Characteristics of Laparoscopic Surgery for Trauma Patients and Risks of Conversion to Open Laparotomy.

BACKGROUND: The discussion is ongoing about appropriate indications for laparoscopic surgery in trauma patients. As timing and risks of conversion to laparotomy remain unclear, we aimed to elucidate characteristics of and risks for conversion following laparoscopic surgery, using a nationwide database. METHODS: A retrospective observational study was conducted, using Japanese Trauma Data Bank (2004-2018). We included adult trauma patients who underwent laparoscopic surgery as an initial surgical intervention. Conversion to laparotomy was defined as laparotomy at the initial surgery. Patient demographics, mechanism and severity of injury, injured organs, timing of surgery, and clinical outcomes were compared between patients with and without conversion. Risks for conversion were analyzed focusing on indications for laparoscopic surgery, after adjusting patient and institution characteristics. RESULTS: Among 444 patients eligible for the study, 31 required conversions to laparotomy. The number of laparoscopic surgeries gradually increased over the study period (0.5-4.5% of trauma laparotomy), without changes in conversion rates (5-10%). Patients who underwent conversion had more severe abdominal injuries compared with those who did not (AIS 3 vs 2). While length of hospital stay and in-hospital mortality were comparable, abdominal complications were higher among patients with conversion (12.9 vs. 2.9%), particularly when laparoscopy was performed for peritonitis (OR, 22.08 [5.11-95.39]). A generalized estimating equation model adjusted patient background and identified hemoperitoneum and peritoneal penetration as risks for conversion (OR, 24.07 [7.35-78.75] and 8.26 [1.20- 56.75], respectively). CONCLUSIONS: Trauma laparoscopy for hemoperitoneum and peritoneal penetration were associated with higher incidence of conversion to open laparotomy.

Timing of repair of blunt thoracic aortic injuries in the thoracic endovascular aortic repair era.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) is the preferred operative treatment of blunt thoracic aortic injuries (BTAIs). Its use is associated with improved outcomes compared with open surgical repair and nonoperative management. However, the optimal time from injury to repair is unknown and remains a subject of debate across different societal practice guidelines. The purpose of this study was to evaluate national trends in the management of BTAI, with a specific focus on the impact of timing of repair on outcomes. METHODS: Using the National Trauma Data Bank, we identified adult patients with BTAI between 2012 and 2017. Patients with prehospital or emergency department cardiac arrest or incomplete data sets were excluded from analysis. Patients were classified according to timing of repair: group 1, <24 hours; and group 2, ≥24 hours. The primary outcome evaluated was in-hospital mortality; secondary outcomes included overall hospital and intensive care unit length of stay. Multivariable logistic regression was performed to identify independent predictors of mortality. RESULTS: The analysis was completed for 2821 patients who underwent TEVAR for BTAI with known operative times. The overall mortality in the patient cohort was 8.4% (238/2821); 75% of patients undergoing TEVAR were repaired within 24 hours. Mortality was more than twofold greater in group 1 compared with group 2 (9.8% [207/2118] vs 4.4% [31/703]; P = .001). This mortality benefit persisted across injury severity groups and was independent of the presence of serious extrathoracic injuries. Logistic regression analysis, adjusting for age ≥65 years, Glasgow Coma Scale score ≤8, systolic blood pressure ≤90 mm Hg at admission, and serious extrathoracic injuries, showed a higher adjusted mortality in group 1 (odds ratio, 2.54; 95% confidence interval, 1.66-3.91; P = .001). CONCLUSIONS: The majority of patients with BTAI undergo endovascular repair within 24 hours of injury. Patients undergoing delayed repair have improved survival compared with those repaired within the first 24 hours of injury in spite of similar injury patterns and severity. In patients with BTAIs without signs of imminent rupture, delaying endovascular repair beyond 24 hours after injury should be considered.

Immediate Angiography and Decreased In-Hospital Mortality of Adult Trauma Patients: A Nationwide Study.

