kidney transplant candidates may benefit from bariatric surgery, particularly sleeve gastrectomy (SG), as the safest, most effective, and long-lasting weight loss option to improve comorbidities and access to transplantation. However, concerns regarding nutritional risks prevent broader dissemination of SG in this population. No specific guidelines tailored to the nutritional needs of patients with renal disease undergoing SG have been developed. Moreover, appropriate monitoring strategies and interventions for muscle loss and functional status preservation, a major concern in this at-risk population, are unknown. We aimed to summarize the available literature on the nutritional requirements of patients with renal disease seeking SG as a bridge to transplantation. We also provide insight and guidance into the nutritional management pre and post-SG.

Deterioration Index in Critically Injured Patients: A Feasibility Analysis.

INTRODUCTION: Continuous prediction surveillance modeling is an emerging tool giving dynamic insight into conditions with potential mitigation of adverse events (AEs) and failure to rescue. The Epic electronic medical record contains a Deterioration Index (DI) algorithm that generates a prediction score every 15 min using objective data. Previous validation studies show rapid increases in DI score (≥14) predict a worse prognosis. The aim of this study was to demonstrate the utility of DI scores in the trauma intensive care unit (ICU) population. METHODS: A prospective, single-center study of trauma ICU patients in a Level 1 trauma center was conducted during a 3-mo period. Charts were reviewed every 24 h for minimum and maximum DI score, largest score change (Δ), and AE. Patients were grouped as low risk (ΔDI <14) or high risk (ΔDI ≥14). RESULTS: A total of 224 patients were evaluated. High-risk patients were more likely to experience AEs (69.0% versus 47.6%, P = 0.002). No patients with DI scores <30 were readmitted to the ICU after being stepped down to the floor. Patients that were readmitted and subsequently died all had DI scores of ≥60 when first stepped down from the ICU. CONCLUSIONS: This study demonstrates DI scores predict decompensation risk in the surgical ICU population, which may otherwise go unnoticed in real time. This can identify patients at risk of AE when transferred to the floor. Using the DI model could alert providers to increase surveillance in high-risk patients to mitigate unplanned returns to the ICU and failure to rescue.

Traumatic Injury in Pregnancy: A Propensity Score-Matched Analysis.

INTRODUCTION: Trauma represents the leading cause of nonobstetrical maternal death. How in-hospital outcomes of acutely injured pregnant patients (PP) compares to that of similarly aged nonpregnant control groups (CGs) has not been described. We hypothesized that PPs suffering acute traumatic injuries would have worse outcomes compared to a matched CG. MATERIALS AND METHODS: The American College of Surgeons Trauma Quality Improvement Program (TQIP) was used to identify traumatically injured females between 2017 and 2019. Propensity score matching on age, race, injury severity score , and type of trauma (blunt, penetrating, or other) was used to compare PPs and the CG. Primary outcomes were mortality, disposition, length of stay (LOS), and complications. RESULTS: A total of 1078 traumatically injured pregnant females were identified. Propensity score matching resulted in 990 patients in the PP and CG cohorts. After matching, PPs were more likely to be assault victims (11% versus 6%, P < 0.001), had longer length of stay (LOS) (5 versus 3 d, P < 0.001), and were more likely to require mechanical ventilation (26% versus 16%, P < 0.001) or intensive care unit (ICU) admission (44% versus 32%, P < 0.001). PPs were more likely to proceed directly to the operating room (OR)(34% versus 15%, P < 0.001) and less likely to be discharged home from the emergency department (ED) (1% versus 12%, P < 0.001). Complications and mortality rates were similar among PPs. CONCLUSIONS: After acute trauma, PPs did not have increased mortality or complications when compared to matched controls, although they were more likely to be victims of assault, directly proceed to the OR, require mechanical ventilation or ICU admission, and have longer LOSs.

Battle of the buttress: 5-year propensity-matched analysis of staple-line reinforcement techniques from the MBSAQIP database.

