Does Practice Match Training? Consultation Practices in Surgical Critical Care.

INTRODUCTION: Intensive care unit (ICU) patient and provider attributes may prompt specialty consultation. We sought to determine practice patterns of surgical critical care (SCC) physicians for ICU consultation. METHODS: We surveyed American Association for the Surgery of Trauma members. Various diagnoses were listed under each of nine related specialties. Respondents were asked for which conditions they would consult a specialist. Conditions were cross-referenced with the SCC fellowship curriculum. Other perspectives on practice and consultation were queried. RESULTS: 314 physicians (18.6%) responded (68% male; 79% White; 96.2% surgical intensivist); 284 (16.8%) completed all questions. Percentage of clinical time practicing SCC was 26-50% in 57% and >50% in 14.5%. ICUs were closed (39%), open (25%), or hybrid (36%). Highest average confidence ratings (1 = least, 5 = most) for managing select conditions were ventilator, 4.64; palliative care, 4.51; infections, 4.44; organ donation, hemodynamics (tie), 4.31; lowest rating was myocardial ischemia, 3.85. Consults were more frequent for Cardiology, Hematology, and Neurology; less frequent for nephrology, palliative care, gastroenterology, infectious disease, and pulmonary; and low for curriculum topics (<25%) except for infectious diseases and palliative care. Attending staffing 24 h/day was associated with a lower mean number of topics for consultation (mean 24.03 versus 26.31, P = 0.015). CONCLUSIONS: ICU consultation practices vary based on consultant specialty and patient diagnosis. Consultation is most common for specialty-specific diseases and specialist interventions, but uncommon for topics found in the SCC curriculum, suggesting that respondents' scope of practice closely matched their training.

Joint Society of Critical Care Medicine-Extracorporeal Life Support Organization Task Force Position Paper on the Role of the Intensivist in the Initiation and Management of Extracorporeal Membrane Oxygenation.

OBJECTIVES: To define the role of the intensivist in the initiation and management of patients on extracorporeal membrane oxygenation. DESIGN: Retrospective review of the literature and expert consensus. SETTING: Series of in-person meetings, conference calls, and emails from January 2018 to March 2019. SUBJECTS: A multidisciplinary, expert Task Force was appointed and assembled by the Society of Critical Care Medicine and the Extracorporeal Life Support Organization. Experts were identified by their respective societies based on reputation, experience, and contribution to the field. INTERVENTIONS: A MEDLINE search was performed and all members of the Task Force reviewed relevant references, summarizing high-quality evidence when available. Consensus was obtained using a modified Delphi process, with agreement determined by voting using the RAND/UCLA scale, with score ranging from 1 to 9. MEASUREMENTS AND MAIN RESULTS: The Task Force developed 18 strong and five weak recommendations in five topic areas of extracorporeal membrane oxygenation initiation and management. These recommendations were organized into five areas related to the care of patients on extracorporeal membrane oxygenation: patient selection, management, mitigation of complications, coordination of multidisciplinary care, and communication with surrogate decision-makers. A common theme of the recommendations is extracorporeal membrane oxygenation is best performed by a multidisciplinary team, which intensivists are positioned to engage and lead. CONCLUSIONS: The role of the intensivist in the care of patients on extracorporeal membrane oxygenation continues to evolve and grow, especially when knowledge and familiarity of the issues surrounding extracorporeal membrane oxygenation selection, cannulation, and management are applied.

Age-related mortality in blunt traumatic hemorrhagic shock: the killers and the life savers.