PURPOSE: This study aimed to elucidate whether immediate angiography within 30 min is associated with lower in-hospital mortality compared with non-immediate angiography. MATERIALS AND METHODS: We conducted a retrospective cohort study using a nationwide trauma databank (2019-2020). Adult trauma patients who underwent emergency angiography within 12 h after hospital arrival were included. Patients who underwent surgery before angiography were excluded. Immediate angiography was defined as one performed within 30 min after arrival (door-to-angio time ≤ 30 min). In-hospital mortality and non-operative management (NOM) failure were compared between patients with immediate and non-immediate angiography. Inverse probability weighting with propensity scores was conducted to adjust patient demographics, injury mechanism and severity, vital signs on hospital arrival, and resuscitative procedures. A restricted cubic spline curve was drawn to reveal survival benefits by door-to-angio time. RESULTS: Among 1,455 patients eligible for this study, 92 underwent immediate angiography. Angiography ≤ 30 min was associated with decreased in-hospital mortality (5.0% vs 11.1%; adjusted odds ratio [OR], 0.42 [95% CI, 0.31-0.56]; p < 0.001), as well as lower frequency of NOM failure: thoracotomy and laparotomy after angiography (0.8% vs. 1.8%; OR, 0.44 [0.22-0.89] and 2.6% vs. 6.5%; OR, 0.38 [0.26-0.56], respectively). The spline curve showed a linear association between increasing mortality and prolonged door-to-angio time in the initial 100 min after arrival. CONCLUSION: In trauma patients, immediate angiography ≤ 30 min was associated with lower in-hospital mortality and fewer NOM failures. LEVEL OF EVIDENCE: Level 3b, non randomized controlled cohort/follow up study.

Follow-up computed tomography and unexpected hemostasis in non-operative management of pediatric blunt liver and spleen injury.

PURPOSE: While follow-up CT and prophylactic embolization with angiography are often conducted during non-operative management (NOM) for BLSI, particularly in a high-grade injury, the utility of early repeated CT for preventing unexpected hemorrhage remains unclear. This study aimed to elucidate whether early follow-up computerized tomography (CT) within 7 days after admission would decrease unexpected hemostatic procedures on pediatric blunt liver and spleen injury (BLSI). METHODS: A post-hoc analysis of a multicenter observational cohort study on pediatric patients with BLSI (2008-2019) was conducted on those who underwent NOM, in whom the timing of follow-up CT were decided by treating physicians. The incidence of unexpected hemostatic procedure (laparotomy and/or emergency angiography for ruptured pseudoaneurysm) and complications related to BLSI were compared between patients with and without early follow-up CT within 7 days. Inverse probability weighting with propensity scores adjusted patient demographics, comorbidities, mechanism and severity of injury, initial resuscitation, and institutional characteristics. RESULTS: Among 1320 included patients, 552 underwent early follow-up CT. Approximately 25% of patients underwent angiography on the day of admission. The incidence of unexpected hemostasis was similar between patients with and without early repeat CT (8 [1.4%] vs. 6 [0.8%]; adjusted OR, 1.44 [0.62-3.34]; p = 0.40). Patients with repeat CT scans more frequently underwent multiple angiographies (OR, 2.79 [1.32-5.88]) and had more complications related to BLSI, particularly bile leak (OR, 1.73 [1.04-2.87]). CONCLUSION: Follow-up CT scans within 7 days was not associated with reduced unexpected hemostasis in NOM for pediatric BLSI.

Gaining or wasting time? Influence of time to operating room on mortality after temporary hemostasis using resuscitative endovascular balloon occlusion of the aorta.

BACKGROUND: The optimal candidates for resuscitative endovascular balloon occlusion of the aorta (REBOA) remains unclear. We hypothesized patients with delayed transfer to operating room (OR) would benefit from REBOA. METHODS: Using the 2016-2017 ACS-TQIP database, patients were divided based on the transfer time to OR: ≤1 h (early) and >1 h (delayed). In each group, patients who underwent REBOA in emergency department (ED-REBOA) were matched with those without REBOA (non-REBOA) using propensity scores, and survival to discharge was compared. RESULTS: Among 163,453 patients, 114 and 138 patients (38 and 46 ED-REBOA) were included in the early and delayed groups, respectively. Survival to discharge was comparable between ED-REBOA and non-REBOA patients in the early group (39.5% vs. 48.7%, p = 0.35), whereas it was higher in ED-REBOA patients in the delayed group (39.1% vs. 12.0%, p < 0.01). CONCLUSIONS: Patients with delayed transfer to OR >1 h benefited from REBOA.

Emergency angiography for trauma patients and potential association with acute kidney injury.