BACKGROUND: Vertical sleeve gastrectomy (VSG) has demonstrated to be safe; however, controversy remains on how to decrease major complications, particularly bleeding and leaks. There are variations in staple-line reinforcement techniques, including no reinforcement, oversewing, and buttressing. We sought to evaluate the effect of those methods on post-operative complications using the Metabolic and Bariatric Surgery Accreditation Quality Initiative Program (MBSAQIP) database. METHODS: The MBSAQIP was queried for patients who underwent VSG during 2015-2019. A propensity-matched analysis was performed between different staple-line reinforcement (SLR) methods, specifically No reinforcement (NR), Oversewing (OS), and Buttressing (BR). The primary outcome of interest was complications within 30 days. RESULTS: A total of 513,354 VSG cases were analyzed. The cohort was majority female (79.0%), with mean (SD) age of 44.2 ± 11.9 years and mean BMI of 45 ± 7.8 kg/m2. Frequency of SLR methods used was 54%BR, 25.6%NR, 10.8% BR + OS, and 9.8%OS. There were no differences in rate of leaks among SLR methods. Compared to NR, BR was associated with decreased rate of reoperations, overall bleeding, and major bleeding (p < 0.05) but prolonged operative time and length of stay (LOS) (p < 0.05). OS was associated with decreased overall bleeding (p < 0.05) but prolonged operative times and length of stay (p < 0.05) compared to NR. Compared to BR, OS was associated with increased operative times, LOS, and rates of post-operative ventilator use, pneumonia, and venous thrombosis (p < 0.05). Patients with bleeding were associated with lower rate of BR (56% vs 61%) and higher rate of NR (34% vs 28%) compared to patients with no bleeding. Bleeding was associated with a greater frequency of leaks (4.4% vs 0.3%), along with higher morbidity and mortality (p < 0.05). CONCLUSIONS: Of the reinforcement methods evaluated, BR and OS were both associated with decreased bleeding despite longer operative times. No method was found to significantly reduce incidence of leaks; however, bleeding was associated with increased incidence of leaks, morbidity, and mortality. The liberal use of SLR techniques is recommended for further optimization of patient outcomes after VSG.

Thromboembolic Outcomes in Tetrahydrocannabinol-Positive Trauma Patients With Traumatic Brain Injury.

INTRODUCTION: Traumatic brain injury (TBI) is a significant source of morbidity and mortality in the United States. Recent shifts in state legislation have increased the use of recreational and medical marijuana. While cannabinoids and tetrahydrocannabinol (THC) have known anti-inflammatory effects, the impact of preinjury THC use on clinical outcomes in the setting of severe TBI is unknown. We hypothesized that preinjury THC use in trauma patients suffering TBI would be associated with decreased thromboembolic events and adverse outcomes. METHODS: The American College of Surgeons Trauma Quality Improvement Program was used to identify patients aged ≥18 y with TBI and severe injury (Injury Severity Score ≥ 16) in admit year 2017. Patients with smoking or tobacco history or missing or positive toxicology tests for drug and/or alcohol use other than THC were excluded. Propensity score matching was used to compare THC+ patients to similar THC- patients. RESULTS: A total of 13,266 patients met inclusion criteria, of which 1669 were THC+. A total of 1377 THC+ patients were matched to 1377 THC- patients. No significant differences were found in in-hospital outcomes, including mortality, length of stay, cardiac arrest, pulmonary embolism, deep vein thrombosis, or acute respiratory distress syndrome. No patients had ischemic stroke, and THC+ patients had significantly decreased rates of hemorrhagic stroke (0.5% versus 1.5%, P = 0.02, odds ratio 0.41 [95% confidence interval 0.18-0.86]). CONCLUSIONS: Preinjury THC use may be associated with decreased hemorrhagic stroke in severely injured patients with TBI, but there was no difference in thromboembolic outcomes. Further research into pathophysiological mechanisms related to THC are needed.

Trends and Burden of Firearm-Related Injuries Among Children and Adolescents: A National Perspective.