BACKGROUND: There are sparse data on the association between age and mortality in hemorrhagic shock (HS). We examined this association in this study. MATERIALS AND METHODS: The Glue Grant database was analyzed. Patients aged ≥16 y with blunt traumatic HS were stratified into eight age groups (16-24, 25-34, 35-44, 45-54, 55-64, 65-74, 75-84, and ≥85 y) to identify the mortality inflection point. Subsequently, patients were restratified into young age (16-44 y), middle age (45-64 y), and elderly (≥65 y). Multivariate analysis was used to determine predictors of mortality by group. RESULTS: A total of 1976 patients were included, with mortality of 16%. Mortality by initial age group is as follows: 16-24 (13.0%), 25-34 (11.9%), 35-44 (11.9%), 45-54 (15.6%), 55-64 (15.7%), 65-74 (20.3%), 75-84 (38.2%), and ≥85 y (51.6%), delineating 65 y as the mortality inflection point. Overall, 55% were young, 30% middle age, and 15% elderly. Predictors of mortality in the young include multiple-organ dysfunction score (MODS; odds ratio [OR]: 1.93, confidence interval [CI]: 1.62-2.30), emergency room lactate (OR: 1.14, CI: 1.02-1.27), injury severity score (OR: 1.06, CI: 1.03-1.09), and cardiac arrest (OR: 10.60, CI: 3.05-36.86). Predictors of mortality in the middle age include MODS (OR: 1.38, CI: 1.24-1.53), cardiac arrest (OR: 12.24, CI: 5.38-27.81), craniotomy (OR: 5.62, CI: 1.93-16.37), and thoracotomy (OR: 2.76, CI: 1.28-5.98). In the elderly, predictors of mortality were age (OR: 1.07, CI: 1.02-1.13), MODS (OR: 1.47, CI: 1.26-1.72), laparotomy (OR: 2.04, CI: 1.02-4.08), and cardiac arrest (OR: 11.61, CI: 4.35-30.98). Open fixation of nonfemoral fractures was protective against mortality in all age groups. CONCLUSIONS: In blunt HS, mortality parallels increasing age, with the inflection point at 65 y. MODS and cardiac arrest uniformly predict mortality across all age groups. Craniotomy and thoracotomy are associated with mortality in the middle age, whereas laparotomy is associated with mortality in the elderly.

Impact of a multicomponent screening, brief intervention, and referral to treatment (SBIRT) training curriculum on a medical residency program.

BACKGROUND: Substance-related disorders are a growing problem in the United States. The patient-provider setting can serve as a crucial environment to detect and prevent at-risk substance use. Screening, brief intervention, and referral to treatment (SBIRT) is an integrated approach to deliver early intervention and treatment services for persons who have or are at risk for substance-related disorders. SBIRT training components can include online modules, in-person instruction, practical experience, and clinical skills assessment. This paper will evaluate the impact of multiple modes of training on acquisition of SBIRT skills as observed in a clinical skills assessment. METHODS: Residents were part of an SBIRT training program, from 2009 through 2013, consisting of lecture, role-play, online modules, patient encounters, and clinical skills assessment (CSA). Differences were assessed across satisfactory and unsatisfactory CSA performance. RESULTS: Seventy percent of the residents satisfactorily completed CSA. Demographics, type of components completed, and number of components completed were similar among residents who demonstrated satisfactory clinical skills compared with those who did not. All components of the training program were accepted equally across specialties and resident matriculation cohorts. CONCLUSION: The authors conclude that the components employed in SBIRT training do not have to be numerous or of a particular mode of training in order to see observable demonstration of SBIRT skills among medical residents. Thus, residency educators who have limited time or resources may utilize as few as 1 mode of training to effectually disseminate SBIRT skills among health care providers. As SBIRT continues to evolve as a promising tool to address at-risk substance-related disorders, it is critical to train medical residents and other health professionals.

The Price of Courage: The Life and Legacy of Dr LaSalle D. Leffall Jr.

This historical retrospective details the life and legacy of Dr LaSalle D. Leffall Jr, a leader in the field of surgical oncology, passionate surgical educator, and indelible mentor. His courage, against the backdrop of the many obstacles presented by American racism, paved the way for the inclusion of multiple generations of women and minority surgeons leaving a lasting impact on the history of American surgery.