BACKGROUND: Angiography has been conducted as a hemostatic procedure for trauma patients. While several complications, such as tissue necrosis after embolization, have been reported, little is known regarding subsequent acute kidney injury (AKI) due to contrast media. To elucidate whether emergency angiography would introduce kidney dysfunction in trauma victims, we compared the incidence of AKI between patients who underwent emergency angiography and those who did not. METHODS: A retrospective cohort study was conducted using a nationwide trauma database (2004-2019), and adult trauma patients were included. The indication of emergency angiography was determined by both trauma surgeons and radiologists, and AKI was diagnosed by treating physicians based on a rise in serum creatinine and/or fall in urine output according to any published standard criteria. Incidence of AKI was compared between patients who underwent emergency angiography and those who did not. Propensity score matching was conducted to adjust baseline characteristics including age, comorbidities, mechanism of injury, vital signs on admission, Injury Severity Scale (ISS), degree of traumatic kidney injury, surgical procedures, and surgery on the kidney, such as nephrectomy and nephrorrhaphy. RESULTS: Among 230,776 patients eligible for the study, 14,180 underwent emergency angiography. The abdomen/pelvis was major site for angiography (10,624 [83.5%]). Embolization was performed in 5,541 (43.5%). Propensity score matching selected 12,724 pairs of severely injured patients (median age, 59; median ISS, 25). While the incidence of AKI was rare, it was higher among patients who underwent emergency angiography than in those who did not (140 [1.1%] vs. 67 [0.5%]; odds ratio = 2.10 [1.57-2.82]; p < 0.01). The association between emergency angiography and subsequent AKI was observed regardless of vasopressor usage or injury severity in subgroup analyses. CONCLUSIONS: Emergency angiography in trauma patients was probably associated with increased incidence of AKI. The results should be validated in future studies.

Delays in Surgical Intervention and Temporary Hemostasis Using Resuscitative Endovascular Balloon Occlusion of the aorta (REBOA): Influence of Time to Operating Room on Mortality.

BACKGROUND: The optimal candidates for resuscitative endovascular balloon occlusion of the aorta (REBOA) remain unclear. We hypothesized that patients who experience delays in surgical intervention would benefit from REBOA. METHODS: Using the Japan Trauma Databank (2014-2019), patients transferred to the operating room (OR) within 3 h were identified. Patients treated with REBOA were matched with those without REBOA using propensity scores, and further divided based on the transfer time to OR: ≤ 1 h (early), 1-2 h (delayed), and >2 h (significantly-delayed). Survival to discharge was compared. RESULTS: Among 5258 patients, 310 underwent REBOA. In 223 matched pairs, patients treated with REBOA had improved survival (56.5% vs. 31.8%; p < 0.01), although in-hospital mortality was reduced by REBOA only in the delayed and significantly-delayed subgroups (HR = 0.43 [0.28-0.65] and 0.42 [0.25-0.71]). CONCLUSIONS: REBOA-treated trauma patients who experience delays in surgical intervention (>1 h) have improved survival.

Microvascular and Systemic Impact of Resuscitation with PEGylated Carboxyhemoglobin-Based Oxygen Carrier or Hetastarch in a Rat Model of Transient Hemorrhagic Shock.

BACKGROUND: Hemorrhage is the leading cause of preventable, traumatic death. Currently, prehospital resuscitation fluids provide preload but not oxygen-carrying capacity-a critical blood function that mitigates microvascular ischemia and tissue hypoxia during hemorrhagic shock. Solutions containing polymerized hemoglobin have been associated with vasoactive and hypertensive events. A novel hemoglobin-based oxygen carrier, modified with PEGylation and CO moieties (PEG-COHb), may overcome these limitations. OBJECTIVES: To evaluate the systemic and microcirculatory effects of PEG-COHb as compared with the 6% hetastarch in a rat model of hemorrhagic shock. METHODS: Male Sprague Dawley rats (N = 20) were subjected to severe, controlled, hemorrhagic shock. Animals were randomized to 20% estimated blood-volume resuscitation with either 6% hetastarch or PEG-COHb. Continuous, invasive, cardiovascular measurements, and arterial blood gases were measured. Microcirculatory measurements of interstitial oxygenation (PISFO2) and vasoactivity helped model oxygen delivery in the spinotrapezius muscle using intravital and phosphorescence quenching microscopy. RESULTS: Hemorrhage reduced mean arterial pressure (MAP), arteriolar diameter, and PISFO2, and increased lactate 10-fold in both groups. Resuscitation with both PEG-COHb and hetastarch improved cardiovascular parameters. However, PEG-COHb treatment resulted in higher MAP (P < 0.001), improved PISFO2 (14 [PEG-COHb] vs. 5 [hetastarch] mmHg; P < 0.0001), lower lactate post-resuscitation (P < 0.01), and extended survival from 90 to 142 min (P < 0.001) as compared with the hetastarch group. CONCLUSIONS: PEG-COHb improved MAP PISFO2, lactate, and survival time as compared with 6% hetastarch resuscitation. Importantly, hypertension and vasoactivity were not detected in response to PEG-COHb resuscitation supporting further investigation of this resuscitation strategy.