INTRODUCTION: Firearm-related injuries in America have been under increasing scrutiny over the last several years. Few studies have examined the burden of these injuries in the pediatric population. The objective of this study was to describe the incidence of firearm-related injuries in hospitalized pediatric patients in the United States and identify the risk factors associated with readmission in this young population. METHODS: The Nationwide Readmission Database was examined from 2010 to 2017. Pediatric patients (aged ≤18 y) who survived their index hospitalization for any firearm injury were analyzed to determine incidence rate, case fatality rate, risk factors for 30-d readmission, and financial health care burden. RESULTS: There were 35,753 pediatric firearm injuries (86.8% male) with an overall incidence rate of 10.49 (95% confidence interval [CI]: 9.26-11.71) per 100,000 pediatric hospitalizations. Adolescents aged >12 y had the highest incidence rate (60.51, 95% CI: 55.19-65.84). In-hospital mortality occurred in 1948 cases (5.5%), with higher case fatality rates in males. There were 1616 (5.7%) unplanned 30-d readmissions. Multivariate analysis showed abdominal firearm injuries (hazard ratio: 1.13, 95% CI: 1.03-1.24; P = 0.006) and longer length of stay (hazard ratio: 1.27, 95% CI: 1.04-1.55; P = 0.016) were associated with a greater risk of 30-d readmission. The median health care cost for firearm-related injuries was $36,535 (interquartile range: $19,802-$66,443), 22% of which was due to readmissions. Cost associated with 30-d readmissions was $7978 (interquartile range: $4305-$15,202). CONCLUSIONS: Firearm-related injury is a major contributor to pediatric morbidity, mortality, and health care costs. Males are disproportionately affected by firearm injury, but females are more likely to require unplanned 30-d readmissions. Interventions should target female sex, injuries of suicidal intent, psychiatric comorbidities, prolonged index hospitalization, and abdominal injuries.

A Propensity-Matched Analysis of Tranexamic Acid and Acute Respiratory Distress Syndrome in Trauma Patients.

INTRODUCTION: Tranexamic acid (TXA) protects the vasculature endothelium after hemorrhage, resulting in a decreased capillary leak. These properties may protect patients receiving TXA from acute respiratory distress syndrome (ARDS), however, clinical studies have yet to examine this topic. We hypothesized that trauma patients receiving TXA would have lower incidence of ARDS. METHODS: This was a retrospective review of adult (18+ y) patients who presented to a large Level I trauma center with an injury severity score ≥ 16 from admit years 2012-2020. Propensity matching was employed to examine how TXA administration is associated with ARDS. RESULTS: There were a total of 2751 patients meeting study criteria, with 162 (5.9%) received TXA. Of the 162 patients that received TXA, only 12 (7.4%) received pre-hospital TXA, while 4 (2.5%) received TXA both pre-hospital and in hospital. Of the 63 patients developing ARDS, 62 (98.4%) did not receive TXA. After propensity matching, 304 patients remained, with 152 in each cohort. The incidence of ARDS (P = 0.08), pneumonia (P = 0.68), any pulmonary complication (P = 0.33), and mortality (P = 0.37) were not different in patients receiving TXA on propensity matching. CONCLUSIONS: TXA did not protect trauma patients from pulmonary complications; however, nearly all patients developing ARDS did not receive TXA. Larger studies should examine this relationship to improve understanding of therapies that may prevent ARDS.

Trampoline Injuries in Children and Adolescents: A Jumping Threat.

OBJECTIVE: As trampoline use grows more popular in the United States, the frequency of injuries continues to climb. We hypothesized that toddlers would be at the highest risk for trampoline injuries requiring hospitalization. METHODS: The National Electronic Injury Surveillance System database was examined for trampoline injuries from 2009 to 2018. Patients were categorized into 3 main age groups: toddlers (<2 years), children (2-12 years), and adolescents (13-18 years). Regression models were used to identify patients at high risk for injury or hospitalization. RESULTS: There was a total of 800,969 meeting inclusion criteria, with 433,827 (54.2%) occurring at their own homes and 86,372 (18.1%) at the sporting venue. Of the total, 36,789 (4.6%) were admitted to a hospital. Fractures (N = 270,884, 34%), strain/sprain injuries (N = 264,990, 33%), followed by skin contusions/abrasions (N = 115,708, 14%) were the most common diagnoses. The most frequent injury sites were lower and upper extremities accounting for 329,219 (41.1%) and 244,032 (30.5%), whereas 175,645 (21.9%) had head and neck injuries. Musculoskeletal injuries (74%) and concussions (2.6%) were more frequent in adolescents than children (67.6% and 1.6%) and toddlers (56.3% and 1.3%). Internal organ and soft tissue injuries were frequent in toddlers. There were no fatalities reported in the injured patients. Multivariate analysis showed adolescents, female sex, extremity injuries, and musculoskeletal injuries were associated with hospitalization. Injury at a sporting venue was not associated with hospitalization. CONCLUSIONS: Adolescents and girls are at increased risk of trampoline injury, warranting hospitalization. Safety standards may help prevent extremity and musculoskeletal injuries in the pediatric population. Finally, use of trampolines at sporting venues does not appear to be particularly dangerous.