Diabetes mellitus is not associated with major morbidity following open abdominal aortic aneurysm repair.

BACKGROUND: It has been suggested that there is an increased morbidity and mortality risk for diabetics undergoing elective aortic surgery. This, however, is not universally accepted. In this study, we utilize a national database to determine if diabetes is associated with adverse outcomes following open, elective, infrarenal abdominal aortic aneurysm (AAA) repair. METHODS: The American College of Surgeons' National Surgical Quality Improvement Program database was queried to identify all patients who underwent an open, elective, nonruptured AAA repair from January 1, 2005 to December 31, 2007. Patient demographics, comorbidities, and outcomes were compared by diabetes status. Multivariate analysis was performed adjusting for demographics and comorbidities. RESULTS: There were 2110 American College of Surgeons' National Surgical Quality Improvement Program patients who underwent an open, elective, nonruptured AAA repair during this time period. Of these patients, 245 (11.6%) had diabetes mellitus. The overall mortality rate was 3.7% (5.3% for diabetics and 3.5% for nondiabetics, P = 0.171). On bivariate analysis, diabetics were more likely to present preoperatively with cardiovascular and renal comorbidities. Postoperatively, there was no significant difference in mortality or in cardiac, pulmonary, or renal complications. Diabetics were more likely to develop superficial surgical site infections (SSIs) (4.5% versus 1.6%, P = 0.002). On multivariate regression, there was no difference in mortality or major complications between diabetics and nondiabetics (OR 1.4, 95% CI 0.68-2.71). Diabetics, however, were almost three times more likely to develop superficial SSIs (OR 2.8, 95% CI 1.29-6.00). CONCLUSIONS: Diabetes mellitus is not associated with significantly worse major outcomes following open, elective, infrarenal AAA repair. Diabetics, however, are more likely to develop superficial SSIs.

Successful treatment of distal intestinal obstruction syndrome with N-acetylcysteine and polyethylene glycol via colonoscopy.

We describe a case of a 46-year-old woman with cystic fibrosis who presented with several days of abdominal pain and distension. She was found to have a small bowel obstruction with inspissated stool in the distal ileum on CT imaging. Despite initial management with conservative measures, her symptoms worsened. She was taken for urgent colonoscopy with administration of 4% N-acetylcysteine (NAC) and polyethylene glycol (PEG) at the distal ileum with resultant dissolution of the fecalith. Over the following days, her symptoms improved, and she was discharged with outpatient follow-up.

Screening, brief intervention, and referral to treatment: public health training for primary care.

OBJECTIVES: The purpose of this study was to elucidate changes in attitudes, experiences, readiness, and confidence levels of medical residents to perform screening, brief intervention, and referral to treatment (SBIRT) and factors that moderate these changes. METHODS: A cohort of 121 medical residents received an educational intervention. Self-reported experience, readiness, attitude, and confidence toward SBIRT-related skills were measured at baseline and at follow-up. Analyses were conducted to evaluate the effects of medical specialization. RESULTS: The intervention significantly increased experience (P<.001), attitude (P<.05), readiness (P<.001), and confidence (P<.001). Residents were more likely to report that their involvement influenced patients' substance use. However, experience applying SBIRT skills varied by country of birth, specialty, and baseline scores. CONCLUSIONS: This study suggested that SBIRT training was an effective educational tool that increased residents' sense of responsibility. However, application of skills might differ by specialization and other variables. Future studies are needed to explore and evaluate SBIRT knowledge obtained, within the context of cultural awareness and clinical skills.

Severe Clostridioides difficile Infection in the Intensive Care Unit-Medical and Surgical Management.