Iliac artery injuries and pelvic fractures: a national trauma database analysis of associated injuries and outcomes.

BACKGROUND: Although infrequent, injury to the common or external iliac artery in association with pelvic fractures can be devastating, and descriptive data are lacking. This study was performed to determine the incidence, injury patterns, and outcomes of blunt iliac artery injuries (BIAIs) in association with moderate or severe pelvic fractures. METHODS: Patients with moderate or severe pelvic fractures (abbreviated injury score of 3 or 4) were identified from the National Trauma Databank. Records with and without common or external BIAI were compared. Admission variables included Emergency Department (ED) hypotension (systolic blood pressure <90), Glasgow Coma Score or=25, femur or lumbosacral fractures, solid organ injury, vascular injury, and hollow viscus injury. The association of BIAI with moderate or severe pelvic fractures was studied. Outcomes were also analyzed, and independent associations with BIAI were determined by logistic regression. RESULTS: Of 6,377 patients with moderate or severe pelvic fractures, 221 (3.5%) had an associated BIAI. Patients with BIAI were more likely to have ED hypotension, Glasgow Coma Score or=25, genitourinary injury, bowel injury, and severe (abbreviated injury score 4) pelvic fractures. BIAI was also associated with higher mortality, lower extremity amputation, compartment syndrome, and overall complications. Independent risk factors for BIAI included severe pelvic fracture, ED hypotension, ISS >or=25, genitourinary injury, and bowel injury. CONCLUSION: BIAI is a rare diagnosis, but when present it is associated with a higher rate of overall complications and mortality. Vigilance is warranted in the diagnosis and management of this infrequent injury, especially in the setting of severe pelvic fractures.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is associated with improved survival in severely injured patients: A propensity score matching analysis.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique for temporary control of arterial hemorrhage. However, its effectiveness and clinical outcomes are unclear. METHODS: Using a nationwide database (2004-2016) in Japan, trauma patients with survival data were identified. Patients were divided between REBOA and non-REBOA groups, and a propensity score was developed using multivariate logistic regression. Survival to discharge was compared between the groups after propensity score matching. RESULTS: Among 82,371 patients included in this study, 385 were treated with REBOA. After propensity score matching, 117 pairs were selected. Survival to discharge was significantly higher among patients treated with REBOA than among those treated without REBOA (53 [45.3%] vs. 38 [32.5%]; odds ratio = 1.72; 95% CI = 1.01-2.93; p = 0.04). CONCLUSIONS: REBOA use was associated with improved survival to discharge and should therefore be considered during the management of severely injured trauma patients.

Effects of Sanguinate on Systemic and Microcirculatory Variables in a Model of Prolonged Hemorrhagic Shock.

BACKGROUND: Hemorrhage and its complications are the leading cause of preventable death from trauma in young adults, especially in remote locations. To address this, deliverable, shelf-stable resuscitants that provide therapeutic benefits throughout the time course of hemorrhagic shock and the progressive ischemic injury it produces are needed. SANGUINATE is a novel bovine PEGylated carboxyhemoglobin-based oxygen carrier, which has desirable oxygen-carrying and oncotic properties as well as a CO moiety to maintain microvascular perfusion. OBJECTIVES: To compare the crystalloid (Lactated Ringer's Solution; LRS), and the colloid (Hextend) standards of care with SANGUINATE in a post "golden hour" resuscitation model. METHODS: Rats underwent a controlled, stepwise blood withdrawal (45% by volume), were maintained in untreated hemorrhagic shock state for >60 min, resuscitated with a 20% bolus of one of the three test solutions, and observed till demise. Parameters of tissue oxygenation (PISFO2), arteriolar diameters, and mean arterial pressure (MAP) were collected. RESULTS: SANGUINATE-treated animals survived significantly longer than those treated with Hextend and LRS. SANGUINATE also significantly increased tissue PISFO2 2 h after resuscitation, whereas LRS and Hextend did not. SANGUINATE also produced a significantly higher MAP, which was hypotensive compared to baseline, that endured until demise. CONCLUSIONS: Resuscitation with SANGUINATE after prolonged hemorrhagic shock improves survival, MAP, and PISFO2 compared with standard of care plasma expanders. Since the pathologies of hemorrhagic shock and the associated systemic ischemia are progressive, preclinical studies of this nature are essential to determine efficacy of new resuscitants across the range of possible times to treatment.