Time-varying Reproductive Rates for SARS-CoV-2 and its Implications as a Means of Disease Surveillance on Lockdown Restrictions.

OBJECTIVE: To quantify the time-varying reproductive rates for SARS-CoV-2 and its implication in Louisiana. SUMMARY OF BACKGROUND DATA: Basic reproductive number (R0) and effective reproductive number (Re or Rt) are 2 measures of the ability of an infectious agent to spread in the environment. They differ in that R0 assumes zero immunity in the population, while Re or Rt accounts for change over time. Reproductive number modeling is influenced by several factors, including serial interval, the time between the onset of symptoms in an infector, and a secondary case. Quantification of the ability of a pathogen to spread is essential in guiding policy. METHODS: Here, we construct epidemic curves and calculate daily Rt values for the state of Louisiana and each of its 9 regions. RESULTS: Our results demonstrated variation over both time and geography in calculated R0 and Rt values. Generally, as time has progressed, predicted R0 and Rt values have decreased. In Louisiana, mean Rt was calculated at 3.07 in March and 0.82 by May. A reproductive number less than one is important as it indicates infectious spread will decline with time. The most recent finding of mean Rt = 0.82 is important. It stands in stark contrast to the situation in April when New Orleans, Louisiana, had the highest per capita coronavirus mortality rate in the United States - twice that of New York City and 4 times the rate in Seattle. CONCLUSION: As locations around the world begin to lift restrictions, monitoring of infectious spread will be essential.

Meta-analysis on Serial Intervals and Reproductive Rates for SARS-CoV-2.

OBJECTIVE: The aim of this study was to systematically review and meta-analyze all literature reporting the basic reproductive number (R0), effective reproductive number (Re or Rt), and the serial interval (SI) values of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection. SUMMARY BACKGROUND DATA: To assess the rate at which an infectious disease can spread in a population, the 2 measures, R0 and Re or Rt, are widely used. One of the parameters which influence the calculations is the SI, the period between symptom onset in an infector and an infectee. METHODS: Web of Science, PubMed, Scopus, and Science Direct searching up to May 10, 2020, was performed. A continuous random-effect model was applied using the DerSimonian-Laird (inverse variance) method. Heterogeneity and publication bias were assessed. RESULTS: A total of 39 articles met the eligibility criteria. Our results demonstrated the mean SI was 5.45 days, with the 95% confidence interval (CI) of 4.23 to 6.66. Pooled estimates for reproduction rates was 3.14 (95% CI: 2.69-3.59) for R0 and 3.18 (95% CI: 2.89-3.47) for Rt. Subgroup analysis by geographical region and date of publication revealed variations over both time and geography in calculated R0 and Rt values. As time has progressed, predicted R0 and Rt values had decreased globally. CONCLUSIONS: The study findings indicate that one SARS-CoV-2-infected person is likely to infect 3 persons, supporting that COVID-19 is a highly contagious disease. As an essential objective metrics implied in risk assessment for this emerging pandemic, monitoring R0 and Re is necessary to indicate the effectiveness or failures of mitigation efforts.

Preinjury Use of Marijuana and Outcomes in Trauma Patients.