Clostridioides difficile remains a major cause of morbidity and mortality in the intensive care unit, and therefore, C difficile guidelines are frequently being updated. Currently, fidaxomicin is the suggested treatment of initial and recurrent infection. Oral vancomycin is an acceptable alternative, followed by rifaximin and fecal microbiota transplantation. Bezlotoxumab is suggested in recurrent cases within 6 months. If patients fail to improve within 3 to 5 days of therapy, especially in patients who have had nasogastric tubes or emergent surgery, fulminant colitis is possible and surgical consultation should be considered for total colectomy.

Successful Non-Operative Management of Extensive Pneumatosis Cystoides Intestinalis Due to Graft Versus Host Disease.

Graft versus host disease is a serious complication of allogenic stem cell transplants and can manifest with gastrointestinal complications including pneumatosis cystoides intestinali (PCI). A 43-year-old male with a history of acute myeloid leukemia presented to the hospital with abdominal pain and sepsis. The patient was intubated and admitted to the ICU. His CT scan demonstrated extensive colonic pneumatosis. He was high risk for laparotomy so was treated non-operatively. He improved and his abdominal exam remained benign. With aggressive resuscitation, close monitoring, and antibiotics, the patient was able to avoid major abdominal surgery. pneumatosis cystoides intestinali is a concerning finding that often leads to surgical interventions. Concurrent sepsis, gut ischemia, and frank perforation often lead to surgical intervention. In patients with high surgical risk and lack of critical bowel findings, non-operative management can be successful.

A disturbing trend: An analysis of the decline in surgical critical care fellowship training of Black and Hispanic surgeons.

BACKGROUND: Underrepresented minorities in medicine (URiMs) are disproportionally represented in surgery training programs. Rates of URiMs applying to and completing General Surgery residency remain low. We hypothesized that the patterns of URiMs disparities would persist into surgical critical care (SCC) fellowship applicants, matriculants, and graduates. METHODS: We performed a retrospective analysis of SCC applicants, matriculants, and graduates from 2005 to 2020 using the graduate medical education resident survey and analyzed applicant characteristics using the Surgical Critical Care and Acute Care Surgery Fellowship Application Service from 2018 to 2020. The data were stratified by race/ethnicity and sex. Indicator variables were created for Asian, Hispanic, White, and Black trainees. Yearly proportions for each race/ethnicity and sex categories completing or enrolling in a program were calculated and plotted over time with Loess smoothing lines and overlying 95% confidence bands. The yearly rate and statistical significance of change over time were tested with linear regression models with race/ethnicity and sex proportion as the dependent variables and year as the explanatory variable. RESULTS: From 2005 to 2020, there were a total of 2,481 graduates. Black men accounted for 4.7% of male graduates with a significant decline of 0.3% per year for the study period of those completing the fellowship (p = 0.02). Black women comprised 6.4% of female graduates and had a 0.6% decline each year (p < 0.01). A similar trend was seen with Hispanic men, who comprised 3.2% of male graduates and had a 0.3% annual decline (p = 0.02). White men had a significant increase in both matriculation to and graduation from SCC fellowships during the same interval. Similarly, Black and Hispanic applicants declined from 2019 to 2020, while the percentage of White applicants increased. CONCLUSION: Disparities in URiMs representation remain omnipresent in surgery and extend from residency training to SCC fellowship. Efforts to enhance the recruitment and retention of URiMs in SCC training are warranted. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; level IV.

The General Surgery Residency Experience: A Multicenter Study of Differences in Wellbeing by Race/Ethnicity.