Application of electronic medical record-derived analytics in critical care: Rothman Index predicts mortality and readmissions in surgical intensive care unit patients.

INTRODUCTION: The Rothman Index (RI) is an objective measurement of a patient's overall condition, automatically generated from 26 variables including vital signs, laboratory data, cardiac rhythms, and nursing assessments. The purpose of this study was to assess the validity of RI scores in predicting surgical ICU (SICU) readmission rates and mortality. METHODS: We conducted a single-center retrospective analysis of surgical patients who were transferred from the SICU to the surgical floor from December 2014 to December 2016. Data included demographics, length of stay (LOS), mortality, and RI at multiple pretransfer and post-transfer time points. RESULTS: A total of 1,445 SICU patients were transferred to the surgical floor; 79 patients (5.5%) were readmitted within 48 hours of transfer. Mean age was 52 years, and 67% were male. Compared to controls, patients readmitted to the SICU within 48 hours experienced higher LOS (29 vs. 11 days, p < 0.05) as well as higher mortality (2.5% vs. 0.6%, p < 0.05). Patients requiring readmission also had a lower RI at 72, 48, and 24 hours before transfer as well as at 24 and 48 hours after transfer (p < 0.05 for all). Rothman Index scores were categorized into higher-risk (<40), medium-risk (40-65), and lower-risk groups (>65); RI scores at 24 hours before transfer were inversely proportional to overall mortality (RI < 40 = 2.5%, RI 40-65 = 0.3%, and RI > 65 = 0%; p < 0.05) and SICU readmission rates (RI < 40 = 9%, RI 40-65 = 5.2%, and RI > 65 = 2.8%; p < 0.05). Patients transferred with RI scores greater than 83 did not require SICU readmission within 48 hours. CONCLUSION: Surgical ICU patients requiring readmission within 48 hours of transfer have a significantly higher mortality and longer LOS compared to those who do not. Patients requiring readmission also have significantly lower pretransfer and post-transfer RI scores compared to those who do not. Rothman Index scores may be used as a clinical tool for evaluating patients before transfer from the SICU. Prospective studies are warranted to further validate use of this technology. LEVEL OF EVIDENCE: Retrospective database review, level III.

Rapid decay of transthoracic echocardiography skills at 1 month: A prospective observational study.

OBJECTIVE: Focused transthoracic echocardiography (FTTE) is an emerging tool in the management of critically ill patients, but the lack of adequate training models has limited the expansion of this technology. Although basic FTTE training courses have been shown to be sufficient in developing echocardiography skills, limited data exist regarding skill retention. In an effort to develop an adequate FTTE training model, we sought to determine the degree of skill retention after FTTE training. DESIGN: A prospective, observational study. SETTING: An academic center. PARTICIPANTS: Surgical residents and medical students: 31 subjects were enrolled from February to June 2016. RESULTS: Participants underwent a 2-hour FTTE course including didactics and a hands-on session measuring ejection fraction of left ventricle (LV) and inferior vena cava (IVC) diameter. Written knowledge and performance examinations applying FTTE were conducted before the course, immediately after, and at 1- and 3-month intervals, which were evaluated on a 0 to 9 scale and analyzed with paired t-tests. Performance examination scores obtaining the LV and IVC views preinitial and postinitial training increased from 1.7 to 6.5 (LV) and from 2.0 to 6.8 (IVC) (p < 0.01), decreased to 5.0 and 4.8, respectively, at 1 month (posttraining vs 1 month, p < 0.01), and did not significantly change at 3 months (5.4 and 5.0, respectively). Written examination scores increased from 42% to 62% (pretraining vs posttraining, p < 0.01), decreased to 48% in 1 month (posttraining vs 1 month, p < 0.01), and further decreased to 34% at 3 months (1 month vs 3 month, p < 0.01). CONCLUSIONS: Although a short training course appears sufficient to impart basic FTTE skills and knowledge, skills are significantly decayed at 1 month and knowledge continually decreases at 1 and 3 months. Future FTTE training models should consider the rapid degradation of knowledge and skills in determining frequency of refresher training and ongoing evaluation.