BACKGROUND: Recent studies have examined the effects of marijuana in various populations; however, there has been limited research on the effect of marijuana use in severely injured trauma patients. We hypothesized that preinjury use of marijuana would be associated with improved outcomes in severely injured trauma patients. METHODS: All adult (18+ y) level I and level II trauma activations who presented to two large regional trauma centers between 2014 and 2018 were reviewed. Delta-9-tetrahydrocannabinol (THC)- indicated absence of drugs confirmed by testing and as THC + confirmed THC without another drug present. RESULTS: Of the 4849 patients included, 1373 (28.3%) were THC+. The THC + cohort was younger, had more males, and was more likely to be injured by penetrating mechanism (P < 0.001 for all) than THC-. THC + patients had shorter median length of stay (LOS) (P < 0.001) and intensive care unit LOS (P < 0.001). Mortality rate was lower in the THC + group (4.3% versus 7.6%, P < 0.001), but not in multivariate analysis. THC + patients with traumatic brain injury had shorter hospital LOS (P = 0.025) and shorter ventilator days (P = 0.033) than THC- patients. In patients with Injury Severity Score ≥16, THC + patients had significantly lower intensive care unit LOS (P = 0.009) and mortality (19.3% versus 25.0% P = 0.038) than drug-negative patients. CONCLUSIONS: Although preinjury use of marijuana does not improve survival in trauma patients, it may provide some improvement in outcomes in patients with traumatic brain injury and those that are more severely injured (Injury Severity Score ≥16). The mechanism behind this finding needs further evaluation.

Is the "Death Triad" a Casualty of Modern Damage Control Resuscitation.

BACKGROUND: Principles of damage control laparotomy (DCL) focus on early surgical control of hemorrhage and contamination in addition to damage control resuscitation (DCR) to combat the significant mortality associated with the "death triad" of hypothermia, acidosis, and coagulopathy. We hypothesized that DCL patients managed with DCR would have lower mortality from the death triad than historical studies. METHODS: A 5-y retrospective chart review of all consecutive adult trauma patients presenting to a Level I trauma center who underwent DCL was conducted. Parameters associated with the death triad were evaluated on admission and 24 h after the presentation. Kaplan Meier survival plots were used to compare the components of the death triad. Univariate and multivariate analyses were performed. RESULTS: A total of 149 adult patients were identified. The overall incidence of death triad was 20.8% (n = 31/149). 24-h mortality for all patients was 5.4% (n = 8/149). Kaplan Meier plots showed that 24-h mortality was significantly increased if 3/3 components of the death triad were present (P < 0.05). At 24-h after admission, mortality occurred in 16.6% (n = 5/30) of patients with the death triad. CONCLUSIONS: This study confirms that the 24-h mortality of trauma patients increased with the addition of all three death triad components. The death triad predicted death in 16.6% of patients treated with DCL and DCR at 24 h. Results suggest that the death triad might not be as applicable in the modern era of DCL in combination with DCR. Other factors contributing to in-hospital mortality need to be further elucidated.

Computed Tomography for Pediatric Pelvic Fractures in Pediatric Versus Adult Trauma Centers.

BACKGROUND: Pediatric pelvic fractures are a significant source of morbidity for children in the United States. In the era of specialized care, the relationship between trauma center designation and outcomes remains unknown. We hypothesized that there would be no difference in patient outcomes when treated at adult trauma centers (ATCs), pediatric trauma centers (PTCs), or dual trauma centers (DTCs). MATERIALS AND METHODS: We used the National Trauma Data Bank to identify pediatric (≤14 y) patients suffering pelvic fractures in 2013-2015. DTCs were defined as centers with level I or II trauma designation for both pediatric and adult care. Primary outcomes included mortality, complications, and computed tomography (CT) utilization. RESULTS: There were 4260 patients who met study criteria. Of these, 1290 (22%) were treated at ATCs, 1332 (30%) at PTCs, and 2120 (48%) at DTCs. Pediatric patients treated at ATCs were more likely to suffer a complication or receive a CT scan. On multivariate analysis, patients treated at PTCs and DTCs were significantly less likely to have a recorded complication or receive head, thoracic, or whole-body CT scans compared with ATCs. DTCs, but not PTCs, used fewer abdominal CT scans. Mortality rates were not predicted by center designation. CONCLUSIONS: For pediatric pelvic fractures, centers with pediatric trauma designation (PTCs and DTCs) appear to have better outcomes despite significantly less use of CT scans. Further studies are needed to determine optimal management of pediatric pelvic fractures while minimizing exposure to ionizing radiation. LEVEL OF EVIDENCE: Level III Retrospective.