Objectives: We explored differences by race/ethnicity in regard to several factors that reflect or impact wellbeing. Background: Physician wellbeing has critical ramifications for the US healthcare system, affecting clinical outcomes, patient experience, and healthcare economics. Within surgery, literature examining the association between race/ethnicity and wellbeing has been limited and inconclusive. Methods: Residents at 16 academic General Surgery training programs completed an online questionnaire. Racial/ethnic identity, gender identity, post-graduate year (PGY) level, and gap years were self-reported. Differences by race/ethnicity in flourishing (global wellbeing) as well as factors reflecting resilience (mindfulness, personal accomplishment, workplace support, workplace control) and risk (depression, emotional exhaustion, depersonalization, stress, anxiety, workplace demand) were assessed. Results: Of 300 respondents (response rate 34%), 179 (60%) were non-male, 123 (41%) were residents of color (ROC), and 53 (18%) were from racial/ethnic groups that are underrepresented in medicine (UIM). Relative to White residents, ROC have significantly lower flourishing and higher anxiety, and these remain significant when adjusting for gender, PGY level, and gap years. Relative to residents overrepresented in medicine (OIM), UIM residents have significantly lower emotional exhaustion and depersonalization after adjusting for gender, PGY level and gap years. Conclusions: Disparities in resident wellbeing based on race/ethnicity and UIM/OIM status exist. However, the experience of ROC is not homogeneous. As part of the transformative process to address systemic racism, eliminate disparities in surgical training, and reconceptualize wellbeing as a fundamental asset for optimal surgeon performance, further understanding the specific contributors and detractors of wellbeing among different individuals and groups is critical.

Screening, Brief Intervention, and Referral to Treatment to Prevent Post-Traumatic Stress Disorder After Gunshot Wounds.

Screening, brief intervention, and referral to treatment (SBIRT) is an intervention originally developed to prevent and deter substance abuse. Adaptation of the SBIRT model to prevent post-traumatic stress disorder (PTSD) may potentially reduce acute stress symptoms after traumatic injury. We conducted a prospective randomized control study of adult patients admitted for gunshot wounds. Patients were randomized to intervention (INT) vs. treatment as usual (TAU) groups. INT received the newly developed SBIRT Intervention for Trauma Patients (SITP)-a 15-minute session with elements of cognitive behavioral therapy techniques. SITP took place during the index hospitalization; both groups had followup at 30 and 90 days at which time a validated PTSD screening tool, PCL-5, was administered. Most of the 46 participants were young (mean age = 30.5y), male (91.3%), and black (86.9%). At three-month follow-up, SBIRT and TAU patients had similar physical healing scores but the SBIRT arm showed reductions in PTSD symptoms.

Examination of Intersectionality and the Pipeline for Black Academic Surgeons.

IMPORTANCE: The lack of underrepresented in medicine physicians within US academic surgery continues, with Black surgeons representing a disproportionately low number. OBJECTIVE: To evaluate the trend of general surgery residency application, matriculation, and graduation rates for Black trainees compared with their racial and ethnic counterparts over time. DESIGN, SETTING, AND PARTICIPANTS: In this nationwide multicenter study, data from the Electronic Residency Application Service (ERAS) for the general surgery residency match and Graduate Medical Education (GME) surveys of graduating general surgery residents were retrospectively reviewed and stratified by race, ethnicity, and sex. Analyses consisted of descriptive statistics, time series plots, and simple linear regression for the rate of change over time. Medical students and general surgery residency trainees of Asian, Black, Hispanic or Latino of Spanish origin, White, and other races were included. Data for non-US citizens or nonpermanent residents were excluded. Data were collected from 2005 to 2018, and data were analyzed in March 2021. MAIN OUTCOMES AND MEASURES: Primary outcomes included the rates of application, matriculation, and graduation from general surgery residency programs. RESULTS: Over the study period, there were 71 687 applicants, 26 237 first-year matriculants, and 24 893 graduates. Of 71 687 applicants, 24 618 (34.3%) were women, 16 602 (23.2%) were Asian, 5968 (8.3%) were Black, 2455 (3.4%) were Latino, and 31 197 (43.5%) were White. Women applicants and graduates increased from 29.4% (1178 of 4003) to 37.1% (2293 of 6181) and 23.5% (463 of 1967) to 33.5% (719 of 2147), respectively. When stratified by race and ethnicity, applications from Black women increased from 2.2% (87 of 4003) to 3.5% (215 of 6181) (P < .001) while applications from Black men remained unchanged (3.7% [150 of 4003] to 4.6% [284 of 6181]). While the matriculation rate for Black women remained unchanged (2.4% [46 of 1919] to 2.3% [52 of 2264]), the matriculation rate for Black men significantly decreased (3.0% [57 of 1919] to 2.4% [54 of 2264]; P = .04). Among Black graduates, there was a significant decline in graduation for men (4.3% [85 of 1967] to 2.7% [57 of 2147]; P = .03) with the rate among women remaining unchanged (1.7% [33 of 1967] to 2.2% [47 of 2147]). CONCLUSIONS AND RELEVANCE: Findings of this study show that the underrepresentation of Black physicians at every stage in surgical training pipeline persists. Black men are especially affected. Identifying factors that address intersectionality and contribute to the successful recruitment and retention of Black trainees in general surgery residency is critical for achieving racial and ethnic as well as gender equity.