Trauma Surgeons' Perspective on Gun Violence and a Review of the Literature.

Background In the United States, there is a constant debate between the proponents of the right to bear arms and those desiring to reduce the epidemic of gun violence. We sought to capture the trauma surgeons' perspective on gun control. Methods We presented an on-line based survey to the members of the American Association for the Surgery of Trauma (AAST). Survey questions were chosen to reflect the popular media poll questions as well as trauma-specific perspectives. We compared the trauma surgeons' perspectives to that of the general populace from a poll conducted by the New York Times (NYT). Results A total of 120 trauma surgeons responded to the survey. The age group ranged from 34 to 82 years, and the median age was 51. Most respondents were male (64%, n = 67) and worked at a Level I trauma center (80%, n = 96) in an academic setting (67%, n = 80). About half of the responding surgeons owned a household firearm (40%; n = 48 of the AAST members vs. 47%; n = 521 of the general populace). Sixty-one percent of the trauma surgeons (n = 73) and 53% (n = 588) of the NYT respondents favor stricter gun control laws. While 80% (n = 888) of the NYT respondents felt that mental health screening and treatment would decrease gun violence, only 56% (n = 67) of surgeons felt that mental health screening would be beneficial. The majority (90%, n = 999) of the NYT poll respondents favor a law restricting the sale of guns only by licensed dealers. Only (66%, n = 79) of the trauma surgeons were in agreement with the stricter gun sale legislation by licensed dealers. Conclusion Trauma surgeons appear to share similar views with the general American populace regarding gun violence and injury control.

Combat Casualties and Severe Shock: Risk Factors for Death at Role 3 Military Facilities.

BACKGROUND: Although significant research has been conducted on combat casualties receiving blood products, there is limited data for the subpopulation presenting in shock. The purpose of this study was to evaluate combat casualties arriving to a role 3 facility with an initial systolic blood pressure (SBP) ≤ 90 in order to identify clinical characteristics and associations between presentation, transfusion therapy, and mortality outcomes. METHODS: The Department of Defense Trauma Registry was queried from 2001 to 2010 for trauma-related casualties who arrived at a role 3 combat surgical facility with a SBP ≤ 90. Transfers from role 2 facilities were excluded. Data captured included demographics, admission vital signs, laboratory values, blood products, and mortality. Relationships between admission physiology, blood product utilization, and mortality were developed. Independent associations between variables were determined by logistic regression analysis. RESULTS: 1,703 patients were identified who met our inclusion criteria and composite mortality was 23%. Mortality in those receiving a balanced transfusion ratio was 18% versus 27% (p < 0.0001). Hypotensive casualties who survived were significantly more likely to have a higher presenting Glasgow Coma Score (GCS), temperature, SBP, shock index, and pH. In addition, this group was also more likely to have a lower international normalized ratio, pCO2, and base deficit (p < 0.001). Age, heart rate, and pulse pressure were not significantly different between groups. Independent predictors of mortality included Injury Severity Score, presentation GCS, and initial pH value (p < 0.0001). In contrast, independent predictors of survival included those with above-knee amputation and a balanced transfusion (p < 0.0001). CONCLUSIONS: Combat casualties hypotensive on arrival to surgical facilities have a significant expected mortality. Those receiving balanced transfusions demonstrated improved survival. Of the five independent risk factors, pH, GCS, and the presence of above-knee amputation are typically available during initial evaluation. These factors may be helpful in determining resource allocation and mortality risk, especially in triage or mass casualty settings.

Endpoints of resuscitation.