The Association of Payer Status and Injury Patterns in Pediatric Bicycle Injuries.

BACKGROUND: Bicycle injuries continue to cause significant morbidity in the United States. How insurance status affects outcomes in children with bicycle injuries has not been defined. We hypothesized that payer status would not impact injury patterns or outcomes in pediatric bicycle-related accidents. METHODS: The National Trauma Data Bank was used to identify pediatric (≤18 y) patients involved in bicycle-related crashes admitted in year 2016. Patients with private insurance were compared with all others (uninsured, Medicaid, and Medicare). RESULTS: There were 5619 patients that met study criteria. Of these, 2500 (44%) had private insurance. Privately insured were older (12 y versus 11, P < 0.001), more likely to be white (77% versus 56%, P < 0.001), and more likely to wear a helmet (26% versus 9%, P < 0.001). On multivariate analysis, factors associated with traumatic brain injury included age (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.06-1.08; P < 0.001) and helmet use (OR, 0.64; 95% CI, 0.55-0.74; P < 0.001). Patients without private insurance were significantly less likely to wear a helmet (OR, 0.52; 95% CI, 0.44-0.63; P < 0.001). Uninsured patients had significantly higher odds of a fatal injury (OR, 4.43; 95% CI, 1.52-12.92; P = 0.006). CONCLUSIONS: Uninsured children that present to a trauma center after a bicycle accident are more likely to die. Although helmet use reduced the odds of traumatic brain injury, minorities and children without private insurance were less likely to be helmeted. Public health interventions should increase helmet access to children without private insurance, especially uninsured children.

Did the Affordable Care Act Reach Penetrating Trauma Patients?

BACKGROUND: The benefits of the Affordable Care Act (ACA) for trauma patients have been well established. However, the ACA's impact on penetrating trauma patients (PTPs), a population that is historically young and uninsured, has not been defined. We hypothesized that PTPs in the post-ACA era would have better outcomes. MATERIAL AND METHODS: The National Trauma Data Bank (NTDB) was queried for all PTPs from 2009 (pre-ACA) and 2011-2014 (post-ACA). Subset analysis was performed in patients aged 19-25 y, as this group was eligible for the ACA's dependent care provision (DCP). RESULTS: There were 9,714,471 patients in the study, with 2,053,501 (21.1%) pre-ACA and 7,660,970 (78.9%) post-ACA. When compared to pre-ACA, patients in the post-ACA cohort were more likely to have commercial/private insurance, less likely to have Medicaid, and more likely to be uninsured. On logistic regression, the pre-ACA era was associated with mortality (HR: 1.02, 95% CI: 1.01-1.04, P = 0.004). Being uninsured was associated with mortality (HR: 1.89, 95% CI: 1.87-1.92, P < 0.001). On subset analysis of the DCP age group, post-ACA patients were more likely to be uninsured (24.1% versus 17.6%; P < 0.001). In addition, for the DCP age group, pre-ACA era was not associated with mortality (HR: 1.03, 95% CI: 0.99-1.06, P = 0.20). CONCLUSIONS: Although the ACA provided a survival benefit to PTPs overall, it did not increase insurance coverage for this population. In addition, the DCP of the ACA did not improve insurance access for PTP in the eligible age group. Further efforts are needed to extend insurance access to this population.

Systemic Inflammatory Response Syndrome (SIRS) Score Independently Predicts Poor Outcome in Isolated Traumatic Brain Injury.