Does the pattern of injury in elderly pedestrian trauma mirror that of the younger pedestrian?

BACKGROUND: Walking is the primary mode of transportation for people aged 65 y and over; hence pedestrian injuries are a substantial source of morbidity and mortality among elderly patients in the United States. This study is aimed at evaluating the pattern of injury in the elderly pedestrians and how it differs from younger patients. METHODS: Retrospective analysis of the National Trauma Data Bank (2002-2006) was performed, with inclusion criteria defined as pedestrian injuries based on ICD-9 codes, excluding age < 15 y. The following age categories in years were created: 15-24 (reference group), 25-34, 35-44, 45-54, 55-64, 65-74, 75-84, and 85-89. The injury prevalence was compared, and multivariate regression for mortality was conducted adjusting for demographic and injury characteristics. RESULTS: A total of 79,307 patients were analyzed. Superficial injuries were the most common at 29.1%, with lower extremity fractures and intracranial injuries following at 25.1% and 21.4% respectively. The very elderly (75-84 and 85-89) had significantly higher rates of fractures of the pelvis(16.2% and 16.8% versus 8.1% in the youngest group), upper (19.3% and 18.4% versus 9.8%), lower extremities (31.1% and 31.9% versus 22.5%) and intracranial injuries (25.5% and 28.7% versus 22.4%), but sustained lower rates of hepatic (2.3% and 1.7% versus 3.0%) injuries, with no difference seen in pancreatic, splenic, and genitourinary injuries. On multivariate analysis, very elderly patients were six to eight times more likely to die (OR 6.24 and 8.27, P < 0.001). CONCLUSION: Elderly patients have higher rates of fractures and intracranial injuries with an extremely worse mortality after pedestrian trauma.

The impact of insurance status on actuarial survival in hospitalized trauma patients: when do they die?

BACKGROUND: Previous work has suggested that insurance status, gender, and ethnicity all have an independent association with mortality after trauma. The purpose of this study is to investigate whether these factors exerted survival impact that could be observed throughout the hospital stay. METHODS: Using the National Trauma Data Bank (version 7.0), a Cox proportional hazards survival analysis was performed on young (19-30 years old) trauma patients to mitigate the impact of comorbid confounders. Variables included in the model were age, gender, ethnicity, Injury Severity Score, presence of shock at presentation, mechanism of injury, insurance status, year of admission, teaching status of the hospital, diagnosis of substance abuse or psychotic disorders, and complications after admission. Rate ratios (RRs) comparing the slopes of the adjusted survival curves were calculated using the Mantel-Cox method. RESULTS: A total of 192,488 young trauma patients were identified with complete data. Increased hazard of death was seen in patients who were uninsured (hazard ratio [HR]=1.69, 95% confidence interval [CI]=1.59-1.80, p<0.001), of a minority ethnicity (HR=1.08, 95% CI=1.01-1.15, p=0.025) or men (HR=1.14, 95% CI=1.04-1.23, p=0.004). RRs were significantly larger between insurance status (RR=1.75, 95% CI=1.58-1.94, p<0.001) than between race (RR=1.23, 95% CI=1.10-1.37, p<0.001) or between gender (RR=1.16, 95% CI=1.01-1.32, p=0.030). CONCLUSION: Risk of death on the first hospital day after injury differs by insurance status, and this disparity becomes more pronounced throughout the hospital stay. Further study is necessary to determine whether this is a result of additional unmeasured patient covariates with insurance status or a difference in provider behavior in response to patient insurance status.