Despite the multiple causes of the shock state, all causes possess the common abnormality of oxygen supply not meeting tissue metabolic demands. Compensatory mechanisms may mask the severity of hypoxemia and hypoperfusion, since catecholamines and extracellular fluid shifts initially compensate for the physiologic derangements associated with patients in shock. Despite the achievement of normal physiologic parameters after resuscitation, significant metabolic acidosis may continue to be present in the tissues, as evidenced by increased lactate levels and metabolic acidosis. This review discusses the major endpoints of resuscitation in clinical use.

Venovenous extracorporeal life support improves survival in adult trauma patients with acute hypoxemic respiratory failure: a multicenter retrospective cohort study.

BACKGROUND: Venovenous extracorporeal life support (VV ECLS) has been reported in adult trauma patients with severe respiratory failure; however, ECLS is not available in many trauma centers, few trauma surgeons have experience initiating ECLS and managing ECLS patients, and there is currently little evidence supporting its use in severely injured patients. This study seeks to determine if VV ECLS improves survival in such patients. METHODS: Data from two American College of Surgeons-verified Level 1 trauma centers, which maintain detailed records of patients with acute hypoxemic respiratory failure (AHRF), were evaluated retrospectively. The study population included trauma patients between 16 years and 55 years of age treated for AHRF between January 2001 and December 2009. These patients were divided into two cohorts as follows: patients who received VV ECLS after an incomplete or no response to other rescue therapies (ECLS) versus patients who were managed with mechanical ventilation (CONV). The primary outcome was survival to discharge, and secondary outcomes were intensive care unit and hospital length of stay (LOS), total ventilator days, and rate of complications requiring intervention. RESULTS: Twenty-six ECLS patients and 76 CONV patients were compared. Adjusted survival was greater in the ECLS group (adjusted odds ratio, 0.193; 95% confidence interval, 0.042-0.884; p = 0.034). Ventilator days, intensive care unit LOS, and hospital LOS did not differ between the groups. ECLS patients received more blood transfusions and had more bleeding complications, while the CONV patients had more pulmonary complications. A cohort of 17 ECLS and 17 CONV patients matched for age and lung injury severity also demonstrated a significantly greater survival in the ECLS group (adjusted odds ratio, 0.038; 95% confidence interval, 0.004-0.407; p = 0.007). CONCLUSION: VV ECLS is independently associated with survival in adult trauma patients with AHRF. ECLS should be considered in trauma patients with AHRF when conventional therapies prove ineffective; if ECLS is not readily available, transfer to an ECLS center should be pursued. LEVEL OF EVIDENCE: Therapeutic study, level III.

Natural history and clinical implications of nondepressed skull fracture in young children.

BACKGROUND: Head injury is the most common cause of neurologic disability and mortality in children. Previous studies have demonstrated that depressed skull fractures (SFs) represent approximately one quarter of all SFs in children and approximately 10% percent of hospital admissions after head injury. We hypothesized that nondepressed SFs (NDSFs) in children are not associated with adverse neurologic outcomes. METHODS: Medical records were reviewed for all children 5 years or younger with SFs who presented to our Level I trauma center during a 4-year period. Data collected included patient demographics, Glasgow Coma Scale (GCS) score at admission, level of consciousness at the time of injury, type of SF (depressed SF vs. NDSF), magnitude of the SF depression, evidence of neurologic deficit, and the requirement for neurosurgical intervention. RESULTS: We evaluated 1,546 injured young children during the study period. From this cohort, 563 had isolated head injury, and 223 of them had SF. Of the SF group, 163 (73%) had NDSFs, of whom 128 (78%) presented with a GCS score of 15. None of the NDSF patients with a GCS score of 15 required neurosurgical intervention or developed any neurologic deficit. Of the remaining 35 patients with NDSF and GCS score less than 15, 7 (20%) had a temporary neurologic deficit that resolved before discharge, 4 (11%) developed a persistent neurologic deficit, and 2 died (6%). CONCLUSION: Children 5 years or younger with NDSFs and a normal neurologic examination result at admission do not develop neurologic deterioration. LEVEL OF EVIDENCE: Epidemiological study, level III.

Initial management of the trauma patient.

Regardless of the injuries sustained or the capabilities of the treating facility, the principles described in ATLS should guide the initial assessment, resuscitation, and treatment of the multiply injured patient.3 The primary and secondary survey should be continually repeated to identify deterioration in the patient's condition and to make appropriate interventions. The use of a prioritized and systematic approach to initial management of the trauma patient ensures that optimal care is delivered and the best possible outcome is achieved.