INTRODUCTION: Systemic inflammatory response syndrome (SIRS) is frequently observed after various types of acute cerebral injury and has been linked to clinical deterioration in non-traumatic brain injury (TBI). SIRS scores have also been shown to be predictive of length of stay and mortality in trauma patients. We aimed to determine the prognostic utility of SIRS present at admission in trauma patients with isolated TBI. METHODS: This was a 5-year retrospective cohort study of adults (≥18 years) with isolated TBI admitted to a Level II trauma center. The prognostic value of SIRS, total SIRS scores, and each SIRS criterion was examined by Χ 2 and logistic regression analyses. RESULTS: Of the 330 patients identified, 50 (15.2%) met SIRS criteria. SIRS was significantly associated with poor outcome (P < 0.001). Relative risk of poor outcome was 2.7 times higher in patients with a SIRS score of 2 on admission (P = 0.007) and increased significantly to 6.5 times in patients with a SIRS score of 3 (P = 0.002). Logistic regression demonstrated SIRS and each criterion to be significant independent prognostic factors (SIRS, P = 0.030; body temperature, P = 0.006; tachypnea, P = 0.022, tachycardia P = 0.023). CONCLUSION: SIRS at admission is an independent predictor of poor outcome in isolated TBI patients. These data demonstrate SIRS to be an important clinical tool that may be used in facilitating prognostication, particularly in elderly trauma patients. Future prospective studies aimed at therapeutic interventions to mitigate SIRS in TBI patients are warranted. LEVEL OF EVIDENCE: Prognostic, Level III.

Bedside Tracheostomy and Percutaneous Endoscopic Gastrostomy on the Patient's Television.

Bedside surgical procedures such as percutaneous dilatational tracheostomy (PDT) and percutaneous endoscopic gastrostomy (PEG) placement in ICU settings are widely accepted; however, these procedures often require the addition of bulky equipment into the patient's room, which consumes valuable space and restrict workflow. A practice modification was developed in our trauma program, which reduces clutter in the patient's room, streamlines workflow, and results in better patient care and teaching. Simple and cost-effective, this has become the standard in our trauma center and could be of benefit to other institutions as well.

PROSPECTIVE EXAMINATION OF THE K/ICA RATIO AS A PREDICTOR FOR MORTALITY IN SEVERE HEMORRHAGE.

ABSTRACT: Background: Patients receiving massive transfusion protocol (MTP) are at risk for posttransfusion hypocalcemia and hyperkalemia. Previous retrospective analysis has suggested the potassium/ionized calcium (K/iCa) ratio as a prognostic indicator of mortality. This prospective study sought to validate the value of the K/iCa ratio as a predictor for mortality in patients receiving MTP. Methods: This was a prospective analysis of adult trauma patients who underwent MTP activation from May 2019 to March 2021 at an urban level 1 trauma center. Serum potassium and iCa levels within 0 to 1 h of MTP initiation were used to obtain K/iCa. Receiver operator characteristic curve analysis assessed predictive capacity of K/iCa on mortality. Kaplan-Meier survival analysis and Cox regression examined the effect of K/iCa ratio on survival. Results: A total of 110 of 300 MTP activation patients met inclusion criteria. Overall mortality rate was 31.8%. No significant differences between the elevated K/iCa and lower K/iCa groups were found for prehospital or emergency department initial vitals, shock index, or injury severity. However, nonsurvivors had a significantly higher median K/iCa ratio compared with those who survived ( P < 0.01). Multivariable logistic regression revealed the total number of blood products to be significantly associated with elevated K/iCa (odds ratio, 1.02; 95% CI, 1.01-1.04; P = 0.01). The Kaplan Meier survival curve demonstrated a significantly increased rate of survival for those with an elevated K/iCa ratio ( P < 0.01). Multivariable Cox regression adjusted for confounders showed a significant association between K/iCa and mortality (Hazard Ratio, 4.12; 95% CI, 1.89-8.96; P < 0.001). Conclusion: This evidence further highlights the importance of the K/iCa ratio in predicting mortality among trauma patients receiving MTP. Furthermore, it demonstrates that posttransfusion K levels along with iCa levels should be carefully monitored in the MTP setting. Level of Evidence: Level II. Study Type: Prognostic/epidemiological.

Impact of Prehospital Exsanguinating Airway-Breathing-Circulation Resuscitation Sequence on Patients with Severe Hemorrhage.