"Diversity in Surgery-How Do We Change the Narrative: Pipeline to Professor?"

The goal of our paper is to provide our perspectives on why there is a need to change the narrative in academic surgery to improve health equity by increasing the pipeline of pre-med students to professors. It is well documented that Health disparities hurt many different people, but they especially hurt Black, Indigenous, and People of color. Black men and women have a decreased life expectancy. Differences in care are associated with greater mortality among minority patients and that care provided to black patients by black physicians can lead to improved compliance with medications and care plans. The lack of black diversity in the medical profession proportional to the societal ethnic distribution is alarming. We have opportunities for improvement for recruitment, retention and promotion within the field of surgery.

Pediatric trauma at an adult trauma center.

BACKGROUND: Accidental traumatic injury is the number 1 cause of morbidity and mortality in the pediatric population. In this study, we aim to prove that certain pediatric patients can be treated with good outcomes at an adult level 1 trauma center. METHODS: Retrospective analysis using the Howard University Hospital trauma registry identified 71 patients treated at Howard University Hospital between the ages of 1 and 17 years old. Specific variables were identified and collected for each patient. RESULTS: The majority of pediatric traumas treated at Howard University Hospital between June 2004 and May 2005 had high survival rates (93%). The patients who did not survive (7%) included 3 patients who were dead on arrival and 2 who died shortly after arrival to the hospital. CONCLUSIONS: Certain pediatric populations who present with minor and/or isolated injuries can be treated in an adult level 1 trauma center with similar outcomes to treatment in a pediatric level 1 trauma center.

Predictors for survival of penetrating trauma using emergency department thoracotomy in an urban trauma center: the Cardiac Instability Score.

BACKGROUND: Emergency department thoracotomy (EDT) is a procedure used in an attempt to save lives of patients in extremis. This study aims to determine predictors of survival and futility by proposing a scoring scale that measures cardiac instability and its use in predicting survival of victims of penetrating trauma undergoing EDT. METHODS: This retrospective study analyzes patients who underwent EDT during a 45-month period at Howard University Hospital, Washington, DC. Vital signs and Glasgow Coma scale (GCS) scores were analyzed at the scene and in the emergency department. A cardiac instability score (CIS) was devised to assign values to vital signs, and the GCS was based on scores from the emergency department. RESULTS: Emergency department vital signs, female gender, absence of cardiopulmonary resuscitation (CPR), and high CIS were found to be statistically significant predictors of survival. CONCLUSIONS: The CIS correlated with survival of patients who underwent EDT and was found to be statistically significant in determining the outcome of an EDT.

Contemporary hemodynamic monitoring, fluid responsiveness, volume optimization, and endpoints of resuscitation: an AAST critical care committee clinical consensus.

This article, on hemodynamic monitoring, fluid responsiveness, volume assessment, and endpoints of resuscitation, is part of a compendium of guidelines provided by the AAST (American Association for the Surgery of Trauma) critical care committee. The intention of these guidelines is to inform practitioners with practical clinical guidance. To do this effectively and contemporarily, expert consensus via the critical care committee was obtained. Strict guideline methodology such a GRADE (Grading of Recommendations Assessment, Development and Evaluation) was purposefully NOT used so as not to limit the possible clinical guidance. The critical care committee foresees this methodology as practically valuable to the bedside clinician.