BACKGROUND: At the 2023 ATLS symposium, the priority of circulation was emphasized through the "x-airway-breathing-circulation (ABC)" sequence, where "x" stands for exsanguinating hemorrhage control. With growing evidence from military and civilian studies supporting an x-ABC approach to trauma care, a prehospital advanced resuscitative care (ARC) bundle emphasizing early transfusion was developed in our emergency medical services (EMS) system. We hypothesized that prioritization of prehospital x-ABC through ARC would reduce in-hospital mortality. STUDY DESIGN: This was a single-year prospective analysis of patients with severe hemorrhage. These patients were combined with our institution's historic controls before prehospital blood implementation. Included were patients with systolic blood pressure (SBP) less than 90 mmHg. Excluded were patients with penetrating head trauma or prehospital cardiac arrest. Two-to-one propensity matching for x-ABC to ABC groups was conducted, and the primary outcome, in-hospital mortality, was compared between groups. RESULTS: A total of 93 patients (x-ABC = 62, ABC = 31) met the inclusion criteria. There was no difference in patient age, sex, initial SBP, initial Glasgow Coma Score, and initial shock index between groups. When compared with the ABC group, x-ABC patients had significant improvement in vitals at emergency department admission. Overall mortality was lower in the x-ABC group (13% vs 47%, p < 0.001). Multivariable regression revealed that prehospital circulation-first prioritization was independently associated with decreased in-hospital mortality (odds ratio 0.15, 95% CI 0.04 to 0.54, p = 0.004). CONCLUSIONS: This is the first analysis to demonstrate a prehospital survival benefit of x-ABC in this subset of patient with severe injury and hemorrhagic shock. Standardization of prehospital x-ABC management in this patient population warrants special consideration.

Every minute matters: Improving outcomes for penetrating trauma through prehospital advanced resuscitative care.

INTRODUCTION: Prehospital resuscitation with blood products is gaining popularity for patients with traumatic hemorrhage. The MEDEVAC trial demonstrated a survival benefit exclusively among patients who received blood or plasma within 15 minutes of air medical evacuation. In fast-paced urban EMS systems with a high incidence of penetrating trauma, mortality data based on the timing to first blood administration is scarce. We hypothesize a survival benefit in patients with severe hemorrhage when blood is administered within the first 15 minutes of EMS patient contact. METHODS: This was a retrospective analysis of a prospective database of prehospital blood (PHB) administration between 2021 and 2023 in an urban EMS system facing increasing rates of gun violence. PHB patients were compared to trauma registry controls from an era before prehospital blood utilization (2016-2019). Included were patients with penetrating injury and SBP ≤ 90 mmHg at initial EMS evaluation that received at least one unit of blood product after injury. Excluded were isolated head trauma or prehospital cardiac arrest. Time to initiation of blood administration before and after PHB implementation and in-hospital mortality were the primary variables of interest. RESULTS: A total of 143 patients (PHB = 61, controls = 82) were included for analysis. Median age was 34 years with no difference in demographics. Median scene and transport intervals were longer in the PHB cohort, with a 5-minute increase in total prehospital time. Time to administration of first unit of blood was significantly lower in the PHB vs. control group (8 min vs 27 min; p < 0.01). In-hospital mortality was lower in the PHB vs. control group (7% vs 29%; p < 0.01). When controlling for patient age, NISS, tachycardia on EMS evaluation, and total prehospital time interval, multivariate regression revealed an independent increase in mortality by 11% with each minute delay to blood administration following injury (OR 1.11, 95%CI 1.04-1.19). CONCLUSION: Compared to patients with penetrating trauma and hypotension who first received blood after hospital arrival, resuscitation with blood products was started 19 minutes earlier after initiation of a PHB program despite a 5-minute increase in prehospital time. A survival for early PHB use was demonstrated, with an 11% mortality increase for each minute delay to blood administration. Interventions such as PHB may improve patient outcomes by helping capture opportunities to improve trauma resuscitation closer to the point of injury. LEVEL OF EVIDENCE: Prospective, Level IV.